ALJDEC decisions subject to certification as final

17A-18695-MDX · Arizona Medical Board · 2018-03-07

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

In the Matter of:

Jeff Crawford, M.D.,

Holder of License No. 18695

For the Practice of Allopathic Medicine

In the State of Arizona.

No. 17A-18695-MDX

ADMINISTRATIVE LAW JUDGE DECISION

HEARING: February 1, 2018, at 9:00 a.m.; the record was held open until February 15, 2018, to allow the Administrative Law Judge to have the benefit of the court reporter’s transcript when she made her recommended decision.

APPEARANCES: The Arizona Medical Board (“the Board”) was represented by Anne Froedge, Esq., Assistant Attorney General; Jeff Crawford, M.D. appeared on his own behalf.

ADMINISTRATIVE LAW JUDGE: Diane Mihalsky

_____________________________________________________________________

FINDINGS OF FACT

Procedure

Dr. Crawford is the holder of Board-issued License No. 18695 for the practice of allopathic medicine in the State of Arizona.

The Board referred this matter to the Office of Administrative Hearings, an independent state agency, for an evidentiary hearing.

On December 27, 2017, the Board issued a Complaint and Notice of Hearing that stated that the Board had received a complaint regarding Dr. Crawford’s care and treatment of C.E., a 58-year-old male patient, alleging excessive prescribing of opioids.

The Complaint and Notice of Hearing also alleged that Dr. Crawford’s medical records for C.E. were illegible, that he had failed to respond appropriately to the Board’s investigation of the complaint involving C.E., and that he had violated a Board order that prohibited him from prescribing controlled substances.

Based on the alleged facts, the Board’s Complaint and Notice of Hearing charged Respondent with having committed unprofessional conduct as defined by A.R.S. § 32-1401(27)(e), (q), (r), and (dd).

The Complaint and Notice of Hearing also stated that because the Board determined that Dr. Crawford’s conduct and the circumstances that the Board found in its investigation had required that it take the emergency action of summarily suspending his license to practice allopathic medicine in Arizona to protect the public health, safety, or welfare under A.R.S. § 32-1451(D).

A hearing was held on February 1, 2018. The Board submitted 28 exhibits and presented the testimony of two witnesses: (1) Raquel Rivera, the Board’s Investigations Manager; and (2) Stephen Borowsky, M.D., the Board’s expert consultant on the care that Dr. Crawford rendered to C.E. Dr. Crawford submitted three exhibits and testified on his own behalf.

Hearing Evidence

Dr. Crawford at the time of the hearing was 63 years old. He testified that earlier in his career, he had subordinates and worked as Asarco’s medical director at his practice in Kearny, Arizona. Because he was raising three kids as a single father, his practice kept him busy. As he got older and after he was diagnosed with diabetes, he slowed down. He stepped down from Asarco in 2011, and now works 40-50 hours/week, seeing patients on Mondays, Tuesdays, Thursdays, and Fridays from 7:00 a.m. to 5:00 p.m. Dr. Crawford testified that he is concentrating on reducing debt and building his practice.

On or about February 9, 2017, the Board received a complaint from Heath Choice, a subsidiary of IASIS Healthcare, that C.E.’s “case was flagged by Health Choice’s data analytics vendor for high utilization of opioids by a non-contracted provider.” The Board opened an investigation and, on February 10, 2017, sent a letter to Dr. Crawford’s address of record notifying him that a complaint had been filed against him.

On March 2, 2017, the Board’s investigator sent a letter to Dr. Crawford that informed him that the investigation had been moved for further review and requested that he provide a complete narrative response to the complaint and C.E.’s complete medical records from his office no later than March 16, 2017. Ms. Rivera testified that Dr. Crawford requested an extension of time and that the Board extended the time for him to respond to the March 2, 2017 letter to April 3, 2017. Despite the extension of time, Dr. Crawford did not respond to the Board’s March 2, 2017 letter.

On April 26, 2017, the Board’s investigator sent a “2nd and Final Notice” letter to Dr. Crawford, requesting that he file a complete narrative response to the complaint and C.E.’s complete medical records from his office no later than May 3, 2017. Ms. Rivera testified that she believed that there were multiple phone calls and emails between Dr. Crawford and Board staff, but that Dr. Crawford did not respond to the Board’s April 26, 2017 letter.

