United States District Court, D. Maryland
W. Grimm United States District Judge
Wexford Health Sources, Inc., Mofikpara Wright, M.D., Muleta
Obsu, M.D., Bolaji Onabajo, M.D., Jonathan Thompson, M.D.,
and Rebecca Barnhart, R.N., move to dismiss or in the
alternative for summary judgment in response to this civil
rights complaint. ECF No. 21. Plaintiff Jeff Farmer opposes
the motion. ECF No. 33. Defendants filed a Reply. ECF No. 36.
Also pending are Defendants' Motion for Protective Order
(ECF No. 37) and Plaintiff's Motions for Temporary
Injunction (ECF No. 38) and for an Extension of Time to file
a Class Action (ECF No. 41). No hearing is necessary.
See Local Rule 105.6 (D. Md. 2016). For the reasons
that follow Defendants' motion, construed as a Motion for
Summary Judgment, is granted in part and denied in part.
Defendants' Motion for Protective Order shall be denied
in part and Plaintiff's Motions for Injunctive relief and
to file a class action shall be denied. Defendants shall file
their answers on or before January 5, 2018.
Jeff Farmer is an inmate committed to the custody of the
Maryland Department of Public Safety and Correctional
Services and currently confined at Eastern Correctional
Institution (ECI). Farmer alleges he has been denied back
surgery and effective pain management pending the surgery;
his prescription for pain medication was reduced to one-third
of his previous dosage for non-medical reasons; his allergy
medication was changed to something less effective; and he
has not received treatment for a shoulder injury sustained
during a fall from a prison van. Compl. 3, ECF No. 1. Farmer
claims that he has moderate and severe disc herniation,
spinal stenosis and broken pieces of bone in his lower back
(lumbar spine at levels L4, L5, and S1). Id. at 4.
He states that prior to his current incarceration he was
scheduled for surgery and claims he is entitled to receive
that surgery (known as kyphoplasty) while he is incarcerated.
Farmer explains he is experiencing such severe pain that he
has difficulties sleeping and continued denial of the surgery
violates his rights under the Eighth Amendment. Id.
The specific claims he raises regarding his care are set
claims that his Neurontin dosage was reduced to one-third of
his previous dosage for no justifiable medical reason;
rather, it was done by Dr. Obsu in retaliation for
administrative remedy procedure complaints
(“ARPs”) Farmer filed regarding medical care.
Compl. 3. Farmer alleges that recent blood tests did not show
a valid reason for the cut in pain medication. Id.
do not deny decreasing the dosage of Farmer's Neurontin
and explain that the dosage initially prescribed to Farmer
was too high. Wright Aff. ¶¶ 5-7, ECF No. 21-5. Dr.
Wright describes the purpose and effects of Neurontin
(a.k.a., Gabapentin), a gabapentinoid. Id. He states
that medications like Neurontin “are widely used in
neurology, psychiatry, and primary healthcare” for the
treatment of “neuropathic pain, fibromyalgia and
postherpetic neuralgia.” Id. It is
“thought to possess GABA-mimetic properties which have
direct and indirect effects on the brain's dopamine
‘reward' system.” Id.
“Neurontin has been regularly prescribed with positive
result in the treatment of patients with chronic pain and in
the management of patients for opioid withdrawal.”
Wright also provides information regarding the dosage for
Neurontin and states that the “FDA recommended maximum
adult dosage is 2400-3600 mg per day.” Id. at
¶ 7. When dosages exceed the recommended dosage,
Neurontin is “reported to cause sedative as well as
dissociative/psychedelic effects.” Id.
Additionally, at higher than therapeutic dosages, drugs like
Neurontin have a higher rate of addictiveness. Id.
Further, in patients “with a history of polypharmacy
and drug abuse” there is “an increased risk of
addiction to [Neurontin's] dopamine ‘reward'
effect resulting in a need for increasing the medications
recommended dosage level beyond the therapeutic dose over
time to receive the same effect.” Id.
Conversely, at therapeutic levels, Neurontin has a low rate
of addiction making it a good option for pain management in
the prison environment. Id. ¶ 8. An increased
dose of Neurontin does not provide additional clinical
benefits as the rate of absorption drops with higher dosages
(e.g., “a 900 mg dose will be absorbed [at a
rate of] 60%, a 2400 mg dose provides a 34% absorption
[rate].”). Id. Side effects such as
“dizziness, somnolence,  headache,  diarrhea, confusion, nausea, and
peripheral edema” increase at higher dosages.
was prescribed 800 mg of Neurontin, two tablets twice daily
between April 13, 2016 through August 13, 2016. Id.
