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February 6, 2002


AUDIOTAPED MEDICAL BOARD INTERVIEW WITH
TOD MIKURIYA, M.D.
PART II

MEDICAL BOARD INVESTIGATOR - TOM CAMPBELL


Also Present:
Dr. Snyder - Medical Board Consultant
John L. Fleer - Defense Attorney for Tod Mikuriya, M.D.


Marcia Schuyler
Verbosity Transcription Services
782 Caliente Ave.
Livermore, CA 94596
925.454.3258

(TAPE 1)
Mr. Campbell: Today is February 6th; it is Wednesday, the year 2002. My name is Tom Campbell, investigator for the Medical Board, and I am at the Pleasant Hill Medical Board office on the second portion of an interview with Dr. Tod Mikuriya. Present is Dr. Mikuriya, Dr. Snyder, the Medical Board's consultant, and Dr. Mikuriya's attorney, Mr. John Fleer - F-l-e-e-r, is that correct?
Mr. Fleer: Yes.
Mr. Campbell: Okay. I want to remind Dr. Mikuriya that he is here pursuant to the court order that was issued to support the subpoena out of Sacramento County. In that regard, I think we can probably regress and go back over a couple of things that we wanted to talk about last week. Dr. Mikuriya, during our last meeting as we didn't get too far into the issue of a description of your practice, I kind of wanted you to clarify a few things. Your other attorney, Susan Lea, has opted - apparently from what you told me before we went on tape - not to be here today. She and you are depending on Mr. Freer. Is that correct?
Dr. Mikuriya: Mr. Fleer, yes.
Mr. Campbell: Fleer.
Mr. Fleer: People mess mine up all the time.
Mr. Campbell: We do all understand that we had some problems with the recording of our last and first portion of our interview. Today I think we have three different recording devices going on the table, so it's clear to everybody that we are all attempting to record this interview.
Dr. Mikuriya: At least in audio.
Mr. Campbell: Right, an audio recording. I stand corrected. In regards to your practice, during our last meeting you indicated that your office was at your home, and that is in Berkeley, Cal. Is that right?
Dr. Mikuriya: Yes.
Mr. Campbell: And do you see patients other places?
Mr. Fleer: I thought we went over that before too?
Dr. Mikuriya: Right. This not nearly pertains to the quality of care in any of the cases that are in question.
Mr. Campbell: Let me ask Mr. Fleer if he has seen the court order out of Sacramento County?
Mr. Fleer: Yes I have. I guess I am interpreting from what you said a moment ago that it is your desire to ask the same questions that were objected to before, primarily by Ms. Lea, and I have no intention of taking any different position than Ms. Lea has taken on behalf of Dr. Mikuriya. On the contrary, I think she is right insofar as there were objections based on questioning that was related to matters other than the 47 files that were subject to subpoena. I was just looking for my copy of the subpoena again which Ms. Simon did provide me so I could recite some of that, but it seemed to be very clear when I reviewed it that Dr. Mikuriya is compelled to give testimony about those 47 treatment files. There is nothing that I recall in the subpoena at all saying a broader scope of inquiry is required. I think Dr. Mikuriya is in the position that anybody is in, in terms of these interviews. He has discretion as to whether he wants to be interviewed about other matters. I think last time, while we had a slow start which I hope we are not having again today, we were really able to start getting through those files in a pretty efficient manner, once we got started. That's the expectation that I came in with today was that we would pick up where we left off. Whatever file that you had next that you wanted to ask him about and that the same sorts of questions would be asked about those. We should just save a lot of time really and you not try to ask the same questions, and I'll not make an objection. We will live with what was said the first time around and that is transcribed if anyone wants to take it to court and do anything else with it.
Mr. Campbell: Let me just point out that in the court order - the court order in my mind clearly says that - and I can read directly from the court order because I do have it in front of me, "Respondent is further ordered to appear before Senior Investigator Campbell at a date and time to be picked by the Board and at the address set forth in paragraph B, to testify and to answer questions." There is no reference at all to the questions being specific to the records. However, my line of questioning is directed at the quality of care and the quality of care issue in these cases relates to, can you do an adequate examination of patients at the locations where Dr. Mikuriya was seeing his patients? Therefore, I believe that the issue of where the examinations took place is pertinent in this matter.
Mr. Fleer: I think the issue of where these examinations took place in each and every one of these 47 files, if you want to ask it, is appropriate, going beyond that is not, and the part that you quote has to be read in context. It's in regard to the 47 files which are compelled to be produced. Dr. Mikuriya hasn't waived his right to privacy, confidentiality of patients, or anything else, and he is not going to. The 47 files are what we are here to talk about. I think that is a pretty straight forward position; it gives us lots to talk about too.
Mr. Campbell: Let me see if I understand your position. Your position is that in lieu of asking it as a general question at the outset, is not asking individually in the case files, your position is that he will answer if asked in the course of each case file where the examination took place? Is that correct?
Mr. Fleer: Yes. I think he has already been asked those sorts of things, and I can't recall a single thing he was asked about in any of the particular files that he didn't respond to. There might be something, but I don't recall it.
Mr. Campbell: Okay. We can do it on that basis. In that case, we would start with our first file which would be [redacted].
Dr. Snyder: [redacted].
Mr. Campbell: [redacted].
Dr. Snyder: Whatever. Then I am going to let you look Dr. Mikuriya because I think we have the only copy. There are a series of questions that I was asking about each one, the diagnosis of the patient when you saw them, and whether you saw them on multiple occasions. So if you would just briefly - looking at [redacted] chart, comment on those areas.
Mr. Fleer: Dr. Snyder, what you gave before - how the patient came to him, the extent of his contact with the patient, and the major medical problems - do you have those in mind when you go through those? How they came to you, how much contact you had and what were the major specific problems.
Dr. Mikuriya : On 6/11/99, [redacted] consulted me, and I am not sure where it was; I would have to go back in my schedule to make that determination.
Dr. Snyder: The location of the visit, the venue?
Dr. Mikuriya: Correct. He came with the problems of neck and back injuries with chronic muscle spasms in his neck and back that he sustained in a motor vehicle injury 8/6/98. This left him with very serious neck and back injuries and muscle strain that he obtained chiropractic treatment for and that other physicians had prescribed anti-inflammatory medicines, and he had received doctor prescribed physical therapy for the same injuries with additional massage. His secondary complaint was difficulty sleeping following his back injury. The chronic recurrent pain caused the secondary problem of persistent insomnia. He stated that it has been suggested by a friend with a similar back problems that expressed that they had gotten relief. He also discovered in his personal use that cannabis helped him sleep at night and controlled his muscle spasms. He used 6-8 grams of cannabis weekly, but used more if he could afford it. He also utilized Motrin for muscle pain relief. I recommended in his treatment plan that he switch as much as possible to vaporization and oral ingestion to optimally medicate for his condition and avoid the irritation of the breakdown products of burning. I am pretty evangelical about recommending vaporization to patients.
Dr. Snyder: Do you have any sort of handouts that you give along those
lines?
Dr. Mikuriya: Of how to vaporize?
Dr. Snyder: Of how to vaporize.
Dr. Mikuriya: In a way because I have a page devoted to that on my website and I always ask the patients if they have access to the internet or a neighbor does or relative and would they go and look it up on the website. Whenever I suggest or enable them to go to a cannabis center, I also make a recommendation that they attempt to have vaporizers demonstrated for them.
Dr. Snyder: Is it fair to say since this is your usual practice that it is likely that you described that to [redacted]? Was that your practice back in 99 when you saw him?
Dr. Mikuriya: Yes.
Dr. Snyder: Did he bring any documents with him, records from any other physician?
Dr. Mikuriya: I don't recall.
Dr. Snyder: Did you perform a physical examination?
Dr. Mikuriya: Well, I looked at him. He was there in front of me, and as I went over his questionnaire that he filled out, I would ask him about details. This is a previous draft of my forms where at that time I was not documenting the actual physical examination that I did in subsequent drafts.
Dr. Snyder: Okay. So in - at the time in mid-99, was there something different that you did then that you are doing now?
Dr. Mikuriya: Trying to document it better, with more complete forms.
Dr. Snyder: Okay. Other than observation, clinical observation, were there any procedures that you did on him or having him bend
over . . .?
Dr. Mikuriya: I observe him when he comes into the consultation room for any kind of gait abnormalities or posture abnormalities, and in subsequent drafts of my interview form, I do have provision for that, but not in this particular draft.
Dr. Snyder: And you have described your recommendation - is there anything other, any other recommendations that you made other than the vaporizer?
Dr. Mikuriya: They utilize it by the oral route also.
Dr. Snyder: Right. You told us previously that you commonly recommend that people, your patients, tell their prior treating physicians that they sought a second opinion. Do you know if you did that in this case?
Dr. Mikuriya: I don't recall.
Dr. Snyder: And the follow-up? What was the recommendation? What was the recommendation regarding follow-up?
Dr. Mikuriya: I don't see that there was a follow-up in this case. This was a single consultation only.
Dr. Snyder: Okay.
Mr. Campbell: Interesting that you mentioned the name, the term, consultation . . .
Dr. Mikuriya: Yes.
Mr. Campbell: Was this a consultation for another physician?
Dr. Mikuriya: No, for the patient.
Mr. Campbell: For the patient? Do you know if the patient was actually under the care of another physician? Do you know who that physician was?
Dr. Mikuriya: I don't have that information in here.
Mr. Campbell: Does that mean that you didn't record it, or you just don't know?
Dr. Mikuriya: I just don't know.
Mr. Campbell: Okay. Do you know if the Motrin that the patient was taking was an over-the-counter Motrin or was it a prescription Motrin?
Dr. Mikuriya: Over-the-counter.
Mr. Campbell: It was an over-the-counter product? Okay. Do you know if the patient was taking any other drugs, anything else that may have been prescribed to him by another physician?
Dr. Mikuriya: I did not collect that information.
Mr. Campbell: Are you ready? Let's move onto the next patient. The next patient is [redacted]. Dr. Mikuriya, I will give you an opportunity to review the chart.
Dr. Snyder: Do you know how [redacted] came to you? That you didn't comment on? Was he self-referred, or you don't know?
Dr. Mikuriya: I don't know.
Dr. Snyder: Would you commence with how the patient came to you, major diagnoses, your recommendations, and the extent of your contact with the patient?
Dr. Mikuriya: I saw this woman whose birthday is [redacted] in Red Bluff on March 8, 1998. I did follow-up with her on 5/7/99.
Dr. Snyder: A face-to-face visit, not telephone?
Dr. Mikuriya: Probably telephone for follow-up. Red Bluff is a long way from Berkeley, and I give patients the option for face-to-face, telephone, or two-way video follow-up if we have a two-way video outfit working, and we did have one in Red Bluff for awhile.
Dr. Snyder: And what was the location Dr. Mikuriya? Were you seeing patients in Red Bluff in 98?
Dr. Mikuriya: I don't recall the exact location.
Mr. Campbell: Was that in regard to some organization in Red Bluff?
Dr. Mikuriya: That's difficult to answer because the situation then was quite fluid then. There were people in the community that were trying to organize a club or some collective activity, but this was not very successful because of problems with different local law enforcement entities.
Mr. Campbell: A club? You are referring to a cannabis club? Is that correct?
Dr. Mikuriya: Yes.
Dr. Snyder: Did you meet with people in private homes or public places?
Dr. Mikuriya: Well, they were not exactly public places. They were privately arranged spaces, offices.
Mr. Campbell: For instance, the Elks Club? Could that have been one?
Dr. Mikuriya: No, not the Elks.
Mr. Campbell: One of the organizations - the men's organizations?
Dr. Mikuriya: Well yes, you are going to unfortunately have fun with this. The International Association of Oddfellows. Unfortunately, the location - while the name is appropriate - was roughly a block away from the police station of Red Bluff Police. The lodge building had enough space, but it was certainly very strange. That arrangement was apparently too odd for the Oddfellows, or at least for their kind of oddness, so the person inhabiting the Oddfellows - whom at that point was a hopeless drunk - whose cozy relationship with the antique dealer that wanted to take over the building was somewhat antithetical to wanting to start up a service organization. But, the Oddfellows have a perfect history of health care delivery and the first medical insurance model in the United States starting back in the 1850s, but I digress. Yes, well it didn't work out, and there was only one clinic that could be held there.
Dr. Snyder: Do you know if Ms. Evans was at that first clinic in Red Bluff?
Dr. Mikuriya: Well, it must be at that date in 98.
