I

I STATE OF OHIO

IIN THE COURT OF COMMON PLEAS

STARK COUNTY

I CASE NO. 05 CV 02475

I MARSHA HERSHEY, ADMX. OF THE)

ESTATE OF JOHN J. HERSHEY,

I PLAINTIFF, VIDEOTAPE DEPOSITION

IVS. OF

Nt.JOSE CASANOVA, M.D., ET AL DR. STEPHENfTHOMAS

I DEFENDANTS. JUDGE LEE SINCLAIR

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I VIDEOTAPE DEPOSITION taken before Jon Jastromb

Ia Notary Public within and for the State of Ohio, pursuant to Notice,

and as taken on June 5, 2006 at the office of Dr. Stephen Thomas, 105

I Braunlich Drive, McKnight Plaza, Suite 410, Pittsburgh, Pennsylvania.

ISaid deposition taken of Dr. Stephen Thomas is to be used as evidence

on behalf of the plaintiff in the aforesaid cause of action, pending in the

I Court of Common Pleas, within and for the County of Stark, for the

IState of Ohio.

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I APPEARANCES:

IMr. Geoffrey Eicher, Esquire and

Mr. Neil Semple, Esquire

I Semple & Eicher

IOne Cascade Plaza

7th Floor

I Akron, Ohio 44308

I330- 535-0124

On Behalf of the Plaintiff,

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I Mr. Thomas Prislipsky, Esquire

IReminger & Reminger

11 Federal Plaza Central

I Suite 300

IYoungstown, Ohio 44503

330-744- 1311

I On Behalf of the Defendants.

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I VIDEOTAPE OBJECTION LOG INDEX

DR. STEPHEN THOMAS - MVS # 11529- 31

I

IDIRECT EXAMINATION BY GEOFFREY EICHER - PAGE 5

Page # Line # Time

I 12 16 14: 15: 31 - OBJ

12 24 14: 15: 49 - OBJ

I14 4 14: 17: 50 - OBJ

14 17 14: 18: 28 - OBJ

15 3 14: 18: 59 - OBJ

I21 1 14: 27:48 - OBJ

27 16 14: 37: 17 - OBJ

29 2 14: 39: 18 - OBJ

I29 5 14: 39: 20 - OBJ

31 18 14: 45:24 - OBJ

32 13 14: 46:20 - OBJ

I33 12 14: 47:49 - OBJ

33 16 14: 47: 51 - OBJ

35 5 14: 50:09 - OBJ

I 37 17 14: 53: 21 - OBJ

38 17 14: 54: 40 - OBJ

41 20 14: 59: 19 - OBJ

I CROSS EXAMINATION BY THOMAS PRISLIPSKY - PAGE 48

I Page # Line # Time

I50 5 15: 18: 45 - OBJ

51 17 15: 20:00 - OBJ

52 1 15: 20: 17 - OBJ

I55 24 15: 24:04 - OBJ

67 17 15: 37:00 - OBJ

70 1 START OF TAPE # 2

I77 22 15: 52: 49 - OBJ

83 13 15: 58:44 - OBJ

85 4 16: 00: 19 - OBJ

I85 10 16: 00:30 - OBJ

88 20 16: 04:27 - OBJ

89 17 16:05: 11 - OBJ

I93 24 16: 09: 16 - OBJ

96 19 16: 12: 10 - OBJ

99 19 16: 15: 14 - OBJ

I 100 8 16: 16: 29 - OBJ

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I REDIRECT EXAMINATION BY GEOFFREY EICHER - PAGE 105

I Page # Line # Time

106 8 16: 33: 36 - OBJ

I 107 5 16: 34:29 - OBJ & MTS

112 6 16:41: 48 - OBJ & COLL.

I114 8 16:45:00 - OBJ

115 20 16:47: 13 - OBJ & MTS

117 12 16: 49: 19 - OBJ

I121 21 16: 55:58 - OBJ

122 8 16: 56:29 - OBJ

IRECROSS EXAMINATION BY THOMAS PRISLIPSKY - PG 125

NO OBJECTIONS MADE

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I END)

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I 5

I1 OPERATOR: We' re on the record.

I 2 Would you raise your right hand, please?

I3 Do you solemnly swear the testimony you' re

4 about to give in this matter to be the truth,

I 5 the whole truth, and nothing but the truth,

I6 so help you God?

7 DR. THOMAS: I do.

I 8 OPERATOR: Thank you.

I9

10 DURING DIRECT EXAMINATION BY MR. GEOFFREY

I 11 EICHER:

I12 Q. Doctor, for the record, my name is

13 Geoff Eicher. We' re come here to your office here today

I 14 in Pittsburgh, Pennsylvania to record your expert

I15 testimony regarding the unfortunate death of Mr. John

16 Hershey. Before we get into your testimony today, I' d

I 17 like you tell the jury something about yourself. Let' s

I18 start with your education background.

19 A. I went to undergraduate school at Case

I 20 Western Reserve where I took my bachelors majoring in

I21 biology, minoring in chemistry, philosophy, and

22 psychology. I then attended medical school at the

I 23 Stanford University School of Medicine in Palo Alto,

I24 California where I graduated in 1984. Following my

25 medical school education I took an internship at The

I

I 6

I1 Presbyterian University of Pennsylvania Medical Center

I 2 in Philadelphia. Then I took my residency in

I3 anesthesiology and critical care medicine at the Johns

4 Hopkins Hospital in Baltimore, Maryland. I was there

I 5 from ' 85 until ' 88. I then did a fellowship in 1987 and

I6 88 I did a fellowship in pain medicine and regional

7 anesthesia, also at the Johns Hopkins Hospital in

I 8 Bal timore.

I9 Q. Does that comprise most of your

10 training, Doctor?

I 11 A. Yes, most of my training, except for

I12 tha t which I do on a regular basis.

13 Q. Understood. Doctor, I assume that

I 14 you' re a nationally board certified physician. Is that

I15 correct?

16 A. Yes.

I 17 Q. What area are you board certified in?

I18 A. My primary certification is in

19 anesthesiology by The American Board of Anesthesiology.

I 20 I have a subspecialty certification in pain medicine also

I21 by The American Board of Anesthesiology. I hold a

22 fellowship of Interventional Pain Practice from The World

I 23 Institute of Pain. I' m a diplomat of The American Board

I24 of Pain Medicine. And I' m a certified independent

25 medical examiner from The American Board of

I

I 7

I1 Independent Medical Examiners.

I 2 Q. When did you earn your board

I3 certification, Doctor?

4 A. My primary certification was earned in

I 5 1989. My subspecialty certification from The American

I6 Board of Anesthesiology was initially earned in 1994

7 wi th re- certification in 2004. The fellowship from The

I 8 World Institute of Pain was earned in January of 2005.

I9 The diploma from The American Board of Pain Medicine

10 was earned in 2006.

I 11 Q. Doctor, do you work as a pain

I12 management specialist?

13 A. Yes, I do.

I 14 Q. How long have you been operating as a

I15 pain management specialist?

16 A. My practice began doing both operative

I 17 anesthetics as well as pain medicine when I was in Air

I18 Force in 1988 to 1992. Over the years my practice has

19 shifted to being exclusively pain medicine from about

I 20 1997.

I21 Q. Doctor, finally how much of your

22 professional time is spent in the active clinical practice

I 23 of medicine?

I24 A. I currently practice about 80 percent of

25 the time treating patients and the other time I spend in

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I 8

I1 my evaluative practice.

I 2 Q. Alright. Doctor, I' m going to be asking

I3 you questions about your review of medical records

4 relative to the case of John Hershey. One of the big

I 5 issues in this ... with regard to Mr. Hershey is his use of

I6 a medication known as Methadone. Do you use that

7 medication in yout practice presently?

I 8 A. Yes, I do.

I9 Q. What for?

10 A. Methadone is an opioid analgesic. It' s

I 11 rela ted to Morphine. It is used in the treatment of pain.

I12 Q. Can you quantify for the jury at all,

13 Doctor, the extent to which you use Methadone in your

I 14 pain management practice?

I15 A. I use Methadone in the treatment of

16 about 50 to 60 patients currently in my pain practice.

I 17 Q. Are those people who you have on

I18 Methadone, Doctor, patients who you placed on

19 Methadone, or are those people that you inherited from

I 20 some other physician?

I21 A. Primarily they' re patients whom I

22 started on Methadone.

I 23 Q. Alrigh t. Doctor, I' m going to hand you

I24 what we' ve previously marked as Plaintiff' s Exhibit

25 Number " 1", which I believe are all of the records from

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I 9

I1 Ri tzman Pharmacy. I' m going to hand you also the

I 2 records from Dr. Khalil and that' s marked as Plaintiff' s

I3 Exhibit Number " 2". I' m going to also hand you

4 Plaintiff' s Exhibit Number " 3", which I believe is the

I 5 entire chart from Dr. Casanova' s office relative to Mr.

I6 Hershey. And finally Plaintiff' s Exhibit Number " 4",

7 which is the Summit County Coroner' s office records

I 8 relative to John Hershey. I hand these to you in

I9 advance, Doctor, so that you may use them as we go

10 through your testimony today.

I 11 MR. EICHER: Mr. Prislipsky, do I have

I12 a stipulation as to the admissibility

13 of all the documents I just handed to

I 14 Dr. Thomas?

I15 A. Yes.

16 Q. Thank you. Doctor, you have reviewed

I 17 all of these records, have you not?

I18 A. Yes, I have.

19 Q. You' ve reviewed other records as well?

I 20 A. Yes, I have.

I21 Q. Alright. Doctor, if you feel at any time

22 that you need to go to any other record to explain any

I 23 part of your testimony, feel free to stop me and we' ll get

I24 those records in front of you, okay?

25 A. Thank you.

I

I 10

I1 Q. From your review of these records,

I 2 Doctor, can you explain to the jury the pertinent facts

I3 that led Mr. Hershey to seek treatment from Dr.

4 Casanova?

I 5 A. Yes. Mr. Hershey was a middle- aged

I6 man in his early 40' s and had undergone... and had an

7 injury to his neck some years previously, and in 1999

I 8 and again in 2002 had undergone cervical spine

I9 opera tions. The first operation had been an anterior

10 cervical diskectomy and fusion and the second operation

I 11 in 2002 had been a posterior diskectomy. He had

I12 undergone fusion operations and been stabilized by

13 those operations and had been returned to relatively

I 14 normal function following that. He had a history of

I15 hypertension and had a history of ischemic colitis,

16 which had been painful episodes that had led him to

I 17 seek medical treatment in the past for pain episodes.

I18 Mr. Hershey had been relatively stable throughout 2003

19 and in 2004 he began to have recurrent neck pain with

I 20 radiation into his arms for which he sought treatment

I21 from his primary care physician, Dr. Khalil. Dr. Khalil

22 saw him and initially prescribed Bextra, an anti-

I 23 inflammatory agent, and Neurontin, an anti- convulsant,

I24 which is sometimes useful in the treatment of nerve

25 paIn. After he had taken his medications for a time and

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I 11

I1 they hadn' t been useful in relieving his pain, he saw Dr.

I 2 Khalil and Dr. Khalil prescribed Vicodin Hydrocodone

I3 with acetaminophen, a relatively mild but nonetheless

4 an opioid analgesic, for Mr. Hershey' s pain complaints.

I 5 While Mr. Hershey was taking this medication there was

I6 a modest escalation in his dosage from about one and a

7 half tablets per day to three tablets of Vicodin per day,

I 8 which is the equivalent of 5 milligrams of Hydrocodone

I9 per tablet. Therefore, he went from about 7. 5 milligrams

10 of Hydrocodone per day to about 15 milligrams of

I 11 Hydrocodone per day while he was treating with Dr.

I12 Khalil. Dr.

Khalil...

13 Q. Well, you were going to say that Dr.

I 14Khalil...

is Dr. Khalil the physician that referred Mr.

I15 Hershey to Casanova?

16 A. Yes, he is.

I 17 Q. Alrigh t.

I18 A. Yes. He thought he needed a pain

19 management consultation.

I 20 Q. Alrigh t. Well, let' s talk about that

I21 then, Doctor. What is the relevant history that you' re

22 able to tell this jury from the one and only visit that Mr.

I 23 Hershey had with Dr. Casanova?

I24 A. Mr. Hershey saw Dr. Casanova on

25 August 11 th of 2004. Dr. Casanova had Mr. Hershey fill

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I 12

I1 out a form, an intake form, which he then used in

I 2 recording his handwritten notes on for the taking of the

I3 history. He took a history, performed a physical

4 examination, and prescribed Methadone, 10 milligrams,

I 5 four times daily, for Mr. Hershey' s pain. In taking the

I6 history, Dr. Casanova recorded that Mr. Hershey was

7 taking one... or allowed Mr. Hershey to record that he

I 8 was taking one Vicodin, three times daily.

I9 Q. Okay. Doctor, based upon your review

10 of the entire chart of Dr. Casanova and all the other

I 11 records that you have in front of you as well, do you

I12 have an opinion, within reasonable medical probability,

13 whether Dr. Casanova operated within the standard of

I 14 care required in his specialty as a pain management

I15 specialist in his care and treatment of John Hershey?

16 14: 15: 31 - MR. PRISLIPSKY:

I 17 Objection.

I18 A. In my opinion, Dr. Casanova did not

19 operate within the standard of care in his care and

I 20 treatmen t of Mr. Hershey.

I21 Q. Doctor, could you please identify those

22 areas in which you believe that Dr. Casanova did not

I 23 operate within the standard of care?

I24 14: 15: 49 - MR. PRISLIPSKY:

25 Objection.

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I 13

I1 A. There were three areas in particular

I 2 that I found that Dr. Casanova did not operate within

I3 the standard of care. The first was in his taking and

4 recording of the history of Mr. Hershey' s medication use.

I 5 Dr. Casanova recorded or allowed Mr. Hershey to record

I6 that he was taking one Vicodin, three times daily. He

7 later stated that Mr. Hershey told him that he was

I 8 taking as many as six Vicodin per day, which would be

I9 twice the amount. That failure to adequately record the

10 history, in my opinion, would be below the standard of

I 11 care. In prescribing Methadone at the dose of 10

I12 milligrams, four times daily, or 40 milligrams per day,

13 it' s my opinion that Dr. Casanova operated below the

I 14 standard of care by giving the patient a gross over

I15 dosage of Methadone, increasing his dose by 800 percent

16 relative to that which he was taking prior to seeing Dr.

I 17 Casanova. And, third, Dr. Casanova failed to adequately

I18 assess the risk to Mr. Hershey of taking that dose of

19 medication at that time, both in terms of his recording

I 20 and his... and his treatment of the patient.

I21 Q. Doctor, at one point in time in the

22 record there is a reference from Dr. Casanova about

I 23 giving the patient a verbal instruction as to how to take

I24 the medication. Do you recall that?

25 A. Yes, I do.

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I 14

I1 Q. Is there... what is the relevance of

I 2 that, Doctor, in terms of the standard of care of a pain

I3 managemen t physician?

4 14: 17: 50 - MR. PRISLIPSKY:

I 5 Objection.

I6 A. In giving the verbal instruction that he

7 now says that he did to get... for Mr. Hershey to take

I 8 Methadone, one tablet, three times daily, while writing

I9 on the prescription that Mr. Hershey should take one

10 tablet, four times daily, and having the nurse instruct

I 11 Mr. Hershey to take one tablet, four times daily, in my

I12 opinion, Dr. Casanova deviated from the standard of

13 care in prescribing Methadone in that fashion.

I 14 Q. Is that deviation, Doctor... your

I15 opinion rather in regard to that deviation, is that within

16 reasonable medical probability?

I 17 14: 18: 28 - MR. PRISLIPSKY:

I18 Objection. ( Voice over)

19 A. Yes, it is. ( Voice over)

I 20 Q. Doctor, I want to talk to you about... I

I21 think you' ve identified essentially three areas that you

22 found problematic. I want to talk to you a little more in

I 23 detail about each of those. In terms of the failure to

I24 assess, I think is the way you described it, what

25 concepts does the jury need to understand in order to

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I 15

I1 come to a conclusion with regard to this... this issue of

I 2 failure to assess?

I3 14: 18: 59 - MR. PRISLIPSKY:

4 Objection.

I 5 A. Mr. Hershey was taking a relatively

I6 small amount of pain medicine when he came to see Dr.

7 Casanova. Dr. Casanova took a history that stated that

I 8 he was taking the small amount of pain medicine and it

I9 implies that he was tolerant to the pain medication.

10 However, the review of the records shows that Mr.

I 11 Hershey was taking over the course of the three months

I12 prior to ... three to four months prior to seeing Dr.

13 Casanova he was taking an average of one and a half

I 14 Vicodin tablets per day, and in the month prior to seeing

I15 Dr. Casanova he was taking three Vicodin tablets per

16 day of small amounts and he then ... and Dr. Casanova

I 17 did not take into account that these small amounts of

I18 medication would not induce the tolerance required for

19 the large dose of Methadone that he then gave to Mr.

I 20 Hershey. Tolerance becomes an important concept for

I21 the jury to understand in this particular case. When a

22 patient is given an opioid pain medication, over a period

I 23 of time they will build up a resistance to that pain

I24 medication. The tolerance that develops develops to a

25 number of the different aspects of the pain medication at

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I 16

I1 different rates and at different times. So, for example,

I 2 the tolerance to the nausea and vomiting of the opioid

I3 pain medication can occur fairly rapidly, while the

4 tolerance to the pain relief or analgesia, or the tolerance

I 5 to the respiratory depression, or the tolerance to the

I6 constipation all occur much more slowly.

7 Q. Doctor, when you talk about tolerance,

I 8 are you talking about tolerance to all of the effects of

I9 the medication?

10 A. No, I am not. The ... while tolerance to

I 11 all of the effects... to most of the effects... I' m sorry...

I12 to most of the effects of pain medications occur they do

13 not occur to all of them. So, for example, constipation

I 14 is never an aspect of an opioid pain medication to which

I15 patients become tolerant. Although patients quickly

16 become tolerant to the nausea and vomiting effects and

I 17 those various degrees of tolerance at various levels, it

I18 becomes very important in understanding whether or not

19 a patient is tolerant. Mr. Hershey was only mildly

I 20 tolerant to the effects of opioid analgesics at the time he

I21 saw Dr. Casanova.

22 Q. And what opioid medication was he on

I 23 that in your opinion made him mildly tolerant?

I24 A. He was taking Vicodin Hydrocodone in

25 a dose of about one tablet or 5 milligrams, three times

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I 17

I1 daily.

I 2 Q. Okay. Doctor, have you prepared any

I3 charts that illustrate your... the testimony that you' ve

4 just given with regard to tolerance to opioid

I 5 medications?

I6 A. Yes, I have.

7 Q. Doctor, could you take a moment to

I 8 explain to the jury how the chart that you' ve prepared

I9 with regard to Hydrocodone prescriptions impacts the

10 issue of tolerance?

I 11 A. This shows the Hydrocodone

I12 prescriptions that Mr. Hershey was receiving in the

13 period from May 2002 to August 2004. At this po in t Mr.

I 14 Hershey had undergone a second neck operation in April

I15 of 2002 and had... was treated with 5 milligram tablets

16 of Hydrocodone, and his average daily dose during the

I 17 period, if he took the maximum number prescribed by

I18 the physician during the period of time over which the

19 prescription was given, he would have taken an average

I 20 dose of 15 milligrams from May 10, 2002 until June 5,

I21 2002, and 10 milligrams thereafter. Mr. Hershey

22 sustained an injury to his leg in December 2002 and he

I 23 was taking... he was given 25 milligram tablets to take

I24 over three days according to the instructions by the

25 physician. Here he had another problem including a

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I1 hand operation, back pain, and I believe in 2003 he also

I 2 had a bout with ischemia colitis which led to a

I3 prescription of Hydrocodone again in limited quantities

4 for limited periods of time, leading to small daily doses

I 5 except during those periods when he was being treated

I6 more vigorously after operations. Then there is a long

7 period during which Mr. Hershey has no prescriptions

I 8 for Hydrocodone. I think this becomes very important

I9 because during these periods his sensitivity to the drug

10 is restored. Tolerance requires exposure to the drug.

I 11 The absence of exposure leads to the loss of tolerance.

I12 So here we have a period where Mr. Hershey receives no

13 Hydrocodone from August 2003 until May of 2004. He

I 14 again had an acute injury, had a brief exposure, and

I15 then he was treated by Dr. Khalil on two occasions on

16 June 28, 2004 and July 8, 2004 with relatively small

I 17 amounts of Hydrocodone. If he took the maximum dose

I18 available to him during the period of his first

19 prescription he would have gotten 10 milligrams per day.

I 20 If he took the maximum dose during the period of his

I21 second prescription he would have gotten 13. 6

22 milligrams per day. And then his last prescription was

I 23 from Dr. Khalil on July 30th, or 22 days after his July 8

I24 prescription, again 13 milligrams per day.

25 Q. Okay, Doctor. I' m going to put up on

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I 19

I1 the easel here ... you prepared another chart. How does

I 2 this chart illustrate your testimony relative to the

I3 tolerance issue?

4 A. It shows that if we look at the... again,

I 5 at the long term with Mr. Hershey it gives a visual

I6 depiction of what the previous numbers showed. It is

7 that he was taking relatively low doses of Hydrocodone

I 8 on a daily basis during each of these months when he

I9 was prescribed it after his neck operation, with his

10 ischemic colitis, with his finger injury. All these were

I 11 very small amounts averaging between 3 ... between 1. 6

I12 and 8 ... I' m sorry... 6. 7 milligrams per day of

13 Hydrocodone. It again shows very visually a long period

I 14 during which he received no Hydrocodone and, therefore,

I15 had his tolerance ... his sensi tivi ty ... I' m sorry...

16 restored and then the relatively small amounts of the

I 17 Hydrocodone that he received during the period he was

I18 treated by Dr. Khalil. Then this shows at the end, here

19 in red, that if we take the dose of Hydrocodone and made

I 20 an acute conversion to the dose of Methadone that he

I21 was given by Dr. Casanova, that if we take the 30

22 milligram dosage, and that is the first red line, that that

I 23 would convert to a dose of 72 milligrams per day of

I24 Hydrocodone on a ... on an acute basis. And if we take

25 the 40 milligram dose, the dose which Dr. Casanova

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I 20

I1 actually wrote for Mr. Hershey to take and had his nurse

I 2 instruct him to take, that that dose would convert to 96

I3 milligrams of Hydrocodone on an acute basis. Now while

4 we are trying to compare apples to oranges, because

I 5 Hydrocodone and Methadone are distinctly different in

I6 that Methadone accumulates and Hydrocodone does not,

7 and that changes their pharmacology greatly, and we' re

I 8 trying to make assumptions about the relative potencies.

