[Federal Register Volume 76, Number 190 (Friday, September 30, 2011)]
[Notices]
[Pages 60900-60922]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-25231]


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DEPARTMENT OF JUSTICE

Drug Enforcement Administration

[Docket No. 11-14]


Jack A. Danton, D.O.; Decision and Order

    On June 17, 2011, Administrative Law Judge (ALJ) Gail A. Randall 
issued the attached recommended decision.\1\ Thereafter, the Government 
filed exceptions to the ALJ's decision.
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    \1\ All citations to the ALJ's decision are to her slip opinion 
as originally issued.
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    Having considered the entire record and the Government's 
exceptions, I have decided to adopt the ALJ's decision except for her 
legal conclusions with respect to whether the Respondent issued 
prescriptions for controlled substances to several undercover officers 
and several of her findings under factor five. However, because I 
otherwise agree with the ALJ's findings as to the public interest 
factors, I adopt her ultimate conclusion that the Government has shown 
that ``Respondent's continued registration would not be in the public's 
interest'' and that the Respondent ``has not accepted responsibility 
for all of her wrongdoing, nor has she adequately assured this tribunal 
of future compliance.'' ALJ at 64. I will therefore order that 
Respondent's registration be revoked and that any pending application 
be denied.

The Government's Exceptions

    The ALJ concluded that the Government failed to establish that 
Respondent's prescriptions to three undercover officers (UC) lacked a 
legitimate medical purpose. ALJ at 42-51; see also 21 CFR 1306.04(a) 
(``A prescription for a controlled substance * * * must be issued for a 
legitimate medical purpose by an individual practitioner acting in the 
usual course of his professional practice.''). In so concluding, the 
ALJ explained that the Government ``provided no expert testimony to 
support this finding,'' and that while the Government ``introduced the 
transcripts and recordings of the undercover transactions, and a 
summary of those transactions via officer testimony[,] * * * the 
Government ha[d] provided no meaningful lodestar by which this court 
can measure the legitimacy of the Respondent's medical practice under 
Florida statutory and regulatory requirements.'' Id. at 43. The ALJ 
noted that ``while the [A]gency has considered over fifty cases 
concerning the legitimacy of a practitioner's prescriptions since 
[Gonzales v. Oregon, 546 U.S. 243 (2006)], the [A]gency has seldom 
found a violation of 21 CFR 1306.04(a) absent expert testimony[,]'' and 
that ``where the [A]gency has found such illegitimacy without an 
expert's testimony, that finding was based on patent violations, where 
diversion was either unrefuted or unquestionable.'' Id. at 43-44 
(citing cases).
    The ALJ also noted that ``expert testimony may not be required'' 
where the evidence shows that a registrant ``has acted in a manner that 
clearly contravened state law governing what constitutes a legitimate 
medical practice,'' such as where a physician

[[Page 60901]]

issues a prescription where ``no physical examination or face-to-face 
communication was conducted'' as through Internet or telephone 
consultations. Id. at 44-45. However, the ALJ then explained that 
``when the Government seeks to use a state law violation as a means of 
establishing a violation of Sec.  1306.04(a), the question remains to 
what extent that state law violation is so tethered to a finding of 
actual illegitimacy that, without expert testimony, it can be used as a 
predicate to a violation of the federal law.'' Id.; see also id. at 45-
46 (citing Gonzales, 546 U.S. at 70 (``the CSA `bars doctors from using 
their prescription-writing powers as a means to engage in illicit drug 
dealing and trafficking as conventionally understood' ''); and Laurence 
T. McKinney, 73 FR 43260, 43266 (2008) (rejecting Government's 
contention that physician's failure to listen to undercover officer's 
heart and lungs and take her blood pressure established a violation of 
21 CFR 1306.04(a); while physician's actions violated a state 
regulation, the officer had presented a medical complaint, identified a 
specific area of her body that was the cause of pain and complained of 
a relatively high pain level and at no point stated that she was not in 
pain, and physician had put her through several different range of 
motion tests'')).\2\
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    \2\ As McKinney explained, establishing a violation of the 
prescription requirement ``requires proof that the practitioner's 
conduct went `beyond the bounds of any legitimate medical practice, 
including that which would constitute civil negligence.' '' 73 FR at 
43266 (quoting United States v. McIver, 470 F.3d 550, 559 (4th Cir. 
2006)).
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    I agree with the ALJ that where the Government fails to provide 
expert testimony to support a finding that a practitioner acted outside 
of the usual course of professional practice and lacked a legitimate 
medical purpose, it can nonetheless prove a violation by: (1) Providing 
evidence that a practitioner committed a violation of a state medical 
practice standard which is sufficiently tied to a state law finding of 
illegitimacy to support a similar finding under Federal law,'' or (2) 
providing evidence showing that Respondent knowingly diverted drugs. 
However, I also conclude that a violation of a state medical practice 
standard which has a substantial relationship to the CSA's purpose of 
preventing substance abuse and diversion is also sufficient to support 
a violation of 21 CFR 1306.04(a). Moreover, I disagree with the ALJ's 
conclusion that the Government has not proved a violation of the CSA's 
prescription requirement.
    In its exceptions, the Government argues that it proved that 
Respondent did not perform a physical examination of either UC1 or UC2. 
Gov. Exc. at 3. The ALJ found otherwise, noting that Florida law does 
not define the term ``physical examination,'' and that at the time of 
the events at issue here, the meaning of the term under the State's law 
was ``nebulous.'' ALJ at 47 & n.25. The ALJ further explained that 
Respondent's ``interpretation, in light of the Government's failure to 
provide a contrary one, must be given considerable weight'' and that 
Respondent had explained that ``[a] physical examination does not 
necessarily entail touching the body'' as ``in the case of chronic 
injury `you can't see--whether you're putting your hands on the patient 
or not, you can't see that evidence of chronic inflammation and disease 
by visual inspection or palpation.'' Id. The ALJ also credited 
Respondent's testimony that she performed a physical examination 
through ``silent observation,'' i.e., by watching how the patients 
walked from the waiting room to the exam room and how they sat. Tr. 
413, 449; ALJ at 47-48. However, when questioned on cross-examination 
as to why Respondent had made no findings in the undercover officers' 
charts as to her observations, Respondent testified that she only 
recorded observations if the patient had complained of pain and then 
``done an inappropriate action'' such as ``complain[ing] of severe low 
back pain'' and then ``bent over and jumped in the air.'' Tr. 543.
    It is far from clear why Respondent's explanation should be 
entitled to ``considerable weight'' given the ALJ's acknowledgment that 
it ``has the potential for being self-serving,'' ALJ at 43 n.23; and 
appears to be patently disingenuous.\3\ Moreover, just as jurors are 
not required in criminal cases to disregard ``their own experiences in 
doctors' care over their lives'' in assessing evidence as to whether a 
physician performed a bona-fide physical exam and thus prescribed in 
the usual course of professional practice, United States v. Armstrong, 
550 F.3d 382, 389 (5th Cir. 2008), so too, an Agency adjudicator can 
call on her experiences with physicians and conclude that merely 
watching a patient walk to an office and sit down does not constitute a 
physical exam, let alone one sufficient to support prescribing 
narcotics.
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    \3\ Among the ALJ's findings which she then proceeded to ignore 
in giving ``considerable weight'' to Respondent's testimony as to 
the proper scope of a physical examination was Respondent's 
discussion of UC2's MRI. More specifically, the ALJ found that 
Respondent had ``explained that she would have `to take the clinical 
symptoms and * * * the exam, [and the] neurological examination' of 
the patient to determine if there was any significance to the 
bulging disc. She further explained that if `someone has a bulge but 
has no symptomatology, now, it's there * * * [but] it's not 
clinically significant.' '' ALJ at 25 (quoting Tr. 454-55). 
Respondent did not, however, perform a neurological exam on UC2 at 
any time. Tr. 289, 297, 300. In addition, as Respondent's testimony 
suggests, an MRI might well show that a person has a bulging disc 
but that the condition is asymptomatic. Yet as the evidence shows, 
Respondent prescribed oxycodone to UC1 and UC2, notwithstanding that 
neither complained of having pain at a level, which according to 
Respondent's own statement to UC3, warrants oxycodone.
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    However, I need not decide whether Respondent performed a 
legitimate physical exam of any of the undercover officers, or whether, 
as the Government argues, ``the plain meaning of the term `physical 
examination' is that a physician [must do] something more than watch 
the patient walk into her office.'' Gov. Exc. at 5. Here, the record 
contains sufficient other evidence to conclude that Respondent both: 1) 
knowingly diverted drugs, and 2) violated State medical practice 
standards that have a substantial relationship to the CSA's purpose of 
preventing drug abuse and diversion so as to support a finding that she 
acted outside of the usual course of professional practice and lacked a 
legitimate medical purpose in issuing the prescriptions. 21 CFR 
1306.04(a).
    As the ALJ recognized, the Florida Board of Osteopathic Medicine 
has, by regulation, promulgated ``Standards for the Use of Controlled 
Substances for Treatment of Pain.'' ALJ at 47 (citing Fla. Admin. Code 
Ann. r.64B15-14.005). The Board has explained that the standards 
``communicate what the Board considers to be within the boundaries of 
professional practice.'' Fla. Admin. Code Ann.r.64B15-14.005(1)(g).
    The first of these standards is the Board's standard for 
``Evaluation of the Patient.'' This provision states:

    A complete medical history and physical examination must be 
conducted and documented in the medical record. The 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. The medical record also 
should document the presence of one or more recognized medical 
indications for the use of a controlled substance.

Id. r.64B15-14.005(3)(a). In addition, the standards state that 
``[a]fter treatment begins, the osteopathic physician should adjust 
drug therapy to the individual medical needs of each patient.'' Id. 
r.64B15-14.005(3)(b). As

[[Page 60902]]

the Board further explained in its discussion of pain management 
principles, ``[p]ain should be assessed and treated promptly, and the 
quantity and frequency of doses should be adjusted according to the 
intensity and duration of the pain.'' Id. 64B15-1.005(1)(c).
    Of note here, even if the Government has not proved that 
Respondent's physical examination was medically inadequate to support 
her diagnoses of UCs 1 and 2, the evidence shows that Respondent's 
evaluations of them failed to comply with the Board's standards in 
several other ways. Moreover, because these violations have a 
substantial relationship to the CSA's purpose of preventing drug abuse 
and diversion they support the conclusion that the prescriptions 
violated 21 CFR 1306.04(a).
    At her first visit, UC1 (Tanya Hall), who indicated that she was 
from Illinois, obtained a prescription for 180 oxycodone 15 mg, as well 
as 30 Xanax 2mg.\4\ RX1, at 1, 5. Yet on her intake form, UC1 rated her 
pain as a 3 on a scale of 1 to 10, and gave as her reason for visiting 
Respondent, ``soreness in neck and shoulder.'' RX 1, at 2, 6. While 
during her first meeting with Respondent, UC1 reported that two months 
earlier, she had been working in a school cafeteria and had some boxes 
of chicken nuggets fall on her as she was getting one of them out of a 
freezer and that she also had a slip and fall incident,\5\ UC1 did not 
make any statement to Respondent that she was currently in pain and 
Respondent did not conduct any further inquiry into the nature and 
intensity of her pain and what effect, if any, it had on her physical 
and psychological functioning. GX 14B. Moreover, during her visit with 
Respondent, UC1 never claimed to suffer from ``breakthrough pain.''
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    \4\ UC1 also obtained prescriptions for 30 Soma 350 mg 
(carisoprodol) and 90 Ibuprofen 800 mg.
    \5\ UC1 also reported auto accidents in 1999 and 2003. However, 
this did not prompt Respondent to ask UC1 about the extent of her 
injuries from these accidents and what treatment had been provided 
for any injuries.
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    Notably, during an encounter with UC3 (which occurred the same 
day), Respondent explained that under her pain scale, pain between 1 
and 3 was ``mild pain,'' that pain at level 4 was ``comfortable pain,'' 
and that at this level, ``I can do whatever I want to do because the 
pain is just not that bad.'' GX 13B, at 12 & 14. Respondent then asked 
rhetorically: ``Is that the time to take a break with narcotic, an 
opiate, a dangerous heroin related drug? No, it's not.'' Id. at 14. 
Shortly thereafter, Respondent added: ``So, if the worst pain is being 
tolerable pain [or level 5 according to Respondent] and it's never 
being as bad as bitching pain [level 6 according to Respondent], maybe 
you don't need a narcotic. Or may be some * * * Vicodin * * * You know, 
Hydrocodone, not an Oxycodone.'' Id. As this makes clear, under 
Respondent's own pain scale, the oxycodone prescriptions she issued to 
UC1 (and UC2) were not medically necessary to treated UC1's (or UC2's) 
reported pain level.
    Moreover, when Respondent asked UC1 ``what kind of medicine have 
you been on?,'' UC1 reported that she had been taking Vicodin and 
Tylenol III (a drug with codeine). GX 14B, at 10. However, Respondent 
did not ask her whether she had previously been (or was currently 
being) treated by another physician, and if so, what treatments had 
been tried. Id. Finally, when Respondent offered to prescribe a drug 
combining oxycodone with acetaminophen, UC1 complained that drugs with 
acetaminophen hurt her stomach. However, when Respondent then asked: 
``Does it make[] you nauseous or bother your stomach? Tell the truth,'' 
UC1 replied: ``No, not really.'' Id. at 12. UC1 persisted in not 
wanting a drug with acetaminophen, and asked Respondent if she could 
try oxycodone 15 mg. Id. at 13. Respondent then agreed, stating: 
``Alright, no big deal,'' and added ``Lucky, I love my patients.'' Id. 
While at this point, Respondent had reason to know that UC1 was not a 
legitimate patient, but rather a drug seeker, she nevertheless 
prescribed 180 tablets of Oxycodone 15 mg to UC1, with the dosing 
instruction to take one tablet every 6 hours and \1/2\; tablet for 
level 6 breakthrough pain.\6\ RX 1, at 5. Notably, at no point did 
Respondent--even though she had reason to know that UC1 was a drug 
abuser--question her about her past drug abuse.
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    \6\ Respondent also prescribed 30 Xanax 2 mg.
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    At UC1's second visit (Mar. 22, 2010), Respondent indicated on the 
progress note that UC1 had pain levels of 6-7/10 and 2-3/10. Id. at 15. 
While UC1 had circled her left shoulder on a pain assessment form, she 
indicated on the form that the worst her pain got was a 3. Id. at 16; 
Tr. 220. Moreover, during the visit, Respondent did not ask UC1 about 
her condition. Tr. 220-21. Respondent, however, issued UC1 a 
prescription for 360 Oxycodone 15 mg, double the amount of the original 
prescription, with the dosing instruction to take two tablets every six 
hours and one tablet for level six breakthrough pain,\7\ as well as 30 
Xanax 2mg. RX1, at 19. Moreover, on this day, Respondent saw UC1 and 
UC2 (Pedro Castillo) together.
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    \7\ The actual prescription was issued on a script bearing the 
name Daniel M. Jacobs, M.D., and apparently signed by Dr. Jacobs. 
See RX 1, at 19. However, UCI did not see Dr. Jacobs that day, and 
received the prescription from Respondent. Tr. 222.
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    On April 20, 2010, UC1 and UC2 returned to Respondent. Once again, 
they saw Respondent together. While at this visit, UC1 indicated that 2 
was her ``acceptable level of pain,'' she left blank the entries on the 
pain assessment form for indicating the ``[p]resent'' intensity, the 
``[w]orst pain gets,'' and ``[b]est pain gets.'' RX1, at 21. Moreover, 
during the visit, Respondent did not ask her any questions regarding 
her pain levels and asked her only if she was getting in the pool and 
the frequency of her doing so, and whether the dosing of the Xanax was 
working well for her. GX 17C, at 7; 17D, at 6. Respondent, however, 
issued UC1 more prescriptions, including one for 180 Oxycodone 15 mg 
and 30 Xanax 2mg. RX1, at 22.
    As for UC2, who also represented that he was from Illinois, at his 
first visit he listed ``stiffness in neck'' as the reason for his 
visit; however, he left the form for indicating his general health 
history entirely blank. RX 2, at 5, 12. Moreover, on his pain 
assessment form, UC2 rated his pain intensity as a 2 on a scale of 1 to 
10 and left the rest of the form blank including the entries for 
describing the ``quality,'' ``onset'', ``manner of expressing,'' ``what 
relieves your pain,'' and ``what causes or increases your pain.'' Id. 
at 15.
    When Respondent asked UC2 what medicine he had been on, UC2 stated 
that he had not ``gotten anything from a doctor'' and he ``was just 
getting some Oxys from a friend * * * because that was the only thing 
that was helping my neck.'' GX 15B, at 34. Respondent noted that UC2 
had ``one * * * mild bulging disc * * * which is basically what Tanya 
has.'' Id. Respondent added that he would ``normally say, `You know 
what, I have four herniated discs, in fact bulging discs, and I get 
fine on Percocet' '' 10/325. Id. Respondent then said he would 
prescribe oxycodone 15 mg, but not oxycodone 30s, which UC2 had stated 
were the ones he was getting from his friend. Id. at 35.
    Subsequently, Respondent noted that UC2 had one bulging disc, which 
was neither torn nor herniated, and was ``not even pressing'' on a 
nerve; Respondent advised that this condition did not warrant oxycodone 
30 mg and required only 10/325. Id. at 39. Respondent further explained 
that oxycodone 10/325s cost only twenty-five cents more