Mr. Campbell: You actually saw her at the Odd Fellow facility in Red Bluff?
Dr. Mikuriya: I believe so. That would seem to be reasonable.
Dr. Snyder: So you saw her face-to-face we believe at the Oddfellows building in . . .
Dr. Mikuriya: I see every patient face-to-face. There is no initial visit that is not face-to-face, never.
Dr. Snyder: In March of 98 - and her presenting problems?
Dr. Mikuriya: Temporal lobe epilepsy. She had suffered this since her early twenties with the typical epileptic aura of some physiologic change in her. It was abdominal discomfort before the onset of the grand mal seizures. She had tried the other antiseizure medications like Dilantin and that gave her adverse side-effects, Tegretol, while apparently it was more tolerable, it caused side-effects of weight gain. This seizure disorder apparently came from an attack of influenzal meningitis at age 9 months. So she was left with that problem that manifested itself only in her early twenties. I would imagine there were probably other difficulties. She was taking Neurontin and half-a-pack a day of nicotine type cigarettes. She started using cannabis interestingly because when she tried to quit it in her early twenties, she noticed an increase in frequency and severity of the seizures. I have heard this story before from other people who were chronic marijuana users and suddenly found themselves in a situation where they couldn't smoke and then having symptoms emerge.
Dr. Snyder: Do you know when her last seizure was?
Dr. Mikuriya: No. On follow-up on 5/7/99, she stated that she in not having the 30+ seizures that she used to experience.
Dr. Snyder: I'm sorry, what?
Dr. Mikuriya: 30+.
Dr. Snyder: 30. I didn't know if you said 3 or 30.
Dr. Mikuriya: She continued taking her Neurontin as well as the cannabis. The only other psychoactive she was taking was coffee, 2 or 3 cups a day.
Dr. Snyder: Do you know if the physician who was prescribing the Neurontin knew about her use of cannabis?
Dr. Mikuriya: I do not.
Dr. Snyder: Did I already ask if she came with any records?
Dr. Mikuriya: No you didn't. I don't have anything on that in the record.
Dr. Snyder: And your recommendation to her?
Dr. Mikuriya: To continue self-medicating with it.
Dr. Snyder: Do you have any information about how many seizures she having - if she went to zero or some lesser number than 30? What that number was daily or weekly?
Dr. Mikuriya: Don't have it.
Dr. Snyder: And your examination of this patient. What did that consist of?
Dr. Mikuriya: Personal one-on-one interview. Listening to her as she elaborated on the symptoms that were described by her in the form, and the annotations reflect this discussion with her. This is in the draft of the forms that pre-dated the ones where I memorialized the physical examination.
Dr. Snyder: Is there any of the writing on the form that is your writing Dr. Mikuriya? I know the patient filled in out, but did you make additional notations on this form? Maybe we can make note of those for the recording.
Dr. Mikuriya: I have the 9 month influenzal meningitis . . .
Dr. Snyder: And then there is a note . . .
Dr. Mikuriya: No develop - I guess no developmental retardation. Then left temporal lobe with abdominal aura.
Dr. Snyder: That's your handwriting?
Dr. Mikuriya: Yes. Then bad side-effects from Dilantin.
Dr. Snyder: So, bad SE stands for side-effects?
Dr. Mikuriya: Correct SE weight gain for both the Dilantin and the Depakote.
Dr. Snyder: It looks like Tegretol is circled.
Dr. Mikuriya: Yeah, it could be, yeah, the Tegretol.
Dr. Snyder: What about weight gain with marijuana or cannabis? What's your - did you discuss that issue with this patient?
Dr. Mikuriya: Yes, and paradoxically, there is less of weight gain with cannabis than with these other medications, although everybody has heard about the munchies, but it's really not the same thing when taken on a chronic basis for a different purpose.
Dr. Snyder: We know she had follow-up. What were your instructions to her about how soon the follow-up should be?
Dr. Mikuriya: I don't recall.
Dr. Snyder: Do you recall what your thinking was that you advised follow-up with her and, for instance, you didn't with the patient that we previously discussed. There is no follow-up recorded with [redacted] and there is a follow-up with . . .
Dr. Mikuriya: Well his was more or less a single consultation without follow-up. Follow-up was for the patient to just check in and let the doctor see how well I'm doing since the last visit. Seizure and epilepsy is the condition treated.
Dr. Snyder: Do you know if the DMV knew about her seizure disorder?
Dr. Mikuriya: I do not know. I don't know if she had a driver's license.
Dr. Snyder: Okay. Do you have any questions?
Mr. Campbell: The issue of driver's license - I see on some of these recommendations that there is an actual photograph of facsimile of a driver's license. Is that a relatively new thing that you . .?
Dr. Mikuriya: I have tried to do this all along.
Mr. Campbell: And in this case you . . .
Dr. Mikuriya: It could be, let's take a look. It's her photo ID card. She doesn't have a driver's license.
Mr. Campbell: Oh, an ID card, okay.
Dr. Mikuriya: I'd feel very nervous if this lady in fact were driving.
Mr. Campbell: Yeah. The next one we are going to look at is [redacted]. One thing that is unique about this record that I want to point out, and I am assuming that we have your entire record here on each of these cases? Is that correct?
Dr. Mikuriya: I hope so.
Mr. Campbell: I didn't get any kind of a certification or anything when the records were provided to us, and I just made that assumption that we had the entire record on each patient. In this particular record, we did not get a copy of the actual physician statement recommending, however, I do have a copy that I placed in there. I obtained a copy of that recommendation from the Tehama County authorities, so when you look through this record, you will see a notation like that.
Dr. Mikuriya: Part of your northern tour?
Mr. Campbell: Yes.
Dr. Mikuriya: Okay, [redacted]: birthday- [redacted]; presenting problems of back muscle spasms and congenital scoliosis who has a 9th grade education and is currently working on a GED. Family: mother and father are in good health. She has had neck and back pain since 1992.
Dr. Snyder: That's age 15?
Dr. Mikuriya: Right.
Dr. Snyder: And when did you see her?
Dr. Mikuriya: I saw her 7/24/99.
Dr. Snyder: Age 22. Was there an injury?
Dr. Mikuriya: No, congenital scoliosis with developing of back muscle spasms and pain. She denied any alcohol use; she admitted to five cigarettes of nicotine a day. I recommended to her that in addition to her letter of recommendation and approval, that she vaporize and that she also get an orthopedic surgeon consultation for corrective appliances.
Dr. Snyder: I was going to ask about that, if she had a brace. Do you know if she had any prior treatment?
Dr. Mikuriya: No, she had not.
Dr. Snyder: No evaluation or treatment?
Dr. Mikuriya: No.
Dr. Snyder: How did you know she had it?
Dr. Mikuriya: Well, she knew she had something wrong with her back, but that's about all she knew. With people who have scoliosis, I definitely encourage some sort of physical therapy intervention at least because my sister, a 56-year old emergency room physician, has just a very mild case of scoliosis, but in the past five years there is increasing nerve root irritation and compression, and finally, there is problems with her lifting her foot. That ended up with her undergoing back surgery which was successful. So, when I meet somebody with scoliosis, I recommend that they become aware of this kind of prognosis if they just let it go and tough it through. That chiropractic does not seem to have any beneficial effect, and the best results that I have had are with physical therapist fitted orthotics.
Dr. Snyder: Did you have that discussion with . . .?
Dr. Mikuriya: I'm sure I did, but I didn't memorialize it.
Dr. Snyder: Do you know if she had ever had back x-rays?
Dr. Mikuriya: No, I don't. I usually have the patient show me their scoliosis. One of the informants for the Medical Board that came for a visit from the record
Dr. Snyder: Uh hum. So do you recall having her show you her back?
Dr. Mikuriya: I do not recall.
Dr. Snyder: But your usual practice is to have the patient show you?
Dr. Mikuriya: Lift the back of their shirt or sweater so I can have - I can visualize their spine.
Dr. Snyder: And that is your customary practice with any patient that complains of having scoliosis? Any more of an examination as far as - other than things you have already described - observing gait and posture with everybody, observing the back, and taking a history?
Dr. Mikuriya: And taking a history.
Dr. Snyder: The follow-up with her?
Dr. Mikuriya: I don't have any record of a follow-up. I think this is a single consultation.
Dr. Snyder: Alright.
Mr. Campbell: I might have missed it - when did you see this patient?
Dr. Mikuriya: Somewhere in Red Bluff.
Mr. Campbell: Could that have been at the same place - at Oddfellows Hall?
Dr. Mikuriya: Might be. Good chance, but then there is a chance . . .
Mr. Campbell: Did you see her on the same date?
Dr. Snyder: I think the date looks different.
Dr. Mikuriya: Must have been somewhere else.
Dr. Snyder: Sorry Chuck. I think you saw [redacted] on 3/8/98, and this person on 7/24/99. So it was a different year.
Dr. Mikuriya: So it was a different year.
Mr. Campbell: Did you use a different facility in Red Bluff to see patients?
Dr. Mikuriya: I don't understand how that is pertinent.
Mr. Campbell: Well, we are just trying to determine if you saw this patient in a parking lot, if you saw this patient in . . .
Dr. Mikuriya: I never see patients in parking lots.
Mr. Campbell: In a private home? Did you see this patient in a medical facility? Did you see the patient in a club situation such as you saw [redacted]? I think it was [redacted].
Dr. Mikuriya: I don't recall. I would have to go back to my . . .
Mr. Campbell: Yeah, [redacted]. You don't recall?
Dr. Mikuriya: No. I don't.
Mr. Campbell: Okay. The next patient we want to look at is [redacted].
Dr. Mikuriya: From Nevada City.
Dr. Snyder: So you know this patient? You recall this patient independently it seems?
Mr. Campbell: The file is probably one of the thicker that we have in my brief review of it. The majority of it seems to be legal documents.
Dr. Mikuriya: Yes. He was frequent consumer of the legal services up in Nevada County as is well-known to you since you are one of the top referrers of complaints to the Medical Board from various entities.
Dr. Snyder: So how did he come to you?
Dr. Mikuriya: How did he come to me? Probably referred by friends.
Dr. Snyder: Okay. Even if you are guessing . . .
Dr. Mikuriya: No, word-of-mouth.
Dr. Snyder: Okay.
Dr. Mikuriya: So I first saw this separated man with a young child on 4/10/99 for the symptoms of irritable bowel and, I believe, anxiety disorder. Irritable bowel syndrome, migraine headache, and PTSD.
Dr. Snyder: And the extent of those?
Dr. Mikuriya: Oh yes, he also had hepatitis C. So that really foreclosed a lot of the treatment options with him.
Dr. Snyder: I'm sorry, in what way Dr. Mikuriya?
Dr. Mikuriya: Because of the liver being impaired and having problems metabolizing various medications.
Dr. Snyder: Do you know what degree of liver impairment?
Dr. Mikuriya: I do not have that record. As a matter of fact, I requested this be obtained as a part of the treatment plan. He had had complaints of recurrent abdominal pain and diarrhea. The question at that time of hep C. This was going back ten years.
Dr. Snyder: He had been told he had hep C ten years previously?
Dr. Mikuriya: Yes.
Dr. Snyder: Do you know how he acquired it?
Dr. Mikuriya: I always ask, but I don't recall what his response was. This is a touchy subject obviously. If there is a question of intravenous drug use and other kinds of intercurrent problems that would also influence my thinking.
Dr. Snyder: So customarily you do ask about IV drug use, history of IV drug use?
Dr. Mikuriya: Yes.
Dr. Snyder: In everybody, or just persons with hep C?
Dr. Mikuriya: I have an item in my questionnaire that specifically inquires about non-prescribed psychoactive drugs.
Mr. Campbell: Is the questionnaire in the file there, for this particular patient, and was that question answered?
Dr. Mikuriya: Yes. The questionnaire is here, and the question is asked and responded to - hepatitis C - by the patient. As part of my treatment plan, in addition to vaporizing it instead of smoking and using oral preparation, that he get tested for his hepatitis C. The other problem that he came to me for was chronic migraine headaches that were classical in nature, with visual changes that preceded excruciating and immobilizing headache that was relieved by sleep. Also, he had chronic tension headaches with shoulder pain, aggravated by anxiety. He also complained of persistent insomnia. On mental status, he was alert and anxious, but oriented. His stream of conversation was pressured.
Dr. Snyder: Is the form that you used on him your revised form?
Dr. Mikuriya: Still a more primitive version.
Mr. Fleer: Don't call it that.
