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XAVIER BECERRA Attorney General of California

2 MATTHEWM.DAVIS Supervising Deputy Attorney General

3 MARTIN W. HAGAN Deputy Attorney General

4 State Bar No. 155553 600 West Broadway, Suite 1800

5 San Diego, CA 92101 P .0. Box 85266

6 San Diego, CA 92186-5266 Telephone: (619) 738-9405

7 Facsimile: (619) 645-2061

8 Attorneys/or Complainant

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BEFORE THE

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MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS

STATE OF CALIFORNIA

In the Matter of the Accusation Against:

Roy Cass Springer, M.D. 6280 Jackson Drive, Suite 8 San Diego, CA 92119-3436

Case No. 800-2017-032022

ACCUSATION

17 Physician's and Surgeon's Certificate No. A 23489,

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Respondent.

PARTIES

21 1. Christine J. Lally (Complainant) brings this Accusation solely in her official capacity

22 as the Interim Executive Director of the Medical Board of California, Department of Consumer

23 Affairs (Board).

24 2. On or about September 5, 1969, the Medical Board issued Physician's and Surgeon's

25 Certificate Number A 23489 to Roy Cass Springer, M.D. (Respondent). The Physician's and

26 Surgeon's Certificate was in full force and effect at all times relevant to the charges brought

27 herein and will expire on December 31, 2021, unless renewed.

28 I I I I

ROY CASS SPRINGER, M.D. - ACCUSATION NO. 800-2017-032022

JURISDICTION

2 3. This Accusation is brought before the Board, under the authority of the following

3 laws. All section references are to the Business and Professions Code (Code) unless otherwise

4 indicated;

5 4. Section 2227 of the Code states:

6 (a) A licensee whose matter has been heard by an administrative law judge of the Medical Quality Hearing Panel as designated in Section 11371 of the Government

7 Code, or whose default has been entered, and who is found guilty, or who has entered into a stipulation for disciplinary action with the board, may, in accordance with the

8 provisions of this chapter:

9 (1) Have his or her license revoked upon order of the board.

10 (2) Have his or her right to practice suspended for a period not to exceed one year upon order of the board.

11 (3) Be placed on probation and be required to pay the costs of probation

12 monitoring upon order of the board.

13 (4) Be publicly reprimanded by the board. The public reprimand may include a requirement that the licensee complete relevant educational courses approved by the

14 board.

15 (5) Have any other action taken in relation to discipline as part of an order of

16 probation, as the board or an administrative law judge may deem proper.

(b) Any matter heard pursuant to subdivision (a), except for warning letters, 17 medical review or advisory conferences, professional competency examinations,

continuing education activities, and cost reimbursement associated therewith that are 18 agreed to with the board and successfully completed by the licensee, or other matters

made confidential or privileged by existing law, is deemed public, and shall be made 19 available to the public by the board pursuant to Section 803.1.

20 STATUTORY PROVISIONS·

21 5. Section 2234 of the Code, states:

22 The board shall take action against any licensee who is charged with unprofessional conduct. In addition to-other provisions of this article, unprofessional

23 conduct includes, but is not limited to, the following:

24 (a) Violating or attempting to violate, directly or indirectly, assisting in or abetting the violation of, or conspiring to violate any provision of this chapter .

.25 (b) Gross negligence.

26 (c) Repeated negligent acts. To be repeated, there must be two or more

27 negligent acts or omissions. An initial negligent act or omission followed by a separate and distinct departure from the applicable standard of care shall constitute

28 repeated negligent acts.

2

ROY CASS SPRINGER, M.D. -ACCUSATION NO. 800-2017-032022

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(1) An initial negligent diagnosis followed by an act or omission medically appropriate for that negligent diagnosis of the patient shall constitute a single negligent act.

(2) When the standard of care requires a change in the diagnosis, act, or 3 omission that constitutes the negligent act described in paragraph (I), including, but

not limited to, a reevaluation of the diagnosis or a change in treatment, and the 4 licensee's conduct departs from the applicable standard of care, each departure

constitutes a separate and distinct breach of the standard of care. 5

6 (f) Any action or conduct which would have warrnnted the denial of a

7 ceriificate.

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9 6. Section 725 of the Code states:

10 (a) Repeated acts of clearly excessive prescribing, furnishing, dispensing, or administering of drugs or treatment, repeated acts of clearly excessive use of

11 diagnostic procedures, or repeated acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of the community of licensees is

12 unprofessional conduct for a physician and surgeon, dentist, podiatrist, psychologist, physical therapist, chiropractor, optometrist, speech-language

13 pathologist, or audiologist.

14 (b) Any person who engages in repeated acts of clearly excessive prescribing or administering of drugs or treatment is guilty of a misdemeanor and shall be

15 punished by a fine of not less than one hundred dollars ($100) nor more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days nor

16 more than 180 days, or by both that fine and imprisonment.

17 (c) A practitioner who has a medical basis for prescribing, furnishing,· dispensing, or administering dangerous drugs or prescription controlled substances

18 shall not be subject to disciplinary action or prosecution under this section.

19 (d) No physician and surgeon shall be subject to disciplinary action pursuant

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to this section for treating intractable pain in compliance with Section 2241.5.

7. Section 2266 of the Code states: The failure of a physician and surgeon to maintain

22 adequate and accurate records relating to the provision of services to their patients constitutes

23 unprofessional conduct.