[[Page 60903]]

than oxycodone 15mg, and that when he had hurt his neck and had four 
herniated discs, he had used 10/325s with his pool program. Id. at 41-
42.
    Respondent noted that if UC2 used his pool program and stayed on 
the Ibuprofen, UC2 would not need to spend $200 on oxycodone ``which 
you don't need.'' Id. at 42. Continuing, Respondent asked: ``So, now 
that I've given you all the options which do you want?* * * Which 
medicine you want?'' Id. UC2 stated that he wanted the oxycodone 15s 
and not the oxycodone 10s, because he thought the 15s would be better 
and he knew his buddy had given him that. Id. Respondent then told UC2 
that he was out of oxycodone 15mg and that he would have to come back 
like his ``friend'' UC1. Id. at 43. UC2 then asked if ``I'll get the 
same other stuff that [UC2] got?'' Id. Respondent answered: ``Yes, yes, 
exactly the same.''
    Finally, Respondent got around to asking UC2 how he got hurt. Id. 
at 44. Initially, UC2 said that he ``had a little accident at home,'' 
but Respondent then asked if he had a ``car accident or what?'' Id. UC2 
said he had been in a motorcycle accident ``in the last year, some 
time'' and that was how he hurt his neck. Id. UC2 stated, however, that 
he did not hurt his lower back, that he did not have numbness or 
tingling in his hands, that he did not have pain radiating into his 
arms or hands, and that his pain was not constant but ``comes and goes 
sometimes.'' Id. at 44-45. Respondent explained that he was going to 
prescribe 180 oxycodone 15mg and that UC2 should take a half of a 15mg 
tablet ``[w]hen level five (5) tolerable pain become level six,'' or 
``very uncomfortable, miserable, bitching pain.'' Id. Respondent then 
asked UC2 whether he had difficulty sleeping, to which UC2 answered 
``sometimes.'' Id. at 47. Respondent said he would give him Xanax, even 
though he had already stated that he would give UC2 the same drugs he 
gave UC1.\8\
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    \8\ Respondent also asked UC2 if he got ``muscle spasms at 
night?'' GX 15B, at 48. UC2 answered, ``yeah.'' Id. Respondent then 
said he would prescribe Soma 350 mg as well, without any further 
inquiry as to how often UC2 has spasms and how debilitating they 
were. See id.
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    Here again, notwithstanding that UC2 never represented at this 
visit that he had pain higher than level 2, Respondent issued him 
prescriptions for 180 oxycodone 15 mg and 30 Xanax 2mg (as well as 
Ibuprofen and Soma). Moreover, on the progress note documenting the 
visit, Respondent wrote that UC2 had a neck injury and that his ``pain 
comes & goes,'' but did not document any pain level. RX 2, at 1.
    As noted above, on March 22, UC2 and UC1 saw Respondent together. 
This time Respondent indicated in the progress note that UC2 had 
``Chronic left shoulder pain'' and wrote pain levels of 6-7/10 and 2-3/
10. RX 2, at 17. UC2 testified, however, that during the second visit, 
there was no discussion of whether he had pain. Tr. 297. UC2 further 
stated that he complained of having only stiffness in his neck, and not 
chronic pain in his left shoulder. Id. at 313-14. Respondent gave UC2 
prescriptions (which, just as for UC1, were written on the script and 
DEA number of Dr. Jacobs \9\) for 360 Oxycodone 15mg (also double the 
previous dose), 30 Xanax 2mg, Ibuprofen and Soma. RX 2, at 19.
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    \9\ Here too, UC2 testified that he did not see Dr. Jacobs that 
day. Tr. 299.
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    Likewise, at the third visit, UC2 noted a pain level of three on a 
form, but again complained only of a stiff neck. RX2, at 16; Tr. 300-
01. On the progress note, however, Respondent noted that UC2 had pain 
levels of 6-7/10 and 2-3/10 and had ``chronic left shoulder pain.'' RX 
2, at 20. While Respondent asked UC2 how he was doing on ``the 180 
program,'' a reference to his oxycodone prescribing, to which UC2 
answered ``awesome,'' at no point during the visit did Respondent ask 
UC2 what his pain levels were. See GX 17C & 17D. Respondent then gave 
UC2 a prescription for 180 oxycodone 15 mg, as well as 30 Xanax, and 
the other two drugs.\10\
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    \10\ Respondent also asked UC2 if he was ``doing wonderful[ly] 
on'' the Xanax dosing; UC2 answered that ``[i]t's working for me.'' 
GX 17D, at 2-3.
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    UC2 testified that Respondent did not perform a physical 
examination of him at any of the three visits. Notwithstanding 
Respondent's testimony that she silently observed UC2, unexplained is 
the basis for her diagnosis that UC2 had ``chronic left shoulder pain'' 
when he never complained of anything other than a stiff neck.
    As the forgoing demonstrates, even assuming that Respondent's 
silent observation of UC1 and UC2 constitutes a valid physical 
exam,\11\ the evidence shows that in multiple other ways, Respondent 
did not comply with the State's standard for evaluating his patient and 
determining whether prescribing controlled substances was warranted. 
She failed to inquire as to whether the UCs had been, or were currently 
being, treated by other doctors for their purported conditions and what 
those treatments involved. Likewise, Respondent made no inquiry as to 
the effect of the UCs' pain on their physical and psychological 
functioning. Moreover, she did not ask either UC about their history of 
substance abuse even though Respondent had reason to know that both UC1 
and UC2 were drug seekers. Finally, at their second (joint) visit, 
Respondent doubled the amount and dosage of UC1's and UC2's oxycodone 
prescriptions even though she did not discuss with either of them their 
current pain levels and the efficacy of the prior prescriptions.
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    \11\ It is also noted that Respondent did not document the 
results of her silent observation.
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    The ALJ did not address whether these requirements, which 
Respondent clearly violated, have a substantial relationship to the 
CSA's core purpose of preventing drug abuse and diversion so as to 
support a finding that Respondent lacked a legitimate purpose and acted 
outside of the usual course of professional practice in prescribing 
controlled substances to UCs 1 & 2. I conclude that they do.
    For example, inquiry into whether a patient is currently being 
treated, or has previously been treated for pain, might reveal that the 
patient is engaged in, or has a history of, doctor shopping or other 
non-compliant behaviors consistent with self-abuse or diversion; such 
inquiry might also show that controlled substances were previously 
tried and not effective. Fla. Admin. Code r.64B15-14.005(3)(d)(noting 
important of reevaluating ``the appropriateness of continued 
treatment''). Inquiry into the effect of pain on a patient's physical 
and psychological functioning would seem to be an essential step in 
determining whether the patient's report of pain is consistent with his 
level of function, and whether prescribing controlled substances is 
even medically indicated to treat a patient's pain, as well as the 
appropriate drug and dosage level, another critical step in preventing 
diversion and self-abuse. Likewise, inquiry into whether a patient has 
a history of substance abuse has an obvious relationship to the CSA's 
purpose. Finally, the failure to adjust drug therapy based on a re-
evaluation of the patient could lead to a patient's becoming addicted 
or overdosing.\12\
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    \12\ It could also result in the patient having extra drugs 
which could be sold on the street.
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    Respondent's failure to comply with these requirements with respect 
to UC1 and UC2 is fundamentally different than the situation at issue 
in McKinney, where the practitioner clearly violated a state regulation 
by not listening to an undercover officer's heart and lungs and taking 
her blood pressure but otherwise

[[Page 60904]]

performed a physical exam. To make clear, this is not a case where a 
physician made some attempt to comply with various state medical 
practice standards and the adequacy of those efforts is at issue.\13\ 
Rather, it is a case where a physician has utterly failed to comply 
with multiple requirements of state law for evaluating her patients and 
determining whether controlled substances are medically indicated and 
thus has ```completely betrayed any semblance of legitimate medical 
treatment.''' McKinney, 73 FR at 43266 (quoting United States v. 
Feingold, 454 F.3d 1001, 1010 (9th Cir. 2006)). Indeed, the State 
Board's statement that its standards ``communicate what the Board 
considers to be within the boundaries of professional practice,'' Fla. 
Admin. Code r.64B15-14.005(1)(g), provides further support for the 
conclusion that Respondent, by failing to comply with them, acted 
outside of the usual course of professional practice and lacked a 
legitimate medical purpose in prescribing oxycodone to UC1 and UC2 \14\ 
and thus violated Federal law. 21 CFR 1306.04(a); see also Fla. Stat. 
Ann. Sec.  893.05(1) (``A practitioner, in good faith and in the course 
of his or her professional practice only, may prescribe * * * a 
controlled substance'').\15\
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    \13\ Such a case would likely require expert testimony to show 
that a physician did not merely commit malpractice, but rather, 
acted outside the boundaries of professional practice.
    \14\ The Government takes exception to the ALJ's finding of fact 
116, in which she credited Respondent's testimony that she ``was 
willing to make a small salary so that people could afford to come 
and learn'' and that ``if I could dispense the pills at a reasonable 
price, it would be an incentive for them * * * to come and stay with 
the program. If they kept with the program and they got used to the 
program, eventually they would be able to get off of narcotics.'' 
ALJ at 33-34 (FoF 33-34); Exceptions at 6-7.
    That this testimony is patently self-serving and disingenuous is 
made clear by the undercover visits of UC1 and UC2, in which 
Respondent prescribed oxycodone to them notwithstanding that the UCs 
reported low pain levels (which were also well below the levels 
Respondent stated warranted oxycodone), and Respondent made no 
inquiry into how each of the UCs' respective pain levels were 
affecting their physical and psychological function, made no inquiry 
into whether they had a history of substance abuse, and made no 
inquiry into whether the UCs had previously been or were currently 
being treated for pain. In any event, having concluded that 
Respondent violated 21 CFR 1306.04(a) with respect to UC1 and UC2 
and thus unlawfully distributed controlled substances to them, 
whether Respondent charged the highest price she could or discounted 
the drugs does not make the distributions any less unlawful.
    The Government also takes exception to the ALJ's having given no 
weight to the testimony of a Diversion Investigator that Respondent 
had stated that she did not dispense controlled substances at a 
patient's first visit. Exceptions at 8 (citing FoF 30 & n.5). It is 
acknowledged that the ALJ stated that she gave ``this testimony no 
weight.'' ALJ at 10 n.5. However, it is not clear whether the ALJ 
was referring to the DI's testimony or the statement Respondent made 
to the DI as the ALJ also noted that Respondent's statement to the 
DI ``is inconsistent with her conduct regarding the undercover 
visits.'' ALJ at 10 n.5. However, because it is clear that 
Respondent issued prescriptions to the UCs at their first visits, I 
conclude that it is not necessary to resolve what the ALJ meant and 
whether she improperly gave no weight to the DI's testimony.
    \15\ In her discussion of factor five--such other conduct which 
may threaten public health and safety--the ALJ found that many 
characteristics of Respondent's practice increased the risk of 
diversion. ALJ at 60-62. More specifically, the ALJ noted that 
Respondent did not conduct urine drugs screens on the undercover 
patients, operated a cash-only dispensary thus foreclosing third-
party review, did not verify the MRIs that were presented by the 
UCs, and failed to obtain past treatment records. Id.
    In contrast to the requirements imposed under the State's 
standard for ``Evaluation of the Patient,'' the Florida standards 
then in effect did not explicitly require that a doctor perform 
urine drug screens or verify the authenticity of an MRI. Moreover, 
while the State's standard required documenting a patient's past 
treatments for pain, it says nothing about obtaining past treatment 
records. Given that these requirements were not explicitly imposed 
by the State's rules, either expert testimony or perhaps medical 
treatises (or articles in peer-reviewed medical journals) was 
necessary to establish that each of these is required as part of the 
accepted standard of professional practice. Because there is no such 
evidence, the ALJ's conclusions that each of these omissions 
constitutes conduct which may threaten public health and safety must 
be rejected.
    As for Respondent's operation of a cash-only clinic, while this 
may be probative evidence of illegal activity when considered with 
the other evidence in the case, by itself, operating a cash-only 
clinic does not constitute conduct which may threaten public health 
and safety.
---------------------------------------------------------------------------

    Moreover, Respondent's testimony makes clear that she does not 
accept responsibility for her misconduct in prescribing to the UCs. 
When asked by her own counsel whether her oxycodone prescriptions were 
medically appropriate, she asserted that they were because ``the PDR 
allows up to 30-milligrams, which is twice the 15 that I recommended 
for these patients,'' Tr. 484, ignoring that UC1 and UC2 never 
complained of pain warranting prescriptions at this level of drug. 
Likewise, in addressing why she gave UC3 an extra twenty oxycodone 
pills after he requested them so that he could repay a friend, 
Respondent offered the disingenuous testimony that she did so so that 
UC3 would ``have those twenty extra pills as a parachute'' and she 
``didn't want him to worry.'' Id. at 512. While in her testimony 
Respondent maintained that this was ``an error of judgment,'' in fact, 
it was a criminal act. 21 U.S.C. 841(a)(1).
    It is true that at UC3's third visit, Respondent refused to give 
UC3 additional pills. However, here again Respondent gave false 
testimony, stating that she had told UC3 that ``[i]f you know you're 
going to be short, you break and take half pills so you won't go into 
withdrawal.'' Tr. 513. However, as the transcript of the undercover 
visit makes clear, there was no discussion of withdrawal. Instead, she 
advised UC3 that if he owed people, he could break the pills and ``take 
a fifteen instead of a thirty and that way'' he could save the extras 
and ``give the money back.'' GX 16B, at 22.\16\
---------------------------------------------------------------------------

    \16\ The evidence shows that UC3 was given a prescription for 
180 Oxycodone 30 mg at his third visit by Dr. Jacobs. See RX 3, at 
11-12.
---------------------------------------------------------------------------

    Respondent's advice to UC3 is fundamentally inconsistent with a 
registrant's obligation to prevent drug abuse; her giving of false 
testimony on this and other issues, as well as the numerous violations 
of the CSA which have been proved on this record make clear that she 
cannot be entrusted with a registration. Accordingly, I will adopt the 
ALJ's ultimate conclusion that Respondent's continued registration 
would be inconsistent with the public interest and her recommendation 
that I revoke her registration and deny any pending applications to 
renew or modify her registration.

Order

    Pursuant to the authority vested in me by 21 U.S.C. 823(f) & 
824(a), as well as 28 CFR 0.100(b), I order that DEA Certificate of 
Registration FD1749057, issued to Jack A. Danton, D.O., a/k/a/Jacalyn 
A. Danton, D.O., be, and it hereby is, revoked. I further order that 
any pending application of Jack A. Danton, D.O., a/k/a Jacalyn A. 
Danton, D.O., to renew or modify her registration, be, and it hereby is 
denied. This Order is effective October 31, 2011.

    Dated: September 19, 2011.
Michele M. Leonhart,
Administrator.
Carrie Bland, Esq., for the Government.
Brian Y. Silber, Esq., for the Respondent.

Recommended Rulings, Findings of Fact, Conclusions of Law, and Decision 
of the Administrative Law Judge

I. Procedural Background

    Gail A. Randall, Administrative Law Judge. The then Deputy 
Administrator, Drug Enforcement Administration (``DEA'' or 
``Government''), issued an Order to Show Cause and Immediate Suspension 
of Registration (``Order'') dated November 19, 2010, proposing to 
revoke the DEA Certificate of Registration, Number FD1749057, of Jack 
A. Danton, D.O., (``Respondent'' or ``Dr. Danton ''), as a 
practitioner, pursuant to 21 U.S.C. 824(a)(4) (2006), and deny any 
pending applications for renewal or modification of such

[[Page 60905]]

registration pursuant to 21 U.S.C. 823(f), because the continued 
registration of the Respondent would be inconsistent with the public 
interest, as that term is used in 21 U.S.C. 823(f) and 824(a)(4). The 
Order also immediately suspended the registration pursuant to 21 U.S.C. 
824(d), because the Respondent's continued registration constituted an 
imminent danger to the public health or safety. [Administrative Law 
Judge Exhibit (``ALJ Exh.'') 1]. The Respondent was served with the 
Order on November 23, 2010. [ALJ Exh. 2].
    The Order asserted that the Respondent dispensed ``inordinate 
amounts'' of controlled substances, primarily oxycodone and alprazolam, 
under circumstances where the Respondent knew or should have known 
``that such prescribing and dispensing are for other than legitimate 
medical purposes and are outside the usual course of professional 
practice.'' [ALJ Exh. 1 at 2].
    Next the Order asserted that many of the patients are from out of 
state, and that they have indicated that the Respondent failed to 
perform physical examinations and only accepted payment in cash. [Id.].
    Next, the Order asserted that between February and April of 2010, 
the Respondent treated three law enforcement personnel, operating in an 
undercover capacity. At each of at least eight visits the Respondent 
issued prescriptions for other than legitimate medical purposes and 
outside the usual course of professional practice. The Respondent's 
prescribing of controlled substances to these individuals violated both 
State and Federal law, per the Order. [Id.].
    By letter dated December 14, 2010, the Respondent, through counsel, 
timely filed a request for a hearing in the above-captioned matter. 
[ALJ Exh. 3].
    At the Respondent's request, the hearing was held in Fort 
Lauderdale, Florida, on April 5-7, 2011. [ALJ Exh. 5-8; Transcript 
(``Tr.'') Volume I-III]. At the hearing, Counsel for the DEA and 
Counsel for the Respondent called witnesses to testify and introduced 
documentary evidence. After the hearing, the Government \17\ submitted 
Proposed Findings of Fact, Conclusions of Law and Argument.
---------------------------------------------------------------------------

    \17\ The Respondent attempted to submit her post-hearing brief 
late. Her request for permission to submit it late was denied. The 
Government timely submitted its brief.
---------------------------------------------------------------------------

II. Issue

    The issue in this proceeding is whether or not the record as a 
whole establishes by a preponderance of the evidence that the Drug 
Enforcement Administration should revoke the DEA Certificate of 
Registration Number FD1749057of Jack A. Danton, D.O., as a practitioner 
pursuant to 21 U.S.C. 824(a), and deny any pending applications to 
renew or modify this registration under 21 U.S.C. 823(f), because to 
continue Respondent's registration would be inconsistent with the 
public interest as that term is used in 21 U.S.C. 823(f). [Transcript 
(``Tr.'') at 6].

III. Findings of Fact

    I find, by a preponderance of the evidence, the following facts:

A. Stipulated Facts

    1. Respondent is registered with DEA as a practitioner in Schedules 
II-V under DEA registration number FD1749057.
    2. Respondent's DEA registration expires by its terms on June 30, 
2012.

