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Notice2022-10592

Fares Jeries Rabadi, M.D.; Decision and Order

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Published

May 19, 2022

Issuing agencies

Justice DepartmentDrug Enforcement Administration

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<title>Federal Register, Volume 87 Issue 97 (Thursday, May 19, 2022)</title>
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[Federal Register Volume 87, Number 97 (Thursday, May 19, 2022)]
[Notices]
[Pages 30564-30608]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-10592]

[[Page 30563]]

Vol. 87

Thursday,

No. 97

May 19, 2022

Part II

Department of Justice

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Drug Enforcement Administration

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Fares Jeries Rabadi, M.D.; Decision and Order; Notice

Federal Register / Vol. 87, No. 97 / Thursday, May 19, 2022 /
Notices

[[Page 30564]]

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DEPARTMENT OF JUSTICE

Drug Enforcement Administration

[Docket No. 20-14]

Fares Jeries Rabadi, M.D.; Decision and Order

On March 2, 2020, a former Acting Administrator of the Drug
Enforcement Administration (hereinafter, DEA or Government), issued an
Order to Show Cause and Immediate Suspension of Registration
(hereinafter collectively, OSC) to Fares Jeries Rabadi, M.D.
(hereinafter, Respondent). Administrative Law Judge Exhibit
(hereinafter, ALJ Ex.) 1 (OSC), at 1. The OSC immediately suspended
Respondent's DEA Certificate of Registration Number BR6081018
(hereinafter, registration or COR) ``because [Respondent's] continued
registration constitutes an `imminent danger to the public health or
safety.' '' Id. (citing 21 U.S.C. 824(d)). The OSC also proposed
revocation of Respondent's registration, the denial of any pending
applications for renewal or modification of such registration, and the
denial of any pending applications for additional DEA registrations
pursuant to 21 U.S.C. 824(a)(4) and 823(f), because Respondent's
``continued registration is inconsistent with the public interest.''
Id.
In response to the OSC, Respondent timely requested a hearing
before an Administrative Law Judge. ALJ Ex. 2. The hearing in this
matter was conducted on September 29-30, 2020, via video teleconference
technology. On December 22, 2020, Administrative Law Judge Mark M.
Dowd, (hereinafter, ALJ) issued his Recommended Rulings, Findings of
Fact, Conclusions of Law and Decision (hereinafter, Recommended
Decision or RD) to which both parties filed Exceptions. I have
addressed both the Respondent's and Government's Exceptions in
footnotes added to the corresponding parts of the RD. While I have made
some modifications to the RD based on the Exceptions, none of those
changes and none of Respondent's arguments persuaded me to reach a
different conclusion than the ALJ in this matter. I issue my final
Order in this case following the Recommended Decision.\*A\
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\*A\ I have made minor, nonsubstantive, and grammatical changes
to the RD and nonsubstantive conforming edits. Where I have added to
the ALJ's opinion to include additional information, I have noted
the additions in brackets or in footnotes marked with an asterisk
and a letter. Where I have made substantive changes, omitted
language for brevity or relevance, or where I have modified the
ALJ's opinion, I have noted the edits in brackets and have included
specific descriptions of the modifications in brackets or in
footnotes marked with an asterisk and a letter. Within those
brackets and footnotes, the use of the personal pronoun ``I'' refers
to myself--the Administrator.
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Recommended Rulings, Findings of Fact, Conclusions of Law, and Decision
of the Administrative Law Judge *B
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\*B\ I have omitted the RD's discussion of the procedural
history to avoid repetition with my introduction.
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The issue to be decided by the Administrator is whether the record
as a whole establishes by a preponderance of the evidence that the DEA
Certificate of Registration, No. BR6081018, issued to Respondent should
be revoked, and any pending applications for modification or renewal of
the existing registration should be denied, and any pending
applications for additional registrations should be denied, because his
continued registration would be inconsistent with the public interest
under 21 U.S.C. 823(f) and 824(a)(4).
After carefully considering the testimony elicited at the hearing,
the admitted exhibits, the arguments of counsel, and the record as a
whole, I have set forth my recommended findings of fact and conclusions
of law below.

