The opinion of the court was delivered by: Hon. Jeffrey T. Miller United States District Judge
ORDER (1) GRANTING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT [DOC. NO. 11] (2) DENYING DEFENDANT'S CROSS-MOTION FOR SUMMARY JUDGMENT [DOC. NO. 16], AND (3) REMANDING CASE FOR FURTHER PROCEEDINGS
Plaintiff Jeff Coleman ("Plaintiff") seeks judicial review of Defendant Social Security Commissioner Michael J. Astrue's ("Defendant") determination that he is not entitled to disability insurance and supplemental security income benefits. The parties have filed cross-motions for summary judgment. Pursuant to 28 U.S.C. § 636(b)(1)(B) and Civil Local Rule 72.1(c)(1)(c), the motions were originally referred to Magistrate Judge Jan M. Adler for a Report and Recommendation. The Court hereby withdraws the referral and finds these matters suitable for determination.
As set forth below, the Court GRANTS Plaintiff's motion for summary judgment, DENIES Defendant's cross-motion for summary judgment, and remands the case for further proceedings.
Plaintiff filed an application for disability insurance benefits on or around June 3, 2005 alleging a disability onset date of January 1, 2002. (Admin. R. at 15, 72-74.) Plaintiff also protectively filed an application for supplemental security income on April 29, 2005. (Id. at 15, 487-89.) Plaintiff's disability claim was denied initially on July 25, 2005, and again upon reconsideration. (Id. at 61-71.) Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). Administrative hearings were conducted on November 20, 2006 and January 18, 2007 by ALJ James S. Carletti, who determined that Plaintiff was not disabled. (Id. at 15-23.) Plaintiff requested a review of the ALJ's decision; the Appeals Council for the Social Security Administration ("SSA") denied Plaintiff's request for review on May 24, 2007. (Id. at 8-10.) Plaintiff then commenced this action pursuant to 42 U.S.C. § 405(g).
Plaintiff was born on June 15, 1956. (Id. at 72.) He has previously worked as a grocery store bagger, molder at a manufacturing plant, customer service representative, stock person, and production mechanic. (Id. at 102.) Plaintiff has never been married and does not have any children. (Id. at 72, 224.) He lives with his older brother, James Coleman, in a trailer inherited from their mother, in a senior trailer park community. (Id. at 273.)
Dr. Joel Juarez Uribe, Sharp Healthcare Chula Vista Plaintiff was seen at Sharp Healthcare in March and June 2002 for hypertensive cardiovascular disease, high blood pressure, anxiety, hyperlipidemia (elevated level of lipids in blood), and chronic obstructive pulmonary disease. (Id. at 173-76.) A chest CT scan taken in July 2002 was unremarkable. (Id. at 177.)
South Bay Guidance Center - Treating Psychiatrist (2003)
Plaintiff was first seen at the South Bay Guidance Center in March 2003 at the referral of his primary care physician. (Id. at 260.) He reported that he started drinking alcohol and using marijuana at the age of 11, used speed at age 14, and sold speed in high school. The peak of his substance abuse was in the mid-1980s. He stated that he had been clean for five years. He complained of anxiety, worry, hopelessness, helplessness, fear of relapsing, depressed mood, and fear of being unable to care for his elderly mother, with whom he then lived. (Id.) His primary care doctor had prescribed Paxil and Diazepan (Valium); he was not satisfied with the Valium and had finished the bottles early.
Plaintiff was instructed to discontinue the Valium, and was prescribed Buspar (for anxiety) and Klonopin (a benzodiazepine used to produce a calming effect). (Id. at 259.)
San Ysidro Health Center - Treating Physician(s) (2004) Plaintiff was seen at the San Ysidro Health Center during the early part of 2004. (Id. at 321-36.) In February 2004, he admitted that he had been taking more Klonopin than he should but stated that his anxiety had been overwhelming. (Id. at 324.)
His physician agreed to fill the prescription but warned Plaintiff that all further refills had to come from his psychiatrist. (Id.) The following month, Plaintiff complained of pain in both legs and feet. (Id. at 323.) In April 2004, he had an anxiety attack and reported that he had been discharged from treatment at the South Bay Guidance Center. (Id. at 322.) The doctor discovered that Plaintiff had been discharged for misuse of "benzo" (benzodiazepine) and that he exhibited symptoms of benzo withdrawal. (Id.)
Alvarado Hospital (December 31, 2004 - January 2, 2005)
Plaintiff was admitted into Alvarado Hospital between December 31, 2004 and January 2, 2005 with complaints of a panic attack and tachycardia (rapid heartbeat). (Id. at 179.) He had been trying to enter a detoxification facility but was shaky and had a fever so was taken to the hospital. (Id. at 183.) Plaintiff was diagnosed with pneumonia. (Id. at 179.) He was also found to have an elevated level of alcohol in his body.
at 179.) He reported that he drank one quart of alcohol daily and that his last drink had been the previous morning.
at 185.) He discharged himself from the hospital without telling any of the medical staff. (Id. at 179.)
Scripps Memorial Chula Vista (January 2005)
The day after walking out of Alvarado Hospital, Plaintiff presented to the emergency room at Scripps Memorial Chula Vista with complaints of chest pain, shortness of breath, shakes, and jitters. (Id. at 223.) He explained that he had left Alvarado Hospital against medical advice as he felt he had been receiving poor care there. (Id.) He advised that he had been hospitalized for alcohol and drug use numerous times in the past, and admitted to drinking one quart of whiskey or other heavy alcohol per day.
at 224.) Plaintiff was treated for his pneumonia and released. (Id. at 229.)