B. Background Facts

    3. The Respondent is a doctor of osteopathic medicine who practices 
in cosmetic dermatology, cosmetic surgery, and some family practice. 
[Tr. 378]. She has practiced in those areas for thirty-five years. [Tr. 
379]. A greater percentage of her practice was ``dealing with 
musculoskeletal injury.'' [Tr. 384]. In 2009, after the demand for 
cosmetic surgery declined, the Respondent added pain management to her 
area of practice. [Tr. 385-87].
    4. Dr. Danton is a veteran of the United States Army and the Viet 
Nam war. [Tr. 379-80].
    5. ``Palliative care'' means that ``once the acute injury heals, 
that there's still something going on from either pinched nerves or 
some kind of pressure or spinal problems that cause the pain nerve to 
remain in active pain, even though the initial injury might heal.'' 
[Tr. 386]. Up to the time of the hearing, the Respondent treated from 
five to ten-thousand pain management patients seeking treatment for 
acute injuries all the way to chronic palliative care. [Tr. 390]. 
However, the Respondent is not Board certified in pain management. [Tr. 
391].
    6. At the hearing, Dr. Danton was recognized as an expert in the 
field of osteopathic medicine with extensive experience in pain 
management assessment and treatment. [Tr. 392].
    7. Dr. Danton described how the human body becomes dependent on 
pain medications and how the body grows to tolerate pain medication. 
[Tr. 395-399]. The Respondent testified that she restricted her 
patients to taking four 15 mg oxycodone tablets a day. [Tr. 400].
    8. In diagnosing muscular-skeletal injuries, the more important 
part of the diagnostic tools would be the MRI, for it is objective 
evidence of such an injury. [Tr. 558].
    9. Prior to opening her own practice, the Respondent worked at a 
pain clinic called the Pain Center of Broward. [Tr. 554]. She also 
supervised a physician assistant, signing all the controlled substance 
prescriptions herself. The role of the physician assistant is to 
examine patients and to either continue or follow the physician's 
treatment plan, or if the physician assistant sees any noted change in 
the patient's condition based on the examination, to inform the 
physician of the change. The physician would write the prescription 
appropriately. [Tr. 570].
    10. The Respondent testified that, although over 400,000 dosage 
units of oxycodone were attributable to her per the ARCOS reports, she 
in fact did not see all of the patients represented by this dosage 
number. The physician assistant saw multiple patients per day as well. 
[Tr. 526, 554]. Another physician was hired, and the Respondent does 
not know whether controlled substances purchased using the Respondent's 
DEA registration were actually dispensed by this physician as well. 
[Tr. 555]. The Respondent left that practice when her ``180 program'' 
was not being followed. [Tr. 526]. She left her DEA Form 222s at the 
Pain Center of Broward when she left the practice. [Tr. 556].
    11. When asked if ``any time an order was placed using your DEA 
number, was that an order done appropriately and legitimately or for 
other purposes,'' the Respondent replied that she was not sure. 
Specifically, she stated that the DEA Form 222s she signed ``were done 
appropriately and legitimately, but if my former employer went and 
ordered stuff and signed my name to it, I had no knowledge or concept 
that it was being done.'' [Tr. 574-75]. It's possible that some of the 
over 400,000 dosage units were ordered without the Respondent's 
knowledge. [Tr. 575].
    12. The Respondent primarily wrote prescriptions using a computer. 
However, she did have prescription pads, and it was possible that such 
a pad was outside her control on the day the search and seizure warrant 
was executed, although she did not intentionally leave such a pad 
outside her control. [Tr. 557]. The Respondent was a dispensing 
physician. [Tr. 210, 237, 341, 346-47, 362].
    13. A pain management clinic would dispense a large number of 
oxycodone

[[Page 60906]]

because the clinic's patients are being seen regularly for chronic pain 
problems and obtaining controlled substances every month. [Tr. 527]. 
The Respondent also believed this over 400,000 dosage units figure 
reported in ARCOS actually corresponds to the number of chronic pain 
patients she and Dr. Jacobs treated. [Tr. 528].
    14. Dr. Danton developed a treatment program she described as the 
``180 program.'' [Tr. 402]. The essential point of the 180 program was 
to help patients control their pain without developing tolerance to the 
pain medication and to keep the patient safe from a drug overdose. [Tr. 
402]. To her knowledge, Dr. Danton is the only physician who limits 
oxycodone prescriptions to 180 dosage units of 15 mg oxycodone. [Tr. 
403]. However, depending on the patient's pain level and the diagnosis, 
the Respondent would sometimes prescribe 30 mg oxycodone. [Tr. 403].
    15. Dr. Danton described a bulging disc as a disc between vertebrae 
in the back that acts as a gel-filled shock absorber. After a high 
velocity injury, the gel begins to thin out and form a bulge of the 
disc material outward, pressing on the nerve roots, causing pain. [Tr. 
406-09].
    16. Dr. Danton described a herniated disc as a disc where the gel 
actually cracked out of the disc and escapes into a very small space in 
the spine, causing more pressure on the nerve roots, thus causing more 
pain. [Tr. 410]. The added pressure can also cause inflammation, which 
causes swelling around the nerve roots, making the pain worse as well. 
[Tr. 410-11].
    17. Scoliosis is an abnormal curvature of the spine and can cause 
pain. [Tr. 417-19]. The nerve roots in the back become impinged and 
inflammation around the nerve roots results which causes the pain. [Tr. 
419]. Scoliosis comes in degrees, and the severity of the scoliosis 
impacts upon the severity of the pain. [Tr. 419-20]. If a patient 
elects not to have surgery, then the appropriate treatment is pain 
management with analgesics. [Tr. 420].
    18. To diagnose and treat scoliosis, Dr. Danton would ask about the 
patient's history, to determine whether the scoliosis was developmental 
and to find out what kind of past treatment the patient has 
experienced. [Tr. 421]. A prior physician would have prescribed an MRI, 
and the patient would bring that MRI report for Dr. Danton to review. 
[Tr. 421-23]. Unlike an X-ray, an MRI shows soft tissue changes such as 
impingement of nerves caused by a herniation of a disc. [Tr. 423-24].
    19. To determine if a patient has either a bulging disc or a 
herniated disc, the Respondent listens to the level of the patient's 
complaint, looks at the medical history forms, and evaluates how the 
patient moves into the treatment room, watching how the patient walks 
and sits as part of the physical examination. [Tr. 412-13]. Next, Dr. 
Danton would look at a purely objective evaluation, such as an MRI. 
[Tr. 414]. She is also evaluating the consistencies of the MRI with the 
patient's complaint, and looking to see if the patient is honest and 
truthful. [Tr. 414]. Patients who are not honest and truthful tend to 
exaggerate their pain levels, so that their complaints do not match up 
with their MRI results. [Tr. 415-16]. The Respondent also testified 
that when patients subjectively rated their pain level, she interpreted 
that rating to mean their pain level with medication. Therefore, if a 
patient rated his pain at 2, then she interpreted the patient's pain to 
be at a level 7 without pain medication. [Tr. 469-70].
    20. According to Dr. Danton, a physical examination does not 
necessarily ``entail touching the body.'' [Tr. 425]. For example, in 
the chronic injury ``you can't see--whether you're putting your hands 
on the patient or not, you can't see that evidence of chronic 
inflammation and disease by visual inspection or palpation.'' [Tr. 
428]. But the physician can inspect the painful area, can get an idea 
of the pain by watching the patient move the body, which is also a part 
of the physical examination. [Tr. 428-29]. Although different now, in 
early 2010, the physician also needed to get a urinalysis test within 
the first four to six months of treatment with oxycodone. [Tr. 429].
    21. The Respondent prescribed 2 mg tablets of Xanax or alprazolam. 
She described this as a moderate dose, and she instructed her patients 
to take .5 mg during the day, .5 mg in the evening, and 1 mg at night. 
If the patient stops taking Xanax in these quantities, there would be 
no adverse side effects. [Tr. 535].
    22. The Respondent was aware that a complete medical history and 
physical examination must be conducted and noted in a patient's medical 
file. [Tr. 557].
    23. The Respondent has been convicted of four counts of mail fraud, 
but the record contains no information that this conviction entailed 
the handling of controlled substances. [Tr. 560].

C. Respondent's Practice

    24. The Respondent is neither a DATA-waived physician nor 
registered as a Narcotics Treatment Program. [Tr. at 533]. The 
Respondent denied providing her patients with detoxification services. 
[Tr. 533]. However, she did see her role as ``to educate patients how 
to take medicine safely and how to safely get off, away from the 
narcotics. That was my goal.'' [Tr. 581]. She also stated her goal was 
to have patients functioning at ``100%.'' [Tr. 500]. The Respondent is 
also not registered as a pain management clinic with the Florida 
Department of Health. [Tr. 185].
    25. Mr. Gordon Berman worked with the Respondent as the primary 
administrator of her practice. He owned the building. [Tr. 163].\18\ He 
ordered the medications, maintained the records, and ensured the 
practice's procedures were consistent with the legal requirements. [Tr. 
505]. He was also responsible for dispensing the medications and for 
conducting the inventories. [Tr. 163]. As of November of 2010, no 
inventories had been conducted. [Tr. 178, 183]. Mr. Berman is not a 
licensed pharmacist, and has had no previous experience dispensing 
drugs or controlled substances. [Tr. 190].
---------------------------------------------------------------------------

    \18\ Mr. Berman did not testify at the evidentiary hearing. 
Therefore, to the extent that the conversation he had with DI McRae 
constitutes hearsay, I will analyze the weight to give such evidence 
accordingly.
---------------------------------------------------------------------------

    26. Mr. Berman told DEA personnel that he was aware of the State 
law which had come into effect on October 1, 2010, providing that only 
a 72 hour supply of medication could be dispensed. [Tr. 185]. However, 
in November of 2010, he had dispensed 180 oxycodone 30 mg., a one-month 
supply. [Govt. Exh. 2 at 4-6; Tr. 185]. He stated that he knew of the 
limitations, but that he had just dispensed the entire amount. [Tr. 
185].
    27. Mr. Berman had told DEA personnel that every patient basically 
received the same thing; 180 oxycodone 30 mg., Xanax, Ibuprofen, and 
Soma. [Tr. 185-86; see also Govt. Exh. 2-5]. The medication was 
purchased in pre-measured volumes of 90 oxycodone, and the physician 
would issue an order sheet showing the amount to be dispensed. Mr. 
Berman would receive the order sheet, he would hand an employee the 
requisite amount of medication, and the employee would take the 
medication to the physician for review, the physician would sign the 
order sheet and either hand the medication to the patient or instruct 
the employee to do so. [Tr. 190]. The Respondent did not have access to 
the computers, and when questioned about them, she referred DI McRae to 
Mr. Berman. [Tr. 170].

[[Page 60907]]

    28. The Respondent accepted cash as a form of payment. It is 
unclear whether this was the sole form of payment accepted. The 
Respondent stated to DI McRae that to accept insurance would require a 
billing department, and that would cost a lot. [Tr. 165-66]. Further, a 
Diversion Investigator overheard the receptionist tell a patient that 
the clinic only accepted cash. [Tr. 226-7]. However, Mr. Berman stated 
that the practice also accepted Medicaid and Medicare. [Tr. 184]. The 
office visit cost $200.00,\19\ and the medication cost $600.00 per 
patient. [Tr. 170].
---------------------------------------------------------------------------

    \19\ However, I note that the undercover officers paid $150.00 
for their office visits. [Tr. 288, 337].
---------------------------------------------------------------------------

    29. Mr. Berman had a nine-year-old daughter who would sometimes 
come to the office after school. When Ms. Hall saw Mr. Berman and his 
daughter walking in the hallway, Mr. Berman said that his daughter was 
a good little helper, and that he had her counting pills.\20\ [Tr. 215; 
Govt. Exh. 14B at 27]. However, Ms. Hall did not observe the child 
handling pills and the Respondent credibly testified that she never saw 
the daughter touch any pills. [Tr. 259, 589].
---------------------------------------------------------------------------

    \20\ As Mr. Berman did not testify at this proceeding, I am 
unable to determine the credibility or sincerity of this comment. 
Therefore, I give this exchange no weight.
---------------------------------------------------------------------------

    30. The Respondent's job was patient care, making sure the patients 
were appropriately treated. The Respondent also managed the front 
office. [Tr. 505]. The Respondent told DI McRae that she saw between 25 
and 50 patients a day. [Tr. 166]. She had told DI McRae that she did 
not dispense controlled substances on the first visit of a patient. 
[Tr. 167].\21\
---------------------------------------------------------------------------

    \21\ This is inconsistent with her conduct regarding the 
undercover visits. Therefore, I give this testimony no weight.
---------------------------------------------------------------------------

    31. Another physician in the practice, Dr. Jacobs, is also 
practicing the Respondent's ``180 program.'' [Tr. 592].
    32. The Respondent acknowledged that the medications were ordered 
under her DEA registration number and that she took full responsibility 
for them. [Tr. 506, 516]. Yet she acknowledged that she gave people 
authority to take certain actions using her registration. [Tr. 507]. 
She stated that to the best of her knowledge ``we were doing everything 
that we thought'' was within the law. [Tr. 507]. There was no power of 
attorney on file affording Mr. Berman with the authority to sign the 
order forms for the controlled substances. [Tr. 163].
    33. When the Respondent became aware of discrepancies, she made 
corrections. She learned that her pain patients could be manipulative, 
and she ``became a little harder and a little more careful in how'' she 
responded to her pain patients. [Tr. 508-09].
    34. The Respondent's office was burglarized four times, and her 
computer systems with all the backups were stolen. [Tr. 515]. The 
computers the Respondent had on November 23, ``were basically only a 
month old, and the information on them was basically information from a 
month or two.'' [Tr. 515]. Three of the four break-ins occurred when 
the Respondent had no oxycodone on the premises. But in the instances 
that drugs were stolen, the Respondent did not handle informing the 
DEA. The thefts were reported to the Sheriff's Department but not to 
the DEA. [Tr. 122-23, 125, 549]. The Sherrif's Department made no 
mention of the Respondent's obligation to inform the DEA. [Tr. 514]. 
The Respondent credibly testified that she believed the Sherrif's 
Department would handle that responsibility. [Tr. 550]. No DEA theft 
and loss reports were found. [Tr. 125].
    35. For security measures, the Respondent had an alarm system, 
video camera system, and security doors as required between the 
treatment area and the medication room. [Tr. 518]. The oxycodone was 
stored in the medication room. [Tr. 518]. Mr. Berman told the 
Respondent that the facility had been inspected and found to be in 
compliance. However, the Respondent did not know who had inspected the 
facility, and the record does not contain any inspection reports 
indicating such compliance. [Tr. 550].
    36. Ms. Danielle Demers, an employee of the Respondent's, would 
bring her Rottweiler to the office wearing a police service dog vest. 
The dog was a deterrent and stayed in the administrative area of the 
office. [Tr. 516-17]. Ms. Demers wore a police belt with a tazer and a 
baton, but she did not carry a firearm in the clinic. [Tr. 517-18]. Ms. 
Demers was subsequently terminated from her employment. She worked for 
the Respondent approximately five months. [Tr. 520].
    37. Ms. Demers had access to all the records in the practice, to 
include inventory records, DEA Form 222s, and invoices. She also had 
access to the computer systems. [Tr. 520-21]. She knew what security 
measures were in place. [Tr. 521].
    38. The Respondent used two large safes behind the secured medicine 
room doors. One safe was for the Respondent's medications, and the 
other safe held the medications of Dr. Jacob.\22\ [Tr. 521-522, 592]. A 
pharmacy tech, Ms. Teresa Way, had access to the medication, Mr. Berman 
had access, and Ms. Demers had access. Ms. Terry Friedman, an employee 
who worked with the Respondent since she started this practice, may 
also have had access to the medications. [Tr. 522].
---------------------------------------------------------------------------

    \22\ It is unclear when these safes were added to the premises. 
The Government did not see any safes when personnel conducted a 
search of the offices in November of 2010. [Tr. 63, 115] In 
addition, it is similarly unclear whether a safe is depicted in 
Government Exhibit 9.
---------------------------------------------------------------------------

    39. The physician would prepare a charge sheet, noting the 
prescriptions authorized for the patient. The charge sheet would go to 
the pharmacy technician for filling. [Tr. 590]. [See Resp. Exh. 1-3]. 
For her patients, the Respondent would then sign the prescriptions. 
[Tr. 590].
    40. The Respondent has interpreted approximately four or five 
thousand MRI written reports in the course of her medical practice. 
[Tr. 561]. In reviewing the MRI reports pertaining to the undercover 
individuals, the Respondent saw nothing that led her to believe the 
reports were fraudulent, modified or illegitimate. [Tr. 561].
    41. The Respondent tried to ``correspond the patient's history and 
their presentation with the MRI report, and in those three (undercover) 
cases they seem to match.'' [Tr. 561]. Later in her practice, the 
Respondent instructed her front office personnel to call and verify the 
MRI report. If the office staff was unable to do so, they were 
instructed to require the patient to take another MRI locally. [Tr. 
586]. ``We didn't do that in the first three months because at that 
point in time I was, and I accept responsibility for it, I was 
na[iuml]ve. And I believed if somebody brought in an MRI that had their 
name on it and the doctor's signature, that it was a real MRI. I found 
information to the contrary. I changed.'' [Tr. 586].

D. DEA's Investigation

    42. On November 23, 2010, the DEA served a Federal search warrant 
at the Respondent's office, as well as the Immediate Suspension Order. 
[Tr. 19]. The clinic had the name posted as J.A. Danton. [Tr. 47]. 
During the search, Group Supervisor Susan Langston discovered a closet 
containing video equipment and several bottles of oxycodone 30 mg, 100 
count each. [Tr. 21, 112-13; see also Tr. 111; Govt Exh. 9]. This 
closet was located in Mr. Berman's office on the second floor of the 
clinic. [Tr. 22]. GS Langston testified that the closet was not a 
securely locked, substantially constructed cabinet suitable for the 
storage of controlled substances, however could not testify as to why 
it did not meet this requirement. [Tr. 22]. The pill bottles

[[Page 60908]]

were all sealed. [Tr. 112]. GS Langston did not know whether the closet 
was locked, and did not inspect the closet. [Tr. 48, 55]. In addition, 
DI Milan, who also saw the closet, stated she did not know whether the 
closet was locked or could be locked, she was not the first to see the 
closet, it was already open when she saw it, and that she did not 
otherwise investigate whether the Respondent had security on the 
premises. [Tr. 109-111].
    43. Also during the search, GS Langston located an empty 
prescription bottle with a label showing that the bottle had contained 
360 Oxycodone 30 mg tablets. The bottle was found in the Respondent's 
office on the first floor of the facility, and the label indicated that 
the medication was prescribed by Dr. Jack Danton to patient Jacqueline 
Danton, a name the Respondent also used. [Tr. 23, 377].
    44. During an interview with a local reporter, the Respondent 
asserted that she was not providing her patients with large quantities 
of oxycodone, she was weaning them off the drug. [Govt. Exh. 19].
    45. GS Langston identified ``red flags'' from the Respondent's 
practice. First, she received telephone calls from pharmacists 
inquiring as to whether prescriptions written by the Respondent were 
legitimate. [Tr. 36-37, 45]. GS Langston also thought it significant 
that the Respondent saw a large number of people from out of state. 
[Tr. 45-46; see also Tr. 93-95; Govt. Exh. 4].
1. The Audit
    46. DI Marjorie Milan also participated in the serving of the 
Immediate Suspension Order. [Tr. 68]. Her assignment was to collect any 
controlled substances that were on the premises. [Tr. 69]. DI Milan 
found bottles of oxycodone 30 mg. She found a total of 4,000 pills. 
[Tr. 69-70].
    47. DI Milan ran an ARCOS \23\ report, searching for the oxycodone 
purchases made using the Respondent's DEA registration number from 
January 1, 2009, through March 31, 2011. [Tr. 70-71]. The first 
transaction date was December 28, 2009, and the last transaction date 
was November 15, 2010. [Tr. 72; Govt. Exh. 18]. To order oxycodone, the 
purchaser would need to use a DEA Form 222. [Tr. 72]. The Respondent 
was ranked in the top 100 practitioners purchasing oxycodone throughout 
the United States. [Tr. 151].
---------------------------------------------------------------------------

    \23\ARCOS stands for automation of reports and consolidated 
ordering system. [Tr. 70; see also 99-101].
---------------------------------------------------------------------------

    48. DI Milan used the ARCOS information to identify the suppliers 
of oxycodone to the Respondent. [Tr. 73]. She then contacted the 
suppliers and received copies of the DEA Form 222 and invoices for the 
purchases made to the Respondent from Paragon Enterprises, Inc., 
Dispensing Solutions, Sunrise Wholesale, Inc., and Anda, Inc.. [Tr. 74-
80; Govt. Exh. 6]. The DEA Form 222 indicates the drug shipped, the 
date shipped, and the quantities shipped. [Tr. 77]. The DEA Form 222s 
were those issued to the Respondent. [Tr. 108].
    49. DI Milan also reviewed the purchase orders that were seized 
from the Respondent during the execution of the search warrant. [Tr. 
81-82; Govt. Exh. 7].
    50. DI Milan conducted an audit of oxycodone products from the 
beginning of business on December 1, 2009, through the close of 
business on November 23, 2010. [Tr. 87-88; Govt. Exh. 1]. DI Milan did 
not find an initial inventory in the records that were seized, so the 
beginning inventory amounts were recorded as ``0''. The computation 
chart is as follows:

                                                         Controlled Substances Computation Chart
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                 Initial     Received*      Total       Closing     Distributed*      Total                    Percent
          Drug name, strength, form             inventory       \1\       accounted    Inventory         \2\        accounted    Deviation    deviation
                                                         A            B    A + B = C            D               E    D + E = F    F - C = G      G/C = %
--------------------------------------------------------------------------------------------------------------------------------------------------------
Oxycodone 30 mg Tablets......................            0      260,700      260,700        4,224         156,753      160,977      -99,723       -38.25
Oxycodone 15 mg Tablets......................            0       18,340       18,340            0           8,880        8,880       -9,460       -51.58
Oxycodone 10 mg Tablets......................            0          500          500            0             200          200         -300       -60.00
Oxycodone 5 mg Tablets.......................            0        1,600        1,600            0             100          100       -1,500       -93.75
Oxycodone 10 mg/325 mg Tablets...............            0        3,700        3,700            0           2,580        2,580       -1,120       -30.27
Oxycodone 5 mg/325mg Tablets.................            0        3,600        3,600            0             300          300       -3,300       -91.67
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Suppliers: Paragon Enterprises, Dispensing Solutions, Sunrise Wholesale, ANDA Inc. (December 2009-November 2010).
\2\ Daily Dispensed Prescriptions.
* Includes Returns from Customers.
** Includes Returns to Suppliers, Thefts and Surrenders.

