[Federal Register Volume 76, Number 160 (Thursday, August 18, 2011)]
[Notices]
[Pages 51412-51415]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-21061]
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DEPARTMENT OF JUSTICE
Drug Enforcement Administration
Joe C. Fermo, M.D.; Revocation of Registration
On September 30, 2009, the Deputy Assistant Administrator, Office
of Diversion Control, Drug Enforcement Administration, issued an Order
to Show Cause to Joe C. Fermo, M.D. (Registrant), of Tulsa, Oklahoma.
The Show Cause Order proposed the revocation of Registrant's DEA
Certificate of Registration, BF7430781, as well as the denial of any
pending applications to renew or modify his registration, on the ground
that his ``continued registration would be inconsistent with the public
interest.'' Show Cause Order at 1 (citing 21 U.S.C. 823(f) and
824(a)(4)).
The Show Cause Order specifically alleged that on February 23,
1990, Registrant was convicted in the District Court for Oklahoma
County, State of Oklahoma, of ten counts of submitting false claims to
the Oklahoma Department of Human Services in violation of Oklahoma law,
and that on June 20, 1990, the United States Department of Health and
Human Services excluded him from participating in federal health care
programs under 42 U.S.C. 1320a-7(a). Id. at 1-2. The Order further
alleged that based on his convictions, on June 21, 1990, the Oklahoma
State Board of Medical Licensure placed his medical license on
probation and that Registrant materially falsified three separate
applications (in 1991, 1994, and 1997) to renew his DEA registration by
failing to disclose the state board's action. Id. at 2 (citing 21
U.S.C. 824(a)(1)).\1\
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\1\ The Show Cause Order alleged that in March 2001, Registrant
and DEA entered into a Memorandum of Agreement (MOA) which settled a
Show Cause Proceeding filed in April 2000 based on the allegations
described above. Show Cause Order at 2. The Show Cause Order also
alleged that under the MOA, Registrant surrendered his registration
and was allowed to reapply no earlier than March 2004, and that in
October 2004, DEA issued him a new registration. Id.
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Finally, the Show Cause Order alleged that on August 27, September
24, and September 26, 2007, an undercover officer had obtained
prescriptions from Registrant for alprazolam (at all three visits) and
propoxyphene (at the first two visits), both of which are schedule IV
controlled substances. Id. The Order further alleged that these
prescriptions lacked a legitimate medical purpose and were issued
outside of the usual course of professional practice in violation of
Federal and State laws. Id. (citing 21 CFR 1306.04 and Okla. Admin.
Code 475.30-1-3(a)).
On or about October 5, 2009, the Show Cause Order, which also
notified Registrant of his right to either request a hearing on the
allegations or to submit a written statement in lieu of a hearing, the
procedures for doing so, and the consequence if he failed to do so, was
served on Registrant by certified mail addressed to him at the address
of his registered location. Id. at 2-3 (citing 21 CFR 1301.43). Since
service of the Show Cause Order, more than thirty days have now passed
and neither Registrant, nor anyone purporting to represent him, has
either requested a hearing or submitted a written statement in lieu of
a hearing. See 21 CFR 1301.43(b)-(d). Accordingly, I find that
Registrant has waived his rights to a hearing or to submit a written
statement. Id. 1301.43(d). I therefore issue this Decision and Final
Order without a hearing based on relevant evidence contained in the
investigative record submitted by the Government.
Findings
Registrant is the holder of DEA Certificate of Registration,
BF7430781, which authorizes him to dispense controlled substances in
schedules II through V as a practitioner at the registered location of
5970 E. 31 St., Suite O, Tulsa, Oklahoma. While his registration was to
expire on September 30, 2010, on August 13, 2010, Registrant filed a
renewal application. In accordance with the Administrative Procedure
Act and DEA regulations, I find that Registrant's registration remains
in effect pending the issuance
[[Page 51413]]
of this Final Order. See 5 U.S.C. 558(c); 21 CFR 1301.36(i).
