United States District Court, N.D. Alabama, Middle Division
MICHAEL E. VAUGHAN, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OF DECISION
DAVID PROCTOR UNITED STATES DISTRICT JUDGE.
Michael E. Vaughan (“Plaintiff” or
“Vaughan”) brings this action pursuant to
Sections 205(g) and 1631(c)(3) of the Social Security Act
(the “Act”), seeking review of the decision of
the Commissioner of Social Security
(“Commissioner”) to deny his claim for disability
insurance benefits (“DIB”) and Supplemental
Security Income (“SSI”). See 42 U.S.C.
§§405(g) and 1383(c). After careful review of the
record and the briefs submitted by the parties, the court
finds that the decision of the Commissioner is due to be
filed applications for DIB and SSI on April 10, 2015, and
March 15, 2016, respectively. (Tr. 49, 136, 249). Plaintiff
alleged disability beginning April 10, 2012. (Id.).
Plaintiff's claim was initially denied on August 12,
2015. (Tr. 70). After his application was denied, Plaintiff
filed a request for a hearing. (Tr. 75-76). On July 19, 2017,
Plaintiff received a hearing before Administrative Law Judge
(“ALJ”) Mary E. Helmer. (Tr. 29-45). On November
13, 2017, the ALJ determined that Plaintiff was not disabled
under Sections 216(i), 223(d), and 1614(a)(3)(A) of the Act.
16, 2018, the Appeals Council denied Plaintiff's request
for review of the ALJ's decision. (Tr. 1-3). Following
that denial, the final decision of the Commissioner became a
proper subject of this court's appellate review. See
Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986)
(finding the ALJ decision final for purposes of judicial
review when the Appeals Council denied review).
was forty-one years old both at the time of his hearing
before the ALJ, and when the ALJ's decision was rendered.
(Tr. 23, 136, 277). Plaintiff competed his GED, two years of
college, and CDL school. (Tr. 175, 320). He has previously
worked in the banking, lawn care, and distribution
industries. (Id.). These jobs included work as a
teller, landscaper, and material handler in a shipping and
receiving facility. (Tr. 32, 42, 160). In the spring of 2012,
Plaintiff was “let go” from his employment at a
shipping and receiving facility for failing to “make
production.” (Tr. 32). He has not regained employment
since his dismissal in 2012. (Tr. 37). He alleges he has not
been able to engage in substantial gainful employment since
March 4, 2015, when he “became unable to work due to
major depressive disorder with psychotic features,
post-traumatic stress disorder (PTSD), panic disorder with
agoraphobia, mood disorder, personality disorder, anxiety
disorder, and cervical and thoracic degenerative disc
disease.” (Doc. #13 at 4).
October 2012, Plaintiff began seeking treatment for back pain
at Med-Assist Doctors Group in Albertville, Alabama. (Tr.
283-84.). He sought pain management for thoracic and
lumbar back pain. (Id.). At the time, Plaintiff was
taking 180 pills of Lortab 10 each month. (Id.).
However, Plaintiff had never had an MRI of his spine.
(Id.). As a result, his treating physician, Dr.
Larry Johnston, M.D., informed him that he would not
prescribe Plaintiff a pain management regiment without
further imaging of his spine. (Id.).
February 2015, Plaintiff sought treatment at Marshall Medical
Center for injuries incurred as a result of a fall. (Tr.
290). He complained of mild pain to his mid-back and right
hand. (Id.). The treating physician, Dr. Lisa
Driskill, M.D., noted that Plaintiff had a painless range of
motion with no tenderness in his neck and a normal range of
motion with mild tenderness over the mid-thoracic spine. (Tr.
291). AP, lateral, and swimmers views of the thoracic spine
revealed no evidence of fractures, dislocation, or soft
tissue abnormality, and Plaintiff's thoracic vertebral
disc bodies and disc spaces were normal. (Id.)
Plaintiff was prescribed pain medication and a muscle
relaxant and was subsequently discharged. (Tr. 293).
March and April 2015, Plaintiff sought treatment numerous
times at Care Plus Family Medical, LLC in Albertville,
Alabama. (Tr. 303-05). He complained of neck and upper back
pain. (Tr. 305). Plaintiff was prescribed pain medication and
a muscle relaxant. (Tr. 306). Plaintiff subsequently sought
referral to an orthopedic specialist. (Tr. 303).
April 2015, Plaintiff was treated at the Orthopaedic Center,
P.C. by Dr. Vandana Maladkar, M.D., for neck and back pain.
(Tr. 311). After examination, Dr. Maladkar diagnosed
Plaintiff with neck pain with bilateral arm pain and thoracic
pain radiating into his chest wall. (Tr. 312). Subsequent
test results and MRI imaging revealed that he did have
“some straightening of the cervical spine and minimal
degenerative changes noted with mild disc desiccation.”