Ms. Rivera testified that if a licensee refuses to provide a narrative response or the patient’s medical records after multiple attempts, the Board will schedule an investigational interview. On May 30, 2017, Dr. Crawford appeared with his medical records for C.E. for an investigational interview before a court reporter. Dr. Crawford’s justifications for failing to respond to the Board’s two letters were that he had a busy practice, he was tired and burnt out, and the complaint was a low priority. Dr. Crawford stated that he followed applicable guidelines in prescribing opioids to C.E., but did not perform a urine drug screen.

The Board submitted a profile for prescriptions that C.E. had received from various providers, including Dr. Crawford, between June 14, 2010, and May 12, 2017, from the Arizona Board of Pharmacy’s Controlled Substance Prescription Monitoring Program database (“CSPMP”). The CSPMP for C.E. showed that Dr. Crawford had prescribed high doses of opioids, including Oxycodone 15 mg, Oxycodone 20 mg, Oxycodone 30 mg, and Hydromorphone 4 mg. to C.E., as well as two benzodiazepines, clonazepam and alprazolam. Ms. Rivera testified that the Board obtained hard copies of the actual prescriptions to verify the prescriptions in the CSPMP.

The Board submitted the medical records for C.E. that Dr. Crawford had brought to the May 30, 2017 investigational interview. The first document in the records was the Arizona Opioid Prescribing Guidelines, which was approximately 40 pages long.

The Board submitted a list of Dr. Crawford’s prescriptions C.E. divided according to the pharmacies where C.E. had filled the prescriptions, including CVS Pharmacy at 100 North Broad St., in Globe, Arizona 85501, Kroger/Fry’s/Smith’s Pharmacy, and Walgreen’s Pharmacy Store No. 03447.

Ms. Rivera testified that once the Board obtains the CSPMP, the hard copies of the prescriptions, the patient’s medical records, and the interview transcript, the Board provides the complaint and documents obtained in the investigation to a consultant, who in this case was Dr. Borowsky.

On September 11, 2017, Dr. Borowsky issued a report that opined that Dr. Crawford had deviated from the standard of care in his treatment of C.E., in relevant part as follows:

2. Proposed Standard of Care: The standard of care for the treatment of chronic pain with opioids requires prescribing for a legitimate purpose, for a documented credible medical condition requiring such medication, with appropriate dosage and quantities, with appropriate monitoring, with documented improvement in pain and function.

3. Deviation from the Standard of Care: Dr. Crawford failed to substantiate and justify a reason for prescribing opioids to [C.E.]. His medical records lacked support from documentation of symptoms, from physical examinations, history, and diagnostic studies to warrant the use of opioids. The records failed to demonstrate achieving the goals of pain management, failing to demonstrate improvement in pain and function. Dr. Crawford fell below the standard of care.

Dr. Borowsky opined that Dr. Crawford’s deviation from the standard of care in his treatment of C.E. caused actual harm in that Dr. Crawford’s excessive prescription of opioids and the absence of appropriate monitoring made it impossible to determine whether C.E. was diverting the medication. Potential harm included addiction, adverse medication reactions, overdose, and death, versus diversion to others that would create similar problems.

Dr. Borowsky also opined that Dr. Crawford’s patient notes for C.E. “comprise two formats both handwritten and partially illegible. One format is a listing of opioid prescriptions, and other appears to represent an actual office visit record.” In addition, Dr. Borowsky noted that Dr. Crawford’s medical records did not document any physical examination of C.E., did not include and CSPMP profiles, and did not include any urine drug testing. Dr. Borowsky characterized the combined opioids that Dr. Crawford prescribed to C.E. as excessive, “with a daily morphine equivalent of 827.”

On September 15, 2017, Board staff sent Dr. Borowsky’s report to Dr. Crawford for his response. Ms. Rivera testified that the Board did not receive any response from Dr. Crawford to Dr. Borowsky’s report and that Dr. Crawford did not request an extension of time to respond to the report.

On October 19, 2017, the Board’s Staff Investigational Review Committee (“SIRC”) considered the complaint and the Board’s documentation of its investigation of the complaint, including Dr. Borowsky’s report. Although SIRC found Dr. Crawford’s conduct egregious, it recommended that the Board allow him to keep his license and, instead, issue a letter of reprimand, impose a three-year probation, impose a practice restriction that he not be allowed to prescribe controlled substances until he received permission form the Board, and assess a civil penalty in the amount of $2,500. SIRC also recommended that Dr. Crawford be required to obtain no less than 15 hours of Board staff pre-approved Category I CME in an intensive, in-person course regarding controlled substances prescribing in addition to the hours required for license renewal.

