January 16, 2002
AUDIOTAPED MEDICAL BOARD INTERVIEW WITH
TOD MIKURIYA, M.D.
MEDICAL BOARD INVESTIGATOR - TOM CAMPBELL
Dr. Schneider - Medical Board Consultant
John L. Fleer - Defense Attorney for Tod Mikuriya, M.D.
Susan Lea - Attorney for Tod Mikuriya, M.D.
Verbosity Transcription Services
782 Caliente Ave.
Livermore, CA 94596
Mr. Campbell: With me today is Dr. Schneider, a medical consultant for the
Board. The purpose of our meeting today is to take an interview with Dr. Mikuriya,
who is responding to a subpoena. With him are two attorneys, Mr. John Fleer
- F-l-e-e-r, and Ms. Susan Lea - L-e-a. Is that correct?
Ms. Lea: Yes.
Mr. Campbell: Okay. A couple of ground rules. Number one is that we are recording this conversation, so we all need to speak up if we are to be put onto the recording. Secondly, is that I need to remind Dr. Mikuriya that he is here pursuant to the service of a subpoena; that he is expected to testify as under oath; and to be truthful and honest in his answers. I have discussed the ground rules briefly outside of the recording with both attorneys that Dr. Mikuriya clearly understands that he is to answer the questions and his attorneys may raise objections as they feel necessary and, if necessary, may consult with their client outside of the recording. Any questions?
Ms. Lea: Not yet.
Mr. Fleer: Well, just for the record, I do want to note that Dr. Mikuriya's request to videotape the interview has been denied and that he is going to record by audio only with the use of his video camera. I don't know if he is going to catch it all - if he has enough tape. In any event, I request that we receive a copy of your tape as soon as that is reasonably possible.
Mr. Campbell: That's agreed.
Ms. Lea: I would also like to put on the record that everybody understands that they are being taped by us.
Mr. Campbell: Dr. Mikuriya, just for purposes of identifying on the tape, your age is?
Dr. Mikuriya: Sixty-eight and a half.
Mr. Campbell: And your date of birth is?
Dr. Mikuriya: 9/20/33.
Mr. Campbell: Okay.
Ms. Lea: Are you going to ask me mine?
Mr. Campbell: No. First of all, I would like to get some basic idea of what your practice is about. Yesterday on the computer you have been so kind as to list you Curriculum Vitae on the internet. We have downloaded that. Is that true and correct?
Ms. Lea: I am going to object to this line of questioning because we went through extensive - in September of last year - extensive amounts of discussion about Dr. Mikuriya's practice, and as we were just noting outside before we came into the room Mr. Campbell, we are here to respond to specific questions that you have about the 47 patient records that you have obtained by subpoena. That's why we are here. You have in your history and the previous transcript of the previous hearing, and then the Marinol hearings, and then too, all kinds of information about Dr. Mikuriya's practice and information about what he has been doing within the context of the kind of cases these 47 patient files represent. So, we would like to respond to specific questions that you have now that you have had a chance to review those files. I object to him, Dr. Mikuriya, revisiting these same issues that we have already visited.
Mr. Campbell: Okay. Your objection is noted.
Ms. Lea: Although . . .
Mr. Campbell: Unfortunately, I am not privy to that information; that is of a different investigation, and I would like to know from Dr. Mikuriya for this investigation. That took place over a year ago and as I said, your objection is noted, and we will continue with talking about . . .
Ms. Lea: Well, I am going to instruct him not to answer, and I will instruct you . . .
Mr. Campbell: Excuse me, Ms. Lea.
Ms. Lea: He is under no obligation to answer your questions.
Mr. Campbell: Yes Ma'am, he is. He is here under subpoena. He is required to provide testimony.
Ms. Lea: Well . . .
Mr. Campbell: If you instruct your client not to answer the questions . . .
Ms. Lea: I made it very clear to you Mr. Campbell, Dr. Mikuriya is here to answer any questions you may have about the 47 patient records that you had subpoenaed, and that is the purpose of the subpoena. I have been in litigation in Sacramento on the purpose of this subpoena for some months, so I think I have a fairly clear understanding of why we are here. Now, Dr. Mikuriya has a public website. You have said you visited it.
Mr. Campbell: Um hum.
