HARRAL v. CORIZON MEDICAL LLC
Entry Denying Motion for Preliminary Injunction - Plaintiff James Harral asks this Court to grant his motion for preliminary injunction requiring the medical staff at the Putnamville Correctional Facility ("Putnamville") to restart his b ipolar and neuropathy medication. Mr. Harral alleges that the defendants removed him from his bipolar and pain medications and as a result he has had to endure extreme manic depressant episodes, such as withdrawal, insomnia, and mood swings. He al so feels he needs to be isolated from the general population. He asks this Court to order the defendants to restart his medications to the same dose and frequency as he was taking prior to July 23, 2015. The defendants responded to the motion for preliminary injunction. For the reasons set forth below, the Court denies Mr. Harral's motion for a preliminary injunction. (See Entry.) Signed by Judge William T. Lawrence on 2/28/2017. (RSF)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
TERRE HAUTE DIVISION
JAMES D. HARRAL, Jr.,
) Case No. 2:16-cv-0027-WTL-DKL
DR. ALUKER, et al.,
Entry Denying Motion for Preliminary Injunction
Plaintiff James Harral asks this Court to grant his motion for preliminary injunction
requiring the medical staff at the Putnamville Correctional Facility (“Putnamville”) to restart his
bipolar and neuropathy medication. Mr. Harral alleges that the defendants removed him from his
bipolar and pain medications and as a result he has had to endure extreme manic depressant
episodes, such as withdrawal, insomnia, and mood swings. He also feels he needs to be isolated
from the general population. He asks this Court to order the defendants to restart his medications
to the same dose and frequency as he was taking prior to July 23, 2015. The defendants responded
to the motion for preliminary injunction. For the reasons set forth below, the Court denies Mr.
Harral’s motion for a preliminary injunction.
A. Medication History
In 2012, prior to his incarceration, Mr. Harral suffered a crush injury to his left arm,
resulting in neuropathic symptoms from his elbow distally (toward his wrist). Mr. Harral’s current
doctor, Dr. Spanenberg, Site Medical Director at Putnamville, employed by Corizon, LLC.,
diagnosed him with mononeuropathy multiplex. More simply put, the crush injury damaged at
least two nerves in Mr. Harral’s lower left arm, resulting in some limited atrophy of his wrist and
the type of pain associated with damaged nerves – burning, tingling, and numbness. [dkt. 47-1, ¶
7]. Mr. Harral also reported lower back pain, but x-rays taken on March 31, 2015, showed only
mild L4-5 intervertebral disc loss. [Dkt. 47-1, ¶ 7; 47-2, p. 8]. In June of 2015, Mr. Harral was
seen by Nurse Fuqua and reported anxiety, irritation, depression and lack of energy. [Dkt. 47-1, ¶
19]. For his nerve pain and depression, Mr. Harral sought three specific drugs – Wellbutrin,
Ultram, and Neurontin. [Dkt. 47-1, ¶¶ 14, 19, 51, 55-56]. All three of these drugs are highly abused.
[Dkt. 47-1, ¶ 14].
Ultram is a synthetic version of an opioid medication and is a schedule IV controlled
substance. Ultram is treated as a narcotic. [Dkt. 47-1, ¶ 8]. Like other narcotic medications, Ultram
is abused. [Dkt. 47-1, ¶ 9].
Neurontin is one of several anticonvulsant medications used for the management of
neuralgia or pain caused by damaged nerves. The Food and Drug Administration (“FDA”)
approved Neurontin for the management of nerve pain arising from shingles and for seizures.
Though controversial, medical providers found Neurontin can be effective for other types of nerve
pain. Neurontin is abused in the correctional setting because it can induce euphoria. There are
several alternative anticonvulsants, such as Dilantin or Tegretol, which can be substituted for
Neurontin without the same abuse issues. [Dkt. 47-1, ¶ 10].
Wellbutrin is heavily abused inside the correctional setting. When crushed and snorted, the
user experiences euphoria and increased arousal. [Dkt. 47-1, ¶ 11].