On November 14, 2017, Board staff sent Dr. Crawford SIRC’s report and an Interim Consent Agreement in which he agreed to be restricted from prescribing controlled substances pending the outcome of a formal interview or formal hearing. Board staff asked Dr. Crawford to return a signed copy of the interim consent agreement no later than November 24, 2017.

Ms. Rivera testified that the interim consent agreement was sent to Dr. Crawford’s email address and address of record. The interim consent agreement would allow Dr. Crawford to continue seeing and treating patients, as long as he did not prescribe controlled substances. Ms. Rivera testified that although the Board received notice that Dr. Crawford had opened and viewed the email on November 15, 2017, he did not respond to the offer of an interim consent agreement.

On December 6, 2017, the Board discussed Dr. Crawford’s case and voted to issue Interim Findings of Fact, Conclusions of Law and Order for Summary Restriction of License, summarily restricting Dr. Crawford’s license “in that [he] shall not prescribe controlled substances in the State of Arizona pending the outcome of a Formal Hearing in this matter.” The order was signed by the Board’s executive director on December 7, 2017.

Ms. Rivera testified that she believed that Dr. Crawford was given notice that his case would be considered at the December 6, 2017 Board meeting and that the December 7, 2017 order summarily restricting Dr. Crawford’s license was sent to him.

Ms. Rivera testified that on December 21, 2017, the assistant manager informed her that a confidential informant had sent an email, stating that Dr. Crawford continued to prescribe controlled substances after the December 7, 2017 order. On December 22, 2017, the Board pulled a CSPMP for Dr. Crawford between December 7, 2017, and December 17, 2017, which showed that he had written 102 prescriptions for controlled substances for 74 patients. The Board also obtained hard copies of Dr. Crawford’s prescriptions.

Ms. Rivera noted that the December 22, 2017 CSPMP showed that patients filled their prescriptions not only in and near Kearny, where Dr. Crawford practices, but in Scottsdale, Peoria, Apache Junction, Gold Canyon, Gilbert, and Chandler. Ms. Rivera testified that the locations of the pharmacies raised a concern because in other cases, it was unusual for patients to travel a long way to get their medications if they were not residing in the same city as the pharmacy.

Ms. Rivera testified that she called Dr. Crawford and informed him that he was in violation of the Board’s December 7, 2017 order and that it would behoove him to stop writing prescriptions for controlled substances. Ms. Rivera testified that Dr. Crawford admitted to writing the prescriptions, but that she did not recall whether he said that he would stop.

On January 4, 2018, the Board pulled another CSPMP for Dr. Crawford’s prescription of controlled substances. The CSPMP showed that between December 22, 2017, and January 2, 2018, Dr. Crawford had written 94 prescriptions for controlled substances. The Board also obtained hard copies of the prescriptions pursuant to subpoena.

On January 4, 2018, the Board met to consider whether to summarily suspend Dr. Crawford’s license to practice allopathic medicine in Arizona. On January 4, 2018, the Board’s executive director signed an order summarily suspending Dr. Crawford’s license, finding that he had committed unprofessional conduct as defined by A.R.S. § 32-1401(27)(e), (q), (dd), and (r), and that the public health, safety, or welfare imperatively required emergency action under A.R.S. § 32-1451(D).

On January 8, 2018, Dr. Crawford sent a letter to the Board, which was dated January 4, 2018, stating in relevant part as follows:

[D]espite the Arizona board’s decision to restrict the prescribing of ongoing prescriptions since 12-07-2017, I cannot and will not stop abruptly prescribing based on your current recommendations at this time. Here is my general assessment of your decision: Dr. Jeff Crawford is essentially prescribing too many opioids thus making his patients into opioid addicts. That is not what I have been doing. In fact, the majority of my cases (>90%) these patients have been on maintenance chronic opioid therapy for several years (>5 years).

Let me present my current practice style. Since 2011, I have changed my daily practice to be a solo practitioner in primary care working alone 2 days out of the normal work week from 7 a.m. to 5 p.m. on the other two days, I have a female CMA worker to assist in the clinic business. I have not been financially able to set up an HER or e-Prescribe capability in my practice. I have been doing the SOAP/Problem-Focused documentation record-keeping. My records are handwritten. At this time I do not anticipate to conform to computerized technology anytime soon—detailed examination versus expanded problem-focused examination. I have practiced in a rural remote area in eastern Pinal County since 6-15-1990. In the majority of my cases, helping these opioid-dependent patients who have used opioids for extended periods of time due to chronic pain and/or addiction present a far greater and difficult challenge when attempting to wean them off of these medications. Health insurance carriers and their respective pharmacies formulate rules and policy makers are constantly changing in very rapid time frames what opioid medications can be covered and/or limits these medications. I generally do not have the time to get prior authorizations as the trend has been to lower the maximum allowed in a month to the goal of less than 660 milligrams per day Med (morphine equivalent dose).