Ms. Lea: There is a transcript on that website that gives you a full and complete read-up of everything that was said in the hearing in this room in September of "99," and please be aware that you are, that we are putting that, that's available to you and you have said you visited it. So, we are not going to go back there.
Mr. Campbell: Ms. . . .
Ms. Lea: We are specifically, and this subpoena specifically is involved with answering questions relative to those 47 patient files. That is what we are here to do.
Mr. Campbell: You objection is noted. Let me ask my questions, and if you object to the questions and you want to instruct your client not to answer them, then that is fine.
Ms. Lea: I will certify those questions. If you want to go back to court on those questions, we are happy to do that.
Mr. Campbell: Dr. Mikuriya, I have downloaded from your website, your CV. Is that accurate? Is it complete? Is it correct?
Dr. Mikuriya: It is correct to a point. The previous positions are indeed correct, but some of the present positions and appointments need to be updated.
Mr. Campbell: Okay. Could you elaborate on which positions need to be updated? Do you have a copy of the . . .
Dr. Mikuriya: Yes, I have a copy of what you downloaded; okay, I am still a psychiatrist in private practice in Berkeley doing medical/psychiatric consultations. I am still a member of the City of Oakland Medical Marijuana Working Group, and we continue to meet to develop standards for the City of Oakland. No longer an attending psychiatrist at Eden Medical Center in Laurel Grove.
Mr. Campbell: Laurel Grove? (*)
Dr. Mikuriya: Correct. I continue to maintain my position on the Vencor Hospital staff, although it has been renamed to Kindred Hospital - Bay Area.
Mr. Campbell: Hum, I didn't know that.
Dr. Mikuriya: These things keep changing.
Mr. Campbell: That is exactly why I have asked to expand on that. These things change.
Dr. Mikuriya: I am still attending psychiatrist at San Leandro Hospital, but no longer am an attending psychiatrist at St. Anthony's Vintage Estates, Courtyard Care Center, Parkview, or the Convalescent Village. I am a consultant at St. Thomas Anthony's Rehabilitation Hospital in San Pablo. I continue to be a Medical Coordinator for various cannabis centers, but they come and go. I am still the coordinator for the Berkeley Cannabis Buyers Cooperative and CHAMP in San Francisco, but I am no longer associated with Humboldt Cannabis Center in Arcada, nor the Hayward Hempery. I am the Coordinator for a new dispensary up in Ukiah, but right now the name slips my mind. My list of publications contains a lot more items that can be read from a different portion of the website. I think there is a specific page on publications.
Mr. Campbell: The training and so forth that is depicted on the first page or so of the CV appears to be . . .
Dr. Mikuriya: Yes, this appears to be . . .
Mr. Campbell: Are there any additions to your status in training or seminars and so forth that you have attended? I know in our previous conversations, you indicated that you had gone to Germany to provide some training?
Dr. Mikuriya: I was going to a conference, the first conference of the International Association for Cannabis as Medicine. I have also presented at the National Clinical Conference for Cannabis in Iowa City in 2000. Also at the NORML, National Organization for Reformed Marijuana Law's conference last - I believe it was - last May. Also the International Cannabanoid Research Society meetings - 1999, 2000, 2001, making clinical presentations there for describing specific clinical applications for cannabis.
Mr. Campbell: Okay. Your current practice is located at?
Dr. Mikuriya: I see very few patients at my office at [redacted] in Berkeley.
Mr. Campbell: That's also your home address?
Dr. Mikuriya: That is also my home address, but I maintain all my administrative activities there, which are fairly significant because . . .
Ms. Lea: I am going to object at this point and instruct you not to answer and certify this question as to any further response. It is not relevant to the subject matter of the subpoena where he is seeing patients.
Mr. Campbell: I accept your objection but, if you want to discuss it with your client, feel free to do so. We will turn off the tape and you folks can go outside and discuss it. Until then, I want Dr. Mikuriya to answer the questions.
Ms. Lea: If I instruct him not to answer, he is not going to answer.
Mr. Campbell: Fine, but I am still going to ask the questions.
Ms. Lea: Please. Put it on the record.
Mr. Campbell: Okay. As you indicated, your practice is basically administratively out of your home office?
Dr. Mikuriya: Yes.
Mr. Campbell: Do you practice any place else?
Ms. Lea: I am instructing - that's the same question - I am instructing him not to answer.