Dr. Mikuriya: Well, less evolved. This is difficult because it all started out with doing a medical consultation, medical psych consultations. Essentially doing what I've been doing all along except with a different population. Instead of dealing with people in nursing homes and chronic, severe, ventilator-dependent illness patients or residents in extended care facilities, just doing med psych consults on a different population.
Mr. Campbell: In that regard, did you write a fair number of recommendations for the use of cannabis to that clientele.
Mr. Fleer: That is outside the scope of these 47. I think the point you are trying to make is that you have changed your form in response to what you have learned with the new population?
Dr. Mikuriya: Yes. You have to remember that I got involved with this back in 1992 or 91, and I would videotape these people that were wanting to be part of a cannabis club. The number of videotapes got too overwhelming, and I became also aware that I didn't think that maybe capturing all sorts of things on videotape was good for the patients' confidentiality. I've been revising ever since.
Mr. Campbell: Evolving.
Dr. Mikuriya: Evolving. Yes. Trying to improve my protocol. Trying to tighten it up and to improve the quality of my keeping records. I never had to keep these kinds of records doing med psych consults in facilities because this information was contained in the admission H&P and other consultations from other specialists. I was just one specialist in a whole array dealing with one patient with multifaceted serious illnesses.
Dr. Snyder: So your prior patient population was institutionalized or a hospitalized population?
Dr. Mikuriya: Yes.
Dr. Snyder: So that you were either in an acute care hospital or a convalescent hospital?
Dr. Mikuriya: Or rehab hospital.
Mr. Campbell: And these were, as you said, acute patients with serious illnesses?
Dr. Mikuriya: Yes.
Mr. Campbell: Is that the term that you used?
Dr. Mikuriya: multisystem serious illnesses. For example, Vancor, or at the time, hospital - mortality rate 46 percent, transfers from acute wards in hospitals that would not be able to keep them on the wards anymore because of the pressure of their situation, but they were too ill to be transferred to a lower level of care, and so they went to this hospital where I was part of the medical team as it were.
Mr. Campbell: Would you characterize the patient clientele that you began seeing when you first became involved with the recommendation of marijuana? Would you characterize those patients in the same way that you characterize the patients that were actually inpatients in various facilities?
Dr. Mikuriya: In what sense? I don't understand the question.
Mr. Campbell: Did they have these multi problems? Were they seriously ill and so forth?
Dr. Mikuriya: Well, I have seen a range of difficult things or patients with difficult conditions. The other patient whose case is still apparently under process within the AG's office . . .
Mr. Fleer: Is he one of the 47?
Dr. Mikuriya: No, he is not one of the 47.
Mr. Fleer: Let's go back to them. Let's stick to them.
Dr. Mikuriya: Okay. Time for a tape change.
Mr. Campbell: No, we are still going. Let me go and clarify my question then. Would you classify the patients that we are talking about here, these 47 patients, as people that have severe illnesses?
Dr. Mikuriya: Not as severe as the ones that were institutionalized. These were all ambulatory, except for maybe some of the rare exceptions. I have people that are quadriplegic that have a whole bunch of different kinds of caregivers ministering to their complicated serious ongoing chronic conditions.
Mr. Campbell: Okay. Ready to move to the next one?
Dr. Snyder: I think so. Did we finish with all the questions on [redacted]? We didn't get to whether he had followed . . . maybe we should go ahead and turn the tape over?
Mr. Campbell: We can. I wanted to finish [redacted]. If we could finish [redacted]. We still have plenty of tape left.
Dr. Snyder: Okay. Alright.
Dr. Mikuriya: [redacted]r was also suffering from problems with the Nevada County authorities.
Mr. Fleer: Dr. Snyder's question though was about follow-up.
Dr. Snyder: Recommendation and follow-up?
Dr. Mikuriya: Yes. I did see him on follow-up and recommended he continue using his milk thistle to help with his liver function and to avoid other kinds of medications and cultivate three different strains to figure out which are the most effective - Indica on irritable bowel syndrome, and Anorexia Sativa for PTSD and headaches. He was attempting to determine which was more efficacious.
Dr. Snyder: Would you remark a little bit on his PTSD? What the trauma was and how it manifested?
Dr. Mikuriya: One source of PTSD was the trouble with the law.
Dr. Snyder: Do you know if it predated any legal difficulties?
Dr. Mikuriya: I would have to study this file more.
Mr. Campbell: Why don't we take a minute and give the doctor an opportunity to study the file and I will change the tape. That beeping in quite annoying.
Dr. Snyder: Right. I am going to take a short break. So, we can go off the record.
(TAPE 2)
Dr. Mikuriya: Recording again, again with the cap over the lens to prevent the capturing of the spirit of the senior investigator.
Mr. Campbell: Okay. It is 11:12. We are all present again, Dr. Mikuriya, attorney Fleer, Dr. Snyder, and myself. We will be continuing and finishing up on patient [redacted].
Dr. Snyder: I had just asked about the extent of [redacted] PTSD, what the trauma was, and whether it predated his having any legal difficulties? Or, if we are able to determine that from the record?
Dr. Mikuriya: I am trying to determine that. I am going to review this. I don't have that in the record, but he was of course involved in the legal problems with Nevada County. There was a newspaper article about him about him and his tastes. I provided a letter to the court on his behalf too. He was, he sticks out in my mind because of his dramatic improvement as compared with how he was the first time I saw him and then on follow-up. He was in a much better emotional state and his condition had subsided. That's what I recall when meeting him on follow-up when I was up in Nevada City.
Dr. Snyder: So you saw him in a face-to-face follow-up?
Dr. Mikuriya: Yes.
Dr. Snyder: And when was that?
Dr. Mikuriya: That was 11/28/00.
Mr. Campbell: That was in Nevada City?
Dr. Mikuriya: Yes.
Mr. Campbell: Where did you see him the first time? In Nevada City also?
Dr. Mikuriya: I don't recall. I could have been at my office in Berkeley or it could have been in some other place up in Nevada County.
Dr. Snyder: And where did you see him the second time?
Dr. Mikuriya: Nevada City.
Dr. Snyder: And the venue?
Dr. Mikuriya: The venue was seeing other patients for follow-up ,and I don't recall exactly where it was in Nevada City.
Mr. Campbell: It would have been at a home or something? Not the Safeway parking lot?
Dr. Mikuriya: You keep coming back to the Safeway parking lot. The answer is no, I don't ever see. . .
Mr. Fleer: No, you only see people in a private setting.
Dr. Mikuriya: Yes. You have some interesting fantasies there.
Dr. Snyder: So there were two visits with [redacted]?
Dr. Mikuriya: Yes.
Dr. Snyder: Any other telephone contact?
Dr. Mikuriya: There probably was because of requests for different communications, declarations.
Dr. Snyder: And the documents are in the record, but the telephone calls are not memorialized?
Dr. Mikuriya: Correct. Well, they could be memorialized, but they are not included in the record.
Dr. Snyder: Do you keep a date book with that sort of information?
Dr. Mikuriya: I try to.
Dr. Snyder: Okay. Is there anything else to add? You said his mental status had improved, or mental state had improved on follow-up? In what way?
Dr. Mikuriya: Much more relaxed, and he wasn't pressured. He was more optimistic. He didn't feel that his life was spinning out of control anymore. His irritable bowel symptoms had subsided.
Mr. Campbell: Do you know if that was after the conclusion of his legal problems in Nevada County or was it prior to . . .?
Dr. Mikuriya: I don't know that legal problems ever conclude in Nevada County, but apparently they were resolved, at least for the present.
Mr. Campbell: At the time you saw him the second time?
Dr. Mikuriya: At the time I saw him. Yes.
Mr. Campbell: That could certainly, I would think, have something to do with improvement of some of those things.
Dr. Mikuriya: Oh yes, definitely we have people who are very stressed and sickened by certain kinds of involvement of with criminal justice entities.
Mr. Campbell: Okay. We'll go on to the next one. The next one we are going to look at is a [redacted].
Dr. Mikuriya: Okay, this is a woman, birth date [redacted]. First seen on 4/30/99, apparently in Red Bluff, but I am not sure. I might add parenthetically, since difficulties have arisen and problems with Red Bluff and Tehama County authorities, that patients have had to drive down to the Bay Area to see me on some occasions. So, it keeps changing. This is a woman with an 11th grade education, working on getting a high school diploma, housewife, and has twin boys age 15½.
Mr. Fleer: Was that the presenting problem?
Dr. Mikuriya: Well. . .
Mr. Fleer: I have a 15 year old, so I can say that.
Dr. Snyder: I'll bet it could be.
Dr. Mikuriya: Very painful headaches brought on by stress, which I diagnose as attention headaches that she had taken Norflex, Anaprox, Lodine, and also had chiropractic treatment. She also suffered from colitis and diverticulitis. She also had injury to her knee and painful shoulder.
Dr. Snyder: I would be interested if you had other records on her?
Dr. Mikuriya: I don't have any.
Dr. Snyder: Why don't I just leave this as an open question to pertain to all the subsequent charts - if - like with scoliosis, there was an additional aspect of the physical examination, if you would note that. For instance, if somebody has shoulder pain, back pain, or abdominal pain, if you did a limited physical other than observation. If you would mention that. If you don't mention it, we'll assume that what's recorded in the record . . .
Dr. Mikuriya: Well, in subsequent drafts of the form, I definitely have that annotated and described as specific abnormalities. So this is a form back in 99.
Dr. Snyder: Can you recall what your practice would have been in 99 with a patient with these complaints? Whether there would have been other aspects of the examination?
Dr. Mikuriya: With this patient, my recommendation was for both regular massage and biofeedback training.
Dr. Snyder: Okay. And follow-up with her?
Dr. Mikuriya: Six to twelve months.
Dr. Snyder: Did she comply with the recommendation?
Dr. Mikuriya: No. At least I don't know because I don't have any follow-up communication except a note that she wrote that is not dated. "My medical record is between my doctor and I. I don't think it is right to ask anybody to turn their medical records over to the Medical Board for public use in or out of court. Whatever is in the medical records is between doctor and patient. I do apologize for the lateness of this note. Signed [redacted]."
Mr. Campbell: That note was written in response to?
Dr. Mikuriya: A letter I had sent notifying patients - that I sent out in July 3, 2001.
Mr. Campbell: If I might paraphrase that, you actually sent out a letter to each of the patients to whom we had issued a subpoena for the records advising them that . . .?
Dr. Mikuriya: Yes. Advising them, "As you are aware, in September of 2000, I was served with subpoenas from the Medical Board of California demanding access to 47 patients' medical records. I complied in supplying three demands that were accompanied by a signed Release from the patient. You are among the 44 who declined to permit release of your medical records in response to the MBC demands. On July 15th, I have a hearing in Sacramento at the Superior Court to argue against the unauthorized release of your records. I need to show the judge how you feel about turning your records over to the Medical Board that become public record. I would appreciate that upon your receiving this, you could write me a note that I could show the judge expressing your views on this matter. Your prompt response to this matter will be appreciated because of the limited time. Ps: I have enclosed a stamped, return-addressed envelope for your convenience."
Mr. Campbell: And the note that you referred to was her response to this?
Dr. Mikuriya: Yes. Did that in fact get shown to the judge in Sacramento?
Dr. Mikuriya: I don't know.
Mr. Campbell: I don't know either.
Mr. Fleer: I'm sure the views were communicated, whether all the notes were shown. . .
Mr. Campbell: Here we are today. So, next question.
Dr. Mikuriya: Yeah, we see how that went over.
Dr. Snyder: I think we are done with[redacted].
Mr. Campbell: Okay, our next one will be [redacted].
Dr. Snyder: I can give them straight to Dr. Mikuriya.
Dr. Mikuriya: This is a male. Birth date [redacted]. Presented with symptoms of recurring depression, tension headaches, dysthymic disorder. He had complaints of decreased sleep and eating. He suffered from chronic pain from an indwelling steel pin in his right leg. Also, apparently alcohol misuse. He only admitted to four drinks a week. He was taking Trazodone 100mg hs, and Zyrtec 1 tab daily as needed. I recommended specifically that he totally discontinue alcohol, and he saw me on follow-up in six to twelve months. I see a notation here that even though it's not elaborated in his family history, he is an adult child of an alcoholic family. He was involved with the law. He was charged with having possession of marijuana for sale. One count of felony. His diagnoses were again, adult children of alcoholic, PTSD type, and also traumatic arthritis. He was seen only for one occasion.
Mr. Campbell: That was where?
Dr. Mikuriya: I believe in Red Bluff.
