[Federal Register Volume 77, Number 58 (Monday, March 26, 2012)]
[Notices]
[Pages 17505-17522]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-7107]


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DEPARTMENT OF JUSTICE

Drug Enforcement Administration

[Docket No. 11-1]


Morris W. Cochran, M.D.: Revocation of Registration

    On September 22, 2010, I, the then-Deputy Administrator of the Drug 
Enforcement Administration, issued an Order to Show Cause and Immediate 
Suspension of Registration to Morris W. Cochran, M.D. (Respondent), of 
Birmingham, Alabama. The Order proposed the revocation of Respondent's 
DEA Certificate of Registration BC1701184, and the denial of any 
pending applications to renew or modify his registration, on the ground 
that his ``continued registration is inconsistent with the public 
interest.'' 21 U.S.C. 824(a)(4).
    More specifically, the Order alleged that while Respondent is 
authorized to prescribe Suboxone and Subutex ``for maintenance or 
detoxification treatment pursuant to 21 U.S.C. 823(g)(2) under DEA 
identification number XC1701184,'' he had ``prescribed methadone,'' a 
schedule II controlled substance, ``to patients for the purpose of drug 
addiction treatment'' without the registration required under 21 U.S.C. 
823(g)(1). ALJ Ex.1, at 1-2.
    Next, the Order alleged that Respondent had prescribed both 
methadone and Suboxone, the latter being a Schedule III controlled 
substance, to numerous patients whose charts show that he ``did not 
obtain a prior medical history,'' that he ``did not perform an initial 
physical exam,'' that he ``established little or no basis for the 
diagnoses,'' and that he ``offered no other treatment other than 
prescribing controlled substances.'' Id. at 2. The Order further 
alleged that ``[s]uch prescribing was not for a legitimate medical 
purpose in the usual course of professional practice in violation of 21 
CFR 1306.04(a), and in violation of Alabama Administrative Code 540-X-
11)(1), which requires that a physician personally obtain an 
appropriate history, perform a physical exam, make a diagnosis and 
formulate a therapeutic plan before prescribing drugs to a patient.'' 
Id. Finally, the Order alleged that Respondent had ``continue to 
prescribe alprazolam, a schedule IV controlled substances depressant, 
to a patient after [the] patient file explicitly noted that the patient 
abused this drug.'' Id.
    Based on the above, I concluded that Respondent's continued 
registration during the pendency of the proceeding ``constitute[d] an 
imminent danger to the public health and safety.'' Id. I therefore 
invoked my authority under 21 U.S.C. 824(d) and immediately suspended 
Respondent's registration.
    Respondent requested a hearing on the allegations and the matter 
was placed on the docket of the Agency's Administrative Law Judges 
(ALJs). On November 2-4, 2010, an ALJ conducted a hearing in 
Birmingham, Alabama. ALJ Decision (also ALJ), at 3.
    On January 5, 2011, the ALJ issued her decision which recommended 
that Respondent's registration be revoked. Id. at 51. Therein, the ALJ 
found that the Alabama Medical Board had not made a recommendation in 
the matter (factor one) and that Respondent has not been convicted of 
an offense related to the manufacture and distribution of controlled 
substances (factor three). Id. at 43, 48.
    With respect to factors two (Respondent's experience in dispensing 
controlled substances) and four (Respondent's compliance with 
applicable laws related to controlled substances), the ALJ made 
extensive findings. First, the ALJ found that Respondent violated DEA 
regulations because he prescribed drugs other than Suboxone or Subutex 
on prescription forms that used only his Data Waiver (or X) number. ALJ 
at 43. The ALJ also found that Respondent ``improperly prescribed 
Suboxone for substance abuse using his regular DEA registration number 
rather than the required ``X'' number.'' Id.
    Next, the ALJ found that Respondent prescribed methadone for 
detoxification and maintenance treatment without holding the separate 
registration required to do so under Federal law. ALJ at 43-45. The ALJ 
specifically rejected Respondent's testimony that he had prescribed 
methadone to nine patients to treat pain (which does not require a 
separate registration), noting that Respondent had initially told a DEA 
Investigator that he was prescribing methadone for detoxification 
purposes, that several patients who had received methadone had told the 
Investigator that they were being treated for substance abuse, and that 
several of the patients had come to Respondent's clinic ``directly 
after'' being treated by a methadone clinic ``where the prescription of 
methadone for pain is prohibited'' and had been diagnosed by Respondent 
as being substance abusers. Id. at 44-45. The ALJ also found that 
Respondent had violated the limitation imposed under Federal law and 
regulations which limit to 100, the number of patients who can be 
treated for substance abuse with Suboxone. ALJ at 46-47 (citing 21 
U.S.C. 823(g)(2)(B)(iii) and 21 CFR 1301.28(b)(1)(iii)).
    Next, the ALJ found that Respondent violated both Federal and State 
regulations because his medical charts ``fail[ed] to list the source 
and severity of pain when chronic pain [wa]s the diagnosis. ALJ at 47 
(citing Ala. Admin. Code 540-X-4.08; 21 CFR 1306.04(a) and 1306.07(c)). 
The ALJ further found that Respondent's charts ``fail[ed] to record 
when medical examinations were conducted and the specific results of 
those examinations in support of diagnoses,'' and that ``[i]n some 
instances, patients actually reported that no examination was 
conducted.'' Id. The ALJ also found that the ``charts failed to show 
the use of any treatment options besides the prescribing of controlled 
substances,'' and that the ``lack of attempts of alternative treatment 
modalities prior to determining that the patient suffers from chronic 
pain violates 21 CFR 1306.07(c).'' Id.
    The ALJ further found that Respondent had post-dated prescriptions 
for schedule II controlled substances in violation of Federal 
regulations. Id. at 47-48 (citing 21 CFR 1306.05(a) and 1306.12(b)). In 
addition, the ALJ found that Respondent had admitted to having issued a 
controlled substance prescription after he was served with the 
Immediate Suspension Order. Id. at 48. The ALJ then found that 
``Respondent testified, and the record contains no expert evidence to 
the contrary, that his treatment of his patients met the standard of 
care.'' Id. However, based on Respondent's improper use of his data-
waiver number on prescriptions, his unauthorized prescribing of 
methadone for maintenance and detoxification purposes, his incomplete 
records, his failure to recommend any treatment options for his chronic 
pain patients besides the prescribing of controlled substances, and his 
issuance of a controlled substance prescription after his registration 
was suspended, the ALJ concluded that these factors supported the 
revocation of his registration. Id.
    With respect to factor five--such other conduct which may threaten 
public health or safety--the ALJ found that Respondent lacked candor. 
More

[[Page 17506]]

specifically, the ALJ noted that ``[p]ractically all of the patient 
charts in this record had the same diagnoses: Chronic pain and 
substance abuse. However, when most of the patients were asked about 
their treatment by the Respondent, they stated that they were being 
treated for substance abuse.'' Id. at 49. While the ALJ acknowledged 
``that it may be difficult to accurately diagnose chronic pain or 
substance abuse,'' she found Respondent's testimony that the patients 
did not know that they were being treated for chronic pain to ``lack[] 
credibility.'' Id. The ALJ thus concluded that Respondent's ``lack of 
candor also threatens public health and safety.'' Id. at 49.
    The ALJ then turned to Respondent's evidence as to his remedial 
measures. The ALJ noted that Respondent had stopped using his X number 
improperly (to prescribe drugs other than Suboxone and for purposes 
other than substance abuse treatment), that he had stopped prescribing 
methadone, and that at the hearing, he had ``apologized for the 
issuance of prescriptions for controlled substances without a proper 
DEA registration.'' Id. at 50. However, noting that upon being served 
with the Immediate Suspension Order, Respondent had stated that he did 
not intend to comply with it, as well as his testimony that while he 
currently lacks ``authority to handle controlled substances, he 
continues to `help' with the Suboxone at [another] clinic,'' the ALJ 
found that Respondent's ``actions do not indicate remorse, but, rather, 
are more indicative of a failure to appreciate the seriousness of the 
allegations against him and the responsibility with which he was 
charged.'' Id. The ALJ further found that ``Respondent, through his 
actions, likely facilitated'' drug abuse. Id.
    The ALJ thus concluded that Respondent had failed to rebut the 
Government's prima facie case. Id. at 51. She further recommended that 
Respondent's registration be revoked and that any pending applications 
be denied. Id.
    Neither party filed exceptions to the ALJ's decision. Thereafter, 
the record was forwarded to this Office for Final Agency Action. Having 
considered the record as a whole, I adopt the ALJ's findings of fact 
and conclusions of law except as otherwise noted herein. I further 
adopt the ALJ's recommendation that Respondent's registration be 
revoked and that any pending application be denied. I make the 
following findings.

Findings

    Respondent is a physician licensed by the Alabama State Board of 
Medical Examiners (hereinafter, State Board or Medical Board) and is 
board certified in family practice. As of the date of the hearing, 
Respondent's state license remains current and unrestricted. Tr. 259. 
The State Board, however, has an open investigation of Respondent. Id. 
at 257-58.
    Respondent is also the holder of DEA Certificate of Registration 
BC1701184, which prior to the issuance of the Immediate Suspension 
Order, authorized him to dispense controlled substances as a 
practitioner in schedules II through V, with the registered location of 
Narrows Health & Wellness, 151 Narrows Parkway, Suite 110, Birmingham, 
Alabama.\1\ ALJ at 4 (stipulated facts). Respondent's registration does 
not expire until August 31, 2012. Id.
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    \1\ Respondent also was practicing at offices in Red Bay and 
Russellville, Alabama. ALJ at 4-5 (Stipulated Facts at para. 4); Tr. 
35.
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    Respondent is also authorized to dispense Suboxone and Subutex, 
under the Drug Addiction Treatment Act of 2000 (DATA), for the purpose 
of treating opiate addicted patients and is authorized to treat up to 
100 patients; Respondent has been assigned identification number 
XC1701184 for this purpose. Id.; see 21 U.S.C. 823(g)(2). Suboxone and 
Subutex are schedule III controlled substances (and are the only 
schedule III through V drugs) which have been approved by the Food and 
Drug Administration for the treatment of opiate addiction by a DATA 
Waiver physician.
    Respondent is not, however, authorized to dispense methadone, a 
schedule II narcotic, for the purpose of treating opiate addiction as 
he does not have the registration required by 21 U.S.C. 823(g)(1). GXs 
1 & 2. Respondent can, however, lawfully dispense methadone for the 
purpose of treating pain.

The Investigation

    Respondent first came to the attention of the authorities when 
several pharmacies complained to a State Board Investigator that he was 
prescribing large amounts of methadone using his X number. Tr. 35-36. 
The State Investigator passed this information on to a DEA Diversion 
Investigator (DI); on February 28, 2010, which was a Sunday morning, 
the two Investigators went to Respondent's Red Bay Clinic and arrived 
there at 6:30 a.m. Id. at 37. While the Investigators were in the 
parking lot taking photographs, they were approached by TS, who said 
``[h]e was waiting to get his methadone from'' Respondent. Id. at 38. 
TS also stated that he paid cash for his visits, that he was seeing 
Respondent for an old football injury, that he did not provide any 
medical records to Respondent, and that he was not asked for 
identification when he first registered as a patient. Id. at 39-40.
    Respondent did not arrive at the office until shortly before 11 
a.m., by which time ``close to 50 people'' were waiting to see him. Id. 
The State Investigator then went inside to register in an attempt to 
see Respondent. Id. However, when the State Investigator was told that 
he would have to wait five to six hours to see Respondent, the 
Investigators decided to identify themselves and interview him. Id. at 
42. Respondent initially told the Investigators that ``he was operating 
a detox clinic where he was using methadone to get his patients onto 
Suboxone.'' Id. at 43. Respondent also said that he accepted cash only, 
that he saw an average of 80 patients on Sundays at the Red Bay clinic, 
and that he also treated chronic pain patients on whom he performed 
``range of motion tests.'' Id. at 43-44.
    With respect to his chronic pain patients, Respondent told the 
State Investigator that he would look for surgical scars on the 
patient's body and that he sent some of his patients for X-Rays and 
MRIs. Id. at 218-19. Respondent admitted to the State Investigator that 
``he did not'' follow the Board's guidelines for the use of controlled 
substances in treating pain. Id. at 220. In the interview, Respondent 
also stated that he would require his substance abuse patients to 
undergo drug screens ``if he felt that they needed one.'' Id. at 219.
    Respondent also maintained that he knew the requirements for using 
his X number and that he was not prescribing any other drugs under this 
number. Id. at 44-45. The State Investigator then showed Respondent a 
methadone prescription he had written under his X number; Respondent 
said that the ``prescription was a mistake.'' Id. at 45. The DI then 
told Respondent that he had found ``close to 200 prescriptions * * * 
written under his X number for'' drugs other than Suboxone and Subutex, 
including Xanax (a schedule IV depressant) and Adderall (a schedule II 
stimulant). Id.; see also id. at 221 (testimony of State Investigator).
    The DI then asked Respondent how many patients he was treating 
under his X number. Id. at 46. Respondent said that he had 60 patients 
at his Red Bay clinic and another 50 patients at his

[[Page 17507]]

Birmingham office. Id. When told by the DI that this exceeded the 100 
patient limit, Respondent claimed that ten of the patients were 
actually being treated with Suboxone for pain. Id. at 46.
    During the visit, the DI encountered JKB in Respondent's waiting 
room and asked to speak with him. Id. at 51. The DI asked JKB what 
Respondent was treating him for; JKB stated that he was treating him 
for an addiction to opiates with methadone. Id. at 52. JKB also told 
the DI that he had previously gone to a narcotic treatment program 
which used methadone and that he was going to Respondent because it was 
cheaper. Id. at 53. JKB also stated that he was not seeing Respondent 
for chronic pain. Id.
    Following this interview, the DI resumed his interview of 
Respondent. Respondent now maintained that he was prescribing methadone 
for pain. Id. When the DI told Respondent that he had just interviewed 
a patient who said he was being treated for opiate addiction with 
methadone, Respondent stated that the patient was mistaken. Id. at 54. 
When the DI reminded Respondent that he had earlier stated that he was 
using methadone to transfer patients onto Suboxone, he stated that he 
had previously misspoken and ``[t]hat he was only using methadone for 
pain'' and not to treat addiction. Id. at 55. When the DI asked 
Respondent whether it was possible to see eighty patients in a day and 
``provide the kind of treatment that was necessary for'' them, 
Respondent stated that ``he was overwhelmed and . . . needed some 
guidance.'' Id. at 56-57.
    Upon leaving the clinic, the Investigators observed ``approximately 
50 patients inside of [the] office and probably another 50 to 60 . . . 
in the parking lot.'' Id. at 57. The Investigators then went to a local 
CVS pharmacy and interviewed its pharmacist, who stated that since the 
opening of Respondent's Red Bay clinic, he had ``seen a tremendous 
spiking in the amount of prescriptions for methadone.'' Id. at 58. The 
pharmacist further stated that Respondent was writing methadone 
prescriptions to treat addiction and that he would not fill these 
prescriptions. Id. at 59; see also GX 7.
    On May 17, 2010, the Investigators (along with a Supervisory DI) 
went to Respondent's Russellville office and obtained various patients' 
files through either an administrative subpoena or a warrant. Tr. 48-
50, 62-63. The Investigators again interviewed Respondent who stated 
that he was mainly seeing pain patients. Id. at 63. The DI then asked 
Respondent if he had made any changes to his practice; Respondent 
states that ``he had switched pretty much everybody from methadone to 
Suboxone and that out of the 85 percent [of his] patients that he was 
seeing for pain, 95 percent . . . were being treated with Suboxone.'' 
Id. at 64. Respondent also stated that he had stopped prescribing 
methadone for pain because he was having more success using Suboxone. 
Id. at 65.
    During the interview, Respondent identified AK as a chronic pain 
patient who he was treating with Suboxone and who was waiting to see 
him. Id. at 65-66. The DI proceeded to interview AK, who had yet to see 
Respondent that day; AK stated that Respondent ``was treating her for 
an addiction to opiates,'' and that after the February visit by the 
Investigators, he had stopped writing methadone prescriptions. Id. at 
66.
    The DI also interviewed another patient, SH, who was in the parking 
lot. Id. at 73-74. SH stated that Respondent was treating him for 
opiate addiction and not for chronic pain. Id. at 74.
    The DIs seized 114 patient files which were selected on the basis 
of pharmacy records showing that Respondent had prescribed either 
Suboxone or methadone to the patients. Id. at 171-72, 174. The files 
were taken to the DIs' office where they were reviewed. Id. at 68. 
Thereafter, the DIs focused their investigation on approximately 28 
patients, whose files were introduced into evidence.\2\ During the 
course of the investigation, the DIs interviewed most of these patients 
by telephone to determine why they were seeing Respondent. Id. at 172.
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    \2\ Twenty-six of the patient files were entered into evidence 
as Government Exhibit 5; the two remaining files were entered into 
evidence as Government Exhibits 22-23. Respondent also introduced 
copies of the same files. See RXS 2, 4-28. I have carefully reviewed 
both sets of files and conclude that there are no material 
differences between the two sets.
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The Patient Files and Interviews