The Allegations

The Government alleges the Respondent violated federal and
California law,\1\ by issuing numerous prescriptions for Schedule II
through IV controlled substances outside the usual course of
professional practice and not for a legitimate medical purpose to seven
individuals as recently as December 31, 2019. These prescriptions fell
below minimal medical standards applicable to the practice of medicine
in California. Therefore, these prescriptions violated federal and
California state law.
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\1\ [Omitted for brevity. Specifically, Respondent was charged
with violating:]
a. Cal. Health & Safety Code Sec. 11153(a), requiring that a
``prescription for a controlled substance shall only be issued for a
legitimate medical purpose by an individual practitioner acting in
the usual course of his or her professional practice'';
b. Cal. Health & Safety Code Sec. 11154(a), directing that ``no
person shall knowingly prescribe, administer, dispense, or furnish a
controlled substance to or for any person . . . not under his or her
treatment for a pathology or condition . . .'';
c. Cal. Bus.& Prof. Code Sec. 2242, prohibiting the
``[p]rescribing, dispensing, or furnishing [of controlled
substances] . . . without an appropriate prior examination and a
medical indication,'' the violation of which constitutes
unprofessional conduct;
d. Cal. Bus. & Prof. Code Sec. 2234, defining unprofessional
conduct to include: ``[g]ross negligence''; ``[r]epeated negligent
acts''; ``[i]ncompetence''; or ``[t]he commission of any act
involving dishonesty or corruption that is substantially related to
the qualifications, functions, or duties of a physician and
surgeon''; and
e. Cal. Bus. & Prof. Code Sec. 725, further defining
unprofessional conduct to include ``[r]epeated acts of clearly
excessive prescribing, furnishing, dispensing, or administering of
drugs. . . .''
Additionally, [Respondent was alleged to have issued
prescriptions outside of] California's applicable standard of care
as outlined in the ``Guide to the Laws Governing the Practice of
Medicine by Physicians and Surgeons,'' Medical Board of California,
7th ed. 2013 (the ``Guide''). [Omitted for brevity.] See ALJ Ex. 1.
[The Government did not address (b) or (d) above in its Posthearing
Brief, so I will not address those allegations herein.]
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The Government alleges the Respondent regularly prescribed highly
addictive and intoxicating combinations of controlled substances to his
patients, and that he consistently failed to: (1) Perform adequate
physical evaluations and obtain appropriate patient histories; (2) make
appropriate diagnoses based on sufficient clinical evidence and
document these diagnoses in his medical records; (3) document a
legitimate medical purpose for the controlled substances that he
prescribed; (4) monitor his patients' medication compliance; and (5)
respond to red flags of drug abuse and diversion. These failures
constitute extreme departures from the standard of care in California,
and that his actions were dangerous and reckless. Because of these
failures, he regularly put his patients at significant risk for harm,
including overdose or death. He also continued to prescribe controlled
substances to these patients despite the fact that he knew they were
suffering from opioid dependencies. [The OSC went on to provide
specific examples of Respondent's alleged failures related to seven
individuals: S.B., M.B., B.C., J.C., D.D., J.M., and K.S. ALJX 1, at
14.] For each of the seven patients, he continued to prescribe opioids
to them, even while noting that each patient suffered from an opioid
dependency.\*C\
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\*C\ Omitted for brevity.
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The Hearing

Government's Opening Statement 2
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\2\ The Respondent waived the opportunity to make an opening
statement. Tr. 30.
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DEA initiated an investigation into Dr. Rabadi, a California
registered physician, upon receipt of a report from the Department of
Health and Human Services Office of Inspector General. Tr. 23. The
report characterized him as a ``high-risk prescriber'' due to his
prescribing of a large number of highly diverted and highly abused
drugs. Initially, DEA reviewed Dr. Rabadi's prescribing practices
through the California PDMP. Tr. 23. Significant red flags were
revealed, including dangerous combinations of controlled substances.
Three drugs, hydrocodone acetaminophen, alprazolam and

[[Page 30565]]