On August 27, 2007, an Agent with the Oklahoma Bureau of Narcotics
went to Registrant's office to perform an undercover visit with Merli
Fermo, M.D., Registrant's wife, who was also a DEA registrant.\2\ Upon
meeting the receptionist, to whom she paid $65, the Agent was told that
she would have to wait one hour to see Merli Fermo and was asked if she
wanted to see Registrant, who was available immediately. The Agent
agreed and was taken to his office.
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\2\ Merli Fermo has since passed away.
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After the Agent and Registrant discussed the former's having spent
some time in Minnesota and why she had returned to Oklahoma, who she
lived with, how she was supporting herself, and her address, Registrant
asked the Agent: ``So what do you want me to put you on?'' The Agent
replied: ``I've been on Xanax. Two milligrams.'' Registrant then asked
the Agent if she had ``been on it for a while?'' The Agent replied that
she had been, that she had ``continued it when'' she had gone to
Minnesota, and had gotten it ``from a doctor up there.''
Registrant then asked: ``You're taking Xanax three times a day?'';
the Agent replied ``four times a day.'' Registrant responded: ``It says
three times a day,'' to which the Agent said, ``I know but it was
increased up there.'' Registrant then told the Agent to ``take it two
times a day. Two milligrams.'' The Agent asked: ``So I'm only get[ing]
it two times a day?'' Registrant replied affirmatively and asked,
``What else are you taking?'' The Agent answered: ``I was taking
Darvocet too.''
Registrant then asked ``are you having some pain?'' The Agent
replied: ``Oh, every once in a while.'' Registrant told the Agent to
``[t]ake it two times a day and I'll give you a hundred''; the Agent
replied: ``Okay. I wish you'd give me the four on this Xanax though.''
After several comments which were unintelligible, Registrant and the
Agent discussed how far the latter had lived from Minneapolis, whether
the Agent went there much when she lived in Minnesota, and Registrant's
having previously lived in the Minneapolis area. Before the visit
ended, Registrant gave the Agent prescriptions for 100 Xanax
(alprazolam) 2 mg and 100 Darvocet-N (propoxyphene) 100 mg, both of
which are schedule IV controlled substances, see 21 CFR 1308.14(b),
(c), as well as Celera, a non-controlled anti-depressant.
On September 24, 2007, the Agent returned to Registrant's office
and paid the receptionist $65. While the Agent was scheduled to see
Registrant's wife, when informed that the latter was not available, she
agreed to see Registrant, and after a short wait, was taken to his
office.
Registrant asked the Agent how she was doing; she replied
``great.'' Registrant then asked ``what's going on with you?'' The
Agent answered: ``Not a thing. I wonder if I could get a hundred and
twenty of the Xanax instead of a hundred?'' Registrant asked why she
wanted one hundred twenty; the Agent answered: ``I ran out.'' \3\
Registrant then said: ``No, not if you take it down * * * the way it is
prescribed for you, you wouldn't run out.'' After the Agent said ``I
know,'' Registrant stated--in contrast to his instruction at the
previous visit to take the Xanax twice a day--``Just take it three
times a day, that's precisely why it's controlled because people have a
tendency to (Inaudible) take it more than what's prescribed.''
Registrant then apparently warned the Agent that she could have
seizures if she took more than what he prescribed ``and then if you
don't take it for some reason or another'' and added ``it's not good to
be doing that.''
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\3\ Based on the dosing instruction he gave the Agent at the
initial visit, the Xanax should have lasted 50 days; the Agent was
thus seeking the drug approximately three weeks early.
