Wayne A. Porretti v. JAMES DZURENDA, Nevada State Prison Director

FOR PUBLICATION
UNITED STATES COURT OF APPEALS
FOR THE NINTH CIRCUIT
W AYNE A. PORRETTI ,
Plaintiff-Appellee,
v.
J AMES DZURENDA, Nevada State
Prison Director; LINDA FOX , Nevada
Director of Pharmacy; BRIAN
W ILLIAMS , Warden; BOB FAULKNER ;
RIO M ANALONG ; FRANCIS OAKMAN ;
PERRY R USSELL ; ALBERTO
BUENCAMINO ,
Defendants-Appellants.
No. 20-16111
D.C. Nos.
2:17-cv-01745-
RFB-DJA
2:17-cv-02403-
RFB-NJK
OPINION
Appeal from the United States District Court
for the District of Nevada
Richard F. Boulware II, District Judge, Presiding
Submitted March 17, 2021*
San Francisco, California
Filed August 30, 2021
* The panel unanimously concludes this case is suitable for decision
without oral argument. See Fed. R. App. P. 34(a)(2).

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2 PORRETTI V. DZURENDA
Before: Mary H. Murguia and Morgan Christen, Circuit
Judges, and Joan H. Lefkow,** District Judge.
Opinion by Judge Murguia
SUMMARY***
Prisoner Civil Rights
The panel affirmed the district court’s preliminary
injunction requiring prison officials to provide plaintiff
certain medication while incarcerated.
Plaintiff received Wellbutrin and Seroquel for his serious
mental illnesses before he was incarcerated in Nevada and
after he entered into the custody of the Nevada Department
of Corrections (“NDOC”). In 2017, without the
recommendation of a health-care provider, NDOC stopped
providing plaintiff his medication because of a new
administrative policy.
The panel held that the district court did not abuse its
discretion in issuing a preliminary injunction that required
Defendants to provide Wellbutrin and Seroquel to treat
plaintiff’s serious mental illnesses. The panel held that the
district court carefully applied the preliminary-injunction
factors and rendered highly detailed factual findings that
** The Honorable Joan H. Lefkow, United States District Judge for
the Northern District of Illinois, sitting by designation.
*** This summary constitutes no part of the opinion of the court. It
has been prepared by court staff for the convenience of the reader.

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PORRETTI V. DZURENDA 3
rejected opinions from Defendants’ experts for reasons
grounded in the record evidence.
Thus, the district court did not err in determining that
plaintiff’s Eighth Amendment claim was likely to succeed
on the merits and that he would suffer irreparable harm in
the form of “very serious or extreme damage to his mental
health” if injunctive relief were not granted. The panel
further found no abuse of discretion in the district court’s
determination that plaintiff’s severe and persistent psychotic
symptoms overwhelmingly outweighed Defendants’
financial or logistical burdens in providing Wellbutrin and
Seroquel; and that an injunction was in the public’s interest
because prisons must comply with the standard of care
mandated by the Eighth Amendment. Considering
Defendants’ actions, the district court did not render any
illogical, implausible, or unsupported factual finding.
COUNSEL
Aaron D. Ford, Attorney General; D. Randall Gilmer, Chief
Deputy Attorney General; Frank A. Toddre II, Senior
Deputy Attorney General; Office of the Attorney General,
Las Vegas, Nevada; for Defendants-Appellants.
Jason C. Makris, Makris Legal Services LLC, Las Vegas,
Nevada; Samuel Weiss, Rights Behind Bars, Washington,
D.C.; for Plaintiff-Appellee.

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4 PORRETTI V. DZURENDA
OPINION
MURGUIA, Circuit Judge:
This case involves Plaintiff-Appellee Wayne Porretti’s
Eighth Amendment right to receive adequate medical care
while incarcerated. Porretti received medication to treat his
serious mental illnesses long before he was incarcerated in
Nevada. Without the recommendation of a health-care
provider, the Nevada Department of Corrections (“NDOC”)
stopped providing Porretti his medication because of a new
administrative policy. Porretti sued and the district court
issued a preliminary injunction requiring the NDOC to give
Porretti his medication. We hold that the district court did
not abuse its discretion in issuing the preliminary injunction.
I.
A.
Wayne Porretti, a sixty-two-year-old man, is currently
incarcerated at High Desert State Prison in Nevada. Porretti
has suffered from serious mental illnesses—Tourette’s
syndrome, depression, obsessive-compulsive disorder,
personality disorder, and paranoid schizophrenia—
throughout his life. Porretti’s mental illnesses have caused
him to attempt suicide and to suffer psychotic symptoms,
including compulsive ingestion of metal objects like razor
blades, paranoid delusions, auditory hallucinations, and
verbal tics.
Porretti asserts that, beginning more than twenty years
ago, his doctors prescribed several different anti-psychotic
or anti-depressant medications to treat his mental illnesses.
But Porretti suffered serious side effects from almost every
medication that his doctors prescribed. The side effects

