BERT W. MILLING, Jr., Magistrate Judge.
In this action under 42 U.S.C. § 405(g), Plaintiff seeks judicial review of an adverse social security ruling denying a claim for disability insurance benefits (Docs. 1, 11). The parties filed written consent and this action has been referred to the undersigned Magistrate Judge to conduct all proceedings and order judgment in accordance with 28 U.S.C. § 636(c), Fed.R.Civ.P. 73, and S.D.Ala. Gen.L.R. 73(b) (see Doc. 15). Oral argument was heard on November 23, 2015. After considering the administrative record, the memoranda of the parties, and oral argument, it is
This Court is not free to reweigh the evidence or substitute its judgment for that of the Secretary of Health and Human Services, Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11
At the time of the administrative hearing, Lee was twenty-nine years old, had completed a high school equivalency education (see Tr. 24; Doc. 11 Fact Sheet), and had previous work experience as a dishwasher, a roustabout, and a construction worker (Tr. 65, 76). Plaintiff alleges disability due to Bipolar Disorder, Schizoaffective Disorder, Major Depressive Disorder with Psychotic Features, Chronic Cannabis Abuse, and Chronic Poly-Substance Dependence (Doc. 11 Fact Sheet).
The Plaintiff protectively applied for disability insurance benefits on September 27, 2012, asserting a disability onset date of December 1, 2011 (Tr. 20, 181-82). An Administrative Law Judge (ALJ) denied benefits after determining that Lee met disability Listing requirements for Affective Disorders and Substance Addiction Disorders; the ALJ further found that if Plaintiff discontinued his drug use, he would be capable of working at specified jobs (Tr. 20-40). Plaintiff requested review of the hearing decision (Tr. 7-9), but the Appeals Council denied it (Tr. 1-5).
Plaintiff claims that the opinion of the ALJ is not supported by substantial evidence. Specifically, Lee alleges that: (1) The ALJ did not properly consider the opinions and diagnoses of his treating physicians; (2) the evidence does not support the ALJ's residual functional capacity (hereinafter RFC) finding; and (3) the ALJ did not properly develop the record (Doc. 11). Defendant has responded to—and denies—these claims (Doc. 12). The relevant evidence of record follows.
On August 22, 2011, Plaintiff went to West Florida Hospital with "the shakes," stating that he wanted to stop using drugs; his drug screen was positive for cannabinoids, benzodiazepines, and opiates (Tr. 475-93). He was discharged the next day.
On August 26, Plaintiff went to Lakeview Center, saying that he was suicidal after taking himself off of methadone; he had mood swings, was depressed, anxious, paranoid, and exhibiting obsessive behavior (having to touch everything with his finger) (Tr. 511-15). The Examiner noted Lee was oriented in four spheres, was of average intelligence, and had fair judgment.
On February 2, 2012, Plaintiff was seen at Tri County Medical Center for chronic, mild lumbar back pain, radiating occasionally to the neck; the Doctor noted scoliosis, by history, and anxiety and prescribed Tramadol
On April 2, Lee was admitted, for one night, to Atmore Community Hospital for a drug overdose; he tested positive for benzodiazepines, methamphetamines, amphetamines, and cannabinoids (Tr. 307-21). Plaintiff was noted to have a history of bipolar disorder, paranoid schizophrenia, and social anxiety.
On April 5, Lee went to Southwest Alabama Behavioral Health Care for individual therapy; he was anxious, delusional, sad, and suicidal with homicidal thoughts (Tr. 333-37, 343; see generally Tr. 324-43). Plaintiff had five more sessions through August 31, 2012 during which he voiced paranoia, anger, and thoughts of hurting someone; he was depressed and smoked marijuana to calm his nerves (Tr. 338-42).
On May 1, Plaintiff was seen at Tri County to get his prescriptions refilled and for anxiety and abnormal weight loss (Tr. 347-48). On September 4, 2012, Lee had normal range of motion (hereinafter ROM), with no noted joint tenderness or swelling; in addition to refilling his Xanax, the Doctor prescribed Flexeril,
On September 12, Lee was admitted to Baptist Hospital for six nights for depression and an overdose of multiple medications requiring intubation; he reported being anxious, paranoid, and having auditory hallucinations (Tr. 352-93). Plaintiff "was feeling up and down when he did not take his medications" (Tr. 353). A drug screen was positive for cannabinoids and benzodiazepines. At discharge, Lee was in no acute distress, had no formal thought disorder, and denied being suicidal, homicidal, or hopeless; he was prescribed an antidepressant and encouraged to follow-up with psychiatric protocols.
On September 19, Plaintiff went to Atmore Community Hospital Emergency Room after having what was thought to be a seizure as a reaction to one of his medications (Tr. 397-412, 621-29). He was given an antihistamine, monitored, and released.
On October 3, 2012, Lee went to Lakeview Center and was evaluated for his thoughts of committing suicide and homicide that was found to be low risk (Tr. 414-16, 633).