Dr. Snyder: Initially you mentioned Dr. Mikuriya, recurrent depression and then a diagnosis of dysthymic disorder, are those diagnoses he came to you with, or are those diagnoses . . .
Dr. Mikuriya: He was complaining with and then as I interviewed him, I got more information as to the genesis of these symptoms. So, it is much more complicated and deep-seated than just the typical anxiety disorder with this type of chaotic abusive background.
Dr. Snyder: So these are diagnoses you made yourself? This attribution of the PTSD being due to his childhood issues?
Dr. Mikuriya: Yes, and his continuing alcohol since he didn't really have any non-alcohol abusive role models.
Dr. Snyder: You say he admits to four drinks a week, but then you concluded there was alcohol misuse? What did you base that on?
Dr. Mikuriya: Well, very frequently people that use alcohol will grossly understate it and try to put the right face on things. I am a certified addictionologist and I'm always listening for those kind of clues.
Dr. Snyder: So it seems fair to say that there was history that was obtained in discussion that was obtained with this gentleman that was not all recorded?
Dr. Mikuriya: That is correct.
Dr. Snyder: And again, the dysthymic disorder was your own diagnosis that you assumed . . .?
Dr. Mikuriya: No, it was his.
Dr. Snyder: Oh, he wrote that on a piece of paper. So he was familiar with that terminology? Okay, so he came with that.
Dr. Mikuriya: These people, none of them are just recent things. All of these are chronic conditions. That is one of the characteristics of the population; they are all chronic, but ambulatory in most cases.
Dr. Snyder: And the medications? Did you make any recommendations regarding other medicines that he was on, the Trazodone or Zyrtec?
Dr. Mikuriya: Well, no. I didn't recommend that he change them. I always recommend that they stop drinking so the medications will actually do what they are supposed to do because people that are continuing to drink and take other kinds of medications are getting a combination of alcohol effects and the other medications.
Dr. Snyder: You mentioned that you are a certified addictionologist. Do you ever refer patients into treatment or Alcoholic's Anonymous, or any type of support system like that?
Dr. Mikuriya: Oh yes.
Dr. Snyder: How would you decide whether . . .?
Dr. Mikuriya: It depends on where they lived, what kinds of resources were available. The sad thing is that there are not very many.
Dr. Snyder: Do you know if you made that kind of recommendation, either for an alcoholic or child of an alcoholic group or AA group for this particular man?
Dr. Mikuriya: I try to refer a lot of these patients to Dr. Timmons Surmak [sic], who is an expert in adult children of alcoholic problems, but his availability and accessability could be better. I try to refer them to him because his office might be able to refer them to a local group of ACA support.
Dr. Snyder: He is in Marin? Is that right?
Dr. Mikuriya: Yes. Mill Valley.
Dr. Snyder: Alright. We went all the way up, to and including that you made a recommendation for follow-up with him?
Dr. Mikuriya: Right.
Dr. Snyder: You made a recommendation that he stop alcohol, you gave him his recommendation and approval, and recommended that he contact me in six to twelve months. Did he do that?
Dr. Mikuriya: No, he didn't.
Mr. Campbell: Okay. The next one we will look at is [redacted].
Dr. Mikuriya: Umm.
Mr. Campbell: It would appear from reviewing that file that [redacted] also had some legal problems?
Dr. Mikuriya: He had. Up in - I believe it was Tehama County - oh yes, it was. My friend, Lynn Stromm - Deputy DA up there. Boy, she was the source of a lot of complaints to the Medical Board as I recall. Okay, [redacted], date-of-birth 8/5/43, married, presenting problems of shoulder injury and lumbosacral pain. He was a chef, and I guess it was a warehouse manager. Presenting problems were the lumbosacral pain with left sciatic nerve. Let the records reflect - nothing - that in 65, he had this accident which left him with a sequelae of lumbosacral problems and left sciatic nerve pain, as well as neck and back pain.
Dr. Snyder: Motor vehicle accident or work related?
Dr. Mikuriya: Not specified. That was a long time ago. Five years ago he had another auto accident that tore his left rotator cup, and also on 12/5/98 or 97, he had an on-the-job lifting accident and fell under a load of 28-44 pounds. He also complained of muscle spasm and sinusitis. He couldn't take aspirin because of stomach irritation, so he uses occasional acetaminophen. He indicated that he had problems with alcohol in the past, but that he discontinued drinking nine years prior to the visit. My plan was recommending oral and vaporized preparations and to consult me again in six to twelve months. He did see me for a follow-up visit on, I believe this was Arcada. He wanted to renew his City of Arcada card in the days when Mel Brown used to be police chief there.
Dr. Snyder: So there was a certificate and recommendation, and slipping in there some sort of card?
Dr. Mikuriya: Okay. At that time, the City of Arcada was issuing ID cards under Police Chief, Mel Brown. [redacted] wanted to qualify for that service.
Dr. Snyder: How long were they good for? You said to renew?
Dr. Mikuriya: I believe they were good for a year, but that program has subsequently been superceded by the Humboldt County Department of Health.
Mr. Campbell: How long are your recommendations good for?
Dr. Mikuriya: How long are they good for?
Mr. Campbell: Is there an expiration date on them?
Dr. Mikuriya: Not usually.
Mr. Fleer: Are you asking from a legal standpoint if these have some time period, or from the doctor's. . .?
Mr. Campbell: From the doctor's position. Does he put - for this person - did he put a limit on it.
Dr. Mikuriya: If I had my druthers, I would put lifetime, permanent.
Dr. Snyder: For [redacted]?
Dr. Mikuriya: Right, subject to my initiative to revoke it if I so desire, but otherwise with [redacted] chronic injury related conditions and his current levels of symptoms, the chances of significant recovery are not very good. It's different for somebody that had an isolated injury or something of that nature. But even for young people, like for example, young alcoholics, these are terrible chronic problems that are not going to go away and the more they continue, the more difficult they are to reverse. I guess you have had a chance to read that paper that I gave you about alcoholism?
Mr. Campbell: Yes. Thank you very much. We did receive it, and I shared it with Dr. Snyder. If she got her copy?
Dr. Snyder: Yes, I got my copy.
Dr. Mikuriya: It really is something that I feel very strongly about, that it should be restored for availability for treatment intervention, that there be better follow through and less recidivism rates. But because of the ignorance and the antipathy towards this in my own profession, in chemical dependancy especially, there is just gross ignorance.
Dr. Snyder: Back to [redacted]?
Dr. Mikuriya: He made a mistake of being in Tehama County, straying from Arcada.
Dr. Snyder: I don't know the geography up there very well.
Dr. Mikuriya: Well, Arcada is a different world from Red Bluff.
Dr. Snyder: Okay.
Dr. Mikuriya: Arcada is a college town. It has Humboldt State University in it, and it's kind of like a rural version of Berkeley compared to Red Bluff, which is not.
Dr. Snyder: And your examination of [redacted]. What did that consist of?
Dr. Mikuriya: Looking at him and seeing his stiffened posture and lessened range of motion in his arm. His obvious pain as he moved.
Dr. Snyder: Did you have him lift up his shirt?
Dr. Mikuriya: No.
Dr. Snyder: Before you discussed advising people not to operate motor vehicles or any other kind of equipment - I know this man has had several accidents - is there anything in his chart that indicates that he was admonished in that regard?
Dr. Mikuriya: No.
Dr. Snyder: Was that your practice back in 90 . . .?
Dr. Mikuriya: If I felt that there was an issue with regard to this, and as I mentioned, he had a prior history of alcohol abuse, but claimed it was arrested.
Dr. Snyder: But how about driving or operating machinery under the influence of cannabis?
Dr. Mikuriya: I write on my green form not to do it.
Dr. Snyder: So it was on the form at that time as well?
Dr. Mikuriya: Yes it was. It has always been on my forms.
Dr. Snyder: Okay. Alright.
Mr. Campbell: Is that it?
Dr. Snyder: Yes.
Mr. Campbell: We'll move next to what I believe is [redacted] spouse, D[redacted].
Dr. Mikuriya: Daphne Kitchen, yes indeed.
Mr. Campbell: Well, let me re -well, we can ask it for both of them I think. Did you see them in a facility in Arcada, or Red Bluff?
Dr. Mikuriya: Well, I could have seen them either place, but probably in Arcada.
Mr. Campbell: Is there a particular place there that you see people, that you saw these folks (inaudible)?
Dr. Mikuriya: It was really a similar situation to Red Bluff with kind of like one place, then it didn't work out, and then we would have to find some other place.
Mr. Campbell: You are saying it was an odd situation?
Dr. Mikuriya: All of these situations are odd, let me tell you. This is not San Francisco or Alameda County Toto. When going up there - as far as different attitude within the community.
Dr. Snyder: I have a question in that regard. When you meet with these folks, do you meet with them individually in a separate room? If there are other people waiting to be seen?
Dr. Mikuriya: Of course. Yes.
Dr. Snyder: There is always a provision for privacy?
Dr. Mikuriya: Oh yes. I mean, I make such an effort to try to prevent the records from being looked at by all sorts of people that I don't think should have access. That is just part of my general approach to patient confidentiality.
Dr. Snyder: Right. So now we are discussing [redacted].
Dr. Mikuriya: [redacted]. Her birthday is [redacted]. Who presented with sequelae of brain injury she suffered at age 21. She had a stroke.
Dr. Snyder: Do you know, from a malformation. . .?
Dr. Mikuriya: Birth control pills. I have another patient in there - it's just tragic - a 25 year old young lady, a physical therapy student who had that, a birth control and nicotine stroke at age 21, and it left her with speech defect. But anyway, [redacted] exhibited certain other kinds of soft signs of chronic effects of brain injury with difficulty maintaining attention concentration sometimes and being somewhat more vulnerable to emotional distraction. Fortunately, she and her devoted husband of many years were able to survive. Of interest to note, her mother had a stroke as well.
Dr. Snyder: Did she have any motor disability?
Dr. Mikuriya: She was rather clumsy. She had a very unusual kind of - it wasn't exactly a broad-based gait - but she just really was not well coordinated.
Dr. Snyder: But no sort of paresis?
Dr. Mikuriya: No. She had emotional lability as I recall, which is very frequent for people who have had brain injury. She also complained of her nicotine dependence which she claims was helped by substituting cannabis.
Dr. Snyder: I was just going to ask. I have read the article about the alcohol dependence and I wondered if there is a correlative. Have you collected cases?
Dr. Mikuriya: No. But I am definitely excited by the findings when I reviewed all those alcoholism and other drug dependence cases. To see how many people have been successful in withdrawing from nicotine dependence because a lot, a number of them spontaneously report this.
Dr. Snyder: Did she herself report a decreased use of nicotine?
Dr. Mikuriya: Yes.
Dr. Snyder: And what were your recommendations to her?
Dr. Mikuriya: Discontinue nicotine and vaporize, and follow-up in six to twelve months.
Dr. Snyder: And did she?
Dr. Mikuriya: Yes she did, 8/10/00.
Dr. Snyder: And her status at that point?
Dr. Mikuriya: I am please to announce that she was abstinent from her nicotine dependence for one year.
Dr. Snyder: Okay.
Dr. Mikuriya: But definitely she was a candidate for vaporizing because of having, she counted two dozen hits a day.
Dr. Snyder: Smoking?
Mr. Campbell: That's two dozen cigarettes a day?
Dr. Mikuriya: No, puffs
Mr. Campbell: Oh, puffs, okay.
Dr. Snyder: The smoking rather than the vaporizing.
Dr. Mikuriya: Right unfortunately.
Dr. Snyder: Is the equipment that they need to vaporize costly?
Dr. Mikuriya: It varies from virtually nothing if you are using concentrated hash oil to slightly under $100 or $300 for a unit that effectively does hot air extraction of the active ingredients, which I recommend.
Dr. Snyder: So, if they are going to use just the plant, they will need a device that costs $200+?
Dr. Mikuriya: Well they can get by with lesser quality units but . . . I have a collection of every vaporizer that is on the market that I have been able to purchase and the hot air gun types are much more efficient. You are looking at a model called the Volcano made in Germany.
Dr. Snyder: How do they get these? How do they purchase a vaporizer?
Dr. Mikuriya: Well, ordering over the internet is probably the least worst alternative for people that live in isolated areas, or to go to the open buyers co-op in downtown Oakland that has a pretty complete line. I recommend that they visit my website and look at the pictures and read what I have written so far.
Dr. Snyder: Is this a pretty standard recommendation?
Dr. Mikuriya: Yes.