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PORRETTI V. DZURENDA 5
included growing male breasts, twitching, jerking, and
swelling of his tongue to the point that he could not talk.
Porretti’s doctors eventually found a combination of
medication that helped treat Porretti’s mental illnesses
without producing the serious side effects: Wellbutrin (an
anti-depressant medication) and Seroquel (an anti-psychotic
medication).
Because the NDOC’s medical staff agreed that
Wellbutrin and Seroquel were appropriate to treat Porretti’s
mental illnesses, they continued to provide those two
medications to Porretti after he entered the NDOC’s custody.
In May 2017, however, the NDOC stopped providing
Wellbutrin and Seroquel to Porretti because of a new
“administrative policy” and without any recommendation
from a health-care provider. According to the NDOC, the
administrative policy discontinued the distribution of
Wellbutrin and Seroquel because the two medications could
be abused in prison. Porretti contends, however, that the
administrative policy discontinued the distribution of
Wellbutrin and Seroquel solely because of financial reasons.
After May 2017, the NDOC’s medical staff instead
offered medication that caused Porretti to experience serious
side effects. Porretti therefore found himself with an
untenable choice: Take the NDOC’s medication and suffer
from serious physical side effects or take no medication and
suffer from severe psychotic symptoms.
B.
In June 2017, Porretti sent a pro se complaint to the
United States District Court for the District of Nevada,
naming several prison officials (collectively, “Defendants”)
and alleging violations of his Eighth and Fourteenth
Amendment rights to be free from cruel and unusual

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6 PORRETTI V. DZURENDA
punishment.1 Porretti experienced years of hurdles in this
litigation, starting with the filing of his pro se complaint.
Although Porretti sent the complaint to the district court in
June 2017, he did not have sufficient funds to pay the federal
filing fee. This resulted in the district court sending
instructions and an application for Porretti to proceed in
forma pauperis (“IFP”). But Porretti failed on multiple
occasions from June 2017 to September 2017 to send a
proper IFP application to the district court.
In March 2018, the district court deferred ruling on
Porretti’s most recent IFP application and ordered the Clerk
of Court to file Porretti’s complaint. The district court then
dismissed Porretti’s complaint without prejudice because he
failed to adequately plead a federal or state claim. In April
2018, Porretti filed a first amended complaint, but the district
court dismissed it for similar reasons in September 2018.
The operative second amended complaint was filed in
September 2018. From June 2017 to September 2018, while
attempting to litigate his case, Porretti received neither
Wellbutrin nor Seroquel.
1.
On January 8, 2019, Porretti sent a letter to the district
court because he was still receiving neither Wellbutrin nor
Seroquel. In that letter, Porretti stated that his treating
psychiatrist at High Desert State Prison, Dr. Carla Carroll,
told him that Wellbutrin and Seroquel were appropriate
treatments but not available in light of the NDOC’s new
administrative policy. The district court construed Porretti’s
1 Defendants include James Dzurenda, Alberto Buencamino, Bob
Faulkner, Linda Fox, Rio Manalang, Francis Oakman, Perry Russell, and
Brian Williams.

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PORRETTI V. DZURENDA 7
letter as a motion for a preliminary injunction that would
require Defendants to treat him with Wellbutrin and
Seroquel.
The district court held a motion hearing on January 18,
2019. During that hearing, Porretti moved the district court
to appoint an independent psychiatrist to examine him
pursuant to Federal Rule of Evidence 706. Instead of ruling
on the Rule 706 motion prematurely, the district court took
that motion under advisement and continued the motion
hearing until late January 2019. The district court requested
that Porretti’s treating psychiatrist at High Desert State
Prison, Dr. Carroll, testify before the district court to explain
Porretti’s current treatment and diagnosis. The district court
ordered that Dr. Carroll receive Porretti’s medical records so
that she could opine as to whether Porretti needed Wellbutrin
and Seroquel.
Dr. Carroll appeared before the district court via
videoconference on January 29, 2019. She testified that she
had visited Porretti only once and that the one visit occurred
via videoconference in November 2018. Dr. Carroll
admitted that the NDOC stopped providing Wellbutrin and
Seroquel to Porretti because of an administrative policy, not
because of any medical recommendation. Dr. Carroll
opined, however, that Porretti no longer needed Wellbutrin,
Seroquel, or any medication at all. The district court
inquired how Dr. Carroll could reach that medical
conclusion even though Porretti’s psychiatrists—and the
NDOC’s psychiatrists—had treated Porretti with medication
for decades. Dr. Carroll responded that the previous
psychiatrists who treated Porretti did not have access to the
“wealth of information” that she reviewed in preparation for
the district court’s hearing. Dr. Carroll reviewed only