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After telling the Agent that she could take the Xanax ``three times
a day,'' Registrant asked her: ``Do you still need the Darvocet?''; the
Agent answered: ``Yes.'' After a conversation about such subjects as
how much social security the Agent was getting, what type of work she
had previously done, her shopping habits, and whether she had a
boyfriend, Registrant told the Agent to take the Celexa because it is
an anti-depressant that works with Xanax and would help her to get
going in the morning. After still more conversation about the Agent's
social life, Registrant gave her new prescriptions for 100 Xanax 2 mg,
100 Darvocet-N 100 mg, and Celexa. Shortly thereafter, the visit
ended.\4\
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\4\ The Government also submitted a copy of the Information
filed by the State of Oklahoma charging Registrant with ten counts
of submitting false claims to the Oklahoma Department of Human
Services; a ``Deferred Sentence, Plea of Guilty, Summary of Facts''
filed in the state court proceedings; a June 20, 1990, letter from
the Office of Inspector General, U.S. Department of Health & Human
Services, which excluded Registrant ``from participation in the
Medicare program and any State health program'' for a period of
fifteen years based on his state court convictions; and a Final
Order of the Oklahoma State Board of Medical Licensure and
Supervision (issued on June 21, 1990) which placed him on probation
for four years and nine months based on his guilty plea in the state
criminal proceeding.
The Government did not, however, submit either the MOA, which
Registrant entered into with DEA, or any of the applications which
it alleged he had materially falsified. Instead, it submitted the
MOA that DEA entered into with his wife and an affidavit of an
Agency Investigator stating that he had ``received information
from'' an Investigator in another office that Registrant's MOA ``was
identical'' to his wife's. Affidavit of Diversion Investigator, at
1.
Even accepting this would establish that Registrant settled the
Show Cause Proceeding on the same terms as his wife did, his wife's
MOA merely stated that an April 21, 2000 Order to Show Cause
``further alleged that on August 13, 1991, September 22, 1994, and
again on August 28, 1997, the Respondent materially falsified her
renewal applications by failing to disclose that the Board placed
her medical license on probation in June 1990.'' MOA, at 2.
Continuing, the MOA states: ``The above matters, if proven at an
administrative hearing, constitute grounds for revocation of the
Respondent's DEA Certificate of Registration, and denial of her
pending application for renewal of that registration.'' Id. Nowhere
in the MOA did Registrant's wife admit to the material falsification
allegation. Thus, even if Registrant's MOA imposed the same terms,
it is clear that the Government has not proved the allegation that
he materially falsified his 1991, 1994, and 1997 applications.
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Discussion
Section 304(a) of the Controlled Substances Act (CSA) provides that
``[a] registration pursuant to section 823 of this title to * * *
dispense a controlled substance * * * may be suspended or revoked by
the Attorney General upon a finding that the registrant * * * has
committed such acts as would render his registration under section 823
of this title inconsistent with the public interest as determined under
such section.'' 21 U.S.C. 824(a)(4). In making the public interest
determination in the case of a practitioner, Congress directed that the
following factors be considered:
(1) The recommendation of the appropriate State licensing board
or professional disciplinary authority.
(2) The applicant's experience in dispensing * * * controlled
substances.
(3) The applicant's conviction record under Federal or State
laws relating to the manufacture, distribution, or dispensing of
controlled substances.
(4) Compliance with applicable State, Federal, or local laws
relating to controlled substances.
(5) Such other conduct which may threaten the public health and
safety. 21 U.S.C. 823(f).
``[T]hese factors are considered in the disjunctive.'' Robert A.
Leslie, 68 FR 15227, 15230 (2003). I may rely on any one or a
combination of factors and may give each factor the weight I deem
appropriate in determining whether to revoke an existing registration
or to deny an application. Id. Moreover, I am ``not required to make
findings as to all of the factors.'' Hoxie v. DEA, 419 F.3d 477, 482
(6th Cir. 2005); (citing Morall v. DEA, 412 F.3d 165, 173-74 (D.C. Cir.
2005)).
[[Page 51414]]
In this matter, while I have considered all of the factors, I
conclude that it is not necessary to make findings with respect to
factors one (the recommendation of the state licensing board), three
(registrant's conviction record) and five (such other conduct which may
threaten public health and safety). I find that the Government's
evidence with respect to Registrant's experience in dispensing
controlled substances (factor two) and his compliance with applicable
Federal and State laws related to the distribution and dispensing of
controlled substances (factor four) makes out a prima facie case that
Registrant has committed acts which render his registration
``inconsistent with the public interest.'' 21 U.S.C. 823(f), 824(a)(4).