Dr. Snyder: We talked about follow-up, examination with her, you mentioned her date and so forth.
Dr. Mikuriya: And her clumsiness, and her emotional lability and easily upset; that she was very dependent on her long-time husband, [redacted], for emotional support. A very nice couple.
Mr. Campbell: Was she under the care of any other physicians at this time?
Dr. Mikuriya: No.
Mr. Campbell: What about [redacted]? I don't know if we mentioned [redacted]?
Dr. Mikuriya: No.
Mr. Campbell: Absolutely no other medical care? You were their prime source of medical care?
Dr. Mikuriya: For the knowable past. I mean they were not having any kind of medical contacts at all for many years.
Mr. Campbell: Okay. And these injuries . . . let me regress to [redacted] for a minute, the injuries that he had received in the automobile accident you mentioned?
Dr. Mikuriya: I believe so.
Mr. Campbell: Do you know if he had any treatment for those injuries? Were there any existing medical records? Were there any x-rays taken of these injuries? Were these injuries that he claimed to be suffering pain supported in any way?
Dr. Mikuriya: I don't believe that he had collateral medical documentation. I was going on his word.
Mr. Campbell: So you basically took him at his word that he had sustained these injuries - that he was needing treatment for them as you provided?
Dr. Mikuriya: Yes, correct. People like [redacted] and [redacted] are just really very on the edge financially in an under served area.
Mr. Campbell: Okay.
Dr. Snyder: I am thinking about regular routine care as far as mammograms - she is in her fifties or so - those kinds of things. Do you get into that kind of discussion with folks? As far as you need to get a doctor or go to a clinic?
Dr. Mikuriya: No. If there is something that pertains to the conditions for which they are presenting.
Dr. Snyder: But as far as routine health care . . .?
Dr. Mikuriya: Right, but not for these other matters.
Mr. Campbell: You mentioned that there are - that the [redacted], are of a type of person or - I am hesitant to say class of people, but are individuals who are extremely limited financially. Do you have some sort of a sliding scale? How do you do your billing with these folks?
Dr. Mikuriya: Yes, I do as a matter of fact - a sliding scale - if they can't afford it, it might be zero.
Mr. Campbell: Because I noticed none of your records contain any reference to billing other than some of them contain reference to your subsequent services in providing testimony at some sort of criminal hearing?
Dr. Mikuriya: Yes.
Mr. Campbell: In the [redacted] files, is there any reference there that you provided subsequent testimony for them? Realizing that - we can go back to the file if you want.
Dr. Mikuriya: Yes, let's go back to the file.
Mr. Campbell: Realizing that both these folks had . . .
Dr. Mikuriya: Both referred by Tehama County. Big mistake to leave Arcada and to the valley.
Mr. Campbell: Yeah, they both had criminal problems in Tehama County.
Dr. Mikuriya: Right, problems with the DA in Tehama County and the lack of any training and information bulletins or general orders for the police.
Mr. Campbell: Do you want to do this one?
Dr. Mikuriya: Yep, there is Lindstrom's name all over it.
Mr. Fleer: Did you do any testifying or writing letters for either of them?
Dr. Mikuriya: Oh yeah, we did a duces tecum for their court case up in Tehama. Yes.
Mr. Campbell: So you went to Tehama County?
Dr. Mikuriya: No, no. We did a duces tecum sending of the medical records.
Mr. Campbell: So you provided him the records?
Dr. Mikuriya: Yes.
Mr. Campbell: I see. Were you required at any time to go forthwith to Tehama County and provide testimony?
Dr. Mikuriya: Fortunately because of vigorous actions by my defense attorney, the answer is no.
Mr. Campbell: By your defense attorney? Did you have a defense attorney in that matter?
Dr. Mikuriya: Well no, it's a question of managing abusive subpoenas from different criminal justice entities.
Mr. Campbell: I don't know if I understand that?
Dr. Mikuriya: Okay. They are saying show up and be a percipient witness for this person and we are not going to pay you expert witness fees. I got suckered by that a few times, what I call milking the cow through the fence syndrome, by different prosecutors where I get up on the stand as a supposed percipient witness and I am asked all these expert witness kinds of questions and then I am stuck because nobody is going to pay for that. If we have any understanding before I go to the court, then this will not happen. But when the prosecutor and the court become aware that I am aware of expert witnesshood, then the picture changes. They are not nearly as enthusiastic to get me up there in person because if they did and they went beyond, "Is that your signature,?" or "Are these your records,?" I would say, "I am sorry. I can't answer that. We are going to have to stop, and I am leaving."
Mr. Campbell: Okay. You are saying that - if I understand you right - then that there is a dividing line between your merely testifying on behalf of a patient that you issued a recommendation based upon your medical finding, and if they go past that issue, your belief is that you are entitled to expert witness fees? Is that correct?
Dr. Mikuriya: If asked anything beyond, "Are those your records," or "Is that your signature?"
Mr. Campbell: Okay.
Mr. Fleer: That is the law as I understand it too.
Mr. Campbell: I am just trying to clarify.
Dr. Snyder: So these folks did have a hearing? This husband and wife, the [redacted], and you provided documents that you generated, that we have seen. Did you write any other . . .
Dr. Mikuriya: Just as required for filling out the forms for the submission to the court in a sealed envelope with a copy that goes to the defense attorney, and one that goes to the prosecutor.
Dr. Snyder: But not any other documents that you generated other than what is required?
Dr. Mikuriya: No.
Dr. Snyder: Since we are about out of tape, why don't we go ahead and take our break now.
Mr. Campbell: Take our lunch break?
Mr. Fleer: Yes.
Mr. Campbell: Okay. It is 12:02.
(TAPE 3)
Dr. Mikuriya: It appears to be recording. Let the record so reflect.
Mr. Campbell: Let me turn ours on.
Dr. Snyder: I think we finished with these two, and this is a third person with the last name, [redacted].
Dr. Mikuriya: Oh, a different [redacted].
Mr. Campbell: Let me preface the tape here. Today is the 6th of February, 2002. It is 12:47 in the early afternoon. My name is Tom Campbell and this is tape 2 of an interview of Tod Mikuriya. Present is Dr. Mikuriya; his attorney, John Fleer; and Dr. Snyder of the Medical Board, and myself. We are going to continue on and the next patient we are going to review is [redacted].
Dr. Mikuriya: This is a 49 year old, once single, Christian Scientist plumber with one year of college who presented with the problems of insomnia and back pain on 2/7/97. He had a history of back pain with scoliosis; he was rejected from the Army for this. He had some chiropractic adjustment. But his other problem was being on probation for marijuana cultivation. Also he had significant problems with numerous tooth extractions. Again he was (inaudible) after the military. His father had died of a CVA five days prior to the interview, and he was stated as post cardiac bypass surgery but not with a good outcome. He also had a history of Federal prison from 12/95 to 5/96 for marijuana possession with intent to distribute. His support system was his friends, but he was currently living alone. His mental status - he had no communication barriers; he was fully ambulatory; capable of self-care; looked his stated age; weight was normal; the rest of his appearance was unremarkable; he was oriented x3, x4; he had some difficulty with proverbs and showed some abstract thinking deficit; he was depressed in his presentation and anxious; his strengths and assets included his supportive group - his family. Primary Diagnosis was adjustment reaction with depressed mood, scoliosis, recurrent pain with muscle spasm, and grief from the recent death of his dad. Formulation, Treatment Plan and Recommendations - he was morally opposed to taking prescribed drugs because of his religious beliefs, but he accepted my prescription for Marinol 10mg #30 with 1hs prn for insomnia, back pain and muscle spasms. His Symptoms were nausea, diarrhea, cough, anxiety, panic attacks, depression, lethargy, weakness, complaint of spinal cord injury, migraine, hypertension, and problems with blood sugar management, apparently being a Type II, but managed with oral medications; he was helped by massage and I recommended that he continue. Family Background - he stated that his mother drank and smoked during pregnancy, and she was still drinking less than before, but she had stopped smoking. He was apparently on probation and he was having dirty tests on marijuana and I guess hoped that this would somehow ameliorate that situation with his probation.
Dr. Snyder: That having the prescription for marijuana?
Dr. Mikuriya: Yes, well recommendation - oh, for Marinol, definitely. I have discovered that certain Federal agencies are very hostile towards recommendations and approvals for medical marijuana but a fully accepting of Marinol because of its legal status.
Dr. Snyder: So he was seen in early 97?
Dr. Mikuriya: Yes.
Dr. Snyder: Do you recall where he was seen? What type of facility?
Dr. Mikuriya: No. I don't recall, but I recommended that he vaporize and use oral cannabis to decrease the irritation to his lungs.
Dr. Snyder: Is this a second visit or on the same?
Dr. Mikuriya: This is a follow-up now.
Dr. Snyder: On the first visit you prescribed the Marinol?
Dr. Mikuriya: Yes.
Dr. Snyder: When was the date of the follow-up?
Dr. Mikuriya: The follow-up was 3/17/99.
Dr. Snyder: So, two years later?
Dr. Mikuriya: Right.
Dr. Snyder: So at that point you recommended that he vaporize and do oral?
Dr. Mikuriya: Yes. He was sleeping better, his mood was more even. At that point in time, he had 50 days left on his probation, and they had accepted the Marinol prescription. This has made it easier on others. Then I had a phone follow-up on 3/13/00. He continued to use cannabis at the rate of seven times a day and was using 42 grams a week and considered it to be very effective. One of his presenting complaints was labile blood pressure, and he feels it was helpful in controlling his blood pressure fluctuations.
Dr. Snyder: Was he taking his own blood pressure or getting it done at a doctor's office or a store?
Dr. Mikuriya: Let's see, my records do not reflect that he was taking other medication for his blood pressure.
Dr. Snyder: Was he measuring his blood pressure?
Dr. Mikuriya: He stated he was.
Dr. Snyder: Oh, he was taking his own blood pressure. Did you measure his blood pressure?
Dr. Mikuriya: No. I did not.
Dr. Snyder: And the oral hypoglycemic medication he was taking, do you know what that was?
Dr. Mikuriya: I do not have this noted in my files.
Dr. Snyder: You mentioned he was a Christian Scientist and he was opposed to prescription medicines. Do you know if he was opposed to seeing medical practitioners, obviously other than you?
Dr. Mikuriya: I don't know.
Dr. Snyder: Your initial prescription for Marinol for him?
Dr. Mikuriya: 10mg, #30 1hs for insomnia, back pain and muscle spasms.
Dr. Snyder: And how long would that have lasted? Was that a month's supply?
Dr. Mikuriya: Yes.
Dr. Snyder: Was that refilled?
Dr. Mikuriya: No.
Dr. Snyder: And his recommendation certificate? When was that issued?
Dr. Mikuriya: The first one was 2/17/97 I believe. The second one . . .
Dr. Snyder: 2/17 or 2/7?
Dr. Mikuriya: 2/17/97.
Dr. Snyder: I wrote down the date of your first meeting as 2/7. Is that correct?
Dr. Mikuriya: 2/17/97.
Dr. Snyder: The meeting and the recommendation happened on the same day?
Dr. Mikuriya: Yes.
Dr. Snyder: So you wrote out the Marinol but you also provided the recommendation on the same - at the initial meeting?
Dr. Mikuriya: Yes.
Dr. Snyder: And why was that?
Dr. Mikuriya: To see if Marinol would do the job that he was taking marijuana for. Anytime I can switch somebody from a smoke group to the oral group, I take advantage of that because there is less irritation to the throat and lungs.
Dr. Snyder: And what was his experience with the Marinol? Do we know?
Dr. Mikuriya: It worked. He was sleeping better, mood more even, He wanted to have the recommendation and approval for the crude cannabis because Marinol is not cheap.
Dr. Snyder: Do you know what a month's supply is?
Dr. Mikuriya: $8 or $9 a capsule.
Dr. Snyder: Is that those prices? Is that 97 or is that 2002?
Dr. Mikuriya: That is still. Listen, they have got this monopoly. The irony is when we have a prescription drug that is more expensive than so called illicit materials, there is something strange going on.
Dr. Snyder: I think that's it. The duration of insomnia. How long had he had that?
Dr. Mikuriya: Gee, I don't know. The first visit was complicated by the fact of his just recently having lost his dad.
Dr. Snyder: He had scoliosis. Did you examine his back?
Dr. Mikuriya: Yes.
Dr. Snyder: How do you know that you did?
Dr. Mikuriya: Always when someone says they have scoliosis, they show me their scoliosis.