Mr. Campbell: Okay. You have indicated in reviewing your CV that you have associations with various hospitals and so forth. Do you practice at these locations?
Ms. Lea: Basically, that has been asked and answered. You went through your CV. You have explained where you are practicing. To that respect . . .
Mr. Campbell: Ms. Lea, please, if you want to make an objection, merely state that you have an objection to it, or that you are instructing your client not to answer.
Ms. Lea: Don't tell me what to do or what not to do Mr. Campbell. Don't tell me what to do or what not to do.
Mr. Fleer: I think she is making her objection and stating the grounds.
Ms. Lea: And, that is what I am required to do. I am putting my objection on the record and am explaining exactly why I am objecting. Do not interrupt me. Thank you.
Mr. Campbell: Dr. Mikuriya, would you describe your current practice please?
Ms. Lea: I am going to object again and instruct the witness not to answer. You can certify that question. We have 47 patient files here to get through. If you would like to start on that, we would be happy to talk about that.
Mr. Campbell: Okay. Dr. Mikuriya, is your practice today based on psychiatry or general medicine?
Ms. Lea: I am objecting again to the argumentativeness and the leading nature of this question and am instructing my witness not to answer. Please certify the question. Again, please get onto the relevancy of this subpoena.
Mr. Campbell: Okay, we are not getting anyplace. Let's go for the first person.
Dr. Schneider: Okay. Generally what I like to do when I interview a physician is to get a little bit of a summary. Now, did you bring your own copies?
Dr. Mikuriya: No.
Dr. Schneider: Of the patient files? Then what we do is look at them together, and we are going to start alphabetically. Some of the basic questions I usually ask is for you to briefly, very briefly - obviously there are a lot files to get through - very briefly describe, if you know, how this patient came to you, the referral, what the extent of your contact with the patient was, length of time they were your patient, and their major medical problems. So, we will start with [redacted], who is the first patient alphabetically.
Ms. Lea: I am going to make a general objection before we get started on this part of the testimony that the documents speak for themselves. I am going to object to the extent that the documents speak for themselves. In every instance the patient files themselves are the primary evidence, and they speak for themselves.
Dr. Mikuriya: I have seen [redacted] since 3/5/97, with his last visit entered in the Access database of 3/22/00, but there has been continuing communication with Mr. Aames, and I have testified on his behalf in Sacramento as an expert witness defending his claims for medical marijuana needs and his responses.
Dr. Schneider: What I am particularly interested in - obviously the notes are legible and there is lots information. There is typed information. What I am particularly interested in, as in all interviews, are anything that you think is pertinent because we will have the cases reviewed by an outside expert. So what I am interested in is anything that you think is pertinent for a reviewer to know; things that are not written in the chart because obviously no physician can write down everything that is said on either side of what the patient said to you, or what you said to the patient, nor do we always write down our though processes. For an expert to know why you arrived at the decisions that you made, whether it is a diagnosis or a recommendation. If there is something - I will ask you specific questions, but if there is something that you think is pertinent to be known, this is your opportunity to sort of fill in the blanks, talk about your rationale, and to give us any additional information that you didn't have the time to write down or, for whatever reason ,didn't put in the record. That is sort of the thrust of my questions. Now, if there is something you recall about [redacted], or what to say about [redacted] from a medical standpoint, I think the legal stuff we can just leave aside. I am not an attorney, I am here to ask questions about the medical stuff.
Mr. Fleer: Just a moment doctor, I'll object to that formally as being overbroad. Dr. Schneider, I understand the approach that you are suggesting and I think it is a reasonable one in many contexts; in this one however, since as Mr. Campbell has pointed out, this is under subpoena, this is under oath. Leaving it to the doctor to bring up things that he thinks are important, I don't think that is the proper format for this proceeding. I do think that your three questions, even though its calling for a bit of a narrative. Maybe that is the best place for Dr. Mikuriya to start to answering those three. Do you have those in mind doctor?
Mr. Campbell: I think what counsel is referring to is he would prefer for us to ask direct questions as to each patient, rather than a narrative. Is that right?
Mr. Fleer: And I was even offering that I thought asking how the patient was referred, or how that person came to Dr. Mikuriya, the time of which you have had contact with that patient, and what their medical problems were would be a good starting point.