    [Tr. 87-90; Govt. Exh. 1]. The Respondent was unable to account for 
a shortage of 99,723 dosage units of oxycodone 30 mg, and a shortage of 
9,460 dosage units of oxycodone 15 mg tablets. [Govt. Exh. 1]. Only the 
Respondent's DEA registration was used to compute the audit figures. It 
is unclear in the record whether Dr. Jacobs' DEA number was ever used 
to order controlled substances. [Tr. 190-91].
    51. In looking at the prescriptions, DI Milan discovered that a 
number of the prescriptions did not have the required dispensing labels 
on the back of the prescriptions. [Tr. 97]. Further, a number of the 
paper copies of DEA Form 222s failed to have the received column and 
the date column properly completed. [Tr. 121-23; Govt. Exh. 7]. A power 
of attorney from the Respondent authorizing another to act on her 
behalf in filling out the DEA Form 222 was not found during the search 
of the Respondent's premises. [Tr. 122].
2. Patient Interviews \24\
---------------------------------------------------------------------------

    \24\ To the extent that this evidence constitutes hearsay, I 
will afford it less weight in forming my opinion below.
---------------------------------------------------------------------------

    52. DI McRae interviewed a patient from Kentucky. He had heard 
about the

[[Page 60909]]

Respondent from someone in Kentucky, and he had been to the clinic 
several times. [Tr. 174]. He said he had been buying Lorcet or Lortab 
off the street, and ``he realized that it was cheaper for him to come 
drive to South Florida to get oxycodone at the pain clinic.'' [Tr. 
174].
    53. GS Langston interviewed some of the Respondent's patients. She 
interviewed a lady, D. L., who admitted that day to having taken 5 
oxycodone 30 mg tablets. GS Langston observed that this woman was 
``highly under the influence'' of the medication. [Tr. 25, 44]. The 
woman was one of three people from Kentucky, and she had seen the 
Respondent the day before. The lady had received 180 oxycodone 30 mg. 
tablets. GS Langston saw the pill bottle, and credibly testified that 
there were at least twenty pills missing. [Tr. 26]. The lady's husband 
was to see the Respondent that day, and the third person, the lady 
could not remember her name, was waiting to join them for the return 
trip to Kentucky. [Tr. 25].
    54. Also during the March 2010 visit, Ms. Hall talked with two 
individuals from Kentucky. One of the individuals explained that the 
doctor would not give him 180 30 mg. pills, but he would give the man 
360 15 milligram pills. [Tr. 218].
    55. Task Force Officer (``TFO'') Thomas interviewed patients of the 
Respondent in August of 2010. [Tr. 128]. The patients were from Ohio, 
and they stated that they could not get the quantity of oxycodone in 
Ohio that they could get in Florida. They had heard of the Respondent's 
practice through word of mouth in Ohio. [Tr. 128-29]. They first 
started seeing the Respondent in June of 2010, when they received 180 
dosage units of 30 mg oxycodone, some Soma, Xanax, and Ibuprofen. [Tr. 
129]. The doctor and the patients talked about pain levels and 
locations of pain, but no physical examination or range of motion 
testing was conducted. [Tr. 129]. The encounter lasted probably less 
than ten minutes. [Tr. 129]. The same procedures were used on the 
second and third visits. During the first two visits, the patients were 
dispensed medication from the clinic, but on the third visit, the 
patients received prescriptions because the clinic had just moved to a 
new location, and the dispensary had not been set up yet. [Tr. 129-30].

E. Undercover Transactions

    56. At the time Dr. Danton treated the undercover personnel, it was 
not a requirement to conduct a urinalysis or a blood test prior to 
treating a pain patient. [Tr. 429-30]. Effective November 8, 2010, the 
law changed and required the physician to order a urinalysis before 
being allowed to prescribe controlled substances. [Tr. 430-31, 577-79; 
Fla. Admin. Code r. 64B15-14.0051(2)(f) (2010)]. The urinalysis will 
determine whether or not the patient is taking the prescribed 
controlled substances, and whether or not the patient ingested illicit 
drugs. [Tr. 596]. If a patient is found to have taken illicit drugs, 
the physician is to discharge that patient from the doctor's practice. 
[Tr. 431]. On the day of the search warrant, November 23, 2010, DI 
McRae noted that she was told that the Respondent had run out of 
urinalysis kits, and no such tests had been taken for the past three 
days. [Tr. 168].
    57. Sometimes the Respondent saw patients in a group. She would 
explain her ``180 program,'' and if the patients did not object, she 
would review each person's MRI and fill out the drug order form for 
that patient in the group setting. Sometimes she would have as many as 
a dozen people sitting through this process. [Tr. 168-69]. If a patient 
wanted to be seen one-on-one, the Respondent would accommodate that 
request. [Tr. 186, 169].
    58. The Respondent did not refer any of her patients out to other 
doctors. [Tr. 169].
    59. During follow-up visits, the Respondent did not ask any of the 
undercover individuals how many oxycodone, Xanax, or Soma they had left 
from their previous prescriptions. [Tr. 537]. However, if the patient 
did not have to take any medication for break-through pain, the 
Respondent would lower the quantity of medication prescribed to that 
patient. [Tr. 579]. However, none of the medical charts in this record 
demonstrate such action. [Resp. Exh. 1-3].
    60. If the Respondent's medical files had no notations regarding 
her observations of a patient's movements, that indicated to the 
Respondent that she had not observed anything inappropriate or 
inconsistent with the patient's complaint and diagnosis. [Tr. 543]. If 
the Respondent did witness suspicious conduct, i.e. ``complained of 
pain * * * bent over and jumped up in the air'' that would have been 
noted. [Tr. 543].
    61. Per the Respondent, the majority of the patients received a 
prescription for oxycodone. [Tr. 548]. Previous doctors may have 
prescribed hydrocodone, felt uncomfortable prescribing oxycodone, and 
would refer the patients to a pain management clinic for further 
treatment. [Tr. 548-49].
    62. The patient files in this record contain no medical reports or 
documents from prior physicians as related to the three undercover 
personnel. When asked if she had ordered such information, the 
Respondent stated that she could not recall. [Tr. 576-77; Resp. Exh. 1-
3].
1. Tanya Hall \25\ (Special Agent Hayes)
---------------------------------------------------------------------------

    \25\ I will refer to the undercover operatives by their 
undercover names to coincide with the documentary evidence in this 
case. [Tr. 208; Resp. Exh. 1].
---------------------------------------------------------------------------

    63. On February 15, 2010, Ms. Hall visited with the Respondent, and 
the visit was audio-recorded. [Tr. 203; Govt. Exh. 14A \26\]. The audio 
recording was subsequently transcribed. [Tr. 205; Govt. Exh. 14B]. Ms. 
Hall signed in and placed her reason for the visit as ``for meds.'' 
[Tr. 206]. Ms. Hall was asked for a copy of her identification and for 
her MRI report. [Tr. 207]. Ms. Hall was informed that she had to watch 
a video before seeing the doctor. The video was of Dr. Danton 
describing her prescribing of medications and her ``180 program.'' [Tr. 
207].
---------------------------------------------------------------------------

    \26\ The actual visit begins at the 1 hour and 45 minute point 
of the audio recording. [Tr. 204].
---------------------------------------------------------------------------

    64. Ms. Hall was given paperwork to fill out, including a pain 
assessment form. Pain was to be rated from one to ten, and Ms. Hall 
rated her pain at a level 3. [Tr. 207; Resp. Exh. 1]. Ms. Hall signed a 
document stating ``there will be no exception to [the rule that the 
maximum amount of 2.0 mg Xanax should be no more than 60 tablets in a 
28 day cycle], so please do not ask the doctor to make an exception for 
you.'' [Resp. Exh. 1 at 8]. In addition, Ms. Hall signed documents 
consenting to be drug screened and acknowledging that a positive test 
result ``disclosing the prescence of an illegal substances no 
prescribed my [sic] any physician associated with Boca Pain and 
Wellness, will result in immediate termination as a patient * * *.'' 
[Respt. Exh. 1 at 9, 10]. Further, Ms. Hall signed a document stating 
that ``lost, stolen or misplaced narcotics will not be replaced'' and 
another form documenting that it is a third degree felony under Florida 
law to possess or attempt to possess a controlled substance by fraud.'' 
[Respt. Exh. 1 at 11, 12].
    65. Ms. Hall was directed to sit in a chair across the desk from 
the Respondent. [Tr. 208]. She was not required to provide a urine 
sample during the visit. [Tr. 208]. Ms. Hall stated that she did not 
receive a physical examination. [Tr. 208]. Ms. Hall told the Respondent 
that she had used Vicodin before. However, she did not tell the 
Respondent that she was currently using Vicodin or any other controlled 
substances. [Tr. 209]. The

[[Page 60910]]

Respondent told Ms. Hall that she had probably built up a tolerance to 
the Vicodin, and then offered to provide Ms. Hall with Percocet. Ms. 
Hall declined the Percocet, saying that the acetaminophen in the 
Percocet upset her stomach. [Tr. 274]. Although the Respondent clearly 
doubted the upset stomach, and Ms. Hall subsequently stated it didn't 
upset her stomach, the Respondent offered the oxycodone 15 mg rather 
than Percocet, pursuant to the patient's request. [Tr. 274; Govt. Exh. 
14B at 11-13]. The Respondent later reiterated that she would have 
preferred to have given the patient Percocet. [Govt. Exh. 14B at 19].
    66. Ms. Hall complained of neck and shoulder pain. [Resp. Exh. 1 at 
6]. Her MRI report stated that the bottom of her spine had evidence of 
thinning of the disc. [Tr. 444; Resp. Exh. 1]. Under impressions, the 
MRI reported mild spondylosis, which means that there was some slippage 
of one vertebra onto another, which can cause pressure on the spine. 
[Tr. 444; Resp. Exh. 1]. Such spondylosis may cause ``a chronic 
impingement of that nerve'' which would cause chronic pain. [Tr. 445]. 
Such an MRI impression was ``more significant than the patient's 
description of their pain levels because * * * patients tend to under-
exaggerate or over-exaggerate their symptoms.'' [Tr. 445].
    67. Ms. Hall told the Respondent that she had had an automobile 
accident in 1999 and in 2003, and she had slipped and fallen on the ice 
in December of 2009, [Govt. Exh. 14B at 9], which could have aggravated 
her spinal condition. [Tr. 446-47; 245; 612]. She also had an accident 
where a box of chicken tenders had fallen on her while she worked in a 
cafeteria. [Tr. 245; Govt. Exh. 14B]. The Respondent noted that the 
injury in 1999 could have resulted in osteophytes and slippage, and the 
slip and fall on the ice could have aggravated the situation, as well 
as the accident resulting in the box of chicken tenders falling on the 
patient. [Tr. 246, 447].
    68. The MRI also noted disc osteophytes, which are bony protrusions 
on the discs that develop over time. [Tr. 446, 452]. The osteophytes 
were consistent with Ms. Hall's history of having been in accidents in 
1999 and 2003. [Tr. at 446-447]. Osteophytes indicate that the injuries 
were chronic. [Tr. 451]. Ms. Hall's MRI showed more damage to her spine 
than the MRIs for Mr. Castillo and Mr. Swanson. [Tr. 542-43]. The 
Respondent further found that ``[i]t had more extensive damage, but the 
extent of the extensive damage I didn't consider warranted increasing 
the medication beyond the starting dose of 15 milligrams.'' [Tr. 563].
    69. The Respondent did not find that the MRI was suspicious, in 
that it did not look fraudulent, modified or illegitimate. [Tr. 561]. 
Specifically, the Respondent was able to correspond the patient's 
history and her presentation with her MRI report. [Tr. 561]. The MRI 
report stated that it was conducted at Ingalls Memorial Hospital in 
Harvey, Illinois. [Respt. Exh. 4 at 5]. The Respondent asked Ms. Hall 
whether she always ``drove this way'' from Harvey Illinois, to which 
the patient responded, ``Well, I'm kind of back and forth; I'm thinking 
about moving here `cause I recently lost my jobs and I got some 
friends'' down here. [Govt. Exh. 14B at 7].
    70. The Respondent did not notice anything specifically when 
observing Ms. Hall walking and standing. [Tr. 449]. Such an observation 
would be consistent with the MRI results, however, since the initial 
accident which would have caused the initial injury happened seven to 
eleven years earlier. [Tr. 448-49]. The Respondent credibly testified 
that Ms. Hall may have ``compensated * * * for that injury.'' [Tr. 
449].
    71. The Respondent diagnosed Ms. Hall as having a bulging disc with 
mild spondylosis, a disc slippage, and disc osteophytes. [Tr. 464]. Ms. 
Hall had been given Vicodin and Tylenol No. 3 by another provider. [Tr. 
464; Resp. Exh. 1 at 1]. The Respondent relied upon the history of two 
motor vehicle accidents, her slip and fall, and the accident with the 
boxes. [Tr. 464]. The Respondent also relied upon Ms. Hall's 
description of her pain as a level three. [Tr. 465].
    72. Ms. Hall presented no red flags, per the Respondent, for she 
was not ``over-exaggerating'' her pain. [Tr. 466].
    73. The Respondent's treatment plan was to enter Ms. Hall into her 
``180 program.'' \27\ [Resp. Exh. 1 at 1]. Ms. Hall's patient chart 
indicates under ``plan'' the controlled substances prescribed by the 
Respondent on each visit, yet does not document anything else. [Respt. 
Exh. 1 at 1, 15, 20].
---------------------------------------------------------------------------

    \27\ This program will be discussed in greater detail infra.
---------------------------------------------------------------------------

    74. The first visit lasted about 15 to 20 minutes. [Tr. 209]. Ms. 
Hall refused the offered Percocet, and the Respondent then offered 
oxycodone. [Tr. 210]. The Respondent prescribed her 180 oxycodone 15 
mg. [Tr. 211, Resp. Exh. 1 at 1]. When asked if she had anxieties, Ms. 
Hall responded ``sometimes.'' [Tr. 210]. Ms. Hall credibly testified 
that the Respondent said she would prescribe the Xanax but ``didn't 
care if I took it.'' [Tr. 210; Govt. Exh. 14B at 16]. The Respondent 
prescribed her 30 Xanax 2 mg. [Resp. Exh. 1 at 1].
    75. When asked if she had trouble sleeping, Ms. Hall again 
responded ``sometimes.'' [Tr. 210]. The Respondent then agreed to 
prescribe the Soma, and she told Ms. Hall to take the Xanax and Soma 
together to help her sleep. [Tr. 210].
    76. Ms. Hall partially filled the prescriptions in house with the 
Respondent. Ms. Hall received 30 Xanax 2 mg, 30 Soma 350 mg, and 90 
Ibuprofen, 800 mg. [Tr. 212-13; Govt. Exh. 10; Resp. Exh. 1 at 5]. The 
Respondent told her that the clinic had run out of oxycodone 15 mg., 
and Ms. Hall returned on the 17th of February to get the oxycodone 
prescription filled. [Tr. 211-12; Govt. Exh. 10]. Although the receipt 
indicates that Ms. Hall received 90 oxycodone, she actually received 
180 oxycodone. [Tr. 212].
    77. Ms. Hall next visited the Respondent on March 22, 2010. The 
receptionist took Ms. Hall's blood pressure and weighed her. Ms. Hall 
asked Ms. Demers, the receptionist, if she and Mr. Castillo could get 
in to see the Respondent faster, and Mr. Castillo offered Ms. Demers 
$100.00. Ms. Demers took the money and said she'd see what she could 
do. [Tr. 216-17, 254].
    78. During this visit, Ms. Hall observed a male patient yelling at 
a female patient, saying ``What are you doing with 15 milligrams?'' He 
pointed to the examining room and told the female patient to ``Get back 
in there and get 30.'' \28\ [Tr. 217]. The male patient then asked for 
the price of prescriptions for four individuals, and he paid cash for 
their prescriptions. [Tr. 217].
---------------------------------------------------------------------------

    \28\ The record contains no evidence, however, that the 
Respondent actually prescribed or otherwise provided 30 mg. 
oxycodone for this patient. In addition, the Respondent testified 
that this patient was later discharged. [Tr. 545].
---------------------------------------------------------------------------

    79. During this visit, Ms. Hall was with Mr. Castillo.\29\ The 
Respondent saw Ms. Hall and Mr. Castillo together. They were directed 
to sit in front of the Respondent's desk. The Respondent gave Ms. Hall 
a pain assessment sheet, and Ms. Hall circled her left shoulder. Ms. 
Hall did not participate in a urinalysis test on this visit. [Tr. 219-
22]. Ms. Hall told the Respondent that she did kickboxing. [Tr. 276]. 
The Respondent gave Ms. Hall the same prescription as on February 15, 
2010. [Tr. 220]. Again, Ms. Hall testified that she was not physically 
examined. [Tr. 220]. Ms. Hall asked if the Respondent would up the 
dosage of the Xanax, and

[[Page 60911]]

the Respondent refused to do that. [Tr. 221]. The Respondent did not 
note in Ms. Hall's medical file the number of pills she had left over 
from the first prescription. [Tr. 537; Respt. Exh. 1].
---------------------------------------------------------------------------

    \29\ Mr. Castillo is Mr. Cesar Flores. [Tr. 219].
---------------------------------------------------------------------------