I9 Although because Methadone has very variable

10 pharmacology in terms of its elimination, which we' ll

I 11 come to later, these... the equivalences are those that

I12 we can safely use to assume how Methadone would

13 compare to Hydrocodone. It is this marked increase in

I 14 the dose of opioid, comparing Methadone to

I15 Hydrocodone, that I believe was responsible for the

16 Methadone toxicity that was the cause of Mr. Hershey' s

I 17 death.

I18 Q. Alrigh t. Doctor, I want to switch to

19 the second issue that you identified, and that is

I 20 the prescription of 40 milligrams per day by Dr.

I21 Casanova.

22 A. 40 milligrams of Methadone.

I 23 Q. Yeah, correct. Explain to the jury,

I24 Doctor, why you believe that that fell below the standard

25 of care?

I

I 21

I1 14: 27: 48 - MR. PRISLIPSKY:

I 2 Objection.

I3 A. Methadone is unique along the... I' m

4 sorry... Methadone is unique among opioid and

I 5 Morphine like pain medications in that it is the only one

I6 of the pain medications that accumulates in the body

7 and has a long duration of action on elimination.

I 8 Because of that it tends to accumulate in the body over

I9 time, being stored in the fat stores of the body, and that

10 accumulation leads to a marked change in the way in

I 11 which it acts, particularly it becomes a longer acting

I12 drug both in terms of its analgesic or pain relieving

13 effects, but also a longer acting drug in terms of its side

II 14 effects, particularly the side effect of respiratory

I15 depression. When we try to use a formula to convert

16 from Hydrocodone to Methadone, we generally do that

I 17 through Morphine equivalents. We compare other

I18 opioids to Morphine because Morphine is the prototype

19 of all opioid medications. The conversion of

I 20 Hydrocodone to Morphine is complicated by the fact that

I21 Hydrocodone is not available in the intravenous form.

22 However, Hydrocodone is generally thought to be about

I 23 80 percent strong... I' m sorry... is generally thought to

I24 be slightly stronger than Morphine with 8 milligrams of

25 Hydrocodone converting to 10 milligrams of Morphine

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I 22

I1 orally. Methadone, on the other hand, tends to be

I 2 relatively equally potent; that is the same strength as

I3 Morphine when taken orally as a single dose. I think

4 this is exceedingly important that I want to ... that I

I 5 want the jury to understand that they are close to each

I6 other as a single dose, but because Morphine is quickly

7 eliminated by the liver and does not store in the body,

I 8 and Hydrocodone is quickly eliminated by the liver and

I9 is not stored in the body, and their by- products are not

10 active and are excreted by the body, they do not have a

I 11 sustaining effect. They are relatively short acting drugs.

I12 Q. How short acting?

13 A. Hydrocodone lasts about 2 to 3 hours.

I 14 Morphine may last slightly longer, generally thought to

I15 be a two to four hour duration from an oral dose. Those

16 short acting properties extend not only to the analgesic

I 17 or pain relieving effect but also the sedative effect and

I18 the respiratory depression effect. With Methadone,

19 however, because it accumulates in the body, when we

I 20 first give it to the patient it has a relatively short

I21 duration of action, slightly longer than that of Morphine,

22 but as we continue to does Methadone and it

I 23 accumulates in the body its duration of action becomes

I24 longer, its side effect profile in particular becomes

25 longer because the increasing amounts of Methadone in

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I 23

I1 the body continue to circulate, continue to affect the

I 2 brain, and particularly to produce respiratory

I3 depression.

4 Q. Can you state how long Methadone

I 5 does stay in the body?

I6 A. For any individual patient it is very

7 difficult to say how long Methadone stays in the body

I 8 because Methadone is due to both disease factors, as

I9 well as genetic factors, metabolized by many people in

10 many different ways. The duration of Methadone' s half-

I 11life...

the half-life is another term that I' m sure the jury

I12 will hear over and over in this case. Half- life is the

13 amount of time that it takes for the body to eliminate

I 14 one half of the drug. The half-life measures how long

I15 the drug stays around. The half-life of Methadone is

16 between 15 and 96 hours in most studies. Now that' s a

I 17 very long range. That' s from half a day to four days.

I18 Generally we use the average half-life to be about 24

19 hours. It makes it easier for us to calculate and it' s...

I 20 it is a general mean tendency. However, in any

I21 individual patient it is exceedingly difficult to tell

22 beforehand how they' re going to handle Methadone

I 23 because we don' t know their pharmacogenetics or the

I24 way in which their body takes care of the drug. That

25 becomes very important in making our decisions.

I

I 24

I1 Q. Doctor, again, have you prepared a

I 2 chart that illustrates the testimony that you' ve just

I3 given with regard to accumulation and or half- life?

4 A. Yes, there is.

I 5 Q. Could you please show the jury this

I6 chart and what it should mean to them?

7 A. Okay. This applies to the Methadone,

I 8 and the half- life here is shown in days and we' re taking

I9 this average half- life to 24 hours. When one begins to

10 take Methadone during the first half-life the... on our

I 11 way to a steady state of the... as the amount of drug

I12 that is eliminated by the body and the amount of drug

13 that is coming into the body reach a balance. On the

I 14 first day the levels are about 30 percent of the steady

I15 state level. On the second day they reach as much as 55

16 percent of the steady state level. And on the third day

I 17 we get to 90 percent of the steady state level. This

I18 increases slightly over time, so that by the fifth day we

19 basically arrive at the steady state at 99 percent of the

I 20 steady state level. I would point out to the jury that if

I21 we take the half- life of Methadone to be one day then on

22 the first day that Mr. Hershey took it he was here, but

I 23 on the fifth day when Mr. Hershey took it he was at 99

I24 percent of his steady state level. He was at the amount

25 of Methadone that was going to get to his system with

I

I 25

I1 the dosage that he was given, and it was on the fifth day

I 2 that Mr. Hershey died.

I3 Q. Doctor, I' m going to put up on the easel

4 now for you the next chart that you' ve prepared with

I 5 regard to Methadone accumulation. Can you please

I6 describe for the jury what this tells you?

7 A. And this goes to what I was saying

I 8 about the difference between Methadone, Hydrocodone

I9 and Morphine. Because if Mr. Hershey had been given

10 Morphine in a dose equivalent to the way in which he

I 11 was given Methadone compared to the Hydrocodone,

I12 then this chart shows what would have happened and

13 what I believe, within a reasonable degree of medical

I 14 certainty, did happen to Mr. Hershey. If we compare the

I15 amount of Hydrocodone that he was taking here in blue,

16 that would be equivalent to about 17 milligrams of

I 17 Morphine here in red so, on the first day when he was

I18 given 40 milligrams of Methadone, that was roughly

19 equivalent to him being given 40 milligrams of Morphine,

I 20 which is two to three times the dose... I' m sorry...

I21 which is a bit more than twice the dose of a Morphine

22 equivalence that he was given of Hydrocodone. However,

I 23 if he would have been given Morphine, because it' s

I24 rapidly excreted, on days one, two, three, four, and five

25 it would have been absolutely equivalent because there

I

I 26

I1 would have been no accumulation in his body. Because

I 2 he was given Methadone, and Methadone does

I3 accumulate, then the equivalence on the first day was 40

4 milligrams to Morphine, but it was equivalent to 85

I 5 milligrams of Morphine on the second day, to 120

I6 milligrams on the third day, to 150 milligrams on the

7 fourth day, and to 160 milligrams on the fifth day. It

I 8 was here when Mr. Hershey was at these toxic levels of

I9 Methadone and a Morphine equivalence of 800 percent of

10 the dose that he had been given prior to ... 800 to 1, 000

I 11 percent of the dose that he was being given prior to

I12 seeing Dr. Casanova in a Morphine... in a relatively

13 opioid intolerant and naIve patient that this escalation

I 14 and the amount of opioid in his bloodstream led directly

I15 to his death.

16 Q. Doctor, is the accumulation factor

I 17 relative to Methadone... does that... does that fact

I18 make it a far more dangerous drug to use than other

19 opioids?

I 20 A. It makes it a more risky drug to use. It

I21 is only dangerous when we use it in this fashion. While

22 the... the fact is is that our ability to predict what

I 23 Methadone will do in the individual patient' s body is ...

I24 we know that it will accumulate; we do not know how

25 fast it will accumulate. So if we use ... if we ... we do

I

I 27

I1 not know in Mr. Hershey, for example, precisely what the

I 2 half-life was. In any individual patient we don' t know,

I3 so when we don' t know, we physicians have an obligation

4 to slow down and to be safe for our patients. If Mr.

I 5 Hershey had a longer half-life, which is certainly

I6 possible, and there' s no way to tell until after you give

7 them the drug, then in fact his accumulation could have

I 8 been greater than this based upon this chart.

I9 Q. I want to go finally to the third issue

10 that you identified for the jury, and that is the issue of

I 11 the verbal instruction that Dr. Casanova gave to Mr.

I12 Hershey to take the Methadone at a rate of 30 milligrams

13 per day, opposed to the 40 milligrams per day as it was

I 14 written on the prescription. Identify for the jury what

I15 issue you take there.

16 14: 37: 17 - MR. PRISLIPSKY:

I 17 o bj ection.

I18 A. It is well known by both anyone who' s

19 gone to the doctor, as well as physicians, that verbal

I 20 instructions are exceedingly difficult for patients to

I21 follow. When we talk to a patient we attempt to give

22 them the information but, in fact, the loss of information

I 23 in that communication is not infrequent. That is well

I24 established in the medical literature. Mr. Hershey got a

25 single verbal instruction from Dr. Casanova to take

I

I 28

I1 Methadone, one milligram... I' m sorry... one tablet,

I 2 three times daily; he got a written instruction from Dr.

I3 Casanova in the form of the prescription to take one

4 tablet, four times daily. In the process at the Aultman

I 5 Pain Center they recognized the failure of verbal

I6 instructions and so they have a nurse sit down with the

7 patient and go through what the doctor' s instructions

I 8 are and give them both a verbal and a written

I9 instruction. He was given that to take Methadone four

10 times daily and, again, he was given... again, when he

I 11 got to the pharmacy and he got the pill bottle it stated

I12 that he should take Methadone, one tablet, four times

13 daily. All of those instructions were actually countered

I 14 to the verbal instruction,s that Dr. Casanova says that

I15 he gave and, in fact, it led to Mr. Hershey taking it, as

he had been instructed, on at least four occasions other16

I 17 than Dr. Casanova' s verbal instructions. The failure of

I18 that verbal instruction, in my opinion, was unnecessary

19 and below the standard of care because Dr. Casanova

I 20 could have easily written the appropriate instruction.

I21 Q. Doctor, do you have an opinion, within

22 reasonable medical probability, whether Dr. Casanova' s

I 23 failure to act with the ordinary skill, care and diligence

I24 of a pain management specialist directly and proximately

caused any injury to Mr. Hershey?25

I

I 29

I1 A. Yes, I do. ( Voice over)

I 2 14: 39: 18 - MR. PRISLIPSKY:

I3 Objection. ( Voice over)

4 Q. What is your opinion?

I 5 14: 39: 20 - MR. PRISLIPSKY:

I6 o bj ection.

7 A. My opinion is that Dr. Casanova,

I 8 through his failures to meet the standard of care in

I9 terms of the history taking, prescribing dosage and

10 instructions to the patient, gave Mr. Hershey an

I 11 overdose of Methadone that led to his death.

I12 Q. Let' s go off the record a second.

13 OPERATOR: We' re off the record.

I 14 OPERATOR: We' re on the record.

I15 Q. Doctor, I' d like you to go back and talk

about tolerance a little bit because, quite frankly, it' s a16

I 17 difficult issue for me to understand too and I want to

I18 make sure the jury understands. This whole issue of

tolerance to opioids, can you please explain that a little19

I 20 better for the jury?

I21 A. Okay. With continued exposure to the

drug the body becomes tolerant. While opioids have22

I 23 many effects, not all of the effects achieve tolerance at

I24 the same rate. So, for example, a patient who is

receiving opioids in the hospital for an acute problem25

I

I 30

I1 will become tolerant to the nausea and vomiting of the

I 2 drugs very quickly. An addict uses opioids in order to

I3 induce euphoria and euphoria or the high of opioids is

4 one that fades very quickly, so addicts tend to need to

I 5 use more, and more, and more drug in order to achieve

I6 the high of the medication. However, because

7 respiratory depression, the dangerous side effect of

I 8 opioids, does not achieve the same degree of tolerance

I9 addicts experience overdose and so they get high, but at

10 the same time they stop breathing and that shows very

I 11 clearly the separation of the tolerance from some effects

I12 of the drugs to others. Again, with pain relief, patients

13 can use opioids at a constant rate over long periods of

I 14 time wi thou t achieving much in the way of the tolerance

I15 or very slowly develop tolerance, but at the same time

16 they will be sensitive to the respiratory depression

I 17 effects and, given high enough doses, they can still stop

I18 brea thing.

19 Q. Doctor, is it safe to say then that there

I 20 are numerous effects that a patient might get from an

I21 opioid but tolerance is not developed to those numerous

22 effects at the same rate?

I 23 A. Absolutely.

I24 Q. Doctor, does a patient' s response or

25 tolerance to Hydrocodone predict the patient' s tolerance

I

I 31

I1 or response to Methadone?

I 2 A. No, it does not. This is primarily

I3 because Hydrocodone is such a short acting drug that

4 doesn' t accumulate, while Methadone accumulates in the

I 5 body and is a much longer acting drug. In addition,

I6 because Hydrocodone tends to be primarily water

7 soluble, that is it absorbs in water, while Methadone is

I 8 lipid soluble, Methadone is stored in the tissues while

I9 Hydrocodone is in the blood and is excreted through the

10 kidneys after being metabolized. So our ability to

I 11 predict the response of the patient to Methadone simply

I12 by their response to Hydrocodone is absolutely zero.

13 Q. Doctor, do you have an opinion, within

I 14 reasonable medical probability, and based upon your

I15 review of all of these records in this case, the amount of

16 Methadone that could have safely been prescribed to Mr.

I 17 Hershey?

I18 14: 45: 24 - MR. PRISLIPSKY:

19 Objection.

I 20 A. In my opinion, the amount of

I21 Methadone that could have... that would have most

22 safely been prescribed to Mr. Hershey is an amount that

I 23 would be roughly equivalent to the amount of

I24 Hydrocodone that he was taking. He was taking... while

25 I think that the use of a shorter acting water soluble

I

I 32

I1 drug may have been preferable, the use of Methadone

I 2 could have been undertaken in a dose of about 2. 5

I3 milligrams, twice a day. I reach that by taking the

4 conversion of Hydrocodone being...

I 5 Q. Well, that' s the next question, Doctor.

I6 A. Okay.

7 Q. I just want to make sure that you and I

I 8 are on the same page. What is the formula, if you will,

I9 for dosing a patient on Methadone... switching a patient

10 from Hydrocodone to Methadone? Is there a formula

I 11 that you use to do that?

I12 A. Yes. ( Voice over)

13 14: 46: 20 - MR. PRISLIPSKY:

I 14 Objection. ( Voice over)

I15 Q. What is it, please?

16 A. The formula is the... first changing

I 17 from Hydrocodone to Morphine equivalence. When we

I18 change from any other drug to any other opioid drug we

19 use Morphine equivalence. Hydrocodone, because of its

I 20 absorption from the GI tract is better than that of

I21 Morphine, is 8 milligrams of Hydrocodone is equal to 10

22 milligrams of Morphine. Therefore, 8 milligrams of

I 23 Hydrocodone would... would be converted on an acute

I24 basis to one to one, to 10 milligrams of Methadone.

25 However, with accumulation into account we use a

I

I 33

I1 three to one ratio, so that would led to 10 milligrams

I 2 of Morphine converting to about 5 mill... I' m sorry...

I3 10 milligrams of Morphine being converted to about 3

4 milligrams of Methadone. He was taking 15 milligrams

I 5 of Hydrocodone, so the dose would have been about 5

I6 milligrams of Methadone or 2. 5 milligrams, three times

7 daily ... I' m sorry... twice daily.

I 8 Q. Okay, Doctor. Again, you prepared a

I9 chart that I' m going to put up on this easel. Does this

10 chart illustrate what you' ve just explained to the jury?

I 11 A. Yes, it does. ( Voice over)

I12 14: 47: 49 - MR. PRISLIPSKY:

13 Obj ection. ( Voice over)

I 14 Q. Could you please go through that for

I15 the jury?

16 14: 47: 51 - MR. PRISLIPSKY:

I 17 Objection.

I18 A. The chart shows the use of equivalen t

19 doses of Hydrocodone in milligrams to Methadone in

I 20 milligrams. Here it shows if the pa tien t were taking low

I21 doses of Hydrocodone, such as Mr. Hershey, about 13. 2

22 milligrams per day, then that would convert to about 5

I 23 milligrams per day of Methadone, 2. 5 milligrams, twice

I24 daily. We ... as we increase the dose of Hydrocodone the

25 dose of Methadone increases, so at about 30 milligrams

I

I 34

I1 of Hydrocodone, that would be roughly equivalent to

I 2 abou t 10 milligrams of Methadone per day or 5

I3 milligrams, twice daily. When we get to much higher

4 levels of Hydrocodone, at about 80 milligrams of

I 5 Hydrocodone, roughly equivalent to 100 milligrams of

I6 Morphine, that would convert to 30 milligrams of

7 Methadone per day. Or at 160 milligrams of

I 8 Hydrocodone, that would convert at a three to one

I9 Morphine to Methadone ratio to 40 milligrams of

10 Methadone.

I 11 Q. Alrigh t. And the yellow line that

I12 appears on that chart represents what, Doctor?

13 A. This is the dose which Dr. Casanova

I 14 chose. While Mr. Hershey was taking roughly 13. 2

I15 milligrams of Hydrocodone per day, Dr. Casanova chose

16 or he stated that he told Mr. Hershey to take 30

I 17 milligrams of Methadone per day, although he wrote that

I18 he should take 40 milligrams per day. Both of these

19 represent massive increases in the amount of opioid

I 20 which the patient was getting and, in my opinion, both

I21 of them represent gross over dosages with the written

22 instructions being much more egregious than the verbal

I 23 ones, but the written instructions were the ones that

I24 were repeated over, and over, and over.

25 Q. Doctor, do you have an opinion, within

I

I 35

I1 reasonable medical probability, whether Mr. Hershey

I 2 would have died if he had been prescribed a Methadone

I3 dose as you have just described as being within the

4 standard of care?

I 5 14: 50: 09 - MR. PRISLIPSKY:

I6 Objection.

7 A. In my opinion, there is nothing to

I 8 suggest that Mr. Hershey would have died had he been

I9 given this low dose of Methadone, and it was likely to

10 prove an adequate analgesic.

I 11 Q. Do you have an opinion, within

I12 reasonable medical probability, Doctor, what caused Mr.

13 Hershey' s death?

I 14 A. Mr. Hershey' s death, in my opinion,

I15 was caused by respiratory depression secondary to

16 Methadone.

I 17 Q. Doctor, could you... I notice you

I18 haven' t referred to any of these exhibits yet. Let' s take

19 a look at Plain tiff's Exhibi t Number " 4", which is the

I 20 coroner' s records relative to John Hershey.

I21 A. Yes.

22 Q. In reviewing those records, Doctor, can

I 23 you identify what the level of Methadone was that was

I24 detected by the coroner in the blood of Mr. Hershey?

25 A. The coroner' s report states that the

I

I 36

I1 Methadone level for Mr. Hershey, when correcting for the

I 2 inaccuracy of their test, was found to be 0. 581

I3 milligrams per liter.

4 Q. What is the significance of that,

I 5 Doctor, if anything?

I6 A. In my opinion, that is a toxic dose of

7 Methadone in an opioid- naive patient.

I 8 Q. From your review of the coroner' s

I9 report, did the coroner also find that to be a toxic level

10 of Methadone?

I 11 A. The coroner' s conclusion was that the

I12 patient died from Methadone toxicity as well.

13 Q. Alright. Now, Doctor, there' s also on

I 14 the... in the very beginning of these coroner' s records

I15 there is a drug and medication listing which lists the

16 medications that were collected by the coroner. I see the

I 17 very first is a listing for Methadone. What is the

I18 significance of that, Doctor, if anything?

19 A. There were 102 of the 120 prescribed

I 20 tablets remaining in Mr. Hershey' s prescription. Given

I21 that he had been taking the medication for four and a

22 half days, that is precisely the number of tablets that

I 23 would be expected if Mr. Hershey was taking the

I24 medication at one tablet, four times daily, as his written

25 instructions had shown.

I

I 37

I1 Q. Now, Doctor, I think you said that you

I 2 believe that the cause of death was respiratory

I3 depression. Is that correct?

4 A. That is correct.

I 5 Q. Is that conclusion consistent with the

I6 coroner' s conclusion?

7 A. It is not exactly consistent, but it is in

I 8 general consistent with the coroner' s conclusion.

I9 Q. What is your understanding of the

10 coroner' s conclusion as to the cause of death?

I 11 A. The coroner listed in terms of the

I12 causes of death myocarditis as the first cause. That is

13 because Mr. Hershey was found to have myocarditis.

I 14 Q. Could you characterize for the jury the

I15 level of myocarditis, if you will, that Mr. Hershey was

16 suffering from?

I 17 14: 53: 21 - MR. PRISLIPSKY:

I18 Objection. Foundation.

19 A. The coroner' s... the autopsy showed

I 20 that Mr. Hershey had some inflammation in his heart

I21 muscle. The areas of inflammation were shown to be in

22 the pumping wall of the left ventricle, the major chamber

I 23 of the heart, and near the AV node. It was relatively

I24 mild. I think that it' s very important when one reads

25 the details of the coroner' s report that there was no

I

I 38

I1 active acute inflammation of the heart, as only chronic

I 2 inflammatory cells were found, and the coroner noted

I3 the presence of fibrosis, and fibrosis is a sign of healing.