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FIRST CAUSE FOR DISCIPLINE

2 (Gross Negligence)

3 8. Respondent is subject to disciplinary action under sections 2227 and 2234, as defined

4 by section 2234, subdivision (b), of the Code, in that he committed gross negligence in his care

5 and treatment of Patients A and B, as more particularly alleged hereinafter:

6 PATIENT A 1

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9. On or about December 16, 2013, Respondent had his first visit with Patient A, a then-

29-year-old-male and family member.2 According to Respondent's chart note, Patient A's chief

complaint was "back pain improved, but had spasm on 12/15." Muscle tightness and L4-5 and

positive straight leg test was noted. Respondent's assessment was "acute low back pain" and the

plan was listed as "Rx Norco3 #30."

II II

1 The patients referenced in this Accusation are designated as "Patient A," Patient B," and "Patient C" in order to maintain and protect their privacy. ·

2 The AMA Code of Medical Ethics states, "[i]n general, physicians should not treat themselves or their own family members" except for limited circumstances which includes "emergency settings or isolated settings where there is no other qualified physician available" or "for short-term, minor problems." As recognized by the AMA, "[t]reating a family member poses several challenges including, but not limited to, professional objectivity, patient autonomy and informed consent." (AMA Code of Medical Ethics Opinion 1.2.1.)

3 Hydrocodone APAP (Vicodin®, Lortab® and Norco®) is a combination of hydrocodone bitartrate and acetaminophen which was formerly a Schedule III controlled substance pursuant to Health and Safety Code section 11056, subdivision (e), and a dangerous drug pursuant to Business and Professions Code section.4022. On August 22, 2014, the DEA published a final rule rescheduling hydrocodone combination products to schedule II of the Controlled Substances Act, which became effective October 6, 2014. Schedule II controlled substances are substances that have a currently accepted medical use in the United States, but also have a high potential for abuse, and the abuse of which may lead to severe psychological or physical dependence. When properly prescribed and indicated, hydrocodone combination products are used for the treatment of moderate to severe pain. In addition to the potential for psychological and physical dependence there is also the risk of respiratory depression, which is increased, when hydrocodone combination products are used with other central nervous system (CNS) depressants and acute liver failure from excessive acetaminophen, which has resulted in black box warnings being issued by the Federal Drug Administration (FDA). The FDA black box warnings included, among other things, that "Concomitant use of opioids with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death" and that "Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death. Most of the cases of liver injury are associated with use of the acetaminophen at doses that exceed 4000 milligrams per day, and often involve more than one acetaminophen containing product." ·

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ROY CASS SPRINGER, M.D. - ACCUSATION NO. 800-20 I 7-032022

10. During the period of on or about January 1, 2014, through December 31, 2014,

2 Patient A had eight visits with Respondent which took place on January 16, January 27, March

3 27, May 14, June 28, September 18, November 26, and December 23, 2014. During this time,

4 Patient A's problems were generally documented as including, but not limited to, left shoulder

5 pain, back pain and occasional muscle spasm. On January 3, Respondent's Physician Assistant

6 Certified (P.A.C.) J.K. issued two prescriptions for controlled substances without any supporting

7 medical documentation. On January 6, another physician in Respondent's clinic, most likely Dr.

8 S.G.,4 had an office visit with Patient A because "Dr. Springer [was] out of town." Thereafter,

9 Patient A's dose ofhydrocodone/APAP (Norco) was increased without sufficient examination,

1 O history, and/Or adequate documentation. During 2014, Respondent's chart notes were cursory

11 and routinely failed to adequately document, among other things, prior treatment, detailed

12 histories, physical examinations, detailed assessments and treatment plans for presenting

13 problems, detailed analysis of pain and effect on quality of life, informed consent for the

14 controlled substances being prescribed, adequate risk screening measures,5 and/or specific and

15 complete information for the controlled substances being prescribed. According to the CURES6

16 repo1t for Patient A, the following prescriptions for controlled substances were filled for Patient A

17 . during2014:

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4 The chart note for January 6, 2014, did not identify the examining physician. However, a prescription was issued by Dr. S.G. to Patient A on that date.

5 Risk screening measures include, but are not limited to, obtaining adequate histories on such items as mental health, drug use, alcohol use, and any other conditions or diagnoses which may be contraindicated for the controlled substances being prescribed, pain management agreements, pill counting, toxicology screening, opioid risk screening tools or checklists, and periodic review of available prescription drug monitoring programs. Risk screening measures are designed to address aberrant drug behavior including, but not limited to, misuse and/or diversion of the controlled substances being prescribed.

6 CURES is California's prescription drug monitoring program which tracks Schedule II, III and IV controlled substance prescriptions that are dispensed in California. One of the explicit purposes of the CURES database is to assist "law enforcement and regulatory agencies in their efforts to control the diversion and resultant abuse of Schedule II, Schedule Ill, and Schedule IV controlled substances." (Health & Saf.Code, § 11165, subd. (a).)

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Date Filled Drug Name Strength Quantity Days Prescriber

01-03-20 I 4 Hydrocodone/ AP AP 10/325 mg 90 30 PAC (J.K.)

01-03-2014 Carisoprodol7 350 mg 90 30 PAC (J.K.)

01-06-2014 Hydrocodone/ AP AP 10/325 mg 20 05 Dr. S.G.

