mh?FILED- STATE OF CALIFORNIA - . . MEDICAL CALIFORNI XAVIER BECERRA . - SACRAMENTO 'Ll .20 I A Attorney General of California 3! 1? v! JANE ZACK SIMON BY ANALYST Supervising Deputy Attorney General LAWRENCE MERCER Deputy Attorney General State Bar No. 111898 . 455 Golden Gate Avenue, Suite 11000 San Francisco, CA 94102-7004 Telephone: (415) 510-3488 Facsimile: (415) 703-5480 Attorneys for Complainant BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA In the Matter of the Accusation Against: .. Case No. 800-2017-030578 David H. Betat, M.D. . 2255CedarHillWay ACCUSATION Lakeport, CA 95453 Physician?s and Surgeon's Certi?cate No. 57755, Respondent. Complainant alleges: PARTIES l. Kimberly Rirchmeyer (Complainant) brings this Accusation solely in her of?cial capacity asthe Executive Director of the Medical Board of California. 2. On or about July 14, 1986, the Medical Board issued Physician's and Su'rgeon's Certi?cate Number 57755 to David H. Betat, MD. (Respondent). The Physician's and Surgeon's Certi?cate was in full force and effect at all times relevant to the charges brought herein I and will expire on April 30, 2020, unless renewed. JURISDICTION This Accusation is brought before the Board, under the authority of the following laws. All section references are to the Business and Professions Code unless otherwise indicated. 4. Section 2227 of the Code provides that a licensee who is found guilty under the Medical Practice Act may have his or her license revoked, suspended for, a period not to exceed 1. (DAVID H. BETAT, M.D.) ACCUSATION NO. 800-2017?030578 one year, placed on probation and required to pay the costs of probation monitoring, or such other . action taken in relation to discipline as the Board deems proper. I 5. Section 2234 of the Code, in pertinent part: states: ?_?The board shall take action against any licensee who is charged with unprofessional conduct. In addition to other provisions of this article, unprofessional conduct includes, but is not limited to, the following: i 'Violating or attempting to or indirectly, assisting in or abetting the violation of, or conspiring to violate any provision of this.chapter. GrOss negligence. I Repeated negligent acts. To be repeated, there must be two or more negligent acts.dr_ omissions; An initial negligent act or omission followed by a' separate and distinct departure from theapplicable standard'of care shall constitute repeated negligentaCts. I Aninitial negligent diagnosis followed by an act or omission medically appropriate for that negligent diagnosis of the patient shall constitute -a Single negligent act. When the standard of care requires a change in the diagnosis, act, or omissionthat constitutes the negligent act described in paragraph (1), including, but not limited to, a reevaluation of the diagnosis or a change in treatment, and the. licensee?s conduct departs from the applicable standard of Care, each departure constitutes a separate and distinct breach of the standard of care.? 6. Section 725, in pertinent part, states: Repeated acts of clearly excessive prescribing, furnishing, dispensing, or administering of drugs or treatment . . . as determined by the standard of the community of licensees is unprofessional conduct for a physician and surgeon .-. 7. section 2266 of the.Code states: failure of a physician and surgeon to maintain adequate and'accurate records relating to the provision of services to their patients constitutes unprofessional conduct.? FIRST CAUSE FOR DISCIPLINE (Gross Negligence/Repeated Negligent Acts/Excessive Prescribing) 2 (DAVID H. BETAT, MD.) ACCUSATION NO. 800-20_17-030578_ 10Respondent David H. Betat, MD. is subject to disciplinary action?under section 22347 and/or 223 4(b) and/or 2234(c) and/or 725 in that Respondent was grossly negligent and/0r committed repeated acts of negligence and/or prescribed excessively. The circumstances are as follows: 0 Patient 11 9. In 2009, Patient 1, a 31-year old male roofer, came under Respondent?s care and treatment for chronic low back pain. Respondent prescribed methadone,-10 mg, #120.2 In his interview with the Board?s investigator, Respondent stated that the patient had been started on methadone by a prior physician ?for at least a year.? Respondent also diagnosed the patient with depression, for which he prescribed Cymbalta, 60 mg.3 In 2010, Respondent added lorazepam4 to the patient?s medications. 10. Respondent?s records for Patient 1 are brief, routinely lack signi?cant discussion of the patient?s complaints, his respOns'e to treatment or the rationale for prescribing. Depo- testosteroneexample, was presumably prescribed for opiate?induced hypogonadism, but Respondent?s records do not discuss either the medical indication or the patient?s response. Similarly, diazepams, 10 mg, #30, is prescribed in May 2013, without any discussion of the medical indication for its use or the rationale for adding another benzodiazepine to the patient?s existing regimen of opiates and benzodiazepines. In his interview with the Board?s investigator, Respondent stated that he discussed the risks with Patient 1 and warned him not to take lorazepam and diazepam together, but this is not documented in his records. 1 Patients? names are redacted to protect privacy. 2 Methadone hydrochloride IS a controlled substance and an opioid indicated for the treatment of pain severe enough to require around?the?clock long?term opioid management and for which alternative treatments have failed.? Methadone exposes users to the risks of opioid addiction, misuse and abuse, which can lead to overdose and death. 