Dr. Schneider: What I said was to set the stage for whatever information comes out. Obviously there is a lot here to go through. We don't need to read each other things that are already written down. But, I am going to get to the question of why certain decisions were made, and that's part of what I ask every physician whom I interview; what is your differential diagnosis, if it is pertinent, how did you arrive at it, and what treatment did you advise and why. So yes, it was very broad, and it was intended to be very broad because that is sort of the basis from which I am approaching the discussion. So, if you either recall or can tell by your record the answer to the first question; if you have a place in your record where you put how the person came to you, I'd be happy to have you look at that; tell us if you don't know, that is also fine.
Dr. Mikuriya: He self-referred to me.
Dr. Schneider: Self-referral, okay. And then you have already given us the dates from 97 to the year 2000 with some ongoing communication afterward?
Dr. Mikuriya: Yes.
Dr. Schneider: And his major diagnoses?
Dr. Mikuriya: General anxiety disorder. I don't know, it verges on major depression, but this is a very complicated case and, unfortunately, I don't have all the pages in the original form because they were somehow accidently given to the prosecutor in Sacramento that was prosecuting him for cultivation, and it has really been a terrible situation for [redacted] since then, this missing information aside, that [redacted] is currently, I believe, starting to have serious mental disorders far away from home in Holland because he has failed to show up for a Sacramento court hearing to appeal and, as a result, left the United States. He continues to send me frantic e-mails with regard to his continuing problems. He is exhibiting more specific psychiatric symptoms than when we first met. When we first met, he was extremely anxious and experiencing difficulties with different employers where he was working as a computer specialist with significant insomnia, depression, feelings of discomfort and anxiety, and fearfulness which were drastically aggravated by his brush with the law in Sacramento. I have been trying to be supportive towards him, and even have offered to send him plane tickets to come back to the United States to possibly get treatment, but he is so realistically fearful that if he comes back, he is going to be ending up in jail in Sacramento. My heart goes out to him, but I can't do anything more for him at this point.
Dr. Schneider: Are these plane tickets at your own expense?
Dr. Mikuriya: Yes, because I am worried about his condition.
Ms. Lea: Just to recap, are you saying documentation is missing from this file because it was handed to the DA in the case in Sacramento and not returned?
Dr. Mikuriya: That is correct.
Ms. Lea: Okay, so this file is not as complete as it was at the time of the original hearings for [redacted]?
Dr. Mikuriya: I wish it was. Yes, and I think I mentioned it to you Mr. Campbell about . . .
Mr. Campbell: Indeed Dr. Mikuriya did. In our last conversation - I checked my file - I do not have any documents that were provided by the Sacramento District Attorney's Office, other than the actual recommendation approval which is the subject of our conversation.
Dr. Mikuriya: Okay, because I specifically brought this up with [redacted] in an e-mail saying that I would appreciate certain kinds of information to fill in the blanks that I needed in order to make the chart complete. His was a very angry response where he made this allegation that Delbert Deloro, the Assistant DA in Sacramento said that he had it on the record and that he laughed when [redacted] wanted it back. We would have to go and revisit that transcript in Sacramento.
Mr. Campbell: Just to recap what you are saying here, some of the records involving [redacted] are no longer in your possession, and this is a copy of his file that is currently in your possession?
Dr. Mikuriya: As much of it as there is, yes.
Dr. Schneider: Is there a copy of the original recommendation?
Dr. Mikuriya: Might be. That's there.
Dr. Schneider: I see a 98.
Mr. Campbell: I have a copy of the recommendation that was provided by the Sacramento Police Department, not the District Attorney's Office that is dated 3/5/97. Is that the same date?
Dr. Mikuriya: Same date, yes.
Dr. Schneider: I have one that is in 98.
Dr. Mikuriya: Well, I had given him updates. In continuing relationships, I really strive to do regular follow-ups and updating of his letter of recommendation and approval.
Dr. Schneider: This 98 one lists gastritis and anxiety disorder. When you are completing this portion Dr. Mikuriya, is this written in a specific order? For instance, is this the primary diagnosis and that the secondary diagnosis?
Dr. Mikuriya: It is very difficult to do that . . .
Dr. Schneider: One would infer that . . .
Dr. Mikuriya: No, you can't, because frequently you have somatic symptoms presenting representing the underlying anxiety process. This is where we got into it with the DA in Sacramento who is attempting to separate this. It is just terrible; you can't do that.