I will therefore order that his registration be revoked and that his
pending application to renew his registration be denied.
Factors Two and Four--Registrant's Experience in Dispensing Controlled
Substances and Compliance With Applicable Laws Related to Controlled
Substances
Under a longstanding DEA regulation, a prescription for a
controlled substance is not ``effective'' unless it is ``issued for a
legitimate medical purpose by an individual practitioner acting in the
usual course of his professional practice.'' 21 CFR 1306.04(a). This
regulation further provides that ``an order purporting to be a
prescription issued not in the usual course of professional treatment *
* * is not a prescription within the meaning and intent of [21 U.S.C.
829] and * * * the person issuing it, shall be subject to the penalties
provided for violations of the provisions of law related to controlled
substances.'' Id.; see also 21 U.S.C. 802(10) (defining the term
``dispense'' as meaning ``to deliver a controlled substance to an
ultimate user by, or pursuant to the lawful order of, a practitioner,
including the prescribing and administering of a controlled
substance'') (emphasis added); Okla. Admin. Code 475:30-1-3(a) (``A
prescription for a controlled dangerous substance to be effective must
be issued for a legitimate medical purpose by a registered or otherwise
authorized individual practitioner acting in the usual course of his/
her professional practice.'').
As the Supreme Court recently explained, ``the [CSA's] prescription
requirement * * * ensures patients use controlled substances under the
supervision of a doctor so as to prevent addiction and recreational
abuse. As a corollary, [it] also bars doctors from peddling to patients
who crave the drugs for those prohibited uses.'' Gonzales v. Oregon,
546 U.S. 243, 274 (2006) (citing United States v. Moore, 423 U.S. 122,
135, 143 (1975)).
Under the CSA, it is fundamental that a practitioner must establish
and maintain a bonafide doctor-patient relationship in order to act
``in the usual course of * * * professional practice'' and to issue a
prescription for a ``legitimate medical purpose.'' Laurence T.
McKinney, 73 FR 43260, 43265 n.22 (2008); see also Moore, 423 U.S. at
142-43 (noting that evidence established that physician ``exceeded the
bounds of `professional practice,' '' when ``he gave inadequate
physical examinations or none at all,'' ``ignored the results of the
tests he did make,'' and ``took no precautions against * * * misuse and
diversion''). The CSA generally looks to state law to determine whether
a doctor and patient have established a bonafide doctor-patient
relationship. See Kamir Garces-Mejias, 72 FR 54931, 54935 (2007);
United Prescription Services, Inc., 72 FR 50397, 50407 (2007).\5\
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\5\ However, on October 15, 2008, the President signed into law
the Ryan Haight Online Pharmacy Consumer Protection Act of 2008,
Public Law. 110-425, 122 Stat. 4820 (2008). Section 2 of the Act
prohibits the dispensing of a prescription controlled substance ``by
means of the Internet without a valid prescription,'' and defines,
in relevant part, the ``[t]he term `valid prescription' [to] mean[]
a prescription that is issued for a legitimate medical purpose in
the usual course of professional practice by * * * a practitioner
who has conducted at least 1 in-person medical evaluation of the
patient.'' 122 Stat. 4820 (codified at 21 U.S.C. 829(e)(1) & (2)).
Section 2 further defines ``[t]he term `in-person medical
evaluation' [to] mean[] a medical evaluation that is conducted with
the patient in the physical presence of the practitioner, without
regard to whether portions of the evaluation are conducted by other
health professionals.'' Id. (codified at 21 U.S.C. 829(e)(2)(B)).
These provisions do not, however, apply to Respondent's conduct.
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Under the Oklahoma Board of Medical Licensure and Supervision's
rule on the ``[u]se of controlled substances for the management of
chronic pain,'' ``[a] medical history and physical examination must be
obtained, evaluated and documented in the medical record.'' Okla.