Inside prisons, medical providers avoid prescribing the more abused medications if other
medications are equally effective. If a medication known to be abused is prescribed, it can be given
as “watch swallow” or crushed in water so a nurse can confirm the patient is taking the medication
rather than “cheeking” it. Providers may also order random drug tests to confirm medication
ingestion. When a patient is found to be diverting medication or misusing it, the medication is
terminated and alternative medications are tried. [Dkt. 47-1, ¶ 12]. Mr. Harral has been diagnosed
with polysubstance abuse, demonstrated by multiple drug related convictions and Indiana
Department of Correction (“IDOC”) disciplinary proceedings for misuse of medications. [Dkt. 411, ¶ 7].
B. Mr. Harral’s Treatment
In 2015, the IDOC removed Wellbutrin from the formulary. After that if a medical provider
wanted to prescribe Wellbutrin, he or she needed to submit a request through Corizon’s Utilization
Management for approval. This extra step ensures providers first try alternative medications before
requesting Wellbutrin. If a patient required Wellbutrin, however, it was available.
Because of Wellbutrin’s removal from the formulary, Mr. Harral was taken off Wellbutrin
and was prescribed an alternative medication called Remeron. On April 10, 2015, Mr. Harral
requested Advanced Practical Nurse (APN) Dawson end Remeron due to “bad” side effects and
restart Wellbutrin. [Dkt. 47-1, ¶ 13; 47-2, pp. 20- 21]. Dawson offered other medications, but Mr.
Harral became angry, threatened to file a lawsuit, and argued until she was forced to ask him to
leave. He insisted “nothing worked but Wellbutrin.” [Dkt. 47-1, ¶ 13; 47-2, p. 20].
On April 13, 2015, Nurse Practitioner (NP) Warren saw Mr. Harral for neuropathy in his
left forearm. [Dkt. 47-2, p. 23]. At the time, he received ibuprofen 400 mg once a day; Tylenol
325 mg once a day; and a Neurontin 600 mg tablet, twice in the morning, once at noon, and twice
at night, for pain management. Mr. Harral requested that NP Warren submit a non-formulary
request for Ultram because he had already tried alternative medications and continued to
experience arm and low back pain. [Dkt. 47-2, p. 23]. NP Warren noted that his most recent xrays were negative, but she submitted a request to start Ultram and planned to consider trigger
point injections. [Dkt. 47-2, p. 24]. The Ultram was approved at one 50 mg tablet, twice a day.
[Dkt. 47-1, ¶ 14; 47-2, p. 31].
On April 19, 2015, Behavioral Health evaluated Mr. Harral. [Dkt. 47-2, p. 28]. He was
irritable and reported poor sleep and appetite. He wanted Wellbutrin and refused any alternative
medications. He saw another mental health professional on April 30, 2015, and requested
Wellbutrin again. [Dkt. 47-2, pp. 32-33]. He then refused the trigger point injection to address his
chronic pain on May 1, 2015. [Dkt. 47-1 ¶ 16; 47-2 pp. 31, 150].
On May 15, 2015, APN Dawson saw Mr. Harral. [Dkt. 47-2, p. 38-40]. He continued to
ask for Wellbutrin and refused all other medications. He also requested a mood stabilizer, but
declined APN Dawson’s proposals of lithium and Depakote. He agreed to try Lamictal if APN
Dawson would move him to a different bed. When APN Dawson declined, Mr. Harral left the
office stating he never wanted to see her again. [Dkt. 47-2, p. 38]. APN Dawson noted that Mr.
Harral exhibited manipulative and drug-seeking behaviors. [Dkt. 47-1, ¶ 18].
On June 1, 2015, Mr. Harral saw NP Penni Fuqua for behavioral health management. [Dkt.
47-1, ¶ 19; 47-2, p. 41-43]. She noted Mr. Harral had tried several medications without success.
He reported that he was sleeping little, his weight had dropped, and he was having trouble
functioning. He reported anxiety, irritation, depression, and lack of energy. NP Fuqua noted to
prescribe Wellbutrin if approved by Dr. Burdine. [Dkt. 47-2, p. 43]. She recommended one 100
mg tablet, twice a day, crushed and floated in water to avoid diversion. He wanted Wellbutrin, so
he agreed to have it crushed and floated. This was approved. [Dkt. 47-1, ¶19; 47-2, p. 48].