4 The way in which the heart muscle heals is by scarring

I 5 and the presence of that scarring shows that the

I6 inflammation was not new; it didn' t just happen; he

7 had had it for awhile; and he was basically on the mend.

I 8 All of the medical records prior to that also showed that

I9 Mr. Hershey had no signs or symptoms of myocarditis.

10 Q. Doctor, I want to state that question

I 11 just a little bit differently to you. Based upon your

I12 review of the coroner' s records and, for that matter, all

13 of the medical records in this case, what is your

I 14 understanding as to the level of myocarditis that Mr.

I15 Hershey suffered from?

16 A. It was mild. ( Voice over)

I 17 14: 54: 40 - MR. PRISLIPSKY:

I18 Objection. Foundation. ( Voice over)

19 A. It was mild and he was healing from it.

I 20 Q. Okay.

I21 A. It produced no signs or symptoms

22 during his life.

I 23 Q. Alrigh t. Doctor, I want to talk to you a

I24 little bit about a concept that' s been discussed both by

25 you previously in this case and by Dr. Miguel previously

I

I 39

I1 in this case in your depositions, and that is the concept

I 2 of post mortem redistribution. What is that, Doctor?

I3 A. Post mortem redistribution refers to

4 the movement of the drug from its various compartments

I 5 in the body after death. Methadone, because it dissolves

I6 in the fat cells of the blood and has what' s called a wide

7 volume of distribution, that is it spreads out into the

I 8 space available for it, once the patient dies, if there a

I9 large amount of Methadone in the fat stores then that

10 tries to reach equilibrium by moving into the

I 11 bloodstream. Under those circumstances the Methadone

I12 level can be up. However, Mr. Hershey had been taking

13 Methadone for a very short amount of time. There was

I 14 not time for a large fat store to build up in his body and,

I15 therefore, if anything, post mortem redistribution would

16 lead to the movement of Methadone out of the

I 17 bloodstream, lowering his blood level, and moving into

I18 the fatty tissues of the spine.

19 Q. If, in fact, post mortem redistribution

I 20 occurred in this case, would you have believed that to

I21 increase or decrease the amount of Methadone that the

22 coroner detected?

I 23 A. Because he' d only been taking it for a

I24 short time it would have decreased the amount of

25 Methadone detected in the blood because Methadone

I

I 40

I1 would have continued to move into the fatty tissues.

I 2 Q. Doctor, now you have reviewed the

I3 deposition testimony of Dr. Miguel in this case. Have

4 you not?

I 5 A. Yes, I have.

I6 Q. Alright. At one point in time Dr.

7 Miguel testified to this ratio that you discussed in this

I 8 chart here and specifically this three to one conversion

I9 from Morphine to Methadone. Dr. Miguel testified that

10 that ratio can go as low as 1. 5 to one. Do you agree

I 11 with that statement?

I12 A. I need to answer yes and no. In ...

13 when one uses Methadone on a single dose or a very

I 14 short acute basis, as in a day or two, the ratio, as I' ve

I15 previously shown in the charts is between one and 1. 5 to

16 one. However, when one uses Methadone chronically

I 17 and continues to administer it and has the accumulation

I18 of Methadone in the body, then the ratio must be made

19 grea ter, particularly because we don' t know what the

I 20 half-life of Methadone is going to be for any individual

I21 patient and to assume that the half- life is gong to be

22 less than 24 hours is to make an assumption that' s not

I 23 established in the literature. When we don' t know

I24 what' s around the corner it is our responsibility to slow

25 down and go slowly and safely for our patients. To use

I

I 41

I1 the 1. 5 to one number is too... is to be, in my opinion,

I 2 reckless with the use of the drug on a chronic basis

I3 because it may accumulate to a greater extent than the

4 three to one ratio if the half- life is longer than 24 hours.

I 5 Dr. Miguel, in his deposition testimony, clearly stated

I6 that the half-life of Methadone can be as great as 96

7 hours or 128 hours. If we' re sitting and looking at a

I 8 patient there' s no possible way that any physician can

I9 reasonably say, I know what your Methadone metabolism

10 is going to be. To think that we can is arrogant and

I 11 unnecessarily risky for our patients.

112 Q. Doctor, along the same lines, Dr.

13 Miguel goes on to say that using a three to one ratio we

I 14 would have a 10 milligram equivalent on the

I15 equianalgesic scale to take him to the point where he

16 was miserable because at that dosing Mr. Hershey was

I 17 miserable. And he goes on to say that because of that

I18 that' s further justification for in ... or decreasing that

19 amoun t even more. Do you agree with that statement?

I 20 14: 59: 19 - MR. PRISLIPSKY:

I21 Objection. It misstates the testimony.

22 A. Because we don' t know what the

I 23 patient' s response to the drug is going to be we must act

I24 as if we do not know. To act as if we know before we

25 know is dangerous. So to the extent that Dr. Miguel

I

I 42

I1 stated that he knew that Mr. Hershey would not respond

I 2 to a lower dose of Methadone is not information that he

I3 could possibly have and... because... and the fact of

4 the matter is is that Mr. Hershey' s pain would do him no

I 5 harm. It' s unpleasant, it hurts, and that is why I' m in

I6 the business I' m in. However, that pain will not kill you

7 and Mr. Hershey would not be dead if his pain were

I 8 adequately treated with a smaller dose of Methadone

I9 because we can always give him more or we could have.

10 Q. Let' s go off the record.

I 11 OPERATOR: We' re off the record.

I12 OPERATOR: We' re on the record.

13 Q. Doctor, I want to hand you what' s been

I 14 marked as Plain tiff's Exhibi t " 5". Can you identify that

I15 for me?

16 A. This is an Aultman Hospital Emergency

I 17 Department Patient Registration Form from May 13,

I18 2004.

19 Q. Doctor, does that record show a

I 20 prescription being written for Mr. Hershey on May 13,

I21 2004?

22 A. Yes, it does.

I 23 Q. Alrigh t. And what was the prescription

I24 and what was the dosage?

25 A. The prescription was for Vicodin. The

I

I 43

I1 dosage was one to two tablets orally every 4 to 6 hours

I 2 as needed for pain, and 20 tablets were dispensed.

I 3 Q. Okay. Doctor, the only reason I hand

4 that to you is I believe that there may have been an

I 5 error on the Ritzman Pharmacy records relative to that

I 6 prescription. Nevertheless, are you actually looking at

7 the actual prescription in Plaintiff's Exhibit Number " 5"

I 8 there?

I 9 A. Yes, I am. From Dr. Hric.

10 Q. Does that, as best you know,

I 11 accurately report the prescription that was written?

I12 A. Yes, it does.

13 Q. And does that prescription show up on

I 14 Plain tiff's Exhibi t Number " 6" in anyplace?

I15 A. Yes, it does.

16 Q. Alrigh t.

I 17 A. It shows up here on May 13, 2004

I18 associated with a finger injury that Mr. Hershey

19 sustained.

I 20 Q. Okay. Just a few more things, Doctor.

I21 I want you to go back to the coroner' s records, which I

22 believe are Plain tiff's Exhibi t Number " 4", and I' d like

I 23 you to turn your attention to the history that shows up

I24 on the... in the report. I will tell you that I believe it' s

25 on the third page of that document; a history that was

I

I 44

I1 purportedly taken from Dr. Khalil. Dr. Khalil apparently

I 2 reported that John J. Hershey had a known past medical

I3 history for a number of things; arthritis, hypertension,

4 so forth and so on, and it goes on to say and a history of

I 5 prescription drug abuse. From your review of all of the

I6 records, Doctor, are you... what is your understanding

7 of whether Mr. Hershey had any type of a drug abuse

I 8 problem?

I9 A. There is no evidence in the record that

10 Mr. Hershey has any... had any form of a drug abuse

I 11 problem. He was prescribed Hydrocodone for somatic

I12 pain complaints and certainly that is the standard of

13 care in modern medicine. He was given very low doses

I 14 for very short periods of time and Dr. Khalil actually

I15 only wrote three prescriptions for him. For one of his

16 prescriptions Mr. Hershey had utilized a 30 day supply

I 17 of Hydrocodone written to be taken twice daily. He had

I18 utilized it in 22 days. That is far from abuse of the

19 drug. It' s a drug to which he had previously been

I 20 exposed; it' s a very short acting drug; and, in fact, the

I21 guidelines of The Federation of The State Medical Boards

22 on the prescription of Opioids recognizes his behavior is

I 23 what would be called pseudo- addiction. That is, Mr.

I24 Hershey used slightly more of the drug in response to

25 somatic pain complaints because he wasn' t given enough

I

I 45

I1 to relieve his pain.

I 2 Q. Alrigh t.

I3 A. There' s no evidence that he abused the

4 drug.

I 5 Q. Doctor, you have also reviewed Dr.

I6 Khalil' s deposition testimony in this case too, correct?

7 A. Yes.

I 8 Q. Alrigh t. And is your understanding of

I9 Dr. Khalil' s concern singly the issue that Mr. Hershey

10 used those three medications slightly quicker than they

I 11 were prescribed?

I12 A. Yes.

13 Q. Okay. No other issue that you' re aware

I 14 of?

I15 A. There was... well, Dr. Khalil stated in

16 his deposition that there was a history of Mr. Hershey...

I 17 of using alcohol or drinking two to three beers per day.

I18 That' s doesn' t appear in Dr. Khalil' s records; it doesn' t

19 appear in Dr. Casanova' s records; and it is distinctly not

I 20 what Mr. Hershey reported on his intake form with Dr.

I21 Casanova. Further, I would say that the pill count is a

22 usual manner in which we currently check for abuse of

I 23 prescription medications. The fact that Mr. Hershey' s

I24 pill count was exactly at the amount that one would

25 expect it to be means that he was taking the medication

I

I 46

I1 in the way that it was prescribed.

I 2 Q. Okay. And, Doctor, finally just to clear

I3 up something, I failed to mark these documents that you

4 prepared to illustrate your testimony. I s Plain tiff's

I 5 Exhibit Number " 6" a document that you prepared to

I6 show Mr. Hershey' s Hydrocodone usage prior to

7 treatment with Dr. Casanova?

I 8 A. Yes, it is.

I9 Q. And Plaintiff' s Exhibit Number " 7",

10 again, Doctor, I' m just going back and retracing our

I 11 steps here, but is this a document that you prepared to

I12 show the steady state of Methadone?

13 A. Yes, it is.

I 14 Q. And Plain tiff's Exhibi t " 8" is a

I15 document that you prepared to show the accumulation of

16 Methadone?

I 17 A. Yes, it is.

I18 Q. And Exhibit Number " 9" is a document

19 that you prepared to show the average monthly

I 20 Hydrocodone usage by Mr. Hershey?

I21 A. Yes, it is.

22 Q. And, finally, Exhibit Number " 10", this

I 23 is a document, again, that you prepared and is entitled

I24 Standard of Care on Initial Methadone Dose, correct?

25 A. Yes, it is.

I

I 47

I1 Q. Okay. Let' s go off the record.

I 2 OPERATOR: We' re off the record.

I3 OPERATOR: We' re on the record.

4 Q. Doctor, finally one last question for

I 5 you. Is there any authority in the area of dosing of

I6 Methadone that you consider reliable?

7 A. There are a number of reliable

I 8 authorities and I' ve referenced quite a few in terms of

I9 my discussion here. There was one that I mentioned in

10 the course of my deposition testimony, a review article

I 11 from The American Family Practice Journal.

I12 Q. And, Doctor, I' m handing you a copy of

13 that document now. Is that the document that you

I 14 referred to?

I15 A. Yes, from The American...

16 Q. Would you identify the title and the

I 17 authors and the source of the publication?

I18 A. Methadone Treatment for Pain States,

19 authored by James D. Toombs, M. D. and Lee A. Kral,

I 20 PHARM. D., from The University of Iowa Hospitals and

I21 Clinics, and it' s from The American Family Physician

22 website.

I 23 Q. Okay. Thank you, Doctor. I have no

I24 further questions for you at this time.

25

I

I 48

I1

I 2

I3 DURING CROSS EXAMINATION BY MR. THOMAS

4 PRISLIPSKY:

I 5 Q. Doctor, good afternoon. How are you?

I6 A. Fine. And you?

7 Q. Good. To give me a roadmap, I' m going

I 8 to take you through some of the same structures that

I9 Mr. Eicher did; talk about your background and

10 training; talk about the materials that you' ve reviewed;

I 11 your opinions concerning Methadone; and then your

I12 opinions concerning Mr. Hershey' s death. Okay?

13 A. Yes.

I 14 Q. First of all, can you and I agree that

I15 there are differences between your background training,

16 education, and experience compared to Dr. Casanova' s?

I 17 A. I' m not sure what you mean. I am ...

I18 because I am an anesthesiologist by training and he is a

19 neurologist?

I 20 Q. Well, let me talk about specifically your

I21 practices today. Are you aware that Dr. Casanova sees

22 inpatients at Aultman Hospital and when Aultman

I 23 Hospital needs an inpatient consultation they will call

I24 Dr. Casanova?

25 A. That is the difference between our

I

I 49

I1 current practices. Although for the eight years that I

I 2 was on staff and the Medical Director of Pain

I3 Management Services at The Mercy Hospital in

4 Pittsburgh, as well as during my development of

I 5 inpatient service in the... at Wright Patterson United

I6 States Air Force Medical Center, I saw those sorts of

7 patients as well.

I 8 Q. SO currently you do not see any

I9 patients on an inpatient level at the hospital, right?

10 A. The only pa tien ts I see that are

I 11 inpatients are patients whom I admit to the hospital

I12 myself.

13 Q. Okay. And in your view, you generally

I 14 avoid inpatients because they are more worth... more

I15 work than they are worth. Is that correct?

16 A. In terms of the amount of time that is

I 17 required for me to see an inpatient at this point in my

I18 current practice, yes, that is correct.

19 Q. Okay. There is a vast difference

I 20 between you and Dr. Casanova in terms of your relative

I21 experiences in the medical- legal arena. Is that correct?

22 A. I don' t know Dr. Casanova' s

I 23 expenences.

I24 Q. Are you aware that Dr. Casanova in his

25 experience as a physician has been deposed on a

I

I 50

I1 handful occasions, three, four, five times?

I 2 A. I believe I read that in his deposition.

I3 Q. You yourself though give up to 20 to 25

4 depositions a year. Is that correct?

I 5 15: 18: 45 - EICHER:

I6 Objection.

7 A. Last year that' s about the number I

I 8 gave.

I9 Q. And are you aware that Dr. Casanova

10 does not do medical examinations for companies or for

I 11 patients who are on Workers' Compensation?

I12 A. I was not aware of that.

13 Q. That is something that you do in your

I 14 practice?

I15 A. That is something I do in my practice.

16 Q. And just so that we' re clear on this,

I 17 this is where you see patients who are on Workers'

I18 Compensation who are not part of your practice, correct?

19 A. Yes. I see them as an independent

I 20 medical examiner. I mentioned that I' m a certified

I21 independen t medical examiner.

22 Q. This is through your business here of

I 23 Pain and Disability Management Consultants, correct?

I24 A. That is correct.

25 Q. And last year you saw about 52 of

I

I 51

I1 these patients?

I 2 A. That is correct.

I3 Q. Around one a week?

4 A. Approxima tely.

I 5 Q. And the vast majority of these patients

I6 that you see in these medical examinations are on behalf

7 of the employer?

I 8 A. Urn, about 90 percent.

I9 Q. And you are aware, are you not,

10 Doctor, that the patients that are being sent to you

I 11 for these medical examinations, the employers who

I12 send them to you have a financial incentive to, ( A) either

13 get these patients back to work as soon as possible

I 14 or, ( B) to limit the amount of recovery that they are

I15 receiving through the Workers' Compensation

16 system?

I 17 15: 20: 00 - MR. EICHER:

I18 Objection.

19 A. That is not my concern.

I 20 Q. Okay. Was... I didn' t ask you if that

I21 was your concern, Doctor. My question was are you

22 aware that there is a financial incentive for these

I 23 companies that send you these patients to examine to

I24 get them, ( A) back to work, or to, ( B) limit their

25 compensation?

I

I 52

I1 15: 20: 17 - MR. EICHER:

I 2 Objection.

I3 A. I' m aware that all insurance companies

4 attempt to limit their outlays.

I 5 Q. Okay. Now this case... the Hershey

I6 case that we' re talking about, that involves Methadone,

7 correct?

I 8 A. Yes, it does.

I9 Q. Dr. Casanova, can you and I agree, has

10 much more experience in dispensing Methadone than

I 11 you do?

I12 A. I would not necessarily say that, no.

13 Q. Do you recall in Dr. Casanova' s

I 14 deposition that he currently has about 200 patients who

I15 are taking Methadone?

16 A. And I would take that to be that Dr.

I 17 Casanova tends to use Methadone more frequently than I

I18 do. Although over the course of the last 20 years I' ve

19 used Methadone in quite a number of patients and I' m

I 20 not sure how many Dr. Casanova has over that same

I21 period of time. I ... it is, in fact, the case that in the

22 use of opioid analgesics in my current practice he has

I 23 more patients on the drug than I do. I don' t know what

I24 his actual experience is.

25 Q. In terms of prescribing Methadone for

I

I 53

I1 patients with chronic pain, that is something that has

I 2 been ... become a practice within the, what, last 10

I3 years?

4 A. I would say no. In fact, I used

I 5 Methadone when I was a fellow. Although the use of

I6 Methadone has become more frequent in the last 10

7 years.

I 8 Q. Okay. So if I go back to my initial

I9 question. Currently Dr. Casanova, you are aware, has

10 approximately 200 patients on Methadone?

I 11 A. That' s what I' ve been told.

I12 Q. Which is about four times the number

13 of patients that you have on Methadone?

I 14 A. Yes.

I15 Q. Okay. This case also involves opinions

16 regarding pathology and interpretation of autopsies,

I 17 correct?

I18 A. Yes, it does.

19 Q. And as I look at your curriculum vitae

I 20 your residency was in anesthesiology, not pathology,

I21 correct?

22 A. That is correct.

I 23 Q. Your fellowship was in pain

I24 management, not pathology?

25 A. That is correct.

I

I 54

I1 Q. You never did a residency in internal

I 2 medicine?

I3 A. No, I did not.

4 Q. Or a residency in surgery or pathology?

I 5 A. No, I did not.

I6 Q. And now you' re aware Dr. Casanova

7 conversely did complete a residency program in internal

I 8 medicine?

I9 A. Yes.

10 Q. Also completed a residency program in

I 11 pathology?

I12 A. I was not aware.

13 Q. Okay. Were you aware that Dr.

I 14 Casanova has Ph. D. in neurochemistry?

II15 A. Yes.

16 Q. Okay. Let' s now talk about the

I 17 documents that you have reviewed in this case. Can you

I18 agree with this sta temen t as a general concept, Doctor,

19 that as an expert witness a physician' s review must be

I 20 thorough, fair and impartial, and it must not exclude

I21 any relevant information?

22 A. In general, yes.

I 23 Q. Okay. Now to explain how this

I24 happens with expert witnesses and how it happened in

25 this case, at one point in time you received a call from

I

I 55

I1 either Mr. Eicher or Mr. Semple and they asked you to

I 2 review some medical records related to Mr. Hershey,

I3 correct?

4 A. Yes.

I 5 Q. Then after you reviewed the medical

I6 records you prepared a report detailing your findings

7 and your opinions in this case?

I 8 A. At some point after, yes, I prepared a

I9 report.

10 Q. And then I think it was maybe a month

I 11 or so ago I had the opportunity to come here and ask

I12 you questions, while you were under oath, to learn the

13 basis of your opinions and the support for your

I 14 opinions, correct?

I15 A. Yes, that' s correct.

16 Q. And that' s how it works in the

I 17 li tiga tion system. You get a call; you review the records;

I18 you prepare a report; and then you get deposed, correct?

19 A. Yes.

I 20 Q. And when we took your deposition even

I21 and actually up until we started your trial testimony

22 today, it was your understanding that Mr. Hershey first

I 23 took Vicodin in 2002. Is that correct?

I24 15: 24: 04 - MR. EICHER:

25 o bj ection.

I

I 56

I1 A. No.

I 2 Q. Not in your report. You first ... you

I3 said that Mr. Hershey first started to take Hydrocodone

4 in 2002?

I 5 A. In the records that I had available of

I6 Mr. Hershey that... detailing his Hydrocodone use was

7 from 2002 forward. However, the exposure in the post

I 8 operative period in, say, 1999 would also be expected,

I9 given the limited number of therapeutic options in the

10 trea tmen t of acu te pain. The use of Vicodin is quite

I 11 common.

I12 Q. You are aware now, as you sit here

13 today, that from 1999 until the time that Mr. Hershey

I 14 passed away the following physicians had ordered him

I15 Vicodin; Dr. Moats, Dr. Zahn, Dr. Donich, Dr. Njus, Dr.

16 Weiner, Dr. Rusnak, Dr. Biggs, Dr. Kakarala, Dr. Hrics,

I 17 and Dr. Khalil?

I18 A. Yes, that' s correct.

19 Q. And you, at the time of your

I 20 deposition, were not aware of the substance of the

I21 deposition testimony of Dr. Khalil. Is that correct?

22 A. No, I had not read it.

I 23 Q. You... have you seen Dr. Khalil' s

I24 deposi tion since then?

25 A. Yes, I have.

I

I 57

I1 Q. And you agree that Dr. Khalil testified

I 2 that he was concerned that Mr. Hershey was taking the

I3 Vicodin against his specific instructions, correct?

4 A. As I stated in my direct testimony, Dr.

I 5 Khalil did state that. However, Mr. Hershey' s use of the

I6 medication, in my opinion, was not excessive under the

7 circumstance.

I 8 Q. Doctor, my question was Dr. Khalil

I9 testified under oath that he was concerned that

10 Mr. Hershey was taking the Vicodin against his express

I 11 instructions, correct?

I12 A. He did testify to that.

13 Q. And that' s something that you as a

I 14 physician would be concerned about, correct?

I15 A. If the duration, nature of the problem,

16 and the overall response of the patient were excessive,

I 17 yes, I would be concerned.