Pain management contracts are nice. My verbal counseling stresses the ongoing DEA opioid diversion control principals at each visit. This is a verbal agreement that is provided with each patient on chronic opioid medications and is constantly reminded of it at each visit. The 2014 State of Arizona opioid management guidelines encourage pain management contracts and advise random urine drug screens which should be done. It is a viable option but is not necessarily mandatory. I have done a few over the years, usually mandated by certain insurance carriers [’] recommendations. Pharmacologically daily Med (Morphine equivalent dose) limit of 660 mg per day is still a good parameter for providers to become concerned with benefit and/or risk problems issued over a long period of time. I have about 15 patients who have a larger daily med limit quantity for several years which includes [C.E.] . . . . Based on the current demographics, I have no way to refer all those patients to any “close by” pain management specialist or other primary care providers who are willing to treat chronic pain issues. I am aware of a physician recently in Globe Arizona as well as another one in Florence Arizona who have had to relinquish their medical licenses for illegal opioid dispensing problems. In regards to [C.E.], I have continued to provide ongoing chronic pain treatment with larger than the standard daily med limit opioid medications. He is a Failed Back Syndrome case who has never had a history of narcotic overdose. He is chronically disabled at this time. There are times he needed an acute close adjustment with tolerance/ dependency and withdrawal issues and overall he has tolerated his current treatment regime well over several years, and I see no reason to change this approach at this time.

Socially, as a reflection of society today to abruptly stop the prescribing of legal opioid medications on the majority of my chronic pain patients would have potential drastic and detrimental results especially with the inability to find other colleagues to refer or help manage these cases as of late. The results would lead to opioid withdrawal, increase illicit drug seeking, potentially increase risk for mental instability and may increase morbidity and mortality (including risk of suicide). Therefore, unless I have fallen below the standard of care, I will not stop prescribing this class of medication to my patients.

Ms. Rivera testified that Dr. Crawford’s response to the summary suspension of his license caused concern at the Board. Ms. Rivera testified that she tried to call Dr. Crawford, but he did not answer the phone and his voicemail box was full.

On January 17, 2018, the Board pulled another CSPMP, which showed that between January 4, 2018, and January 16, 2018, Dr. Crawford had continued to prescribed controlled substances. The prescriptions were filled in Kearny, Apache Junction, Tucson, Gold Canyon, and Claypool. The Board obtained hard copies of the prescriptions.

Ms. Rivera testified that the Board’s operations manager obtained confirmation from FedEx that the Board’s January 4, 2018 order summarily suspending Dr. Crawford’s license was delivered to his address in Kearny at 12:56 p.m. on January 5, 2018. The Board had sent an email to Dr. Crawford, to which it attached the summary suspension order, on January 4, 2018 at 1:50 p.m.

Dr. Borowsky has been licensed as an allopathic physician in Arizona since 1980. He started his internship in 1970 after he graduated from medical school. He completed a residency and fellowship at Harvard. The nature of Dr. Borowsky’s medical practice in Arizona is that in 1980, he was recruited as an anesthesiologist at a Surgicenter, where he worked until ten years ago. He is on the staff of various hospitals and teaches pain management at the University of Arizona medical school. He is on the governor’s committee for opioids and is the founder of the Arizona Pain Society.

Dr. Borowsky testified that he prescribes opioids to patients. He has seen the practice of pain management evolve. At first, opioids were only prescribed to cancer patients but, beginning in the 1990’s, pharmaceutical companies started advertising Oxycodone as only minimally addictive and promoting its use by non-cancer patients. Dr. Borowsky is board-certified in anesthesiology and pain management. Although Dr. Borowsky is retired, he is still involved in pain management and prescribes opioids in his practice, mainly in industrial cases.

Dr. Borowsky testified consistently with his September 11, 2017 report. Dr. Borowsky reviewed Dr. Crawford’s January 8, 2018 response, which did not change in his mind but, instead, reinforced his concerns. Dr. Borowsky testified that prescription of opioids may be appropriate if evidence shows that the patient may benefit from reducing pain and improving function. Dr. Borowsky testified that even if patients show improvement, they should be monitored through urinalysis and CSPMP to prevent diversion, early refills, or use of non-prescribed substances.