    80. Ms. Hall received a receipt for 360 oxycodone 15 mg, and the 
receipt reflected Dr. Jacobs' name, even though Ms. Hall had seen Dr. 
Danton that day. [Tr. 222]. Further, Dr. Danton only prescribed 180, 15 
mg. oxycodone, but Ms. Hall actually received 360 oxycodone 15 mg., 30 
Xanax, 30 Soma and 90 Ibuprofen. [Tr. 222-23; Govt. Exh. 10].
    81. Next, Ms. Hall visited the clinic on April 20, 2010. Again, she 
was accompanied by Mr. Castillo. A video was taken of the visit, and a 
transcription was also made of the visit. [Tr. 223-25; Govt. Exh. 17A, 
B]. Again, Ms. Hall and Mr. Castillo saw the Respondent together. [Tr. 
228]. The Respondent asked Ms. Hall if the medication was working for 
her, and Ms. Hall responded yes. [Tr. 229]. Ms. Hall received 
prescriptions from Dr. Danton, and the receptionist explained that the 
clinic had run out of medication. [Tr. 236; Govt. Exh. 10]. The 
Respondent provided prescriptions for the same quantity, strength, and 
type of medications as the last visit. [Tr. 237; Govt. Exh. 10]. At no 
time did the Respondent ever try to lower the dose of oxycodone. [Tr. 
275]. The Respondent again did not ask how many pills Ms. Hall had left 
over from the prior prescription. [Tr. 537].
2. Pedro Castillo (Special Agent Flores)
    82. Mr. Castillo visited with the Respondent in February, March, 
and April of 2010. [Tr. 285; Govt. Exh. 15A \30\ and B]. His first 
visit was on February 15, 2010. [Tr. 287]. He paid $150.00 for the 
office visit. [Tr. 288]. Mr. Castillo told the Respondent that he had 
stiffness in his neck. He stated that he did not receive a physical 
examination, and he did not participate in a urinalysis test. [Tr. 
289]. The Respondent described to the patient her ``180 Program'' 
including the exercise component. [Govt. Exh. 15B at 23-42]. The 
Respondent described the medications that she offered, acknowledged 
that the Respondent had a mild disc bulge and stated that 30 mgs would 
be ``overkilling'' and that the Respondent does not need more than 15 
mgs of oxycodone. [Govt. Exh. 15B at 34-35]. The Respondent then asked 
the patient ``which medicine do you want?'' The patient responded ``I 
want oxys.'' The Respondent confirmed that the patient wanted 15 mgs 
and not 10 mgs. [Govt. Exh. 15 at 42]. Then, the Respondent discussed 
with the patient how he acquired his injuries. The patient told the 
Respondent that he had been in a motorcycle accident. [Govt. Exh. 15B 
at 44]. On the pain assessment form, Mr. Castillo noted that his pain 
was at level 2. [Tr. 290; Resp. Exh. 2 at 15]. Mr. Castillo told the 
Respondent that he was getting oxycodone from a friend. [Tr. 290]. Mr. 
Castillo did not complain of problems sleeping or of anxiety. [Tr. 
290].
---------------------------------------------------------------------------

    \30\ The actual visit with the Respondent begins at 2 hours and 
23 minutes on the audio recording. [Govt. Exh. 15A].
---------------------------------------------------------------------------

    83. Mr. Castillo's MRI \31\ noted mild scoliosis, with the 
``vertebral body heights and disc spaces * * * maintained despite the 
scoliosis, according to his interpretation.'' [Tr. 453]. Yet, when a 
specific analysis was written, the radiologist noted that there was 
mild bulging of the disc in the cervical spine. [Tr. 454]. The 
radiologist recommended that the physician interpret these results in 
conjunction with the clinical symptoms. [Tr. 454]. Dr. Danton explained 
that she would have ``to take the clinical symptoms and * * * the exam, 
[and the] neurological examination'' of the patient to determine if 
there was any significance to the bulging disc. [Tr. 454]. She further 
explained that if ``someone has a bulge but has no symptomatology, now, 
it's there * * * [but] it's not clinically significant.'' [Tr. 455]. 
The Respondent did not find that the MRI was suspicious, in that it did 
not look fraudulent, modified or illegitimate. [Tr. 561]. Specifically, 
she was able to correspond the patient's history and his presentation 
with his MRI report. [Tr. 561].
---------------------------------------------------------------------------

    \31\ The MRI did not have the name of the radiology facility 
written on it, but a physician's name was written on it [Resp. Exh. 
4 at 1; Tr. 532]. The Respondent did not verify this MRI. [Tr. 532].
---------------------------------------------------------------------------

    84. Dr. Danton's diagnosis for Mr. Castillo was a bulging disc in 
the cervical spine area. [Tr. 455, 463; Resp. Exh. 2 at 1]. The proper 
treatment for this chronic condition would be analgesics, for ``nobody 
would do surgery on a * * * bulge.'' [Tr. 456]. Mr. Castillo's patient 
chart indicates under ``plan'' the controlled substances prescribed by 
the Respondent on each visit, yet does not document anything else. 
[Resp. Exh. 2 at 1, 17, 20].
    85. Mr. Castillo presented no red flags in Dr. Danton's 
observations, which meant that he was probably legitimate, for he also 
was not over-emphasizing his injury. [Tr. 456]. Dr. Danton also noted 
that Spanish men, like her assessment of Mr. Castillo, ``in general 
tend to minimize * * * any descriptions that they have.'' Further, they 
tend to under-describe their levels of pain. Someone who is faking pain 
will generally go overboard in their descriptions of their pain. [Tr. 
457-58].
    86. The appropriate treatment was to use a moderate analgesic. [Tr. 
463]. The Respondent prescribed 180 oxycodone 15 mg., 30 alprazolam 
(Xanax) 2 mg, 30 tablets of carisoprodol (Soma) 350 mg., 90 Ibuprofen, 
800 mg. [Tr. 291-93; Govt. Exh. 12]. Mr. Castillo signed forms 
identical to those signed by Ms. Hall regarding Xanax, urinalysis, lost 
medication, and fraud. [Resp. Exh. 2 at 8-11, 13].
    87. Mr. Castillo next visited the Respondent on March 22, 2010.\32\ 
[Tr. 293, 315]. He stated that he did not receive a physical 
examination. [Tr. 297]. Again, Mr. Castillo did not do a urinalysis. 
[Tr. 297]. Mr. Castillo received a receipt for the medication he 
received, indicating that he received 360 oxycodone 15 mg from Dr. 
Jacobs, whom he had not seen that day. [Tr. 298-99; Govt. Exh. 12]. The 
Respondent actually ordered 180 oxycodone 15 mg. [Tr. 299; Resp. Exh. 2 
at 17-18]. Yet Mr. Castillo actually received 360 oxycodone 15 mg. [Tr. 
299]. Mr. Berman dispensed the controlled substances. [Tr. 328]. The 
Respondent did not note in Mr. Castillo's medical file how many pills 
he had left over from the first prescription. [Tr. 537].
---------------------------------------------------------------------------

    \32\ This visit was not audio or video recorded. [Tr. 315].
---------------------------------------------------------------------------

    88. Mr. Castillo's last visit was in April of 2010. [Tr. 285]. He 
stated he was not physically examined by the Respondent or asked to 
provide a urine sample. [Tr. 300, 328-29]. He was asked to assess his 
pain level, and he wrote a 3 for his level of pain, on a scale of one 
to ten. [Tr. 301].
    89. Mr. Castillo received the same prescriptions, and he did not 
fill them at the clinic that day. [Tr. 301; Govt. Exh. 12]. Again, the 
Respondent did not ask how many pills remained from the last 
prescription. [Tr. 537].
3. Ron Swanson \33\ (TFO Kevin Doyle)
---------------------------------------------------------------------------

    \33\ Mr. Swanson is actually Task Force Officer Kevin Doyle. 
[Tr. 333].
---------------------------------------------------------------------------

    90. Mr. Swanson visited the Respondent's clinic in February, March, 
and April of 2010. [Tr. 334]. The February visit was recorded, and the 
recording was transcribed. [Govt. Exh. 13A and B]. Mr. Swanson paid 
$150.00 for the first visit. [Tr. 337]. Mr. Swanson signed forms 
identical to those signed by Ms. Hall and Mr. Castillo regarding Xanax, 
urinalysis, lost medication, and fraud. [Respt. Exh. 3 at 17-21]. Mr. 
Swanson explained that he had been in

[[Page 60912]]

a car accident, a friend had given him oxycodone, and that he had come 
to the Respondent to obtain oxycodone. [Tr. 337]. He did not indicate 
that he was currently taking oxycodone, however. [Tr. 338]. Mr. Swanson 
was not required to provide a urine sample. [Tr. 337-38]. The 
Respondent did ask Mr. Swanson to raise and lower his arms, and that 
was the extent of the physical examination. [Tr. 338]. Mr. Swanson had 
rated his pain at a level 2. [Tr. 338].
    91. At the first visit, when asked, Mr. Swanson stated that he had 
problems sleeping and that he had anxiety. [Tr. 339]. Mr. Swanson was 
given a receipt for 90 oxycodone 15 mg., but that was not what had been 
prescribed that day. He actually was prescribed and received 180 
oxycodone 15 mg. [Tr. 340, 374; Govt. Exh. 11]. He also received 30 
alprazolam 2 mg. (Xanax), 30 carisoprodol 350 mg. (Soma) and 90 
ibuprofen 800 mg. [Tr. 340-41; Govt. Exh. 11]. All of the prescriptions 
were dispensed on-site from a back room, out of sight of the patients. 
[Tr. 341, 362].
    92. When looking at Ron Swanson's MRI,\34\ Dr. Danton noted that if 
Mr. Swanson and Mr. Castillo had come into her office at the same time, 
she would have noticed that their MRIs were almost exactly the same. 
[Tr. 459]. However, at that time, the Respondent did not find that the 
MRI was suspicious, in that it did not look fraudulent, modified or 
illegitimate. [Tr. 561].
---------------------------------------------------------------------------

    \34\ The MRI did not have the name of the radiology facility 
written on it, but a physician's name was written on it [Resp. Exh. 
4; Tr. 532]. The Respondent did not verify this MRI. [Tr. 532].
---------------------------------------------------------------------------

    93. Dr. Danton noted that the MRI identified a bulging disc. She 
explained that ``there was no pressure on the spinal cord as such from 
this bulge, but if there's a bulge, it means there's a narrowing of the 
disc, and if there's a narrowing of the disc, then there is going to be 
some impingement or some kind of abnormal pressure on that disc space 
which is going to effect those lateral nerves that are coming out and 
are going to effect things like the shoulder or parts of the neck.'' 
[Tr. 459].
    94. The MRI also described a mild scoliosis, which means that 
``there was an abnormal curvature to the spine, and that abnormal 
curvature can put abnormal pressures on nerve roots, as well.'' [Tr. 
459-60]. Dr. Danton acknowledged that the MRI showed very small 
changes, ``but if you multiply those small changes, it can build into 
something.'' [Tr. 460].
    95. Mr. Swanson complained of pain in his right shoulder. [Tr. 354, 
460; Resp. Exh. 3]. Although he had minimal complaints, Dr. Danton 
noted that if he had taken medication, that would have lowered his pain 
levels. [Tr. 460]. Mr. Swanson had also told the Respondent that on 
December 23, 2009, he had had a motor vehicle accident. [Tr. 461]. Dr. 
Danton had also observed that there were no red flags concerning her 
observations of his behavior. [Tr. 461]. Specifically, she was able to 
correspond the patient's history, complaints, and his presentation with 
his MRI report. [Tr. 460, 561].
    96. Mr. Swanson had reported to Dr. Danton that he had taken 
roxicodone, a form of oxycodone, for his pain. [Tr. 468; Resp. Exh. 3 
at 2]. However, the documentation is unclear as to whether he had taken 
the medication recently. [Tr. 338; Resp. Exh. 3 at 2].
    97. Putting all the information the Respondent had available, she 
determined that Mr. Swanson had chronic pain that was ``not that bad'' 
when he took pain medicine. [Tr. 461, 469]. The Respondent credibly 
testified that a mild to moderate pain killer would be appropriate. 
[Tr. 462]. Given his condition, absent medication, Dr. Danton would 
expect his pain level to be a five to a seven. [Tr. 469]. At a level 
seven, a person would be dysfunctional. [Tr. 470].
    98. The Respondent confirmed that she did not need to do any 
further physical examination to reach her diagnosis in Mr. Swanson's 
case. [Tr. 470]. Under plan, the Respondent documented in the patient's 
chart her prescription of controlled substances. [Respt. Exh. 3 at 1].
    99. During the March 22, 2010 visit, Mr. Swanson informed the 
Respondent that he owed a friend some oxycodone, and he asked for 20 
extra oxycodone in his prescription. [Tr. 345, 512]. The Respondent 
gave Mr. Swanson prescriptions for 200 oxycodone 15 mg., and the same 
amount of the previous prescriptions for \35\ Xanax, Soma, and 
ibuprofen. [Tr. 345-46; Govt. Exh. 11]. He had the prescriptions filled 
at the Respondent's clinic. [Tr. 346-47]. Mr. Berman brought the bag 
containing the medicine bottles to the receptionist, who handed it to 
Mr. Swanson. [Tr. 374]. Mr. Swanson did not see who actually placed the 
tablets in the medicine bottles. [Tr. 374].
---------------------------------------------------------------------------

    \35\ I do not find credible the Respondent's testimony that she 
gave the Respondent 20 extra oxycodone to save in case he did not 
make it back to her office in 30 days, since he was traveling from 
the Chicago area. Further, I do not find it credible that she gave 
him the extra 20 mills so he would not fear ``the concept of 
withdrawal.'' [Tr. 510-11]. Rather, given her subsequent testimony 
concerning the wrongfulness of her conduct, I find it more credible 
that she prescribed the extra 20 mills at the patient's request for 
repaying his friend.
---------------------------------------------------------------------------

    100. The Respondent told Mr. Swanson not to borrow pills, and she 
gave him an extra twenty pills. Later, she realized this conduct was 
wrong, and she ``decided that I would never do it again.'' [Tr. 511]. 
She credibly testified that she knows not to give more that a thirty-
day supply, that her giving of the twenty extra pills was ``an error of 
judgment,'' but that she corrected it, and she has ``never done it 
since.'' [Tr. 513]. In fact, when Mr. Swanson asked for additional 
pills on his next visit, the Respondent refused to give them to him. 
[Tr. 350, 513].
    101. Mr. Swanson's second visit in March was not recorded due to 
malfunctioning equipment. [Tr. 342]. The waiting area was quite 
crowded, Mr. Swanson provided the receptionist with $50.00 to be seen 
earlier, and the receptionist kept the money. [Tr. 344].
    102. During the second visit, Mr. Swanson testified that the 
Respondent did not perform a physical examination on him. [Tr. 373]. 
The Respondent did not ask Mr. Swanson for a urine sample or how many 
pills he had left over from the first prescription. [Tr. 373, 537].
    103. During the third visit, Mr. Swanson again paid the 
receptionist $50.00 to be seen ahead of other waiting patients. [Tr. 
347]. On this April visit, Mr. Swanson was seen by Dr. Jacobs. [Tr. 
347-48]. This visit was also recorded and a transcription was made of 
the recording. [Tr. 348; Govt. Exh. 16A and B]. Dr. Jacobs asked Mr. 
Swanson whether he had any oxycodone remaining from his earlier 
prescription which he answered ``no.'' Dr. Jacobs noted that in the 
patient's chart as well as that the patient was to continue the 180 
program. [Govt. Exh. 16B at 15; Respt. Exh. 3 at 9]. Mr. Swanson 
received prescriptions for the controlled substances, and this time his 
prescription was for 180 oxycodone 30 mg. The remaining prescriptions 
for Xanax, Soma, and ibuprofen remained the same. [Tr. 352; Govt. Exh. 
11].
    104. Subsequently in the hallway, he saw the Respondent and again 
asked for 20 additional pills. The Respondent refused that request. 
[Tr. 350, 513; Govt. Exh. 16B at 21-23]. The Respondent did however 
instruct Mr. Swanson that if he had to repay anyone, to break down the 
15's. [Tr. at 350].

F. The ``180 Treatment Program''

    105. The Respondent began her ``180 Treatment Program'' in January 
of 2010, and the program was discontinued by the DEA's action in 
November of 2010. [Tr. 495].

[[Page 60913]]

    106. Dr. Danton explained to DI McRae that the ``180 program'' 
involved prescribing patients 180 oxycodone 30 mg, 30 Xanax 2 mgs, 90 
Ibuprofen 800 mg, and either Soma or Flexoril. [Tr. 157-58]. The 
Ibuprofen helped with swelling and inflammation, and the patient was to 
take this medication three times a day with meals. [Tr. 158]. The Xanax 
tablet was to be broken into four parts, and the patient was to take 
one part in the morning, one part in the afternoon, and two parts at 
bedtime. The morning and afternoon portions were to control anxiety, 
and the bedtime portion was to assist with sleep. [Tr. 158].
    107. After six hours, a pain medicine becomes ineffective. However, 
depending on what a patient is doing, the patient may need additional 
medication before the six hours is over to handle breakthrough pain. 
When the pain medication metabolizes down, pain starts to increase, and 
the patient's ability to function can be compromised. [Tr. 479-80]. 
``And so the object of the program is to make people able to function 
at a hundred percent level all the time.'' [Tr. 480].
    108. Yet for breakthrough pain, Dr. Danton credibly testifies that 
the patient may not be given a dose equal to the original dose. A half 
of the original dose would control the breakthrough pain. [Tr. 480]. 
Dr. Danton would teach her patients to take this one-half tablet when 
their functioning was compromised. [Tr. 480]. Thus, a patient would be 
able to take 4 full-strength tablets and 4 half-strength tablets in a 
twenty-four hour time period, or six doses. That equals to 180 tablets 
in a month. [Tr. 481]. If the patient did not need the one-half tablet, 
the patient was to save these extra pills in a bottle the Respondent 
called an ``emergency parachute.'' [Tr. 159]. These pills were to be 
used in the event the patient could not get back to see Dr. Danton in 
exactly thirty days. [Tr. 482]. If the patient saved up 180 tablets in 
the ``emergency parachute,'' the patient would have a visit which was 
free, and the patient would not be prescribed any oxycodone on that 
visit. [Tr. 159]. Yet the patient medical files in this record do not 
demonstrate that the Respondent annotated the whereabouts of the extra 
pills or the exact quantity of pills consumed or retained by the 
patients. [Resp. Exh. 1-3].
    109. The Respondent testified that it would still be medically 
appropriate for the patient to take the full 180 oxycodone pills during 
the course of a month. One hundred and eighty 30 mg dose tablets is the 
maximum safe dose for oxycodone. Such action by the patient, however, 
would not be consistent with the Respondent's treatment plan, and she 
would discharge the patient on that basis. [Tr. 488-89].
    110. Dr. Danton credibly testified that prescribing 180, 15 mg 
oxycodone, was medically appropriate for the three undercover 
transactions. [Tr. 483-84].
    111. Sometimes a patient will report anxiety and the lack of 
ability to sleep as well as pain. The Respondent instructed her 
patients to take .25 milligrams or .5 milligrams of Xanax for this 
problem. That dosage would ``take care of anxiety, but it will still 
enable (the patient) to function at the hundred percent full level.'' 
[Tr. 500; Govt. Exh. 15B at 47]. The Respondent instructed the patients 
not to take the Xanax if they did not need it. [Tr. 500; Govt. Exh. 14B 
and 15B]. The Respondent also prescribed a muscle relaxer to take at 
night to help a patient with sleep, while still allowing the patient to 
wake up after a full-night's sleep and to be able to function at a 
hundred percent. [Tr. 500].
    112. The Respondent asked the three undercover patients if they 
were having anxiety problems or muscle spasm problems, the patients 
answered ``Yes,'' and the Respondent wrote prescriptions for Xanax and 
Soma. The patients were told to take these medications only when 
needed. [Tr. 501; Govt. Exh. 14B and 15B].
    113. Lastly, the Respondent prescribed ibuprofen, an anti-
inflammatory medication that will treat the inflammation around the 
nerve roots. [Tr. 502]. For para-spinal inflammation, the Respondent 
credibly testified that a patient would need 2400-milligrams of 
ibuprofen per the twenty-four hour day. [Tr. 502]. Dr. Danton credibly 
concluded that ``someone who's got a chronic permanent injury is going 
to have to take an anti-inflammatory for most of their life.'' [Tr. 
503].
    114. Also part of the ``180 program'' was an exercise component 
involving a swimming pool. The exercise was to assist the patient in 
pain management. [Tr. 160, 490-492]. Such exercising would produce 
endorphins, which create potent analgesic-like effects in the brain. 
[Tr. 492].
    115. After four months, if the patient was saving a large quantity 
of medication, the Respondent would begin the weaning portion of the 
program.\36\ [Tr. 485-86]. The weaning process consisted of weaning 
safely and slowly to 90 oxycodone tablets within a month. [Tr. 486-87, 
497]. This process avoided placing the patient into withdrawal. [Tr. 
498]. ``No one had a problem with withdrawal on the 180 program * * 
*.'' [Tr. 498]. Yet when asked if anyone had successfully completed the 
program, ``she said that there were a couple of patients who had called 
her and said that they no longer needed the medication.'' [Tr. 161]. 
Yet the patient files of these individuals did not contain any 
annotations concerning these calls. [Tr. 161].
---------------------------------------------------------------------------

    \36\ The Respondent credibly testified that the three undercover 
personnel did not stay in the program long enough to begin the 
weaning portion of the program.
---------------------------------------------------------------------------

    116. The Respondent credibly testified that she ``was willing to 
make a small salary so that people could afford to come and learn.'' 
[Tr. 494]. Dr. Danton also stated that ``if I could dispense the pills 
at a reasonable price, it would be an incentive for them (the patients) 
to come and stay with the program. If they kept with the program and 
they got used to the program, eventually they would be able to get off 
of narcotics.'' [Tr. 495].
    117. To determine if a patient was following the ``180 Treatment 
Program,'' the Respondent would ask the patient three distinct 
questions and the answers would tell the Respondent if the patient was 
actually following the program. [Tr. 496]. The patient was asked:
    1. How many whole pills were they allowed to take in a 24-hour time 
period?
    2. How many one-half pills were they allowed to take in a 24-hour 
period?
    3. When could they take the one-half pills?
    If the patient failed two quizzes, the patient would be discharged 
from the practice. [Tr. 496]. However, the record fails to demonstrate 
that on the subsequent visits of the undercover officers, these 
questions were asked. [Resp. Exh. 1-3].