I18 Q. Well, at a minimum, if a patient is

19 going to vary from the approach that you and the patient

I 20 have agreed to in terms of pain management medication,

I21 you would want that patient to call you and say, hey,

22 Doctor, I know that you' ve been prescribing this. It' s

I 23 not working. Can I take a couple extra pills or one extra

I24 pill ? You would want that at an absolute minimum,

25 agreed?

I

I 58

I1 A. Well, in my practice that is something

I 2 that I detail with the pa tien ts specifically. However, the

I3 fact of the matter is is that when patients have had prior

4 exposure to medication; when those details are not

I 5 discussed with the patient specifically; when there is not

I6 an opioid informed consent; when those... when that

7 has not been clearly specified by the physician, the

I 8 tendency of patients to use an ad lib, that is a PRN, as

I9 needed medication in slightly greater doses is not at all

10 uncommon.

I 11 Q. Okay. My question wasn' t whether it

I12 was uncommon or not. My question was you would want

13 at a minimum, if a patient is going to vary from the

I 14 protocol that you and this patient have agreed to, you

I15 want this patient to call you and get your permission,

16 agreed?

I 17 A. In my practice that would be a written

I18 agreement.

19 Q. Okay. And in Dr. Khalil' s actual

I 20 pharmacy medication refill list he writes, " Using too

I21 much. Should have lasted to 8/ 8." Do you remember

22 seeing that after your deposition, Doctor?

I 23 A. Yes, I do.

I24 Q. And before your deposition at the time,

25 number one, that you reviewed the records and then,

I

I 59

I1 number two, at the time when you wrote your report

I 2 and, number three, at the time that you gave your

I3 deposition you were not aware of that?

4 A. I was not aware of that. Although I

I 5 was aware that he had written a prescription for a twice

I6 a day usage and that the patient had used it in 22 days.

7 Q. Were you also aware, Doctor, at the

I 8 time that we took your deposition that on July 6, 2004

I9 Mrs. Hershey telephoned Dr. Khalil' s office and said that

10 he ... she had not received a call back from pain

I 11 management and that quote, unquote, " He was really

I12 hurting." Do you remember reading that now in Dr.

13 Khalil' s medical records? If you haven' t, Doctor, I have

I 14 it handy for you. I' m going to hand you what has been

I15

16 A. Can you refresh my memory?

I 17 Q. yeah... pre- marked as Defendant' s

I18 Exhibit "A- I".

19 A. I had not seen this, no.

I 20 Q. Okay. Do you remember seeing that as

I21 an exhibit to Dr. Khalil' s deposition?

22 A. It may have been included. I

I 23 concen tra ted on his verbal deposition.

I24 Q. Fair enough. In any event, I mean

25 that' s not something that' s surprising. Clearly based

I

60

I1 upon everything that you reviewed in this case, Mr.

I 2 Hershey was in some significant pain in July of 2004?

I3 A. Mr. Hershey was complaining of pain,

4 yes.

I 5 Q. Alright. I want to ask you abou t some

I6 of the diagrams that you have prepared and I don' t want

7 to mess up your diagrams. By the way, the diagrams

I 8 that you' ve used today, are these diagrams that you

I9 prepared yourself or that plain tiff's counsel has

10 prepared for you?

I 11 A. Under my instruction they prepared the

I12 diagrams.

13 Q. I' m going to hand you what I have

I 14 marked as Defendant' s Exhibit " B", which is the average

I15 monthly Hydrocodone use.

16 A. Yes.

I 17 Q. Now, if you can... how about if I give

I18 you a highligh ter.

19 A. Uh- huh.

I 20 Q. And if we can zoom in ... and if you

I21 have an opportunity can you put that on the board,

22 Doctor? What I want to do is use that in conjunction

I 23 with one of your other exhibits that was prepared that

I24 says on March 18th of 2003 Mr. Hershey was taking an

25 average daily dose of 50 milligrams of Hydrocodone;

I

I 61

I1 April 4, 2003, 50 milligrams of Hydrocodone; July 3,

I 2 2003, 50 milligrams of Hydrocodone. And instead of

I3 doing this on an average monthly basis...

4 A. Uh- huh.

I 5 Q. if you could just mark my exhibit for

I6 those time frames of 50 milligrams of Hydrocodone in

7 March, April and then July of 2003. Now also July of

I 8 2003. Alright. That' s there. Alright.

I9 A. March, April, July.

10 Q. N ow I know in one of the exhibi ts it

I 11 talked about 5 milligrams during the latter period of

I12 July and early period of August, 2004. I' m not really

13 certain as I sit here what your understanding of Mr.

I 14 Hershey' s Vicodin intake was at the time that he saw Dr.

I15 Casanova but, can you and I agree that based upon what

16 you have reviewed, it is your understanding that Mr.

I 17 Hershey was taking 15 milligrams of Hydrocodone in

I18 July and August of 2004, not 5 milligrams of

19 Hydrocodone?

I 20 A. He was taking 5 milligrams, three times

I21 a day in July and August.

22 Q. Which would be 15 milligrams per day?

I 23 A. Which would be 15 milligrams per day.

I24 Q. And at the time of your deposition,

25 Doctor, you had not yet received and reviewed the full

I

I 62

I1 compilation of the coroner' s report, is that correct,

I 2 including the toxicology results?

I3 A. That is correct.

4 Q. Okay. And so at the time of your

I 5 deposition you were not aware that EDDP, which is a

I6 metabolite of Methadone, was not found in the toxicology

7 screen after his death, correct?

I 8 A. At the time of my deposition I was not

I9 aware of that.

10 Q. Okay. Now let' s shift gears a little bit

I 11 and we' ll talk about your opinions concerning the care

I12 and treatment. Now you use the term, and it' s on one of

13 your exhi bi ts, standard of care. You and I can agree,

I 14 Doctor, that in all likelihood the ladies and gentlemen of

I15 this jury have probably never used the term standard of

16 care in their career or their life, correct?

I 17 A. That' s true.

I18 Q. SO that we can make it a little bit more

19 lay perspective, when we talk about standard of care

I 20 what we are basically saying is what a reasonably

I21 prudent doctor would do under similar circumstances?

22 A. Yes. And by prudent we mean careful.

I 23 Q. Right. It is a reasonable physician

I24 standard?

25 A. Yes. A reasonably careful physician

I

I 63

I1 standard.

I 2 Q. I understand. I' m not trying to play

I3 games with the words either. A reasonably careful

4 physician standard?

I 5 A. Yes.

I6 Q. And it' s based upon the physician' s

7 background, training, expertise, and board

I 8 certifications, correct?

I9 A. In part.

10 Q. Alrigh t. Now there is no one standard

I 11 of care, so we can put that to rest, for all circumstances

I12 all of the times. Is that agreed?

13 A. That is agreed.

I 14 Q. You use your medical judgment as a

I15 physician probably 50 to 100 times a day, if not more?

16 A. I don' t know how many times a day. I

I 17 use it frequently.

I18 Q. Okay. And you can be wrong in making

19 a decision, but yet your judgment be reasonably careful

I 20 and still satisfy this mythical or mystical standard of

I21 care, agree?

22 A. I' m not sure I understand the question.

I 23 Q. Well, let me ask it a different way. You

I24 can have a scenario where you have a patient who comes

25 in, you and another board certified pain management

I

I 64

I1 specialist both are looking at this patient, and you can

I 2 reach different conclusions in terms of the best

I3 treatment modality for this patient, disagree with one

4 another, but yet both positions and both physicians be

I 5 reasonable and within the standard of care?

I6 A. I think it' s possible. It' s not the case

7 in this one.

I 8 Q. Okay. Well, and I' m talking about in

I9 general. I mean, there is no one- way to do anything,

10 correct?

I 11 A. That' s correct. There' s no one- way.

I12 Q. And when we look at some of the

13 specifics of this case... and let' s talk about August 11 th,

I 14 2004. Now can you and I agree that Dr. Casanova' s

I15 history that he obtained from Mr. Hershey complied with

16 the standard of care, was reasonable, and appropriate?

I 17 A. To the extent that it was recorded, I

I18 would say that it did.

19 Q. Okay. Because when I asked you that

I 20 question in your deposition, I said, Doctor, this is not a

I21 memory test. And I said, can you and I agree that Dr.

22 Casanova' s history of Mr. Hershey was reasonable and

I 23 within the standard of care? Do you remember what

I24 your answer was?

25 A. I think it was something close to what I

I

I 65

I1 just said.

I 2 Q. It was, yes. And that history basically

I3 went through what you had just talked about earlier;

4 that Mr. Hershey had a herniated disc; that he had

I 5 fusion surgery which was unsuccessful; that he had a

I6 laminectomy surgery which was unsuccessful in

7 relieving his pain; that he had pain in the neck radiating

I 8 down both ...

I9 A. I' m sorry. I have to stop you.

10 Q. You' re going to disagree when you say

I 11 unsuccessful?

I12 A. Yes.

13 Q. Okay. Let me start again.

I 14 A. Okay.

I15 Q. He had a herniated disc, correct?

16 A. Yes.

I 17 Q. He had a fusion surgery?

I18 A. He did.

19 Q. The fusion surgery did not relieve his

I 20 pain?

I21 A. It did not relieve his pain in the long

22 run.

I 23 Q. Okay. And he had a laminectomy

I24 thereafter?

25 A. That' s correct.

I

I 66

I1 Q. And the laminectomy in the long run

I 2 did not relieve his pain?

I3 A. Initially it was successful and relieved

4 his arm pain. His neck pain greatly improved and, thus,

I 5 we had a long period of time of which he used no opioid

I6 analgesic. He had a recurrence of his pain complaints

7 later.

I 8 Q. Back in 2004 his complaints of pain

I9 returned?

10 A. That is correct.

I 11 Q. And the history further elicited by Dr.

I12 Casanova said that the pain in his neck was radiating

13 down both arms, agreed?

I 14 A. Yes.

I15 Q. He described it as a constant burning?

16 A. Yes.

I 17 Q. That when he would bend or stoop that

I18 would aggravate his pain?

19 A. That was recorded.

I 20 Q. That he had numbness in his hands?

I21 A. That was recorded.

22 Q. That he was only sleeping 4 hours a

I 23 nigh t?

I24 A. Yes.

25 Q. And even though he had been taking

I

I 67

I1 the Vicodin, the Vicodin was not controlling his pain?

I 2 A. That is true.

I3 Q. And he described his pain on a scale of

4 one to 10 as about a 7. S?

I 5 A. Yes, he did.

I6 Q. And, again, that' s pretty moderate to

7 severe pain?

I 8 A. We assume that it' s moderate to severe

I9 paIn. Although that number is not one that I would

10 generally use because it' s like trying to do calculus

I 11 using a ruler. He was complaining of pain complaints

I12 and he said that they were moderately severe, yes.

13 Q. And, again, based upon the note that

I 14 you just saw for the first time at Dr. Khalil' s testimony

I15 or Dr. Khalil' s deposition, Mrs. Hershey, from what she

16 observed, said that he was really hurting, correct?

I 17 15: 37: 00 - MR. EICHER:

I18 Objection.

19 A. Yes, that' s what the note said.

I 20 Q. Okay. And Dr. Casanova' s physical

I21 examination was reasonable and met the standard of

22 care?

I 23 A. His physical examination was limited

I24 but did not violate the standard of care. That' s correct.

25 Q. And when we talk about, again, this

I

I 68

I1 concept of standard of care... because I assume this is

I 2 probably a foreign concept... if we were to pull five or

I3 six different physicians and go through Dr. Casanova' s

4 history and the physical examination, there may be

I 5 disagreemen ts between the physicians whether this

I6 should have been done or this could have been done, but

7 in all likelihood all of the physicians would agree that

I 8 the history and the physical examination were

I9 reasonable?

10 A. I think that I have some confusion

I 11 about what you mean by history. If by history you mean

I12 that which Dr. Casanova recorded, then I agree with

13 you. If you mean by history that which Dr. Casanova

I 14 now says occurred, I disagree with you.

I15 Q. Okay.

16 A. Because, in fact, if Mr. Hershey did tell

I 17 Dr. Casanova that he was taking twice as much

I18 medication as he was instructed to take; twice as much

19 medication as he could possibly take given the

I 20 prescription data that we have, then that would have

I21 been important information to record in the history and,

22 to that extent, his history was substandard.

I 23 Q. Okay. So let' s talk about that in the

I24 recorded history and then the physical examination that

25 Dr. Casanova went ahead and did on Mr. Hershey. If we

I

I 69

I1 would get five or six different physicians in the room and

I 2 talk about Dr. Casanova' s recorded history and the

I3 physical examination, although there might be

4 disagreements among the five or six physicians, in all

I 5 likelihood all five or six would agree that both were

I6 reasonable?

7 A. That they met the standard of care.

I 8 Q. Yes. And absolutely Dr. Casanova' s

I9 decision to DC ... discontinue Mr. Hershey' s Vicodin was

10 a reasonable decision, correct?

I 11 A. Yes, it was.

I12 Q. And absolutely Dr. Casanova' s use of

13 Methadone was reasonable and met the standard of

I 14 care?

I15 A. Dr. Casanova could choose any opioid,

16 Methadone included.

I 17 Q. And his use of Methadone, Doctor, was

I18 reasonable... we' ll talk about the prescription in a

19 moment ... but Dr. Casanova' s decision to place Mr.

I 20 Hershey on Methadone was a reasonable decision?

I21 A. It was not one that violated the

22 standard of care.

I 23 Q. Okay. Go ahead.

I24 OPERATOR: We' re off the record.

25 END OF TAPE ONE.

I

I 70

I1 START OF TAPE TWO.

I 2 OPERATOR: We' re on the record.

I3 Q. You' re all set, Doctor?

4 A. Thank you.

I 5 Q. Alrigh t. Now I think where we come to

I6 an area of disagreement is related to the amount of

7 Methadone that Dr. Casanova prescribed, correct?

I 8 A. Yes.

I

II9 Q. Alrigh t. And throughout the course of

10 today' s testimony you keep referring to the fact that you

I 11 believe Mr. Hershey was taking 40 milligrams of

I12 Methadone per day, right?

13 A. Mr. Hershey was instructed to take 40

I 14 milligrams per day.

I15 Q. Well, my question was you' re under the

16 assumption and had been working under the assumption

I 17 that Mr. Hershey was taking 40 milligrams of Methadone

I18 per day, right?

19 A. All of the evidence points to that.

I 20 Q. Well, so you are absolutely discounting

I21 what Mrs. Hershey testified to in her deposition then?

22 A. I am ... Mrs. Hershey testified that she

I 23 heard Dr. Casanova say that he instructed Mr. Hershey

I24 to take 10 milligrams, three times per day to start and

25 then increase the dose. What I don' t know is I don' t

I

I 71

I1 know what Mr. Hershey heard and I can' t ask him what

I 2 he heard. In the nature of verbal communication, the

I3 same people in the same room listening to the same

4 thing will hear different things. The fact of the matter is

I 5 is that when I look at the occurrence of events and the

I6 multiple reinforcement of 40 milligrams per day, with

7 the single... against the single verbal occurrence of 30

I 8 milligrams per day, I understand that Mr. Hershey was

I9 taking the medication in the way that he was instructed

10 to do so.

I 11 Q. Well, you were aware that Dr. Casanova

I12 does not recall Mrs. Hershey being present during that

13 examination, right?

I 14 A. I read that as a discrepancy in their...

I15 in their depositions.

16 Q. SO let' s talk about two possible

I 17 scenanos. The one is Mrs. Hershey was at the

I18 appointment and clearly, by her testimony, she heard

19 Dr. Casanova instruct her husband as to taking 30

I 20 milligrams of Methadone per day, agreed?

I21 A. Tha t could have occurred.

22 Q. Okay. And if the other scenario of

I 23 what Dr. Casanova testified to is accurate; that Mrs.

I24 Hershey wasn' t there; if she knew after the appointment

25 that Mr. Hershey was supposed to take 30 milligrams of

I

I 72

I1 Methadone per day, the only conclusion would be that

I 2 Mr. Hershey told her that. Is that reasonable?

I 3 A. I would be speculating as to those

4 occurrences.

I 5 Q. Okay. Alright. Again, it is your

I6 testimony that if we get five physicians in this room and

7 ask them through the course of the facts, the history

I 8 and the physical, that all five physicians would say...

I9 and I' m going to use for the purposes of this

10 examination, Doctor, 30 milligrams of Methadone... and

I 11 I want you to assume for my questions that Mr. Hershey

I12 was taking 30 milligrams of Methadone and that' s what

13 Dr. Casanova prescribed, okay?

I 14 A. I will assume that.

I15 Q. Thank you. If we get five, six

16 physicians in this room and we go through the facts;

I 17 that there are no areas of disagreement; that five boar,d

I18 certified pain management specialists would come to the

19 same conclusion that you have; that prescribing a

I 20 patient such as Mr. Hershey 30 milligrams of Methadone

I21 was below the standard of care; that was unreasonable,

22 correct?

I 23 A. If I speculate as to what five pain

I24 management physicians would say that would be

25 speculation. It is my opinion that the standard of care

I

I 73

I1 does not include an increase of 600 percent in the oral

I 2 opioid dose when one is converting from Hydrocodone to

I3 Methadone. The use of 30 milligrams per day is outside

4 of the standard of care, as is the use of 40 milligrams

I 5 per day.

I6 Q. I guess what I' m saying is when we

7 talked about earlier that you can have reasonable

I 8 physicians look at one set of facts and come to different

I9 conclusions and yet still hold reasonable opinions. In

10 this case, you believe if a physician holds the opinion

I 11 that starting a patient, such as Mr. Hershey, on 30

I12 milligrams of Methadone that would be an unreasonable

13 opinion?

I 14 A. Yes.

I15 Q. Okay. So when Dr. Casanova testified

16 in retrospect in his deposition... Dr. Casanova, board

I 17 certified in pain manage men t, board certified in

I18 electromyography, board certified in neuroradiology,

19 board certified in neurology and psychiatry with

I 20 residencies in internal medicine and surgical pathology,

I21 when he said that that' s a reasonable amount to start

22 Mr. Hershey, he was wrong?

I 23 A. He was wrong. And that' s without

I24 regard to what board certifications he holds. The fact of

25 the matter is is that increasing using Methadone from 15

I

I 74

I1 milligrams of Hydrocodone per day to 30 milligrams of

I 2 Methadone, leading to the death of the patient is

I3 unreasonable, unnecessary and outside of the standard

4 of care.

I 5 Q. And, again, Dr. Casanova is absolutely

I6 dead wrong, correct?

7 A. In my opinion, yes.

I 8 Q. SO then when we have Dr. Miguel...

I9 and you' ve read Dr. Miguel' s deposition, correct?

10 A. Yes.

I 11 Q. You' ve reviewed his curriculum vitae?

I12 A. Yes.

13 Q. When we have the President elect of the

I 14 State of Florida Association of Anesthesiologists testify

I15 that 30 milligrams of Methadone being prescribed to a

16 patient such as Mr. Hershey...

if he says that' s

I 17 unreasonable... I' m sorry... if he says that' s

I18 reasonable, he' s also wrong?

19 A. Yes, because Dr. Miguel' s basis for

I 20 saying that is using a ratio of 1. 5 to one. 1. 5 to one is a

I21 ratio that can be utilized safely in patients who are

22 undergoing an acute transition from Methadone to

I 23 Hydrocodone. However, his statement that one can look

I24 at the patient, say that they are healthy and robust, and

25 by that means determine what... how they are going to

I

I 75

I1 metabolize Methadone, thereby making that a safe dose,

I 2 that is unreasonable in my opinion.

I3 Q. Again, so when Dr. Miguel, the

4 President elect of the Florida Association of

I 5 Anesthesiologists, says that 30 milligrams of Methadone

I6 for Mr. Hershey, prescribed by Dr. Casanova, was

7 reasonable, he was wrong?

I 8 A. He was wrong. Particularly given

I9 that he said that the... that the half-life of the drug

10 could be up to 96 hours... up to ... I' m sorry... 128

I 11 hours, and given that there is no way for him to tell

I12 what Mr. Hershey' s half- life was then, yes, that' s

13 unreasonable.

I 14 Q. So Dr. Casanova is wrong; Dr. Miguel

I15 is wrong; you are right?

16 A. In my opinion, Dr. Casanova and Dr.

I 17 Miguel are incorrect.

I18 Q. Doctor, I' m going to hand you what we

19 have marked as ... excuse me ... I apologize...

I 20 Defendant' s Exhibit " C", Evaluation and Treatment of

I21 Chronic Pain. And I have this flagged in certain areas.

22 And this is a piece of literature that when you review the

I 23 facts of this case, Doctor, you actually did review this

I24 li tera ture, correct?

25 A. No, the Aronoff book that I referred to

I

I 76

I1 was The Handbook of Pain Management, 2004.

I 2 Q. Well, generally speaking, is Dr.

I3 Aronoff, if your view, a reliable physician based upon

4 what you have read in the past?

I 5 A. Yes.

I6 Q. Okay.

7 A. In general.

I 8 Q. Alrigh t. If I ... if you turn then,

I9 Doctor, to page 400 that is flagged.

10 A. Yes.

I 11 Q. Are you there? Do you see where it has

I12 highlighted up top, " Starting Dose of a Patient Over 50

13 Kilograms." Do you see that?

I 14 A. Yes.

I15 Q. And if we go down to Methadone, it has

16 20 milligrams, q 8 hours", correct?

I 17 A. That is what it says.

I18 Q. And that is actually more than what

19 Dr. Casanova prescribed Mr. Hershey, if the prescription

I 20 was 30 milligrams, threetimes...

I' msorry...

10

I21 milligrams, three times per day, correct?

22 A. Yes.

I 23 Q. Okay. So ...

I24 A. However.. .

25 Q. you disagree then with this

I

I 77

I1 literature?

I 2 A. Yes. In particular, I think that the

I3 context of this literature must be taken into account.

4 This is the 1999 addition of Aronoff' s book. In Aronoff' s

I 5 book, copyright 2004, he states that... he does not state

I6 a starting dose. He states that the equianalgesic dose

7 should be decreased by 50 to 75 percent in conversion.

I 8 In part ...

I9 Q. Well, Doctor, we' re going to go ... go

10 ahead. I' m sorry. I was going to say we are going to go

I 11 through more than Aronoff, I can assure you. But go

I12 ahead.