Respondent's Methadone Patients

TP
    On June 1, 2010, the DI spoke with TP. TP told him that Respondent 
did not physically examine her, that she paid $100.00 for the visit and 
that he prescribed methadone to her. Tr. 103-105; GX 5X. TP went to 
Respondent because she had heard that he was using methadone to treat 
addiction. Tr. 105.
    TP saw Respondent on three occasions (Feb. 7 and 21, and Mar. 7, 
2010). GX 5X. TP completed an intake form on which she listed her 
medications as ``methadone 12 10s a day'' and wrote that her pharmacy 
was the ``methadone clinic.'' Id. at 2. At her first visit, Respondent 
checked ``YES'' for whether TP had pain and listed her legs and back as 
the location. Id. at 3. Respondent diagnosed TP as having chronic pain, 
substance abuse and anxiety. Id.
    However, Respondent did not document the nature and intensity of 
the pain, current and past treatments for the pain, and its effect on 
TP's physical and psychological functioning. Id. at 3, 5. No vital 
signs were recorded at any of her visits. Id. In addition, the chart 
contains no medical history. See generally GX 5X.
    Moreover, while TP indicated that she had previously gone to a 
methadone clinic, Respondent did not know the name of the clinic and 
did not even attempt to obtain her treatment records. See generally GX 
5X; Tr. 727-28. In addition, the progress note for TP's third visit 
contains no information other than her name, date of birth and the date 
of the visit.
    At each of TP's three visits, Respondent prescribed a daily dose of 
eleven tablets of methadone 10 mg, with the first two prescriptions 
being written under his X number for 154 tablets each. See GX 5X. While 
TP told the DI that after DEA's February 28, 2010 visit, Respondent 
told her that he was no longer prescribing methadone, Tr. 105; on March 
7, Respondent again prescribed 88 tablets of methadone 10 mg to her. GX 
5X, at 1. When Respondent offered TP alternative medications to 
methadone, she elected to return to a methadone treatment program. Tr. 
501, 728.
    When asked on cross-examination if the methadone clinic which TP 
had previously gone to was treating her for abusing narcotics, 
Respondent testified that while the only purpose of a methadone clinic 
is to treat ``substance abuse,'' she was ``going for pain.'' Id. at 
728. While Respondent also diagnosed TP as having substance abuse, he 
did not document the substances that she was abusing. GX 5X.
DG
    DG first saw Respondent on January 3, 2010. GX 5O. On the intake 
form, DG listed his medications as ``methadone.'' Respondent made a 
diagnosis of chronic pain even though he checked ``NO'' for whether DG 
had pain and the progress note for the visit does not document the 
nature and intensity of the pain, whether any treatments had been 
previously tried, and the pain's effect on his psychological and 
physical function. GX 5O, at 4. While Respondent noted that he 
performed a physical exam, he found each of the areas of the 
examination to be normal. Id. Respondent prescribed methadone to

[[Page 17508]]

DG at this visit, as well as on January 12, 19, and February 1, 14, and 
28, 2010. Id. at 5, 7, 9, 11.
    On July 9, 2010, the lead DI interviewed DG. Tr. 106. DG stated 
that Respondent had told him on February 28, 2010, that he would no 
longer prescribe methadone, but that he would prescribe Suboxone to DG 
if he was having trouble getting off of the methadone. Id. at 107-08, 
386.
    Respondent testified that on January 19, 2010, he diagnosed DG as 
having a substance abuse problem, yet the medical chart does not 
document the basis for that diagnosis. Id. at 701-02. Respondent 
testified that his diagnosis was based on DG's demeanor and ``probably 
. . . also a drug screen.'' Id. However, there is no drug screen in the 
file. See GX 5O.
    DG testified at the hearing. The ALJ found credible his testimony 
that he was also seeing the Respondent for pain in his shoulder and 
lower back. ALJ at 23. While DG believed this pain was a result of 
masonry work he had done since he was a teenager, as well as a 
snowboarding accident he had when he had lived in Utah, DG's chart does 
not reflect any of this information. Tr. 367, 374; GX 5O.
    According to DG, Respondent examined him and would spend about 7 to 
10 minutes with him during his visits. Tr. 370. DG also denied having 
told the DI that Respondent did not perform a physical exam on him and 
that he was seeing Respondent for substance abuse. Tr. 371.
    Respondent used his X number to prescribe methadone for DG. GX 5O, 
at 5, 7, 9, 11. The methadone prescriptions were for lesser and lesser 
amounts. GX 5O, at 1. In March of 2010, Respondent proposed to offer DG 
an alternative medication treatment plan. Id. at 11; Tr. 386-87. The 
medical chart stops at that point. GX 5O. Respondent stated that he 
believed his treatment of DG was appropriate. Tr. 488.
MB
    On July 20, 2010, the lead DI interviewed MB. Tr. 108; GX 5A. MB 
stated that she was seeing Respondent for an addiction to Lorcet and 
not for chronic pain, that she paid cash for her prescriptions, and 
that Respondent did not perform any physical examinations. Tr. 109-110. 
MB also commented that she thought there were too many people waiting 
inside and outside the office to see Respondent. Id. at 109.
    On the progress note for MB's first visit, Respondent circled 
``YES'' for whether she had pain and diagnosed her as having chronic 
pain due to headaches. GX 5A, at 7. At the hearing, Respondent 
testified that MB was being treated for both periodic headaches and 
substance abuse. Respondent did not, however, further document the 
nature and intensity of the pain, how it affected MB's ability to 
function, and any prior treatments for her pain. See id. Nor did he 
document the history of MB's substance abuse. Tr. 533-37. Respondent 
did not obtain information from MB's prior physicians. Tr. 533-34. 
While Respondent indicated that the physical examination was normal, he 
did not take MB's vital signs. Tr. 532-33; GX 5A, at 7.
    Respondent described his treatment of MB as tapering her down on 
her methadone prescriptions, and the prescriptions show that Respondent 
was gradually reducing her daily dosage from 150 mg to 130 mg over the 
course of the slightly more than two months in which he treated her.\3\ 
Tr. 463, 545, 550; GX 5A, at 5-6. At MB's last visit (Mar. 14), 
Respondent offered her the option of using different medication to 
control any potential withdrawal symptoms she may have from the lack of 
methadone. Tr. 464-65. However, MB chose to seek treatment elsewhere. 
Tr. 551.
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    \3\ Respondent issued MB a total of six methadone prescriptions 
between January 5 and March 14, 2010. GX 5A, at 2. Some of the 
prescriptions indicated that they were ``for pain.'' Id. at 4, 6.
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    Respondent issued MB two methadone prescriptions on his X 
prescription pad. Tr. 541-42; GX 5A, at 6. MB's file has no entry for 
her visits of February 28 and March 14, even though MB's drug log notes 
that a methadone prescription was issued on each date for 182 and 106 
dosage units of methadone respectively. GX 5A, at 2-3.
JC1
    Respondent saw JC1 three times in February and March of 2010. GX 
5N. On his intake form, JC1 listed his medications as methadone and 
Xanax. GX 5N, at 2. On the progress note for JC1's first visit (Feb. 
9), Respondent noted that he had been in an automobile accident and 
wrote ``back'' on the chart. Id. at 4. However, Respondent also noted 
that JC1 had ``NO'' pain and did not document the nature and intensity 
of the pain, details regarding the accident such as when it occurred, 
what treatments had been used, and the pain's effect on his physical 
and psychological functioning. Id. The progress note indicated that 
Respondent did a physical exam, during which he did not find any area 
to be abnormal. Id. Respondent did not document having taken JC1's 
vital signs. Id. At this visit, Respondent gave JC1 prescriptions for 
210 tablets of methadone 10 mg, with a daily dose of 15 tablets, and 60 
tablets of Valium, even though he noted that JC1 was not agitated or 
moody and did not have insomnia. Id. at 4-5. These prescriptions were 
written under his X number. Id. at 5.
    At JC1's next visit (Feb. 23), Respondent again indicated that he 
had ``NO'' pain and did a physical exam at which he found all areas 
normal. Id. at 4. At this visit, Respondent noted diagnoses of both 
chronic pain and substance abuse. Id. Respondent issued JC1 a 
prescription for 210 tablets of methadone 10 mg, with a daily dose of 
15 tablets ``for pain.'' Id. Respondent wrote the prescription under 
his X number. Id. at 5.
    On March 9, Respondent wrote JC1 two more prescriptions, one for 
another 210 tablets of methadone with the same daily dose ``for pain'' 
as before, and one for twenty-eight tablets of Valium. Id. at 1, 7. 
Respondent wrote the prescriptions under his X number. Id. at 7. 
Respondent did not, however, create a progress note to document the 
issuance of the prescriptions. See generally GX 5N.
    Respondent testified that JC1 had been in an automobile accident 
and had fractured his back, that he had developed a tolerance for pain 
medicine and was taking more and more, and thus went to a methadone 
clinic. Tr. 486. Respondent further testified that JC1 had come from 
either the Shoal's clinic or a narcotic treatment program in Hamilton 
because he ``wanted to take a cleaner medicine for his pain.'' Id. at 
486, 699. Respondent denied that JC1 had gone to the narcotic treatment 
program ``to be treated for addiction'' and maintained that ``he was 
going there to be treated for pain from a fractured back.'' Id. at 699.
    As for the basis of the substance abuse diagnosis which he made at 
JC1's second visit, Respondent testified that ``we probably got our 
February 9 drug screen back. And he probably had some [illicit] drug in 
there.'' Id. at 700. However, Respondent acknowledged that he was 
speculating about this because JC1's chart did not contain any drug 
test results. Id.
    Respondent prescribed methadone at a lower dosage amount than the 
dosage JC1 reported he had been on. Id. at 486; GX 5N at 1, 5, 7. 
However, while Respondent maintained that JC1 ``wanted to take a 
cleaner medicine for his pain,'' Respondent did not taper the methadone 
prescriptions for JC1, but rather prescribed the same daily dose of 150 
mg in each prescription between February 9, 2010, and March 9, 2010. 
Tr. 486; GX 5N, at 1, 5, 7. When in

[[Page 17509]]

March, Respondent offered him alternative medications, JC1 elected to 
go to another treatment facility. Tr. 486. Respondent maintained that 
his care of JC1 was appropriate. Id. at 487.
JB
    Respondent treated JB in February and March of 2010.\4\ GX 5L. On 
the intake form, JB listed his medications as ``methadone,'' and on the 
progress note for his visit, Respondent wrote that JB had been a 
patient at the Shoals Treatment Center, that he had been on 230 mg. of 
methadone, but that he ``was kicked out.'' GX 5L, at 5. Respondent 
further wrote that JB ``desires to get off methadone.'' Id. In 
addition, Respondent noted that JB had foot pain, back pain and knee 
pain which had been caused by ``a four-wheeler accident.'' Id.; Tr. 
696. Respondent performed a physical examination and took JB's blood 
pressure and heart rate. GX 5L, at 5. Respondent also noted that JB had 
withdrawal, was agitated/moody, had insomnia, and had a positive MDQ 
(Mood Disorder Questionnaire). Id. Respondent then issued JB a 
prescription for a fourteen-day supply of methadone 10 mg, at a daily 
dose of 18 tablets, id., and noted that his plan included placing JB on 
his alternative medication (KCZZU) program. Id. Respondent issued JB a 
prescription for methadone, which was written under his X number, and 
wrote on it ``for pain.'' Id. at 6. Respondent also wrote JB a 
prescription for Ultram, a non-controlled drug, on the same form, which 
listed only his X number. Id.
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    \4\ It is unclear whether JB is the same person as JKB, who was 
interviewed in the waiting room on February 28, 2010, and who told 
Investigators that he had previously gone to a methadone clinic and 
that Respondent was treating him for opiate addiction, as the 
Government did not establish that this chart (GX 5L) was JKB's.
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    On February 28, 2010, JB again saw Respondent. Respondent circled 
``YES'' for whether JB had pain and insomnia, and made a further 
notation that his pain was worse, although the precise area is 
illegible. Id. at 5. Respondent again noted a diagnosis of chronic pain 
and issued JB another prescription for 252 methadone 10 mg, with a 
daily dose of 18 tablets ``for pain.'' Id. at 6. This prescription was 
also issued under his X number.
    At JB's final visit (Mar. 14), Respondent noted that his ``pain 
persists'' and that he was ``anxious about stopping methadone.'' Id. at 
3. Respondent issued him a prescription for 156 tablets of methadone 10 
mg with a daily dose of 17 tablets ``for pain.'' Id. at 4. Respondent 
wrote the prescription on a form, which contained both his X number and 
regular DEA number. Id.
    Respondent testified that JB had been asked to leave a drug 
treatment program before he saw the Respondent. Tr. 482. Respondent 
testified that he had done a drug screen on JB and that he did not 
``see anything that bothered [him], such as cocaine * * * or marijuana 
at that time.'' Id. at 483. However, JB's file does not contain the 
results of a drug screen. GX 5L.
    According to Respondent, JB had been in a four-wheeler accident, 
took narcotics, and went to the drug treatment program because his 
other physician would not write anymore prescriptions for narcotics. 
Tr. 696. Respondent did not, however obtain JB's records from the drug 
treatment program and Respondent maintained that the fact that JB was 
being treated at a methadone clinic did not tell him that JB was being 
treated for opiate addiction. Id. at 695-96. Respondent stated that he 
prescribed methadone in a tapered amount to prevent JB from going into 
withdrawal. Id. at 483; GX 5L, at 1.
    Respondent also testified that he had provided JB with the option 
of other treatment medications, but that he elected to go to another 
methadone clinic. Tr. 483. Respondent annotated in the medical chart 
that he was treating JB for back and knee pain. GX 5L, at 5-6. 
Respondent did not document the severity of the pain. GX 5L. Respondent 
stated that his treatment of JB was appropriate. Tr. 483-84.
NB
    Respondent saw NB three times in February and March of 2010. GX 5M. 
At her first visit (Feb. 7), Respondent diagnosed her as having chronic 
pain even though he indicated that she had ``NO'' pain. GX 5M, at 3. 
Respondent did not document any further information regarding NB's 
condition (such as the nature and intensity of the pain, its history, 
whether any treatments had been previously tried, and the pain's effect 
on her psychological and physical functioning) at any of her three 
visits. Id. at 3, 5.
    The progress note for NB's first visit indicates that Respondent 
performed a physical exam. Id. at 3. However, Respondent noted that all 
areas were normal. Id. Respondent did not document having taken NB's 
vital signs. Id. At this visit, Respondent issued NB prescriptions 
under his X number, for 210 tablets of methadone 10 mg (with a daily 
dose of 15 tablets) and 30 Xanax. Id. at 4. Respondent did not diagnose 
NB as having anxiety; indeed, he noted that she was not agitated/moody 
and did not have insomnia. Id. at 3.
    On Feb. 21, Respondent issued NB additional prescriptions for 
methadone and Xanax under his X number. Id. at 4. The progress note for 
this visit, however, contains no information regarding her medical 
condition. Id. at 3. On the progress note for NB's final visit (Mar. 
7), Respondent circled ``CHRONIC PAIN'' but made no other findings. Id. 
at 5. At this visit, Respondent issued her prescriptions for 112 
tablets of methadone 10 mg, with a daily dose of 14 tablets ``For 
Pain,'' and for 20 tablets of Klonopin ``for anxiety.'' Id. at 6. 
Respondent wrote the prescriptions on a form which listed both his X 
number and his regular registration number. Id.
    Respondent testified that NB told her at the initial visit that she 
had been on 180 mg of methadone and that ``she was taking it for 
pain.'' Tr. 484. He then testified that ``she also had some anxiety'' 
and that she was a ``troubling patient'' because she was ``on a 
combination of methadone and Xanax'' which caused him great concern, 
especially if ``those two drugs get mixed with alcohol.'' Id. at 485. 
None of this was documented.
    Respondent also testified that he gave her ``150 methadone,'' which 
was ``much less methadone than she was on,'' and that he ``gave her 28 
tablets of the Xanax in fear of seizure potential if we went below 
that.'' Id. At her last visit, Respondent offered NB the option of 
alternative medications, after which she did not return to his clinic. 
Id. 485; GX 5M. Respondent believed his care of NB was appropriate. Tr. 
485-86.
KI
    Respondent saw KI four times in February and March of 2010. GX 5T. 
On the intake form, KI noted that her medications included ``methadone, 
Xanex[sic], [and] Ambien.'' Id. at 2.
    According to Respondent, KI was being treated at Shoals, a narcotic 
treatment facility, and she wanted out of the clinic. Tr. 494. 
Respondent testified that KI had back pain; however, Respondent 
indicated that she had ``NO'' pain on the progress note for her first 
visit. Tr. 494, GX 5T, at 3. Although Respondent wrote ``Back'' as the 
location, once again, he did not document the nature and intensity of 
the pain, the history of the pain, what treatments had been used, and 
the pain's effect on KI's physical and psychological functioning. GX 
5T, at 3; Tr. 494, 718.
    Respondent performed a physical examination but did not note any 
abnormalities; he also did not document

