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Martsolf v. Colvin

United States District Court, W.D. Missouri, Western Division

January 9, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


          NANETTE K. LAUGHREY United States District Judge

         Plaintiff James Martsolf appeals the Commissioner of Social Security's final decision denying his application disability insurance benefits and supplemental security income under the Social Security Act. The decision is affirmed.

         I. Background

         Martsolf was born in 1956. He alleges he became disabled beginning 12/31/2011. He last worked in an IT department as a help desk person until June 2007, when his contract expired. The Administrative Law Judge held a hearing on 12/18/2014 and denied his application on 1/15/2015. The Appeals Council denied his request for review on 2/19/2016.

         A. Medical history

         In December 2006, James Marx, D.O., diagnosed Martsolf with somatic dysfunction of the cervical spine. In March 2007, Martsolf was under stress and believed he was about to lose his job. He had high anxiety and severe neck and shoulder pain. Dr. Martsolf diagnosed somatic dysfunction, as well as generalized anxiety disorder. In May 2007, Martsolf reported that his neck and shoulder pain were worse with certain movements.

         At a December 2008 visit, Dr. Marx recommended neck exercises.

         In June 2009, Martsolf was continuing to use narcotic pain medications prescribed by Dr. Marx. He had high anxiety from job hunting.

         In July 2010, Martsolf complained to Dr. Marx that he had cervical pain radiating into his arm. Dr. Marx found tenderness in the cervical muscles on the right and decreased range of motion. Diagnoses included degenerative disc disease of the cervical spine and generalized anxiety disorder. Dr. Marx prescribed OxyContin and Percocet, and ordered a neurosurgical consult. An August 2010 MRI showed cervical disc protrusion and desiccation, and straightening of the normal lordotic curve of the cervical spine.

         At the visit with the neurosurgeon, John Gianano, M.D., in September 2010, Martsolf said he was not sure why he was there. He said he had no neck pain as long as he used his narcotic medication. He could mow his lawn and use a weed eater, and had no numbness, tingling, or weakness. Dr. Gianano noted Martsolf was on high doses of narcotics and recommended conservative treatment: anti-inflammatories, NSAIDs, and physical therapy.

         Dr. Marx noted at a September 2010 follow up appointment that the neurosurgeon had not recommended surgery, or even steroid injections, but that Martsolf should continue medications. He also noted that Martsolf's anxiety levels were high at times. Diagnoses included degenerative disc disease of the cervical spine and generalized anxiety disorder.

         Martsolf started seeing another primary care provider, Elaine Joselyn, D.O. in October 2010. He complained that he was treated like a drug addict when he went to an outpatient, pain management clinic at the Truman Medical Center, where he was told to use Advil and do neck exercises. He asked for refills to avoid running out and experiencing withdrawal. The doctor refilled his OxyContin and Percocet for one month. In November 2010 he requested a refill of OxyContin and hydrocodone, saying the medicine had given him his life back. He was given prescriptions and told to return the next month. In December 2010, he asked for Percocet to deal with break-through pain, and suggested that he be given multiple months of refills. He was worried that his medication would not be refilled. The doctor gave him a new referral to a pain management clinic.

         At a January 2011 follow up with Dr. Joselyn for prescription refills, Martsolf had no complaints, rated his pain at 0 out of 10, and said his pain was well controlled with OxyContin and Percocet. At visits over the next several months, the doctor tried adjusting Martsolf's narcotic medications to avoid development of tolerance, but in June 2011, the doctor prescribed OxyContin and Percocet. In early July 2011, Dr. Joselyn and Martsolf discussed the peaks and valleys of narcotic use. The doctor noted that Martsolf could turn his head more freely when not aware of what he was doing. Later the same month, Martsolf complained of sharp pain and gabapentin was added. Martsolf later admitted to the doctor's staff that he “over [did] it” and felt “stupid.” Tr. 325. At a routine follow up at the end of July 2011, Martsolf asked for refills of OxyContin and Percocet, telling the doctor his pain was controlled with those medications. He had no other complaints.

         Martsolf saw the doctor monthly from August 2011 through April 2012 for pain medication refills. His neck condition was stable. In May 2012, Martsolf told the doctor that he was doing better and had been more active, doing yard work and driving, among other activities. In June 2012, he told the doctor that his pain was controlled most days. At an August 2012 follow up, he reported that his pain was the same, but that his OcyContin only lasted 6 hours and he was waking up at night. The doctor continued OxyContin and instructed Martsolf to take Percocet in between OxyContin doses. His neck condition was stable in September and October 2012. His medications were refilled and he was referred to a pain management clinic. In November 2012, he complained that his pain was worsened by driving to the clinic, but he said his medication made the pain manageable.

         His condition was stable from December 2012 through June 2013 and the doctor continued to renew his medications. He remarked at the March and April 2013 visits that his pain was well controlled. June 2013 was difficult for him due to family and financial problems. The doctor tried changing his OxyContin to morphine. Martsolf's financial and family issues were better by his July 2013 visit, but he said the morphine was not entirely effective, and that OxyContin and Percocet would control his pain well, and the doctor prescribed them. From August to September 2013, his pain medications were refilled and he worked to be approved for a program to cover his prescription costs. In October 2013, he complained of breakthrough pain and his doctor recommended adding a muscle relaxer, but he refused it. He complained of a flare up in November 2013. He had osteopathic manipulative therapy in December 2013 and was give refills of his pain medication. From January to April 2014, his condition was stable and the doctor continued to refill his prescriptions. In May 2014, he told Dr. Joselyn that his neck pain was exacerbated by driving to the appointment. He had limited bilateral range of motion in his neck. He saw the doctor in June 2014, reporting that he had used the weed eater the previous day and had arm pain. His medications were refilled. His condition was stable in July 2014.

         In August 2014, Martsolf reported having withdrawal effects when waiting 8 hours to take his dose of slow-release OxyContin, and asked to be changed back to regular OxyContin, which the doctor did. His Percocet was decreased. His medications were refilled at monthly visits from September 2014 through December 2014. At his December 2014 visit, Dr. Joslyn noted Martsolf had a stiff neck and limited range of motion to the left and right.

         2. Mental health treatment

         Martsolf saw a psychiatrist, Innocent Anya, M.D., about every three or four months from April 2011 to November 2014, and the doctor prescribed and adjusted medications at the visits. In April 2011, Dr. Anya diagnosed depressive disorder and anxiety disorder. In November 2011, Dr. Anya noted Martsolf was stable. From August 2012 to May 2013, Martsolf complained of trouble sleeping and the doctor made medication adjustments. At his May 2013 and August 2013 visits, Martsolf complained of financial stressors and inability to afford insurance. Dr. Anya noted in November 2013 that Martsolf was stable. In February 2014, Martsolf reported that he was doing fine on his current medication, although he had run out of it because he had lost his insurance. Martsolf's medications were adjusted in June and July 2014, and at an August 2014 visit, he reported that he was doing much better, and his medications were refilled. He reported a pretty good mood and that his anxiety was level at his November 2014 visit, and the doctor refilled his medications.

         B. Expert opinions

         Dr. Altomari, a state agency psychologist, reviewed Martsolf's records and opined that Martsolf had no severe mental impairment. The ALJ gave Dr. Altomari's opinion significant weight, noting it was supported by Dr. Anya's treatment records which ...

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