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8 PORRETTI V. DZURENDA
Porretti’s medical records. She opined that Porretti was
malingering.
In April 2019, the district court issued an order deeming
Dr. Carroll’s testimony not credible. The district court
explained that Dr. Carroll examined Porretti once over
multiple years, that the one visit was short in length and
conducted over videoconference, and that her medical
conclusion contradicted that of multiple psychiatrists who
had treated Porretti with medication for decades. The district
court concluded that Dr. Carroll—an NDOC employee—
created a medical opinion tailored to support Defendants’
litigation position.
In the same April 2019 order, the district court ordered
each party to select a psychiatrist to conduct an independent
examination of Porretti. This would allow the district court
to have a more fully developed record before ruling on
Porretti’s motion for a preliminary injunction. The district
court mandated that each psychiatrist provide a written
medical report addressing the following topics:
a) [Porretti’s] current diagnosis including a
review of his medical history; b) whether
[Porretti’s] prior prescriptions for Wellbutrin
and Seroquel are medically necessary given
his current diagnosis; c) the existence and
efficacy of potential alternative medications
and/or treatments; and d) requirements for
[Porretti’s] future care.
Porretti was appointed pro bono counsel and chose
Dr. Norman Roitman as his psychiatrist. Dr. Roitman had
examined Porretti more than fifteen times since 2004.
Defendants chose Dr. Wade Exum, who—although not
technically an NDOC employee—is a contractor whose

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PORRETTI V. DZURENDA 9
medical practice consists only of NDOC prisoners.
Dr. Roitman and Dr. Exum both provided written medical
reports. Throughout evidentiary hearings held in September
and November of 2019, the district court reviewed each
psychiatrist’s medical report, heard live testimony from both
psychiatrists, and received other evidence.
2.
In May 2020, the district court issued a written order—
the order currently on appeal—granting Porretti’s motion for
a preliminary injunction. The district court first found that
Dr. Roitman’s medical report, which stated that Porretti
should receive Wellbutrin and Seroquel, was credible and
medically acceptable. Dr. Roitman’s twenty-page report
relied on approximately fifteen to twenty prior examinations
of Porretti. Dr. Roitman reviewed Porretti’s medical
records, family history, and mental-health history.
Dr. Roitman also provided ten pages of medical findings,
explained the potential limitations of his findings, and
determined that Wellbutrin and Seroquel are not prone to
abuse in the prison system. Finally, Dr. Roitman explained
why treatments other than Wellbutrin and Seroquel are not
medically appropriate for Porretti.
On the other hand, the district court found that
Dr. Exum’s report, which recommended that Porretti receive
cognitive behavioral treatment, was medically unacceptable
and not credible for several reasons. Dr. Exum’s brief four-
page report relied almost exclusively on one short interview
with Porretti. And although Dr. Exum called Porretti a “very
poor historian” of his own medical history, Dr. Exum relied
almost exclusively on Porretti’s self-reported medical
history. In addition, the district court found that Dr. Exum
did not review Porretti’s medical records, failed to discuss
the potential abuse of Wellbutrin and Seroquel in the prison