[[Page 17510]]

having taken KI's vital signs. GX 5T, at 3. Respondent noted the 
diagnoses of both chronic pain and substance abuse and prescribed a 
lesser dose of methadone (130 mg per day) than what KI reported she had 
been receiving at Shoals (150 mg). Tr. 494; GX 5T, at 3-4. However, 
Respondent did not taper KI's methadone prescriptions; rather, he 
prescribed 130 mg per day of methadone to her three times between 
February 7, 2010, and March 7, 2010, with the first two prescriptions 
being written under his X number. GX 5T, at 1, 4, 6.
    Respondent did not obtain treatment records from the narcotic 
treatment facility and did not know what substance KI was abusing; he 
also did not obtain any records related to her back pain. Tr. 715-16. 
Respondent testified that KI began taking narcotics to treat her pain, 
became addicted to those narcotics, but then denied that she had told 
him that she then entered the methadone clinic to treat her addiction. 
Id. at 716-17. Respondent testified that he offered alternative 
medications to KI, that on March 21, 2010, he refused to prescribe 
methadone to her, and that she then ``went to another facility.'' Id. 
at 494-95. Respondent maintained that his care of KI was appropriate. 
Id. at 495.

Respondent's Suboxone Patients

SS
    On June 1, 2010, the DI spoke with SS by phone. Tr. 96. SS said 
that he was being treated for opiate addiction, that he received a 
Suboxone prescription from Respondent, and that he was not being 
treated for chronic pain. He also stated that he paid $100.00 cash 
directly to Respondent for his prescription and that Respondent did not 
conduct any examination on him. Tr. 95-98; GX 5H.
    SS saw Respondent only on May 2, 2010. GX 5H, at 2-3. On the intake 
form, SS listed methadone as his medication and Respondent noted on the 
progress note that he was on 120 mg. Id. at 3. Respondent diagnosed SS 
as having both chronic pain and methadone use; while Respondent checked 
``NO'' for SS's pain, he indicated that SS had disc surgery at L5S1. 
Id. at 3; Tr. 475. While Respondent recalled, and the chart reflects, 
that SS had back surgery, SS's chart does not contain any copies of 
records related to his back surgery and does not document the date of 
the surgery. Tr. 475, 673; GX 5H. SS's chart does not document the 
nature and intensity of the pain, current and past treatments for it 
other than the surgery, and the pain's effect on his physical and 
psychological functioning. GX 5H, at 3. No vital signs were recorded at 
SS's visit. Id.
    Respondent testified that SS was on methadone, which he was getting 
``off the street,'' but that fact is not annotated in his chart. Tr. 
672. Respondent, however, refused to prescribe methadone to SS. 
Instead, he prescribed Suboxone and offered SS the choice of an 
alternative medical treatment program for getting off of methadone. Id. 
at 475-76, 674. Respondent believed that he gave SS appropriate care. 
Id. at 476.
AG
    On May 17, 2010, the DI interviewed AG. Id. at 80. AG stated that 
she was seeing Respondent for treatment of her addiction to Lortab, a 
schedule III narcotic containing hydrocodone. Id. at 80-81. AG further 
explained that she was not being treated for chronic pain, although 
such treatment was indicated in her chart. AG stated she did not know 
why her chart listed this condition. Id. at 81; see also GX 5P.
    According to her chart, Respondent diagnosed AG as having chronic 
pain and substance abuse as a secondary condition. GX 5P, at 3; Tr. 
488-89. However, the chart does not specify the basis for this 
diagnosis and Respondent checked ``NO'' for whether AG had pain. Tr. 
704; GX 5P, at 3. In addition, Respondent did not record any vital 
signs at this or any subsequent visit.
    Respondent prescribed Suboxone to AG at both the initial and 
several subsequent visits. Tr. 488; GX 5P, at 1, 4, 6, 8, 9. Moreover, 
at subsequent visits, Respondent continued to diagnose AG as having 
both chronic pain and substances abuse while checking ``NO'' for 
whether she had pain. See id. In other instances, the progress notes 
indicate that AG visited on a certain date but are otherwise blank even 
though Respondent issued AG a prescription. GX 5P, at 5. At AG's final 
visit, Respondent circled ``YES'' for whether she had pain but provided 
no further documentation as to the location of the pain, the nature and 
intensity of the pain, current and past treatment for pain, and its 
effect on her physical and psychological functioning. Id. at 7. In 
addition, the chart contains no medical history. See generally GX 5P. 
Respondent nonetheless maintained that he met the standard of care with 
respect to AG. Tr. 489.
LM
    On June 1, 2010, DI Michael Jones interviewed LM by telephone. Id. 
at 82. LM stated that the Respondent was treating her for an addiction 
to pain killers. Id. at 83. Respondent had been treating LM since 
December 27, 2009, at the Red Bay clinic. LM confirmed that she was not 
being treated for chronic pain. Tr. 82-83.
    LM completed a form in which she listed her medications as Adderall 
and Oxycontin, the latter being a schedule II narcotic. Tr. 193; GX 5V, 
at 2. At LM's first visit, Respondent diagnosed LM as having chronic 
pain, substance abuse, and bipolar disorder. GX 5, at 3. While 
Respondent checked ``YES'' for whether LM had pain and listed her 
``back'' as the location, the chart does not document the nature and 
intensity of the pain, current and past treatments for pain, and its 
effect on her physical and psychological functioning. Id. In addition, 
the chart contains no medical history. See generally id. Respondent 
prescribed Suboxone and Adderall on an X prescription pad. GX 5V, at 4, 
6. Subsequently, he prescribed both controlled substances using his 
regular DEA registration number. GX 5V, at 6-7.
    At subsequent visits, Respondent continued to list chronic pain as 
a diagnosis while checking ``NO'' for whether LM had pain.\5\ Id. at 3. 
Respondent testified that he was treating LM for back pain and for 
bipolar disorder. He further stated that LM was on Oxycontin and wanted 
to get ``onto a better pain medicine.'' Tr. 498. However, when asked on 
cross-examination as to whether his diagnosis of substance abuse was 
``based on her abuse of Oxycontin,'' Respondent stated: ``I think it 
had to do with--she had multiple things. She had stimulants * * * such 
as Adderall,'' and ``I think she had taken periodically Xanax.'' Id. at 
723.
---------------------------------------------------------------------------

    \5\ At LM's second visit, Respondent listed substance abuse as a 
diagnosis; however, at two subsequent visits, he no longer listed 
substance abuse as a diagnosis. See GX 5V.
---------------------------------------------------------------------------

    LM's progress notes do not, however, indicate what substance(s) she 
was abusing. GX 5V, at 3 & 5. Moreover, notwithstanding his testimony 
that her substance abuse was based in part on her use of Adderall, 
Respondent prescribed this drug to LM at four of her subsequent visits. 
Id. at 4, 6, 7. Respondent believed his treatment of LM was within the 
standard of care. Tr. 498-99.
ET
    On June 1, 2010, the DI interviewed ET by telephone. ET explained 
that the Respondent was treating him for an addiction to pain killers. 
Tr. 83-84. Respondent prescribed Suboxone to ET on an X pad on four 
occasions between December 2009 and March 2010; in

[[Page 17511]]

April, he prescribed Suboxone to ET on a prescription pad which listed 
both his X number and his practitioner's registration number. GX 5Z, at 
4, 6, 8. ET told the DI that he was not being treated for chronic pain. 
Tr. 83-84.
    The first two progress notes (one of which is undated but which is 
above the note for January 5, 2010 \6\) indicate a diagnosis of chronic 
pain but not substance abuse, the latter not being listed as a 
diagnosis until ET's third visit (Feb. 2, 2010). GX 5Z, at 3, 7. Here 
again, Respondent noted on the chart that ET had ``NO'' pain and the 
chart does not indicate the location of the pain, the nature and 
intensity of the pain, current and past treatments for the pain, and 
its effect on his physical and psychological functioning. Id. at 3, 5, 
7. No vital signs were recorded at any of ET's visits. Id. In addition, 
the chart contains no medical history. See generally GX 5Z. Respondent 
maintained that his care of ET was appropriate. Tr. 503.
---------------------------------------------------------------------------

    \6\ For this reason, I conclude that the undated note was for ET 
visit of December 8, 2009, at which Respondent issued him a 
prescription for Suboxone. See GX 5Z, at 1 & 4.
---------------------------------------------------------------------------

CT
    On June 2, 2010, a DI spoke with CT. CT stated that Respondent was 
treating her for opiate addiction with Suboxone. Tr. 87-88. On the 
intake form, CT listed her medications as ``Suboxone, methadone, and 
Zanex [sic].'' GX 5Y, at 2.
    At CT's first visit, Respondent diagnosed her as having both 
substance abuse and chronic pain. GX 5Y, at 3. However, Respondent did 
not indicate in the chart what substance she was abusing. Id. Moreover, 
Respondent indicated that she had ``NO'' pain. Id. Respondent did not 
indicate a location of CT's pain until the third visit (approximately 
two months later) when he noted its location as her ``back,'' but once 
again checked that she had ``NO'' pain. Id. at 5. While Respondent 
listed a diagnosis of chronic pain at each of CT's four visits, he 
never checked ``YES'' for pain on any of the progress notes. Id. at 3, 
5. Respondent did not document the nature and intensity of the pain, 
current and past treatments for the pain, and its effect on CT's 
physical and psychological functioning. Id. Nor did he record vital 
signs at any of CT's visits. Id.
    In his testimony, Respondent admitted that he did not know what 
substance(s) CT was abusing, but added that ``usually they're on 
multiple medicines to get whatever desired effect they want.'' Tr. 729-
30. Respondent did not obtain any prior treatment records for CT, 
whether for pain or substance abuse. Id. at 731.
    Respondent wrote CT prescriptions for Suboxone on a pad which 
contained only his X number, as well as on a pad which contained both 
his X number and his regular DEA registration number. GX 5Y, at 4, 6. 
Respondent believed his treatment of CT was within the standard of 
care. Tr. 502.
JH
    On June 2, 2010, the lead DI spoke with JH. JH stated that 
Respondent was treating him for ``a bad addiction to Oxycontin'' with 
Suboxone and that he was not being treated for chronic pain. Tr. 89-90; 
GX 5R. JH listed his medications as ``OXY 80 mg x4.'' GX 5R, at 9. 
According to Respondent, JH was taking ``four [Oxycontin] a day for his 
pain,'' which he was getting off the street because ``his doctors fired 
him.'' Tr. 710.
    At JH's first visit, Respondent diagnosed him as having substance 
abuse, attention deficit disorder and chronic pain. GX 5R, at 10. While 
in his testimony, Respondent maintained that JH had told him that he 
needed OxyContin ``to get by with his pain,'' on JH's chart, Respondent 
indicated that JH had ``NO'' pain and did not document a cause of the 
pain. Id. Moreover, while JH saw Respondent multiple times thereafter 
and diagnosed him as having chronic pain at each visit, Respondent 
never checked ``YES'' in the pain entry of the progress notes and never 
provided a description and location of the pain. See generally GX 5R. 
Moreover, Respondent never recorded vital signs for any of JH's visits. 
See generally id. Nor does JH's chart include a medical history. See 
generally id.
    Respondent obtained a printout of JH's prescriptions from the 
State's prescription monitoring program. Id. at 2-8. While the report 
showed that JH had also obtained Suboxone from another physician (Dr. 
H.), Respondent neither obtained JH's records from Dr. H. nor conferred 
with him. Tr. 711-12; GX 5. Respondent wrote JH prescriptions for both 
Suboxone and Adderall under his X number. GX 5R, at 11, 15. However, 
Respondent required JH to undergo a drug test; while this test showed 
that JH was taking Suboxone (buprenorphine) and amphetamine (Adderall), 
he also tested positive for marijuana use. GX 5R, at 12. Respondent 
believed his care of JH was appropriate. Tr. 492.
KP
    On June 2, 2010, the lead DI spoke with KP. KP stated that 
Respondent was prescribing Suboxone to treat her opiate addiction and 
that she was not being treated for chronic pain. Tr. 92-94. While 
Respondent testified that KP was on a narcotic which she wanted off of, 
KP did not list any medications she was on. GX 5W, at 2. Moreover, 
Respondent did not document the name of the narcotic in KP's record. 
Tr. 499.
    Respondent testified that KP had ``a complaint of pain.'' Id. At 
KP's first two visits (Dec. 6, 2009 and January 3, 2010), Respondent 
diagnosed her as having only chronic pain. GX 5W, at 3. However, for 
both visits, Respondent checked ``NO'' for whether KP had pain and did 
not list a cause or location of any such pain. Id.
    Respondent did not make a diagnosis of substance abuse until her 
third visit (Jan. 19, 2010); however, none of the progress notes for 
KP's subsequent visits list a diagnosis of substance abuse.\7\ See id. 
at 5, 7, 9, 11. Moreover, while Respondent continued to diagnose KP as 
having chronic pain, he did not check ``YES'' for whether she was 
having pain on any of the progress notes. See id. Nor did he document 
the cause, location or severity of her pain, or record her vital signs, 
at any of her visits. See id.
---------------------------------------------------------------------------

    \7\ Respondent also diagnosed KP as having anxiety, for which he 
prescribed Xanax. GX 5W, at 5.
---------------------------------------------------------------------------

    KP stated that she had to pay cash for her prescriptions as 
Respondent would not file a claim with Medicare for her. Tr. 94. She 
also stated that the Respondent did not perform any medical 
examinations on her, although Respondent indicated on the progress 
notes that he had done so and noted that the various parts of the 
examinations were normal (by either checking or lining through them). 
Tr. 95, see also GX 5W, at 3, 5, 9.
    Respondent prescribed Suboxone and Xanax for KP on an X 
prescription pad. Id. at 499; see also GX 5W, at 4, 6. Respondent 
believed his treatment of KP was within the standard of care. Tr. 500.
TB
    On June 10, 2010, the lead DI spoke with TB. TB stated that 
Respondent was prescribing Suboxone to him for both pain and addiction. 
Tr. 98-99; GX 5B. TB wrote on the intake sheet that he had used 
Suboxone, but Respondent did not know who prescribed it, and he 
commented that he could not tell from TB's chart if the Suboxone had 
been prescribed for substance abuse. GX 5B, at 1; Tr. 580-81.
    At the first visit (Dec. 20, 2009), Respondent diagnosed TB as 
having chronic pain and substance abuse. Tr.