IV. Statement of Law and Discussion

A. Position of the Parties

1. Government's Position
    The Government asserts that the Respondent failed to properly 
dispense and maintain readily retrievable records as required by 
Florida statutes for a dispensing physician. [Government's Proposed 
Findings of Fact and Conclusions of Law ``(Govt. Brief) at 11]. The 
Respondent also violated Florida law when she dispensed more than a 72-
hour supply of controlled substances after October 1, 2010. [Govt. 
Brief at 11].
    The Government notes that the Respondent was unable to account for 
more than 100,000 dosage units of oxycodone, failed to have an initial 
inventory, failed to properly execute DEA Form 222s, and had multiple 
DEA

[[Page 60914]]

Form 222s missing, in violation of DEA regulations. [Govt. Brief at 
11]. The Government concludes on this point that the ``Respondent's 
inability to maintain effective controls against diversion and lack of 
compliance with State and Federal Laws regarding controlled substances 
is clear and weighs heavily in favor of revocation of her DEA 
Certificate of Registration.'' [Govt. Brief at 11].
    The Government next argues that prescriptions were issued not for a 
legitimate medical purpose nor in the usual course of professional 
practice, as required by law. Specifically, the Government asserts that 
undercover patients Hayes and Castillo asserted that they did not 
receive a physical examination. [Govt. Brief at 12]. The Government 
asserts that Florida law requires that a physician perform a physical 
examination and document that exam in the patients' files, institute a 
treatment plan and document that plan in the patients' files. [Govt. 
Brief at 8 (citing Fla. Admin. Code R. 64B8-9.013), 12]. The Government 
notes that what the Respondent did with Hayes and Castillo was not a 
physical examination, and even if it was, the exam results were not 
documented in the patient files. The only treatment plan was to 
continue prescribing controlled substances. [Govt. Brief at 12]. In 
conclusion on this point, the Government argued that the Respondent 
``did little that would indicate that she established a bona fide 
physician-patient relationship or that the controlled substances she 
distributed were for a legitimate medical purpose in the usual course 
of professional practice.'' [Govt. Brief at 13].
    Next, the Government argues that the Respondent knowingly engaged 
in diversion when she provided Mr. Swanson with extra oxycodone to 
repay a friend 20 tablets. [Govt. Brief at 13]. The Government further 
argues that instructing Mr. Swanson on how to break down pills to repay 
his friends constituted intentional diversion. [Id.].
    Lastly, the Government argues that the Respondent did not truly 
accept responsibility for her misconduct, for her acceptance of 
responsibility ``was often followed by an excuse, or a shift of 
blame.'' [Govt. Brief at 14]. Although the medical files clearly 
established that Ms. Hall and Mr. Castillo were dispensed 360 oxycodone 
tablets when only 180 tablets had been authorized by the Respondent, 
the Respondent failed to address that error to the patients on their 
subsequent visit. Rather, at the hearing, the Respondent justified the 
error by stating that even 360 tablets would be within the standard of 
care for a chronic pain patient. [Govt. Brief at 15].
    Next, the Respondent failed to note that two patients, seen on the 
same day, actually gave the Respondent the same MRI. The Respondent 
ignored such red flags, and she presented ``no evidence demonstrating 
that the Respondent could be trusted with a DEA registration and would 
not engage in similar misconduct should Respondent retain a DEA 
registration.'' [Govt. Brief at 15]. In conclusion, the Government 
asserts that revocation of the Respondent's DEA registration is needed 
to protect the public health and safety. [Govt. Brief at 16].
2. Respondent's Position \37\
---------------------------------------------------------------------------

    \37\ The Respondent failed to timely file her post-hearing 
brief. However, Counsel for the Respondent made a closing argument 
at the hearing. From this argument, I find the Respondent's position 
regarding this case. [Tr. 603-619].
---------------------------------------------------------------------------

    In reviewing the public interest factors from 21 U.S.C. 823(f), the 
Respondent first asserts that there were no recommendations from a 
state licensing board concerning these matters. [Tr. 605]. The 
Respondent's experience in dispensing controlled substances was limited 
to her practice within the last two years. She asserts a large learning 
curve, and she states that the undercover officers came into the clinic 
during the first three months of operation. [Tr. 605]. The Respondent 
asserted that, as time progressed, she ascertained the rules and 
changed and modified her conduct to be consistent with those rules. 
[Tr. 605-06]. As she found errors or omissions in conduct, she took 
corrective action. [Tr. 606]. Also, as new requirements came into 
effect, such as urinalysis testing, she took action to adhere to that 
requirement. [Tr. 606].
    Further, with experience, the Respondent realized that some of her 
patients were drug seeking individuals, and she instituted a policy of 
checking out all the MRI's that were submitted, and if she had doubts, 
she would send her patients out to obtain a local MRI. [Tr. 606].
    Next, the Respondent notes that she has had no convictions that 
relate to the manufacture, distribution or dispensing of controlled 
substances. [Tr. 606].
    As for complying with state, federal or local laws in handling 
controlled substances, the Respondent admits she has made errors, 
especially in the accounting and inventory of controlled substances. 
[Tr. 607]. Yet, as she learned that her pharmacy technician was failing 
to handle controlled substances correctly, she terminated that 
technician. [Tr. 607]. She also terminated Ms. Demers when the 
Respondent suspected, but could not prove, that Ms. Demers was involved 
in the theft of oxycodone. [Tr. 607]. Also, whenever there was a break-
in, it was reported to the police. [Tr. 608]. Computers were stolen, 
which resulted in missing records. The Respondent believes that those 
missing records ``would correlate to the missing oxycodone that the 
Government is saying is not accounted for.'' [Tr. 608].
    Next, the Respondent suggests that, in considering any other 
conduct that may threaten the public health and safety, I see the two 
main issues as the inventory and record-keeping problems, and the 
legitimacy of the Respondent's prescriptions. [Tr. 610]. As for the 
legitimacy of the prescriptions, the Respondent notes that the 
Government failed to produce an expert witness to address that topic in 
the context of this case. [Tr. 610]. The Government has put on no 
evidence to explain to this Court what the appropriate standard in 
diagnosing a patient and when prescribing a treatment regimen. [Tr. 
618]. Although the Government relies upon a Florida statute that 
requires a physical examination, there is no expert testimony that 
defines what an appropriate physical examination entails. ``The only 
evidence before this Court is the evidence provided by Dr. Danton as 
testified in her expert capacity in the field of osteopathic medicine 
with experience in pain management, and her testimony is not refuted.'' 
[Tr. 610]. The Respondent asserts that, rather than rely on my own 
personal knowledge of what a physical exam consists of, I should rely 
upon the Respondent's testimony in light of her training and 
experience. [Tr. 611].
    The Respondent argues that I should look closely at the evidence as 
it was before the Respondent when she made her diagnosis and treatment 
plan for the three undercover officers. [Tr. 611-12]. I should hear the 
patients' complaints in light of their previous automobile or 
motorcycle accidents and the corresponding MRI reports. [Tr. 612]. Even 
though the patients complained of mild pain, the record contains no 
evidence that only severe or moderate pain should be treated. [Tr. 
612]. ``The field of palliative medicine addresses all chronic pain.'' 
[Tr. 612-13].
    The Respondent asks me to consider the Respondent's ``180 
program,'' and her true intent in implementing this program. [Tr. 613]. 
The Respondent argues that this program ``is a legitimate and well 
thought out'' program, with the results of treating her patients' pain 
and to eventually wean them off narcotics. [Tr. 614].

[[Page 60915]]

    As for the regulatory violations, the Respondent acknowledged that 
she takes full responsibility for all discrepancies. [Tr. 614]. Given 
the learning curve and the complicated nature of the regulatory scheme, 
the Respondent asserts that revocation of her registration is too 
extreme of a sanction. [Tr. 615]. Rather, the Respondent proposes that 
her registration should be suspended and she be placed on probation, 
that she be required to take additional medical education on how to 
operate a pain management practice consistent with all the ``legal 
requirements of the [C]ontrolled [S]ubstances [A]ct.'' [Tr. 615].
    The Respondent concludes that the public interest is best served by 
``having doctors who care like Dr. Danton,'' who make changes when they 
learn that their practice is not in compliance, and who train their 
patients in how to properly consume controlled substances and to wean 
themselves off narcotics. [Tr. 616]. The Respondent argues that I 
should formulate an appropriate remedy, given the Respondent's 
acknowledged failings in this matter. [Tr. 618-19].

B. Statement of Law

    Pursuant to 21 U.S.C. 824(a)(4) (2006), the Deputy Administrator 
\38\ may revoke a DEA Certificate of Registration if she determines 
that the continuance of such registration would be ``inconsistent with 
the public interest'' as determined pursuant to 21 U.S.C. 823(f). 
Section 823(f) requires that the following factors be considered:
---------------------------------------------------------------------------

    \38\ The Deputy Administrator has the authority to make such 
determinations pursuant to 28 CFR Sec.  0.100(b) and 0.104 (2010).

    (1) The recommendation of the appropriate State licensing board 
or professional disciplinary authority.
    (2) The applicant's experience in dispensing, or conducting 
research with respect to 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).
    These factors may be considered in the disjunctive: The Deputy 
Administrator may properly rely on any one or a combination of these 
factors, and may give each factor the weight she deems appropriate, in 
determining whether a registration should be revoked or an application 
for registration denied. [David H. Gillis, M.D., 58 FR 37,507, 37,508 
(DEA 1993); see also D & S Sales, 71 FR 37,607, 37,610 (DEA 2006); 
Joy's Ideas, 70 FR 33,195, 33,197 (DEA 2005); Henry J. Schwarz, Jr., 
M.D., 54 FR 16,422, 16,424 (DEA 1989)].
    As the Supreme Court recently explained, ``the 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))]. When an administrative tribunal elects to disregard 
the uncontradicted opinion of an expert, it runs the risk of improperly 
declaring itself as an interpreter of medical knowledge. [Ross v. 
Gardner, 365 F.2d 554 (6th Cir. 1966)]. Whether expert testimony is 
needed in any case necessarily depends on the nature of the allegations 
and the other evidence in the case. Where, for example, the Government 
produces evidence of undercover visits showing that a physician 
knowingly engaged in outright drug deals, expert testimony adds little 
to the proof necessary to establish a violation of Federal law. 
[Michael J. Aruta, M.D., 76 FR 19,420, n. 3 (DEA 2011)].
    Also, in an action to revoke a registrant's certificate, the DEA 
has the burden of proving that the requirements for revocation are 
satisfied. [21 CFR 1301.44(e) (2010)]. Once the Government has met its 
burden of proof, the burden of proof shifts to the Respondent to show 
why her continued registration would be consistent with the public's 
interest. [Medicine Shoppe, 73 FR 364, 381 (DEA 2008); see also Thomas 
Johnston, 45 FR 72,311, 72,312 (DEA 1980)]. Specifically, the 
Respondent must present ``sufficient mitigating evidence to assure the 
Administrator that [she] can be entrusted with the responsibility 
carried by such a registration.'' [Medicine Shoppe, 73 FR at 387].
    DEA precedent has also held that ``past performance is the best 
predictor of future performance.'' [ALRA Labs, Inc. v. DEA, 54 F.3d 
450, 452 (7th Cir. 1995)]. Further, DEA has repeatedly held that 
``where a registrant has committed acts inconsistent with the public 
interest, the registrant must accept responsibility for [her] actions 
and demonstrate that [she] will not engage in future misconduct.'' 
[Medicine Shoppe, 73 FR at 387; see also Samuel S. Jackson, 72 FR 
23,848, 23,853 (DEA 2007)].

C. Analysis

1. Factor I. Recommendation of the Appropriate State Licensing Board
    In this case, it is undisputed that the Respondent holds a valid 
and current State license to practice medicine. [Finding of Fact 
(``FOF'') 3]. The record contains no evidence of a recommendation 
regarding the Respondent's medical privileges by any State licensing 
board or professional disciplinary authority.
    However, that a State has not acted against a registrant's medical 
license is not dispositive as to whether continuation of her 
registration is consistent with the public interest. [Patrick W. 
Stodola, M.D., 74 FR 20,727, 20,730 (DEA 2009); Jayam Krishna-Iyer, 74 
FR 459, 461 (DEA 2009)]. It is well-established Agency precedent that a 
``state license is a necessary, but not a sufficient condition for 
registration.'' [Robert A. Leslie, M.D., 68 FR 15,227, 15,230 (DEA 
2003); John H. Kennedy, M.D., 71 FR 35,705, 35,708 (DEA 2006)]. 
Therefore, I find this factor neither weighs in favor of nor against a 
finding that the Respondent's continued registration is consistent with 
the public interest.
2. Factors II and IV. Respondent's Experience in Dispensing Controlled 
Substances and Compliance with Applicable Laws.
a. Legitimate Medical Purpose
    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'')].
    Under the Controlled Substances Act (``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

[[Page 60916]]

issue a prescription for a ``legitimate medical purpose.'' [Laurence T. 
McKinney, 73 FR 43,260, 43,265 n.22 (DEA 2008); see also Moore, 423 
U.S. 122, 142-43 (1975) (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, however, 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 54,931, 54,935 (DEA 2007); United Prescription Services, 
Inc., 72 FR 50,397, 50,407-08 (DEA 2007)].
    Here the Government asks this tribunal to conclude that the 
Respondent's prescriptions to the three undercover officers, who 
presented fraudulent MRI's to the Respondent, were for an illegitimate 
medical purpose. The Government, however, provided no expert testimony 
to support this finding. Rather, the Government introduced the 
transcripts and recordings of the undercover transactions, and a 
summary of those transactions via officer testimony. In that regard, 
the Government has provided no meaningful lodestar by which this court 
can measure the legitimacy of the Respondent's medical practice under 
Florida statutory and regulatory requirements.
    The Respondent, however, did present expert testimony. The 
Respondent was qualified as an expert in the field of osteopathic 
medicine with extensive experience in pain management, assessment and 
treatment.\39\ [FOF 6]. She asserted that her issuance of prescriptions 
for controlled substances to the undercover agents, based on the 
objective evidence of their medical conditions as presented in the MRI 
reports and as corroborated by their subjective reporting, was well-
within the standard of care for appropriate pain management. [FOF 68-
71, 84-85, 93-96, 98-99].
---------------------------------------------------------------------------

    \39\ I acknowledge that the Respondent's testimony has the 
potential for being self-serving, however, and I take that factor 
into account when determining the weight to give her expert 
conclusion.
---------------------------------------------------------------------------