Dr. Snyder: Did you write it in the chart?
Dr. Mikuriya: Um, Yes.
Mr. Campbell: What did you say in the chart?
Dr. Mikuriya: Scoliosis, recurrent pain and muscle spasm, and axis 3 of his mental status examination.
Mr. Campbell: That is just what he filled out? Is that right?
Dr. Mikuriya: No, no.
Mr. Campbell: This is your writing?
Dr. Mikuriya: The psychiatric examination is what I filled out.
Dr. Snyder: Okay. Thank you.
Mr. Campbell: The next one we would like to look at is [redacted].
Dr. Snyder: Do you have any independent recollection of that?
Dr. Mikuriya: Part of a family that have received different letters of recommendation and approval. Okay - this was a 30 year old white, married Protestant homemaker with a 10th grade education plus GED, who presented with depression and chronic or lengthy abusive relationship. She had tried Prozac in the past but this caused anorexia, nausea and vomiting. She also had a medical history of dysmenorrhea since puberty. At age 17, she discovered that cannabis has helped her symptoms.
Dr. Snyder: What age?
Dr. Mikuriya: At age 17.
Dr. Snyder: Helped the dysmenorrhea or?
Dr. Mikuriya: Yes. She was involved in an eight year long abusive relationship from age 16 to 24. Additionally, she was given away at age nine months and abused by her adopted family. Her adoptive parents then divorced and she went to live with the father but he abandoned her. She had lived in foster group homes from age 12 through age 16. She had taken 15 different psychotropic agents in the past. Her mental status, her constitutional appearance was obese, 64 inches tall, weighed 160 lbs. Grooming was normal; hygiene clean; fully ambulatory; no communication barriers; total self-care; oriented to place, time and person; no evidence of hallucinations or abnormal psychiatric symptoms; she had good abstract thinking ability, and despite this horrendous background, a relatively positive outlook. But she did have serious recurrent problems of depression, and I recommended in my treatment plan weight reduction and continued cannabis. Follow-up 9/99. Her symptoms on anxiety, menstrual pain, and depression were doing okay. She had increased to 30 grams per week from 20 grams. She was not taking any non-prescribed psychotropics except for a cup of coffee a day. She had unfortunately run afoul of the law with 177 plants, raided and charged 12/31/98, along with her boyfriend. Otherwise, she was making okay progress and the next follow-up visit was a phone follow-up on 12/8/99, I'm sorry, December 5, 2001. Both her major depression recurrent and her dysmenorrhea remained improved as far as no or lesser symptoms. She was still smoking, not vaporizing any or eating any. She described gradual but continuing improvement, decrease in depressive symptoms. She was happy with her children and being a mother. I described her efficacy of treatment as being excellent and recommended that she vaporize at less than 360 degrees Fahrenheit. I guess that was it until she got a subpoena. I don't know. If she was one of the ones that consented, I don't know.
Dr. Snyder: Does she have a letter from you in there about . . .?
Dr. Mikuriya: No.
Mr. Fleer: A letter from Dr. Mikuriya.
Dr. Snyder: That's what I mean.
Dr. Mikuriya: It's to me, from investigational subpoena duces tecum to produce papers and documents before the Department of Consumer Affairs, State of California.
Dr. Mikuriya: Dated? What is the date?
Mr. Campbell: Her records were subject to the subpoena?
Dr. Mikuriya: Right.
Mr. Campbell: As a matter of fact, this is the one record that somehow got overlooked when I picked up the initial box of records at your place and you subsequently mailed this one up to me.
Dr. Mikuriya: That probably explains it, I think.
Dr. Snyder: When you evaluated her for depression initially, did you ask her about suicidal ideation?
Dr. Mikuriya: If they seem really depressed, I do. But, she didn't seem that depressed, and this had been going on for a long time with all these other things happening in her life. Its strange that people who come from abusive and dysfunctional background - unless they become borderline personalities and act out a lot - usually, at least I have not encountered in my clinical experience increased suicidality.
Dr. Snyder: Do have any recollection of how long your interview with her would have been? I know we talked about this (inaudible).
Dr. Mikuriya: I don't recall. At least a half hour for the initial, I'm sure.
Mr. Campbell: Typically, a patient - and we can talk specific if necessary - typically, a patient would come to you with this form already completed; is that right?
Dr. Mikuriya: Yes.
Mr. Campbell: I think we went over that before too. They come to you with the form completed and you review it with them?
Dr. Mikuriya: Yes.
Mr. Campbell: The next patient that we are going to look at is Patricia [redacted].
Dr. Snyder: Do you have an independent recollection of this patient?
Dr. Mikuriya: I have independent recollections of how she was being hassled in Napa County for a cultivation case, and then she moved to Nevada County and apparently had continuing efforts to get out from under the scrutiny and punishment of different criminal justice entities.
Dr. Snyder: Was this cultivation for self-use only?
Dr. Mikuriya: I don't know. I hope so. I am trying to find the original form.
Dr. Snyder: You mentioned a quantity with one of these patients. I don't know if it was the last one or the one before. The one that went from 20 grams to 30 grams. And that's a week?
Dr. Mikuriya: Um hum.
Dr. Snyder: What plant-wise would be needed to provide that?
Dr. Mikuriya: Gee, I don't' know. Really it would depend on the potency and the quality. But going from two-thirds of an ounce to an ounce roughly, like 28.5 grams in an ounce. So, going from two-thirds of an ounce . . .
Dr. Snyder: I know, but I'm trying to ascertain how many plants would it take to provide let's say a month's worth at this rate, or what fraction of a plant?
Dr. Mikuriya: Sorry, not in my area of expertise. I'd talk to Ed Rosenthal perhaps.
Mr. Campbell: A six to eight foot plant would product about four pounds.
Dr. Snyder: Okay, so one pound would be more than a year's supply. I mean, one plant would be more than a year's supply?
Mr. Fleer: Well, that is a big plants Tom grows up his territory.
Dr. Snyder: Right.
Mr. Campbell: It is difficult to say in how much, time-wise, a plant would provide. The numbers that have generally been presented to me is that a plant is worth about $4,000 right now.
Dr. Snyder: A single plant?
Mr. Campbell: A single plant.
Dr. Snyder: Because it produces how many pounds? Four to six pounds?
Mr. Campbell: Yeah, a plant will produce somewhere between four pounds and up of finished, high-quality bud. The plants that are being produced today are extremely potent in THC as compared to plants that were being grown early, ten years ago.
Dr. Mikuriya: That is not true really because of the fact that the potency is a function of both the plant and how it is being stored and what part of the plant it is. There are some plants that have the right kind of appearances, but in fact, are virtually a placebo. They were working with different strains in Europe, experimenting with different illnesses and they developed strains that were highly resinous but had absolutely no psychoactive effects. One never knows when one puts a seed into the ground, or takes a clone from somebody what kind of results are going to happen because there is a lot of variability among plants and crop failure is an issue. It is really very inconstant. That is why I put in my recommendation, my updated form, that they should cultivate more than one strain for comparative efficacy purposes because you can't go down to the pharmacy and get a known amount. That is why we don't have any prescribing. That is why it is recommendation and approval rather than prescribing. I wish I knew. It would be ideal to have this. Then we would be able to talk in normal kinds of dosage terms; we would be talking in terms of realistic amounts. Right now it is kind of fumbling in the dark and the irony is that we have a great variety of ideas as to what the amount should be depending on different usually criminal justice entities and their judgment calls that are from the whole cloth for the most part.
Dr. Snyder: But from what was reported to you, this is a weight; it's not a strength so this person was using roughly two-thirds of an ounce a day and increased to roughly one ounce a day?
Dr. Mikuriya: No, a week.
Dr. Snyder: I'm sorry, a week. Of whatever it was the strength of the plant that she was using? So by weight, she was using roughly one ounce a week? That is 52 weeks . . .
Dr. Mikuriya: Let's see, where was I in describing [redacted]?
Dr. Snyder: I think we had just started when I had that question about the plants.
Dr. Mikuriya: Born [redacted], with 12 years of school and an occupation as an auditor. There was a history of alcoholism in the family of both parents. Mother died of cancer - age 72. Father died at age 76. She presented for migraine with a classical pattern of premonitory photophobia and left frontal beginning with it being immobilizing. Also persistent insomnia and then her alcoholism that she admitted to. Also a nicotine habit.
Dr. Snyder: Do you know how much she was drinking at the time you saw her?
Dr. Mikuriya: Let's see, how much was she drinking at the time? Yes, three or four, fifth's of whiskey a week, drinking solitary. I recommended discontinuing alcohol and vaporizing her cannabis and follow-up in 6 to 12 months. The kind of follow-up I got was from Napa duces tecum from Napa County which was, of course, complied with. Then I also have follow-up with her on 4/10/99 and she was at that point in drug diversion in Grass Valley.
Dr. Snyder: Criminal drug diversion?
Dr. Mikuriya: Apparently. I prescribed Marinol 5 mg 1 or 2 q 6 prn #10 to see how that might substitute for cannabis. Oh yes, her attorney, Don Laughridge, said that the DA's office said, "We know all about him," referring to me. Eight police and the Assistant DA, Anthony Perez, paid her a visit.
Dr. Snyder: So on the 10th of April, 1999, you prescribed her a trial of Marinol.
Dr. Mikuriya: A trial of Marinol, 5 mg.
Dr. Snyder: They only 10. Then what happened after that?
Dr. Mikuriya: I haven't seen her since. I have no idea.
Mr. Campbell: She hasn't returned to you?
Dr. Mikuriya: No.
Mr. Campbell: Do you have any idea why?
Dr. Mikuriya: No I don't. She may have found another doctor up in her neck of the woods like Dr. Bannister, whom you are familiar with.
Mr. Campbell: Surprisingly, what she told me over the telephone was that she was no longer seeing you because she found out that you were a psychiatrist and she wanted to see a doctor who could care for her medical problems.
Dr. Mikuriya: Alright.
Mr. Campbell: She got a good referral.
Dr. Mikuriya: Huh, that is interesting. I hope she is off probation now and they are not chasing her from those two counties. She is really a very severe alcoholic I was very concerned about her.
Dr. Snyder: When you made the recommendation for her to stop alcohol and you obviously discussed the Marinol and so forth, did you make any other recommendations about AA or other kind of group or support or doctor?
Dr. Mikuriya: Of course, but she was in no shape at that time to take those kind of recommendations because she really did not appear to be ready to stop drinking.
Dr. Snyder: And how did you assess that?
Dr. Mikuriya: By her responses and her attitude towards different suggestions.
Dr. Snyder: Do you know if the drug diversion entails that kind of requirement - the drug diversion that she was in?
Dr. Mikuriya: I do not know. Oh yes, an entry in my database - 8/18/99, learned that I am targeted by Napa DA, Anthony Perez.
Dr. Snyder: What does that mean?
Dr. Mikuriya: I was just part of his ongoing vendetta that involves the 11 Northern California Counties.
Dr. Snyder: Do you perceive that to be against you or against your patients?
Dr. Mikuriya: It really depends on the situation. I mean, none of the patients have been free from involvement from criminal justice entities, and that is what sets them apart. So . .
Mr. Fleer: None of the ones. . .
Dr. Snyder: None of the ones we are talking about.
Mr. Campbell: You mean everyone that we are talking about has problems with the court?
Dr. Mikuriya: Yes. I mean this is where all the referrals came from. You didn't have any of the patients' families complaining, didn't have any patients complaining, didn't have any family physicians or treating physicians complaining; it all came from the criminal justice entities in these 11 counties that wanted to illegitimately expand and extend their investigatory reach.
Mr. Fleer: And if I might just add on the issue of vendetta Dr. Snyder, I think you might be concerned if Dr. Mikuriya is paranoid or whatever himself, there is documentation as far back as 97 where the Attorney General has put out a request to forward any recommendations that they are aware of that Dr. Mikuriya has made to the Attorney General's office. I think in that light, it would be natural for somebody to see themselves as being the target of, whether the word is vendetta or extra-special attention, I think that is where that comes from.
Mr. Campbell: Is that a written request out of the AG's office, because I haven't seen it?
Dr. Mikuriya: Well, maybe this is an appropriate time.
Mr. Fleer: Let's start it going then.
Dr. Mikuriya: That's right, well now that you have. . . now that you have opened up Pandora's Box . . . This in fact is from the General's predecessor.
Mr. Fleer: Just identify that.