01-29-2014 Hydrocodone/ AP AP 10/325 mg 40 10 Respondent

01-29-2014 Hydrocodone/ APAP 10/325 mg 120 30 Respondent









07-05-2014 Hydrocodone/ AP AP 10/325 mg 160 26 Responqent


08-25-2014 · Hydrocodone/APAP . 10/325 mg 160 26 Respondent





7 Carisoprodol (Soma®) is a Schedule IV controlled substance pursuant to Health and s p

afety Code section 11057, subdivision (d), and a dangerous drug pursuant to Business and rofessions Code section 4022. When properly prescribed and indicated, it is used for the short-

erm treatment of acute and painful musculoskeletal conditions. Soma® is commonly used by t t A I

hose who abuse opioids to potentiate the euphoric effect of opioids, to create a better "high." ccording to the DEA, Office of Diversion Control, "[c]arisoprodol abuse has escalated in the

ast decade in the United States. According to Diversion Drug Trends, published by the DEA on he trends in diversion of controlled and noncontrolled pharmaceuticals, carisoprodol is a

c ommonly diverted drug.

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atient A had twelve visits with Respondent which took place on February 20, March 18, April 1, 2 p

3 A pril 22, May 18, June 1, June 15, July 20, September 15, November 14, December 11, and

4 D ecember 21, 2015. During this time, Patient A's problems were generally documented as

5 ncluding, but not limited to, spasm, ankle sprain (documented on April I), and dental infection

6 ( documented on December 21 ). In general, Respondent's chatt notes were cursory and routinely

7 fi ailed to adequately document, among other things, prior treatment, detailed histories, physical

8 e xaminations, detailed assessments and treatment plans for presenting problems, detailed analysis

9 0 f pain and effect on quality of life, informed consent for the controlled substances being

10 p rescribed, adequate risk screening measures, and/or specific and complete information for the

11 c ontrolled substances being prescribed. During this period of time, Patient A's morphine

12 e quivalency doses were as high as 136 milligrams per day. According to the CURES report for

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atient A, the following prescriptions for controlled substances were filled for Patient A during

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Date Filled

01-24-2015

03-04-2015

04-01-2015

04-23-2015

05-18-2015

06-01-2015

06-15-2015

07-20-2015

08-20-2015

09-15-2015

10-06-2015

10-22-2015

Drug Name Strength Quantity Days Prescriber

Hydrocodone/ APAP 10/325 mg 90 30 Respondent

Hydrocodone/ AP AP 10/325 mg 40 06 Respondent











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ROY CASS SPRINGER M.D. - ACCUSATION NO. 800-2017-032022

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Date Filled

11-16-2015

12-11-2015

12-22-2015

Drug Name Strength

Hydrocodone/ APAP 10/325 mg

Hydrocodone/ APAP 10/325 mg

Hydrocodone/APAP 10/325 mg

Quantity Days Prescriber

120 20 Respondent

150 25 Respondent

80 13 Respondent

5 12. During the period of on or about January 1, 2016, through December 31, 2016,

6 Patient A had six visits with Respondent which took place on February 1, April 13, May 9, May

7 31, June 29, and November 22, 2016. During this time, Patient A's problems were generally

8 documented as including, but not limited to, tooth pain, low back spasms, and left sciatica. On

9 May 31, Respondent noted left-sided sciatica but failed to document urinary or bowel symptoms,

10 perinea) sensation, or anal wink, and he failed to exclude cauda equina syndrome.8 On June 29,

11 there was notation to "See specialist (pain) soon [and] Arrange for MRI." On July 13, Patient A

12 was seen by Dr. B.W., physical medicine and pain management, who recommended Norco

13 10/325 mg q.i.d., continued stretching, consider MRI, consider physical therapy and continue

14 current plan. During this time, Patient A's problems were generally documented as including, but

15 not limited to, left shoulder pain, back pain and occasional muscle spasm. In general,

16 Respondent's chart notes were cursory and routinely failed to adequately document, among other

17 things, prior treatment, detailed histories, physical examinations, detailed assessments and

18 treatment plans for presenting problems, detailed analysis of pain and effect on quality of life,

19 nfonned consent for the controlled substances being prescribed, adequate risk screening

20 measures, and/or specific and complete infonnation for the controlled substances being

21 prescribed. There was no documentation for the prescription from Physician Assistant H.H.

22 which was filled on August 18, 2016. There was no documentation for the prescriptions from Dr.

23 B.L., which were filled on September 12, October 18, and December 17, 2016. During this

24 period of time, Patient A's morphine equivalency doses were approximately 60 milligrams per

25 day. According to the CURES report for Patient A, the following prescriptions for controlled

26 substances were filled for Patient A during 2016:

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28 8 Cauda equina syndrome is a neurological emergency created by compression of the

distal spinal column which if untreated and unrecognized can lead to paralysis.

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05- i'o-2016 Hydrocodone/ AP AP 10/325 mg 150 25 Respondent


06-30-2016 Hydrocodone/APAP 10/325 mg 150 25 Respondent

07-26-2016 Hydrocodone/ APAP 10/325 mg 150 25 Dr. B.W.

08-18-2016 Hydrocodone/ APAP 10/325 mg 150 25 P.A. (H.H.)

09-12-2016 Hydrocodone/ APAP 10/325 mg 150 25 Or. B.L.9

10-18-2016 Hydrocodone/ AP AP 10/325 mg 150 25 Dr. B.L.

11-23-2016 Hydrocodone/APAP 10/325 mg 150 25 Respondent


13. During the period of on or about January I, 2017, through December 31, 2017,

p atient A had seventeen visits with Respondent or Respondent's colleague, Dr. B.L., which took

lace on February 23 (Dr. B.L. visit), April 27 (Dr. B.L. visit), June 12 (Dr. B.L. visit), June 23, p

J uly 3 (Dr. B.L. visit), July 17, August 8, September 11, September 30, October 2, October 20,

0 ctober 27, November 14, November 27, December 9, December 14, and December 21, 2017.