Dr. Borowsky testified that C.E. became Dr. Crawford’s patient before 2006 and his last office visit was on May 17, 2017. Dr. Crawford’s patient records did not contain any records from other health care providers. Dr. Crawford prescribed opioids with benzodiazepines, which increased the risk of abuse and the side effect of sedation. Dr. Crawford also prescribed Soma to C.E., which is a tranquilizer and added to potential complications and side effects.

Dr. Borowsky testified that Dr. Crawford’s records of his treatment of C.E. did not comply with any aspects of federal and state guidelines for the prescription of opioids. First, Dr. Crawford did not identify a credible physical problem supported by objective evidence such as history, radiographic studies, or a physical examination, or evidence of objective improvement in function or pain after the treatment. Dr. Crawford’s records did not include any objective examination, such as an observation of the patient walking, palpitation, or noted areas of tenderness or loss of sensation. Physicians who treat their patients with opioids must look at the evidence in a skeptical way to see if there is a credible problem. Dr. Borowsky testified that there was no such documentation in Dr. Crawford’s records for C.E.

Dr. Borowsky noted that C.E. underwent back surgery in 2011. However, 2009 x-rays showed only mild evidence of degenerative disc disease in his thoracic and lumbosacral spine. An x-ray of C.E.’s right hip and pelvis was unremarkable. An impression of C.E. lumbar spine in 2009 showed a “prominent osteophyte” that Dr. Borowsky testified could cause pain, but C.E. had surgery in December 2011. A radiographic study from December 2012 of the KXR/sacrum/coccyx showed the fusion and pedicle screws but was otherwise unremarkable.

Dr. Borowsky testified that the standard of care requires a doctor to obtain objective evidence of a condition that could cause the patient to experience pain. After treating C.E. for 4-1/2 years, Dr. Crawford obtained no further radiographic studies, even though C.E. complained of severe back pain and was prescribed high doses of opioids. Dr. Borowsky testified that there needed to be evidence of a credible problem to prevent possible drug-seeking behavior. There needed to be evidence that C.E. was benefitting from the treatment.

Dr. Borowsky testified that, in addition, doctors who prescribe high doses of opioids to their patients need to perform urine tests to make sure the patients are not diverting their drugs.

Dr. Borowsky testified that anything over 120 mg morphine daily equivalent dose (“M.E.D.”) is considered high under federal guidelines. Arizona recently adopted 100 M.E.D., and urges caution for any prescription over 50 M.E.D. Dr. Borowsky reviewed the medications that Dr. Crawford had prescribed to C.E. in 2016, and testified that it was 827, well above 120 M.E.D., without any urinalysis. Dr. Borowsky testified that it was impossible to know whether C.E. was taking or diverting the medication.

Dr. Borowsky noted that Dr. Crawford did not obtain any CSPMP profiles for C.E. and that the CSPMP for an 8-month period between October 2016 and May 2017 that the Board obtained showed regular early refills, for an extra 11 days of medication.

Dr. Borowsky noted that in September 2012, after C.E.’s back surgery, he went into Palo Verde Hospital in Tucson for detoxification, but that C.E. saw Dr. Crawford one week later and resumed his high opioid regimen. Dr. Borowsky testified that if a doctor knows that a patient has undergone detoxification, the doctor should follow up and determine whether the detox was voluntary or involuntary, but that Dr. Crawford did nothing. Dr. Borowsky testified that a doctor should not wipe out the possible benefits of a detoxification.

Dr. Borowsky testified that Dr. Crawford’s records for C.E. were illegible at times. It was important for continuity of care for a doctor to maintain legible records of patient care so that another provider could take over the patient’s care.

Dr. Crawford did not cross-examine Dr. Borowsky.

Dr. Crawford acknowledged that according to his records, on September 25, 2012, C.E.’s wife called his office and stated that he had been treated at the Oro Valley ER and had undergone detoxification at Palo Verde for narcotics. Dr. Crawford next saw C.E. on October 2, 2012, and noted that C.E. only lasted five days in detox. Dr. Crawford did not request medical records from Palo Verde. Dr. Crawford acknowledged that it would have been prudent for him to get Palo Verde’s records. Dr. Crawford acknowledged that without urinalysis, he had no way of knowing whether C.E. was taking other drugs and that C.E. would have undergone urinalysis in the detox facility.