[[Page 17512]]

466. Respondent checked ``YES'' for whether TB had pain and indicated 
the location as the lumbar area. GX 5B, at 6. While Respondent 
testified that ``[w]e got him to tell us about his back problems,'' if 
he had undergone any surgeries and how ``it affect[ed] his everyday 
activity,'' Respondent did not document the nature and intensity of the 
pain, whether any treatments had been previously tried, and the pain's 
effect on his psychological and physical function. Id.; Tr. 578-79. 
Moreover, Respondent did not know if TB's back pain was caused by an 
injury or a degenerative condition. Tr. 578-79.
    The chart indicates that Respondent performed an examination at 
which all areas including TB's back were found to be normal. GX 5B, at 
6. However, no vital signs were recorded. Id. at 6-7. Respondent 
prescribed Suboxone to TB, as well as Ambien. Id. While Respondent 
testified that he prescribed the Suboxone for TB's back pain, he issued 
the prescription under his X number; he also issued the Ambien 
prescription on the same form. Id. at 7.
    Respondent also saw TB on January 19, February 16,\8\ and May 2, 
2010. Id. at 4-7. At both the January and February visits, Respondent 
prescribed both Suboxone and Ambien to TB using his X number. Id. at 5, 
7; Tr. 466-67, 587-88. Respondent did not obtain TB's records from 
other doctors even though TB listed Suboxone as one of his medications. 
Tr. 578-580; GX 5B. When asked if he knew the name of the doctor who 
had previously prescribed Suboxone to TB, Respondent testified ``We 
might have found it out--I just didn't document it * * *. It could be a 
local doctor there.'' Tr. 581. When asked why TB had previously gotten 
Suboxone, Respondent could not definitively answer if it had been for 
pain or substance abuse. Id. at 582. With respect to the Ambien 
prescriptions, Respondent admitted that he did not document an insomnia 
diagnosis. Id. at 583.
---------------------------------------------------------------------------

    \8\ In the progress note for this visit, Respondent indicated 
that TB had ``NO'' pain while continuing to indicate that he had 
chronic pain. GX 5B, at 4. In his testimony, Respondent explained he 
``marked off that [TB's] pain was controlled under the no part.'' 
Tr. 588. The ALJ did not, however, credit this testimony. See ALJ at 
21-22. Nor do I.
---------------------------------------------------------------------------

SW
    SW's chart indicates that he was being treated for chronic pain and 
substance abuse. While the chart for SW's first visit indicates that he 
was on Oxy 160 mg, Respondent checked ``NO'' for whether SW had pain 
and did not document the cause or severity of SW's pain. GX 5J at 3, 5. 
Respondent did not identify a potential source of SW's pain until his 
third and final visit, when he noted that SW had a herniated disc in 
his back and had undergone surgery. Id. at 3.
    SW testified at the hearing and the ALJ found credible his 
testimony that he had a herniated disc in his back, that he had been 
taking Oxycontin for the pain, and that he had begun treatment with the 
Respondent in order to get a different pain medication. Tr. 346. The 
ALJ also found credible SW's testimony that he told a DI that 
Respondent was treating him for chronic pain and that the Respondent 
had performed a physical examination on him.\9\ However, the ALJ also 
found credible SW's subsequent testimony that he had told the DI that 
he was being treated for substance abuse because ``it was better being 
on Suboxone than it was Oxycontin.'' Tr. 363.
---------------------------------------------------------------------------

    \9\ The ALJ noted that the testimony of the lead DI and SW 
conflicted on this point. ALJ at 22 n.3. The DI testified that SW 
told him that Respondent was not treating him for chronic pain and 
had not performed a physical examination on him; SW testified to the 
contrary. Compare Tr. 102-03, with id. at 348-49. The ALJ found, 
however, that the DI had difficulty recalling the conversation that 
he had with SW and his memory had to be refreshed by the use of his 
notes, id. at 101-102, but that SW's memory required no similar 
refreshment. Id. at 345-65. I therefore adopt the ALJ credibility 
finding that SW's testimony is a more reliable account of the 
conversation that took place between SW and the DI.
---------------------------------------------------------------------------

    Respondent did not know who had prescribed Oxycontin to SW, and 
SW's chart does not contain any prior medical records. Tr. 684-85; GX 
5J. SW testified that he was addicted to his pain medications. Tr. 355. 
Respondent spent 15 to 20 minutes with SW and prescribed Suboxone to 
him. Id. at 351-52; GX 5J. SW testified that he had an MRI in 2005 or 
2006, and a bone scan in 2001 or 2002, but these test results were not 
part of his patient chart in evidence. Tr. 346, 349, 353, 357; GX 5J.
    SW saw Respondent three times. See GX 5J.\10\ At the time of the 
hearing, SW was still taking Suboxone, but he was not getting it from 
Respondent. Tr. at 364-65. Respondent refused to file an insurance 
claim for SW., and required that he pay $100 cash for the visits. Id. 
at 102-103.
---------------------------------------------------------------------------

    \10\ SW testified that he saw Respondent four or five times. Tr. 
364. However, SW's patient file documents only three visits.
---------------------------------------------------------------------------

CL
    CL first saw Respondent on December 20, 2009. See GX 22, at 6. 
Respondent made a diagnosis of both chronic pain and bipolar disorder; 
however, Respondent did not document the nature and intensity of the 
pain (he did not check either ``YES'' or ``NO'' for whether CL had 
pain), the history of the pain, whether any treatments had been 
previously tried, and the pain's effect on her psychological and 
physical function. Id. While Respondent noted that he had performed a 
physical exam and found all areas normal, he did not record any vital 
signs. Id. Respondent did not make a substance abuse diagnosis at this 
visit and yet prescribed Suboxone to CL under his X number. Id. at 7.
    Respondent saw CL again on January 17, 2010. Id. at 6. At this 
visit, Respondent again diagnosed CL as having pain even though he 
noted that she had ``NO'' pain and made none of the findings as 
explained above. Id. He also diagnosed her as having substance abuse 
and required that CL undergo a drug screen, the results of which are 
not in her chart. Tr. 127-28, 153-54; GX 22. Respondent did not, 
however, document CL's history of substance abuse. GX 22, at 6. 
Respondent again provided CL with a prescription for Suboxone. Id. at 
7.
    Respondent provided CL with prescriptions for Suboxone on February 
14, March 14, April 10, and May 9, 2010. Id. at 2-3, 5. However, the 
progress notes for both February 14 and March 14 contain no information 
besides CL's name, date of birth and the date of the visit. Id. at 4. 
The progress note for April 10 indicates that CL had chronic pain even 
though Respondent checked ``NO'' for her pain and no longer listed 
substance abuse as a diagnosis. Id. at 1. Finally, the progress note 
for CL's last visit (May 9) again lists chronic pain as one of three 
diagnoses even though Respondent checked that she had ``NO'' pain. Id. 
While the notes for both the April 10 and May 9 visits indicate that 
CL's physical exam was normal, Respondent did not document having taken 
any vital signs as either visit. Id.
CP
    The earliest progress note for CP is dated December 20, 2009, which 
also corresponds with the earliest date listed on the record of CP's 
Suboxone prescriptions. GX 23, at 5, 10. The progress note indicates a 
diagnosis of chronic pain, even though Respondent checked that CP had 
``NO'' pain and contains no other documentation (such as the nature and 
intensity of the pain, its history, and its effect on CP's functioning) 
to support this diagnosis. Id. at 5. Respondent also diagnosed CP as 
having substance abuse (with no supporting findings) and anxiety. Id. 
While Respondent performed a physical exam and found all areas normal, 
he did not document having taken CP's vital

[[Page 17513]]

signs. Id. Respondent prescribed Suboxone and Xanax at this visit using 
his X number.
    At the next visit, Respondent again noted that CP had chronic pain 
while indicating that he had ``NO'' pain. Id. Respondent, however, made 
an entry in the blank for ``EXT'' and for the ``Location,'' both of 
which are illegible. Id. Respondent did not, however, note a diagnosis 
of substance abuse at this or any subsequent visit. See generally id. 
at 1,3,5.
    At CP's next visit (Feb. 16), Respondent again diagnosed him as 
having chronic pain while noting that he had ``NO'' pain. Id. at 3. 
Subsequently, at CP's April 10 visit, Respondent again checked that CP 
had ``NO'' pain while writing ``knee pain'' in the ``Review of 
Systems'' section; he also made a note next to the ``EXT'' section of 
the Examination which is illegible but was not asked about this during 
his testimony. Id. Finally, at CP's final visit, Respondent again 
diagnosed him as having chronic pain but noted that he had ``NO'' pain 
and did not otherwise document any other findings regarding CP's pain. 
Id. at 1. Moreover, the Government did not offer any testimony as to 
whether it had interviewed CP.
    Respondent issued CP prescriptions for Suboxone on Dec. 20, 2009, 
Jan. 17, Feb. 16, Mar. 16, April 10, and May 9, 2010; he also wrote CP 
prescriptions for Xanax on each of these dates except for April 10. GX 
23. Respondent wrote both the Suboxone and Xanax prescriptions on Dec. 
20, 2009, as well as the Jan. 17, Feb. 16, and March 16, under his X 
number. Id. He also wrote the April 10 Suboxone prescription under his 
X number even though he did not list a diagnosis of substance abuse on 
any of CP's visits after the first visit. Id; Tr. 130-31.
CML
    On June 23, 2010, another DI interviewed CML and asked whether she 
was ``being treated for pain or addiction.'' Tr. 266-67. CML stated 
that she was being treated for addiction to controlled substances and 
that the Respondent was prescribing Suboxone to her. Id. at 267-68. She 
paid $100.00 cash for her visits. Id. at 268.
    On the progress note for CML's first visit (Dec. 8, 2009), 
Respondent checked that she had both pain and chronic pain, as well as 
insomnia. GX 5F, at 7. While Respondent noted that her physical exam 
was normal in all areas, he did not record any vital signs and did not 
document the nature and intensity of the pain, the history of the pain, 
whether any treatments had been previously tried, and the pain's effect 
on her psychological and physical function at any of her subsequent 
visits. See GX 5F. Respondent did not document that CML had back pain 
until her sixth and final visit (April 27, 2010), while on the same 
note checking that she had ``NO'' pain. Id. at 3.
    Indeed, several of the progress notes for CML's visits contain no 
medical information whatsoever. With respect to this, Respondent 
testified, ``In fact, there's some entries I didn't even put in on 
February and March of 2010 and I don't know why that's the case.'' Tr. 
472.
    At CML's second visit, Respondent noted a diagnosis of substance 
abuse. GX 5F, at 7. However, Respondent did not note this diagnosis at 
any of CML's subsequent visits. See GX 5F. Moreover, the chart contains 
no information about what substances CML was abusing and her history of 
substance abuse. GX 5F, at 7; Tr. 666.
    Respondent admitted that the chart fails to adequately document 
CML's pain. Tr. 472. Respondent also testified that he was tapering 
CML's dosages of Suboxone to find the appropriate levels to treat her 
chronic pain. Id. at 473. Respondent maintained that his care of CML 
was within the standard of care. Id. Respondent prescribed Suboxone 
(and Ambien at the first visit) to CML under his X number at several of 
the visits even though he did not document that he was treating her for 
substance abuse at those visits. See GX 5F.
SJW
    On December 29, 2009, SJW made her initial visit to Respondent.\11\ 
GX 5I, at 7. At the visit, Respondent diagnosed SJW as having both 
chronic pain and substance abuse, although he noted that she had ``NO'' 
pain and did not document the nature and intensity of the pain, the 
history of the pain, whether any treatments had been previously tried, 
and the pain's effect on her psychological and physical function at 
this or any of her subsequent visits. Id. While Respondent indicated 
that all areas of her physical examination were normal, he did not 
record any vital signs at this visit. Id. Nor did Respondent make any 
notes regarding SJW's history of substance abuse. There is, however, no 
evidence that Respondent prescribed to SJW at this visit.
---------------------------------------------------------------------------

    \11\ SJW's file includes an intake form in which she listed her 
medications as ``Suboxin.'' GX 5I, at 1.
---------------------------------------------------------------------------

    Respondent did, however, prescribe Suboxone (and Xanax) to SJW at 
her second visit, which occurred one week later. Id. at 7-8. On the 
progress note for this visit, Respondent listed the diagnoses as 
chronic pain (while indicating that she had ``NO'' pain and failing to 
document any other information regarding her condition) and substance 
abuse, again without any documentation. Id. at 7. Moreover, he again 
documented that SJW's physical exam was normal but did not record any 
vital signs. Id. Nor did Respondent document that SJW had anxiety, the 
condition for which Xanax is typically prescribed, and, in fact, 
Respondent indicated ``NO'' for whether she was agitated/moody. Id.
    While SJW's chart shows that she received prescriptions for 
Suboxone (and Xanax) in February and March, the progress notes for this 
period contain no information regarding her medical condition(s). Id. 
at 2,--5-6. Regarding these incidents, Respondent stated: ``I don't 
have an explanation for it unless I had to zip over and take care of 
another patient and I just took care of her and then took off. I don't 
know the situation.'' Tr. 681.
    On May 9, 2010, SJW made her final visit to Respondent. GX 5I, at 
3. At this visit, Respondent again diagnosed her as having chronic pain 
while indicating that she had ``NO'' pain and that her physical 
examination was normal in all areas. Id. at 3. Respondent also 
diagnosed her as having anxiety, even though he indicated ``NO'' for 
whether she was agitated or moody. Id. Respondent issued her 
prescriptions for both Suboxone and Xanax. Id. at 4.
    On June 23, 2010, a DI phoned SJW and interviewed her. SJW told the 
DI that Respondent was treating her for her addiction to controlled 
substances and that she paid $100 cash for each visit. Tr. 268-69. On 
two occasions (Jan. 5 and Feb. 2), Respondent prescribed both Suboxone 
and Xanax to SJW under his X number. Tr. 269; GX 5I, at 6, 8. 
Respondent testified that he was treating SJW for pain and anxiety. Tr. 
477, 679.
    As for how he made his diagnosis of substance abuse, Respondent 
testified that ``[i]t could be in her history with me; it could be a 
drug screen.'' Id. at 679. There is, however, no evidence in SJW's 
chart establishing that Respondent took a history or that he required 
her to undergo a drug screen. See generally GX 5I. Moreover, when asked 
``do we see an indication that [SJW] complained of pain?,'' Respondent 
answered: ``No. I did not fill that out.'' TR. at 679-80. As for 
Respondent's failure to note why he prescribed Xanax, Respondent 
testified: ``No, I did not put an anxiety there. And there was a good 
chance that she was on Xanax already. Did not give it to her in the 
December because she probably