Dr. Schneider: Why don't you tell us what you mean by what you wrote there?
Dr. Mikuriya: Gastritis, anxiety disorder, he was having symptoms of dyspepsia, indigestion, nausea, fullness, and at the same time, anxiety disorder with his persistent anxiousness,which was responding to all these different things happening in his life.
Dr. Schneider: Were other treatments tried?
Dr. Mikuriya: No.
Dr. Schneider: Did he have another psychiatrist or have any prior history of treatment for anxiety?
Dr. Mikuriya: No.
Dr. Schneider: What was your recommendation to him?
Dr. Mikuriya: That he should utilize cannabis through the inhaled route and, if possible, to find an oral preparation and, even better, vaporize so that he could avoid irritation to his throat and lungs. Also, part of the treatment was making myself available as an expert witness in his corner, which he utilized. I continue to want to do whatever I can to help him in his continuing difficulties. I am one of, I think, the two people that he trusts in the United States. He is continuing to be very fearful and isolated in Holland. I am worried about him. I am afraid that he may be starting to decompensate and start to show certain kinds of psychotic symptoms because his last e-mail was inappropriate.
Dr. Schneider: As far as the diagnosis of anxiety, you described it as being persistent anxiousness. Are there other things that you recall about his history?
Dr. Mikuriya: Chronic insomnia.
Dr. Schneider: Did you make other recommendations, as far as sort of mental hygiene type of recommendations?
Dr. Mikuriya: I believe that I recommended that he get a regular massage.
Dr. Schneider: Are there any other - and this is where my sort of open-ended question was - is there anything else of that nature that you want us to know as far as the things that you did diagnostically, things that you entertained as other diagnoses, other recommendations that you made that you might not have recorded, and other treatments that you considered and eliminated, either in discussion with him or in internal dialog?
Dr. Mikuriya: Well, my relationship with him also included discussing his case with his mother with whom he was living near Sacramento, and she is also a patient of mine. She has chronic depression and serious lower back problems which diminish her mobility. [redacted] was having to take care of her needs as well, so I was involved informally doing family therapy.
Ms. Lea: Excuse me, do you need some water? Do you mind?
Dr. Mikuriya: Back on the record.
Mr. Campbell: Okay. We have been off tape for a few minutes so that Dr. Mikuriya could get some water. It is 12:13, and we are back on the tape. Ms. Lea is absent for a few moments, and we will continue on in her absence. Dr. Schneider?
Dr. Schneider: You were just telling me that you had done informal family therapy with this patient and his mother?
Dr. Mikuriya: Yes.
Dr. Schneider: Relating to other stressors and his anxiety disorder?
Dr. Mikuriya: Yes.
Dr. Schneider: The other part of my question about other treatment modalities that you have offered him, emotional support, family therapy, the suggestion of massage, is there any other. . .?
Dr. Mikuriya: Being there for him legally.
Dr. Schneider: Right, which was the source of some of the stress? Did his stress, his anxiety disorder predate his legal difficulties?
Dr. Mikuriya: Yes.
Dr. Schneider: Do you know how far back?
Dr. Mikuriya: Years.
Dr. Schneider: Do you know the extent of it, whether he has panic attacks?
Dr. Mikuriya: Panic attacks and persistent insomnia, and ongoing problems with keeping a job with different companies that he worked for.
Dr. Schneider: Is there any question of personality disorder?
Dr. Mikuriya: Oh yes, definitely a question of personality disorder.
Dr. Schneider: Does he have other psychiatric diagnoses?
Dr. Mikuriya: I have been loathe to put other psychiatric diagnoses on his chart because the potential negative or adverse consequences. Especially in light of his response to loneliness and stress.
Dr. Schneider: As I said, if there is something, anything else that you think would be helpful to a reviewer, a psychiatrist or an expert reviewer as far as - and I think this is important to come out - that you have considered the question of personality disorder in this patient . . .
Mr. Campbell: Switching to Side 2 of the first tape. I hope. I'll let Dr. Tod work this thing. He is probably better at it than me.
Dr. Mikuriya: It's telling me it wants a new battery.
Dr. Schneider: One thing Tom, is if . . .
Mr. Campbell: Are we ready to go back on tape?
Dr. Schneider: Hold on just a second. This is good for us too. If you put it back on 1 and run it all the way to the end, because there is a big gap of blank tape so if you . . .