Dr. Crawford testified that he thought he had 30 to 60 days to file a written response to the December 7, 2017 order. Dr. Crawford’s attention was called to the Board’s December 7, 2017 order, which stated that his ability to prescribed controlled substances was summarily restricted pending a hearing and that the Board’s executive director was instructed to refer the matter to the Office of Administrative Hearings to be held within 60 days of the Board’s order.

Dr. Crawford acknowledged that he received the Board’s January 4, 2018 order summarily suspending his license to practice allopathic medicine on January 5, 2018.

Dr. Crawford testified that he did not attend the December 6, 2017 Board meeting at which the Board restricted his ability to prescribe controlled substances. He did not remember getting notice of the meeting. Dr. Crawford acknowledged that he may have seen the Board’s order in an email, but testified that he felt that he had to continue writing prescriptions for controlled substances to the 156 patients who needed drugs to control their pain.

Dr. Crawford presented the testimony of his patient Susan K. Miller-Middaugh. Ms. Miller-Middaugh testified that Dr. Crawford has been her family’s physician for many years. She has many health conditions, including rheumatoid arthritis and chronic pain in her back and neck, migraines, high cholesterol, and high blood pressure. Ms. Miller testified that Dr. Crawford prescribes Tylenol III to control her pain and alprazolam for her anxiety. She also sees a psychiatrist for her depression. Ms. Miller Middaugh testified that she received her last pain shot for migraine two to three years ago. She testified that Dr. Crawford referred her to Dr. Welch in Tucson for her rheumatoid arthritis, but that she has not seen Dr. Welch for two to three years because after she missed an annual appointment, Dr. Welch did not call her back and sent her to a physician’s assistant.

Ms. Miller-Middaugh testified that Dr. Crawford has taken good care of her and her family. He takes his time to explain things and to ask questions. Ms. Miller Middaugh does not want to drive a long ways to see a doctor. Although other doctors have practiced in Kearny, they have come and gone. Since the Board suspended Dr. Crawford’s license, Ms. Miller-Middaugh has been seeing Dr. Charles. Ms. Miller-Middaugh testified that if the Board reinstates Dr. Crawford’s license, she will return to him.

Dr. Crawford also presented the testimony of his patient Stephen England. Mr. England testified that when he moved to the Kearny area in 1993 as the new postmaster, Dr. Crawford was the only doctor in the area. Mr. England testified that he has gone through a “doctor mill” since he was five years old due to bone and allergy issues. As a young man, Mr. England decided to take charge of his body. Mr. England testified that when he first met Dr. Crawford, he told him that he did not like or trust doctors.

Mr. England testified that at 63 years old, he is still able to run down hills and raft. Dr. Crawford spent time on the Navajo reservation and takes the position that western medicine is not the only way to treat illness. Mr. England testified that he takes Tylenol IV and Soma about once a month. Mr. England testified that Dr. Crawford is the best supportive doctor that he has ever had because he treats his pain mostly with herbs and exercises.

Mr. England testified that if the Board revokes Dr. Crawford’s license, it will deprive 3,000 or 4,000 people of the only doctor that they can access. Many of Dr. Crawford’s patients are elderly or diabetic and that they will have to drive 2 hours to see another doctor. Mr. England testified that he has known Dr. Crawford for 24 years and that Dr. Crawford interacts well with people in Kearny. People trust him with their lives.

Dr. Crawford submitted a petition signed by approximately 30 people entitled “Copper Corridor Area Petition,” with the following narrative:

As a resident of this area I am deeply concerned about our possible loss of basic medical services that Jeff Crawford has faithfully and generously provided us for nearly three decades while many other medical providers have come and gone. We have [utmost] confidence in his medical care for our generations of family members, friends and acquaintances. He is very approachable and we often speak with him in the daily life of our community and he addresses many of us personally by name. His biggest fault is not overprescribing medication but not charging sufficiently for his services. He is a simple man, provides his medical services in very basic manner; we like that. Restore his Medical License promptly as our community is very unlikely to ever attract a suitable replacement!!

Dr. Crawford testified that one of his friends who had an office in Kearny started the petition. Dr. Crawford testified that Globe is at the north end and Oro Valley is at the south end of the Copper Corridor. Dr. Crawford testified that he has patients in Globe, 45 miles away from Kearny, Tucson, 75 miles from Kearny, Apache Junction, and Mesa because patients that he treated in Kearny relocated to those other cities.