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10 PORRETTI V. DZURENDA
system, failed to discuss Porretti’s experience with
Wellbutrin and Seroquel, and provided testimony designed
to support Defendants’ litigation position. The district court
found, in sum, that Dr. Exum’s report did not conform to that
of a “prudent professional[] in the field” and was biased.2
After rendering these factual findings, the district court
analyzed the four-part test for issuing a preliminary
injunction. First, the district court determined that Porretti’s
Eighth Amendment claim would likely succeed on the merits
because he could show that Defendants acted with deliberate
indifference to a serious medical need. Second, the district
court determined that Porretti would suffer irreparable harm
absent injunctive relief. The irreparable harm included
“very serious or extreme damage to his mental health should
[injunctive] relief not be imposed.” The district court “d[id]
not reach this finding lightly but only after consideration of
the testimony of two NDOC physicians, an independent
psychiatrist, and a review of the extensive records in this
case.”
Third, the district court determined that the “balance of
equities” tipped in Porretti’s favor. The district court
explained that Porretti’s ongoing and severe mental-health
symptoms, combined with the denial of medication that
helps him, “overwhelmingly outweighs” Defendants’
logistical and financial burdens in providing Wellbutrin and
Seroquel. Fourth, and finally, the district court determined
that the “public interest” favored injunctive relief because
prisons must comply with the standard of care mandated by
the Eighth Amendment. The district court explained that the
2 The district court again deemed Dr. Carroll’s testimony from the
January 29, 2019 hearing not credible for the same reasons mentioned in
the April 2019 order.

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PORRETTI V. DZURENDA 11
“public has an interest in ensuring the continued dignity of
[individuals] incarcerated in federal prisons” and “[i]nherent
in that dignity is the recognition of serious medical needs,
and their adequate and effective treatment” pursuant to the
Eighth Amendment.
Because Porretti satisfied each part of the preliminary-
injunction test, the district court granted Porretti’s motion for
a preliminary injunction in its May 2020 order. The order
required Defendants to submit a treatment plan that included
Wellbutrin and Seroquel. Defendants timely appealed the
district court’s order.
C.
Unfortunately, Defendants failed to follow the district
court’s order granting the preliminary injunction while their
appeal was pending in our court. In June 2020, Defendants
submitted a treatment plan that clearly violated the terms of
the district court’s order because it stated that Porretti would
receive Wellbutrin and Seroquel only if the NDOC’s
medical provider decided to prescribe them. The district
court responded in a July 2020 order that explained the court
“did not afford Defendants the opportunity to ‘decide’
whether to follow the Court’s ordered treatment” of
Wellbutrin and Seroquel. Considering Defendants’ “blatant
violation” of the district court’s order, the district court
scheduled a hearing for August 7, 2020 to evaluate
Defendants’ compliance with the district court’s injunction.
The district court stated that it would impose sanctions on
Defendants if a treatment plan that complied with the court’s
order was not submitted by August 7, 2020.
By August 7, 2020, however, Porretti started having
heart problems. During the August 7, 2020 hearing,
Porretti’s counsel stated that the heart problems occurred

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because Defendants treated Porretti with narcotics instead of
Wellbutrin and Seroquel. Moreover, according to Porretti’s
counsel, doctors at the University Medical Center in Nevada
examined Porretti’s heart and suggested that the NDOC’s
medical staff was potentially overdosing Porretti on
narcotics. After medical-treatment complications and
additional court hearings, the district court finally approved
a treatment plan—providing Wellbutrin and Seroquel to
Porretti—in January 2021.3
In the end, Porretti waited approximately four years to
receive the medication he requires.
II.
We have jurisdiction pursuant to 28 U.S.C. § 1292(a)(1).
We review the grant of a preliminary injunction for abuse of
discretion. Sw. Voter Registration Educ. Project v. Shelley,
344 F.3d 914, 918 (9th Cir. 2003) (en banc) (per curiam). A
district court abuses its discretion when it “relies on an
erroneous legal standard or clearly erroneous finding of
fact.” Arc of Cal. v. Douglas, 757 F.3d 975, 983 (9th Cir.
2014) (citation and internal quotation marks omitted). A
district court’s factual finding is clearly erroneous “if it is
illogical, implausible, or without support in inferences that
may be drawn from the facts in the record.” Id. at 983–84
(citation and internal quotation marks omitted). Our
“[r]eview of factual findings at the preliminary injunction
stage” is restricted to the “record available to the district
3 Defendants’ unopposed motion to supplement the record (Doc. 46)
is GRANTED. We take judicial notice of the district court’s minute
order on January 6, 2021, which adopts a treatment plan consistent with
the district court’s directives. See Reyn’s Pasta Bella, LLC v. Visa USA,
Inc., 442 F.3d 741, 746 n.6 (9th Cir. 2006).