    The importance of expert testimony to support a finding of 
illegitimacy has been underscored by this agency in its post-Gonzales 
decisions. Specifically, while the agency has considered over fifty 
cases concerning the legitimacy of a practitioner's prescriptions since 
Gonzales, the agency has seldom found a violation of 21 CFR Sec.  
306.04(a) absent expert testimony. [See e.g. Cynthia M. Cadet, M.D., 76 
FR 19,450 (DEA 2011) (expert); Roni Dreszner, M.D., 76 FR 19,434 (DEA 
2011) (expert); Aruta, 76 FR at 19,420 (expert); George C. Mathew, 
M.D., 75 FR 66,138 (DEA 2010) (expert)].
    In those instances where the agency has found such illegitimacy 
without an expert's testimony, that finding was based on patent 
violations, where diversion was either unrefuted or unquestionable. For 
example, in Robert F. Hunt, 75 FR 49,995 (2010), the Deputy 
Administrator concluded that expert testimony was not required to make 
a finding of illegitimacy where the Respondent told the patient he was 
documenting a diagnosis of osteoporosis ``just to cover [his] ass.'' 
[Id. at 50,003]. Similarly, in Peter W.S. Grigg, 75 FR 49,992, 49,993 
(DEA 2010), the agency found a violation where the Respondent met with 
an undercover police officer in a parking lot and sold the officer 60 
tablets of oxycodone in exchange for $100. [See also Armando B. 
Figueroa, M.D., 73 FR 40,380, 40,382 (DEA 2008) (where Respondent's 
issuance of prescriptions to patients without seeing them and as many 
as twenty prescriptions at a time was tantamount to drug pushing), 
Kennedy, 71 FR 35,705 (where Respondent wrote prescriptions for a 
patient and instructed the patient to sell the drugs and return a 
portion of the profits to the Respondent)]. Such patent violations of 
Sec.  1306.04(a) can best be described as ``outright drug deals'' as 
that phrase was used by the Deputy Administrator in her most recent 
decision on this point. [Aruta, 76 FR at 19,420, n. 3; See also 
Dispensing Controlled Substances for the Treatment of Pain, 71 FR 
52,715, 52,717 (DEA 2006) (stating ``that the types of cases in which 
physicians have been found to have dispensed controlled substances 
improperly under Federal law generally involve facts where the 
physician's conduct is not merely of questionable legality, but instead 
is a glaring example of illegal activity).]
    Similarly, where the Respondent has acted in a manner that clearly 
contravened state law governing what constitutes a legitimate medical 
practice, expert testimony may not be required. Violations in those 
instances are most obvious in Internet prescribing practices were no 
physical examination or face-to-face communication was conducted. 
[Garces-Mejias, 72 FR at 54,931 (where Respondent's involvement in 
Internet scheme constituted drug dealing); Dale E. Taylor, 72 FR 30,855 
(DEA 2007) (similar conclusion)]. However, when the Government seeks to 
use a state law violation as a means of establishing a violation of 
Sec.  1306.04(a), the question remains to what extent that state law 
violation is so tethered to a finding of actual illegitimacy that, 
without expert testimony, it can be used as a predicate to a violation 
of the federal law.
    DEA precedent indicates that when a state law violation would 
compel a finding of illegitimacy under state law, the agency should 
reach a similar conclusion. For example, in Kamir Garces-Mejias, 72 FR 
54,931 (DEA 2007), the Respondent's failure to conduct an in person 
physical exam violated certain state laws including (1) a California 
law making it a crime to issue prescriptions via the Internet to its 
residents; (2) an Ohio law stating that a failure to conduct a physical 
examination would constitute the issuance of a prescription for an 
``illegitimate medical purpose;'' and (3) a Virginia statute 
establishing no bona-fide physician-patient relationship exists without 
a medical examination. [Id. at 54,935]. There, a clear nexus existed 
between the violation and a finding of illegitimacy under state law, 
and therefore, easily facilitated a similar conclusion under federal 
law.
    However, absent such a nexus, a finding of per se illegitimacy 
under federal law under the circumstances of this case cannot be made. 
Indeed, to hold otherwise may result in the unfortunate corollary of a 
Respondent's violation of any state law predicating a violation of 
Sec.  1306.04(a), a holding that would be inconsistent with the Supreme 
Court's decision on this point and DEA precedent. [See Gonzales, 546 
U.S. at 270 (stating the CSA ``bars doctors from using their 
prescription-writing powers as a means to engage in illicit drug 
dealing and trafficking as conventionally understood'') (emphasis 
added); See also McKinney, 73 FR at 43,266 (finding that the 
Respondent's failure to listen to the undercover officer's heart and 
lungs and take her blood pressure may have violated Pennsylvania 
regulations, however, it does not support a finding that the Respondent 
engaged in illicit drug dealing, and noting the Government's failure to 
create a connection between that regulatory violation and a violation 
of the Pennsylvania Controlled Substances Act)].
    Therefore, it is clear that to establish a violation of Sec.  
1306.04, absent expert testimony, the Government must provide either 
(1) evidence that the Respondent committed a violation that is 
sufficiently tied to a state law finding of illegitimacy so as to make 
a similar finding under the federal law or (2)

[[Page 60917]]

other evidence of ``outright drug dealing.''
i. Violations of Sec.  1306.04 Based on State Law Violations
    The Government argues that all of the Respondent's prescriptions to 
the undercover officers were issued for an illegitimate medical 
purpose, as they violated certain professional standards.\40\ However, 
I find that the Government has either (1) not sufficiently proven a 
violation of those standards or (2) proven a violation yet not 
established a nexus between that violation and a finding of 
illegitimacy under state law to justify a per se violation under 
federal law.
---------------------------------------------------------------------------

    \40\ The Government also argues that the Respondent ``did little 
that would indicate a bona fide patient relationship.'' However, I 
find this argument unpersuasive as the Government has the burden of 
proof with regard to Sec.  1306.04(a) violations. Further, I am not 
persuaded by the argument that the agency should find a violation in 
this case based on its similarity to another DEA matter where the 
Government met its burden of proof by providing expert testimony. 
[See Govt. Brief at 13 citing Jacabo Dreszer, M.D., 76 FR 19386 (DEA 
2011) (where the ALJ relied on expert testimony, that was 
unchallenged, to find the recordkeeping and documentation in patient 
files were substandard and that Respondent's practice didn't 
resemble a legitimate one)].
---------------------------------------------------------------------------

    First, it should be noted that although the Government, in its 
brief, cites to the regulatory provisions that govern a medical 
doctor's practice in Florida, those regulations are inapplicable to the 
Respondent. [Govt. Brief at 8 (citing Fla. Admin. Code r. 64B8-
9.013(g))]. The Respondent is a Doctor of Osteopathy, and the State of 
Florida treats the practice of medicine as an osteopathic physician 
distinct from the practice of medicine as a medical doctor. Indeed, 
each profession has separate boards, licensure requirements, and 
statutory and regulatory schemes. [See Fla. Stat. Ann Sec.  458.001, et 
seq. (statutory scheme governing medical doctors); Fla. Stat. Ann. 
Sec.  459.001, et seq. (statutory scheme governing osteopathic 
physicians); Fla. Admin. Code r. 64B8-9 (regulations governing practice 
of medicine set forth by Board of Medicine); Fla. Admin. Code r. 64B15 
(regulations promulgated by the Board of Osteopathy (``Board''))]. In 
that regard, the standards that govern medical doctors cannot be used 
to ascertain the scope of professional practice for osteopathic 
physicians. Conveniently, however, the regulation governing appropriate 
pain management for osteopathic physicians is identical to that 
governing appropriate pain management for medical doctors. [Compare 
Fla. Admin. Code r. 64B15-14.005 (2009) with Fla. Admin. Code r. 64B8-
9.013 (2009)].
    The Government alleges that the Respondent failed to conduct a 
physical examination on the patient. [Govt. Brief at 12]. However, I 
find that the Government has not met its burden of proof regarding this 
violation. First, the meaning of physical examination, as that term was 
used in Florida state law during the time of the Respondent's actions 
here,\41\ is nebulous, and the Respondent's expert interpretation, in 
light of the Government's failure to provide a contrary one, must be 
given considerable weight. The Respondent testified that ``[a] physical 
examination does not necessarily entail touching the body.'' [FOF 20]. 
For example, in the case of chronic injury ``you can't see--whether 
you're putting your hands on the patient or not, you can't see that 
evidence of chronic inflammation and disease by visual inspection or 
palpation.'' [Id.]. Further, she stated that her clinical observations 
of how the patients moved, coupled with the MRI reports and medical 
histories, provided an adequate and consistent basis for her diagnoses 
and treatment. [FOF 110, 41, 60, 69, 70, 83, 95, 98]. Therefore, 
without expert testimony to the contrary, I cannot find that the 
Respondent failed to conduct a physical examination of the three 
undercover patients as that term is used under Florida law. [See 
McKinney, 73 FR at 43,266 (``[n]otwithstanding that Respondent failed 
to perform several steps required by Pennsylvania law, the physical 
exam he conducted cannot be characterized as deficient or cursory in 
the absence of expert testimony establishing as much.'')].\42\ 
Accordingly, I find the Government has failed to sufficiently prove a 
violation of state law on this basis.
---------------------------------------------------------------------------

    \41\ See Fla. Admin. Code r. 64B15-14.005(2) (2009) (failing to 
define ``physical examination'').
    \42\ This interpretation is also supported by the Board's new 
regulation, effective November 8, 2010, which states that ``the 
exact components of a physical examination shall be left to the 
judgment of the clinician who is expected to perform a physical 
examination proportionate to the diagnosis that justifies the 
treatment.'' Fla. Admin. Code r. 64B15-14.0051(2)(a) (2010).
---------------------------------------------------------------------------

    Next, the Government asserts that the Respondent failed to document 
a physical examination in the patient's chart, as required by the 
Florida law.\43\ [Govt. Brief at 12]. Similarly, however, I find that 
the Government has failed to prove that the Respondent's documentation 
regarding the patient's symptoms/physical examination in the chart fell 
below the state's standard. To the extent that the review of an MRI 
report, coupled with a physical observation of the patient constitutes 
a ``physical examination,'' the Respondent included the MRI reports in 
her charts and would record those physical observations that she deemed 
suspicious. [FOF 60; Resp. Exhs. 1,2,3]. In addition, while I do find 
her decision not to write down her observations suspicious,\44\ absent 
expert testimony to the contrary, I cannot find, however, that the 
Respondent's lack of documentation failed to satisfy the Florida 
physical examination recordation requirement. [See Jacobo Dreszer, 
M.D., 76 FR 19,386, 19,400 (DEA 2011) (basing a finding of a violation 
of Florida's patient recordkeeping violations on unrefuted expert 
testimony)].
---------------------------------------------------------------------------

    \43\ See Fla. Admin. Code. r.B15-14.005(e) and (f) (requiring a 
physical examination and documentation of such but not further 
defining it).
    \44\ Although Mr. Swanson was asked to raise and lower his arms, 
even in Mr. Swanson's case, the Respondent did not record her 
observations concerning this ``physical examination.'' [FOF 60, 65, 
83, 88, 90, 91, 103].
---------------------------------------------------------------------------

    Last, the Government asserts that the Respondent failed to record a 
treatment plan in the patients chart and hence issued prescriptions for 
an illegitimate medical purpose. [Govt. Brief at 12-13]. While I find 
that the Respondent did violate this professional standard, I do not 
find that based on this violation, the Respondent issued prescriptions 
for an illegitimate medical purpose. Florida law states ``the written 
treatment plan should state objectives that will be used to determine 
treatment success, such as pain relief and improved physical and 
psychosocial function, and should indicate if any further diagnostic 
evaluations or other treatments are planned. After treatment begins, 
the osteopathic physician should adjust drug therapy to the individual 
medical needs of each patient.'' [Fla. Admin. Code. r. 64B15-
14.005(3)(b) (2007)].
    Here, the Respondent's recordkeeping clearly violates Florida law. 
While the Respondent's charts indicate a continued plan of treating the 
patient with narcotics, there is no statement of objectives that she 
would use to ascertain treatment success, nor is there any indication 
of other potential treatment or diagnostic evaluation. [See FOF 73, 84, 
98]. Further, the Respondent did not tailor her treatment to meet the 
individual needs of her patients. All of the undercover patients, for 
example, were prescribed the exact same combination of controlled and 
non-controlled substances at each visit despite the varying MRI 
reported results. [FOF 27, 61, 86, 91; see also FOF 53, 55]. Also, the 
Respondent's treatment records failed to document any justification for 
this continued prescribing. Although the Respondent testified that she 
questioned her patients

[[Page 60918]]

to ensure compliance with her ``180 program,'' she did not engage the 
three undercover patients in such a dialogue. [FOF 77-81, 87-88, 103, 
but see FOF 103 (where Dr. Jacobs engaged Mr. Swanson in such a 
dialogue on his third visit and recorded such)].
    Therefore, I find that the Respondent violated the Board of 
Osteopathy's regulations in not properly documenting a treatment plan. 
However, I do not find that based on this failure, the Respondent 
issued prescriptions to the undercover officers for an illegitimate 
medical purpose. Specifically, I find that the Government has not 
sufficiently created a nexus between that violation and a finding of 
illegitimacy under state law so as to reach a similar conclusion under 
federal law.
    The Florida Board of Osteopathic Medicine (``Board'') defined the 
bounds of prescription legitimacy when it stated that it ``will 
consider prescribing, ordering, administering, or dispensing controlled 
substance for pain to be for a legitimate medical purpose if based on 
accepted scientific knowledge of the treatment of pain or if based on 
sound clinical grounds.'' [Fla. Admin. Code r. 64B15-14.005(e) (2007) 
(emphasis added)]. In the preamble to its regulation, the Board states 
``[t]he following guidelines are not intended to define complete or 
best practice, but rather to communicate what the Board considers to be 
within the boundaries of professional practice.'' Id. at (g). Recently, 
the DEA concluded that that language ``supports an inference that the 
standards provide the minimum requirements for establishing conduct 
that comports with the professional practice of controlled substance-
based pain management in the state.'' Dreszer, 76 FR at 19,398 
(emphasis in original). However, as the Deputy Administrator indicated 
in McKinney, a physician who falls below such minimum standards commits 
malpractice, yet he does not necessarily engage in illicit drug 
dealing. See McKinney, 73 FR at 43,266 (finding a violation of 
Pennsylvania's ``minimum standards'' for pain management yet no 
violation of federal law).
    Here, I find that the Respondent's failure to document a treatment 
plan, as that term is defined in Florida law, does not lead to the 
conclusion that all of the Respondent's prescriptions to the undercover 
officers were for an illegitimate medical purpose. The Board states, 
``Osteopathic physicians should not fear disciplinary action from the 
Board * * * for prescribing * * * controlled substances for a 
legitimate medical purpose and that is supported by appropriate 
documentation establishing a valid medical need and treatment plan.'' 
[Fla. Admin. Code. r. 64B15-14.005(b) (2009)]. Thus, it is possible 
under Florida law that a practitioner could issue prescriptions for a 
legitimate medical purpose, i.e. based on sound clinical grounds, yet 
fail to provide sufficient documentation of a treatment plan. While 
that failure may subject the physician to professional discipline, it 
does not predicate a conclusion that the physician engaged in illicit 
drug dealing.
    Based on this interpretation, I find that the Government has not 
proven that the Respondent issued prescriptions for an illegitimate 
medical purpose when she failed to record a proper treatment plan in 
her patient's charts.
ii. Out-right Drug Dealing
    However, I do find that there is evidence of outright drug dealing 
by the Respondent, and, therefore the Government has proved a violation 
of Sec.  1306.04(a) on that basis. Specifically, when the Respondent 
prescribed an additional twenty pills to Ron Swanson on his second 
visit to her practice, that conduct constituted actual diversion. The 
Respondent admitted that she provided twenty extra pills to Ron Swanson 
upon his request for those pills and on the basis that he had borrowed 
twenty pills from his friend. In this circumstance, the Respondent knew 
or should have known that the patient was planning to re-pay his friend 
with those pills and that he would not use them for his own pain 
management.\45\ [FOF 100]. Obviously, since the Respondent's friend was 
not a patient of the Respondent, the Respondent's issuance of those 
extra pills was outside the scope of her medical practice and therefore 
a violation of Sec.  1306.04(a). [See Garces-Mejias, 72 FR at 54,935; 
United Prescription Services, 72 FR at 50,407 (requiring a bona-fide 
patient/physician relationship)]. Certainly no bona fide patient-
physician relationship can exist, where absolutely no patient-physician 
contact has occurred.
---------------------------------------------------------------------------

    \45\ I do not find credible the Respondent's explanation that 
she gave the patient extra pills to help him avoid possible 
withdrawal symptoms. [FOF 100, n.19]. Such an explanation is 
inconsistent with the Respondent's later testimony that providing 
him with those pills was ``wrong.'' [FOF 100]. If the Respondent 
believed that such pills were necessary to treat him for his medical 
condition and prevent the onset of withdrawal, then the Respondent 
would not have testified that the prescription was ``wrong.'' 
Furthermore, if the Respondent believed that that quantity of 
medication, 200 dosage units, was necessary to manage the patient's 
condition, such belief does not explain her decision to later issue 
a lesser quantity, 180 dosage units, to the patient. [see FOF 103]. 
Therefore, I find it more likely that the Respondent knew the twenty 
pills would not be used by the patient but were intended to be given 
to his friend.
---------------------------------------------------------------------------

    I do not find, however, that the Respondent violated Sec.  
1306.04(a), when she instructed Mr. Swanson on how to break-down his 
pills, [FOF 104], although I do believe such evidence weighs in favor 
of revocation under Factor V, as discussed infra. Although Mr. Swanson 
certainly presented red flags of diversion when he indicated that he 
needed additional pills, the Respondent did not supply him with 
additional pills on the subsequent visit. [FOF 104]. Thus, to the 
extent that she believed the prescription she issued him was necessary 
to manage his pain, I do not find the Respondent's actions tantamount 
to actual diversion on this occasion.
    Last, while I find suspicious the Respondent's conversation with 
Pedro Castillo, I do not find that, without expert testimony, that 
conversation is sufficient evidence that the Respondent issued 
prescriptions to him for an illegitimate medical purpose. During her 
patient interview with Mr. Castillo, the Respondent explained her 180 
program, including the exercise component. The Respondent then 
explained the controlled substances that she issued as part of that 
program. She then asked the patient ``which medicine do you want?'' The 
patient chose oxycodone, and the Respondent confirmed that he wanted 15 
mgs and not 10 mgs. [FOF 82]. While I find that giving the patient the 
decision to choose his/her prescription could lead to the conclusion 
that those prescriptions were issued ``on demand,'' \46\ I find that 
here, given the context of that question, these circumstances do not 
rise to the level of outright drug dealing. The Respondent was 
presented with an MRI report documenting objective injury, explained 
her program and the drugs she typically prescribed as part of that 
program, and confirmed with the patient the nature of his injuries. 
[FOF 82]. Therefore, without expert testimony to the contrary, I do not 
find that such conduct rises to the level of outright drug dealing and 
thus justifies a conclusion that the Respondent issued prescriptions to 
Pedro Castillo for an illegitimate medical purpose.
---------------------------------------------------------------------------

    \46\ See Robert L. Dougherty, 60 FR 55,047, 55,049 (DEA 1995); 
Harold Footerman, M.D., 56 FR 58,400 (DEA 1991).
---------------------------------------------------------------------------

b. Dispensing Violations
    As of October 1, 2010, a dispensing practitioner in Florida ``may 
not dispense more than a 72-hour supply of a controlled substance 
listed in Schedule II, Schedule III, Schedule IV,

[[Page 60919]]

or Schedule V * * * for any patient who pays for the medication by 
cash, check or credit card in a clinic registered under [section] 
459.0137.'' [Fla. Stat. Ann Sec.  465.0276]. Section 459.0137 requires 
``[a]ll privately owned pain-management clinics, facilities, or 
offices, hereinafter referred to as ``clinics,'' which advertise in any 
medium for any type of pain-management services, or employ an 
osteopathic physician who is primarily engaged in the treatment of pain 
by prescribing or dispensing controlled substance medications, must 
register with the department unless'' certain exceptions which do not 
apply here. [Sec.  459.0137].
    As of the date of this hearing, the Respondent's clinic was not 
registered as a pain management clinic. [FOF 24]. Under a strict 
reading of the statute, the 72 hour requirement would apply to only 
those clinics actually registered with the state. However, I find it 
more likely that the Florida legislature intended this requirement to 
apply more broadly to clinics who are required to register and not just 
those who actually are. In line with that reading, I find that this 
requirement applies to the Respondent, and that the Government has 
proved by a preponderance of the evidence that the Respondent failed to 
abide by this limitation. [FOF 26].
d. Recordkeeping Violations
    The Respondent credibly testified that on one occasion her office 
was broken into and controlled substances were stolen. However, she 
failed to report the theft and loss of the controlled substances to the 
DEA, in violation of federal law. \47\ [FOF 34].
---------------------------------------------------------------------------

    \47\ See 21 CFR 1301.76(b) (2010) (stating ``the registrant 
shall notify the Field Division Office of the Administration in his 
area, in writing, of the theft or significant loss of any controlled 
substances within one business day upon discovery of such loss or 
theft. The registrant shall also complete and submit to the Field 
Division Office DEA Form 106 regarding the loss or theft'').
---------------------------------------------------------------------------