Admin. Code 435:10-7-11(1). Moreover, ``[t]he medical record should
document the nature and intensity of the pain, current and past
treatments for pain, underlying or coexisting diseases or conditions,
the effect of the pain on physical and psychological function and
history of substance abuse.'' Id. The Oklahoma rule also requires,
inter alia, that a ``physician should discuss the risk and benefits of
the use of controlled substances with the patient.'' Id. at 435:10-7-
11(3).
As found above, on two occasions, Registrant prescribed Darvocet-N
100 mg., a drug which includes propoxyphene, a schedule IV narcotic
controlled substance, as well as Xanax (alprazolam) to an OBN Agent
acting in an undercover capacity. Notably, during the first visit,
Registrant did not ask the Agent whether she had any medical
complaints. Rather, after engaging in small talk and asking for her
address, Registrant asked the Agent: ``So what do you want me to put
you on?'' While the Agent stated Xanax 2 mg, and told her she had been
getting it from another doctor, Registrant did not even ask her if she
had anxiety.
Moreover, Registrant then asked the Agent: ``what else are you
taking?'' After the Agent replied that she ``was taking Darvocet too,''
Registrant asked: ``I think, are you having some pain?'' While the
Agent replied: ``[e]very once in a while,'' Registrant did not ask the
Agent any questions regarding ``the nature and intensity of the pain,''
the ``effect of the pain on [the Agent's] physical and psychological
function,'' whether the Agent had been previously treated for pain, or
whether she had a ``history of substance abuse'' as required under the
Oklahoma rule. See Okla. Admin. Code 435:10-7-11(1). Moreover, while
under the Oklahoma rule a physical examination must ``be obtained,''
the transcript of the undercover visit contains no indication that
Registrant performed a physical examination and developed a diagnosis.
See id. I thus conclude that at the Agent's first visit, Registrant
failed to establish a doctor-patient relationship with her. I further
conclude that he lacked a legitimate medical purpose and acted outside
of the usual course of professional practice in prescribing Xanax and
Darvocet-N to her and thus violated Federal law. See 21 CFR 1306.04(a);
21 U.S.C. 841(a)(1).
The Xanax and Darvocet prescriptions Respondent gave the Agent at
her second visit also violated Federal law. While at this visit,
Registrant, after being told by the Agent (who was seeking an even
larger quantity of the drug and was three weeks early in seeking the
refill) that she had run out of Xanax, did discuss with her that she
should not take more of the drug than he prescribed and explained that
the drug is controlled ``because people have a tendency to'' take more
than is prescribed, once again, he did not determine that the Agent had
anxiety or another medical condition that might warrant a prescription
for the drug.
Likewise, after telling the Agent to only take the Xanax three
times per day, he then asked her if she ``still need[ed]
[[Page 51415]]
the Darvocet?'' The Agent answered ``yes,'' but Registrant did not even
ask her if she had pain, let alone ask her any questions regarding the
nature and intensity of the pain, whether the Darvocet was helping to
alleviate her pain, or how the pain was affecting her physical and
psychological function. Accordingly, with respect to the Agent's second
visit, I again conclude that Registrant failed to establish a doctor-
patient relationship with her. I also conclude that Registrant lacked a
legitimate medical purpose and acted outside of the usual course of
professional practice in prescribing Xanax and Darvocet-N to her and
violated Federal law. See 21 CFR 1306.04(a); 21 U.S.C. 841(a)(1).
As the forgoing demonstrates, Registrant has committed acts which
``render his registration * * * inconsistent with the public
interest.'' 21 U.S.C. 824(a)(4). I will therefore order that his
registration be revoked and that any pending applications be denied.
Order
Pursuant to the authority vested in me by 21 U.S.C. 823(f) and
824(a), as well as by 28 CFR 0.100(b), I hereby order that DEA
Certificate of Registration, BF7430781, issued to Joe C. Fermo, M.D.,
be, and it hereby is, revoked. I further order that any pending
application of Joe C. Fermo, M.D., to renew or modify his registration
be, and it hereby is, denied. This Order is effective September 19,
2011.
Dated: August 5, 2011.
Michele M. Leonhart,
Administrator.
[FR Doc. 2011-21061 Filed 8-17-11; 8:45 am]
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