D uring this time, Patient A's problems were generally documented as including, but not limited

t o, low back pain, right ankle pain, and back spasms (unchanged). Respondent's chart note of

A ugust 8, indicated "no longer seeing B.L. (pill mill) 10- no referrals ever done or suggested"

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9 Patient A filled prescriptions from Dr. B.L., who worked with Respondent, on eptember 12, October 18, and December 17, 2016, which had no corresponding medical record ocumentation.

10 The chart notes indicates that Respondent and Dr. B.L. both worked at the Center for amily Health which was owned by Respondent. Respondent's "pill mill" reference is ironic F

c onsidering that Respondent subsequently issued numerous similar prescriptions of

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with a notation to "Use Oxy for severe pain" and, in regard to referrals, "MRI and PT soon." On

2 August 8, Patient A had a MRI with the "impression" reported as "straightening of normal

3 ordotic curvature, compatible with muscle spasm." On August 11, Patient A had a rehabilitation

4 evaluation where physical therapy was recommended. During this time, Patient A's problems

5 were generally documented as including, but not limited to, left shoulder pain, back pain and

6 occasional muscle spasm. In general, Respondent's chart notes were cursory and routinely failed

7 o adequately document, among other things, prior treatment, detailed histories, physical

8 examinations, detailed assessments and treatment plans for presenting problems, detailed analysis

9 of pain and effect on quality of life, informed consent for the controlled substances being

IO prescribed, adequate risk screening measures, and/or specific and complete information for the

11 controlled substances being prescribed. During this period of time, Patient A's morphine

12 equivalency dose exceeded 90 mg per day. 11 According to the CURES report for Patient A, the

13 following prescriptions for controlled substances were filled for Patient A during 2017:

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01-10-2017 Hydrocodone/APAP 10/325 mg 150 25 Dr. B.L.

02-02-2017 Hydrocodone/ APAP I 0/325 mg 150 25 Dr. B.L.

02-24-2017 Hydrocodone/ APAP I 0/325 mg 150 25 Respondent

03-20-2017 Hydrocodone/APAP 10/325 mg 150 25 Dr. B.L.

04-04-2017 Hydrocodone/ AP AP I 0/325 mg 150 25 Dr. B.L.

hydrocodone/APAP (Norco) 10/325 mg (#150) and later added Oxycodone/APAP (Percocet) which actually increased the overall morphine equivalency dosage for Patient A, and put him at greater risk of, among other things, psychological or physical dependence, respiratory depression, overdose, and/or death.

11 On March 18, 2016, the Centers for Disease Control and Prevention (CDC) issued its Guideline for Prescribing Opioids for Chronic Pain. One of the recommendations was that 'When opioids are started, clinicians should prescribe the lowest effective dose. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage [greater than] 50 [MED/day], and should avoid increasing to [greater than] 90 [MED/day] or carefully justify a decision to titrate dosage to [greater than 90 [MED/day]." Additionally, the American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine (hereinafter collectively referred to as "Academies") note that extreme caution is necessary when a patient is receiving over 90-100 MED/day.

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Date Filled Drug Name Strength Quantity Days. Prescriber


05-22-2017 Hydrocodone/ APAP 10/325 mg 150 25 Dr. B.L.

06-15-2017 Hydrocodone/ APAP 10/325 mg 150 25 Dr. B.L.



08-08-2017 Oxycodone/APAP12 10/325 mg 50 10 Respondent


08-28-2017 Oxycodone/ APAP 10/325 mg 50 07 Respondent



09-30-2017 Oxycodone/ AP AP 10/325 mg 40 20 Respondent





11-27-2017 Oxycodone/ AP AP 10/325 mg 50 13 Respondent ,

12-10-2017 Oxycodone/APAP 10/325 mg 50 12 Respondent




p atient A had fifteen visits with Respondent which took place on January 11, February 3, March

12 Oxycodone/APAP [acetaminophen] (Percocet®), an opioid analgesic, is a Schedule II ontro1led substance pursuant to Health and Safety Code section 11055, subdivision (b ), and a c

d p T A

angerous drug pursuant to Business and Professions Code section 4022. When properly rescribed and indicated, it is used for the management of moderate to moderately severe pain. he Drug Enforcement Administration has identified oxycodone, as a drug of abuse. (Drugs of buse, A DEA Resource Guide (2011 Edition), at p. 41.) The Federal Drug Administration has

ssued a black box warning for Percocet® which warns about, among other things, addiction, a buse and misuse, and the possibility of "life-threatening respiratory distress."

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3, April 18, May 14, June 6, July 1, July 17, July 26, August 18, September 12, October 4, 2

2 N ovember 19, December 6, and December 14, 2018. During this time, Patient A's problems

3 w ere generally documented as including, but not limited to, left shoulder pain, back pain and

4 0 ccasional muscle spasm. On March 23, Respondent charted that Patient A was "using less

5 N orco" which was inaccurate. 13 In general, Respondent's chart notes were cursory and routinely

6 fi ailed to adequately document, among other things, prior treatment, detailed histories, physical

7 e xaminations, detailed assessments and treatment plans for presenting problems, detailed analysis

8 0 f pain and effect on quality cif life, informed consent for the controlled substances being

9 p rescribed, adequate risk screening measures, and/or specific and complete information for the

10 .c ontrolled substances being prescribed. During this time, Patient A's problems were generally

11 d ocumented as including, but not limited to, low back pain ·and back spasms. During this period

12 0 f time, Patient A's morphine equivalency dose exceeded 90 mg per day. According to the

13 c URES repo11 for Patient A, the following prescriptions for controlled substances were filled for

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atient A during 2018:











13 According to the CURES report for Patient A, he continued to fill prescriptions of ydrocodone/ APAP (Norco) in 2018 in the range of 5-6 tabs per days (which he consistently

28 eceived in 2017) and filled a prescription for Norco 10/325 mg (# 150- 20 day supply) on July 26, r

2 018, which represented 7.5 tabs per day.