13 A. In part, that' s because in the period

I 14 from 1998 through 2005 the number of deaths that have

I15 occurred due to the use of Methadone in this fashion

16 has escalated greatly, and I would say that what we

I 17 believed in 1999 is not what we believe today.

I18 Q. Okay. You didn' t say anything about

19 that in your deposition testimony that the standards

I 20 have changed between 1999 and 2004, did you?

I21 A. No. Voice over)

22 15: 52: 49 - MR. EICHER:

I 23 Objection. ( Voice over)

I24 A. But, in fact, you asked me about

25 Aronoff and the Aronoff that I referred to in answering to

I

I 78

I1 your question in the deposition was his 2004 book.

I 2 Q. And if we turn to the other portion that

I 3 is flagged, " Although there are exceptions, most patients

4 appear to require a minimum of four doses per day to

I 5 achieve sustained analgesia with Methadone." Do you

I 6 agree with that statement, Doctor?

7 A. No, I do not.

I 8 Q. Okay.

I 9 A. In fact, when we look at studies of

10 pa tien ts who ... while Methadone in the short run ... and

I 11 most of the studies... and I' m not sure which study is

I12 cited to lead to this statement... in the short run

13 Methadone does require four times a day dosing for the

I 14 use in acute pain. In cancer patients, for example, they

I 15 tend to ... when they' re allowed to use the drug ad lib,

16 they tend to use two to three doses per day and that

I 17 would be the appropriate dose...

I18 Q. You bring up a good point, before we

19 get on to the rest of the literature. There is a lot of

I 20 literature written about the use of Methadone and

I21 Morphine in cancer patients, correct?

22 A. Yes.

I 23 Q. Big difference between a cancer patient

I24 and a patient who has chronic pain secondary to

25 diskectomies, correct?

I

I 79

I1 A. Yes.

I 2 Q. Okay. For instance, a cancer patient is

I 3 really by nature of the entire diagnosis more debilitated

4 medically than a patient who has just has chronic pain

I 5 secondary to diskectomies, correct?

I 6 A. Not necessarily, but they could.

7 Q. Well, you need to be more cautious

I 8 when you' re prescribing Methadone to a cancer patient

I 9 because of the cancer and the other medications, the

10 chemotherapy, than you need to with a pa tien t who has

I 11 chronic pain secondary to diskectomies?

I12 A. I think not. In fact, because they have

13 cancer and because their pain is a sign of something

I 14 that will kill them, we ... the data is that we are much

I15 more liberal and, in fact, those patients tend to be much

16 more opioid tolerant because of more rapid escalation in

I 17 their short acting opioids prior to the institution of

I 18 Methadone.

19 Q. Doctor, I' m going to hand you what we

I 20 have marked as Defendant' s Exhibit " D", which is

I21 Goodman & Gilman' s. I believe in your deposition you

22 said this was another ... or excuse me ... this was one of

I 23 the pieces of literature that you did review. Is that

I24 correct?

25 A. Yes.

I

I 80

I1 Q. Okay. Again, are Goodman & Gilman

I 2 generally thought to be reliable by you?

I 3 A. It is a book that I' ve read and I use...

4 I' ve used since medical school.

I 5 Q. If we go to the first flag, page 573, " The

I6 typical oral dose" ... talking about Methadone...

7 A. Uh- huh.

I 8 Q. is 2. 5 to 15 milligrams depending

I 9 on the severity of the pain and the response of the

10 patient." Correct?

I 11 A. Yes, that is what it states.

I12 Q. Do you agree with that statement,

13 Doctor?

I 14 A. In fact, I would have given Mr. Hershey

I15 between 2. 5 and 15 milligrams... in fact, I have stated

16 that I would have given him 2. 5 milligrams, twice a day,

I 17 that ... I take that to be a daily dose.

I18 Q. Didn' t we already talk abou t the ... in

19 the Aronoff book that typically it' s four doses per day?

I 20 A. You are taking a statement in one book

I21 and applying it to another. I am taking that to be a

22 daily dose.

I 23 Q. SO you' re taking this... and don' t get

I24 ahead of me, if you would, Doctor. You' re taking that

25 statemen t that what I just read to be two to 15

I

I 81

I1 milligrams per day, not per dose. Is that correct?

I 2 A. Yes. As it states later, " Care must be

I3 taken when escalating the dose because of the prolonged

4 half-life of the drug and its tendency to accumulate over

I 5 a period of several days with repeated dosing."

I6 Q. Okay. Doctor, let' s talk about then the

7 second flag, page 580, the chart, " Dosing Data for Opioid

I 8 Analgesics. Recommended Starting Dose," again, " Adults

I9 More Than 50 Kilograms of Body Weight." Do you see

10 tha t?

I 11 A. Yes.

I12 Q. Do you see if we use Methadone and go

13 across, what does it say? 20 milligrams, q 6 to q 8

I 14 hours." Correct?

I15 A. Yes.

16 Q. And if we' re looking at what Dr.

I 17 Casanova prescribed Mr. Hershey, this book, the 20

I18 milligrams, q 6 to q 8 hours is actually more than what

19 Dr. Casanova prescribed, correct?

I 20 A. Yes, it is.

I21 Q. And I take it that you disagree with

22 this book as well?

I 23 A. However, if you read the footnote...

I24 Q. Doctor, my question is you disagree

25 with that statement?

I

I 82

I1 A. No, I ... I disagree with the blanket

I 2 statement that that is an appropriate starting dose,

I3 given the footnote ...

4 Q. Go ahead.

I 5 A. which states, " Because there is not

I6 complete cross tolerance among these drugs, it is

7 usually necessary to use a lower than equianalgesic dose

I 8 when changing drugs and to retitrate to response." That

I9 is the question that I agree with.

10 Q. SO you dis ...

I 11 A. And so in the ...

I12 Q. I' m sorry.

13 A. in light of the fact that we ... that

I 14 the patient experienced incomplete cross tolerance, and

I15 in light of the fact that he was using another opioid, in

16 fact my ... the use of an equianalgesic starting dose, in

I 17 my opinion, would have been appropriate, and to start

I18 him at 20 milligrams every six to eight hours for the

19 pain that he was having, under the circumstances in

I 20 which he was having it, would be inappropriate, yes.

I21 Q. SO then when this textbook says

22 Methadone... the recommended starting dose... by the

I 23 way, Mr. Hershey was clearly over 50 kilograms, correct?

I24 A. He was 85 kilograms.

25 Q. Right. The recommended starting dose

I

I 83

I1 is 20 milligrams, q 6 to q 8 hours, you disagree with

I 2 that, fair?

I3 A. Except for the context in which I just

4 stated.

I 5 Q. Let' s go again, Doctor. How about

I6 Defendant' s Exhibit " E", " The Professional' s Handbook of

7 Drug Therapy for Pain." Are you familiar with this?

I 8 A. No.

I9 Q. Well, I will represent to you that this is

10 going to be ... the foundation is going to be laid that this

I 11 is a reasonable journal. Do you see where I have

I12 flagged, Doctor... ( Voice over)

13 15: 58: 44 - MR. EICHER:

I 14 Objection. ( Voice over)

I15 Q. the indications and dosages for

16 severe pain of Methadone, " 2. 5 to 10 milligrams, P. O,

I 17 q 3 to 4 hours." Do you see that, Doctor?

I18 A. Yes.

19 Q. And I take it that you disagree with

I 20 this as well?

I21 A. No. However, I would state that...

22 Q. Wait, Doctor, hold on. Let ... I' ll give

I 23 you an opportunity to explain it. Let me ask you first,

I24 do you disagree with that statement?

25 A. Not in the con text in which it was

I

I 84

I1 written.

I 2 Q. Okay. Go ahead.

I 3 A. Okay. It states, " 2. 5 to 10 milligrams,

4 P. O., I.M. or S. C." ... that is intramuscularly or

I 5 subcutaneously... " every 3 to 4 hours as needed or

I 6 around the clock." The... that is clearly using

7 Methadone in the acute state, not in the chronic one. It

I 8 is ... and, therefore, under those circumstances with

I9 appropriate monitoring it would be appropriate to dose it

10 in that fashion.

I 11 Q. SO 10 milligrams, three times per day

I12 is appropriate?

13 A. 10 milligrams, three times per day in

I 14 the acute fashion, yes, because that would not allow for

I15 the accumulation of the drug and the production of

16 respiratory depression.

I 17 Q. Doctor, you are aware, are you not,

I18 that Methadone is used across the world, not just in the

19 United States, agreed?

I 20 A. Yes, it is.

I21 Q. And it has been studied and the use

22 has been studied across the world, correct?

I 23 A. Yes, there are other places that use

I24 Methadone.

25 Q. Let' s... let me show what is

I

I 85

I1 Defendant' s Exhibit " F". Have you ever seen this

I 2 periodical, Doctor, Methadone is safe for Treating

I3 Hospitalized Patients with Severe Pain.

4 16: 00: 19 - MR. EICHER:

I 5 Objection.

I6 A. No.

7 Q. Okay. I will again represent to you

I 8 that a foundation will be laid that this is a reliable

I9 periodical. If you can... ( Voice over)

10 16: 00: 30 - MR. EICHER:

I 11 o bj ection. ( Voice over)

I12 Q. go to the area that is flagged,

13 Doctor.

I 14 A. Uh- huh.

I15 Q. Oral Methadone in Adults: In opioid-

16 naive adults" ... and opioid- naive you said are patients

I 17 that really have not developed a tolerance to the opioid,

I18 correct?

19 A. Yes, that' s true.

I 20 Q. In opioid- naive adults, the initial

I21 Methadone does did not exceed 5 to 10 milligrams bid to

22 tid, and was titrated carefully according to the clinical

I 23 response and side effects."

I24 A. Yes.

25 Q. And in that study then, they gave up to

I

I 86

I1 30 milligrams of Methadone per day in this study,

I 2 correct, Doctor?

I3 A. Yes. And may I point out that the

4 statement again applies to Methadone is safe for treating

I 5 hospitalized patients. I think that it is a very different

I6 circumstance in the treatment of a hospitalized patient

7 with an acute pain problem than the treatment of an out

I 8 patient who does not... with a chronic pain problem for

I9 which they are being treated.

10 Q. Okay. So you agree with that

I 11 statement, but in a hospitalized patient. Is that what

I12 you' re saying; in an acute phase?

13 A. For an acute phase in a hospitalized

I 14 patient where, number one, accumulation is not a

I15 problem, and monitoring is not a problem then, yes, that

16 would be appropriate.

I 17 Q. SO if the patient was hospitalized for

I18 five days you would have no problem with that dosage?

19 A. If the hosp ... if the patient were

I 20 hospitalized and monitored, and that was necessary and,

I21 as it states, titrated carefully according to the clinical

22 response and the avoidance of side effects then, no, I

I 23 would not have a problem with that.

I24 Q. SO my question is, again, if a patient is

25 hospitalized for five days you do not have a quarrel with

I

I 87

I1 using 30 milligrams of Methadone per day for five days.

I 2 Is that correct? That' s what you just said under oath,

I3 Doctor.

4 A. In the acute setting, under appropriate

I 5 monitoring, which is not with the patient at home taking

I6 a bottle of pills which is, in my opinion, is a totally

7 differen t circumstance, ti tra ted to the clinical effect and

I 8 the avoidance of side effects, no, I would not have a

I9 problem with that.

10 Q. Well, titrate also means titrating up,

I 11 true?

I12 A. Ti trated carefully. It could be up, it

13 could be down. It would depend upon the nature of the

I 14 circumstances. I think one of the things that we know is

I15 that in these hospitalized patients with severe pain most

16 of those patients have had operations; they have

I 17 significan t lesions. I have not read this article, so I

I18 cannot comment on it in detail. However, in my

19 experience of treating hospitalized patients, that is a

I 20 very different clinical circumstance than the patient that

I21 presents to you for out patient treatment such as Mr.

22 Hershey.

I 23 Q. Let me ask the question in this way.

I24 Dr. Hersh... Dr. Casanova had planned to titrate Mr.

25 Cas... strike that. Let me ask it this way. I apologize.

I

I 88

I1 Dr. Casanova planned to titrate Mr. Hershey' s

I 2 medication on day five, correct?

I3 A. He currently states that he had

4 planned to titrate Mr. Hershey' s medication on day five.

I 5 Q. And just so I' m clear, and the jury

I6 hears this clearly, you do not quarrel if a pa tien t is

7 given Methadone, 30 milligrams per day, for five days as

I 8 long as you said the patient is in an acute setting?

I9 A. In the acute setting, when the patient

10 is appropriately monitored, and under the circumstances

I 11 described in this article, I do not have a quarrel with it.

I12 Q. Okay. I listened as attentively as I

13 could during your direct examination and I didn' t hear

I 14 anywhere when Mr. Eicher was questioning you where

I15 you said 30 milligrams in an acute setting is reasonable,

16 but because Mr. Hershey was not in an acute setting in

I 17 this case, that' s where Dr. Casanova fell below the

I18 standard of care. I didn' t hear that anywhere. Did you

19 say that and I missed it?

I 20 16: 04: 27 - MR. EICHER:

I21 Objection.

22 A. I did not say that. However, the fact of

I 23 the matter is is that the differences between acute pain

I24 and chronic pain are myriad. There are very different

25 sources of treatment paragons between the two. And the

I

I 89

I1 fact that the patients... and, in fact, I think I did say

I 2 that in the acute setting the use of Methadone is

I3 different than the treatment with Methadone in the

4 chronic setting.

I 5 Q. Let' s go on, Doctor. Defendant' s

I6 Exhibit " G", if you can go to the... first of all, have you

7 ever reviewed The Pain Management Hand book...

I 8 A. No, I ...

I9 Q. A Concise Guide to Diagnosis and

10 Trea tmen t?

I 11 A. No, I have not.

I12 Q. By Gershwin and Hamilton?

13 A. I' m sorry. No, I have not. So r ry .

I 14 Q. I will, again, make the same

I15 representation that an adequate foundation will be laid

16 at the time of trial to discuss this.

I 17 16: 05: 11 - MR. EICHER:

I18 Objection.

19 Q. If we go to the chart on the last page,

I 20 Opioid Analgesic Doses for Moderate to Severe Pain in

I21 Opioid- NaYve Adults." First of all, you and I can agree

22 that Mr. Hershey was in moderate to severe pain based

I 23 upon what he said, correct?

I24 A. Yes.

25 Q. And if we look at the chart on the page

I

I 90

I1 that is flagged, Doctor, " Methadone, 2. 5 to 10

I 2 milligrams, every 3 to 8 hours." Do you see that,

I3 Doctor?

4 A. I see it.

I 5 Q. SO 10 milligrams every 8 hours would

I6 be what Dr. Casanova had written in his chart, correct?

7 A. Yes.

I 8 Q. And I take it that you disagree with

I9 this chart then as well, correct?

10 A. I' m sorry. Let me back up. Dr.

I 11 Casanova did not write that in his chart.

I12 Q. Well ...

13 A. What Dr. Casanova wrote in his chart

I 14 was 10 milligrams every 6 hours.

I15 Q. Fair enough. He dictated it. Did he

16 not dictate it in his ...

I 17 A. Yes.

I18 Q. Okay.

19 A. Yes, he did. And what he wrote to Mr.

I 20 Hershey was 10 milligrams every 6 hours.

I21 Q. SO he dictated in his chart 10

22 milligrams every 8 hours, correct?

II 23 A. Yes.

I24 Q. SO you disagree with that chart I take

25 it, Doctor, correct?

I

I 91

I1 A. I believe that that does... is

I 2 hazardous, yes.

I3 Q. Okay. Let' s go on. Defendant' s Exhibit

4 H", Management of Cancer Pain. And we said that one

I 5 of the areas in which patients receive Methadone is in

I6 cancer care, correct?

7 A. That' s correct.

I 8 Q. And if we look here, Doctor, " The Chart

I9 Dose Equivalence for Opioid Analgesics in Opioid- Naive

10 Adults and Children Over 50 Kilograms of Body Weight,"

I 11 again that would be Mr. Hershey, correct?

I12 A. Yes.

13 Q. Usual starting dose for moderate to

I 14 severe pain," under " Methadone, it' s " 20 milligrams

I15 q 6- 8 hours." Correct?

16 A. Yes.

I 17 Q. And that is more than what Dr.

I18 Casanova prescribed to Mr. Hershey, correct?

19 A. Yes. And this is cancer pain, not

I 20 chronic, non- malignant pain.

I21 Q. Alrigh t. So you disagree with that as

22 well, Doctor?

I 23 A. No, I' m saying Mr. Hershey didn' t have

I24 cancer, so this is not applicable.

25 Q. I understand. Alright. So you and I

I

I 92

I1 can agree that Dr. Casanova is wrong; Dr. Miguel is

I 2 wrong; and some of the authors who wrote these tables

I 3 are wrong, correct?

4 A. Yes, and Mr. Hershey is dead.

I 5 Q. Alright, Doctor. Let' s take a look at

I 6 your report. First of all, before we get to there, let' s talk

7 about Mr. Hershey' s cause of death. Now it is your

I 8 testimony that Mr. Hershey died as a result of

I 9 Methadone toxicity or Methadone overdose, correct?

10 A. Yes.

I 11 Q. You disagreed with the coroner when

I 12 the coroner had listed the number one cause of death for

13 Mr. Hershey to be myocarditis, correct?

I 14 A. Yes.

I15 Q. The coroner, in your view, is wrong?

16 A. The coroner, in my view, did not take

I 17 into account the toxicity of Methadone as being a

I 18 primary factor in Mr. Hershey' s death.

19 Q. And, again, in your view, the coroner is

I 20 wrong, correct?

I21 A. Yes.

22 Q. Can you tell the ladies and gentlemen

I 23 of the jury, Doctor, how many autopsies in your career

I24 you' ve performed?

25 A. In my career, I' ve probably only

I

I 93

I1 performed a dozen autopsies.

I 2 Q. Okay. Now there' s no doubt that Mr.

I 3 Hershey had myocarditis on his autopsy, correct?

4 A. That is correct.

I 5 Q. And the myocarditis was located near

I 6 the AV node, right?

7 A. That is correct.

I 8 Q. And myocarditis located near the AV

I 9 node can lead to a bradycardic arrhythmia, agreed?

10 A. That is correct.

I 11 Q. And no doubt whatsoever that

I12 Methadone does not cause myocarditis?

13 A. Methadone does not cause myocarditis.

I 14 That is correct.

I15 Q. And the number one cause of sudden

16death...

and from what you could piece together, Mr.

I 17 Hershey had died a sudden death, correct?

I18 A. From what I could piece together, Mr.

19 Hershey died. I do not know if he died suddenly. He

I 20 certainly died.

I21 Q. The number one cause of sudden death

22 of 20 to 45 year old individuals in this country is a

I 23 lethal arrhythmia, correct?

I24 16: 09: 16 - MR. EICHER:

25 Objection. ( Voice over)

I

I 94

I1 A. Yes. ( Voice over)

I 2 Q. And myocarditis near the AV node can

I3 cause a bradycardic arrhythmia?

4 A. I think you just flipped the definitions

I 5 of what you' re using. Lethal arrhythmias in young

I6 adults tend to be ventricular arrhythmias, not

7 bradycardic arrhythmias. Therefore, lethal arrhythmias

I 8 tend to be ventricular fibril... ventricular... I' m sorry...

I9 ven tricular tachycardia followed by ventricular

10 fibrillation. However, bradycardia and bradycardic

I 11 arrhythmias involving dysfunction of the AV node tends

I12 to lead to a slow heart rate. It is based upon the

13 treatment of bradycardic arrhythmias that the entire

I 14 pacemaker industry in the United States is built.

I15 Generally, as I stated in my prior deposition, the

16 production of a slow heart rate tends to lead to syncope,

I 17 and once the patient is laying down a slow heart rate

I18 does not tend to be lethal.

19 Q. Okay. Doctor, myocarditis can lead to

I 20 a bradycardic arrhythmia, correct?

I21 A. Myocarditis can lead to a number of

22 arrhythmias.

I 23 Q. Alrigh t. One of them being a

I24 bradycardic arrhythmia?

25 A. It could, yes.

I

I 95

I1 Q. And you had testified in your

I 2 deposition that one of the bases of concluding that Mr.

I3 Hershey' s death was, in fact, related to Methadone was

4 because he had on post a finding of hemorrhagic

I 5 pulmonary edema, right?

I6 A. Yes.

7 Q. A bradycardic arrhythmia can also lead

I 8 to hemorrhagic pulmonary edema, correct?

I9 A. A bradycardic arrhythmia could lead to

10 hemorrhagic pulmonary edema if there is also airway

I 11 obstruction or if there is heart failure. One of the

I12 things that we don' t find on Mr. Hershey' s post is other

13 evidence of heart failure with engorgement of the organs

I 14 or dilation of the heart. What we do ... although he has

I15 left ventricular hypertrophy, which is thickening of the

16 wall, which is different than dilation like a balloon. So,

I 17 in fact, if Mr. Hershey had been capable of breathing

I18 while his heart rate was slow, it is my opinion that he

19 would have still been alive. It is the respiratory

I 20 depression secondary to the Methadone that led to his

I21 death.

22 Q. SO part of your opinion is based upon

I 23 the fact that Mr. Hershey did not have dilatation of the

I24 heart?

25 A. Part of my opinion is based upon what

II

I 96

I1 Mr. Hershey did have and the fact that he did not have

I 2 dilatation of the heart. Although he had left ventricular

I3 hypertrophy, he had no evidence of heart failure and

4 during his lifetime he had no evidence of his

I 5 myocardi tis.

I6 Q. Okay. Let' s talk about the toxicology

7 results. When Methadone is ingested it' s broken down

I 8 into the metabolite EDDP, correct?

I9 A. Dh- huh. Yes, that' s correct.

10 Q. And when we took your deposition last

I 11 month or so you didn' t know whether EDDP shows up

I12 first in the blood or in the urine after the ingestion of

13 Methadone, correct?

I 14 A. That' s correct. It' s clinically

I15 irrelevant.

16 Q. Well, whether it' s clinically irrelevant

I 17 or not, Doctor, I think it' s relevant in this case. But in

I18 any event ...

19 16: 12: 10 - MR. EICHER:

I 20 Objection.

I21 Q. you didn' t know how long it took for

22 EDDP to show up in a patient' s blood, correct?

I 23 A. No, I did not.

I24 Q. And you believe that there was no

25 straight line ratio between a patient' s Methadone and

I

I 97

I1 the EDDP level. Is that correct?