(Tr. 310). Further, Dr. Maladkar noted that there was
“some mild osteophytes and facet hypertrophy consistent
with arthritis.” (Id.). Dr. Maladkar discussed
treatment options with Plaintiff including
“anti-inflammatory, physical therapy and
epidurals.” (Id.). Plaintiff stated that he
would think about his treatment options and that he would
like something for pain in the meantime; however, Dr.
Maladkar responded that he does not prescribe pain
management, but he could refer Plaintiff to a pain clinic if
pain was an issue. (Tr. 310).
2015, Plaintiff underwent a psychological evaluation, which
was performed by Dr. Mary Arnold, Psy.D. (Tr. 318-19).
Plaintiff told Dr. Arnold that he started a pain management
methadone program on April 20, 2015 which requires a daily
commute to Huntsville, Alabama. (Id.). Dr. Arnold
noted that Plaintiff had a lengthy history of substance abuse
including use of Demerol, oxycodone, oxytocin, dilaudid,
heroin, and methamphetamine. (Tr. 320). Dr. Arnold also noted
Plaintiff's visits to Dr. Lachman, a psychiatrist;
however, no admission to a psychiatric unit had been
reported. (Id.). Further, Dr. Arnold also noted that
he displayed “no overt indicator of pain or
impairment” and that he was “passively compliant
and his demeanor [was] mellow.” (Id.). After
several cognition, information, thought processing, abstract
reasoning, and judgment tests, Dr. Arnold concluded that
Plaintiff's FSIQ was “estimated to be [in the] low
average range.” (Tr. 321).
June 19, 2017, Plaintiff was still undergoing treatment at
Huntsville Metro Treatment Center for a “chemical
dependency.” (Tr. 336). This treatment requires him to
receive a 220-milligram dose of methadone per day and serves
to “eliminate [Plaintiff's] illicit narcotics
cravings, prevents the onset of any withdrawal illness, and
serves to establish a blockade effect against other narcotic
use.” (Id.). As part of the program, Plaintiff
meets with a counselor once a month, at a minimum, and is
subjected to random mandatory drug screening. (Id.).
March 3, 2015, Plaintiff began being treated by Dr. Elizabeth
Lachman, M.D., a psychiatrist. (Tr. 326). From March 3, 2015
to July 21, 2017, Plaintiff was evaluated eighteen times by
Dr. Lachman. (Tr. 364-65). Dr. Lachman concluded that he had
“a history of severe and worsening mental symptoms of
serious mental illness as defined by DSM V, a further history
of polysubstance abuse and is [sic] the case of many
with a history of Bipolar I Disorder, and yet a further
history of chronic, severe, declining occupational, social
and personal functioning . . . .” (Tr. 325, 328, 364).
Dr. Lachman's official diagnoses included “Major
Depressive Disorder, Severe, Recurrent, With Psychotic
Features . . . Post Traumatic Stress Disorder . . . Panic
Disorder With Agoraphobia [and] Complicated
Bereavement.” (Id.). Dr. Lachman concluded:
Mr. Michael Eric Vaughan's psychiatric symptoms led to a
marked, severe, and sometimes extreme degree of impairment in
all areas related to occupational functioning. Mr. Michael
Eric Vaughan is unable to work an eight hour day or even a
four hour day. He is unable to perform routine work. He is
unable to work with colleagues appropriately and unable to
take orders from supervisors. He is unable to follow even
simple and certainly complex directions. He is unable to
adapt to changes in the work routine or the work environment.
He is unable to interact appropriately with the public.
(Tr. 327, 330, 365). Dr. Lachman determined that Plaintiff
was “unsafe and not able to function in the
occupational setting.” (Id.). Initially, Dr.
Lachman opined that Plaintiff was unable to work for
approximately 12-24 months; however, she subsequently altered
the duration to that “foreseeable future.”
August 2015, a non-examining state medical consultant, Dr.
Teresa Moran, M.D., determined that Plaintiff was able to
remember locations and work-like procedures. (Tr. 63). Dr.
Moran opined that Plaintiff was also able to remember very
short and simple instructions; however, Dr. Moran determined
that he was unable to remember those that are longer or more
complex. (Tr. 63-64). Dr. Moran determined that Plaintiff was
able to maintain activities within a schedule, interact with
the general public, ask simple questions or request
assistance, and maintain appropriate behavior in the
workplace. (Tr. 64-65). However, Dr. Moran opined that
Plaintiff had moderate limitations in these areas: being
distracted by others; maintaining a routine without a
supervisor; concentrating for ...