Mr. Campbell: So, if I put it on 2 and rewind?
Dr. Schneider: Yeah, whichever way you get it to the cue up to the beginning.
Mr. Campbell: I see what you are saying here.
Dr. Schneider: Do you need a plug? I don't know that there is one on that side of the room. We could run it under the table.
Mr. Campbell: There is a plug over here. Will it reach? Are we ready? It looks like we are recording now. It is 12:38 and we are going back on tape.
Dr. Schneider: I was asking - there is a question apparently of his having peptic ulcer disease. Do you know anything about his follow-up with other physicians?
Dr. Mikuriya: No I do not. I just know about the original work-up that was supplied to me.
Dr. Schneider: Did you speak with any other . . .?
Dr. Mikuriya: No, however I reviewed the written report of the procedure.
Dr. Schneider: What is your practice Dr. Mikuriya, as far as contacting other treators?
Dr. Mikuriya: I make myself available to contact, to be contacted by them, and with suitable release of information by the patient and request, I will contact another physician if so asked.
Dr. Schneider: Did you make any other recommendations to him as far as diet, general recommendations, other than your recommendation for cannabis?
Mr. Campbell: You always wonder if those things are really working or not.
Mr. Fleer: Well, we have a backup this time.
Dr. Mikuriya: We will be glad to give you a copy of it. Well, my last visit with him, I recommended that he do vaporization to avoid or minimize irritation to his throat and lungs.
Dr. Schneider: Do you know if he was having symptoms of irritation?
Dr. Mikuriya: No, but I assume that this chronic condition that he has had for many years in not going to somehow magically go away. It is a chronic state that is familial in its origin and probably will require continuing monitoring and his discovering what it is that in fact will aggravate his symptomatology so that we can develop strategies over the years to manage these kinds of conditions.
Dr. Schneider: I am not certain I understand?
Dr. Mikuriya: Things aggravate your symptoms, and what are you doing to not do it.
Dr. Schneider: Did you ask that of [redacted]?
Dr. Mikuriya: I don't see that I recorded or memorialized it.
Ms. Lea: But there is no reason why you wouldn't have just because you didn't write it down in the patient record?
Dr. Mikuriya: That is true.
Dr. Schneider: So, with a patient with gastritis, your customary practice would be to ask them what aggravates it and what are you doing to change that?
Dr. Mikuriya: Correct.
Dr. Schneider: How long was your initial encounter with him?
Dr. Mikuriya: I don't know, probably 15-20 minutes.
Dr. Schneider: And the follow-up?
Dr. Mikuriya: Same.
Dr. Schneider: Do you have any questions? Anything else you want to add?
Dr. Mikuriya: No I don't.
Mr. Campbell: No I don't. Okay the next patient I have here is [redacted].
Dr. Mikuriya: Oh yes.
Dr. Schneider: Do you have an independent recollection of [redacted]?
Dr. Mikuriya: Vividly.
Dr. Schneider: Okay.
Mr. Fleer: It sounded like you did.
Dr. Schneider: That's right.
Mr. Campbell: I don't know if that's good or bad.
Dr. Mikuriya: Well, it just is. This is the nature of the way people present.
Dr. Schneider: First we can address those three questions of how she came to you, if you know?
Dr. Mikuriya: She was self-referred.
Dr. Schneider: The extent of your contact?
Dr. Mikuriya: We had one initial meeting and, let's see, and some other interactions over her continuing difficulties with the law. Her diagnosis was PTSD.
Dr. Schneider: Her initial diagnosis?
Dr. Mikuriya: Yes.
Dr. Schneider: Her first visit? What year was that?
Dr. Mikuriya: It was 8/9/97. I have not had any contact with her since.
Ms. Lea: That was the first and last visit in 97?
Dr. Schneider: What's the basis of . . .
Dr. Mikuriya: Wait, wait, what is the basis, chronic depression recurrent was what her complaint was and she also had a history of recurrent irritable bowel for previous ten years with nausea, vomiting , diarrhea, secondary to anxiety and depression.
Dr. Schneider: Are there other manifestations with the PTSD?
Dr. Mikuriya: Okay, her history with her coming from an abusive family. . .
Dr. Schneider: And that's in the chart?
Dr. Mikuriya: I'm sorry?
