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Pot Doc Down

Hany Youssef Assad, MD, who has approved cannabis use by some 40,000 patients over the past seven years, is having his license revoked by the Medical Board of California.  The board issued its order Oct. 23. Assad can no longer see patients after Nov. 23.

The state medical board is under the Department of Consumer Affairs.  It has 21 members, 12 of them MDs appointed by the governor for two- or four-year terms. The board is staffed by more than 100 career investigators —gun-carrying “peace officers” whose proper mission is to bust quacks and incompetents. The investigators act on complaints by patients —or made on behalf of patients by third parties— alleging improper treatment by a doctor. When the investigation of the doctor’s practice turns up serious infractions, a lawyer from the Attorney General’s office files an accusation and proposes disciplinary action. If the doctor chooses not to accept the punishment, he or she defends his or her practice standards at a hearing held by an Administrative Law Judge appointed by the board itself. (That’s right, the accuser employs the judge. Welcome to the world of regulatory law.)

The practice standards that must be adhered to by Assad and other doctors approving cannabis use in California nowadays were defined in a 2004 case involving Tod Mikuriya, MD, the most prominent clinician in the field.  In prosecuting Mikuriya the board employed as an expert witness a UCSF psychiatrist who had never once approved a patient’s use of cannabis. She opined that Mikuriya’s failure, in various cases, to conduct a physical exam and to keep adequate records, constituted “extreme departure from the standard of practice.”

Mikuriya’s expert witness was Philip A. Denney, MD, who at that time had monitored cannabis use by some 7,500 patients.  Denney reviewed Mikuriya’s files and concluded that in every case there was enough information to support a recommendation for treatment with cannabis. Every patient had told Mikuriya that they were successfully self-medicating. (“Conferring legitimacy is a cannabis consultant’s most important role,” Mikuriya himself testified.)

The Administrative Law Judge ruled against Mikuriya and the board promptly made its decision “precedential.”

NorCal Healthcare

Hany Assad has been operating a chain, “NorCal Healthcare,” with offices in Oakland, Ukiah, Bakersfield and Arcata. He employs nurse practitioners and physician’s assistants to examine patients. He flies from city to city in his own small plane, reviews records prepared by his aides, signs letters of approval, and addresses large groups of patients on the use of marijuana as medicine.

NorCal Heathcare is now up for sale. Interested parties should contact Assad’s lawyer, Tim Aspinwall, at the Nossaman firm in Sacramento. Seller strongly motivated.

News that Assad’s license was being yanked reached employees in his Oakland office on Monday, Oct. 26, causing consternation. A call to the medical board led to a policy decree: letters of approval issued by Assad post-Oct. 23 would be valid only through Nov. 23.  Some patients demanded refunds, others took the approval letters and went immediately to get ID cards that would be good for a year. (There are various kinds of ID cards. County-issued state cards can get you a pass from law enforcement. Privately issued cards get you past security at the dispensary door.)

NorCal staffers have been telling patients that new ownership is imminent and that other doctors will be taking Dr. Assad’s place —but it’s not known when, so please call back to make an appointment.

Assad is a tall man in his mid-50s with an eager-to-please manner. He was born and educated in Egypt, graduating from medical school in 1979.  He moved to the U.S. in 1992 and did a residency in Internal Medicine at Texas Tech University Medical School, then went to work for Kaiser Permanente in Vacaville.  When two women complained that Assad made sexual moves on them, the medical board filed an accusation. Assad, who says he was framed, accepted a probation deal from the medical board that barred him from treating female patients for seven years.

Assad began issuing cannabis approvals in October, 2003. He was employed initially by a dispensary operator in Oakland.  In July 2004 he launched NorCal, employing nurse practitioners and PAs to make possible a high-volume practice. He thus got around the ban on seeing women.

“He was trying to get away with as much as he could,” according to a healthcare worker who followed Assad’s career. He was reportedly seeing 30 or more new patients per day at the Oakland office alone, and issuing almost as many renewals. (Physicians usually specify that approvals expire after a year, but there is no legal obligation to impose a time limit.)

Assad’s downfall stemmed from his approval of cannabis use by SW, an 18-year-old (male) whom he diagnosed with Attention Deficit Disorder in February 2007.  The case was unusual in that Assad had examined SW himself. SW’s parents complained to the medical board. The ensuing investigation focused on whether Assad “departed from the ‘standard of practice’ in reaching his ADD diagnosis and cannabis recommendation (which does not require parental approval for patients over 18).  A hearing was held in August of this year, in Oakland, before Administrative Law Judge Mary-Margaret Anderson.

Phil Denney appeared as an expert witness for the defense but could not bring himself to say anything positive about Assad’s record keeping or his physical exam, which consisted of a handshake. Denney contended that an ADD diagnosis did not constitute an “extreme departure” from the standard of care, given the symptoms described by the patient, which included insomnia, stress, and Intermittent Explosive Disorder.  Denney also defended Assad’s decision not to notify SW’s regular doctor that he was issuing a cannabis approval. (SW did not want word getting back to his parents.)

Although Denney had treated some 20,000 medical cannabis users,  the judge assumed that  highest truth resided in the pages of journals funded by drug company ads.  “When asked about medical literature concerning the use of medical cannabis,” Anderson wrote in her opinion, “Denney was dismissive. He finds patient reports concerning efficacy to be more useful, in part because the political climate in the United States inhibits meaningful research… Dr. Denney’s opinionswere not very helpful.”

The judge had nothing but admiration for the prosecution expert,  Dr. Barbara Neyhart, an expensively coiffed member of the faculty at UC Davis who limits her clinical practice to women between the ages of 40 and 60. Neyhart has issued exactly one medical-marijuana recommendation during her career, “for an elderly patient with unremitting arthritic pain in both knees who requested the recommendaton.”

Anderson wrote that Neyhart’s “analysis was objective, thoughtful, and well grounded in the facts of this case and in her education and experience. Her explanations were consistent with the standard of practice. Accordingly, Dr. Neyhart’s opinions were persuasive and significantly informed the factual findings.” The judge was especially impressed by Neyhart’s citation of a study linking cannabis use to mental health problems in adolescence.

The ‘Script Mill Rationale

On one occasion in 2005 Hany Assad accepted Tod Mikuriya’s invitation to attend a quarterly meeting of a pro-cannabis doctors group. (The group is now known as the Society of Cannabis Clinicians).  Some of Mikuriya’s colleagues grumbled about Tod’s asking Assad, whose operation they characterized as a “script mill.”

In introducing himself to the group,  Assad said:

“I came from a family that disapproved of hashish. In Egypt, like here, the white collar class looks down on working people who use hashish. One day when I was a young man I moved some furniture and I was suffering for three or four days. I used to wonder how did movers —when I hired movers— how did they do that every day? I didn’t have the answer but now I have the answer. These blue collar are using hashish for pain every night so they can sleep and do the same thing the next day. Now I feel guilty that I was not very smart to think about that. There is no question in my mind that it is a good medication and a safe medication.”

Assad recalled that when working as a doctor in Dakahualia, a state in Eastern Egypt, “I never had to admit a patient for an overdose or withdrawal. The only time I was called to admit a patient was an overdose of hashish when the patient had overeaten and was constipated.” The remarkably benign safety profile of marijuana, Assad concluded, gave him courage him to recommend it readily. Way too readily, it turned out.

FRED GARDNER can be reached at plebesite.com. He edits O’Shaughnessy’s, the journal of cannabis in clinical practice.

 

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Fred Gardner is the managing editor of O’Shaughnessy’s. He can be reached at fred@plebesite.com

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