On June 2, 2015, Mr. Harral requested that his Ultram dose be increased. [Dkt. 47-2, pp.
42, 151]. He reported that the medication had worked previously, but no longer. Dr. Alukar kept
the prescription at one 50 mg tablet twice a day. [Dkt. 47-1, ¶ 20; 47-2, pp. 42, 169]. On June 3,
2015, Mr. Harral saw Dr. Alukar for back and hip pain. [Dkt. 47-1, ¶ 21; 47-2, pp. 48-49]. Dr.
Alukar noted that Mr. Harral had back spasms in the L3 to L5 levels with a decreased range of
motion. He prescribed Robaxin, a muscle relaxer. [Dkt. 47-2, p. 49]. Dr. Alukar then performed a
corticosteroid injection on June 26, 2015, and obtained continued approval for Mr. Harral’s
Neurontin prescription. [Dkt. 47-1, ¶ 21].
On July 6, 2015, NP Warren saw Mr. Harral for left arm and hand neuropathy. [Dkt. 47-2
pp. 50-52]. He reported chronic pain, tingling, and numbness after a car fell on his arm, pinning it
under a tire for twenty minutes. He did not suffer any broken bones. Mr. Harral reported good
results on Ultram, but wanted it increased to two 50 mg tablets twice a day. He wore a glove for
further pain control and requested a new back brace after his was taken away in segregation. [Dkt.
47-2, p. 50]. NP Warren requested an increase in the patient’s Ultram to 100 mg twice a day,
ordered him a compression glove, and provided a new back brace. [Dkt. 47-2, pp. 51, 153]. The
increase in the Ultram was approved. [Dkt. 47-1, ¶¶ 22, 23; 47-2, pp. 52- 53].
On July 13, 2015, NP Fuqua met with Mr. Harral for medication management. He
requested that his Wellburtin be increased. He reported feeling overwhelmed, anxiety, and
paranoia with “minimal” improvement on Wellbutrin. NP Fuqua noted to request an increase in
Wellbutrin. [Dkt. 47-1, ¶ 24; 47-2, pp. 56-58, 62].
On July 23, 2015, NP Warren entered the following administrative “note” into the medical
record. A correctional officer received a tip that Mr. Harral and other inmates were diverting
medication to sell. When staff shook Mr. Harral’s cell down, the officer witnessed him take ten to
twelve pills. Mr. Harral admitted that he cheeked his morning medications rather than swallowing,
so he was given activated charcoal to protect against overdose and placed in observation for
monitoring. Pursuant to IDOC and Corizon policy, medical staff ended his non life-sustaining
medications for six months which were the same medications he diverted: Neurontin, Ultram, and
baclofen. [Dkt. 47-1, ¶ 25; 47-1, pp. 63-64]. Mr. Harral’s prescription for Wellbutrin was also
terminated. [Dkt. 47-1, ¶¶ 11, 26].
On July 28, 2015, Mr. Harral saw Dr. Byrd for neuropathy. He admitted to diverting the
medications, but claimed he did so to handle breakthrough pain without the midday dose. He also
stated that he bought pills on the yard. [Dkt. 47-1, ¶ 27; 47-2, pp. 69-70].
On August 26, 2015, APN Dawson saw Mr. Harral for evaluation after termination of the
Wellbutrin. He reported a low mood and crying. APN Dawson offered Effexor, Prozac, Celexa,
Zoloft, Pamelor, Tofranil, and Remeron, which are all effective medications for depression, but
Mr. Harral refused them all. APN Dawson also noted that Mr. Harral refused Valpoic acid and
lithium as mood stabilizers. [Dkt. 47-1, ¶ 30; 47-2, pp. 77-79].