[[Page 17514]]

already had an active prescription for it. And we probably got that 
from the drug monitoring system.'' Id. at 680. Respondent believed his 
treatment of SJW was appropriate, but that his documentation was 
``terrible.'' Tr. 478.
LMJ
    On her intake form, LMJ listed her medications as ``Loricets'' 
[sic]. GX 5E. At her first visit (Feb. 16, 2010), Respondent made 
diagnoses of both chronic pain and substance abuse. Id. at 4. However, 
Respondent noted that LMJ had ``NO'' pain, that her physical 
examination was normal and did not document the nature and intensity of 
the pain, the history of the pain, whether any treatments had been 
previously tried, and the pain's effect on her psychological and 
physical function at this visit or her next two visits. Id. at 2 & 4. 
Respondent did not note a location of any pain LMJ had until her final 
visit; even then, however, he did not document any information other 
than that the pain was in her ``back & arms.'' Id. at 2. Respondent did 
not document having taken LMJ's vital signs at any of her visits. Id. 
at 2, 4. Moreover, while at LMJ's first three visits, Respondent listed 
a diagnosis of substance abuse, the chart contains no information as to 
her history of substance abuse. Id. at 2, 4. At each of LMJ's visits, 
Respondent prescribed Suboxone to her. Id. at 3, 5.
    On June 24, 2010, a DI interviewed LMJ by phone. Tr. 270. The DI 
asked LMJ whether she was seeing Respondent for pain or for addiction 
to controlled substances; LMJ said that she was seeing Respondent for 
addiction for which he was prescribing Suboxone. Id. LMJ also stated 
that she paid $100.00 cash for each visit. Id.
    The ALJ found that Respondent credibly testified that he did not 
``have a good grasp on her history and physical as to, is this chronic 
pain or substance abuse, so we put the differential as both of these 
right now.'' Id. at 470. She also found credible Respondent's testimony 
that LMJ was a patient ``who wanted to get off Lorcet because she was 
building such a tolerance having to take more and more of this for her 
pain, but I could not totally rule out that she had a substance abuse 
problem.'' Id. at 471. While Respondent testified that he could 
sometimes rule out a substance abuse diagnosis ``later on as [I] get a 
grasp on these patients, and periodic random drug screens help me with 
this also,'' there is no evidence that Respondent required LMJ to 
undergo a drug test. Id. Respondent thought his treatment of LMJ was 
within the standard of care. Id.
MR
    MR first saw Respondent on December 15, 2009. GX 5G, at 7. 
Respondent diagnosed MR as having chronic pain even though he noted 
that MR had ``NO'' pain. Id. Respondent documented the pain's location 
as MR's ``Teeth'' and prescribed Suboxone to him. Id. at 7-8. 
Respondent testified that MR's pain was in his mouth and jaw, but the 
chart does not contain any other information regarding this condition. 
Tr. 474, 668; GX 5G. Moreover, Respondent continued to list a diagnosis 
of chronic pain at MR's visits of Jan. 17, Feb. 14, and Mar. 30, even 
though on the respective progress notes, he checked ``NO'' for whether 
MR had pain, did not list a location of the pain, noted that the 
physical exam was normal in all areas, and did not document having 
taken any vital signs Id. at 5, 7. Nor is there any evidence that 
Respondent referred MR to a dentist.
    On both the January 17 and March 30 progress notes, Respondent also 
listed a diagnosis of substance abuse. Id. at 5, 7. However, Respondent 
did not document the basis for his diagnosis. Id. At MR's final visit, 
Respondent no longer listed a diagnosis of substance abuse. However, he 
now documented that MR had right shoulder pain as the result of a motor 
vehicle accident. Id. at 3; Tr. 671. Respondent testified that MR had 
gone to the emergency room, but that he had not obtained those records. 
Tr. 671.
    When asked whether MR's tooth pain ``was no longer an issue in the 
subsequent visits''; Respondent maintained that ``I just didn't enter 
it.'' Id. at 672. As for the diagnosis of substance abuse, Respondent 
did not note in MR's chart the substances he abused, and Respondent 
could not remember during his testimony.\12\ Id. at 668-69; GX 5G.
---------------------------------------------------------------------------

    \12\ The ALJ found credible Respondent's testimony that he had 
also diagnosed MR with bipolar disorder, but that he had failed to 
annotate that in the patient's chart as well. Tr. 474.
---------------------------------------------------------------------------

    On June 24, 2010, a DI phoned MR and interviewed him. Id. at 271. 
The DI asked MR whether he was seeing Respondent for chronic pain or 
for addiction; MR stated that ``he was addicted.'' Id. at 271-72. MR 
also said that he paid $100.00 cash for each visit. Id. at 272. MR was 
treated with Suboxone, which was written on an X prescription pad. Tr. 
474; GX 5G, at 6, 8. Respondent believed his treatment of MR was 
appropriate. Tr. 475.
SHY
    SHY first saw Respondent on December 13, 2009. GX 5D, at 8. On the 
intake form, SHY listed his medications as Suboxone and Zyprexa. Id. at 
1. Respondent diagnosed SHY as having chronic pain even though he 
circled ``NO'' for whether SHY had pain, did not note the location of 
the pain, and did a physical examination during which he found all 
areas normal. Id. at 8. Moreover, Respondent did not document a history 
of the pain, whether any treatments had been previously tried, and the 
pain's effect on his psychological and physical function at this visit. 
Id. Respondent also did not document having taken SHY's vital 
signs.\13\ Id.
---------------------------------------------------------------------------

    \13\ Respondent also diagnosed SHY as having major depression.
---------------------------------------------------------------------------

    At SHY's subsequent visits, Respondent continued to document that 
SHY had chronic pain even though he repeatedly noted that he had ``NO'' 
pain, never found anything that was not normal during the physical 
exams, and never listed a location of any pain. Id. at 4, 6. Respondent 
also noted a diagnosis of substance abuse on two separate occasions, 
but did not document SHY's history of substance abuse and what 
substances he was abusing. Id. He did, however, require SHY to undergo 
a drug screen at the first visit, the results of which were negative 
with the exception of the test for synthetic opioids, which was 
consistent with SHY having indicated that his medications included 
Suboxone. Id. at 1, 10-11.
    On June 22, 2010, a DI called SHY, and asked him why he was seeing 
Respondent. Tr. 288. SHY said that he was being treated for opiate 
addiction and that he was not being treated for chronic pain. Id. at 
288-89.
    At the hearing, Respondent testified that he thought SHY was 
probably abusing either Lorcet or Oxycontin. Id. at 659. However, he 
then admitted that he did not document this. Id. Respondent then 
claimed that SHY ``probably had a little marijuana or something like 
that in a drug screen, and that's where we probably gave him a 
substance abuse diagnosis.'' Id. at 660. SHY did not, however, test 
positive for THC. See GX 5D, at 10-11. Respondent also admitted that he 
``did not document * * * any details of the pain,'' but then stated 
that ``[a] lot of these people with major depression have pain from the 
depression, but we still put a diagnosis of potential chronic pain.'' 
Id. at 468, see also id. at 655-56. Respondent acknowledged that he 
inappropriately prescribed other medications than Suboxone using his X 
number to SHY. Id. at 468. Respondent believed his care of SHY was 
within the standard of care. Id. 469-70.

[[Page 17515]]

JC2
    Respondent treated JC2 for chronic pain, substance abuse, attention 
deficit disorder, and extreme anxiety. Tr. 458; GX 5C. Respondent 
acknowledged that JC2 was ``a tough patient,'' who had been ``fired'' 
by other doctors and had abused Xanax. Tr. 458-60. A note in JC2's 
chart dated ``9-1-09'' indicates that a friend of JC2 had stated that 
he was taking twelve Xanax pills at a time. GX 5C, at 3.
    Respondent noted in the chart that JC2 was abusing Xanax and ``MUST 
STOP XANAX.'' Id. at 2, 12; see also Tr. 459-60, 628. In his testimony, 
Respondent stated that his treatment plan was to gradually taper JC2 
off Xanax, which could take up to a year, or to manage JC2's intake. 
Tr. 460-62, 630. The chart also notes that in November 2009, JC2 missed 
two appointments and was jailed for distribution. GX 5C, at 8. The 
chart also again notes ``Reported taking [greater than] 12 
Xanax @ a time.'' Id. Respondent also testified that he knew ``for a 
fact in this young man's history [that] he has been jailed before'' for 
``doing things [that were] inappropriate.'' Tr. 631.
    The ALJ found that Respondent credibly testified that he could not 
just cease prescribing Xanax to JC2 because he could have seizures. Id. 
at 460-61. However, the patient file shows that notwithstanding 
Respondent's testimony that he planned to taper JC2 off of Xanax, he 
actually increased the daily doses of the prescriptions. Compare GX 5C, 
at 11 (Aug. 30, 2009 RX for 30 tablets of Xanax 1.0 mg, [frac12] BID 
(for daily dose of 1 mg)), with id. at 10 (Oct. 25, 2009 RX for 90 
tablet of Xanax 1.0 mg., 1 TID (for daily dose of 3 mg)), with id. at 5 
(Apr. 17, 2010 RX for 60 tablets of Xanax 2.0 mg, 1q12, with 2 refills 
(for daily dose of 4 mg)). The chart also demonstrates that Respondent 
wrote multiple Xanax and Suboxone prescriptions under his X number 
prior to February 28, 2010. GX 5C, at 7, 9-11, 13. Respondent testified 
that he conducted drug screens on JC2, but the results of these tests 
were not in JC2's medical record. Tr. 633-34.
    Respondent testified that he prescribed Suboxone to treat JC2's 
substance abuse and that substance abuse was JC2's primary diagnosis. 
Id. at 643, 645. Moreover, a note for a visit of April 5, 2009, states 
``Desires To Get OFF Narcotics.'' GX 5C, at 15. Respondent also 
testified that JC2 was being seen for chronic pain caused by a football 
injury when he was a teenager, but he then admitted that JC2's chart 
does not document the source or severity of that pain. Tr. 654-55. Nor 
did Respondent document the history of the pain, any prior treatments 
for it and its effect on JC2's functioning. See GX 5C. Respondent 
maintained, however, that he knew JC2's history and ``that he's had a 
lot of problems.'' Tr. 655.
    Respondent also testified that JC2 had been in a narcotic treatment 
program in 2007 or 2008 and had left against medical advice. Id. at 
631-632. Yet Respondent did not document this in JC2's chart and did 
not obtain his treatment records from the narcotic treatment facility. 
GX 5C. Respondent believed he treated JC2 within the standard of care. 
Tr. 461.
DA
    DA saw Respondent three times: in December 2009, and in January and 
February of 2010. GX 5K. According to the progress note for the first 
visit, Respondent diagnosed DA with chronic pain and anxiety. Id. at 3. 
Respondent circled ``YES'' for whether DA had pain and noted that the 
location was his back and both legs. Id. Respondent did not, however, 
document the nature and intensity of the pain, its history, whether any 
treatments had been previously tried, and the pain's effect on his 
psychological and physical function at either this visit or his next 
visit. Id. at 3. Moreover, the progress notes for DA's first two visits 
(there is no note for a third visit on Feb. 21, 2010, even though there 
is a prescription for this date), indicate that Respondent performed a 
physical examination and found all areas normal. Id. Respondent did not 
document DA's vital signs for either visit. Id. Respondent also noted a 
diagnosis of substance abuse at DA's second visit but did not document 
the basis for this diagnosis. Id. Respondent issued DA prescriptions 
for both Suboxone and Xanax at all three visits, including on the 
second visit when he noted that DA had ``NO'' pain; on each occasion, 
Respondent issued the prescriptions under his X number. Id. at 4-5.
    On June 1, 2010, the lead DI interviewed DA by phone. Tr. 85. DA 
told the DI that he was addicted to pain killers and that Respondent 
was treating him for this condition and not for chronic pain. Id. at 
85-87. In his testimony, Respondent admitted that he did not get DA's 
medical records for his pain condition but maintained that he was 
familiar with this patient from treating him in the emergency 
department of the Red Bay Hospital. Tr. 693; see generally GX 5K. 
Respondent believed that his care was appropriate for DA. Tr. 482.
AH
    Respondent saw AH four times beginning on December 13, 2009, and 
ending on March 28, 2010. GX 5S. Respondent noted that AH was taking 12 
Lortab 10 mg a day, which she was getting ``from doctors, friends, 
[and] off the street.'' Tr. 493. Respondent diagnosed AH with both 
substance abuse and chronic pain as a secondary diagnosis. GX 5S, at 3. 
While Respondent noted ``YES'' for whether AH had pain, he did not 
document the nature, intensity and location of the pain; the history of 
the pain; what treatments had been used; and the pain's effect on her 
physical and psychological functioning. Id. at 3. Respondent also noted 
that AH was undergoing withdrawal, was agitated/moody, had insomnia and 
a positive MDQ. Id. AH's physical exam was normal and Respondent did 
not document having taken her vital signs. Id. At this visit, 
Respondent prescribed Suboxone to her under his X number. GX 5S, at 4.
    At AH's second visit (Feb. 1), Respondent noted that she had ``NO'' 
pain and did not make any other findings about her pain; he also 
indicated that she did not demonstrate withdrawal, that she was not 
agitated or moody and did not have insomnia or a positive MDQ. GX 5S, 
at 7. Respondent did not note any abnormalities in the physical exam 
and did not document having taken AH's vital signs. Id. Respondent 
noted his diagnosis as Suboxone 16 mg. and gave AH a prescription for 
Suboxone which he wrote under his X number. Id. at 8.
    On Feb. 28, Respondent issued AH a third prescription for Suboxone, 
again using his X number. Id. at 8. The progress note for this visit, 
however, lists AH's name, date of birth and a visit date but contains 
no medical information. Id. at 7.
    On March 28, AH again saw Respondent. Id. at 5. At this visit, 
Respondent circled ``YES'' for whether she had pain and noted its 
location as her neck and back. Id. Once again, he did not document the 
nature and intensity of the pain, the history of the pain, what 
treatments had been used, and the pain's effect on her physical and 
psychological functioning. Id. Again, Respondent performed a physical 
exam but found no abnormalities; he also did not document having taken 
AH's vital signs. Id. Respondent made diagnoses of both chronic pain 
and substance abuse. Id. Respondent issued AH a new prescription for 
Suboxone, which was written on a prescription form that contained both 
of his numbers. Id. at 6.