Dr. Schneider: Are you finding that in the chart?
Dr. Mikuriya: Yes. Because when I started including an item in my questionnaire which asks, "are you an adult child of an alcoholic or abusive family," and her answer was "yes." This is very typically a progenitor of lifelong problems including symptoms of PTSD and other significant disturbances. I performed a more formal mental status examination with her because of her psychiatric difficulties. She was recently arrested and detained, complaining of nightmares and panic attacks in her involvement with efforts to start a cannabis center in Arcada.
Dr. Schneider: When you describe a more formal mental status, if you could just say a little bit more for us, what that entails?
Dr. Mikuriya: Well, going down a check list, including communication barriers, mobility, dependency level, appearance, orientation, speech, whether or not there are hallucinations or delusions, cognition, memory, intellectual level, functioning, insight, affect and mood, this goes into a more differentiated diagnosis psychiatrically with both her symptoms of depression, which I diagnosed as dysthymic disorder and acute Post-traumatic Stress Disorder. She also, even though I deferred the personality diagnosis. Again, I don't like to put personality diagnoses in the chart because of potential pejorative connotations and problems. She also had a physical diagnosis of sciatic injury on her right and soft tissue injuries.
Dr. Schneider: You are referring to a written or typed mental status form. Is this something that - I haven't seen this in other charts - this is something you are using selectively?
Dr. Mikuriya: Selectively, when I feel issues of serious mental illness are involved, or whether or not they have a compensation case or an injury kind of thing that might need to be documented or referred to later on, I go through that.
Dr. Schneider: Could you estimate how long your initial evaluations occur?
Dr. Mikuriya: With this lady? About an hour.
Dr. Schneider: I have a question about, again, about what her recommended follow-up was?
Dr. Mikuriya: Come back as needed.
Dr. Schneider: PRN. And, any other recommendations for her other than the cannabis recommendation?
Dr. Mikuriya: I gave her a certificate of condonement for cannabis. I was still struggling with myself as to how to word the recommendation and approval and was criticized by certain patients for it not being in compliance with the wording of the law, which gave people opportunities to discount it and say that it was not a legal document.
Dr. Schneider: But that was what you were using at the time?
Dr. Mikuriya: Yes.
Dr. Schneider: How about any other recommendations as far as either behavioral or medicinal?
Mr. Fleer: Lifestyle?
Dr. Schneider: That sort of thing?
Ms. Lea: Redo your childhood. Go back, start over.
Dr. Mikuriya: Well, because of her presentation of being quite negative, argumentative and paranoid, and accusing people of different kinds of things, she had really isolated herself and didn't have anybody that she could count on for support in her continuing struggles with the [redacted] authority. She unfortunately became even more threatening and abusive and violated the restraining orders. This ended up with her being incarcerated for a period of time. I think that I was aware of this underlying significant disturbance at the time because of my memorializing a relatively formal mental status examination.
Mr. Campbell: Do you know if her troubles with the law enforcement agency predated your first seeing her?
Dr. Mikuriya: Predated? Yes.
Mr. Campbell: So, she was having . . .?
Dr. Mikuriya: Having these problems before.
Mr. Campbell: Do you know what those problems were about?
Dr. Mikuriya: I do not know.
Ms. Lea: You mentioned Temporary Restraining Orders. Do you know if those existed prior to your seeing her?
Dr. Mikuriya: I think I had heard just by rumor, later, about all these other kinds of problems, but this was after I had seen her and given the recommendation.
Dr. Schneider: I would like to ask a more general question but, first, I'd like to ask a more specific question. In her case, was there any reservation about giving her the certificate of condonement?
Dr. Mikuriya: Not at all.
Dr. Schneider: Okay. Maybe you could go into, should go into your . . .?
Dr. Mikuriya: She discovered that cannabis really helped her with emotional control. Without it, she just really would become highly angry, abusive, and cause herself even more grief. It is clear from her difficulties that cannabis would not really do the trick. It was not as adequate as it could be, but knowing her, the chance of her being willing to take any other psychotropic prescribed medication would be zilch.
Dr. Schneider: Did you discuss that with her?
Dr. Mikuriya: Yes.
Dr. Schneider: Could you describe that to us?
Dr. Mikuriya: Well, she was categorically opposed to any "chemicals," and just wanted to utilize "organic" remedies.