¶ 9. Farmer was also receiving: 800 mg of Ibuprofen as
needed three times a day; Excedrin migraine; 50 mg of
times a day; and 350 mg of Soma one tablet twice per day. Id. On
July 15, 2016, when Dr. Wright saw Farmer at Dorsey Run
Correctional Facility (“DRCF”), he reviewed the
medications Farmer was receiving and determined that the
amount of Neurontin he was receiving was too high, given all
the other medications he was taking. Id. ¶ 10.
Dr. Wright changed the prescription to 800 mg of Neurontin,
one tablet twice daily. Id. ¶ 11.
Wright explains that Neurontin is a “non-formulary
medication” at DRCF, meaning it takes a period of time
to process the request for the drug and at times the request
is “disapproved.” Id. With those factors
in mind, Dr. Wright wrote orders “to discontinue
[Farmer's] existing 800 mg Gabapentin, 2 tablets twice
daily if the new order for 800 mg, 1 tablet twice daily was
approved.” Id. An error was made, however, and
Farmer's prescription order was “transcribed as
‘Gabapentin 800 mg take two by mouth three times per
day, discontinue the old order for Neurontin, if this order
is approved.'” Id. Based on that erroneous
order, Farmer was given 4800 mg per day, a dose that Dr.
Wright states was “supratherapeutic and not
continued to receive the incorrect dosage until October 24,
2016, when Dr. Obsu discontinued it and prescribed 800 mg,
one tablet twice daily. Id. ¶ 14. Farmer's
other prescriptions for Soma and Ultram were unchanged.
Id. Prior to Dr. Obsu changing the prescription, Dr.
Syed Rizvi noted the excessive dosage of Neurontin during an
August 3, 2016 chronic care clinic visit with Farmer.
Id. ¶ 12. Dr. Rizvi indicated his intention to
follow up with Dr. Wright regarding the prescription and
continued it in the interim. Id. Although Farmer was
seen on August 22, 2016, for his shoulder pain, his
medications were not reviewed at that time. Id.
¶ 13. It is this change to the prescribed Neurontin upon
which Farmer bases his claim against Dr. Obsu. See
complained about the change in dosage on April 6, 2017, when
he was seen by Dr. Thompson at Maryland Correctional Training
Center (MCTC) and informed the doctor he needed 800 mg of
Neurontin three times a day. Farmer Med. R. 50, ECF No. 21-4.
Dr. Thompson explained to Farmer that “institutional
policy was to issue medications twice daily, and it would not
be changed for [Farmer].” Id. Farmer's
prescription for Neurontin provided for 2400 mg per day with
two 600 mg tablets, twice a day. Id. Farmer's
additional request for an increase in Tramadol was denied as
it was not clinically indicated. Id.
also claims that on October 25, 2016, Dr. Obsu changed his
allergy medication “from Claritin back to Zyrtec (that
I was on for many months and did not work either).”
Compl. 4. Despite putting in sick call slips regarding the
change in medication, Farmer states that he was not seen by a
doctor until November 8, 2016. At that time, he was seen by
Dr. Wright whom he claims “did absolutely nothing about
my allergy medication.” Id. Farmer claims Dr.
Wright told him he would contact Dr. Obsu to determine if
there was a reason for the change in medication; however,
when Farmer asked about it, the nurses told him there was
nothing noted in his record. Id. Farmer opines that
this is “the definition of deliberate indifference to
my ailments.” Id. He claims he saw Dr.
Obanajero on an unspecified date, and Farmer was told that
his allergy medication would be changed, but as of January
24, 2017, no change had occurred. Id. at 5.
Wright admits that Farmer was taking Zyrtec, but states that
he had been prescribed that medication since April 13, 2016,
and it was continued through August 3, 2016, when it was not
renewed. Wright Aff. ¶ 16. The Zyrtec prescription was
renewed on October 24, 2016, as Farmer “had not
submitted any complaints that [it] was not effective.”
Id. However, Dr. Wright initially states that Farmer
complained that Zyrtec was ineffective and that his
prescription was changed to Aprodine on February 10, 2017,
“in response to Plaintiff's complaints.”
Id. Wright concludes that it is his “opinion
to a reasonable degree of medical probability” that the
change to Aprodine “was an appropriate medication
change for [Farmer's] allergic rhinitis.”
Injury and Surgery
states that the condition of his back requires surgery which
should be performed during his incarceration so he will not
have to miss work when he returns home. He claims that
surgery was recommended prior to his incarceration. Compl.
do not directly address Farmer's claim that he is
entitled to back surgery, but provide verified medical
records that make mention of two previous imaging results of
Farmer's lumbar spine. Farmer Med. R. 1. As early as
September 30, 2014, Dr. Ben Oteyza noted that Farmer had a
history of back pain and that MRI reports regarding the
condition of Farmer's back were conflicting. Id.