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10-24-2018 Tramadol 14 50 mg 120 30 Respondent







15. On or about January 9, 2019, Respondent documented persistent back pain of unclear

e tiology, minimal success with physical therapy, "[u]ses hydrocodone and occasional

0 xycodone," with a review of symptoms. A comprehensive physical exam was documented

w hich included a questionable genital exam and questionable clinical breast exam including lack

0 f dimpling. 15 A back examination was not documented.

14 Tramadol Hydrochloride (Ultram®, Ultracet®), an opioid analgesic, is a Schedule IV ontrolled substance pursuant to Health and Safety Code section 11057, subdivision (d), and a c

d p a

angerous drug pursuant to Business and Professions Code section 4022. When properly rescribed and indicated, it is used for the treatment of moderate to severe pain. The FDA-pproved labeling under the Drug Abuse and Dependence section warns, among other things, that '[t]ramadol hydrochloride may induce psychic and physical dependence ... Dependence and buse, including drug-seeking behavior and taking illicit actions to obtain the drug are not limited o those patients with prior history of opioid dependence. The risk in patients with substance

a t a t d n

buse has been observed to be higher. Tramadol hydrochloride is associated with craving and olerance development. Withdrawal symptoms may occur if tramadol hydrochloride is iscontinued abruptly." According to the DEA, "[t]ramadol is most commonly abused by arcotic addicts, chronic pain patients, and health professionals."

15 A comprehensive clinical breast examination with comments about the absence of asses and dimpling is appropriate for a routine health care maintenance examination of an adult

emale patient, which is not typically done on a male patient such as Patient A, absent specific m fl c omplaints regarding his breasts or unless he had atypical gynecomastia (enlargement of a man's

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16. Respondent committed gross negligence in his care and treatment of Patient A which

included, but was not limited to, the following:

II II

(a) Respondent undertook treatment and continued treatment of a family

member, Patient A, over an extended period of time, which included, but

was not limited to, issuing numerous prescriptions of controlled

substances and failing to actively pursue or consider other conditions or

diagnoses including, but not limited to, comorbid depression and anxiety

and/or cauda equina syndrome;

(b) Respondent repeatedly prescribed controlled substances to Patient A, a

family member, without adequately obtaining, providing and/or

documenting, among other things, prior treatment, detailed histories,

physical examinations, detailed assessments and treatment plans for

presenting problems, detailed analysis of pain and effect on quality of life,

informed consent for the controlled substances being prescribed, adequate

risk screening measures, and/or specific and complete information for the

controlled substances being prescribed;

(c) Respondent failed to document why Physician Assistant J.K. prescribed a

higher dose of hydrocodone/APAP (Norco) and issued a prescription for

carisoprodol (Soma) on or about January 3, 2014;

(d) Respondent repeatedly prescribed opiates in excessive doses which

increased the risk of harm to Patient A;

(e) Respondent failed to carefully coordinate and/or document any

coordination of care with Dr. B.L.; and

(f) Respondent inaccurately charted that Patient A was "using less Norco" on

March 23, 2018.

breasts usually due to hormone imbalance or hormone therapy). Similarly, the performance of a genital examination on one's family member is not something that would typically be done in such a clinical setting.

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PATIENT B

2 17. On or about September 2, 2014, Respondent had his first documented visit with

3 Patient B, a then-31-year-old-female and family member, which took place nearly eight months

4 after he began prescribing controlled substances to Patient B. According to Respondent's chart

5 note, Patient B's chief complaint was "severe spine/back pain from a rear impact motor vehicle

6 accident in 201 O." The subjective section of the chart note indicated, among other things, "Now:

7 sudden onset of LBP [low back pain] I may be from yoga exercising." Respondent documented a

8 checkbox physical examination which was normal except for the back area with no further details

9 provided. The documented assessment was "Low back spasm" and his plan was "will try

1 O occasional] Norco for pain ... may need [muscle] relaxant." Respondent prescribed Norco

11 (hydrocodone/ APAP) 10/325 mg (# 160) one tablet every four hours as needed for pain.

I 2 I 8. Respondent had one more documented office visit with Patient B which took place on

13 October 29, 2014. According to_ Respondent's chart note, Patient B reported that she was "Doing

14 better [with] Less pain/spasm" and that she had a muscle spasm episode "but now resolved."

I 5 Respondent documented a checkbox physical examination which was normal for cardiac,

I 6 extremities, neurological and abnonnal for back indicating "80-90 [percent with] pain." The plan

I 7 was to continue exercising and stretching and to prescribe "Norco# 160 but use only sparingly"

18 with no strength documented in the chart note. A copy of the handwritten prescription was

19 ncluded as part of the certified medical records. During the course of2014, Respondent

20 ncreased the risk of harm to Patient B in increasing her morphine equivalency dose from I 5 mg

21 per day to 61 .5 mg per day while concurrently prescribing Soma (carisoprodol) 350 mg.