Dr. Mikuriya: This, identified for the tape is Daniel E. Lundgren, Attorney General, State of California, Department of Justice, Proposition 215 Update: No.9, Date: October 28, 1997. The last paragraph in this 8 page communique says, "If your jurisdiction has received recommendations signed by either Dr. Eugene Shoenfeld or Dr. Tod Mikuriya, please notify John Gordenier at (916) 324-5169." Guess who Deputy Attorney Simon and Mercer used to work for? John Gordenier. There are their names here on People versus Dennis Parone [sic]and Beth Moore, Deputy Attorney General Jane Zack Simon and Deputy Attorney General Larry Mercer, Senior Assistant Attorney General John Gordenier. So, I am providing this to you.
Mr. Campbell: This is a copy we can have?
Dr. Mikuriya: Yes.
Mr. Campbell: Thank you.
Dr. Mikuriya: It is clear that since that time, there has been this ongoing effort with certain individuals within the AG's office to block implementation compliance with 215 and the Compassionate Use Act of 1997 that I am specifically named and specifically solicited from all of these different enforcement sources and indeed they have complied. That is where your trip up north came from. I guess February 2000, when things got rolling up in Tehama County. This is an ongoing effort by the AG's office, and I feel that the Medical Board is being used. That it is caught in the middle trying to do the bidding of this clique of individuals withing the criminal justice system that owes their allegiance not to the law, but to other special interests such as the California Narcotics Officers Association.
Dr. Snyder: I think it is probably time for us to get back to the remainder of these cases, but obviously this is recorded and will add the document to the file.
Mr. Campbell: We do appreciate your concerns in regards to the interpretation of enforcement of 215, but that is not our goal here. Our goal is merely to make the determination as to whether or not you are practicing good and safe medicine. The issues are 215 are issues for other people to handle.
Dr. Mikuriya: But they contaminate the proceedings here because, what happened after our last interview, Jane Zack Simon calls Susan Lea angrily with all sorts of threats and also calls up attorney Fleer here with other complaints and efforts to influence the investigation. Judging from where she is coming from, this really seems like a continuation of this departmental problem and the Medical Board get caught.
Mr. Campbell: Well, I certainly hope that is not the case because - I'll repeat myself - our single goal here is not to make a determination as to the legalities or the correctness of Proposition 215, but to make a determination through the investigative process as to whether or not you are practice of medicine in this regard is proper, is safe, and is in the best interest of your patients. I think that Dr. Snyder shares that goal with me and that's the goal that we are looking at. With that we need to go through a few more. This next patient that we will look at will be [redacted].
Dr. Mikuriya: Oh yes, [redacted].
Dr. Snyder: My notes on him appear to be in another location. Here we go - wait. Okay let's go ahead.
Mr. Campbell: Have we been through that area? No.
Dr. Mikuriya: Okay, [redacted]; Date of Birth: [redacted]; He is definitely a male, although he mistakenly put female on his first page. Two years of college; nuclear power school in the Navy; lasted 18 months in the military; did not have Vietnam service; was the recipient of a General Discharge indicating there were problems; lists his religion as Pagen; did not state that he was an adult child of alcoholic family. Presenting problem was depression and bipolar disease that had been treated with Librium, lithium, Serzone, Effexor and 3 years counseling. Also his other problem of HIV and nausea. He had gone through AZT, 3TC, and other antivirals. He expects at that time to undergo other kinds of antiviral therapy. He discovered after beginning cannabis use at age 19 in a social context - he discovered that it was useful for treating his symptoms of bipolar illness when he was 46 or 47 brought on by discovering that it stopped his obsessive thinking.
Dr. Snyder: Do you know when he last had any of the medicines that you listed, the lithium . . .?
Dr. Mikuriya: I do not know.
Dr. Snyder: Under the care of another psychiatrist?
Dr. Mikuriya: He listed two.
Dr. Snyder: Did you communicate with them or have any records?
Dr. Mikuriya: He would not let me.
Dr. Snyder: Do you know why?
Dr. Mikuriya: I don't know, but a lot of patients don't want me to communicate because of fear of being rejected, kicked off their health plan. Believe me, I wouldn't be doing all these examinations if we had other physicians who would be willing to step forward and do them.
Dr. Snyder: Did you have any documentation about his HIV status?
Dr. Mikuriya: No, I relied merely on what he told me. He did not supply me with any collateral documents.
Dr. Snyder: Do you know whether the doctor who was treating him, providing his antivirals, refused to approve cannabis or whether it was ever brought up?
Dr. Mikuriya: I do not know. He stated the use of cannabis has been almost lifelong as a means of self-medication for depression and anxiety, possibly brought on by post-traumatic stress of early childhood experiences.
Dr. Snyder: And that is in his handwriting?
Dr. Mikuriya: Yes. So here we have an man with HIV positive status, plus this chronic mood disorder.
Dr. Snyder: And the recommendation for him?
Dr. Mikuriya: To take it orally and vaporize and to see me in 6 to 12 months.
Dr. Snyder: Did you see him on more than one occasion?
Dr. Mikuriya: No. but we submitted to Tehama County to Ms. Lynn Stromm, the Deputy DA duces tecum for records. [redacted] on 7/8/01 wrote a letter to me saying, "To Whom It May Concern: I do not want my medical records to become public and I do not give my permission for release of my records to the Medical Board of California."
Mr. Campbell: Do you know if [redacted] was under the care of another physician for his HIV?
Dr. Mikuriya: I assume he was, but I did not know him.
Mr. Campbell: You don't know if he was or if he was not, is that right?
Dr. Mikuriya: I don't know.
Mr. Campbell: So you wouldn't know then if he was under the care of another physician, what medications he was taking?
Dr. Mikuriya: That is correct. The patient described presently using Effexor. Previously using lithium, Serzone and Librium. Then presently using flax oil, and no longer using three different, four different antiviral preparations.
Mr. Campbell: And how is it that this particular patient came to your attention? Was he referred by somebody or (inaudible)?
Dr. Mikuriya: I think he was referred by one of the cannabis centers.
Mr. Campbell: Okay. Did you see him at one of the cannabis centers? Do you recall?
Dr. Mikuriya: I don't recall.
Mr. Campbell: He is from where?
Dr. Mikuriya: Rio Nido.
Mr. Campbell: Rio Nido? That is in . . .?
Dr. Mikuriya: Is that Sacramento County?
Mr. Campbell: Its in the Delta, isn't it?
Dr. Mikuriya: Somewhere.
Mr. Campbell: I could figure it out but . . .
Dr. Mikuriya: And we provided duces tecum records to, as I mentioned, to Tehama County.
Dr. Snyder: What was he in trouble for, possession?
Dr. Mikuriya: Let me see, what was he in trouble for? It doesn't say.
Dr. Snyder: So he was using complimentary medicine and not taking his antivirals anymore?
Dr. Mikuriya: He was I believe taking some of his antivirals. Let's see, which one was he . . . No, he was not using antivirals at the time he consulted me but indicated that he was planning to go through another series of them.
Dr. Snyder: Oh, okay. Do you know if he had symptoms of the disease or just a positive . . .?
Dr. Mikuriya: Yes, he had anorexia, chronic anorexia.
Mr. Campbell: You only saw [redacted] on one occasion, is that right?
Dr. Mikuriya: Yes.
Mr. Campbell: And that was June 14 of 99?
Dr. Mikuriya: I've got 1/26/00. Something is going on here.
Mr. Campbell: What I am looking at here is a recommendation that was presented with your signature on it dated June 14, 1999. Maybe we don't have all the records here. Why don't you take a look at that and I will flip our tapes over.
Dr. Mikuriya: Wait a minute now, this is a different person.
Mr. Campbell: Is that a different person?
Dr. Mikuriya: [redacted]. This is [redacted].
Mr. Campbell: Maybe I misread the name, and caused you a heart attack! Let's go off the tape for a minute and we will straighten this out and put on a new tape. It is 1:41 in the afternoon.
(TAPE 4)
Mr. Campbell: It is 1:45 and we have turned the tape over. We are going back on. All are present, Dr. Snyder, Dr. Mikuriya, Mr. Fleer, and myself, Tom Campbell. Any comments on the other side of this tape regarding a recommendation issued to [redacted], there was some confusion on my part and that is in fact incorrect. Dr. Mikuriya saw [redacted] on a single occasion and my comments were in fact incorrect. So we will go onto the next patient. The next patient is [redacted].
Dr. Mikuriya: Okay. I saw the lady whose birth date is [redacted] on 5/25/99 with the presenting complaints of neck pain and pressure on different nerve roots. This is a CNA single parent with . . .
Dr. Snyder: CNA?
Dr. Mikuriya: Certified Nursing Assistant. She denied coming from an alcoholic or abusive family. Her parents were loving. Her mother has hypertension, degenerative spinal disorder, and gallbladder problems. Her sister, age 23, already had gallbladder removed; sister, age 20, has problems with acid reflux disease. She had an ovarian cyst removed and tubal ligation, gallbladder attacks, and chronic sciatic nerve problems with muscle spasms.
Dr. Snyder: This is the patient herself?
Dr. Mikuriya: Yes. Her presenting problem was sciatic nerve irritation. She had taken in the past Vicodin which had caused upset stomach and gallbladder reflux; Soma, but she was unable to function because of its sedation; Tylenol 3 caused dizziness; Motrin, gallbladder problems; cold compresses for some relief. Her symptoms were aggravated by bending and stooping. She was apparently undergoing a neurological work-up for this condition and there was a question of an epidural anesthetic that she had in the past possibly aggravating this condition. She also complained of another concurrent condition of hypertension.
Dr. Snyder: At the age of 20 something?
Dr. Mikuriya: Yes, I guess she would have been 28 at the time. So my treatment plan for her was to change to oral and vaporize and open up a case with the Department of Rehab. I don't know if she ever did though.
Dr. Snyder: That was your recommendation to her, to go to the Department of Rehab?
Dr. Mikuriya: Yes. So she was seen on only one occasion, but she was apparently living with a man who had some legal issues. Another patient of mine, [redacted].
Mr. Fleer: Is he one of the ones that we couldn't produce?
Dr. Mikuriya: I think he was one of the patients in the group here, [redacted].
Dr. Snyder: That does sound familiar. Yes, we did have his records.
Dr. Mikuriya: Right. Her letter to me dated June 14, 1999. Re: [redacted]. I need two prescriptions written out so [redacted] probation officer can understand it. I received one before for [redacted], but can't use it because we grow outdoors. I need it to say 40 plants a year for [redacted] and 40 plants a year for me. Don't specify flowering because we are having trouble making the cops understand what that means. Just 40 each year. We will describe the other prescriptions. My name is [redacted] and [redacted] and I both have prescriptions, which is of course incorrect, recommendations and approvals. Also, I am wondering if you could help [redacted] get some pain medication in jail. The cops won't give him his medication like they are supposed to and the meds in jail are not strong enough. Thank you very much for your time.
Dr. Snyder: Do you have any recollection about that? About how you responded to that letter?
Dr. Mikuriya: I don't know what happened. I don't have anything except that letter I sent saying that your case was turned over to the Medical Board. You know, that form letter I sent out.
Dr. Snyder: Does your recommendation and approval letter have a specification for a certain number of plants?
Dr. Mikuriya: Not usually. No.
Dr. Snyder: Did you provide them
Dr. Mikuriya: Yes.
Dr. Snyder: . . .with a letter that said . . .did you provide them with a different letter?
Dr. Mikuriya: I asked . . . I put down in my physician statement, 20 plants yearly.
Dr. Snyder: For this one?
Dr. Mikuriya: For this one because they asked. I thought it was reasonable so I went ahead and did it. Sometimes the patients would have situations where they were involved with somebody from the criminal justice system that would want some specific number to be on the paperwork. So, if I thought it reasonable, I would certainly oblige.
Dr. Snyder: Do you think that 40 plants was reasonable?
Dr. Mikuriya: Certainly. It really depends on their maturity and, again, this issues of flowering or not because you can have a whole bunch of little seedlings that are not worth anything. This is part of the problem with the ambiguity of . . .
Dr. Snyder: So that addition to the recommendation was at the patient's request? The one that we have a copy of for 20 plants?
Dr. Mikuriya: Yes.
Dr. Snyder: Do you have any concerns about your patients cultivating for distribution?
Dr. Mikuriya: This is always a possibility but it is something I really can't take responsibility for. It is their responsibility. I can merely fulfill my obligation as a physician.
Dr. Snyder: I have a hypothetical situation to ask you and I think I'll just. . . . I'll just go ahead and ask it. It is totally hypothetical. Is there an amount? If they said would you write it for 100 plants or 300 plants, is there a level beyond which you wouldn't think it was reasonable? If you think both 20 and 40 for a single individual or a couple ?