Dr. Schneider: Do you know if she had been treated in the past with psychotropics?
Dr. Mikuriya: No, because of her alcoholism before that, and because of making her condition even worse with misusing alcohol. This is so common with people with abusive or alcoholic families that they don't know any better really. So they use alcohol which aggravates their problems. I am so glad when I can switch somebody away from alcohol and to substitute cannabis. As a matter of fact, I presented a paper on that in Berlin just this last October on 104 patients in my practice.
Dr. Schneider: Could you make that available to us?
Dr. Mikuriya: Sure.
Mr. Campbell: It's not on the internet?
Dr. Mikuriya: No. Oh, it's on the internet, but it's prettier if I send it to you. The resolution on the internet is not very nice sometimes.
Dr. Schneider: Do you know if she had been in psychiatric treatment before?
Dr. Mikuriya: Not to my knowledge.
Dr. Schneider: Or been hospitalized?
Dr. Mikuriya: Not to my knowledge.
Dr. Schneider: As far as your sense - and I understand now how you are reconstructing your assessment that there was something more complicated - because this patient has a complete mental status documented and the prior two or three don't. You said that you had absolutely no reservation about your cannabis recommendation because you have explained that to us. I don't know how to phrase this - what did you intend to do with your other hunch or intuition about the possibility of more significant or a more serious problem?
Dr. Mikuriya: There was really nothing that could be done given her circumstance, given her existing support network, given her geographic location and the mental health resources in the community.
Dr. Schneider: Or lack thereof.
Dr. Mikuriya: Or lack thereof.
Mr. Campbell: Geographical location meaning the distance between . . . ?
Dr. Mikuriya: No, if she were closer to the Bay Area or to an urban center, there would be a better chance of having the kinds of mental health resources available. But, you go up to Humboldt County, and there isn't very much. Go up beyond Humboldt County, and its even worse.
Dr. Schneider: So there is no county mental health?
Dr. Mikuriya: Yes, but its spread very thin, and a person has to be willing to accept help. With her abrasive, confrontational personality, this just wasn't going to happen.
Mr. Campbell: If her personality is such, how is it she came to see you?
Dr. Mikuriya: Because she wanted to get a letter of recommendation and approval so that she could get her medicine legally.
Mr. Campbell: I see. So the sole purpose of her coming to see you then was to get a recommendation?
Dr. Mikuriya: Yes.
Dr. Schneider: The question of paranoia - and this is something I am interested in - in your experience, have you seen people get more paranoid under the influence of cannabis?
Dr. Mikuriya: Yes and no.
Dr. Schneider: If you would just elaborate briefly?
Dr. Mikuriya: Yes, for neophyte users and for people that have certain kinds of sensitivities to cannabis, but no, because I have quite a few paranoid patients and people that suffer from paranoid schizophrenia that have discovered that cannabis can control the paranoia and permit them to have emotional contact with others. This has not been written up in any journals which . . .
Dr. Schneider: Are you able to distinguish who is going to have that paranoid reaction? Can one anticipate?
Dr. Mikuriya: The people coming to me will not have that paranoid reaction because they come to me because they want to take it to self-medicate. If they experience this kind of paranoia, they certainly wouldn't be coming in to ask me for a recommendation and approval for this.
Dr. Schneider: Do you do any sort of informed consent or disclosure about the possibility of paranoia?
Ms. Lea: I am going to object to the extent that there is no foundation in here that in fact . . . Okay, you are asking questions based on the assumption that you have sort of briefly stated. There is no foundation that has been laid that in fact there is any statistically significant percentage of people who do cannabis that get paranoid.
Dr. Schneider: Why don't you - I'll ask specifically about her, and then we will generalize it of what you do tell folks, what you told her, understanding that she was not a neophyte. Did you tell her anything as far as watch out for so and so? If I prescribe penicillin to somebody, I would say, here, this is for your throat infection, but if you get a rash, call me.
Dr. Mikuriya: I usually say avoid alcohol with people like this.
Dr. Schneider: So, do you have reason to believe that you told her that?
Dr. Mikuriya: I have reason to believe that in fact I did tell her that.
Dr. Schneider: Okay. So your warnings would have been specifically to avoid alcohol? Anything else you told this particular patient?
Dr. Mikuriya: Time out for a second.
Dr. Schneider: Sure.