22 According to the CURES report for Patient B, the following prescriptions for controlled

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s ubstances were filled for Patient B during 2014:

Date Filled Drug Name Strength Quantity Days

01-13-2014 Hydrocodone/ APAP 5/325 mg 90 30

01-13-2014 Carisoprodol 350 mg 90 30

02-10-20 I 4 Hydrocodone/ APAP 5/325 mg 90 30

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Prescriber

Respondent

Respondent

Respondent

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02-10-2014 Carisoprodol 350 mg 90 30 Respondent





05-07-2014 Hydrocodone/APAP 7.5/325 mg 120 30 Respondent


06-05-2014 Hydrocodone/ APAP 7.5/325 mg 120 30 Respondent


07-02-2014 Hydrocodone/ AP AP 7.5/325 mg 120 30 Respondent


08-01-2014 Hydrocodone/ AP AP 7.5/325 mg 120 30 Respondent






19. Respondent committed gross negligence in his care and treatment of Patient B which

ncluded, but was not limited to, the following:

(a) Respondent undertook treatment and continued treatment of a family

member, Patient B, over an extended period of time, which included, but

was not limited to issuing numerous prescriptions of controlled

substances;

(b) Respondent repeatedly prescribed controlled substances to Patient B, a

family member, without conducting any good faith examinations;

I /II

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ROY CASS SPRINGER, M.D. - A CCU SA TION NO. 800-2017-032022

(c) Respondent repeatedly prescribed controlled substances to Patient B, a

2 family member, without adequately obtaining, providing and/or

3 documenting, among other things, prior treatment, detailed histories,

4 physical examinations, detailed assessments and treatment plans for

5 presenting problems, detailed analysis of pain and effect on quality of life,

6 informed consent for the controlled substances being prescribed, adequate

7 risk screening measures, and/or specific and complete information for the

8 controlled substances being prescribed;

9 (d) Respondent prescribed controlled substances without adequately assessing

1 O the effectiveness of such treatment;

11 (e) Respondent repeatedly prescribed Soma (carisoprodol) over an extended

12 period of time without adequately documenting why it was necessary, safe

13 and effective to do so; and

14 (f) Respondent repeatedly increased the risk of harm to Patient B by

15 prescribing Soma (carisoprodol) in combination with escalating doses of

16 Norco (hydrocodone/ APAP).

17 SECOND CAUSE FOR DISCIPLINE

18 (Repeated Negligent Acts)

19 20. Respondent is further subject to disciplinary action under sections 2227 and 2234, as

20 defined by section 2234, subdivision (c), of the Code, in that he committed repeated negligent

21 acts in his care and treatment of Patients A, B, and C, as more particularly alleged herein:

22 PATIENT A

23 21. Respondent committed repeated negligent acts in his care and treatment of Patient A

24 which included, but was not limited to, the following:

25 (a) Paragraphs 9 through 16, above, are hereby incorporated by reference as if

26 fully set forth herein;

27 (b) Respondent undertook treatment and continued treatment of a family

28 member, Patient A, over an extended period of time, which included, but

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was not limited to, issuing numerous prescriptions of controlled

2 substances, and failing to actively pursue or consider other conditions or

3 diagnoses including, but not limited to, comorbid depression and anxiety

4 and/or cauda equina syndrome;

5 (c) Respondent repeatedly prescribed controlled substances to Patient A, a





IO informed consent for the controlled substances being prescribed, adequate



13 (d) Respondent failed to document why Physician Assistant K.K. prescribed a

14 higher dose ofhydrocodone/APAP (Norco) and issued a prescription for

15 carisoprodol (Soma) on or about January 3, 2014;

16 (e) Respondent repeatedly prescribed opiates in excessive doses which

17 increased the risk of harm to Patient A;

18 (f) Respondent failed to carefully coordinate and/or document any

19 coordination of care with Dr. B.L.; and

20 (g) Respondent inaccurately charted that Patient A was "using less Norco" on

21 March23,2018.

22 PATIENTB

23 22. Respondent committed repeated negligent acts in his care and treatment of Patient B


25 (a) Paragraphs 17 through 19 above, are hereby incorporated by reference as

26 if fully set forth herein;

27 (b) Respondent undertook treatment and continued treatment of a family

28 member, Patient B, over an extended period of time, which included, but

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was not limited to issuing numerous prescriptions of controlled

2 substances;

3 (c) Respondent repeatedly prescribed controlled substances to Patient B, a

4 family member, without conducting any good faith examinations;

5 (d) Respondent repeatedly prescribed controlled substances to Patient B, a





1 O informed consent for the controlled substances being prescribed, adequate



13 (e) Respondent prescribed controlled substances without adequately assessing

14 the effectiveness of such treatment;

15 (I) Respondent repeatedly prescribed Soma (carisoprodol) over an extended

16 period of time without adequately documenting why it was necessary, safe

17 and effective to do so; and

18 (g) Respondent repeatedly increased the risk of harm to Patient B by

19 prescribing Soma (carisoprodol) in combination with escalating doses of

20 Norco (hydrocodone/ APAP).

21 PATIENT C

22 23. Patient C was a long-term female patient of Respondent's with a multitude of medical

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problems. 16 During the period of on or about January 1, 2014 (when Patient C was 52-years-old)

through December 31, 2014, Patient C had eight visits with Respondent which took place on

January 8, March 3, April 30, May 27, June 30, August 25, October 22, and December 15, 2014.

During this time, Patient C's problems were generally documented as includin_g, but not limited

16 Respondent was unable to recall specifically when he first started treating Patient C but estimated it was sometime between 2005 and 2008. According to Respondent, the earlier medical records were not available because they had been destroyed.