[[Page 17516]]

    Respondent testified that AH had some neck and back pain, but 
``appeared to be functional.'' Tr. 493. He was also ``not convinced 
that [he] could not add the substance abuse potential to her.'' Id. 
Respondent stated that his treatment of AH was within the standard of 
care. Id. at 494.
NK
    NK saw Respondent three times during February and March 2010. GX 
5U. On the intake form, NK listed his medications as Suboxone and 
Xanax. Id. at 2. On the progress note for NK's first visit, Respondent 
noted that he had ``NO'' pain and did not indicate a location for any 
pain. Id. at 3. Respondent noted that he had performed a physical 
examination, but found no abnormalities; Respondent also did not 
document having taken NK's vital signs. Id. Respondent nonetheless 
diagnosed NK as having both chronic pain and anxiety (but not substance 
abuse) and gave him prescriptions for Suboxone and Xanax, both of which 
were written under his X number. Id. at 5.
    On March 9, Respondent issued NK a second prescription for 
Suboxone, and on March 21, he issued NK prescriptions for both Suboxone 
and Xanax. Id. at 4-5. However, the progress note dated Mar. 9 contains 
no medical information and there is no note for Mar. 21. See generally 
GX 5U.
    On May 25, 2010, the lead DI interviewed NK. Tr. 78. NK stated that 
Respondent was treating him for opiate addiction, and not for any other 
medical problem including chronic pain. Id. at 79. NK also told the DI 
that he was no longer seeing Respondent and that ``he would kick the 
habit himself.'' Id. at 78. NK's chart also contains a prescription for 
Suboxone dated April 17, 2010, even though NK did not see Respondent on 
that date. GX 5U, at 6. Respondent explained that he had prepared the 
prescription in advance of NK's visit, but that ``no one gets that 
prescription unless I hand it to them.'' Tr. 497.

Respondent's Post-Suspension Conduct

    On September 27, 2010, Respondent was personally served with the 
Order to Show Cause and Immediate Suspension of Registration. At that 
time, the lead DI explained to Respondent that, as of that date, he was 
no longer authorized to prescribe or handle any controlled substances. 
Tr. 112-13. Respondent told the DI that ``he was not going to abide by 
this order and that (the DI) didn't have the authority to tell him that 
he couldn't prescribe any controlled substances.'' Id. at 113.
    Thereafter, the lead DI discovered that Respondent had issued 
controlled-substance prescriptions which were dated September 29, 
October 3 and October 4, 2010. Tr. 114; GX 6. While the ALJ found that 
there were a total of four post-suspension prescriptions, two of the 
prescription forms contained prescriptions for two controlled 
substances. ALJ at 34; but see GX 6, at 3-4.
    The first prescription, which was issued to CW and dated September 
29, 2010, was for the drug Adderall, a schedule II controlled 
substance. GX 6, at 1. CW told the lead DI that Respondent wrote the 
prescription after she had been seen by Respondent's Physician's 
Assistant, CC. CW picked up the prescription the next day, September 
30. Tr. 115-118; GX 6, at 1. Respondent admitted to signing this 
prescription. Tr. 506-07; see also RX 29, at 17-19 (CW's chart for 
Sept. 29, 2010 visit).
    The second prescription, which was issued to JB and dated October 
3, 2010, was also for Adderall. Tr. 118-19, 200-01; GX 6, at 2. 
However, the evidence showed that Respondent had issued the 
prescription on September 3, 2010. Tr. 119-20, 508, 733-34. This 
prescription did not, however, include Respondent's registration number 
and listed only his X number. GX 6, at 2.
    The lead DI contacted the pharmacist who filled the prescription, 
and was told that the pharmacy would not accept a post-dated 
prescription for a scheduled drug. Tr. 123. The pharmacist remembered 
this prescription and further stated that it had actually been 
presented for filling on October 3, 2010. Tr. 123-24, 158-59. The lead 
DI testified that while it would have been permissible to write a 
prescription and sign it on September 3, 2010, with the annotation of 
``do not fill until October 3, 2010,'' it was not permissible for 
Respondent to sign a schedule II prescription on September 3 but date 
the prescription for October 3rd. Tr. 124.
    The evidence also included two prescriptions issued (on a single 
prescription form) to MK and dated October 4, 2010; the prescriptions 
were for 60 Adderall and 90 Lortab 10 mg, another schedule III 
narcotic. GX 6, at 3. The lead DI contacted MK about the prescriptions; 
MK confirmed that the prescriptions were written and received on 
October 4, 2010. Tr. 124-25. While Respondent testified that the 
prescriptions had been post-dated, he admitted to having written the 
prescriptions on September 29, two days after he was served with the 
Immediate Suspension Order. Tr. 508-09; 740-41. Respondent maintained 
that the prescription was given to MK by mistake. Id. at 741. MK's 
patient file includes a progress note which establishes that she saw 
Respondent on September 29, 2010. RX 32, at 28. Notwithstanding the 
testimony regarding MK's statement as to the date the prescriptions 
were written, I find that the prescriptions were written on September 
29.
    The evidence also included two prescriptions which were issued to 
DH and also dated October 4, 2010. GX 6, at 4. The prescriptions were 
for 90 Lortab 10 mg and 90 Xanax 1 mg. Tr. 126, 509; GX 6, at 4.
    Respondent testified that he thought that he had seen DH in 
September but that he did not know ``exactly which day I saw him.'' Tr. 
509. Respondent admitted, however, that the prescription was in his 
handwriting and that he ``signed it.'' Continuing, he maintained that 
he did not have an explanation for it, that ``[t]his was an accident,'' 
and that he ``would never do anything to violate an order.'' Id. at 
509.
    According to DH's patient file, DH saw Respondent on September 29, 
2010.\14\ RX 31, at 28. The chart for the visit noted that DH was 
``Here for med refills'' and that he was ``here for Dr. Cochran,'' and 
that his ``Current Meds'' were Lortab and Xanax. Id. In addition, 
Respondent signed the chart. Id. I therefore find that Respondent wrote 
the prescriptions on September 29.
---------------------------------------------------------------------------

    \14\ DH's previous visit was on August 4, 2010. RX 31, at 30.
---------------------------------------------------------------------------

Respondent's Testimony

    Respondent maintained that some of the patients did not know what 
they were being treated for. Tr. 743-44. However, Respondent did not 
document any patient's lack of understanding of his diagnosis in the 
patient files. Tr. 745. Moreover, the ALJ did not find this testimony 
credible. ALJ at 49.
    As noted above, Respondent provided evidence that he had stopped 
prescribing methadone to his patients. Moreover, Respondent established 
that he had stopped using his X number to write prescriptions for drugs 
other than Suboxone and when prescribing Suboxone to treat pain. 
However, on September 3, 2010, Respondent wrote a further controlled 
substance prescription for Adderall (which was post-dated) under his X 
number. GX 6, at 2.
    Respondent also testified that he maintained the drugs screens he 
ordered on his patients in a separate file which he called the ``Drug 
Screen Book.'' Tr. 687. Respondent testified that when the

[[Page 17517]]

DIs obtained the patient files, they did not take the Drug Screen 
Book.'' Id. Respondent did not, however, submit the Drug Screen Book 
for the record.
    Respondent agreed that his patient charts were incomplete. Tr. 452. 
In one case Respondent testified that his record keeping was incorrect 
and he had mistakenly written the wrong primary diagnosis for the 
patient. Id. at 654. Respondent, however, offered no evidence that he 
was prepared to comply with the Alabama Board's Guidelines For The Use 
Of Controlled Substances For The Treatment Of Pain. See Ala. Admin Code 
r.540-x-4-.08.

Discussion

    Section 304(a) of the Controlled Substances Act provides that a 
``registration pursuant to section 823 of this title to * * * dispense 
a controlled substance * * * may be suspended or revoked by the 
Attorney General upon a finding that the registrant * * * has committed 
such acts as would render his registration under section 823 of this 
title inconsistent with the public interest as determined under such 
section.'' 21 U.S.C. 824(a)(4). In determining the public interest, 
Congress directed that the following factors be considered:
    (1) The recommendation of the appropriate State licensing board or 
professional disciplinary authority.
    (2) The applicant's experience in dispensing * * * controlled 
substances.
    (3) The applicant's conviction record under Federal or State laws 
relating to the manufacture, distribution, or dispensing of controlled 
substances.
    (4) Compliance with applicable State, Federal, or local laws 
relating to controlled substances.
    (5) Such other conduct which may threaten the public health and 
safety.
    21 U.S.C. 823(f). In addition, pursuant to 21 U.S.C. 824(d), 
``[t]he Attorney General may, in his discretion, suspend any 
registration simultaneously with the institution of proceedings under 
this section, in cases where he finds that there is an imminent danger 
to public health or safety.''
    The public interest factors are considered in the disjunctive. 
Robert A. Leslie, 68 FR 15227, 15230 (2003). I may rely on any one or a 
combination of factors and may give each factor the weight I deem 
appropriate in determining whether to revoke an existing registration 
or to deny an application for a registration. Id. Moreover, I am ``not 
required to make findings as to all of the factors.'' Hoxie v. DEA, 419 
F.3d 477, 482 (6th Cir. 2005); see also Morall v. DEA, 412 F.3d 165, 
173-74 (DC Cir. 2005).
    The Government has ``the burden of proving that the requirements 
for * * * revocation or suspension pursuant to section 304(a) * * * are 
satisfied.'' 21 CFR 1301.44(e); see also 21 CFR 1301.44(d) (Government 
has ``the burden of proving that the requirements for [a] registration 
pursuant to section 303 * * * are not satisfied''). However, where the 
Government satisfies its prima facie burden, the burden then shifts to 
the registrant to demonstrate why he can be entrusted with a new 
registration. Medicine Shoppe-Jonesborough, 73 FR 364, 380 (2008).
    Having considered all of the factors, I conclude that the 
Government's evidence pertinent to factors two (Respondent's experience 
in dispensing controlled substances) and four (Respondent's compliance 
with applicable laws related to controlled substances), establishes 
that Respondent has committed acts which render his registration 
``inconsistent with the public interest.'' 21 U.S.C. 824(a)(4). I 
further conclude that Respondent has not rebutted the Government's 
prima facie case.

Factors One and Three--The Recommendation of the State Board and 
Respondent's Record of Convictions Under Laws Relating to the 
Manufacture, Distribution and Dispensing of Controlled Substances

    The record establishes that the State Board has an open 
investigation of Respondent. However, the Board has not made a 
recommendation in this matter, and it is undisputed that Respondent's 
medical license remains active and unrestricted. Accordingly, this 
factor does not support a finding either for, or against, the 
continuation of Respondent's registration. See Joseph Gaudio, 74 FR 
10083, 10090 n.25 (2009); Mortimer B. Levin, 55 FR 8209, 8210 (1990).
    There is also no evidence in the record that Respondent has been 
convicted of an offense related to the manufacture, distribution or 
dispensing of controlled substances. While this factor supports the 
continuation of Respondent's registration, DEA has long held that this 
factor is not dispositive. See, e.g., Edmund Chein, 72 FR 6580, 6593 
n.22 (2007).

Factors Two and Four--Respondent's Experience in Dispensing Controlled 
Substances and Compliance With Applicable Laws Related to Controlled 
Substances

    The record establishes that Respondent violated numerous provisions 
of Federal law and DEA regulations. These include: (1) The prescribing 
of methadone for substance abuse treatment without being registered to 
do so under 21 U.S.C. 823(g)(1), in violation of 21 U.S.C. 841(a)(1); 
(2) the prescribing of methadone for substance abuse treatment, in 
violation of 21 CFR 1306.04(c) and 1306.07; (3) prescribing controlled 
substances without a legitimate medical purpose, in violation of 21 CFR 
1306.04(a); (4) the post-dating of prescriptions, in violation of 21 
CFR 1306.05(a); and (5) prescribing controlled substances when his 
registration had been suspended, in violation of 21 U.S.C. 843(a)(2).

The Methadone Prescriptions

    Under 21 U.S.C. 823(g)(1), ``practitioners who dispense narcotic 
drugs to individuals for maintenance treatment or detoxification 
treatment shall obtain annually a separate registration [from their 
practitioner's registration] for that purpose.''\15\ In the Drug 
Addiction Treatment Act of 2000, Congress provided that the requirement 
to obtain a separate registration is ``waived in the case of the 
dispensing (including the prescribing), by a practitioner, of narcotic 
drugs in schedule III, IV, or V or combinations of such drugs if the 
practitioner meets the conditions specified in [section 823(g)(2)(B)] 
and the narcotic drugs or combinations of such drugs meet the 
conditions specified in [section 823(g)(2)(C)].'' Id. Sec.  
823(g)(2)(A) (emphasis added).
---------------------------------------------------------------------------

    \15\ An applicant for registration under this provision must 
meet three requirements: (1) The applicant must be ``determined by 
the Secretary [of HHS] to be qualified * * * to engage in the 
treatment with respect to which registration is sought; (2) the 
Attorney General must ``determine[] that the applicant will comply 
with standards * * * respecting (i) security of stocks of narcotic 
drugs for such treatment, and (ii) the maintenance of records * * *. 
on such drugs,'' and (3) ``if the Secretary determines that the 
applicant will comply with standards * * * respecting the quantities 
of narcotic drugs which may be provided for unsupervised use by 
individuals in such treatment.'' 21 U.S.C. 823(g)(1).
---------------------------------------------------------------------------

    Methadone is, however, a schedule II narcotic, and thus, except for 
where a patient presents with acute withdrawal symptoms (and then for 
no more than a total of three days), cannot be lawfully dispensed for 
the purpose of maintenance or detoxification treatment absent the 
practitioner's holding a registration under section 823(g)(1). See 21 
U.S.C. 812(c) (Schedule II (b)(11)); 21 CFR 1308.12(c)(15). Moreover, 
under DEA's regulations, ``[a] prescription may not be issued for 
`detoxification treatment' or `maintenance treatment,' unless the 
prescription is for a Schedule III, IV, or V narcotic drug approved by 
the Food and Drug Administration

[[Page 17518]]

specifically for use in maintenance or detoxification treatment.'' 21 
CFR 1306.04(c).\16\ See also id. 1306.07(a) (``A practitioner may 
administer or dispense directly (but not prescribe) a narcotic drug 
listed in any schedule * * * for the purpose of maintenance or 
detoxification treatment if the practitioner * * * is separately 
registered with DEA as a narcotic treatment program [and] is in 
compliance with DEA regulations regarding treatment qualifications, 
security, records, and unsupervised use of the drugs pursuant to the 
[CSA].'') (emphasis added); id. 1306.07(b) (``Nothing in this section 
shall prohibit a physician * * * from administering (but not 
prescribing) narcotic drugs to a person for the purpose of relieving 
acute withdrawal symptoms when necessary while arrangements are being 
made for referral for treatment. Not more than one day's medication may 
be administered to the person or for the person's use at one time. Such 
emergency treatment may be carried out for not more than three days and 
may not be renewed or extended.'') (emphasis added).
---------------------------------------------------------------------------

    \16\ See also 21 CFR 1306.07(d) (``A practitioner may administer 
or dispense (including prescribe) any Schedule III, IV, or V 
narcotic drug approved specifically by the Food and Drug 
Administration specifically for use in maintenance or detoxification 
treatment to a drug dependent person if the practitioner complies 
with the requirements of [21 CFR 1301.28].'' 21 CFR 1301.28 is the 
provision which implements the DATA Waiver Act.
---------------------------------------------------------------------------