I 2 A. In fact, the EDDP levels from my

I3 reading do vary widely depending upon the Methadone

4 ratio, and I think I stated in my prior deposition that I

I 5 believe the ratio in the blood tended to be in the range of

I6 14 to 15 to one.

7 Q. Okay. So 14 to 15 to one would mean

I 8 if I have a patient who has 580 nanograms of

I9 Methadone, you would expect to see around 40

10 nanograms of EDDP in the blood?

I 11 A. That' s correct.

I12 Q. Okay. We know at post Mr. Hershey

13 did not have EDDP in his blood, did he?

I 14 A. No, we do not know that. Because

I15 what I did not have at the time of my prior deposition

16 was the data from the coroner' s toxicology, and I think

I 17 that that becomes very important. One of the things

I18 that ...

19 Q. Wait, let me ask... before you go on,

I 20 Doctor. Are you saying that when you reviewed the

I21 toxicology results Mr. Hershey had EDDP found in his

22 blood?

I 23 A. No. I' m saying that we don' t know if

I24 EDDP was in his blood based upon the toxicology

25 results.

I

I 99

I1 A. Yes.

I 2 Q. Towards the bottom of the page, and

I 3 this is in essence what you said earlier, " The record is

4 clear that Mr. Hershey did not tend to overuse his

I 5 prescribed opioid pain medication." Correct?

I 6 A. Yes.

7 Q. We know from Dr. Khalil' s deposition

I 8 that he would disagree with you, true?

I 9 A. Yes.

10 Q. Okay. You also said on direct

I 11 examination that you did not see any evidence of

I 12 Mr. Hershey using any elicit drugs as well, correct?

13 A. There was no data in the records to

I 14 suggest that, and his urine and blood screens were

I 15 positive only for Methadone.

16 Q. Okay. In all the records you reviewed

I 17 you never saw any evidence of Mr. Hershey using any

I 18 elici t drugs. Is that correct? (Voice over)

19 16: 15: 14 - MR. EICHER:

I 20 Objection. ( Voice over)

I 21 Q. That is what you' re saying?

22 A. Yes, that is correct.

I 23 Q. Doctor, what is THC?

I24 A. THC is Tetrahydrocannabinol. It is the

25 active ingredient in marijuana.

I

I 100

I1 Q. I' m going to hand you what has been

I 2 Bates stamped as 215. This is from Mr. Hershey' s Akron

I 3 General Medical Center records dated July 1, 2003, and

4 I' ve highlighted urine THC. Can you tell the ladies and

I 5 gentlemen of the jury underneath urine THC after the

I 6 reference range of whether it' s detected or non- detected;

7 what the result was on July 11 th, 2003 for Mr. Hershey?

I 8 16: 16: 29 - MR. EICHER:

I 9 Objection.

10 A. It states that TCH was detected.

I 11 Q. In your expert report, Doctor, if you

I12 can turn back to that, please. You say that Mr.

13 Hershey' s heart was normal in size. With all due respect

I 14 page four, third paragraph ...

I15 A. Yes.

16 Q. That is wrong, correct?

I 17 A. He had moderate left ventricular

I18 hypertrophy.

19 Q. Not only did he had moderate left

I 20 ventricular hypertrophy, did he have cardiomegaly?

I21 A. That' s the same thing.

22 Q. Okay.

I 23 A. Well, his heart... his heart was

I24 thickened and somewhat enlarged...

25 Q. Well, left ven tric ... left ventricular

I

I 101

I1 hypertrophy just talks about his left ventricle, right?

I 2 That' s just one half of the heart or one part of the heart,

I 3 righ t?

4 A. Yes. But there is no evidence that he

I 5 had pulmonary hypertension or right ventricular

I6 hypertrophy.

7 Q. Well, what did the autopsy say Mr.

I 8 Hershey' s heart weighed? Was it about 475 grams?

I9 A. Yes.

10 Q. I think it' s on the last page, Doctor.

I 11 A. On the last page? Excuse me.

I12 Q. There you are.

13 A. 475 grams, yes.

I 14 Q. The normal male heart is about 300

I15 grams?

16 A. Yes.

I 17 Q. SO he did have a big heart?

I18 A. He had a big heart, yes.

19 Q. SO when you put in your report that his

I 20 heart was normal size. That was wrong, correct?

I21 A. Yes.

22 Q. Can we turn to page three... I' m

I 23 sorry... page five. Methadone is known to potentially

I24 cause a condition known as prolongation of the Q- T

25 in terval." Do you see that?

I

I 102

I1 A. Yes.

I 2 Q. There' s absolutely no correlation in

I3 this case between the use of Methadone and

4 prolongation of the Q- T interval, correct?

I 5 A. There is not.

I6 Q. Okay.

7 A. His doses were not high enough.

I 8 Q. Well, exactly. And there' s no literature

I9 out there that talks about prolongation of the Q- T

10 interval on a dose of 30 to 40 milligrams per day of

I 11 Methadone, correct?

I12 A. As I stated in my prior deposition.

13 Q. SO when you put Methadone is known

I 14 in your expert report when you put Methadone is

I15 known to potentially cause a condition known as

16 prolongation of the Q- T interval, that was completely

I 17 irrelevan t to this case?

I18 A. Not completely irrelevant, but it did not

19 apply to Mr. Hershey.

I 20 Q. Why did you put it in there then?

I21 A. Because it was part of my thinking at

22 the time I was preparing the report.

I 23 Q. Later in that same page you have,

I24 Hydrocodone is generally thought to be one- half and

25 one- third as potent as Morphine." And, Doctor, that is

I

I 103

I1 just flat out wrong.

I 2 A. Actually in vitro Hydrocodone is not as

I 3 poten t as Morphine. However, with the absorption of the

4 drug being greater than that of Morphine, in vivo it is

I 5 more potent than Morphine.

I 6 Q. Hydrocodone is more potent than

7 Morphine, correct?

I 8 A. After it is absorbed, so in the body it

I9 reaches higher levels of Morphine and, thus, is more

10 potent than Morphine after taken as an oral dose.

I 11 Q. SO after taking 15 milligrams of

I12 Hydrocodone, what would be the equianalgesic dose of

13 Morphine be?

I 14 A. The equianalgesic dose of Morphine

I15 would be approximately 20 milligrams.

16 Q. SO when you write in your report right

I 17 after that...

I18 A. Uh- huh.

19 Q. if he had been taking 15 milligrams

I 20 of Hydrocodone the equianalgesic dose of Morphine

I21 would be 7. 5 milligrams per day, that is flat out wrong?

22 A. Yes. However, the conclusion that his

I 23 dose was increased by 800 percent remains the same.

I24 Q. Doctor, what is the difference between

25 7. 5 milligrams per day in terms of a percentage and

I

I 104

I1 what the actual accurate equianalgesic dose of Morphine

I 2 is? Are you off by a couple hundred percent in your

I3 expert report?

4 A. 125.

I 5 Q. Okay. So, again, when you wrote that

I6 in this report that you prepared after doing a thorough

7 review of the medical records you were just flat out

I 8 wrong?

I9 A. Yes. But the conclusion that his dose

10 was increased by a marked degree in ... with a drug that

I 11 should not have been increased by that same degree is

I12 correct.

13 Q. Doctor, don' t you think the jury would

I 14 expect that an expert who comes to them in Stark

I15 County, Ohio and is going to testify that a Stark County

16 physician caused a man' s death should know the

I 17 accurate equianalgesic dose of Methadone and

I18 Hydrocodone?

19 A. Yes.

I 20 Q. I don' t have any other questions.

I21 Thank you.

22 OPERATOR: We' re off the record.

I 23 OPERATOR: We' re on the record.

I24

25

I

I 105

I1

I 2 DURING REDIRECT EXAMINATION BY MR. GEOFFREY

I3 EICHER:

4 Q. Doctor, I want to follow up on some of

I 5 the questions that Mr. Prislipsky asked of you. First of

I6 all, you were asked quite extensively about your review

7 of Dr. Khalil' s deposition and the fact that you had not

I 8 reviewed it prior to your deposition. Do you have any

I9 idea when Dr. Khalil' s deposition was taken?

10 A. No, I don' t.

I 11 Q. Alrigh t. It has been said to you since,

I12 correct?

13 A. Yes, it was.

I 14 Q. Alrigh t. Would it surprise you to learn

I15 that it was taken just days before your deposition?

16 A. No, not at all.

I 17 Q. Alrigh t. Nevertheless, you receive that

I18 deposition after having Mr. Prislipsky take your

19 deposi tion in this case, correct?

I 20 A. That' s correct.

I21 Q. And after reviewing that deposition did

22 it change any of your opinions that you' ve stated here

I 23 today?

I24 A. N one whatsoever.

25 Q. Alrigh t. Mr. Prislipsky asked you

I

I 106

I1 about EDDP and, again, whether you had reviewed

I 2 records relative to EDDP. Now are you aware, Dr.

I3 Thomas, that Mr. Prislipsky was in possession of those

4 records and we simply ... we meaning me or anyone in

I 5 my office... simply did not have those records at the

I6 time your deposition was taken?

7 A. I ... ( Voice over)

I 8 16: 33: 36 - MR. PRISLIPSKY:

I9 Let me just object because I think

10 it almost suggests that I didn' t turn

I 11 them over. But go ahead.

I12 A. I did not know anything of those

13 records.

I 14 Q. And I don' t mean to suggest that Mr.

I15 Prislipsky was withholding anything, but the fact of the

16 matter is that nobody had on ... from my offiye even had

I 17 the ability to send those to you. Were you aware of

I18 that?

19 A. I was not.

I 20 Q. Okay. Regardless of the whether you

I21 had the ability to review those :' ecords relative to EDDP,

22 what significance does that have in this case?

I 23 A. I think that,.. I would say that it does

I24 not have any direct clinical significance to whether or

25 not Mr. Hershey died from Methadone toxicity. And even

I

I 107

I1 more importantly I think the use of the laboratory data

I 2 and the way that Mr. Prislipsky has implied is

I3 misleading.

4 Q. How so?

I 5 16: 34: 29 - MR. PRISLIPSKY:

I6 o bj ection. Move to strike.

7 A. The EDDP shows up on a graph, which

I 8 I' d like to show the jury, if I might.

I9 Q. That' s fine. Put it up on ...

10 A. And ... yes. And I' d like to show both

I 11 the... first the serum level for Mr. Hershey' s serum,

I12 which is his blood, and then show his urine.

13 Q. Alrigh t. Now before you get into this,

I 14 Doctor... I know you want to show the serum level and

I15 you want to show the urine, but I want to put a question

16 to you ...

I 17 A. Yes.

I18 Q. given Mr. Prislipsky' s objection.

19 Could you please explain to the jury, Doctor, what these

I 20 coroner' s records relative to these blood tests... explain

I21 the significance of that to the jury.

22 A. Okay. The coroner takes a ... took a

I 23 sample of Mr. Hershey' s blood and measured, using this

I24 spectra for the measurative technique, on Mr. Hershey' s

25 Methadone level and this IS, this line here, is the

I

I 108

I1 internal standard. The ...

I 2 Q. What do you mean by internal

I3 standard?

4 A. That is ... that is the standard spike

I 5 that they' re using to check their machine.

I6 Q. Okay. One of the problems that I have

7 with the statement that EDDP does not appear on this

I 8 graph is that if we look very closely this is not a straight

I9 up and down line, it has a slurring in this region. That

10 is exactly the same region where the major spike for

I 11 EDDP occurs, as shown here. Now if I go back to the

I12 results of the test for Mr. Hershey' s Methadone... and

13 that' s shown here and I will explain it so that it makes

I 14 some sense to the jury... here we have the standard,

I15 one milligram per liter. That is to say that when they

16 took a known sample that contained one milligram per

I 17 liter of Methadone, the number that they came up with

I18 was said to be 2. 4 percent of the amount that was in the

19 con tainer.

I 20 Q. SO are you saying, Doctor, that they

I21 checked their own test for its accuracy?

22 A. Yes. And it states, " Ratio, 0. 724."

I 23 Q. SO by the coroner' s own calculation

I24 how inaccurate was their test?

25 A. It was off by 27 percent.

I

I 109

I1 Q. Okay. The significance of that is what?

I 2 A. Is that the test is nearsighted. It can

I3 see 72 percent of the amount of any substance which it

4 is measuring. That 72 percent is ... means that it may

I 5 be below the level of detection which we don' t have for

I6 this test. We don' t know how much or how little the test

7 can detect, so in order to calculate Mr. Hershey' s level

I 8 they had to take what they actually measured, which

I9 was not 0. 58 milligrams per liter but 0. 42 milligrams per

10 liter, and imply their internal standard ratio.

I 11 Q. SO are you saying, Doctor, that the

I12 coroner tested its own test, found it to be off by some 20

13 some percent, and then further relied upon that error

I 14 when coming up with the mill... nanograms per

I15 milliliter with regard to the level of Methadone in the

16 blood?

17 A. That is absolutely correct.

I18 Q. Okay.

19 A. N ow one of the things that we know

I 20 about these tests is the lower level of detection or the

I21 detection limit for many of these tests is in the range of

22 50 nanograms per ml in some studies. I don' t know

I 23 what the range is for Mr. Prislipsky' s study, but I know

I24 that whatever it is it' s only... the test that the coroner

25 performed is only going to measure 72. 4 percent of that.

I

I 111

I1 Q. Okay. So what you' re saying is we

I 2 have no idea how much of that medication Mr. Hershey

I3 took, correct?

4 A. That is correct.

I 5 Q. But if he took every pill that was

I6 prescribed to him, the maximum that he could have

7 taken over that two or three day period was 50

I 8 milligrams?

I9 A. 50 milligrams per day, yes.

10 Q. What importance does that mean to the

I 11 issue of tolerance, Doctor?

I12 A. It means absolutely nothing, given this

13 long period between these short doses during which he

I 14 was being treated for acute pain. That is he had a finger

I15 laceration, an infected joint, the other operations, and

16 those short periods of trea tmen t with this long lapse did

I 17 not contribute to his tolerance in any way whatsoever at

I18 the time of his death.

19 Q. Okay. And while Mr. Prislipsky had

I 20 you draw these lines on here, and this chart is set up to

I21 show the months of March, July, but the actual

22 medication was only taken for two or three days during

I 23 that month. Is that correct?

I24 A. Yes. That is his average dosage was

25 what is shown in the black lines and that we showed on

I

I 112

I1 our previous diagram, although he had these very brief

I 2 spikes in which he was taking more medication.

I 3 Q. Okay. I want to ask you now, Doctor,

4 about some of thee articles that Mr. Prislipsky put in

I 5 front of you.

I6 16: 41: 48 - MR. PRISLIPSKY:

7 Just for the record, I' m going to

I 8 object to any examination from

I 9 plain tiff's counsel regarding the

10 literature that was used for

I 11 Dr. Thomas during cross examination.

I12 It is my position that literature can

13 be used for cross examination to

I 14 impeach an expert witness, but up

I15 until the end of the month and starting

16 July 1 st, 2006 literature can not be

I 17 used to rehabilitate or to direct an

I 18 expert witness. With that, I' ll just

19 ask for a continuing objection so I

I 20 don' t have to continue to interrupt or

I21 object during the redirect examination.

22 MR. EICHER: And clearly I recognize

I 23 your right to put an 0 bj ection on the

I24 record, but it' s my belief that if you' ve

25 asked questions of an expert witness

I

I 113

I1 rela tive to documents I would certainly

I 2 have the right to cross examine with

I3 regard to the questions that you asked

4 him.

I 5 MR. PRISLIPSKY: Fair enough.

I6 Thanks. Can I just have a continuing

7 o bj ection for the record?

I 8 MR. EICHER: You can.

I9 MR. PRISLIPSKY: Thank you.

10 Q. Doctor, first I want to ask you about a

I 11 document that Mr. Prislipsky gave you regard to Aronoff.

I12 Do you... do you have that in front of you.

13 MR. PRISLIPSKY: I have mine.

I 14 Do you want to go off the record.

I15 MR. EICHER; Yes, please.

16 MR. PRISLIPSKY: I have mine

I 17 OPERATOR: We' re off the record.

I18 OPERATOR: We' re on the record.

19 Q. Doctor, I want to ask you in regard to

I 20 Defendant' s Exhibit " C", an article by Gerald M. Aronoff,

I21 is it your testimony, Doctor, that this is old literature?

22 A. It is a textbook and it is by Dr. Aronoff.

I 23 And Dr. Aronoff has since edited other textbooks to

I24 which I have previously referred and that are consistent

25 with my position on the use of Methadone as opposed to

I

I 114

I1 what is written in that 1999 textbook.

I 2 Q. Okay. So this old literature that you

I3 have in Defendant' s Exhibit " C" would stand for the

4 proposition apparently that you could... that a pain

I 5 management physician could prescribe a higher dose of

I6 Methadone, but Aronoff has changed his mind. Is that

7 what you' re saying?

I 8 16: 45: 00 - MR. PRISLIPSKY:

I9 o bj ection.

10 A. In his current textbook he ... he uses a

I 11 formula that states that one should decrease the

I12 equianalgesic dose. That is after you calculate and have

13 apples to compare to apples, with Methadone you should

I 14 decrease it by 50 to 75 percent.

I15 Q. Okay. And I' m going to hand this to

16 you now, Doctor, this Defendant' s Exhibit " C" ... and as

I 17 I have only looked through that for a minute or two, is

I18 that an article that talks about the use of Methadone in

19 HIV patients?

I 20 A. Yes. It states, " Management of Pain in

I21 HIV -Infected Persons."

22 Q. Is ... does that have any bearing,

I 23 Doctor, on whether this article that Mr. Prislipsky has

I24 pu t in front of you is even relevant to the topics we' re

25 discussing?

I

I 115

I1 A. In my opinion it would make it much

I 2 less relevant.

I3 Q. Thank you. Let' s look at Defendant' s

4 Exhibit... excuse me ... Defendant' s Exhibit " D". Mr.

I 5 Prislipsky asked you to speak to some of the issues in

I6 this document. I' m gong to hand it to you and on page

7 573 it makes reference to the cau ... to some cautionary

I 8 notes. What do those say, Doctor?

I9 A. As I stated previously, " Care must be

10 taken when escalating the dose because of the prolonged

I 11 half-life of the drug and it' s tendency to accumulate over

I12 a period of several days with repeated dosing. Despite

13 its longer plasma half-life, the duration of the analgesic

I 14 action of single doses is essentially the same as that of

I15 Morphine. With repeated use, cumulative are seen, so

16 either lower doses or longer intervals between doses

I 17 become possible."

I18 Q. Alright. Doctor, if you could hand that

19 back to me, please.

I 20 16: 47: 13 - MR. PRISLIPSKY:

I21 o bj ection. Move to strike.

22 Q. Doctor, I' m going to hand you now

I 23 Defendant' s Exhibit " E", The Professional Handbook of

I24 Drug Therapy for Pain. Mr. Prislipsky put this in front

25 of you for the purpose of talking about the dosing, but

I

I 116

I1 on page 324 of that document it talks about some of the

I 2 side effects of over medication of Methadone. What does

I3 it say in that regard, Doctor?

4 A. Overdose typically causes CNS

I 5 depression, respiratory depression, and miosis ( pinpoint

I6 pupils) . It may also cause hypotension, bradycardia,

7 hypothermia, shock, apnea," which means that the

I 8 patient stops breathing, " cardiopulmonary arrest,

I9 circulatory collapse, pulmonary edema, and seizures."

10 Q. Okay. Now you have testified, have you

I 11 not, that you believe that respiratory depression was one

I12 of the side effects suffered by Mr. Hershey.

13 A. Yes.

I 14 Q. Correct? Okay. Now Mr. Prislipsky

I15 also asked you about whether or not you agreed

16 or disagreed with the coroner on certain things. I

I 17 want to ask you about that as well. Did the coroner

I18 find that Mr. Hershey was suffering from Methadone

19 toxicity?

I 20 A. Indeed the coroner found Methadone

I21 toxicity as being a contributory cause of death.

22 Q. What does that mean, Methadone

I 23 toxici ty?

I24 A. Methadone toxicity means that the

25 blood levels of Methadone were high enough to stop him

I

I 117

I1 from breathing.

I 2 Q. You agree with the coroner on that,

I3 don' t you?

4 A. I believe that the primary cause of his

I 5 death was Methadone toxicity, leading to respiratory

I6 failure and death.

7 Q. Alrigh t. Now, Doctor, the fact that you

I 8 have some differences with the coroner relative to the

I9 condition of Mr. Hershey' s heart has no impact on the

10 deci ... the opinions rather that you' ve stated here

I 11 today, does it?

I12 16: 49: 19 - MR. PRISLIPSKY:

13 Objection. Leading.

I 14 A. No, the coroner' s... the differences I

I15 have with the coroner are based upon my clinical

16 experience with the use of Methadone. The information

I 17 in the coroner' s report, however, the findings of fibrosis,

I18 with healing of the myocarditis speak for themselves.

19 Q. Defendant' s Exhibit " E" that was put in

I 20 fron t of you for the first time today, and specifically on

I21 page 324, does it make any reference to pulmonary

22 edema?

I 23 A. Yes, it does.

I24 Q. Alrigh t.

25 A. It states that pulmonary edema can

I

I 118

I1 occur.

I 2 Q. As a result of an overdose or over

I 3 medication of Methadone?

4 A. Yes, that' s correct.

I 5 Q. Is that something that the coroner also

I6 found to be present in Mr. Hershey?

7 A. Yes, it is.

I 8 Q. Do you agree with the coroner on that

I9 on that point?

10 A. And, in fact, it was the coroner' s

I 11 finding of pulmonary edema that led to my conclusion,

I12 given that many patients who die with... or from

13 Methadone toxicity has pulmonary edema found at

I 14 autopsy.

I15 Q. Defendant' s Exhibit " F" is a document

16 entitled, Methadone is Safe for Treating Hospitalized

I 17 Patients with Severe Pain. Doctor, do you know whether

I18 that' s a study that was done in a controlled setting in a

19 hospital?

I 20 A. Yes, it was.

I21 Q. And the significance of that is what, if

22 anything?