    Under Florida law, a dispensing physician is required to abide by 
the statutory and regulatory recordkeeping provisions identical to 
those levied against a pharmacy. [Fla. Stat. Ann. Sec.  465.0276(2)(b) 
(2009)]. That includes compliance with 21 CFR 1304.04, which requires 
dispensed prescriptions to be maintained in a readily retrievable 
manner for two years after dispensing. [See Fla. Admin. Code r. 64B16-
28.140 (2009) (stating a pharmacy must comply with Sec.  1304.04)].
    In addition, under federal law, a dispensing physician is required 
to keep certain records similar to those kept by retail pharmacies. For 
example, 21 CFR Sec.  1304.03(d) requires a registered practitioner who 
regularly dispenses to keep records of Schedule II-V controlled 
substances that he dispenses. Specifically, the registrant is required 
to keep inventories of schedules I and II controlled substances. In 
addition, the registrant is required to keep inventories of schedules 
III through V controlled substances either separate from all other 
records of the respondent or in a manner that is readily retrievable. 
[Sec.  1304.04 (f)(1) and (2); See also Sec.  1304.04(g) (imposing this 
requirement on registered practitioners required to maintain records)].
    Federal regulations also set out in detail the requirements of 
those inventories. [See Sec.  1304.11(e)(3) (specifying that a 
dispensing practitioner's inventory of Schedules I and II must be 
conducted by hand count but that Schedules III through V can be 
estimated provided the container holds less than 1000 tablets and 
requiring the practitioner to maintain records identical to those 
maintained by manufacturers under Sec.  1304.11(e)(1)(iii) and (iv)].
    Here, the Respondent failed to meet such requirements. 
Specifically, the Respondent failed to conduct required inventories of 
controlled substances. [FOF 25, 50]. Next, when conducting an 
accountability audit, the DEA found that the Respondent was unable to 
account for 99,723 dosage units of oxycodone 30 mg tablets, 9,460 
dosage units of oxycodone 15 mg tablets, 300 dosage units of oxycodone 
10 mg tablets, 1,500 dosage units of oxycodone 5 mg tablets, 1,120 
dosage units of oxycodone 10 mg/325 mg tablets, and 3,300 dosage units 
of oxycodone 5 mg/325 mg tablets. [FOF 50]. Here, there is evidence 
that those shortages resulted from actual diversion in the cases of Ms. 
Hall and Mr. Castillo. [FOF 76, 80, 87]. Further, this agency has made 
clear that it ``need not find that diversion was the cause of the 
shortages to conclude that Respondent does not maintain effective 
controls against diversion.'' [McBride Marketing, 71 FR 35, 710 (DEA 
2006). See also Sunny Wholesale, Inc., 73 FR 57,655 (DEA 2008), 
Alexander Drug Company, Inc., 66 FR 18,299 (DEA 2001)].
    Further, the receipts given to the Respondent's undercover patients 
fail to correctly record what was actually dispensed, and in two 
instances, the correct name of the dispensing physician was missing. 
[FOF 76, 80, 87, 91]. Such recordkeeping errors contribute to the 
inability of the Respondent and subsequently the DEA to conduct an 
accountability audit with accurate results. In addition, it violates 
federal law. [See 21 CFR 1304.22(c) (requiring dispensing practitioners 
to record ``name and address of the person to whom it was dispensed, 
the date of dispensing, the number of units or volume dispensed, and 
the written or typewritten name or initials of the individual who 
dispensed or administered the substance on behalf of the dispenser'')].
    Next, the Respondent failed to safeguard her DEA Form 222s. 
Specifically, when she left the Pain Center of Broward, the Respondent 
left her DEA Form 222s there. [FOF 9, 10]. Also, Mr. Berman was given 
unsupervised access to the Respondent's DEA Form 222s to order 
controlled substances for the Respondent's practice. [FOF 25, 32]. The 
Respondent did not know, at any given time, whether the ordering was 
done in compliance with DEA statutory and regulatory provisions. Next, 
when asked if at ``any time an order was placed using your DEA number, 
was that an order done appropriately and legitimately or for other 
purposes,'' the Respondent replied that she was not sure. [FOF 11]. 
Indeed, ARCOS data reflects that the Respondent was one of the top 100 
purchasers of oxycodone from January 1, 2009, through March 31, 2011, 
however, she believed that all of the dosage units purchased under her 
registration during that time frame, over 400,000, were not necessarily 
dispensed to patients that she personally saw. [FOF 47, 10]
    Although the Respondent intimated that copies of her 222's were 
stolen during the thefts and break-ins, the Respondent failed to report 
the lost or stolen 222's to DEA in violation of federal law. [Sec.  
1305.16(b)-(e); FOF 34]. Therefore, the Respondent failed to handle the 
DEA 222's, a critical form used to account for Schedule II controlled 
substances, in a responsible manner.
    Even though the Respondent credibly testified that she relied upon 
Mr. Berman to properly handle inventories, ordering and dispensing,\48\ 
such reliance does not absolve the registrant from her responsibilities 
to ensure compliance with DEA regulations. Indeed, wrongful conduct by 
the registrant's agent is imputed to the registrant. [Edmund Chein, 
M.D., 72 FR 6580 (2007) (stating ``under DEA precedents, a registrant 
is responsible for violations of the CSA committed by his employees and 
his practice's failure to comply with the Act'') (citing Merkow, 60 FR 
at 22,076)].
---------------------------------------------------------------------------

    \48\ FOF 25.

---------------------------------------------------------------------------

[[Page 60920]]

e. Failure To Conduct Urinalysis Screening as Required by State Law
    At the time the Respondent treated the undercover personnel, it was 
not a requirement to conduct a urinalysis prior to treating a chronic 
pain patient. However, effective November 8, 2010, the law changed, 
requiring a physician to order a urinalysis and review the results 
before the initial prescribing of controlled substances.\49\ On the day 
the search warrant was executed, November 23, 2010, DI McRae noted that 
the Respondent had run out of urinalysis kits, and that no such tests 
had been taken for the past three days. [FOF 56]. However, the 
Government provided no evidence that the Respondent actually saw new 
patients and actually issued initial controlled substances 
prescriptions during that three-day window. Therefore, the Government 
has failed to meet its burden of proof regarding this violation.
---------------------------------------------------------------------------

    \49\ Fla. Admin. Code r. 64B15-14.0051(2)(f) (2010) (stating 
``patient drug testing * * * shall be conducted and the results 
reviewed prior to the initial issuance or dispensing of a controlled 
substance prescription, and thereafter, on a random basis at least 
twice a year and when requested by the treating physician).
---------------------------------------------------------------------------

f. Prescribing Controlled Substances for Her Own Use
    Under Florida statutory law, the grounds for professional 
discipline of an osteopathic physician include ``[p]rescribing or 
dispensing any medicinal drug appearing on any schedule set forth in 
chapter 893 by the osteopathic physician for himself or herself or 
administering any such drug by the osteopathic physician to himself or 
herself unless such drug is prescribed for the osteopathic physician by 
another practitioner authorized to prescribe medicinal drugs.'' Fla. 
Stat. Sec.  459.015(u) (2009). During the search of the Respondent's 
clinic, the DEA found evidence that the Respondent was prescribing 
oxycodone for her own use. [FOF 43]. Therefore, the Respondent violated 
Florida law by self-prescribing this controlled substance.
g. Lack of Physical Security
    Federal law requires that a registrant store controlled substances 
in a ``securely locked, substantially constructed cabinet.'' 21 CFR 
1301.75. During the search of the Respondent's clinic, the DEA found 
evidence of the Respondent's failure to store controlled substances in 
a secured location. Oxycodone was found in a closet containing security 
monitoring equipment. [FOF 35, 42]. GS Langston testified that this 
closet failed to comply with 21 CFR 1301.75(b) as ``it was not a 
securely locked, substantially constructed cabinet suitable for the 
storage of controlled substances.'' [FOF 42]. However, GS Langston 
testified that she did not know whether the cabinet was or could be 
locked and DI Milan was similarly unaware. [FOF 42]. Therefore, I find 
that GS Langston had an inadequate basis upon which to draw her 
conclusion concerning the adequacy of the storage cabinet. Likewise the 
photograph is unclear concerning the nature of this cabinet. The record 
does contain evidence that the cabinet was in the dispensing area of 
the clinic. [FOF 42].
    Further, although the Government failed to locate the safes that 
the Respondent purportedly maintained on the premises, [FOF 38], the 
Government bears the burden of proof, and absent GS Langston's 
conclusory statements, its evidence fails to establish that the 
Respondent violated this regulation. [See FOF 42]. Therefore, I find 
the Government has failed to prove the Respondent violate Sec.  
1301.75(b).
    In sum, I find that the Government has proved by a preponderance of 
the evidence that the Respondent violated federal law when she 
prescribed an additional twenty pills to Ron Swanson and failed to 
maintain adequate dispensing records. In addition, I find that the 
Respondent violated state law when she failed to record a treatment 
plan, self-prescribed controlled substances, and dispensed controlled 
substances for more than a 72 hour period. Further, her failure to 
adequately account for over 100,000 dosage units of controlled 
substances is an egregious failure. To the extent that these violations 
represent her experience in handling controlled substances, they 
certainly do not merit a finding that her continued registration would 
be in the public's interest. In total, Factors 2 and 4 weigh in favor 
of revocation of the Respondent's registration.
3. Factor III. Respondent's Conviction Record Under Federal or State 
Laws Relating to the Manufacture, Distribution, or Dispensing of 
Controlled Substances
    It is uncontested that the Respondent has not been convicted of a 
federal or state crime relating to the manufacture, distribution, or 
dispensing of controlled substances. While a history of criminal 
convictions for offenses involving the distribution or dispensing of 
controlled substances is a highly relevant consideration, there are any 
number of reasons why a registrant may not have been convicted of such 
an offense, and thus, the absence of such a conviction is of 
considerably less consequence in the public interest inquiry. [Krishna-
Iyer, 74 Fed Reg. at 461; Chein, 72 FR at 6,593 n.22]. Accordingly, 
that Respondent has not been convicted of an offense related to the 
distribution or dispensing of controlled substances is not dispositive 
of whether the continuation of her registration is consistent with the 
public interest.
4. Factor V. Such Other Conduct Which May Threaten The Public Health 
and Safety
a. Diversion Risks
    Although factor five is quite broad, the Deputy Administrator has 
qualified its breadth by limiting the considerations made under that 
factor to those where there is ``a substantial relationship between the 
conduct and the CSA's purpose of preventing drug abuse and diversion.'' 
[Tony T. Bui, 75 FR 49,979, 49, 988 (DEA 2010)].
    Here, I find that many characteristics of the Respondent's practice 
significantly increased the risk of diversion. I also find that the 
Respondent did little to otherwise mitigate that risk, to the peril of 
her practice and the public.
    First, the Respondent testified that her ``180 Program,'' if 
successful, would result in patients having extra pain medication 
remaining at the end of the month. [FOF 108, 112]. However, on nearly 
all follow up visits, the Respondent did not account for those extra 
pills. [FOF 79-81; 87-88; 103; see Resp. Exh. 1,2,3; but see Respt. 
Exh. 3 at 9 (where Respondent indicated in Ron Swanson's chart that he 
had no remaining pills at the end of the month)]. Also, while 
Respondent instructed her patients not to take the Xanax if they didn't 
need it, she provided her patients with a Xanax prescription at each 
visit and did not inquire whether or not the patient had taken the 
prior prescribed Xanax. She also did not conduct urine screens of the 
undercover officers to ensure they were actually taking the medication. 
[FOF 59, 74, 115]. Therefore, by conducting her practice in this 
manner, the Respondent created the opportunity for her patients to 
divert their medication, yet failed to otherwise screen whether such 
diversion was occurring.
    Second, I find disturbing the Respondent's choice to operate a 
cash-only dispensary concerning, in light of her refusal to adopt other 
effective controls against diversion. [FOF 28]. By eliminating 
pharmacies and third party payors, the Respondent removed necessary 
checks on patient doctor

[[Page 60921]]

shopping as well as her own prescribing.
    In addition, while the Respondent attempted to mitigate the risk of 
doctor-shopping and diversion by other means, such as doctor-patient 
contracts, consent for urinalysis, warnings about lost medication, [FOF 
64, 86, 90], she did so ineffectually. While she instructed patients to 
acknowledge their criminal liability for perpetuating fraud, she did 
not verify the source of a patient's diagnostic report despite the fact 
that those reports either (1) purported to be conducted at out-of-state 
facilities or (2) had no contact information for the facility. [FOF 64, 
86, 90, 69, 83, 92]. For example, when the Respondent was presented 
with fraudulent MRI reports, she was unable to detect such as she 
failed to verify their authenticity. [FOF 40].
    Further, despite physical conditions that were years' old, the 
Respondent did not obtain prior treatment records. [FOF 62]. Such 
treatment records would also provide a prescribing history so the 
Respondent could confirm prior drug use.
    Third, I find it significant that, when risks of actual diversion 
were present, the Respondent failed to take action. For example, Mr. 
Castillo and Mr. Swanson told Respondent that, prior to their visits, 
they had received oxycodone from a friend. [FOF 82, 90]. However, the 
Respondent continued to prescribe them controlled substances. [FOF 86, 
91]. Further, in the March 2010 visit, both Mr. Castillo and Ms. Hall 
were given twice what the Respondent had prescribed for them, 360 
oxycodone 15 mg rather than 180 oxycodone, thus affording the patients 
with the opportunity to divert 180 dosage units of oxycodone each. [FOF 
81, 89]. This prescribing was not discussed and subsequent prescribing 
altered accordingly in the April visit. [FOF 81, 88, 89].
    The Respondent also instructed Mr. Swanson to ``break down'' his 15 
mg pills if he needed to repay his friend, which is an inappropriate 
response to the patient's indication that he may be illegally obtaining 
controlled substances. [FOF 104]. It also interferes with the DEA's 
responsibility to prevent diversion.
    In addition, the Respondent was often presented with large groups 
of out of state patients. [FOF 45, 57]. Her decision not to verify MRIs 
and to obtain past treatment records in those situations, if not 
culpable, may equate to turning a blind eye.
    Fourth, I am not persuaded that the Respondent's choice to delegate 
dispensing authority to a non-pharmacist was a wise one. [FOF 25]. 
Indeed, the Respondent exacerbated the risk that her delegate would 
irresponsibly handle the controlled substances by not conducting her 
own audits. Hence, the Respondent had no way of detecting whether 
controlled substances were being diverted under her registration, which 
they clearly were. [See FOF 76, 80, 87 (where Ms. Hall and Mr. Castillo 
received twice the number of oxycodone as actually prescribed)].
    In sum, while a registrant may operate her practice in any manner 
she chooses provided she does so lawfully, when the means chosen 
increase diversionary risks and fail to otherwise mitigate those risks, 
her registration threatens the public interest. Here, I find that 
despite the increased risks the Respondent created through her 
practice's design, she failed to implement other adequate controls 
against diversion, thus weighing against her continued registration.
b. Subsequent Remedial Measures and Contrition
    In general, the Respondent argues that she naively entered the 
practice of pain management, and has since become more aware of 
diversion risks as well as the specific legal requirements that govern 
her practice. However, naivety regarding the handling of controlled 
substances can weigh as heavily against continued registration as 
culpability. [See Paul J. Caragine, Jr., 63 FR 51562, 51601 (DEA 1998) 
(stating ``just because misconduct is unintentional, innocent or devoid 
of improper motivation, [it] does not preclude revocation or denial. 
Careless or negligent handling of controlled substances creates the 
opportunity for diversion and [can] justify revocation'')]. Thus, if 
the Registrant is unable to adequately assure the agency of future 
compliance, a lack of intentional violation will do little to save her. 
[Jon Karl Dively, M.D., 72 FR 74332 (2007) (a proceeding under 303 ``is 
a remedial measure based upon the public interest and the necessity to 
protect the public * * * Respondent must prove by a preponderance of 
the evidence that she can be entrusted with the authority that a 
registration provides by demonstrating that she accepts responsibility 
for her misconduct and that the misconduct will not re-occur.'')].
    Here, I find the Respondent credibly acknowledged some of her 
wrongdoing. Specifically, I find it highly persuasive that the 
Respondent did not prescribe additional pills to the undercover officer 
on his third visit, and admitted her earlier decision to do so was 
``wrong.'' [FOF 100]. I find this admission, in light of its occurrence 
prior to her becoming aware of the DEA's investigation of her 
registration, highly probative of a finding that the misconduct will 
not reoccur. [FOF 100].
    Yet, I also find that while the Respondent recognized her ultimate 
responsibility for the dispensing and accounting errors found at her 
practice, I did not find her remorseful for improperly managing that 
responsibility. Throughout the hearing she justified dispensing errors 
on the fact that those responsibilities were delegated to her business 
partner and justified that delegation. [FOF 32]. In addition, she 
alluded that some of her recordkeeping errors and, the corresponding 
shortages, may have been attributed to thefts. However, the record 
makes clear that at least some of those shortages were attributable to 
actual diversion, and, despite that clarity the Respondent failed to 
acknowledge her wrongfulness in irresponsibly managing her registration 
and creating the opportunity for that diversion.
    As for future assurance of compliance, the Respondent presented 
evidence that she has, or would, implement some changes in her practice 
to address the DEA's concerns regarding her practice. Specifically, the 
Respondent testified that she instructed her staff to verify patients' 
MRI reports. [FOF 41]. Next, she has installed two safes for the 
storage of controlled substances. [FOF 38]. The Respondent also 
augments her prescribing of controlled substances with the requirement 
of exercise to help alleviate chronic pain. [FOF 114]. As for the 
myriad of other issues the Respondent was silent. The Respondent failed 
to provide any assurance that she would better account for controlled 
substances, better prevent the reoccurring thefts and break-ins at her 
practice, and address the diversion that occurred through her 
dispensary. Thus, I am not convinced that if the Respondent were 
allowed to continue operating under her DEA registration, that she 
would be able to adequately manage that responsibility.

V. Conclusion and Recommendation

    In Conclusion, I find that Factors II, IV, and V weigh in favor of 
discontinuing the Respondent's registration. The Government proved by a 
preponderance of the evidence that the Respondent violated Florida law 
in failing to adequately document a treatment plan and by self-
prescribing controlled substances. Also, the Government proved that the 
Respondent violated federal law in failing to adequately account for 
her controlled

[[Page 60922]]

substances and maintain her DEA 222 forms. More importantly, however, 
the record clearly reflects that the Respondent created serious risks 
of diversion through her practice and failed to otherwise mitigate 
those risks. Thus, I find the Government has met its burden of proof 
that the Respondent's continued registration would not be in the 
public's interest.
    The Respondent, however, has not accepted responsibility for all of 
her wrongdoing, nor has she adequately assured this tribunal of future 
compliance.
    In balancing the statutory public interest factors and the 
Respondent's remedial efforts, I conclude that revocation of the 
Respondent's DEA Certificate of Registration, and denial of any pending 
renewal applications, would be consistent with the public interest in 
this case.
    Accordingly, I recommend that the Respondent's Certificate of 
Registration be revoked and any pending applications for renewal be 
denied.

    June 17, 2011.

Gail A. Randall,
Administrative Law Judge.

[FR Doc. 2011-25231 Filed 9-29-11; 8:45 am]
BILLING CODE 4410-09-P