San Ysidro Health Center - Treating Physician(s) (2005)
Plaintiff admitted to increased alcohol consumption and requested medication for anxiety during a visit to the San Ysidro Health Center in early 2005. (Id. at 320.) He was given a trial prescription of Zoloft, but elected to take Paxil instead. (Id. at 319-20.) He complained of headaches, as well as joint, muscle, knee and back pain. (Id. at 317-18.) X-rays taken in April 2005 showed mild degenerative changes in both knees and an old compression fracture at L3. (Id. at 212-14, 316.) Plaintiff was referred to physical therapy, which he attended from May to June 2005. (Id. at 206-11, 256-58, 316.) Bilateral knee x-rays taken in June 2005 showed only minimal patella spurring. (Id. at 371.)
Plaintiff continued to be seen during 2005 for chronic low back pain, for which he was prescribed a fentanyl patch and given referrals for pain management, an orthopedic evaluation, and physical therapy. (Id. at 309-11, 313-15.)
UCSD Medical Center (2005)
Plaintiff underwent an orthopedic consultation in September 2005 at the UCSD Medical Center in Hillcrest for his low back pain. (Id. at 384-86.) He described his pain as aching and stated that he had injured his back after falling off of a truck in 1995. (Id. at 385.) Although he had previously been able to manage his pain with various medications, including Vicodin and Fentanyl patches, his pain had gotten progressively worse. (Id.) After Dr. Yo-Po Lee, an orthopedic surgeon, discussed the risks and benefits of surgical intervention, Plaintiff advised that he was not interested in surgery. (Id.) Dr. Lee referred Plaintiff to a pain management physician.
Plaintiff visited the UCSD Pain Clinic the following month and saw Dr. Albert Y. Lung. (Id. at 383-84.) Plaintiff described his back pain level as 8 on a scale of 10, but declined having any radiating pain into his legs. (Id. at 383.) Dr. Lung reviewed Plaintiff's lumbar MRI findings from August 26, 2005 and opined that Plaintiff's low back pain was probably being caused by the L3 compression fracture. (Id. at 383-84, 467-68.) Dr. Lung indicated that there was nothing the Pain Clinic could offer Plaintiff to treat his pain, and recommended that Plaintiff see Interventional Radiology for vertebroplasty, a surgical treatment, for pain relief. (Id. at 384.)
South Bay Guidance Center - Treating Psychiatrist (2005)
Plaintiff returned to the South Bay Guidance Center in April 2005 and was seen by Dr. Alexander Papp. (Id. at 255.) He reported that he was feeling "worse again" because his brother had been pressuring him to look for a job. He advised that he had last worked a year previously, and was let go from a box boy job at Vons after a 60 day trial period. (Id.) Plaintiff advised that his brother was supporting him and that this created tension between the two of them. Plaintiff's medications included Trazodone (for insomnia), Klonopin (for agitation), Depakote (for mood swings), and Effexor (for anxiety and agoraphobia). Plaintiff requested that his dosage of Klonopin be doubled, but Dr. Papp declined to do so due to Plaintiff's prior history of drug abuse. (Id.) Dr. Papp switched Plaintiff to Effexor for his anxiety and agoraphobia as Paxil CR was no longer on the market. (Id.)
Dr. Papp indicated that Plaintiff's diagnoses included depressive disorder in partial remission and polysubstance abuse in remission, and questioned whether Plaintiff had bipolar traits. (Id. at 240.) In later visits in 2005, Dr. Papp noted that Plaintiff was less nervous outside of the home, had occasional tearfulness when he thought about his mother, who had recently passed away, and was having trouble sleeping. (Id. at 244-48.) Plaintiff continued having serious conflicts with his brother and also had a falling out with his AA sponsor. (Id. at 242-45, 357-62.)
Dr. Sandra Eriks, Seagate Medical Group -Examining Physician (2005)
Plaintiff underwent an internal medicine evaluation with Dr. Sandra Eriks of Seagate Medical Group on December 19, 2005 at the request of the Department of Social Services. (Id. at 268-71.) Plaintiff reported that he lived with his brother and that they supported themselves on his brother's Social Security Disability.
at 269.) Dr. Eriks observed that Plaintiff was "somewhat somnolent" and "very slowed," which she attributed to the use of high-dose narcotics. (Id. at 271.) She reported that Plaintiff had a long-standing history of low back pain, and opined that Plaintiff had the residual functional capacity ("RFC") to lift and carry 20 pounds occasionally and 10 pounds frequently, stand and/or walk 2 hours out of an 8 hour day, and sit for 2 hours out of an 8 hour day. (Id.)
Dr. Jaga Nath Glassman - Examining Psychiatrist (2005)
Plaintiff received a psychiatric disability evaluation from Dr. Jaga Nath Glassman on December 23, 2005 at the request of the Department of Social Services. (Id. at 273-77.) Plaintiff explained that he had last worked in 2001 at Vons, and that he was let go after two months because he "didn't fit in" in terms of "the mental aspects." (Id. at 273.) Plaintiff stated that he felt incapable of ...