I 23 A. The significance of hospitalized

I24 treatment is that in the hospital one is able to monitor

25 the patient; there are nurses available; pulse oximetry or

I

I 119

I1 the use of oxygen monitoring is frequently used; and

I 2 oxygen is frequently administered. It' s a very different

I3 setting than the out patient setting in which Mr.

4 Hershey was given the doses of Methadone that he was.

I 5 Q. You also made reference to there being

I6 a difference in the situation where Methadone is being

7 prescribed for acute pain. Describe for the jury why

I 8 that is so important.

I9 A. One of things that we know from

10 studies of patien ts in pain is that acute pain... when

I 11 you have pain with a broken bone, or an incision, or

I12 that short term sharp, localized pain, that in particular

13 acts as a counter balance to the respiratory depression

I 14 effects of all opioids. So under the acute pain

I15 circumstance the production of respiratory depression is

16 in part blocked by the pain, while in chronic pain the

I 17 respirations return to normal. There is no protective

I18 effect of chronic pain on the respiratory depression

19 effects of opioids.

I 20 Q. And with patients with acute pain, is

I21 the term of treatment often times much shorter?

22 A. It is considerably shorter. And the

I 23 tendency to be able to titrate, and with Methadone that

I24 is usually titration down due to the build up of the drug

25 in the system, is much greater and some authorities

I

I 120

I1 would suggest that using Methadone only on an as

I 2 needed basis tends... as opposed to an around the clock

I3 basis tends to limit the occurrence of overdose and

4 respiratory depression.

I 5 Q. I' m handing you what' s been marked as

I6 Defendant' s Exhibit " G". Doctor, from your review of

7 this document, which is was also just put in front of you

I 8 for the first time today, can you tell whether this was

I9 done in a clinical setting or if it was in reference to

10 acute pain management treatment or not?

I 11 A. No, there is no information here to tell

I12 the difference between acute and chronic pain.

13 Q. SO it mayor may not be relevant to the

I 14 issues in this case?

I15 A. Absolutely.

16 Q. Thank you, Doctor. Defendant' s

I 17 Exhibit " H", again can you tell from having just seen

I18 this document today for the first time... can you tell

19 whether that was a situation that was done in a clinical

I 20 or acute setting, or if there are other factors that bring

I21 into question its relevance?

22 A. This practice guideline on the

I 23 management of cancer pain is also an older document

I24 and it is in the management of cancer pain. As I stated

25 previously, because of the way in which we approach

I

I 121

I1 cancer pain with greater monitoring and much more

I 2 aggressiveness, given the fact that cancer pain is going

I3 to kill the patient and our tendency towards compassion

4 becomes much greater because we don' t have time to get

I 5 them comfortable, it definitely changes the way in which

I6 we approach the use of these drugs.

7 Q. Thank you. Is it safe to say then,

I 8 Doctor, that many of these exhibits that Mr. Prislipsky

I9 put in front of you, specifically these articles from

10 textbooks, journals, and what not, is it your belief that

I 11 many of them are not relevant to the issues in this case?

I12 A. Absolutely irrelevant.

13 Q. Doctor, we ... I had you make reference

I 14 to an article entitled Methadone Treatment for Pain

I15 States previously on direct examination. I' ve now

16 marked this as Plaintiff' s Exhibit " 11", so that you can

I 17 refer to it more accurately. What does... what does this

I18 well, first of all, Doctor, let me just re- establish, is

19 this a source that you consider to be reliable?

I 20 A. Yes, I ... I ( Voice over)

I21 16: 55: 58 - MR. PRISLIPSKY:

22 Obj ection. ( Voice over)

I 23 A. Yes, I utilized it in the development of

I24 my opInIOns.

25 Q. And by reliable, what do you mean?

I

I 122

I1 A. I mean that the information contained

I 2 in it is current; it is applicable given our known level of

I3 knowledge regarding the use of the drug; and comports

4 with those... with that information.

I 5 Q. Okay. Doctor, what does... what does

I6 that authority state with regard to the dosing of

7 Methadone in an opioid- naive patient?

I 8 16: 56: 29 - MR. PRISLIPSKY:

I9 Objection. I' m going to 0 bj ect here

10 because we had a previous

I 11 conversation about using literature

I12 that was used in cross examination.

13 Now this is completely different. This

I 14 is using literature that was not used in

I15 cross examination, but literature now

16 that is used for redirect. I also have a

I 17 foundation objection to it as well that

I18 I' ll make on recross as well.

19 A. The paper states, " The recommending

I 20 starting dose in an opioid- nalve patient is 2. 5 milligrams

I21 every 8 hours. Frail, older patients may need to begin

22 as low as 2. 5 milligrams orally, once daily. In the out

I 23 patient setting increases may be made every five to

I24 seven days, depending upon the response."

25 Q. The date of that study, Doctor?

I

I 123

I1 A. April 1, 2005.

I 2 Q. Thank you.

I3 OPERATOR: We' re off the record.

4 OPERATOR: We' re on the record.

I 5 Q. Doctor, finally I want to ask you, Mr.

I6 Prislipsky was asking you about your testimony in your

7 deposition, and at one point in your deposition earlier

I 8 on, and making specific reference to page 28, he asked

I9 you about whether the history taken by Dr. Casanova

10 was reasonable and within the standard of care, but you

I 11 didn' t have the opportunity to look at the context of that

I12 question. So I want you to take a look at page 68, your

13 answer, and then flip back through the previous pages

I 14 and see the context of the question. Have you had an

I15 opportunity to review that now, Doctor?

16 A. Yes.

I 17 Q. The con text of the question, Doctor,

I18 was what?

19 A. He had been asking about the history

I 20 of Mr. Hershey' s medication usage and whether or not he

I21 was taking more medication than Dr. Khalil had

22 prescribed, and that he was... was he taking six Vicodin

I 23 per day or not, and the amount of sleep, and regarding

I24 his cardiomegaly, his enlarged heart, and then the

25 issues surrounding the myocarditis.

I

I 124

I1 Q. Okay. The questions most previous to

I 2 the question about the history was in relation to the

I3 myocarditis?

4 A. Yes, that' s correct.

I 5 Q. Alrigh t. Were you in any way trying to

I6 mislead Mr. Prislipsky when you gave your answer that

7 it was within the standard of care?

I 8 A. No, I was not.

I9 Q. Alright. Later on when he asked you

10 for all of the deviations of the standard of care, and I' ve

I 11 tabbed that page for you, Doctor, did you not clearly

I12 identify the failure to accurately document the opioid

13 usage?

I 14 A. Yes, I did.

I15 Q. Okay.

16 A. In fact, it states, " Failure to accurately

I 17 record the history of opioid usage as he now states it is,

I18 in my opinion, below the standard of care."

19 Q. And that question was answered in the

I 20 very same deposition that the other question was asked

I21 of you, correct?

22 A. Yes, it was.

I 23 Q. Alrigh t. And that answer is consistent

I24 with your testimony today, is it not?

25 A. Yes, it is.

I

I 125

I1 Q. Alright. Thank you, Doctor. I have no

I 2 further questions.

I3

4

I 5

I6 DURING RECROSS EXAMNATION BY MR. THOMAS

7 PRISLIPSKY:

I 8 Q. Doctor, just a couple of brief questions

I9 on recross. First of all, you were asked some questions

10 on redirect about Dr. Khalil' s deposition and whether

I 11 you knew the contents of the deposition or whether you

I12 reviewed his deposition prior to your deposition. Before

13 we got started this afternoon with your trial testimony,

I 14 did you have an opportunity to speak with Mr. Eicher or

I15 Mr. Semple regarding the substance of what your

16 testimony was going to be?

I 17 A. Uh, the substance of it ... we reviewed

I18 Dr. Khalil' s deposition and some of the questions he was

19 going to ask me.

I 20 Q. Okay. And that' s fine. I' m not saying

I21 that there was anything improper about that. Before

22 your discovery deposition did you and Mr. Eicher or Mr.

I 23 Semple have an opportunity to, again, meet in private to

I24 discuss the substance of your deposition testimony?

25 A. Yes, we did.

I

I 126

I1 Q. Well, if Dr. Khalil' s deposition was

I 2 taken before yours, did Mr. Eicher or Mr. Semple tell

I3 you, you know, Doctor, we don' t have the transcript

4 back yet but, in essence, this is what Dr. Khalil testified

I 5 to?

I6 A. I don' t remember. Once again, that

7 would have been a verbal admonishment.

I 8 Q. I understand. Well, in your deposition

I9 when I asked you do you know from any source what Dr.

10 Khalil testified to you said no. Do you remember that?

I 11 A. Yes.

I12 Q. Okay. And this journal article or

13 Plain tiff's Exhibi t " 11", Methadone Trea tmen t for Pain

I 14 States that was published after Mr. Hershey died,

I15 correct?

16 A. Yes.

I 17 Q. Okay. And just the last area... and I

I18 don' t believe Mr. Eicher was doing this, but I just want

19 to make sure that there' s not an unfair characterization

I 20 that I may have tried to take your testimony out of

I21 context, so if we could go back to page 68 of your

22 deposition, if you would, please. While you get that,

I 23 Doctor.. .

I24 A. Yes.

25 Q. during your deposition I gave you

I

I 127

I1 the opportunity to look at any records, didn' t I?

I 2 A. Yes, you did.

I3 Q. Did you feel at any point during your

4 deposition that I was trying to mislead you?

I 5 A. No.

I6 Q. Okay. In fact, before we got in to the

7 subject of Mr. Hershey' s history that was given to Dr.

I 8 Casanova, I specifically said, Doctor, this is not a

I9 memory test. Feel free to take a look at any of the

10 medical records, in essence, right?

I 11 A. Yes.

I12 Q. And after the deposition was typed up

13 by the court reporter was it sent to you for approval?

I 14 A. It was sent to me so that I could

I15 correct anything that was misstated...

16 Q. Okay.

I 17 A. by the court reporter.

I18 Q. Well, do you ...

19 A. But specifically so that I could not

I 20 change my testimony.

I21 Q. Well, do you know that actually under

22 Ohio law you have the right to change the substance of

I 23 your testimony if you believe that you said something

I24 incorrect?

25 A. No, I do not know that.

I

I 128

I1 Q. Fair to say though, you did not make

I 2 any changes to page 68?

I3 A. I did not make any changes to page 68.

4 Q. Thanks, Doctor. I have nothing else.

I 5 MR. EICHER: I have no further

I6 questions.

7 MR. PRISLIPSKY: Thank you.

I 8 OPERATOR; Doctor, you have a right

I9 to view this videotape to prove its

10 accuracy or you may waive that right?

I 11 DR. THOMAS: I will waive.

I12 MR. EICHER: We' ve got to get it to

13 the court.

I 14 OPERATOR: We' re off the record.

I15 END OF THE TESTIMONY AS GIVEN BY DR. STEPHEN

16 THOMAS.

I 17

I18

19

I 20

I21

22

I 23

I24

25

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One Cascade PlazaAkron; Of,l.44308

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Attentionz:'TI1omasP. Semple;,Esqu;re .,;' . '. ... ..' "

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I ~

I.- '. J'

RECORD REVIEW

f ! ".- . . ., . "0'- '

Dear Mr.: semple. : ' . ,k.: '. ,

I had the~~ or.tunity to.revi~: 1hemedical records forwardedto'~ e regarding Mr. John Hershey. .The foUoWingr~presents my: analySis :of. thoSe records With respe~ to the medical care rendered toMr. Hershey' eading to. his death on AugUst 16.2004~ ;, . . .

I ".' . . ."

Recor~J:R~ i_:' "

i~;.~::\~iH~' ;.:., ;', .. r",1. ~,,;;,d)lagnostics... .. '1.~.: r..,"", .....I ! ." .; .. . .. --'.. ,.

i:::i~ElOI~~,-~!,,~~ L~..}{nee' 1.~ 106I99 .., .' '..

r?'~diolbgy ReportRi,ght Hand~ rnpleteQ2I28100. .',l; t,:,;;~tV1RI. Rf:pOrtC~ 8!Spin~ wittl/WithQ~ tpph~ 02l0pI02 ' . v' . ;

5i~~ omato~e~ fF~ R~ po,llse:04lt61P.4~/ O?;_. ': "'" '. ,;'1EKG04Il6/02.. '. . .... i . .' '. .' .'

LaboratoryJl\.lcmbiologyReports. o4r16102;' 0'5/05/0'2,.'0&/25103, 0'7130103, 08101/ 03,i:08J02I03, 0&/13/03,'0'1124/04, 01/ 25104

SurgicalPathology Report04/25102, 07131/ 03,' 08/01/ 03 ; ,

Radiology Report Left LOwer Leg APlLateral12114/ 02 ' ,

RadiOlogy ~ p.ort Cervi~aJ Spine Including Obliques 0015/03

i~ "' Vascular Laboratory Report 04/15/03 . !a,diQlogy Report Chest PAlLateral 06/25/ 03. !

CT Scan Brain. 06128/03

Radiology Report Chest 06128/03EKG'06/28/03.

1--'

i

I. . J' I'

RE: JohnH~ y, t- " P~ e'2, NovemtJer21, 20051 ; . ~ .

r";~\~ ~ ep.ortO~/~8!~07/01lO3 l ,

1~"

r:f: i'_ undUPP'~r,AbdOriUriaJ 06130,'03 ":, /". , j;' .., .r~

i:;:

TOo109r~ hyReportAbdomen( Pelvis with IV & Contrast 07/29103

c;r.Abdomen l pelviS 07/ 29/03' .": ; .

CoIonoscopy 08102103 .

Radiolo,9Y Report Right Index Finger, Three, Views Q5113/ 04

2." AkrQn ~ eral Medjcal Center: .

ER Records 06128103-07/ 0.1/ 03

3. i'; 4..u1trnal1 HOspital: . , ' '.ERRecords( left:leg pain) 12/14/02

ER,ReCQrds{ ceUgh) 06119/03p" _ ' '

fER:.Records,( fever/headachel06l25l03atJO: 47 & 18:;42

EWAd~ nRecords (abdominalpain) 07129103- 081O?,03

ER1~~misSlon' Kecprds,(abdomin,a1:paln) .Ct.l1? 4104

EftiRecords (rightlndex finger).05l13104 .

4. Dr. ;Gilcr~' . _ . HeaI1h HiStmy & Progress Notes 11106J99-04/01/ 02

5. Dane J. Donich, MD. Center.for Neum and Spine:, '

6. Progress' Note&--01128102.04I01/ 02

Bradley K. Weiner. MD: 'initialConsuItaDCln& Follow-up Progress NoteS 04I10J02.Q9/ 04/02

7. , Summa Health,System Saint Thomas HospitSl:, .Operative Report {Posterior Lamlnoforanino1Drny ce. 70n the left, Fusion C~ 7 with

LocalBone Graft & Wiring) and Discharge Summary 04125/02.04126102.

ER ReCords (redness &, drainage from incision) 05105/02

8. ... ,; 1 ~:;1(jMeYJ' MD. Aultman west Immediate :care Centei':

il~ atS,;.careNote - 05126/ 03 ." .I. .). 1,.,,:... ?~. '.,._ _ .'. .... '. . . "

9. "', Wrii~ JosE!pM{ ttal~; MD:.., :" >.:. ' ', c, ! of

cProgress'No~ 08l12103-06/ 28/04 .

10~ Phannacies: ' i; ', rresr..rip. tiQnIJ~ g-a3' 14f04.08/11104 ". ',; .,;:' , ,... '

I .. : Jn~a t"~l:l:lInn\ 1:a' Mn AiJltmi!lln CenterfOr Pain MwaernentI. '."~~_""""""'-"- i:.'

I..-.-'._--._. - ~~~-' -.,..,-~'-. -;.., . -. -

PatienUlltake Forms, R~ferral Form, Treatment Agreement. Consent to Trea1ment

Admission Assessment, Initial Consu\tatio'n/ Diagnostic Tdng 9rdarsj Prescription

Ust DischargeJnstructions, Charge ,Sheet &Commun~ ation Notes 08/11/ Q4a08/17J04

12. Summit County Medical Examiner:

Report of Investigation. Report of Autopsy &. Request for Records 08117/04- 08/18/ 04

Historv~'

According to.1he records received for review, Mr. JOhn Hershey was a 45- year-old man who'

sustainedan-injury to his neck thatreq~ired' operative intervention in 1999. That initial procedure,a C6-1 anterior.cervlcal,diScectomy fusion and plating procedure'VfBS well t,olorated and refl6ving of

his SymptoITisL::Mr. Hersheyretumed to ,the operating surgeon. D~ ne J. Oonich. M.I;l., !n January2002 with recur.rcntnepk, pain, radiating to the leftupper,extremity. 'At that time, M[ Hersheywas

noted lobe he~ y withnQ major medical iUnesse$ and ,was not taking any medicaticms. A 'cervical

J

1 .,' ['"

RE: JrJhntlersheyif Page 3 ' NOIIfJmber 21, 2005

MRI was performed that showed m~tal artifact but did not demonstrate any instability or immediate

indicatiop' ~ r!,uriher surgicai interventiOrL H'1S neck pain iiliQiSCraed ~' d, as a i~ult. a ~ei"ical

myelogram'.' ortlered. ' ' '~~' ' " , '\ "',,' '1.

l"' . '. '.' ..; ,.".,. L. . .

k'~, lhi~: I ,;',;' ;:'~', " '" -/ ,:

c' '" " ,,:';.,;'; ,:'

Mr. Her$hey's/c.Fe wastrartSferred to Bradley K.,WelneriM,D.,on04l101?OOZ<Oi. Weiner

beneve~,Mf.'!t~y:s~~, from. ps~udaarth~ iS~~ lno~unioq{ ofhifamer~ r ce~ cal,fusionat C6-7.; He. , ,' JnotBdthepresence of an osteophyte cnthe-le1\ atthaC&::7'tevel., Dr. Weiner

offered '~ dPEmP.~ ~ m;~ de90mpression'at' C&-7.. With,posteriorceniiCal' lamnotomy.' " , ' ,m~'ia~d fu.c;ion,with wiring ~ t.c6- 7~ ,This operation was 'perfonned on 04125/02. ,The'

operation Was cprilpncatE!d bya'woun~:Jnfection that. requiredit.t~~ n; 'drainage and treatJne~ with

antibiotiCs~' Tne:patienfsradicularpaili was relieved foRewing the procedure. He co!1tiJlued1ohave so~ riepk:pain that maune2002, wasnoted,tobe1reated with "a half a Vicodin here and

there.. ,Oval hiS conditio~~ aS stably improved., "v.'," ' '

I" ,-. ' ",' .-

The p~ erit.~resented on a single occasion to 111e emergency department on December 14, 2002,

for anac~~ i.tlwt? ~islefUC!)wer extremity., He was treafsd 'with a small dose ofVic;~din with ?O

tablets bein~;diSpensed~ , ~ is no continuing tr~ ntfor that injury. "if~: l, ,""; .{;'. J:1i{ . : ,':_,~, ~:. i< 1"/' .;:;' '... '. ::

Another;aC~~~ jcal Pl'9blem s~ jn June2003d~, onset-of abdominalp,ain, fe\1~ r~and

headacl1~ ' Se~ emer,QeRCy: toom visitswere,requiEdTJriOrto admiSSion tohbspitat. 'While in

hospital, Mt~~ fS~ey, was: dijgnosed as having ischemic:Colitis with' an acute jnj~ry w,his' colon.

Th~ e!swnPtoms: primarilY-resolved followingfhatadmisSion.. There was another. aclmissioo:forabdomil,alpainj~ Jariuary '2004. ' '''~ /

I ';

I,: t l"; . . .- {.-

HlsfollOW-:upiwidl ~ is:iprlmary care physician wBS'remarltablc for th~ .recurrence of necKipain,

radiating'~to'nis;leftarm;,jn:0ecerr1ber;2003. This was treated with Neurontin andBextra, non.

opioidanalgisiCs. ':In FebiUary:2004, he'noted inereasingneck pain~ The primarv care physician

contiITtJea:t.his:, medications withoutchange.' Mr.+t~rsbey;~ mplair,uad,of'worsening, localizecl neck

pain to his~ ijlia;y\care;iPtJYSician, Dr. Khalil, on06l2810t,yDr.' Khalil:increased:iiis :~ose,ot \ 'I: , .:;>~';'. . ' i' -] ". ;..:~.", - ,. ." , ' '-',' , .:', ",' . ,

Neu~ R,tin.;~~ f~~" While;'n~~ nti9.Jled in his:~fiice:l1OteSr~he~~ dalsobegun,19 p'r.escrt~ ,

Vicodi~ ~~l1~~~ fAt;. mgphen, 5/500 mR):mr~ e;1re,atmentof~ r.,'Hers~ey'~-n~ck pain.ThQ dqs~,~)<< 9D.djni~~~ dwere.mQdest ~ 1 " ~," ,;' ,', -. " \. :, ,

i,;~i~ li J ,{~" ih',,~' ,'. ',;;,< il:Pt+:" ,,' ,'.:;;,,(,", k.... };,o,:" "

The ,phaftn~ 4'~ rds::r.eria! that Mr.'HerShey cibtained a,prescri~ on for~Mcoclin'from,Timothy

Hric on,051,:f3ia4~ ,; TWElnty tablets weredispensed. ,.No';additienal:opioidanal,g~ we~ dispenseduntil theD6/28l04 appointment some six weeks later, when Dr. Kh~ B prescribed 20 tablets of

Vicodin. Tendays later. 60table1s ofVicodin were prescribed. Three weeks I~ 30 tablets were

presCribed.~tTMs. ithe recOrd reflects' Mr. Hersher.s'periodof exposure taopioid analgesics. priorto his' (eferral, to;Dr. Casanova,on August 11, 2004; was :90 days.' ln: those,gO days, Mr. Hershey'

had reeeivedatotal of t30tablets ofVlCOdin., That isno;.say that ii1 the'90 , days prior to see~ng Dr.