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to, right shoulder pain and lower back pain. In general, Respondent's chart notes were cursory

and routinely failed to adequately document, among other things, prior treatment, detailed

histories, physical examinations, detailed assessments and treatment plans for presenting

problems, detailed analysis of pain and effect on quality of life, informed consent for the

controlled substances being prescribed, adequate risk screening measures, and/or specific and

complete information for the controlled substances being prescribed. According to the CURES

report for patient C, she filled numerous prescriptions from Respondent in 2014 for various

controlled substances including, but not limited to, phentermine, 17 OxyContin, morphine sulfate, 18

modafinal, 19 and lorazepam.20

17 Phentermine HCL (Lonamin®, Fastin®, Adipex®), an anorectic, is a Schedule IV controlled substance pursuant to Health and Safety Code section 11057, subdivision (f), and a dangerous drug pursuant to Business and Professions Code sect'ion 4022. When properly prescribed and indicated phentermine HCL is used as a short term adjunct in a regiment of weight reduction based on exercise, behavioral modification, and caloric restriction. According to the DEA fact sheet for anorectic drugs, phentermine can produce amphetamine-like effects and is frequently encountered on the illicit market.

18 Morphine sulfate (MS Contin®), an opioid analgesic, is a Schedule II controlled substance pursuant to Health and Safety Code section 11055, subdivision (e), and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, it is used for the management of pain that is severe enough to require daily, around-theclock, long-term opioid treatment and for which alternative treatment options are inadequate. The Drug Enforcement Administration has identified oxycodone, as a drug of abuse. (Drugs of Abuse, A DEA Resource Guide (2011 Edition), at p. 40.) The Federal Drug Administration has issued a black box warning for MS Cantin® which warns about, among other things, addiction, abuse and misuse, and the possibility of life-threatening respiratory distress. The warning also cautions about the risks associated with concomitant use of MS Cantin® with benzodiazepines or other central nervous system (CNS) depressants.

19 Modafinil (Provigil®, Alertec®, Modavigil®) is a Schedule IV controlled substance pursuant to Health and Safety Code section 11057, subdivision ( d), and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated it is used to improve wakefulness in adult patients with excessive sleepiness associated with narcolepsy, obstructive s.leep apnea, or shift work disorder.

20 Lorazepam (Ativan®), a benzodiazepine, is a centrally acting hypnotic-sedative that is a Schedule IV controlled substance pursuant to Health and Safety Code section 11057, subdivision (d), and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, it is used for the management of anxiety disorders or for the short term relief of anxiety or anxiety associated with depressive symptoms. Concomitant use of lorazepam with opioids "may result in profound sedation, respiratory depression, coma, and death." The Drug Enforcement Administration (DEA) has identified benzodiazepines, such as lorazepam, as a drug of abuse. (Drugs of Abuse, DEA Resource Guide (2011 Edition), at p. 53.) The FDA has issued a black box warning indicating that concomitant use oflorazepam with opioids "may 1:esult in profound sedation, respiratory depression, coma, and death."

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2 Patient Chad seven visits with Respondent which took place on February 9, March 30, April 27,

3 June 24, August 25, October 14, and December 9, 2015. During this time, Patient C's problems

4 were generally documented as including, but not limited to, neuropathy, shoulder pain, ankle

5 pain, chest congestion, asymmetrical breasts, and vertigo. In general, Respondent's chart notes

6 were cursory and routinely failed to adequately document, among other things, prior treatment,

7 detailed histories, physical examinations; detailed assessments and treatment plans for presenting

8 problems, detailed analysis of pain and effect on quality of life, informed consent for the

9 controlled substances being prescribed, adequate risk screening measures, and/or specific and

1 O complete information for the controlled substances being prescribed. According to the CURES

11 report for patient C, she filled numerous prescriptions from Respondent in 2015 for various

12 controlled substances including, but not limited to, phentermine, OxyContin, morphine sulfate,

13 modafinal, and lorazepam. Respondent's physician assistant, under Respondent's supervision,

14 also issued five prescriptions for Patient C without documentation for the prescriptions.21


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Patient Chad seven visits with Respondent which took place on February 3, March 28, May 18,

July 12, September 14, October 13, and November 9, 2016. During this time, Patient C's

problems were generally documented as including, but not limited to, shoulder pain,

asymmetrical breasts, and narcolepsy. Neurologic, orthopedic and breast surgery consultations

were referenced in the medical records. On July 12, a right shoulder X-ray showed a humeral

head deformity and possible subluxation (paiiial dislocation of the shoulder joint). On November

23, Patient C was seen by a neurologist who performed an EKG/NCV study with diagnoses for

right brachia! plexopathy (a form of peripheral neuropathy) most likely from prior radiation

therapy and carpal tunnel syndrome. In general, Respondent's chart notes were cursory and

routinely failed to adequately document, among other things, prior treatment, detailed histories,

physical examinations, detailed assessments and treatment plans for presenting problems, detailed

21 According to the CURES report, Physician Assistant H.H issued prescriptions for OxyContin, morphine sulfate and/or phentermine on April 3, April 14, April 20, May 11, and May 19, 2015.

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analysis of pain and effect on quality of life, informed consent for the controlled substances being

2 prescribed, adequate risk screening measures, and/or specific and complete information for the

3 controlled substances befog prescribed. According to the CURES report for patient C, she filled

4 numerous prescriptions from Respondent in 2016 for various controlled substances including, but

5 not limited to, phentermine, OxyContin, morphine sulfate, modafinal, and lorazepam.