Dr. Mikuriya: I don't feel comfortable writing for any large amounts, and I would never write for 100 on . . .
Dr. Snyder: Fair enough.
Dr. Mikuriya: But something that was within what the Oakland guidelines recommend, I would feel very good about that.
Dr. Snyder: And what is that?
Dr. Mikuriya; The original Oakland guidelines were six and a half pounds per year and 90 plants of different levels of maturity, but this was specified as to how many of which. I don't recall the exact numbers for each category.
Dr. Snyder: The original Oakland recommendations, was that 97 or prior to that?
Dr. Mikuriya: I think it was prior to that; well no, I guess it was around 97. I can't give you the exact date because, again, this is a work in progress and we have the Oakland working group of which I am a member and we are still negotiating the right kind of general orders and training and information bulletins for the Oakland Police. This is definitely a problem for the beat officer to make this judgment call and the more guidance he or she has from supervisors, the happier we are.
Mr. Campbell: In regards to recommending a specific amount, we have talked about each of these cases and I don't recall whether we looked at each one individually, and I don't believe we have, as to whether you have actually put some limitations on it. The way I've read the majority of these is that once you write a recommendation, the recommendation is that there are no time constraints, amount constraints or anything on it. It is just a recommendation which pretty well leaves it wide open. Is that an unfair statement?
Dr. Mikuriya: No.
Mr. Campbell: So with your recommendation then, it would stand forever. A person need never come back to you or to another health professional, but would have a recommendation to utilize marijuana for the remainder of their lives on earth?
Dr. Mikuriya: Well, that's a possibility, but again its different from prescribing since we don't have any specific amounts, we don't have a pharmacy where one could fill the prescription, so it really doesn't work the same way. This is where I think a lot of mistakes come as far as specifying this recommendation and approval statement is in fact a prescription because it is not. Looking for these different parameters of amounts still remain to be quite mysterious and as we know, there is a great deal of variation amongst different counties as to the amounts they will come up with that we recall Attorney General Lockyer sending out this enumeration. So we have a lot of ambiguity in this area and it is really not the role of the physician to attempt to fill this. We can't be (inaudible). We don't have this kind of talent and, unfortunately, neither do the police, but that hasn't stopped them from developing guidelines and protocols.
Mr. Campbell: We could discuss that for a long time.
Dr. Snyder: Yeah right, I'm ready to go onto the next patient.
Dr. Snyder: I think this can probably be the last case that actually want to go over. That is the case of one [redacted].
Dr. Mikuriya: Um hum, [redacted].
Mr. Campbell: I have some particular reason for wanting to do that one.
Dr. Snyder: Okay.
Dr. Mikuriya: On 10/9/99, I saw [redacted] who has a birth date of [redacted]. Single Caucasian male. He did not list his occupation. He described his parents as both being alive at age 42 and 40, and no description of any health problems for them. His sister, age 21, has some problem with high blood pressure. Mr. Smidt has had some serious problems; shunts in place in his head for a seizure disorder indicating some hydrocephalus, and also a car wreck at an unspecified time. He is on dialysis for chronic renal failure since December of 1996. He was currently taking coumadin, Dilantin, and Labetalol. He had chronic problems with sleeping and itching which is not unknown with people on dialysis. People on chronic dialysis have a multitude of problems including mood swings with serious depression.
Dr. Snyder: Did he have that?
Dr. Mikuriya: No, I'm just commenting in general that this is not a person with any trivial kind of condition. He had problems with insomnia as well as itching and what came along was a medical work-up from 7/28/99.
Dr. Snyder: He provided that to you?
Dr. Mikuriya: Yes, he provided this to me and it was an account of his motor vehicle injuries and sequelae from crashing into an oak tree at 40 miles an hour. Fairly complete work-up at the local hospital with trauma, alert with multiple contusions, laceration left foot, chronic renal failure. So this was going on before, this aggravating kind of condition. He was kept in the ICU overnight and I don't know what the disposition was after that.
Dr. Snyder: This was from an incident that occurred sometime before you initially saw him?
Dr. Mikuriya: Yes.
Dr. Snyder: And he brought this document in?
Dr. Mikuriya: Yes, he brought this document in for me to include in his record, which I usually don't do.
Dr. Snyder: That's my question because clearly there is documentation that substantiates this gentleman's condition that you felt would be assisted or made better or provide some relief by marijuana?
Dr. Mikuriya: Yes.
Dr. Snyder: One of my concerns is we don't see that kind of documentation in but a handful.
Dr. Mikuriya: Because rarely do I have an opportunity to include this kind of documentation because it is not provided to me. If it is not too overwhelmingly large, I will definitely include copies for this purpose but I am not going to include lengthy hospital records and outpatient clinic records that will go back many years that they bring to me and say, Doc, here I brought this for you. So my approach is that I review the records at the time when they bring them in and turn them back to the patient.
Dr. Snyder: Do you make any notations within the records that we have gone through that have merely been the question and answer? Do you make any entry in those cases where a patient actually brings you some sort of a document for you to review, some sort of a confirmation?
Dr. Mikuriya: I do. In my latest draft of records, in fact, I do have a check box for this very point that you raise.
Dr. Snyder: Do you have or did you have a box indicating that there is some confirmation of the information that a patient brings to you. For instance, I know that I could walk into a doctor and say I've got x malady, for instance, headaches, and I want to get something for my headaches, and they ask him for Imitrex or something that is a controlled drug and say I'd be treated by someone else. Generally they are going to want to make a call to that other physician to confirm my diagnosis to be sure I don't have something really seriously wrong with me. I am seeing an absence of that confirming call of what's really wrong with these people in any of these?
Mr. Fleer: Before you answer that. It is argumentative and the problem I have with this is you are really coming from a law enforcement point-of-view. I don't think there is a physician obligation to check on history given by patients. I would say that happens less often than happens, and people do prescriptions of much more dangerous substances than cannabis just on patient reports of their subjective complaints and their history. I hear you making a case as opposed to asking questions. I understand your point-of-view and I want to be clear that I don't agree with it, but I also don't think it is a question for the doctor.
Mr. Campbell: My question is does he memorialize or does he make it his general practice to confirm in any way and to memorialize that confirmation any place in any of his records?
Mr. Fleer: Well, as to these 47 records, you know what is memorialized about that. You have the records.
Mr. Campbell: I didn't see it. Did I miss it?
Dr. Mikuriya: No.
Mr. Campbell: No. Okay.
Dr. Mikuriya: In my latest drafts I do have a check box for that very issue that you bring up, and this is a continuing process where I am attempting to improve the quality of the documentation in the record and realizing that it has been this evolutionary process over these years of starting from complete ambiguity.
Mr. Campbell: I understand what you are saying and forgive me, I didn't mean to sound argumentative, I was just trying to find out if I had overlooked something in the record when I reviewed it because I wanted to be sure.
Dr. Snyder: There are a couple more that I just want to briefly look at; they are in the W's. They are here at the end. They are in the 40s, 47, I guess this one alphabetically comes first, [redacted].
Dr. Mikuriya: [redacted].
Dr. Snyder: [redacted], is that . . .?
Dr. Mikuriya: Okay. [redacted].
Dr. Snyder: Oh [redacted] is this one, I'm sorry.
Mr. Campbell: Is that [redacted] or [redacted]?
Dr. Mikuriya: No, [redacted].
Mr. Campbell: Oh, [redacted].
Dr. Snyder: If you would just briefly - if you are drowning. . .?
Dr. Mikuriya: I am just thinking of all the interaction that I have in fact had with [redacted] regarding his out-of-control drinking and his migraine headaches and other symptoms that were related.
Dr. Snyder: Okay, do you want to give us a brief summary of that?
Dr. Mikuriya: Yes.
Dr. Snyder: Other symptoms that are related to his drinking?
Dr. Mikuriya: He is another adult child of an alcoholic family, who doesn't have any role models and was just in the process of being on the verge of destroying his young family; with his wife that was having a hard time taking care of the children and his out-of-control drinking.
Dr. Snyder: He is in his 20s is that correct?
Dr. Mikuriya: Yes. His birth date is [redacted] and his presenting complaints were alcoholism and persistent insomnia. My intervention was to prescribe Antabuse for him and I even went to the extent of writing this on his letter of recommendation and approval because I felt so strongly that this was going bad places fast and that in my subsequent follow-up evaluations and interactions with him and - I don't know if I memorialized it here but - had performed conjoined interviews with both him and his wife about this issue of neglecting his family and out-of-control drinking and what he had to do in order to keep his family together. So he first complied with the Antabuse, but then like many alcoholics, stopped it and resumed his drinking, timed it just right before the 72 hours was up before he went on his next binge. Was complaining of persistent insomnia, was evicted, and also had issues with the local court where he had court cases and I supplied duces tecum documentation for him and the court, supplied a declaration for him, also a copy of my first paper that I published in, Medical Times back in 1970. My first case of "Cannabis Substitution as a Adjunctive Therapeutic Tool in the Treatment of Alcoholism." Subsequent follow-up of - oh yeah- also another - I don't know how these articles crept in here but I may have given them to him. Another one from my book, Marijuana Medical Papers 1839 - 1972 , "Cannabis and Indica as an Anodyne and Hypnotic," written by J.B. Madison, M.D., 1891. Madison by the way was an expert addictionologist in his time and a famous medical leader back then. Also the article, "The Use of Indian Hemp in the Treatment of Chronic Chloryl and Opium Poisoning." Plus, an article by the Eli Lilly Company, February 1982, "The Ely Lilly's Bulletin No. 18," which paraphrased Dr. Madison's description.
Dr. Snyder: And these are in the record because the patient was either informed or given separate copies of those? That somehow relates to his condition because of his insomnia and his alcoholism?
Dr. Mikuriya: His case, that is correct.
Dr. Snyder: Are there other discussions or is there anything pertinent to his care and treatment that you didn't record that you want us to know about?
Dr. Mikuriya: Let's see, on 2/1/01, again I saw him. This time he had a car accident and was complaining of whiplash as well as persistent insomnia and he says, "I still drink when I have shitty marijuana." This is a case that I believe eventually will triumph over it. I hope that his family condition improves. I had another interview with him and his wife 5/7/00 and was dealing with the issue of recommending both him and his wife to an MFCC because she had an affair with somebody and that added to the uproar in the home. So definitely, I was engaged with this family.
Dr. Snyder: So you made this referral? Did you refer them to a specific person or a general referral?
Dr. Mikuriya: I recommended him to go to the County, Nevada County, where they already had a case open with regard to the domestic court and to play along with them and reinforce their messages to help him get control of his drinking. This is a work in progress.
Dr. Snyder: Alright, well I think we'll stop there.
Mr. Fleer: Before we stop, I meant to raise this right at the beginning, the last case that was discussed on the first meeting, of [redacted], Dr. Mikuriya had looked at that chart more carefully after we had the meeting and did want to note that there is a parent signed consent for treatment. That was the minor girl.
Dr. Snyder: Right, the 16 year old? Is that correct?
Dr. Mikuriya: Yes
Mr. Fleer: Maybe you were aware of that anyway.
Dr. Snyder: I did see it. Did you do anything to verify that it was actually written by a parent and not the . . .?
Dr. Mikuriya: No, no, no. I definitely do not accept a note by just a parent.
Dr. Snyder: So did you call the parent?
Dr. Mikuriya: Oh yes.
Dr. Snyder: Is that in there somewhere?
Dr. Mikuriya: I don't recall.
Dr. Snyder: Okay.
Dr. Mikuriya: Probably not.
Dr. Snyder: But you do have an independent recollection of having called her father.
Dr. Mikuriya: Absolutely.
Mr. Campbell: We could pull that out quick and take a look at it if you like?
Dr. Snyder: I saw the note , and I wondered if you had verified it because obviously kids write their own school tardy slips or whatever.
Mr. Campbell: That's the record on [redacted].
Dr. Mikuriya: And that is definitely not her signature, not her handwriting, as we can see by this note and then her signature on the Patient Declaration on the bottom of the recommendation and approval form.
Dr. Snyder: But you said that you called him in addition to knowing its not her handwriting?
Dr. Mikuriya: Either called, or he was with her.
Dr. Snyder: Okay.
Mr. Campbell: Do we have anything else? Okay it is now . . .
Dr. Mikuriya: 2:15
Mr. Campbell: 2:17 I have, and we will be going off the tape.
(END