Casanova Mr. Hershey had, been prescribed 650 mg.;of!Hydrocod9ne whleh;:1fJie hatUaken all of

it, would,h~~ beenttle ;equivalent of 7.2 mg of Hydroeodone per,~ay , There .haci been amild

escalatiort:,t~. e 1teque,flCYtin, Hydrocodone presiriptierm;toward' th'9~ndcof that'brief 90~~3y

period. )M~,'~jf('r e,; , f. " ' "" ,'~'ii

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RE:Jahn HeiAAey.: j , : ,i. Page4,.!.(,;,;':, .!.,~",..[.;, NOvember2f 2005

Dr. ~_,~~, m.,Jose~~~ Jw~~~ i::'~\Managel\Tl~ PtiiQr.:~~ ri6va;iiAY." Mr. .HersheY-on A~gUst 1 i;2004. . ~1r. HersneypieS$iifed '

complaijrigqfi~~ y~y ~ ver;e p~; pain,recorded 'asapproXimately 7.5 out of 10 on 'a visual

alog ~~.~~~~ ffpii~~;.~,(. :~ an~ at~ ~; i~ ~ ngY~ dinon~ ~ 1e,t,~~~.:.~aiIYwithout ~e~~ i;.~~; lnfonn.e~hQ~.. ~ asancva ofhis,~YWP.tp,I~., past ,"~ lCaIir!$tofY~' as ~ I. asllis

surgical.~iStorY.~:He reported}~is history ofcigaretle ~ ngthatcorttinued at~~ pa~~~~r.dayover the.;pc~~t~~l# years. . Ha.:d9nicd any use ofiUicit drugsa~d he drank riD aI!=,,~91, . H~ repQrtedthat he c~ntin.~ed 10 ~ self-employed in tile construction trades, An opio!d co~~ nt ~gree~

was~ d'.:{i; .,.,::'....... ,;.'

i';.'::~,;.~,.,~i~ _:- .! . _' '., . j "" ;.;.

Dr. ~ an~';~. ne~;the:p~ ent noting ~. clecr~; in; his c~ i~ range o{moti?nlal~ ft;", .S?a1dl~g,sJq~;.~,( N~n,~ ~

i~~. nelll'ql?glcal ~~ afj~fl!~ e I~~ dr~ e..patient~;;,..! ":;~~'d'SCOnti~~;;~~~ e,~fM~~~m;;~d p~ MetJiadpRe:.~. O..~ij;,T~, dl.~~, h~pr~tCa~Fn,ova

states th~~~';~~ e; of!MetflsdOnewas Initially 1O,~,' 1;a~ t;ht:ee ~ iQaOy;;antli~.m'WIer. l1i;increased;,ti):'1'Q;

i*,g~fodr'times'daily. 'However, theplj!scription and cthernot'e$in,the 'Ch~ reflect

Uli:lllheipa. ti~)il( j,~:i~ trUc~~-Uo ~ ke, Methadone,{DC,lopNn" j to mg every~siX,hburs:: An.MR! of

e ceN!Cii$~~.. 6rd~;;~ w~ not otiiained. . Mra::~ersheprlaS foun~,.de.~~jnj~ iS110I'l1e on

the aftet,nOo~~ f~~gust16, 2Q04~. ;!_., . " . ';:.''''l~' i~.:~t//":'';''i/. ", .'. .;......:<,;",..:.,:';;;.

i'. i.<~.'. ~~... c: /

An .autqps.Y'~~ IPerformed.: (Ehe,autopsy findingsware.r.emadtableJor1he ' absenc~ ofs~gnifi~ant

c:oro~ ~ W~~ ase., Th~~heart wasnorm3linsizeJ- withOUt.~,,~ atomic.ab~Qrjna1iiieS. The .

remalntf.er:~t~~ gross ,'autopsy.was notably unreu:narkab1e. ,' ij1e toXicology report.revl?~ed ,a

Methad~~: leverof b.58 mg per liter,. and the abSence of a detedable blood ethanOl level ~or any

other to;ij~~~ ces,' Jl)e: J1liCfO$COpiC examincni~ Of the h~~ was.J~~ . for..th~cflndjngsof mycc.a{ dillsllit,ti ~~ m~ iY Ciells in ,the left ~e.fl1ricrut. tree;wall a,,~,,~~rtn~s.pv.~ntri~ lar

1 . I"'.~~/, 'i!;...~,.: ;t- ~~f~ ,',,;' .,.'- : :,'f'.'-, .:.: _.' _! ':'.': ", ',.

I' '. ~. ~ : _ .' , ~..' ,;' i;. . .;' F'"

node. 'Np~~ i~e~l,rtfl;a~ r,y,foCt~ @~ not~ I~. di,~ tlP'l1y~, ardlalJl~~~. Qr-~i~~~J~"~" .

cutr~P;~l!~!~~~;iml-~lc;au~.;~ de~. noted~'Y~tIl~~ r~~w~~~.~~~ ne

ngestiqn~ 4m~~,~ OS!~~; 4a,~, disea~ wered~ I);!~,a.:~ p.W~ JY~ln:~~1J~ ath~~';i~\\~i~t~l~ :\ i

CHc~. 1~~f;i~~;'. ,.' \F!\' 1r.r!~:~\~ i~ li,'~~~~~~~i,:~~;;',In my oeirli~~,;~r:.30s~ g~ an~ abreach8dthe ~ daro'Glf~~ elO:pre$~~ in~iYltrth~d~!lej? i.rngeV~rJ ~ p~~~ an PPOJ~~~ ve;p,~ on. It was~ e,.pJ;escqp1j~,f:lr~~~ MetbadQJlei;1p::~~ ntimes

daily, bV mi1.~ aqo.~ thatfU1:~ny 'opIOIon,.w_ tbe .di~ 1and' pmxlI",atei'causc;a~IMr;~~~ Ys

death. ~~~ p~ IYPrude~t.;physjcianishould b~ve~ wn ~ at ~~Q~ e.~~ apQn~~~~ mg per

day in 9pi~i' hn~ivdsubj~ represented;.a gross, o'iiefpose' oUh,at~~ Il~ation:::i;J; ,. c. ,. C', .'.( \

Ap;;!;\. : ; j;"n~tr; ir>.' U." '. ~ t.. i;;: ~,~ ~{~\f~ J,: i.V(:~.';;:;!:~: . J;i%~';;'ii.:;.r;./ it h~ l" ',;

Mr. JO~~~~ fS~~Y ).Vasaf~~ w~ ld man who hadi~nd,~ pne ~ O;'Cerv~~~ pio~!.-9.P~r~ on$:.'and

had ~ ir4.,,,i~~;I~ain~J@?m.9.ti~ t~qi~ lar,, or !\~TM~~ Qt:~YJ'IP:~; zMrr~ije!~~1t.Q~~.~ n

1reated~\l~p'~~j~ y~;~~ ctJJ'lg~ P!Qi4anCllQe~ q~ f;'Jpqr~! qg:!"~ i~P,;,P~~ 9.J.~~~\$. Jor

three mop.th~,Mqrj~ jhiM~1.~~; i. The {e.cordis cl~. Mt~, ~ SheY'di~ Qti~ t1,tq~ yer.u~~ his

prescd~~ Qpif~~9;p~q.;madl~~~ OJ'l~~~9niy, 130 tabl~ts.:of; a. weak()pioidl HydrocQdGne, ha~ peen

dispe~."~~~.~'~ CW~~ i~~~~ P;'~~ cp~ ng,'o~d.~r1~ e:i~ e/pf~~~t..,~asa~\f~,;,~~ij.i!~~~ r:;'~~e.$hey

accur~~~~~ it,o. Dr; C~ ano~ ti}at behaa'b~ n:taking Vlcod!ll thre.ei~m~' danYj.<thl~. ,

medi~~ p~~ g:!b,qb,~ jP~fN~q.only.b9~fty:b~ qr~ re.se~ v,e of ~e: oqrQ'l::~ThJ;t~~}~F~r.t,~~jSbeY

JSf "' d .-. . With desti wlfD tbiutw .~. .was aj~:,.;~c~.,:;.;'"..~ pJQL;'JJ~~~ P.~~ C1!l...~,}~\ .. rnQ .', "..,"~~ QYii?~,.!Fr~ n~~i"

r~'.,;-..;....~~t..'~ S~\.,~;"f~"'"

r~ Vt;~1i"'~~}; :~:" '. :~~,i:~~:;f(7~,

nl'~~~~~~~

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I '{~:. 1i~} . i~)~'~~~'~:':;-~~~%(~~f{U~~ jUI-i~~~l ~

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X!~ . . ! r '.' Pa~ ~~ ,,-' . '~ 1; , ". I,4~~ mber21.2005

j~2~~",,~" );; l.... - ~ ';:i .~: L~,,;.:,;:; :';.; -.';

r' 2~~~ te.l_al. IQ~~l@lg~'" Or~ Orphlll~ J~, drdg,;fiUiCII,js:.urlig., vilt;.,. ,'.' .~\

harrnaCOiG " 0::' :f9p,etties~; 'r, ~;

nfi

ilat class efa .~" .:.j' ;ooiJ1>~ ri~~sjsb" 'r I : ,'~~ , "",,,:~.,, ;~~. .

Predi\l"

IlJ!. ..,.,. ,. 9 ." . ll!I}its, ,1;.,.9 -,~ . i~ il5

Iow . ;: '~~;~: m~~~~~71', MO~ 9P~ id~ als~~~ r.e.ri1pidly~ taboljz~dtanQJ~Wit# oral;;:; .Jn~ esiiO~i ~ f:"~~'~~g'~

i~n~ in~ cI'ln, ~ es~:p~ p~ rtj),~~~~~~\~ly' efip1lll~~~ tr;o~ ~,~~ y,

with ah~ 7~ m~~ ng~ oftwOtofour~o~,~ ethadQn~, on,tf1~.othe~;i}and, I$ SIQwJY ; ."eliminatectlrQrtJ Jhe bDdy,~ isiw~ lIab$OrbedJrom the gas1rointestinal Vact, and .has, a half..~me 'in the

body offt.~~~An';axerag~.y lrl~ olTle:i~dividu~I$'ith~:b~~ me ,c~~':be ,~ QJ)gl~? 2r~~9~1S': 1hus,

9~1.~ 1~~. 1~ S:.~~ StrM~ ad~~~~~~. u.niqU~'~~~:~~ epi~id'ai1~~~ jnt)l~~i~i~~'

h~:' isi9n.ifi~'~~ i~ ewn,

cardiov~ cu~~ Wi9!ty,'~;:~~i~ u.,latl~ ~ la. d to~ e~~ qal~ y.~~~;9f;.the;,~~~; ~~ e~ e.~gpleJ$: .known 'U):l~l)ti.ally:cau~'~ 1~ ndition' knownaspfi)l~gati~n ofthE!Q- !ilPWt.\fcili ,q.ptrp~ eJ

which _~, l~~ mia. otatinormal'beating;g~ at ",~,'i.;~ur,,;~q;:fW;~.hi~~~;:{" f'; d'; ': 1

14?if~:~;~~ :;.!S; ;:!C~:") f.i; l~ t;:;ln .;~ ,'~. .' J i ~!\:.~~?1". ti~i,~~i.~~

i~"; \ tk;i-~~~~ j!li~q; 4~" ..Mr. Het~:~y,~i~:p~~~~ ng:;~~j)ti'~~~ Yf~; a, ~d~ 9~,q,;~b~;.~ P~~~~~ JJB~ c,f~tte

smokeff. , iij!"~'::P~{l:l1S~~,ofipmii~ nosed car~ ov~ arrqlS,e.~~: nO\In$lgnm,c~ ~ Tf,Il~~.I.ia

reason~ ly:P,t.ud.ent:phyaicianwduld have ~ . greater;~:~ n~ m1S. cn:the: dosirigJ~ fMetbaaoneJ

particul~rfy:~.;~~ ctto,epioid equivalences 'and:iflcompl~. C( 6sS tDleran~~\' ,,, :" ..' .,,:, ",

1 . i~}1;i~~';, t, ,:,;~,,', 4i,y,;, .,' ,\ i" ;. # li! i;~ t~~~.:.it,j " ii' tJ;,,~'.:;,j~~S\~~t;~~ ........ )t~~l%i .' l" \.

lncompl~ tF;tql~ e.~~ia'phen~ nori:amOn9'opioid . naJge,sics.:, aJji~~ YI~~ Q.~Methad~ ni~~ 4~~,.~~~ tQ .O~~~~! bid. is nQ,~p~~~\~.~: equat;to~6r~ ce,t?,~~p,\o,ids.

Th~~, ~"' r~ 9~~~ Y~ t.U~ nt~ hy~ an ~ ro.~.~e)1in~~ p~~>~ mthe'D~s~ :o,~~~.~~~o.~~

epIDld\~~ t~ M~~~ A~, !h.e'equlvalent CI~ e:,spQQld.~;; C~ 9ulatedf:. l):itl~r~c;q:~ fflied

rEt:i~~==$a~rIn the~~ M#:t'Se~ b~ letahceinad nOrDe'!n~estatJr '6etb[~ is;abse' ;G~ . . eFan~ iWas

l"~' ...... j, ",., , 'I, !' c1l'.itlf"'" . r.":-,,,.. ". . I. .'. c.' . "....', '. ". . ..:' ~~,.,:,. '''',f;' > .. ,.' t., J~...,",,,,,,, "'. <",,,"~"i-" "',':..

apparentlifk~: bj_. ofmiSrmedication. taking~,w,mri~_ ONa;~ tNIdih_ t8sta9IiSR~d~ thistoryi';....~..'.,' r (".! fJ::~,;,:.:.. y.l'.',.;"~': f!l:,tl "~;'."f' ',"/" ';>'

i'!':"'" . -,'., ,~',':-'.-'_: i. d:. ",";'.:,-:.:,;..".6.-;:1<,"~~":" ..~~ t~:. l.Jj'.- f.>rn..~:!l'i;.1?'!.*

I...,.-:..;-;:! 1

oflnedi~'~ i"!':Oib' ViQt" dQritoj' tescdbin' r 'IQjll~ 'j) 'esiCStfor.tfe. ,atie.atisWblle;. " ids

f...,.",,:....;..~..,!. .."'Pi,,.......,., ...g:qp '.' IQ"'''I ., l "'. fPr". .~.,..,..'.':,"r',..'...~

are nO~'.~QI~~~ ti~ ..:,~ I~ i1i:t}(to.prod~ tolemnqer;;thisliS;~,p~enb~~ noJtN!ISi~~~ n1sndsign~) i~:iq~~~~ ris;or ~pprop9~ opi9id'p~ in~~:S9ifiMr~ll;tershe, y; h~d,been,tblerant

then ~~'~~ rd ~ 11;t.ng: a'RlOre potent Orlonger-a&ting'- oplold would b.~,~ crpEmd' 91P~ the

calCUI~ G~ ttbe:sta: ndai'd;:equianal~ icdOS~ge,of;tItle~ dO~ lo ~ Ydr.OcQdOrtif:; 71* oCQ,dGne is

a relalj~~* qpOtent)?pi~iditamJI9eaic ~ direQtaqu~ n~lgesic ~ entr@iio.fLq;JJEHngr(tftiCtilt to

ascertail1;~ras:1here j$;no pmnpletely aVailable intr:a~ no~sJerrp of. t,hislll) Jg.; ,; Hydro~ odQne'J~

gene~ f.tIj~ ht tobe:belween one::half and o)1&-: thirdias pote~;~ Morphine~: tJ.I~tfl~~one"

gene~ l~ 850~': bioaV'lnabnity: pythe oral route;/is:~ ute\yilthoughtto'; be:eguClUY"Po~~ t;tp Morphine,

with ~ erca\ie~, of iricGmp~ete,cross tolerance npfed:above. Thus; if Mr,;Mersh~ yhad':lJeen~ ldng

15 rn~ ~ y,. cqdone: (Vicodin' 1tablet three times daJiyjJ~th~ equianalgesic .dO~ Qf,Morphil1e

woul~,:~~.~ g]) er:daY!~Tb~'bioavailabmiY.ofMOrpbine~ m th~,\gas1rointestin~~~ s,.generally

lim~~~ i,l~,;tl1at\) fiM~th~ o" e :is,: n~ . The ,equian, a1ge$i~~d~~e;Qf:Morp~in~W~~~!~~ 1i:t'lt~' .'.

apprc:oorna~' Y,~ mg:;m.5img qf, MoQlhineeq\.livi1e$; pend2Yt Tnerefore,~all~~ B~t;d,o.~~ of 40

mg at ~~~.~ n~ iper4~.,~ ulted\!~ an infre~! j"iO~ ioid me~i.p~ti~n',(i~ag.~!:!~y';~j~ r,pt eight

to te~ ~!AJ~ 21,1h.~. GoOcIY~IOnJS inescapable" In.;ttlatllJste~d of;de~ asmg\th~1QqUlan~ l.,g~ I~,[dose by

jJ~ JJ~J;:..' .' ." ... ~'>~: tk~" ,.{:i~ 4i~.f~ !,k,t? j.

c..it :f":'\'.:: .: j' .\" '.

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f': .:.~~

j.~~iP}:t~:"- '~~f.: : ~-;' ,,' ,.' .~

Re mm'!:I;1~ :' V::"'\ ' '., '~ Wi' ," i~;" ,,' j;, ':~ j},,~:~

21; 2005

50% to 7~ lv.ro~~' be~ derrt to 'do'whenteatfhgt~ptoidtoleran~pafentS\v.nth1. lt\~e~e,

Dr. Casa"~_~ d_; iiose1b': 50&tOl!OOO%in~an; '''''iaid1iilWletane:ati~rtt~~'D. Msj ,

overdos~g~~Cff~ th. done/ i~~ my:c;Jniolt, was:th~ proi1m~;' aiJ~ir~fthe;~~,~~ 1a~~::~~~ ey.

jA':/;,:;; il':: : ,;.i,~ :- '. .. i,.: , ;;" . ., , i\,':',.,: ~:';;'J'. '''';' rJti''/,iP,,:'''{. i::.:,\!::<

Mr..~e~'~ J:~;~~ sYj!Oundto. ~ e;amo~~fate:'degr~ ~ f~ ocartutisiA~ol,vin~,;~e'.~~

ventricu~ar.~ a1I' In',1he' region of the a1rialventricUlar;node~ 'It IS 'n6teworthythat the:,rnelicaJ

ord fai~~~~ rtI$.nfionan.y s.~ tJms; v~ ed-'bYMr. I' I~~:~ ociatcd ~ thi.s~~ din~t.The

infl~' PeJlS fo~ d! llt,l~s:"myqcardlumwere chrome mflammatory ce~ts~.an.~;it )S'me:dlcally

certain th..m~=:hEl'd ,nDt~cute(y aevelop8d myocarditiS~ ' GNp-n.the 'absence'of'symPtDms~ nd'tbe

active ~~ i$O!iOf his:hm~ ionJ 'if~; uni"kely that:hismy.ocarciitiS: wout~,jhave: expresse~' *seW

in 'any rii~ n~ iri,lhe abst!~~tof toxic QOses of Methadona ' Given,that th~HaleCtfOcardiographic

abno~~,~ n..witt1.'~~ done.are' dase.rel~ d;;;a:'~ OnabltP'rUde~ti,p~YS~C,i~ Wgul~. ina\1B

used, a ~~ 1P.'~ Ose'ofMethadQne and tIlu~~~vold~ Ithe~@te'nti,at. ititeraoobifolt!lis~~~~ J'lown

underly\~ t{tfa$.~~~ 1th'f1ilifl1~..;:T~e$foreithe': pfes~ i~~ti:'.e'ln; lde~ tiGiRg(Gfmw~~~ Itis

was bro,li~,\~~~*~~~. tfie:::~~t)fRhigj~~~~ f:rf~"~ p'e\p~~~~~~ ttl.~e

Casanov__~ e~~'; JOhnIHershey. ,-, if>: ". ~ ';h.f!"'fi'/ P' ,;' H~~:",:.r.:.4t~ jl;,ib'\1f'.itj~i'1'~;~?~"~; ~ t',;;l'

In~~~~,~~~;~~~~::;'}

myocar[di6S1hJi4rl: JOtm~He~ hey ;j~leaditig ,to;'ms :deathdlmm~ dallfof:~_' Was' fYid~~~ iJose

Cas~ Q~~~ l.?j;;:yJ. h&ri~ ' ptescriber; tNJatbadc; nlet46mlg;~ y'Jo :em. QPioid-maTv~ mid~ aged,

hyperte!.n$~t;Qbe$e~ qgaretie"~mok~ With a.hiDbra:p1fodiik.eU~~ d:,for'Gd~v. cJ;l.Ia,:{~~~...e, In

this setti~~:" e~ ightlOi,ten;fold.inc~ e ill.Opioid:vanalgeSic"provid~j to,Mr~ H$r:s.h~y~~ Mi~1l in

excessf'~ d!mt~ oSirlgJql1hiS.tlatient",and,:wJtbjn!aimas~nable"!degre&;$f!~ea~ ~~~ my, was

the '

1:lJ::~;~~>~ ' Ii~;;'~~:;:""~" ,:,', ;;:;!',,~h~~,l~~~l~;\~;

The 0 '~~( U' lthiS~~ rtf'.. a.~_ dlYlitfimjal:r;easQ\ l~ leJi...' :ee.il:f'maa~ te~ -~ . ff

mnw

iW'J' '. ' , ~, t"....""." ItWt.~.,.., '''~~",..,

0~~~ t;~iii~"l1<!\. t:I<;

IJn ,. "'11, : J;:~ rt~~c: ',~?{::j~~ T:~r~t; ,Truly 1. r~Ji:;~) Si~l~ jt1{J;!~IEI"~r~"~!. ~;.(t(~):~;:1l :.,; ~;, f;

1\\~i() J~~; i~';~'/.":Jil!;\1,,'

r.::;i;:,:@;~g\~ 1!~~a~f'f#~~.<;l:;~: t '

J!:~j~.~~':tr~i','.~"'l;:~;~~~;:~';~~;;i~.j'

I ~~,." ~..~'Z7,~. ' '~~.. ,,, 11"'" ..."~, " Jill,,,,,,,,",,,,

J~;c.,.IE' 'i" , j'i!r: i;;,;i;;;:,7JI~; I;;;;~~'~~i;~r:

Olpl~'.~' iaardrafA'nestheslology . .i'" . ~

e,.",..~.,,,,,,

f~r~~~ j:~~::~ :~~~;~J: i~~'~!~';;p_~': iii!<~ :,;;,,~'::;1~i!,~~.. Qii'.i>\i',; . ",.,:'~; qi.~~.r~,","o' . dl'f!"f", l~ j.....,..",..\'.f.4'-~lj ~~ .~

f'i\'~f~~~~t~; f ii, " ,; f~~. ~,' ':.i,~,-, ';~u'

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