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PORRETTI V. DZURENDA 13
court when it granted or denied the injunction motion.”
Zepeda v. INS, 753 F.2d 719, 724 (9th Cir. 1983).
III.
“A preliminary injunction is an extraordinary remedy
never awarded as of right.” Winter v. Nat. Res. Def. Council,
Inc., 555 U.S. 7, 24 (2008). At the same time, however,
federal courts “must not shrink from their obligation to
enforce the constitutional rights of all persons, including
prisoners.” Brown v. Plata, 563 U.S. 493, 511 (2011)
(citation and internal quotation marks omitted). Nor may
federal courts “allow constitutional violations to continue
simply because a remedy would involve intrusion into the
realm of prison administration.” Id.
To obtain a preliminary injunction, Porretti “must
establish [1] that he is likely to succeed on the merits, [2] that
he is likely to suffer irreparable harm in the absence of
preliminary relief, [3] that the balance of equities tips in his
favor, and [4] that an injunction is in the public interest.”
Winter, 555 U.S. at 20. Where, as here, the government
opposes a preliminary injunction, the third and fourth factors
merge into one inquiry. Drakes Bay Oyster Co. v. Jewell,
747 F.3d 1073, 1092 (9th Cir. 2014). We address these
factors in turn.4
4 We need not discuss whether the district court’s preliminary
injunction was “prohibitory” or “mandatory” because a preliminary
injunction was appropriate under the standard for both types of
injunctions, and we note that the district court here applied the higher
standard for mandatory preliminary injunctions. See Edmo v. Corizon,
Inc., 935 F.3d 757, 784 n.13. (9th Cir. 2019) (per curiam).

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A.
The first factor of the preliminary-injunction test
requires Porretti to show that his Eighth Amendment claim
will likely succeed on the merits. Winter, 555 U.S. at 20.
The Eighth Amendment prohibits “cruel and unusual
punishments.” U.S. Const. amend. VIII. A prisoner suffers
cruel and unusual punishment when prison officials act with
deliberate indifference to the prisoner’s serious medical
need. See, e.g., Edmo v. Corizon, Inc., 935 F.3d 757, 766
(9th Cir. 2019) (per curiam). Because Defendants do not
dispute that Porretti’s mental illnesses constitute a serious
medical need, we address only deliberate indifference.
For a prison official to act with deliberate indifference to
a serious medical need, the prison official must knowingly
disregard an excessive risk to a prisoner’s health. Peralta v.
Dillard, 744 F.3d 1076, 1082 (9th Cir. 2014) (en banc). This
requires the prisoner to show “that the course of treatment
the [prison official] chose was medically unacceptable under
the circumstances and that the [prison official] chose this
course in conscious disregard of an excessive risk to the
[prisoner’s] health.” Hamby v. Hammond, 821 F.3d 1085,
1092 (9th Cir. 2016) (citation and internal quotation marks
omitted).
The issue here, like in many other Eighth Amendment
cases, is whether Porretti showed only a mere disagreement
of medical opinion between dueling experts, as opposed to
deliberate indifference in treating Porretti. See, e.g., Edmo,
935 F.3d at 786–87; Toguchi v. Chung, 391 F.3d 1051, 1058
(9th Cir. 2004). We have explained that a mere
disagreement of medical opinion between experts does not
demonstrate deliberate indifference as a matter of law. See,
e.g., Edmo, 935 F.3d at 786; Toguchi, 391 F.3d at 1058. But
that is true only if both dueling medical opinions are

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PORRETTI V. DZURENDA 15
“medically acceptable under the circumstances.” Edmo,
935 F.3d at 786.
Our recent opinion in Edmo v. Corizon, Inc. illustrates
the point. There, a transgender prisoner, Edmo, sought a
preliminary injunction because of inadequate medical care.
See id. at 775, 781. Edmo’s experts testified that Edmo
needed gender confirmation surgery to treat gender
dysphoria, but the State’s experts testified that gender
confirmation surgery was not medically necessary. Id.
at 787. The district court determined that Edmo’s experts
were credible because they had extensive experience treating
gender dysphoria. Id. at 780, 787. On the other hand, the
district court rejected the contrary opinions of the State’s
experts because they lacked extensive experience treating
gender dysphoria and “because aspects of their opinions
were illogical and unpersuasive.” Id. at 780, 789. The
district court discredited the State’s experts, granted Edmo’s
motion for a preliminary injunction, and ordered the State to
provide gender confirmation surgery. See id. at 780–81.
We affirmed the district court’s order granting injunctive
relief to Edmo. Id. at 803. Because the district court in
Edmo determined that the State’s expert reports were not
credible and not medically acceptable under the
circumstances, the district court was not faced with a mere
disagreement of medical opinion involving two medically
acceptable treatments. See id. at 786–92. Edmo’s experts
had the requisite experience and therefore were credible in
the district court’s view. Id. at 787. But the State’s experts
in Edmo lacked the requisite experience and therefore were
not credible in the district court’s view. Id. Because “the
district court did not clearly err in making its credibility
determinations,” it was “not our role to reevaluate them” on
appeal. Id.