On August 29, 2015, Mr. Harral wrote a letter to Fuqua. He apologized if he made Fuqua
feel threatened or bullied. He then wrote as follows:
Last month, I made the poor decision to bring my neuropathy meds back to the
dorm to take a little later. Noon medications call out was ceased by Mrs. Bunch
because they just fired an employee and didn’t have the staff to run the pharmacy.
Well, I have a [chronic] injury to my left arm that was being treated [three] times a
day because it causes me a lot of pain [and] discomfort. Taking away noon meds
was making the needle pain and numbness worse, so I brought my Neurontin and
Ultram back [two] days in a row, but on the second day, I was told on and
[Dkt. 47-1, ¶ 32; 47-2, pp. 157-58].
On October 28, 2015, Mr. Harral saw Dr. Kiani. He reported that he was in pain all the
time, but Dr. Kiani did not see any distress. Dr. Kiani elected to restart the Neurontin on November
5, 2015, at a lower dosage, 600 mg twice a day. [Dkt. 47-1, ¶ 35; 47-2, pp. 85-86, 90; 47-3, pp.
161, 164, 166].
On April 7, 2016, a correctional officer caught Mr. Harral passing Neurontin to another
offender. The officer notified NP Finote, who discontinued the prescription. After Mr. Harral was
found not guilty of passing Neurontin in a disciplinary proceeding, the prescription was reinstated
at 600 mg tablet, twice a day. [Dkt. 47-1. ¶ 44; 47-2, pp. 107-08].
Dr. Spanenberg ordered Mr. Harral’s Neurontin levels checked July 5, 2016. On July 9,
2016, the lab report returned showing that the patient’s Neurontin was at non-therapeutic levels,
which means he was not taking his medication. Mr. Harral’s prescription for Neurontin was
cancelled. [Dkt. 47-1 ¶¶ 46, 47; 47-3, pp. 117, 146].
On August 26, 2016, Dr. Spanenberg met with Mr. Harral, custody, and the HSA to discuss
the patient’s drug diversion issues and pain control. He admitted diverting Neurontin because other
offenders had forced him to do so over a long period. His lab results confirmed that he was not
taking Neurontin. Dr. Spanenberg would not reorder Neurontin as Mr. Harral was misusing the
medication, but agreed to order Ultram for a few weeks while the medical staff worked through
other options for pain control. [Dkt. 47-1, ¶ 50; 47-3 pp. 127-29].
More recently, in January of 2017, Mr. Harral was caught by correctional officers
attempting to ingest several unknown orange squares. He tested positive for Suboxone, which is
consistent with the orange squares he was seen ingesting. Suboxone is used to manage recovering
opioid addict to prevent relapse. Like other opioids, Suboxone can cause euphoria and dependency.
It is manufactured in a thin dissolvable filmstrip form and is not prescribed inside prison facilities.
[Dkt. 51-2, ¶ 5].
Substance abuse and addiction to analgesic medications are manifestations of the brain
changes caused by the drugs. The drugs bring intense pleasure. Ending abuse is physically difficult
due to a craving for the addictive substance and the need to ward off withdrawal symptoms. When
taken off the medications, the patient may experience transient increases in pain with withdrawal
symptoms. The treatment plan for such patients requires transition to rational polypharmacy
(multiple medications) with non-narcotics, particularly antidepressants and anticonvulsants
(avoiding addictive Neurontin in this patient’s case). The process is not immediate – weaning off
of addictive medications never is – it can take several months for the patient’s body to physically
adjust to functioning without the addictive substance. [Dkt. 47-1 ¶ 58].
In Mr. Harral’s situation, his reported pain did not impact his physical function. He was
able to perform his activities of daily living, work, and follow the rules of the facility – with the
exception of medication compliance. Dr. Spanenberg and other providers conducted numerous
physical examinations to assess objectively Mr. Harral’s pain and its cause. While his
examinations did reveal some nerve damage and slight narrowing of one lumbar disc, the
examinations ruled out objective symptoms that correlated with his reported severe pain. Mr.