Oteyza observed that “[p]ersonal opinion is that this
patient is not suffering the magnitude of discomfort that he
claims. May need a good, thorough orthopedic
evaluation.” Id. Despite that observation,
Oteyza did not order a referral at that time, but instructed
a “follow up if condition worsens or no improvement
within 14 days.” Id. at 2. When Oteyza saw
Farmer again on October 23, 2014, and Farmer asked for a
referral, the referral was made. Id. at 3. That
referral was “declined” following collegiate
review. Id. at 10.
first of the MRI reports referenced, dated September 1, 2008,
indicated that Farmer had a “large left paramedian disk
herniation at ¶ 5-S1 . . . [m]oderate central disk
herniation at L-4-5.” Id. (Nov. 16, 2015
Provider Visit). The second MRI report, dated November 14,
2013, is noted as showing
[m]arked improvement in the large left paracentral disk
herniation L5-S1 since the study of 9/1/2008. There remains a
small left apracentral disk protrusion minimally affecting
the left S1 nerve root . . . . Mild spinal stenosis L3-4
appearing since previous study . . . secondary to broad-based
central disk protrusion. Mild central protrusion of the L4-5
Id. The noted purpose of Farmer's November 16,
2015 medical exam was for review of his record for an
orthopedic referral. Id. It is noted that the
referral was declined and that Farmer was referred for
physical therapy (PT) which he had begun receiving on July
Id. Farmer was complaining of chronic low back pain
“with intermittent paresthesia and left leg weakness” at that
December 28, 2015, Farmer was seen by Dr. Jason Clem and Dr.
Getachew, via telemed regarding whether neurosurgery for his
back was necessary. Id. at 15. During the
examination “he was able to touch his toes with ease,
bend laterally, and bend minimally to back, no pain.”
Id. It was further noted that Farmer reported
“walking over a mile on [a] regular basis without
issue.” Id. Clem and Getachew attempted to
explain to Farmer that, given his “good function he
would not be [a] surgical candidate” but Farmer focused
instead on the fact he was not receiving narcotic pain relief
as he was prior to incarceration. Id. Upon Dr.
Getachew's suggestion, Farmer's prescription for
Ultram was increased and Farmer was assured that Ultram is an
opiate. Id. Farmer was also referred to psychology
and his “drug seeking behavior” was noted.
February 11, 2016, Farmer was seen for “continued
chronic back and shoulder pain” and reported
“that he had fallen out of the top bunk while he was
trying to get out of bed” because “his leg
‘gave out.'” Id. at 17. The fall
occurred on January 18, 2016, and Farmer reported that since
the fall he was unable to perform PT exercises; he had last
received PT on January 22, 2016. Id. The medical
director, who is not named in the record submitted, was
consulted regarding further PT sessions and Farmer was
instead “encouraged to work on exercises and stretching
exercises as he is able to slowly regain flexibility and
range of motion.” Id. At that time, Farmer had
received 12 PT sessions and a “formal consult”
was “not placed at this time.” Id.
April 13, 2016, when Farmer was seen for pain management, the
two MRI reports from 2008 and 2013 were still the only
reports being relied upon for an assessment of Farmer's
lumbar spine. Id. at 20. The same record notes that
the plan of care was to “[i]ncrease Tramadol from 50
mg BID to 100 mg BID” and there was improvement noted
with that increase, but Farmer reported that he “still
has significant low back pain that radiates down the left
leg.” Id. Despite the noted improvement,
Farmer's Tramadol prescription was changed upon renewal
to “50 mg BID on 4/1/16 without provider visit, ”
causing Farmer's pain to increase. Id. It is
noted that Farmer “[s]till wants to consider corrective
surgery” but reportedly was considering delaying
surgery until after his release so that “he can consult
with surgeon of his own choosing.” Id.
does not appear to have had further testing done to determine
the source of his chronic back pain. A record dated February
10, 2017, reports that Farmer has suffered from lower back
pain since 2003, from “lifting and hitting his back
against the corner of a bench.” Id. at 45.
Farmer reported that the pain has gotten worse “with
associated numbness in the [leg]” and that “he
fell last week from his [leg] giving out.” Id.
It is noted that Farmer has no history of incontinence and
does not use a cane, walker or wheelchair. Id. The
physical exam that was provided during this visit revealed
“no areas of swelling or redness” and
Farmer's gait was described as normal. Id.
Because his back pain was worsening, a consultation with an
orthopedic doctor, Lawrence Manning, MD, was requested.
was seen by Dr. Manning on March 7, 2017, who noted that
Farmer required “lumbar MRI scan asap.”
Id. at 48. Manning further noted that Farmer should
return with the results of that scan. Id. The
consultation for the recommended MRI was not generated until
April 6, 2017, almost one month after Dr. Manning saw Farmer.
Id. at 50-51. There is no indication in the records
provided that Farmer was provided with an MRI of his lumbar
spine, the results shown, or whether surgery is indicated by