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Patient Chad seven visits with Respondent which took place on January 3, February 22, April 4,

May 16, June 27, July 25, and November 20, 2017. During this time, Patient C's problems were

generally documented as including, but not limited to, shoulder pain, weight loss, diarrhea, face

rash, and falls. Patient C was hospitalized from March 9 through March 15, with family reporting

altered mentation. During the hospital admission, concern was raised regarding misuse of

prescribed drugs. Patient C was discharged with Megace (appetite stimulant) added, phentennine

discontinued, and morphine dosage reduced. On November 20, Respondent documented "[follow

up] from healthcare center' discharge (without any further details on the specifics) and noted in the

History of Present Illness section of his chaii note that Patient C was "Off of the opioids" and that

she was "Thinking of getting a medical marijuana card to replace other medications." In general,

Respondent's chart notes were cursory and routinely failed to adequately document, among other

things, prior treatment, detailed histories, physical examinations, detailed assessments and

treatment plans for presenting problems, detailed analysis of pain and effect on quality of life,

informed consent for the controlled substances being prescribed, adequate risk screening

measures, and/or specific and complete information for the controlled substances being

prescribed. According to the CURES report for patient C, she filled numerous prescriptions from

Respondent in 2017 for various controlled substances including, but not limited to, phentermine

(last filled on July 19), OxyContin (last filled on June 28), morphine sulfate (last prescription

from Respondent filled on August 2), modafinal (last prescription from Respondent filled on July

25), lorazepam (last filled on August 15), temazepam22 (first filled on September 1), and tramadol

22 Temazepam (Restoril®), a benzodiazepine, is a centrally acting hypnotic-sedative that is a Schedule IV controlled substance pursuant to Health and Safety Code section 11057,

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(first prescription from Respondent filled on November 22).


3 Patient C had six visits with Respondent which took place on January 24, March 26 (nurse

4 practitioner visit), April 9, August 20, October 30, and November 26, 2018. During this time,

5 Patient C's problems were generally documented as including, but not limited to, back pain,

6 injury to ankle, and heart palp_ations. In general, Respondent's chart notes were cursory and

7 routinely failed to adequately document, among other things, prior treatment, detailed histories,

8 physical examinations, detailed assessments and treatment plans for presenting problems, detailed

9 analysis of pain and effect on quality of life, informed consent for the controlled substances being

1 O prescribed, adequate risk screening measures, and/or specific and complete information for the

11 controlled substances being prescribed. According to the CURES report for patient C, she filled

12 numerous prescriptions from Respondent in 2018 for various controlled substances including, but

13 not limited to, temazepam, tramadol, hydrocodone/APAP, and OxyContin (resumed prescription

14 from Respondent beginning November 2).

15 28. Respondent committed repeated negligent acts in his care and treatment of Patient C


17 (a) Respondent repeatedly failed to adequately document physical

18 examinations for the treatment he provided;

I 9 (b) Respondent repeatedly failed to adequately document histories for the

20 treatment he provided;

21 (c) Respondent repeatedly failed to adequately document necessary and

22 specific information for the therapies he provided and/or the controlled

23 substances being prescribed;

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subdivision (d), and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, it is used to treat seizure disorders and panic disorders. Concomitant use oftemazepam with opioids "may result in profound sedation, respiratory depression, coma, and death." The Drug Enforcement Administration (DEA} has identified benzodiazepines, such as temazepam, as drug of abuse. (Drugs of Abuse, DEA Resource Guide (2011 Edition), at p. 53.) The FDA has issued a black box warning indicating that concomitant use of temazapam with opioids "may result in profound sedation, respiratory depression, coma, and death."

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(d) Respondent repeatedly failed to adequately document his rationale for

prescribing two long acting opiates;

(e) Respondent repeatedly failed to adequately document his rationale for

prescribing benzodiazepines concurrently with the opiates he was

prescribing;

(1) Respondent failed to adequately document the care and treatment that was

provided by his physician assistant including, but not limited to, the

prescriptions issued by the physician assistant in 2015;

(g) Respondent failed to adequately document the circumstances of Patient

C's hospital admission in March 2017 and her changes in treatment,

including the discontinuation and/or tapering of controlled substances

shortly thereafter; and

(h) Respondent failed to adequately document his rationale for discontinuing

lorazepam and substituting temazepam in August and September 2017.

THIRD CAUSE FOR DISCIPLINE

(Repeated Acts of Clearly Excessive Prescribing)

17 29. Respondent is further subject to disciplinary action under sections 2227 and 2234, as

18' defined by section 725, of the Code, in that he has committed repeated acts of clearly excessive

I 9 prescribing of drugs or treatment to Patient A as determined by the standard of the community of

20 physicians, as more particularly alleged in paragraphs 9 through 16, above, which are hereby

21 incorporated by reference and realleged as if fully set forth herein.

22 FOURTH CAUSE FOR DISCIPLINE

23 (Failure to Maintain Adequate and Accurate Records)

24 30. Respondent is further subject to disciplinary action under sections 2227 and

25 2234, as defined by section 2266, of the Code, in that he failed to maintain adequate and

26 accurate records in his care and treatment of Patients A, B, and C, as more particularly

27 alleged in paragraphs 9 through 28, above, which are hereby incorporated by reference

28 and realleged as if fully set forth herein.

24


PRAYER

2 WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged,

3 and that following the hearing, the Medical Board of Califomia issue a decision:

4 1. Revoking or suspending Physician's and Surgeon's Certificate Number A 23489,

5 issued to Respondent Roy Cass Springer, M.D.;

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2. Revoking, suspending or denying approval of Respondent Roy Cass Springer, M.D.'s

authority to supervise physician assistan,t§~d advanced practice nurses; :,~~ ·:

3. Ordering Respondent Roy Cass Springer, M.D., if placed on probation, to pay the

9 Board the costs of probation monitoring; and

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4.

DATED:

Taking such other and further action as deemed necessary and proper.

APR 2 2 2020 --------

17 SD2020700552

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