3'Cymbalta IS a trade name for duloxetine, a selective serotonin and norepinephrine reuptake inhibitor used for treating depression, anxiety disorder and pain. 4,Lorazepam which' 13 marketed under the trade name Ativan, is controlled substance and a benzodiazepine used to treat anxiety, among other conditions. Benzodiazepines, when taken 1n conjunction with opiates, increases the risk of respiratory arrest. 5Diazepam, which Is marketed under the trade name Valium, is a controlled substance and benzodiazepine used to treat anxiety. When taken in conjunction with opiates, it can increase the risk of respiratory arrest. 3 . (DAVID H. MD.) ACCUSATION NO, 800?2017-030578 ?.28 11. Patient 1 developed tolerance to methadone and his dosage increased to as much as 120 mg/day, which he then sought to taper. As of October, 2013, the patient?s medications included methadone, 10 mg, #120, diazepam, 10 mg, lorazepam, 1 mg, #60 and . hydrocodonei 10/325 mg, #60. 12. On October 5, 2013, Patient 1 died. The Coroner listed ?Polypharmacy (diazepam, methadone, hydrocodone)? as the probable cause of death. 13. In and before 2015, and continuing through June 2017, Patient 2, a 46?year old male with a history signi?cantfo'r multiple abdominal surgeries and chronic pain, was under Respondent?s care for chronic pain management. During this time, Respondent prescribed methadone, 10 mg, and oxycodone7, 30mg, for long-acting and short-acting pain relief.-A1though the plan documented in Respondent?s records Was for 300 tablets/month methadone and 120 1 tablets of oxycontiri, Respondent?regularly prescribed-far in excess of the planned amount of methadone such that, between 2015 and 2017, the patient would receive from 500 to more than 1,000 tablets in a month. Moreover, the amount prescribed did not correlate to the patient?s documented pain complaints, with some additional prescriptions being written at times thatthe patient reported feeling better. Although Respondent?s records- stated that the patient ?admitted 'to taking extreme amounts of methadone per day,? it was stated that the patient?s ?nances would not permit a change of opiate "medication. Respondent also noted that the patient Was utilizing multiple'pharmacies to obtain additional amounts of opiates and, although at one point in time Respondent restricted the patient to a single pharmacy, Respondent continued to prescribe the opiate medication in high doses. It was only when Respondent closed his privatepractice that? Patient 2 was referred to a pain specialist for management of his chronic pain. 6 Hydrocodone bitartrate and acetaminophen, also marketed under the trade name Norco, is a controlled substance and a short-acting opiate medication. When taken in combination with a long?acting opiate, such as methadone, and benzodiazepines, hydrocodOne 1ncreases the risk of respiratory arrest. 7Oxycodone is a narcotic analgesic with multiple aetions similar to those of morphine. Oxycodone is a controlled substance and is available 1n combination with other drugs or alone. It can produce drug dependence and, therefore has the potential for being abused. _4 (DAVID H. BETAT, NO. 800-2017-030578. La21VPatient 3 14. In and before 2015, and continuing through June 2017, Patient 3, a 51-year old female, was under Respondent?s care and treatment for myofascial pain and mild degenerative arthritis. Respondent prescribed mg, #120, and hydrocodone bitartrate/acetaminophen, 10/325 mg, #120, for management of Patient 3?s chronic pain. Beginning in or about April 2016, Respondent added Baclofeng, 10 mg, #120, to the patient?s medication regimen. Respondent did not chart the medical indication or rationale for. utilizing a combination of two short-acting opiates and a muscle relaxant, nor did he document his discussion of the risks of this drug combination with the patient. Patient 4 15. Patient 4, a 54-year old male with a history signi?cant for? Bipolar Disorder, chronic pain treated With high dose opiates and chronic obstructive pulmonary disease (COPD). Beginning in or about January 2015 Patient 4 complained of feeling tired and his mother, who accompanied him to his appointment on January. 20, 2015, reported that he looked yellow to her._ No additional history regarding the patient?s fatigue or the mother?s report of a jaundiced appearance was recorded and the objective ?ndings in the record for the visit were identical to three previous visits, which suggests that the ?ndings were simply carried forward from prior visits. Although the patient had, chronic COPD and recurrent pneumonia, his lungs were reported to be clear, with no rales or wheezes, as had been the ?nding on every prior visit. Respondent did not order any lab tests or otherWise assess the new complaint of'fatigue. On June 8, 2015, Patient 4 reported left lateral pain over the upper abdomen and ribs. Respondent noted tenderness to the area, but did not further describe or investigate the new complaint. On July 6, Patient 4 returned, complaining of left sharp pain, which was made worse with taking deep breaths. The patient was noted to be very drowSy and he reported that he had been unable to sleep at night. The objective. ?nding from the prior Visit was carried forward in the note of the visit, but no further description 8 Baclofen is a muscle relaxant that may potentially have adverse reactions, including drowsiness. When Baclofen is taken in combination with opiate medications, the risk of respiratory depression and hypotension is increased. . - 5 . - (DAVID H. BETAT, MD.) ACCUSATION NO. 800-20?17-030578 4;wa540. was stated and no diagnostic or lab tests were ordered. The patient? 