    Also relevant here is the definition of the term ``maintenance 
treatment.'' 21 U.S.C. 802(29). Under the CSA, the term ``means the 
dispensing, for a period in excess of twenty-one days, of a narcotic 
drug in the treatment of an individual for dependence upon heroin or 
other morphine-like drugs.'' Id.\17\
---------------------------------------------------------------------------

    \17\ The CSA also defines the term ``detoxification treatment.'' 
21 U.S.C. 802(30). The term ``means the dispensing, for a period not 
in excess of one hundred and eighty days, of a narcotic drug in 
decreasing doses to an individual in order to alleviate adverse 
physiological or psychological effects incident to withdrawal from 
the continuous or sustained use of a narcotic drug and as a method 
of bringing the individual to a narcotic drug-free state within such 
period.'' Id.
---------------------------------------------------------------------------

    Finally, Respondent claimed that most of the patients whose files 
were introduced into evidence (including some of the methadone 
patients) were chronic pain patients. Under a longstanding DEA 
regulation, to be effective, ``[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.'' 21 CFR 1306.04(a). As the Supreme Court has 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)).
    Under the CSA, it is fundamental that a practitioner must establish 
and maintain a bonafide doctor-patient relationship in order to act 
``in the usual course of * * * professional practice'' and to issue a 
prescription for a ``legitimate medical purpose.'' Laurence T. 
McKinney, 73 FR 43260, 43265 n.22 (2008); see also Moore, 423 U.S. at 
142-43 (noting that evidence established that physician ``exceeded the 
bounds of `professional practice,''' when ``he gave inadequate physical 
examinations or none at all,'' ``ignored the results of the tests he 
did make,'' and ``took no precautions against * * * misuse and 
diversion''). The CSA, 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 54931, 
54935 (2007); United Prescription Services, Inc., 72 FR 50397, 50407 
(2007).
    By regulation, the Alabama Board of Medical Examiners has adopted 
Guidelines For The Use of Controlled Substances For The Treatment of 
Pain. See Ala. Admin. Code r. 540-X-4-.08. According to the Board, the 
``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. (1)(g). Guideline (2)(a), 
which is captioned ``Evaluation of the Patient,'' 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. (2)(a).\18\
---------------------------------------------------------------------------

    \18\ See also Ala. Admin. Code r. 540-X-4.08(2)(b) (``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.'').
     The Guidelines also provide that:
    The physician should keep accurate and complete records to 
include
     1. The medical history and physical examination;
     2. Diagnostic, therapeutic and laboratory results;
     3. Evaluations and consultations;
    4. Treatment objectives;
     5. Discussion of risks and benefits;
     6. Treatments;
     7. Medications (including date, type, dosage and quantity 
prescribed);
    8. Instructions and agreements;
    9. Periodic reviews.
    Id. 2(f).
---------------------------------------------------------------------------

    The record contains substantial evidence that Respondent prescribed 
methadone to opiate addicted patients for the purpose of providing 
maintenance treatment. During his initial interview (on Feb. 28, 2010) 
with the Investigators, Respondent told them that ``he was operating a 
detox clinic where he was using methadone to get his patients onto 
Suboxone.'' Tr. 43. It was not until later that day, when the 
Investigators interviewed Respondent for the second time, that he 
claimed that he prescribed methadone for pain and that he had 
previously misspoken. Id. at 55.
    Other evidence supports the conclusion that Respondent was 
prescribing methadone to provide maintenance or detoxification 
treatment to opiate addicted patients. On the date of the visit, 
Investigators interviewed JKB, who told them that he was being treated 
by Respondent with methadone for opiate addiction. Id. at 52. JKB 
further stated that he had previously gone to a narcotic treatment 
program, which used methadone, and that he was seeing Respondent 
because the latter charged less. Id. at 52-53. JKB also stated that 
Respondent was not treating him for chronic pain. Id. at 53.
    The Government introduced into evidence seven files of patients who 
received methadone prescriptions from Respondent. GXs 5X; 5O; 5A; 5N; 
5L; 5M; and 5T. The Government also elicited the testimony of the DIs 
to the effect that they had interviewed several of the patients to 
determine what condition they were being treated for.
    Patient TP related that she had gone to Respondent because she had 
heard that he was using methadone to treat addiction; TP also noted on 
her intake form that she had previously gone to a methadone clinic and 
was taking twelve tablets of methadone 10 mg strength a day. Respondent 
issued her prescriptions for methadone on three separate dates over the 
course of a month, and ultimately TP returned to a methadone clinic.
    While Respondent maintained that TP had been going to the methadone 
clinic for pain, he conceded that the purpose of a methadone clinic is 
to treat addiction. Moreover, while Respondent noted diagnoses of both 
chronic pain and substance abuse on TP's progress

[[Page 17519]]

notes, he did not document having taken a medical history, the nature 
and intensity of any pain, current and past treatments for paint, and 
its effect on her physical and psychological functioning.
    I thus conclude that Respondent prescribed methadone to TP for 
maintenance or detoxification purposes and not to treat chronic pain. 
In doing so, he violated the CSA because he did not have the 
registration required under section 823(g)(1) to dispense methadone for 
this purpose; he also violated DEA regulations which prohibit the 
prescribing of narcotic drugs for this purpose except for those drugs 
in schedules III through V which have been specifically approved by the 
FDA to provide maintenance or detoxification treatment. 21 CFR 
1306.04(c).
    The DIs also interviewed MB, who stated that she was being treated 
by Respondent for an addiction to Lorcet and not for chronic pain. 
Respondent testified, however, that he was treating MB both for chronic 
pain cause by headaches and substance abuse. Respondent prescribed 
methadone to her on six different dates.
    Notably, the Government did not produce any evidence corroborating 
MB's statement that she was not being treated for chronic pain. See 
Consolidated Edison Co. v. NLRB, 305 U.S. 197, 230 (1938) (``Mere 
uncorroborated hearsay * * * does not constitute substantial 
evidence.). However, even if this evidence is not sufficient to 
establish that Respondent was treating her only for substance abuse and 
crediting his testimony that he was also treating her for chronic pain, 
I conclude that the prescriptions were unlawful.
    Notably, Respondent did not document the nature and intensity of 
her pain, its effect on both her physical and psychological function, 
any prior or current treatment for it, and her history of substance 
abuse. See Ala. Admin Code r.540-X-4.08(2)(a). Accordingly, because 
Respondent did not make any of the findings required under the Alabama 
guidelines, I conclude that he did not have a basis for his diagnosis 
of chronic pain. I thus conclude that Respondent acted outside of ``the 
usual course of * * * professional practice'' and lacked a ``legitimate 
medical purpose'' in issuing the methadone prescriptions to MB and 
violated Federal law. 21 CFR 1306.04(a).\19\
---------------------------------------------------------------------------

    \19\ As explained above, if Respondent was treating MB for 
substance abuse, the methadone prescriptions were illegal because 
methadone cannot be prescribed for this purpose and because he did 
not hold the required registration. See 21 U.S.C. 823(g)(1); 21 CFR 
1306.07(a) & (b).
---------------------------------------------------------------------------

    Respondent issued three methadone prescriptions (on Feb. 9, 23, and 
Mar. 9) to JC1 (GX 5N), each of which was for 210 tablets with a daily 
dose of 150 mg. Respondent admitted that JC1 had come from another 
methadone clinic even though he denied that JC1 had gone to the clinic 
to be treated for addiction and maintained that he had gone there for 
pain management. Moreover, while Respondent also maintained that JC1 
had come to him because ``he wanted to take a cleaner medicine for his 
pain,'' when Respondent stopped writing methadone prescriptions, JC1 
decided to go to another treatment facility.
    In addition, notwithstanding Respondent's claim that he was 
treating JC1 for pain, at his first two visits (and at which Respondent 
prescribed methadone), Respondent noted that JC1 had ``NO'' pain; and 
at the third visit, where he issued a further methadone prescription, 
Respondent did not even make a progress note. Respondent also failed to 
document any of the findings set forth in Alabama's Guideline 2(a). 
Accordingly, I conclude that Respondent prescribed methadone to JC1 for 
maintenance/detoxification purposes without the required registration 
and violated DEA regulations which prohibit the prescribing of schedule 
II narcotics for this purpose. 21 U.S.C. 823(g)(1); 21 CFR 1306.04(c).
    JB also came to Respondent from a narcotic treatment program, which 
he had been kicked out of. Respondent noted this in the chart and that 
JB ``desire[d] to get off methadone.'' Respondent asserted that the 
fact that JB had been treated at a methadone clinic did not mean that 
the clinic was treating him for addiction, even though that is the 
purpose of a methadone clinic; moreover, he admitted that he did not 
obtain JB's records from the clinic. After Respondent stopped 
prescribing methadone to JB, the latter went to another methadone 
clinic.
    While Respondent documented that JB had foot and knee pain, and the 
progress notes include a few additional statements regarding his pain 
such as the location and that JB had been in an accident, the notes do 
not document the nature and intensity of pain, any prior treatments for 
it, and its effect on JB's functioning. Moreover, Respondent noted that 
he planned to put JB on his alternative medication program. Given JB's 
prior history of substance abuse treatment and his express ``desire to 
get off methadone,'' I conclude that Respondent's primary purpose in 
prescribing methadone to him (which he did on three occasions over a 
month) was to provide maintenance/detoxification treatment. I thus 
conclude that Respondent violated the CSA and DEA regulations in doing 
so. 21 U.S.C. 823(g)(1); 21 CFR 1306.04(c).
    Respondent testified that NB told him at the initial visit that she 
had been on 180 mg of methadone which she was taking for pain. He also 
testified that she was a ``troubling patient'' because she was on both 
methadone and Xanax and that this was a great concern, especially if 
she mixed the drugs with alcohol. Respondent diagnosed NB as having 
chronic pain even though he noted on her chart that she had ``NO'' 
pain, and he did not document any further findings to support a 
diagnosis of chronic pain. Moreover, notwithstanding his express 
concern that NB was on both methadone and Xanax, Respondent prescribed 
Xanax to her and did not document that she had anxiety, although he 
maintained in his testimony that she ``had some anxiety.''
    The evidence is insufficient to support the conclusion that NB 
sought treatment from Respondent for a substance abuse problem. 
However, the evidence does support the conclusion that Respondent acted 
outside of the usual course of professional practice and lacked a 
legitimate medical purpose in prescribing methadone to her. 21 CFR 
1306.04(a). Having noted on NB's chart that she had ``NO'' pain, and 
having failed to document any further findings as required by the 
Guidelines to support his chronic pain diagnosis (and to explain the 
inconsistency between his diagnosis and his notation that she had no 
pain), it is clear that Respondent lacked a legitimate medical purpose 
in prescribing methadone to her.
    KI noted on her intake form that she was using three controlled 
substances: methadone, Xanax and Ambien. Respondent also acknowledged 
that KI had previously been treated at a narcotic treatment facility 
and that she had taken narcotics and become addicted to them. However, 
he denied that KI had told her that she had gone to the methadone 
clinic to treat her addiction--as if there was any other reason a 
person would seek treatment from a methadone clinic. While Respondent 
maintained that KI had diagnoses of both substance abuse and chronic 
pain, on the progress note for her initial visit, he noted that she had 
``NO'' pain although he wrote ``Back'' as the location. Respondent did 
not document any findings that would explain the inconsistency between 
his diagnosis and his having noted that KI had ``NO'' pain; he also did 
not document the history of any pain, what

[[Page 17520]]

treatment had been used, and the pain's effect on her physical and 
psychological functioning.
    Respondent issued three methadone prescriptions to KI. I conclude 
that Respondent's purpose in doing so was not to treat pain, but to 
provide maintenance/detoxification treatment to her. I thus conclude 
that Respondent violated Federal law by prescribing methadone to KI for 
maintenance/detoxification treatment without the required registration 
and violated DEA regulations which prohibit the prescribing of schedule 
II narcotics for this purpose. 21 U.S.C. 823(g)(1); 21 CFR 
1306.04(c).\20\
---------------------------------------------------------------------------

    \20\ Given the conflicting evidence regarding DG, I decline to 
make any legal conclusions regarding Respondent's prescribing of 
methadone to him.
---------------------------------------------------------------------------

The Suboxone Prescriptions

    As found above, Respondent also prescribed Suboxone, a schedule III 
controlled substance, to numerous patients. The Government elicited the 
testimony of the DIs as to phone interviews they conducted with sixteen 
of these patients, the majority of whom said that Respondent was 
treating them for substance abuse and not chronic pain. See Tr. at 78 
(NK); id. at 80-81 (AG); id. at 82-83 (LM); id. at 83-84 (ET); id. at 
85-87 (DA); id. at 87-88 (CT); id. at 89-90 (JH); id. at 92-94 (KP); 
id. at 95-98 (SS); id. at 266-67 (CML); id. at 268-69 (SJW); id. at 270 
(LMJ); id. at 271 (MR); id. at 288-89 (SHY).
    As found above, Respondent testified that many of these patients 
were actually being treated for chronic pain in addition to substance 
abuse, or were just being treated for chronic pain. Moreover, 
Respondent frequently noted both diagnoses on the patient's charts, 
although in some instances he did not note a substance abuse diagnosis 
until after the first visit (and sometimes not until after several 
visits). See, e.g., GX 5P (AG); GX 5V (LM); GX 5Y (CT); GX 5R (JH); GX 
5B (TB); GX 5J (SW); GX 5I (SJW); GX 5E (LMJ); GX 5D (SHY); GX 5K (DA).
    However, even if it is the case that most of the Suboxone patients 
were being treated only for substance abuse, the Government did not 
offer any evidence (whether in the form of clinical standards or expert 
testimony) establishing what the appropriate course of professional 
practice requires of a physician treating patients for substance 
abuse.\21\ In short, while in its brief, the Government repeatedly 
argues that Respondent lacked a medical justification to support his 
diagnosis of substance abuse for the various patients and his issuance 
of the Suboxone prescriptions, the Government's failure to offer any 
probative evidence as to the standards of medical practice for 
diagnosing and treating a substance abuse patient precludes a finding 
that Respondent lacked a legitimate medical purpose when he prescribed 
Suboxone to these patients.
---------------------------------------------------------------------------

    \21\ While the Government introduced the Alabama Guidelines on 
using controlled substances to treat pain, it offered no evidence 
establishing that these standards apply to the treatment of 
substance abuse patients.
---------------------------------------------------------------------------

    Respondent, however, testified that many of the Suboxone patients 
were actually being treated for chronic pain, and he noted this as his 
primary diagnosis in many of their charts. As explained above, the 
Alabama Guidelines require that a physician who prescribes controlled 
substances to treat pain, obtain ``[a] complete medical history'' and 
document this in the patient's medical record. Moreover, the Guidelines 
state that the 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.'' Ala. Admin. 
Code r. 540-X-4-.08(2)(A).
    As found above, at the initial visits of nine of the Suboxone 
patients, Respondent diagnosed them as having chronic pain but not 
substance abuse. See supra Findings for Patients SS, ET, KP, CL, CML, 
MR, SHY, DA, and NK. Notwithstanding his diagnosis, Respondent 
typically did not even list a location of a patient's purported pain 
and/or did not list a location until after the patient had made several 
visits. See supra Findings for ET, KP, CL, CML, SHY, NK. Moreover, 
Respondent did not document the nature and intensity of the patient's 
pain, the pain's effect on the patient's ability to function, and 
rarely documented any past treatments for the pain, and the patient's 
substance abuse history at either the initial visit or follow-up 
visits.\22\
---------------------------------------------------------------------------

    \22\ While Respondent's charts included a Plan section, none of 
them included the ``objectives that will be used to determine 
treatment success.'' Ala. Admin. Code r.540-X-4-.08(2)(b).
---------------------------------------------------------------------------

    Tellingly, in the charts, Respondent frequently noted that the 
patients had ``NO'' pain, yet nonetheless diagnosed them as having 
chronic pain. See Findings for SS, ET, KP, CL, MR, SHY, and NK. 
Respondent offered no explanation for the inconsistency between his 
findings and his diagnosis with respect to any of these patients. Based 
on Respondent's having noted that these patients had no pain and his 
failure to offer any explanation for why he nonetheless diagnosed the 
patients as having chronic pain, I conclude that Respondent lacked a 
legitimate medical purpose and acted outside of the usual course of 
professional practice in violation of 21 CFR 1306.04(a) when he 
prescribed Suboxone to these patients for the purpose of treating 
chronic pain.
    The Government further argues, and the ALJ agreed, that Respondent 
violated 21 CFR 1306.07(c), because his ``charts failed to show the use 
of any treatment options besides the prescribing of controlled 
substances.'' ALJ at 47. The ALJ further explained that ``[s]uch lack 
of attempts of alternative modalities prior to determining that the 
patient suffers from chronic pain violates'' this regulation. Id.
    Both the Government and the ALJ clearly misread the regulation. 
This provision, which is part of the regulation setting forth the 
requirements for dispensing narcotic controlled substances ``to a 
narcotic dependant[sic] person for the purpose of maintenance or 
detoxification treatment'' states:

    This section is not intended to impose any limitations on a 
physician or authorized hospital staff to administer or dispense 
narcotic drugs in a hospital to maintain or detoxify a person as an 
incidental adjunct to medical or surgical treatment of conditions 
other than addiction, or to administer or dispense narcotic drugs to 
persons with intractable pain in which no relief or cure is possible 
or none had been found after reasonable efforts.