Dr. Crawford also submitted approximately 26 letters of reference from his patients, generally praising the quality of his medical care and approachability. The patients also stated that Dr. Crawford provided a much-needed service in this small, rural community.

Dr. Crawford testified that he has 4,400 regular patients in his general practice and that there are no other physicians in the practice. Dr. Crawford believes that he still has 20 or 30 years left to devote to his patients in his rural practice.

Dr. Crawford testified that the manual states that 660 M.E.D. is a high dose. When he first started treating C.E., he was on a low dose of opioids. In May 2017, C.E. was on a much higher dose. Dr. Crawford acknowledged that he found his chronic pain practice “overwhelming” and that it might be wise for him to refer chronic pain patients to others so that he can concentrate on his general medical practice.

Dr. Crawford submitted his letter dated February 1, 2018, that provided in relevant part as follows:

After reviewing all documents provided for me in the past 2 weeks, I want to express my deepest apology for not responding to all the concerns in a timely manner. I also agree that I fell below the standard in managing the case off CE in regards to his chronic pain management.

While having time to review my current cases of patients who have been on ongoing opioid medication on a chronic basis, I found 156 patients out of 4400 registered patients who met the criteria. Of the 156 patients on chronic opioid therapy, 18 patients have been on, or near high, or above the high MED limit of 660 mg./day. In this group 5 patients have been to the ER for opioid treatment and 1 patient ended up in jail. I have been aggressively referring these patients to appropriate/qualified pain management specialists since 01-05-2018.

I agree I need definitely to modify this practice if I am ever going to practice . . . again in regards to chronic pain medication with opioid prescriptions in the future. This requires a more [judgmental] attitude for monitoring urine drug test screening regularly and a written contract should be included. I always in the past have had more trusting, compassionate, and caring attitude in my profession. I will definitely improve my responding time to the Arizona Medical Board as part of my commitment for notifications of investigational requests.

Because of loss of income generation from the license suspension, I hope the $2500 “penalty” fee can be waived. I am a man who lives and provides via simple means. I consider myself a good service provider. I know I can still provide good or above standard level medical care as an allopathic physician. . . .

The Board submitted documents to show Dr. Crawford’s past non-disciplinary history with the Board, as follows: (1) On January 29, 1993, the Board issued an advisory letter of concern because it was concerned about his inadequate care of six patients; (2) On January 30, 1996, the Board issued an advisory letter of concern regarding his inappropriate placement of a Foley catheter causing damage to the patient’s urethra; and (3) On June 28, 2001, the Board issued an advisory letter of concern for Dr. Crawford’s performance of a lymph node biopsy without adequate knowledge of the surgical anatomy of the posterior neck, causing damage to the patient’s spinal accessory nerve.

/ / / /

CONCLUSIONS OF LAW

The Board is the duly constituted authority for licensing and regulating the practice of allopathic medicine in the State of Arizona. This matter lies within its jurisdiction.

The Board bears the burden of proof to establish cause to sanction Dr. Crawford’s license to practice allopathic medicine and factors in aggravation of the penalty by clear and convincing evidence. Dr. Crawford bears the burden to establish affirmative defenses and factors in mitigation of the penalty by the same evidentiary standard. Clear and convincing evidence is “[e]vidence indicating that the thing to be proved is highly probable or reasonably certain.”

A.R.S. § 32-1401(2) defines “adequate records” as follows:

"Adequate records" means legible medical records, produced by hand or electronically, containing, at a minimum, sufficient information to identify the patient, support the diagnosis, justify the treatment, accurately document the results, indicate advice and cautionary warnings provided to the patient and provide sufficient information for another practitioner to assume continuity of the patient's care at any point in the course of treatment.

Dr. Borowsky testified that parts of Dr. Crawford’s records for C.E. were illegible. Dr. Crawford did not dispute that the records did not document that C.E. had a credible medical condition that required opioid prescription to manage or that C.E.’s function or subjective pain improved with opioid treatment. The Board established by clear and convincing evidence that Dr. Crawford failed to keep adequate records for C.E. as defined by A.R.S. § 32-1401(2), thereby committing unprofessional conduct as defined by A.R.S. § 32-1401(27)(e).