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Here, Defendants argue that Porretti cannot show
deliberate indifference because Porretti’s case involves a
mere difference of medical opinions among Dr. Roitman,
Dr. Exum, and Dr. Carroll concerning different acceptable
treatments under the circumstances. This argument fails
because the district court found that only Dr. Roitman’s
medical report was credible and medically acceptable under
the circumstances. See id.; Toguchi, 391 F.3d at 1058 (a
mere “difference of medical opinion . . . [is] insufficient, as
a matter of law, to establish deliberate indifference,” but not
if the “chosen course of treatment was medically
unacceptable under the circumstances”) (citation and
internal quotation marks omitted). With only one credible
and medically acceptable recommendation, Porretti’s case
did not involve a mere disagreement of medical opinion
between experts over different acceptable treatments. See
Edmo, 935 F.3d at 787; Toguchi, 391 F.3d at 1058.
Contrary to Defendants’ suggestions, the district court’s
findings as to Dr. Roitman’s, Dr. Exum’s, and Dr. Carroll’s
medical reports and recommendations are not clearly
erroneous. The district court deemed Dr. Roitman’s medical
report and ultimate recommendation—Wellbutrin and
Seroquel—credible and medically acceptable for several
reasons grounded in record evidence. Dr. Roitman’s twenty-
page report included ten pages of medical findings; relied on
approximately fifteen to twenty prior examinations of
Porretti; and took into account Porretti’s medical records,
prior medical treatment, family history, and mental-health
history. Dr. Roitman determined that Wellbutrin and
Seroquel are not prone to abuse in the prison system and
explained why alternative treatments are not appropriate for
Porretti.

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PORRETTI V. DZURENDA 17
By contrast, the district court deemed Dr. Exum’s
report—recommending only cognitive behavioral
treatment—not credible and medically unacceptable for
reasons supported by record evidence. Dr. Exum’s four-
page report relied almost exclusively on one short interview
with Porretti and Porretti’s self-reported medical history.
Dr. Exum called Porretti a “very poor historian” of his own
medical history, but, at the same time, he relied almost
exclusively on Porretti’s self-reported medical history to
compose his brief four-page report. Moreover, the district
court found that Dr. Exum failed to review Porretti’s medical
records, failed to discuss Porretti’s experience with
Wellbutrin and Seroquel, and failed to discuss whether
Wellbutrin and Seroquel are prone to abuse in the prison
system. Considering those failures, among others, the
district court determined that Dr. Exum provided biased
testimony designed to support Defendants’ litigation
position and that Dr. Exum’s medical evaluation did not
conform to that of a “prudent professional[] in the [medical]
field.”
Similarly, the district court did not clearly err in deeming
Dr. Carroll’s report not credible. Dr. Carroll examined
Porretti only one time for a few minutes over
videoconference but recommended that Porretti receive no
medication despite many other doctors—including the
NDOC’s doctors—providing medication to Porretti for
decades to treat his serious mental illnesses. Dr. Carroll
testified that Porretti exhibited addictive and drug-seeking
behavior, but the record showed no formal diagnosis of drug
abuse and instead showed the “drug-seeking” behavior to
involve Porretti seeking the medication that he had been
prescribed for years, Wellbutrin and Seroquel. The district
court found that Dr. Carroll, an NDOC employee, created a

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medical review tailored to support Defendants’ litigation
position.
In the end, because “the district court did not clearly err
in making its credibility determinations,” it is “not our role
to reevaluate them.” Edmo, 935 F.3d at 786; see also Caro
v. Woodford, 280 F.3d 1247, 1253 (9th Cir. 2002)
(explaining that we “must afford the District Court
considerable deference in its determination that the
witnesses were qualified to draw [their] conclusions”). The
district court properly found that only Dr. Roitman’s medical
recommendation was credible and acceptable.
* * *
After the district court determined that Porretti’s case did
not involve dueling experts disagreeing over medically
acceptable treatments, the district court pointed out that
Defendants stopped providing Wellbutrin and Seroquel
because of an administrative policy, without the
recommendation of any health-care provider, and without
any evidence that Porretti abused Wellbutrin or Seroquel.
The district court also pointed out that Defendants failed to
provide Dr. Exum’s recommended cognitive behavioral
treatment, which suggests Porretti received no treatment at
all for periods of time, despite his serious mental health
condition. Considering these facts, among others, the
district court did not clearly err in determining that
Defendants likely acted with deliberate indifference to
Porretti’s serious medical need. See Edmo, 935 F.3d at 786–
90; Caro, 280 F.3d at 1253. The district court therefore did
not err in determining that Porretti’s Eight Amendment
claim will likely succeed on the merits. See Edmo, 935 F.3d
at 786–90, 793–94; Caro, 280 F.3d at 1253.