Harral misused his medications and then lied to his medical providers when caught. It did not
happen once, it happened multiple times. [Dkt. 47-1, ¶ 59]. Based on Dr. Spanenberg’s extensive
experience, Mr. Harral had all the hallmarks of a polysubstance abuser, seeking medication he did
not need in order to abuse it. Providers do not prescribe addictive medications to patients with a
substance abuse history. To do so renders the patient highly likely to relapse into drug addiction.
[Dkt. 47-1 ¶ 60].
Giving addictive medications to a patient with a demonstrated history of noncompliance
invites relapse with deleterious effect on his health. [Dkt. 47-1 ¶ 6].
II. Preliminary Injunction Standard
“[A] preliminary injunction is an extraordinary and drastic remedy, one that should not be
granted unless the movant, by a clear showing, carries the burden of persuasion.” Mazurek v.
Armstrong, 520 U.S. 968, 972 (1997) (citation omitted). There are four requirements a movant
must establish to be entitled to a preliminary injunction: (a) likely of success on the merits; (b)
irreparable harm in the absence of preliminary relief; (c) the balance of equities tips in the movants’
favor; and, (d) that an injunction is in the public interest. Winter v. NRDC, Inc., 129 S. Ct. 365,
374 (2008). The “movant has the burden to show that all four factors . . . weigh in favor of the
injunction.” Davis v. Pension Benefit Guar. Corp., 571 F.3d 1288, 1292 (D.C. Cir. 2009). “If the
court determines that the moving party has failed to demonstrate any one of these [ ] threshold
requirements, it must deny the injunction.” Girl Scouts of Manitou Council, Inc. v. Girl Scouts of
U.S.A., Inc., 549 F.3d 1079, 1086 (7th Cir. 2008).
Mr. Harral has failed to establish his right to injunctive relief. Mr. Harral has not shown
that he is likely to succeed on the merits of his claims or that he will suffer irreparable harm if
immediate relief is not granted.
A. Likelihood of Success on the Merits
The defendants argue that Mr. Harral is not entitled to a preliminary injunction because he
has not shown a likelihood of success on the merits of his claim. Mr. Harral’s claim is brought
pursuant to 42 U.S.C. § 1983. To state a valid Eighth Amendment claim for inadequate medical
care, Mr. Harral must “allege acts or omissions sufficiently harmful to evidence deliberate
indifference to serious medical needs.” Estelle v. Gamble, 429 U.S. 97, 106 (U.S. 1976). A
deliberate indifference claim is comprised of two elements: one objective and one subjective.
McGee v. Adams, 721 F.3d 474, 480 (7th Cir. 2013). The defendants do not dispute that Mr. Harral
suffers from a serious medical condition. To establish the subjective element, Mr. Harral must
show that the defendants were aware of his serious medical need and were deliberately indifferent
to it. Id.
Here, Mr. Harral disagrees with his medical care and the decisions about the medicine he
was being (or not being) prescribed. A dispute about his proper course of treatment does not state
a claim of deliberate indifference. “Under the Eighth Amendment, [the plaintiff] is not entitled to
demand specific care. [H]e is not entitled to the best care possible. [H]e is entitled to reasonable
measures to meet a substantial risk of serious harm to h[im].” Forbes v. Edgar, 112 F.3d 262, 267
(7th Cir. 1997). Mr. Harral “is not entitled to demand specific care.” Id. Here, the defendants took
proper measures to meet a substantial risk of serious harm to his health. More specifically, the
defendants prescribed Neurontin, Ultram, and Wellbutrin to treat Mr. Harral’s neuropathy and
associated pain and his depression. However, Mr. Harral diverted Neurontin (on two occasions)
and Ultram and later tested positive for Suboxone. As such, these medications were terminated
pursuant to IDOC policy. However, the defendants did not leave Mr. Harral without any care. In
fact, APN Dawson offered Mr. Harral Effexor, Prozac, Celexa, Zoloft, Pamelor, Tofranil, and
Remeron for his depression, but he refused them all. Similarly, Mr. Harral was prescribed other
medications for pain, just not Neurontin, Ultram, and Wellbutrin. [Dkt. 47-1, ¶ 27]. Mr. Harral
refused all of the alternative pain medications without allowing sufficient time to allow for pain
control. [Dkt. 47-1, ¶ 52].