A.R.S. § 32-1401(27)(q) defines “unprofessional conduct” to include “[a]ny conduct or practice that is or might be harmful or dangerous to the health of the patient or the public.” Dr. Crawford did not dispute Dr. Borowsky’s expert opinion that Dr. Crawford’s excessive and unmonitored prescription of opioids to C.E. caused actual harm because it made it impossible to determine whether C.E. was taking the opioids or diverting them to others. Dr. Crawford also did not dispute Dr. Borowsky’s expert opinion that Dr. Crawford’s excessive and unmonitored prescription of opioids to C.E. caused potential harm in that C.E. or the persons to whom he might be diverting the opioids might experience addiction, adverse medication reactions, overdose, or death. Therefore, the Board established by clear and convincing evidence that Dr. Crawford committed unprofessional conduct as defined by A.R.S. § 32-1401(27)(q).

The Board established by clear and convincing evidence that Dr. Crawford continued to prescribe controlled substances to his patients after the Board issued its December 7, 2017 order summarily restricting his ability to prescribe controlled substances. Therefore, the Board established that Dr. Crawford committed unprofessional conduct as defined by A.R.S. § 32-1401(27)(r).

The Board established by clear and convincing evidence that Dr. Crawford failed to provide a complete narrative response or C.E.’s medical records in response to Board staff’s March 2, 2017 and April 26, 2017 letters requesting this information and documents. Therefore, the Board established that Dr. Crawford committed unprofessional conduct as defined by A.R.S. § 32-1401(27)(dd).

Dr. Crawford’s initial refusal to respond to the Board’s investigation and the Dr. Borowsky’s conclusions about Dr. Crawford’s prescribing practices in his treatment of C.E. justify the Board’s December 7, 2017 order summarily restricting his ability to prescribe controlled substances. Dr. Crawford’s continued prescription of controlled substances to his patients after the Board summary restricted his ability to make such prescriptions justifies the Board’s January 4, 2018 order summarily suspending his license to practice allopathic medicine. Both orders comport with A.R.S. § 32-1451(D).

With respect to the appropriate penalty under A.R.S. § 32-1451(M) for Dr. Crawford’s repeated acts of unprofessional conduct, until two weeks after the Board issued the January 5, 2018 order summarily suspending his medical license, Dr. Crawford was defiant and uncooperative. Until early 2018, it did not appear that Dr. Crawford could be regulated.

Many of Dr. Crawford’s patients have contacted the Board on his behalf to let it know the hardship that they will face if his medical license is revoked. His patients’ support and needs may have caused Dr. Crawford to reconsider his priorities and resistance to regulation. Dr. Crawford credibly testified that he feels remorse for his past mistakes, that he is committed to his patients, and that to continue serving his patients, he has resolved to be more responsive to the Board’s inquiries and respectful of the Board’s duty to regulate his practice of allopathic medicine to protect both Dr. Crawford’s patients and the public.

Dr. Crawford acknowledged that it might be better if he does not treat chronic pain patients because of the unique demands of this kind of practice. Dr. Crawford credibly testified that he is trying to refer all 156 chronic pain patients to specialized practitioners who are better able to meet these patients’ treatment needs. Given the demands of Dr. Crawford’s busy practice, the Administrative Law Judge agrees that Dr. Crawford should not treat chronic pain patients or prescribe opioids.

RECOMMENDED ORDER

Based on the foregoing, it is ordered affirming the Board’s December 7, 2017 order summarily restricting Jeff Crawford, MD’s ability to prescribe controlled substances and January 4, 2018 order summarily suspending his License No. 18695 for the practice of allopathic medicine in the State of Arizona.

It is further ordered that a letter of reprimand shall be issued against Dr. Crawford’s License No. 18695 on the effective date of the final order in this matter.

It is further ordered that Dr. Crawford’s ability to prescribe opioid medications shall be permanently restricted, prohibiting him from ever prescribing opioids as long as he continues to practice allopathic medicine in the State of Arizona.

It is further ordered that Dr. Crawford shall be required to complete 12 hours of Board staff pre-approved CME in medical records within six months of the effective date of the final order in this matter.

It is further ordered that Dr. Crawford’s License No. 18695 shall be placed on disciplinary probation for a period of three years after the effective date of the final order in this matter. During the probationary term, the Board may perform random audits of Dr. Crawford’s medical records to determine whether the records are legible and include the information required by A.R.S. § 32-1401(2), as well as whether the records show any standard-of-care or practice issues.

It is further ordered requiring Dr. Crawford to pay $1,500.00 as a civil penalty to the Board within three months of the effective date off this order.

In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order will be five days from the date of that certification.

Done this day, March 7, 2018.

/s/ Diane Mihalsky

Administrative Law Judge

Transmitted electronically to:

Patricia E. McSorley, Executive Director

Arizona Medical Board