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PORRETTI V. DZURENDA 19
B.
The second factor of the preliminary-injunction test
requires Porretti to show that he would suffer irreparable
harm absent injunctive relief. Winter, 555 U.S. at 20.
Notably, “the deprivation of [a prisoner’s] constitutional
right to adequate medical care is sufficient to establish
irreparable harm.” Edmo, 935 F.3d at 798. Emotional
injuries, psychological distress, and risk of suicide may
constitute irreparable harm. See id. at 797–98; see also
Thomas v. Cnty. of L.A., 978 F.2d 504, 511 (9th Cir. 1992)
(“Plaintiffs have also established irreparable harm, based on
this Court’s finding that the deputies’ actions have resulted
in irreparable physical and emotional injuries to plaintiffs
and the violation of plaintiffs’ civil rights.”).
Here, the district court determined that Porretti would
suffer irreparable harm in the form of “very serious or
extreme damage to his mental health” if injunctive relief
were not granted. The “very serious or extreme damage”
included suicide or self-harm and “debilitating symptoms”
like paranoid delusions, auditory hallucinations, and
“compulsive ingestion of metal parts.” The district court did
not abuse its discretion in determining that these injuries and
risks of additional harm to Porretti’s mental health likely
constituted irreparable harm and therefore required
injunctive relief. See, e.g., Edmo, 935 F.3d at 797–98; see
also Thomas, 978 F.2d at 511.5
5 Defendants suggest that Porretti would not suffer irreparable harm
because Defendants offered a treatment plan after the preliminary
injunction was ordered. This argument is meritless because we review
the district court’s factual findings on the record “available to the district
court when it granted . . . the injunction motion.” Zepeda, 753 F.2d
at 724 (emphasis added).

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C.
The third and fourth factors of the preliminary-injunction
test—balance of equities and public interest—merge into
one inquiry when the government opposes a preliminary
injunction. See Drakes Bay, 747 F.3d at 1092. The “balance
of equities” concerns the burdens or hardships to Porretti
compared with the burden on Defendants if an injunction is
ordered. See Winter, 555 U.S. at 24–31. The “public
interest” mostly concerns the injunction’s “impact on non-
parties rather than parties.” Bernhardt v. L.A. Cnty.,
339 F.3d 920, 931 (9th Cir. 2003) (citation omitted).
Here, the district court first weighed the equities. It
determined that Porretti’s severe and persistent psychotic
symptoms “overwhelmingly” outweighed Defendants’
financial or logistical burdens in providing Wellbutrin and
Seroquel to Porretti. The district court then explained how
an injunction was in the public’s interest: “The public has an
interest in ensuring the continued dignity of [individuals]
incarcerated in federal prisons” and “[i]nherent in that
dignity is the recognition of serious medical needs, and their
adequate and effective treatment” pursuant to the Eighth
Amendment’s mandated standard of care. We see no abuse
of discretion here. See Melendres v. Arpaio, 695 F.3d 990,
1002 (9th Cir. 2012) (“[I]t is always in the public interest to
prevent the violation of a party’s constitutional rights.”)
(citation omitted); Preminger v. Principi, 422 F.3d 815, 826
(9th Cir. 2005) (“Generally, public interest concerns are
implicated when a constitutional right has been violated,
because all citizens have a stake in upholding the
Constitution.”).
Defendants nevertheless argue that the district court
abused its discretion because it did not adequately consider
the public’s interest in stopping abuse of Wellbutrin and