Here, the record reflects that medical staff had a reasonable basis for terminating Mr.
Harral’s prescriptions for narcotics and switching them to non-narcotics. Mr. Harral has a history
of polysubstance abuse and ingested the drug Suboxone, which was contraband. Under these
circumstances, withholding Neurontin, Ultram, and Wellbutrin does not amount to deliberate
indifference and Mr. Harral has not shown that he is likely to succeed on the merits of his claim.
B. Irreparable Harm
“Irreparable harm is harm which cannot be repaired, retrieved, put down again, atoned
for.... [T]he injury must be of a particular nature, so that compensation in money cannot atone for
it.” Graham v. Med. Mut. of Ohio, 130 F.3d 293, 196 (7th Cir. 1997). Here, defendants argue that
Mr. Harral cannot show an actual injury or imminent irreparable injury because he was offered
numerous alternative medications and his medical conditions (pain and depression) are being
monitored regularly. Mr. Harral has not presented any evidence to rebut this showing. The Court
agrees that Mr. Harral’s health is not at immediate risk because he is not being prescribed
Neurontin, Ultram, and Wellbutrin.
C. Balance of Harms
Because Mr. Harral seeks injunctive relief, he has the burden of proving by a clear showing
that a balancing of the equities falls in his favor. Mazurek 520 U.S. at 972. Mr. Harral does not
address this factor. Rather, he alleges he needs to take Wellbutrin because it is the only medicine
that has been effective in the past. However, the facts simply do not bear this out. Mr. Harral was
offered multiple other drugs for his nerve pain and depression. However, he refused to either take
them or to allow sufficient time for pain control. Moreover, giving addictive medications to a
patient with a demonstrated history of noncompliance, such as Mr. Harral, invites relapse with
deleterious effect on his health.
At this time, Mr. Harral’s allegations of pain and mental illness do not support a conclusion
that he needs immediate treatment in the form of narcotic or other opioid based medications.
D. Public Interest
Mr. Harral also does not address this factor. The defendants argue that the public interest
is in their favor to the extent that prisons should be given deference as to the day to day
maintenance and medical care of the inmates. The Court agrees that the defendants should be
accorded deference at this time to provide the most appropriate medical treatment and medications
for Mr. Harral’s depression and pain.
The Seventh Circuit has previously stated that, “. . . federal courts are most reluctant to
interfere with the internal administration of state prisons because they are less qualified to do so
than prison authorities.” See Thomas v. Ramos, 130 F.3d 754, 764 (7th Cir.1997). As the Supreme
Court has stated:
The problems that arise in the day-to-day operation of a corrections facility are not
susceptible of easy solutions. Prison administrators therefore should be accorded
wide-ranging deference in the adoption and execution of policies and practices that
in their judgment are needed to preserve internal order and discipline and to
maintain institutional security. ‘Such considerations are peculiarly within the
province and professional expertise of corrections officials, and, in the absence of
substantial evidence in the record to indicate that the officials have exaggerated
their response to these considerations, courts should ordinarily defer to their expert
judgments in such matters.’
See Bell v. Wolfish, 441 U.S. 520, 547-48 (1979) (quoting Pell v. Procunier, 417 U.S. 817,
827) (1979) (citations and footnotes omitted).
A prison medical professional’s “treatment decisions will be accorded deference unless no
minimally competent professional would have so responded under those circumstances.” Jackson
v. Kotter, 541 F.3d 688, 698 (7th Cir. 2008)(internal quotations omitted).
For the foregoing reasons, Mr. Harral has not shown he is entitled to preliminary injunctive
relief. Accordingly, his motion for a preliminary injunction [dkt. 37] is denied.
IT IS SO ORDERED.
Hon. William T. Lawrence, Judge
United States District Court
Southern District of Indiana
Carol A. Dillon
BLEEKE DILLON CRANDALL, P.C.
JAMES D. HARRAL, JR.
PUTNAMVILLE - CF
PUTNAMVILLE CORRECTIONAL FACILITY
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