5 lungs were again reported to be clear. Respondent discharged the patient from his care for illicit drug use. 16. On July 13, 2015, Patient 4 was seen in the local emergency room with complaints of shortness of breath over the previous 8 or 9 days. A chest Vx-ray showed a patchy consolidation in the right upper lobe. A CT scan identi?ed a number of lesions 1n the lung and 1n the liver. Lab studies showed signi?cant elevated alkaline phOsphatase (3 82), elevated AST (115), anemia, elevated bilirubin (1. 3) and abnormal creatinine (1.20). Patient 4 was diagnosed with metastatic cancer and died on July 25, 2015. A Patient 5 17. Patient 5, a 70-year old man with COPD had been prescribed morphine sulfate9 as well as other opiates and sedative hypnotics for an extended period. In 2013, Patient 5 was receiving prescriptions from another physician until'March, when Respondent recommenced prescribing to him. On March 19, 2.013, Respondent noted that the patient ?feels tired a lot. ?feels week. overmedicated by opiates?? Nevertheless, Respondent prescribed a full month supply of the patient?s opiate medications. On April 17, 2013, Respondent carried forward the patient?s past complaints of fatigue, as well as the possibility that the patient was overmedicated; however, Respondent did not alter his prescribing. Patient 5 died on April 21, 2013, of cardiorespiratory arrest. 18. On March 19, 2013, when Patient 5? wife raised the concern that he was overmedicated, Respondent obtained and recorded an abnormal oxygen saturation level of 87%. He also noted ?crackles? in the right lower base of the lungs. Respondent did not record. the patient?s respiratory rate. DeSpite these abnormal ?ndings, Patient 5?s COPD was stated to be stable. On April 17, 2013, Abnormal ?ndings in the lung continued, as did the patient?s complaints of fatigue. Neither an oxygen saturation level nor a reSpiratory rate was obtained. 9 Morphine sulfate is a controlled substance and a potent opioid intended for the management of pain severe enough to require daily, around-the-clock, long?term opioid - management and for which alternative treatment options are inadequate. Morphine sulfate tablets expose patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. 6 (DAVID H. ACCUSATION 800-2017-0305-78 43~Although the patient was hypertensivewith a blood pressure of 152798, the assessment stated that he was ?normotensive, in no acute distress.? Patients 1 through 5 l9. Respondent IS guilty of unprofessional conduct and Respondent?s certi?cate IS subject to disciplinary action based on his gross negligence, repeated negligent acts and/or excessive prescribing as set forth above and including, but not limited to, the following: I A. Respondent prescribed exceSsively and/or inappropriately to Patients 1 through 5; B. Respondent failed to follow up appropriately on acute changes 1n Patients 4 and 5. SECOND CAUSE FOR DISCIPLINE- (Failure to Maintain Adequate and Accurate Records) 20. Complainant incorporates the allegations of the First Cause for Discipline as though fully set out here. Respondent is guilty of unprofessional conduct and Respondent?s certi?cate is subject to disciplinary action for violation of Section 2266 of the Code for failure to keep adequate and accurate medical records, including but not limited to the following de?ciencies. 21. In addition to- the patients described 1n the First Cause for Discipline, complainant alleges that Patient 6, a former landscaper, was under Respondent?s care for chronic pain management. As with the other patients, Respondent?s records for Patient 6 are inaccurate and/or . omit important information about the patient?s vital signs or how abnormal ?ndings were managed. As with the other patients, high blood pressure readings were described as. ?normotensive? on sOme occasions, while no reading was obtained on other occasions, yet the patient wasstill described as norrnotensive. 22. Respondent?s records regularly lacked a description of the condition' in question as well as supportive facts, such as palliative or provocative factors, quality, quantity, region, radiation, severity at timing._ I 23. I Respondent?s-records regularly- stated that a medication had been prescribed or re?lled for the patient, but did not state the medical indication or rationale for the prescription or re?ll. 7 1 (DAVID l-l. BETAT, MD.) ACCUSATION NO. 800-2017-030578 ?17WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged, and that following the hearing, the Board lssue a decision: 1. Revoking or suspending Physician's and Surgeon? 3 Certificate Number 57755, issued to David H. Betat, . 2. Revoking, suspending or denying approval of Betat, M.D.'s authority to supervise physician assistants and advanced practice nurses; 3. Ordering David H. Betat, D. ,if placed on probation, to pay the Board the costs of probation monitoring; and Taking such other and further action as _deemednecessary and proper. DATED: August 21. 2018 . KIMBERLY K1 CHMEYER Executive Direc Medical Board of California State of California Complainant SF2018201058 21199820.doc 8 (DAVID H. BETAT, MD.) ACCUSATION NO. 800-2017-0305'78