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PORRETTI V. DZURENDA 21
Seroquel in prison. Defendants cite Dr. Carroll’s testimony
to support their view that Wellbutrin and Seroquel are
abused in prison. Yet the district court discredited
Dr. Carroll’s testimony and instead credited Dr. Roitman’s
finding that no scientific evidence validated the fear that
Wellbutrin and Seroquel are prone to abuse in the prison
system. And we already have determined that the district
court did not abuse its discretion in crediting Dr. Roitman’s
testimony over Dr. Carroll’s testimony.
Yet even if Dr. Carroll is correct about prisoners
potentially abusing Wellbutrin and Seroquel, the district
court ordered only that Porretti receive Wellbutrin and
Seroquel in High Desert State Prison. The district court did
not order that Wellbutrin and Seroquel be rendered available
for all prisoners at High Desert State Prison. The district
court’s order would therefore present other prisoners with
almost no opportunity to abuse Wellbutrin and Seroquel.
IV.
Defendants offer other unpersuasive arguments against
the issuance of a preliminary injunction, which we briefly
address and reject. First, Defendants argue that the district
court erred in rendering credibility determinations among
medical doctors because factual findings are the jury’s
responsibility. This argument fails because our case law
makes clear that the district court may render credibility
determinations before deciding a motion for a preliminary
injunction. Edmo, 935 F.3d at 787 (reviewing expert
medical testimony in a prison-conditions case and
explaining that because “the district court did not clearly err

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in making its credibility determinations,” we would not
“reevaluate them”).6
Second, Defendants contend that the district court’s
preliminary injunction is not narrowly drawn. Defendants
are correct that the Prison Litigation Reform Act (“PLRA”)
requires that preliminary injunctions in prison cases be
“narrowly drawn” and the “least intrusive means necessary
to correct th[e] harm.” 18 U.S.C. § 3626(a)(2). But the
PLRA “merely codifies existing law [governing injunctive
relief] and does not change the standards for determining
whether to grant an injunction.” Gomez v. Vernon, 255 F.3d
1118, 1129 (9th Cir. 2001) (citation omitted). Here, the
district court issued a narrow and simple injunction: Create
a treatment plan and provide Porretti with the two
medications that he needs, Wellbutrin and Seroquel.
Nothing about the district court’s preliminary injunction is
overbroad.
Third, Defendants contend that the district court
impermissibly micromanaged Porretti’s case. See
Armstrong v. Brown, 768 F.3d 975, 983 (9th Cir. 2014)
(stating that a district court’s preliminary injunction in the
prison context may “provide guidance and set clear
objectives” but may not micromanage prison
administration). The record clearly shows, however, that the
district court held multiple status conferences and hearings
because Defendants repeatedly refused to follow the district
6 Defendants also appear to argue that the district court should have
conducted a Daubert analysis before making a credibility determination
among the medical doctors in this case. Because Defendants never filed
a Daubert motion in the district court, their Daubert argument is
forfeited. Orr v. Plumb, 884 F.3d 923, 932 (9th Cir. 2018) (“The usual
rule is that arguments raised for the first time on appeal . . . are deemed
forfeited.”).

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PORRETTI V. DZURENDA 23
court’s orders, refused to give Porretti the court-ordered
medications, and allowed several months to pass without
providing any medical treatment to Porretti. Simply put,
after Defendants failed to follow court orders, they
unpersuasively characterize the district court as a
micromanager because it enforced its orders.
Fourth, Defendants suggest that the district court altered
the preliminary injunction after the notice of appeal was filed
in this case. But the district court never changed its
injunction, and Defendants fail to point to a new injunction.
Instead, the district court attempted to enforce the same
preliminary injunction that Defendants routinely failed to
follow. The district court explained that “the only thing” it
sought to do was implement the existing order that required
the NDOC to treat Porretti with Wellbutrin and Seroquel.
Finally, Defendants suggest that changed factual
circumstances—Porretti’s heart problems—require the
district court to modify the preliminary injunction.
Defendants’ current appeal, however, is not an appropriate
vehicle to argue that changed factual circumstances justify
modification of the injunction. That is because our “[r]eview
of factual findings at the preliminary injunction stage” is
restricted to the “record available to the district court when
it granted or denied the injunction motion.” Zepeda,
753 F.2d at 724 (emphasis added).
V.
In the end, the district court carefully applied the
preliminary-injunction factors and rendered highly detailed
factual findings that rejected opinions from Defendants’
experts for reasons grounded in record evidence.
Considering Defendants’ actions in the present case, the
district court did not render any illogical, implausible, or

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unsupported factual finding. The district court did not abuse
its discretion in issuing a preliminary injunction that required
Defendants to provide Wellbutrin and Seroquel to treat
Porretti’s serious mental illnesses.
AFFIRMED.

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