On October 23, psychiatric advanced registered nurse practitioner (hereinafter ARNP) Cheryl Pawloski examined Plaintiff, finding him irritable and having psychomotor agitation; he became angry when she indicated that he needed to quit taking the Xanax and threatened to find another provider (Tr. 417-19, 634-35). On November 2, Dr. Heather Rohrer examined Lee and prescribed Mobic,
On March 27, Lee went to the Atmore Community Hospital following a suicide attempt, his third, by taking twelve Zyprexa, twelve anti-depressants, a half bottle of Nyquil, and six Restoril
On March 29, Lee returned to Lakeview Center complaining of depression, auditory hallucinations, and feeling worthless, hopeless, helpless, and suicidal; he had smoked Marijuana and Spice the night before (Tr. 432-35, 640-644). The Examiner noted that Plaintiff had depressed mood and affect, poor judgment and insight, and fair attention and concentration. Thought content was depressed, angry, paranoid, and anxious while his thought process was delusional and circumstantial with auditory hallucinations. The next day, he was oriented in four spheres with limited insight and judgment; Lee expressed hatred toward random people, voicing ways of hurting them (Tr. 445-49, 645-46). Seroquel
On June 10, Plaintiff was admitted to West Florida Hospital for three nights after being off of his medications for two months; a drug screen was positive for cannabinoids and benzodiazepines (Tr. 521-53). At admission, Lee admitted being depressed and sad; Plaintiff began taking his medications while hospitalized and his depression, anxiety, and sleep improved. Discharge medications were BuSpar, Celexa,
On June 14, 2013, the day after being discharged, Lee returned to the Emergency Room at West Florida Hospital and was admitted to the Hospital for depression, suicidal ideation, and auditory hallucinations; he reported that he had not filled his prescriptions, so had not been taking them, after his previous discharge (Tr. 554-96). Plaintiff was discharged after three days in the hospital in improved condition.
On July 16, Lee reported to ARNP Pawloski that he was sad, depressed, irritable, and anxious; he reported that he was not smoking Marijuana and that that had helped (Tr. 452-53, 647-48). Plaintiff also reported that he was "so much better on his medications" (Tr. 452). He was oriented in four spheres with fair insight and judgment. Depakote
On September 6, Plaintiff went to Atmore Community Hospital ER to be treated for priapism (Tr. 608-20). He was transferred to Mobile Infirmary where he reported that he did not drink alcohol or use illicit drugs; he was treated with corporal irrigation and an injection with a decongestant (Tr. 649-55).
This concludes the Court's review of the evidence.
In bringing this action, Lee first asserts that the ALJ did not properly consider the opinions and diagnoses of his treating physicians. Plaintiff references Drs. Messina, Javellana, and Narahari (Doc. 11, pp. 4-5). It should be noted that "although the opinion of an examining physician is generally entitled to more weight than the opinion of a non-examining physician, the ALJ is free to reject the opinion of any physician when the evidence supports a contrary conclusion." Oldham v. Schweiker, 660 F.2d 1078, 1084 (5th Cir. 1981);
The ALJ faithfully reviewed the evidence of record, including that of the physicians on which Lee brings this claim. After doing so, the ALJ made the following findings with regard to the conclusions of those medical sources:
(Tr. 32).
Plaintiff has asserted that the evidence does not support the ALJ's RFC finding.
In his decision, the ALJ found that Plaintiff's impairments met the requirements of Listings 12.04 and 12.09 for Affective Disorders and Substance Addiction Disorders, respectively (Tr. 30). However, the ALJ went on to find that if Lee stopped his substance abuse, he would not still have an impairment or combination of impairments that would meet these Listing requirements (Tr. 33). Then the ALJ fashioned an RFC that set out Lee's capabilities, finding him capable of performing specific jobs (Tr. 35-39).
In bringing his first two claims, Plaintiff seemingly forgets that the medical record consists, almost exclusively, of his multiple substance abuse problems. During those rare periods of sobriety when Plaintiff following his prescribed medication regimen, Lee acknowledged he was doing much better (see Tr. 443, 452, 638). Those periods, however, were short-lived and are only barely reflected in the record. While treating physicians indicated debilitating mental impairments, those diagnoses were given while Plaintiff was abusing alcohol and drugs and failing to follow their advice. As noted by the ALJ, "[t]here have been no credible medical opinions in the record which indicate that the claimant has been disabled from all work or even has had limitations more stringent than those determined in this decision, absent drug abuse" (Tr. 36). This finding remains unrefuted.
Plaintiff next claims that the ALJ did not properly develop the record. More specifically, Lee argues that the ALJ should have ordered a consultative psychological examination (Doc. 11). The Eleventh Circuit Court of Appeals has required that "a full and fair record" be developed by the ALJ even if the claimant is represented by counsel. Cowart v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981). However, the ALJ "is not required to order a consultative examination as long as the record contains sufficient evidence for the [ALJ] to make an informed decision." Ingram v. Commissioner of Social Security Administration, 496 F.3d 1253, 1269 (11
The Court notes finds no merit in this claim. The more-than-three-hundred-pages of medical evidence in this record consists, almost exclusively, of medical personnel in the mental health arena counseling Plaintiff to quit taking drugs, quit drinking, take the medications prescribed, and follow through with the various therapies available to help him with his psychological/psychiatric problems. Adding another voice to the choir would be of no benefit under these circumstances.
Plaintiff has raised three different claims in bringing this action. All are without merit. Upon consideration of the entire record, the Court finds "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Perales, 402 U.S. at 401. Therefore, it is