21 CFR 1306.07(c).
    The Government's and the ALJ's construction of this regulation as 
imposing--by implication no less--an affirmative obligation for a 
physician to engage in alternative treatment modalities cannot be 
squared with the purpose of the CSA, which ``manifests no intent to 
regulate the practice of medicine generally,'' an authority which 
remains vested in the States. Gonzales v. Oregon, 546 U.S. 243, 270 
(2006). Rather, in any case, whether a physician has an adequate basis 
for concluding that ``no relief or cure is possible'' for a patient's 
pain, or that alternative treatments should be tried, is a clinical 
judgment which must be assessed by reference to the standards of 
medical practice as set by the state medical boards and the profession 
itself. While a practitioner's failure to recommend alternative 
treatments may provide some evidence as to whether a prescription 
complies with 21 CFR 1306.04(a), the Government produced no expert 
testimony establishing with respect to any patient, that under the 
standards of medical practice,

[[Page 17521]]

Respondent was required to recommend alternative treatments.\23\
---------------------------------------------------------------------------

    \23\ The ALJ noted that ``Respondent testified, and the record 
contains no expert evidence to the contrary, that his treatment of 
his patients met the standard of care.'' ALJ at 48. While evidence 
as to the standard of care is admissible in criminal prosecutions 
under 21 U.S.C. 841(a)(1), I conclude that the Alabama Guidelines 
provide substantial evidence as to accepted boundaries of 
professional practice in prescribing controlled substances for the 
treatment of pain. See Ala. Admin. Code r. 540-X-4-.08(1)(g) 
(guidelines are intended ``to communicate what the Boards considers 
to be within the boundaries of professional practice'').
---------------------------------------------------------------------------

Other Allegations

    The ALJ found that ``[t]he parties do not dispute that Respondent 
improperly used his `X' prescription registration to prescribe 
controlled and non-controlled substances other than Suboxone or 
Subutex.'' ALJ at 43. The problem with the ALJ's reasoning is that an X 
number is not a registration at all, but only an identification number.
    As the statute states: ``Upon receiving a notification under 
subparagraph (B) [of a practitioner's intent to prescribe narcotic 
drugs in schedules III through V for maintenance or detoxification 
treatment], the Attorney General shall assign the practitioner involved 
an identification number under this paragraph for inclusion with the 
registration issued for the practitioner pursuant to subsection (f) of 
this section.'' 21 U.S.C. 823(g)(2)(D)(ii) (emphasis added). See also 
21 CFR 1301.28(a) (``An individual practitioner may dispense or 
prescribe Schedule III, IV, or V narcotic controlled drugs * * * which 
have been approved by the Food and Drug Administration (FDA) 
specifically for use in maintenance or detoxification treatment without 
obtaining the separate registration required by Sec.  1301.13(e). * * 
*''); id. Sec.  1301.28(d)(1) (``If the individual practitioner has the 
appropriate registration under Sec.  1301.13, then the Administrator 
will issue the practitioner an identification number. * * * '') 
(emphasis added).
    Moreover, under DEA's regulations,

    [a]ll prescriptions for controlled substances shall be dated as 
of, and signed on, the day when issued and shall bear the full name 
and address of the patient, the drug name, strength, dosage form, 
quantity prescribed, directions for use and the name, address and 
registration number of the practitioner. In addition, a prescription 
for a Schedule III, IV, or V narcotic drug approved by FDA 
specifically for `detoxification treatment' or `maintenance 
treatment' must include the identification number issued by the 
Administrator under Sec.  1301.28(d) of this chapter or a written 
notice stating that the practitioner is acting under the good faith 
exception of Sec.  1301.28(e).

    21 CFR 1306.05(a). See also 21 CFR 1301.28(d)(3) (``The individual 
practitioner must include the identification number on all records when 
dispensing and on all prescriptions when prescribing narcotic drugs 
under this section.'').
    As found above, Respondent issued numerous controlled substance 
prescriptions (for both Suboxone and other drugs) on forms that listed 
only his X number. The Suboxone prescriptions issued in this manner 
violated DEA's regulation because Respondent was required to include 
both his X number and his practitioner's registration number on them. 
See 21 CFR 1306.05(a). Moreover, because he did not include his 
practitioner's registration number, the non-Suboxone controlled 
substance prescriptions violated this provision as well.
    The ALJ also concluded that ``Respondent improperly prescribe 
Suboxone for substance abuse using his regular DEA registration number 
rather than the required X number.'' ALJ at 43. Apparently, this was 
because Respondent eventually started listing both numbers on his 
prescription blanks. However, as set forth above, DEA's regulation 
expressly requires that a practitioner include both his registration 
number and his X number when issuing a prescription for Suboxone for 
maintenance or detoxification treatment under the authority of 21 CFR 
1301.28. See 21 CFR 1306.05(a).
    Moreover, while a ``practitioner must include the identification 
number * * * on all prescriptions when prescribing narcotic drugs'' for 
the purpose of providing maintenance or detoxification treatment, id. 
1301.28(d), nothing in DEA regulations prohibits a practitioner from 
including both his practitioner's registration number and his X 
identification number on his prescription blanks. Nor does any DEA 
regulation require that a practitioner cross-out his X number when 
writing a prescription for controlled substances other than Suboxone 
(or Subutex) on a prescription blank that includes both numbers.
    The evidence also shows that Respondent violated the Immediate 
Suspension Order by issuing multiple prescriptions after he was served 
with the Order. Under 21 U.S.C. 843(a)(2), it is ``unlawful for any 
person knowingly or intentionally * * * to use in the course of the 
distribution[] or dispensing of a controlled substance, a registration 
number which is * * * suspended[.]''
    The evidence clearly shows that Respondent was personally served 
with the Immediate Suspension Order on September 27, 2010, at which 
time he told the Investigator that ``he was not going to abide by this 
order and that [the DI] didn't have the authority to tell him that he 
couldn't prescribe any controlled substances.'' Tr. 113. True to his 
word, two days later, however, he issued prescriptions to CW for 
Adderall, to MK for Adderall and Lortab, and to DH for Lortab and 
Xanax. Respondent's explanation that these prescriptions were just 
mistakes or accidents is totally unpersuasive.
    The prescriptions to MK and DH, as well as a further Adderall 
prescription which was issued to JB, were unlawful for the further 
reason that they were post-dated. As set forth above, under 21 CFR 
1306.05(a), ``[a]ll prescriptions for controlled substances shall be 
dated as of, and signed on, the day when issued.'' Respondent admitted 
that on September 3, 2010, he issued CW a prescription for Adderall, a 
schedule II controlled substance which he dated October 3, 2010. 
Moreover, both Respondent's testimony and documentary evidence 
establish that Respondent wrote the prescription to MK and DH on 
September 29, while post-dating them to October 4. Accordingly, I also 
find that Respondent violated DEA regulations in writing these 
prescriptions.
    I further find that Respondent lacked a legitimate medical purpose 
in prescribing Xanax to JC2. The evidence shows that Respondent knew 
that JC2 was abusing Xanax and that he had been jailed for 
distribution. While Respondent testified that he could not simply stop 
prescribing the drug to JC2 because JC2 could have seizures, and that 
he planned to taper JC2 off the drug, Respondent actually increased the 
daily dose of JC2's Xanax prescriptions. Given the inconsistency 
between the medical justification Respondent offered for his continuing 
to prescribe Xanax to JC2 and the actual prescriptions he issued, I 
conclude that Respondent lacked a legitimate medical purpose and acted 
outside the usual course of professional practice in prescribing Xanax 
to JC2. 21 CFR 1306.04(a).
    The record thus establishes that Respondent's experience in 
dispensing controlled substances (factor two) and his record of 
compliance with applicable laws related to controlled substances 
(factor four) is characterized by his multiple violations of Federal 
law. These include his prescribing of methadone for maintenance or 
detoxification purposes without being registered to do so and in 
violation of DEA regulations prohibiting the prescribing of methadone 
for this

[[Page 17522]]

purpose; his prescribing of controlled substances to treat chronic pain 
without a legitimate medical purpose; his prescribing of Xanax to JC2; 
his issuance of prescriptions which lacked his practitioner's 
registration number; his issuance of post-dated prescriptions; and his 
issuance of multiple prescriptions after his registration had been 
suspended. I further conclude that the Government has made a prima 
facie showing that Respondent has committed acts which render his 
registration ``inconsistent with the public interest,'' 21 U.S.C. 
824(a)(4), and that this conduct is sufficiently egregious to warrant 
the revocation of his registration.\24\
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    \24\ With respect to factor five, the ALJ found that 
Respondent's ``lack of candor * * * threatens public health and 
safety.'' ALJ at 49. As support for this conclusion, the ALJ noted 
that most of the patients who were interviewed by the Investigators 
had stated that Respondent was treating them for substance abuse, 
yet Respondent testified that they were being treated for chronic 
pain but did not realize this. Id.
    While I agree with the ALJ that Respondent lacked candor, and 
appreciate that she personally observed his testimony, I do so based 
on different evidence. First, during the initial interview on Feb. 
28, 2010, Respondent told the investigators that he was operating a 
detox clinic and was using methadone to transfer his patients to 
Suboxone. Tr. 43. Yet later that day, he claimed that he was 
prescribing methadone only for pain and had previously misspoken. 
Id. at 54-55. Second, when confronted with evidence that several of 
his methadone patients had come to him from methadone clinics, he 
attempted to justify his unlawful prescribing of methadone to them 
by claiming that the patients had actually gone to these clinics to 
treat their pain. See Tr. 695-96 (testimony regarding JB); id. at 
699 (testimony regarding JC); id. at 716-17 (testimony regarding 
KI); id. at 728 (testimony regarding TP). This factor thus also 
supports revocation.
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Sanction

    Under Agency precedent, where, as here, the Government has made out 
a prima facie case that a registrant has committed acts which render 
his ``registration inconsistent with the public interest,'' he must `` 
`present[] sufficient mitigating evidence to assure the Administrator 
that [he] can be entrusted with the responsibility carried by such a 
registration.' '' Samuel S. Jackson, 72 FR 23848, 23853 (2007) (quoting 
Leo R. Miller, 53 FR 21931, 21932 (1988)). ``Moreover, because `past 
performance is the best predictor of future performance,' ALRA Labs., 
Inc. v. DEA, 54 F.3d 450, 452 (7th Cir. 1995), this Agency has 
repeatedly held that where a registrant has committed acts inconsistent 
with the public interest, the registrant must accept responsibility for 
[his] actions and demonstrate that [he] will not engage in future 
misconduct.'' Medicine Shoppe-Jonesborough, 73 FR 364 (2008). As the 
Sixth Circuit has recognized, this Agency also ``properly consider[s]'' 
a registrant's admission of fault and his candor during the 
investigation and hearing to be ``important factors'' in the public 
interest determination. See Hoxie, 419 F.3d at 483.
    The ALJ found, and the record supports the conclusion, that 
Respondent eventually ceased prescribing methadone for maintenance and 
detoxification purposes. ALJ at 49-50. The record generally supports 
the conclusion that Respondent stopped writing controlled substance 
prescriptions which did not include his registration number, as 
required by DEA regulations. However, as found above, in September 
2010, Respondent issued a further Adderall prescription to JB and did 
not include his registration number.
    The ALJ further noted that Respondent expressed remorse for some of 
his wrongdoing. ALJ at 50. However, while Respondent maintained that he 
had mistakenly issued the post-suspension prescriptions, and ``would 
never do anything to violate an order,'' Tr. 509, his testimony is 
belied by the evidence that upon being served with the Immediate 
Suspension Order, he stated his intention not to comply with it. 
Indeed, his testimony is patently disingenuous, given that he wrote the 
prescriptions only two days after he was served with the Order. In 
short, Respondent's conduct manifests a deliberate and egregious 
disregard for his obligations as a DEA registrant.
    Finally, while the ALJ noted that ``Respondent testified 
passionately about the prevalence of narcotic abuse in Red Bay and his 
want to eliminate it,'' she further concluded that he ``likely 
facilitated some of that abuse.'' Id. The ALJ's conclusion is well 
supported. Indeed, as found above, in numerous instances, Respondent 
issued controlled-substance prescriptions for the purported purpose of 
treating a patient's pain, even though he recorded in the patient's 
chart that the patient had ``NO'' pain and/or failed to make the 
findings required under the State's Guidelines to properly diagnose the 
patient. Moreover, during one of the interviews by the Investigators, 
Respondent admitted that he did not follow the State's Guidelines. Tr. 
220. Respondent, however, offered no evidence that he now intends to 
comply with the Guidelines.
    Accordingly, I hold that Respondent has not rebutted the 
Government's prima facie case. I will therefore order that Respondent's 
registration be revoked and that any pending application be denied. For 
the same reasons that led me to order the Immediate Suspension of 
Respondent's registration, I conclude that the public interest requires 
that this Order be effective immediately.

Order

    Pursuant to the authority vested in me by 21 U.S.C. 823(f) & 
824(a)(4), as well as by 28 CFR 0.100(b) & 0.104, I order that DEA 
Certificate of Registration, BC1701184, and Identification Number 
XC1701184, issued to Morris W. Cochran, M.D., be, and they hereby are, 
revoked. I further order that any application for renewal or 
modification of such registration be, and it hereby is, denied. This 
Order is effective immediately.

    Dated: March 16, 2012.
Michele M. Leonhart,
Administrator.
[FR Doc. 2012-7107 Filed 3-23-12; 8:45 am]
BILLING CODE 4410-09-P