carisoprodol constituted over 95% of the controlled substance
prescriptions he issued between November 20, 2015, and November 21,
2018. Tr. 24. In combination, these three drugs make up a highly
dangerous and diverted cocktail commonly known among drug seekers as
the Holy Trinity.
On November 6, 2018, an undercover agent (hereinafter, UC) posing
as a prospective patient with back pain, sought treatment from Dr.
Rabadi. Dr. Rabadi declined to treat UC, explaining that he was an
internist and did not treat back pain. Tr. 24.
In February of 2019, DEA executed federal search warrants on Dr.
Rabadi's clinic, home, and three safety deposit boxes. DEA seized a
number of prescriptions and patient files. Tr. 24. DEA also seized an
unusually large amount of cash from Dr. Rabadi's home and clinic
examination room suggestive of diversion and mis-prescribing. Tr. 25.
Subpoenas to pharmacies produced prescriptions for a number of Dr.
Rabadi's patients, including the seven patients at issue in this case.
Tr. 25.
The Government's expert, Dr. Timothy Munzing, will testify that his
review of the patient files and prescriptions revealed, in his opinion,
that Dr. Rabadi prescribed controlled substances to each of the seven
patients outside the usual course of professional practice in
California. Tr. 25. Dr. Munzing will testify that Dr. Rabadi never
established a legitimate medical purpose for the controlled substances
he prescribed, and was not acting in the usual course of professional
practice. Tr. 25. Dr. Munzing will testify that Dr. Rabadi consistently
failed to meet fundamental elements of the California standard of care
for prescribing controlled substances, including failure to obtain
appropriate medical histories, failure to perform minimally appropriate
physical exams, failure to make appropriate diagnoses based on
sufficient medical evidence, failure to document appropriate treatment
plans, failure to document a legitimate medical purpose for the
controlled substances, failure to discuss the risks and benefits of the
cocktails and controlled substances he prescribed, failure to conduct
even a single urine drug screen, and failure to respond to red flags of
abuse and diversion. Tr. 27. Dr. Rabadi prescribed controlled
substances in dangerous and addictive combinations and outside the
usual course of professional practice and without establishing a
legitimate medical purpose. Dr. Rabadi diagnosed neck and back pain
without sufficient medical evidence. Tr. 27. Dr. Rabadi frequently and
plausibly diagnosed opioid dependency for patients on long term opioid
use. Dr. Rabadi frequently issued Norco prescriptions to treat M.B.,
B.C., J.C., D.D., J.M., and K.S. for opioid dependency, which was a
dangerous and illegal course that was outside the standard of care. Tr.
27-28. Dr. Rabadi prescribed Xanax in dangerously high dosages to
Patients S.B., B.C., J.M., and K.S. of six to eight mgs per day, almost
twice the recommended maximum dosage for anxiety disorder. Tr. 28. With
early refills of Xanax, the Respondent exposed J.M. to more than 10 mgs
per day for nearly two years. Tr. 29. He further exposed these patients
to the risk of overdose and death by concurrently prescribing them
opioids. Tr. 28.
Thus, the Respondent was not providing medical care to these
patients, he was exposing them to risk of harm by handing out dangerous
and addictive drugs without medical justification. Dr. Rabadi's
controlled substance prescriptions to Patients S.B., M.B., B.C., J.C.,
D.D., J.M., and K.S. were not issued for a legitimate medical purpose,
were not issued by a practitioner acting within the usual course of
professional practice in California, and were issued in violation of
the standard of care in California and in violation of the laws of the
United States. Tr. 29. Accordingly, the Government then requested that
the tribunal recommend revocation of Dr. Rabadi's DEA certificate of
registration.\3\
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\3\ Government allegations included a reference to statistics
that 95% of the Respondent's prescriptions were for the ``Holy
Trinity'' suggesting that evidence, in itself, demonstrated
illegitimate prescribing by the Respondent. The Government confirmed
that those statistics did not form an independent allegation. Tr.
32-33.
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Government's Case-in-Chief

The Government presented its case-in-chief through the testimony of
two witnesses. First, the Government presented the testimony of a DEA
Diversion Investigator (DI). Secondly, the Government presented the
testimony of Dr. Timothy Munzing, M.D.

Diversion Investigator

DI has served as a Diversion Investigator at DEA's Los Angeles
Field Division for three years. Tr. 33-34. Previously, she served with
United States Citizenship and Immigration Service for four years. Tr.
75. As a DI, she enforces compliance with the Controlled Substances Act
(CSA), looking for signs of diversion within the registration system,
including monitoring for regulatory compliance. Tr. 34-35. She has
attended the basic diversion investigation training at the DEA Academy,
which included training to spot signs of diversion, investigating
diversion and enforcing compliance with the CSA, both in the criminal
and administrative settings. Tr. 35. She has also received training
regarding CURES--the California prescription drug monitoring program.
Regarding the Respondent, in April 2018, DEA received a report from
the Department of Health and Human Service (HHS) that the Respondent
was on a ``high-risk model for overprescribing of controlled
substances.'' Tr. 37, 75. DEA ran two CURES reports, one in April of
2018, which revealed numerous red flags, including prescribing
hydrocodone at the maximum strength and a large amount of
polypharmaceutical cocktails or combinations of a benzodiazepine and an
opioid. Additionally, the volume of opioid prescribing was high, at
over 9,000 prescriptions over the course of three years from November
2015 to November 2018. Tr. 38-39, 42, 56-57, 82; GX 16-19. Fifty-
percent of these were for hydrocodone. Tr. 42. According to DI, the
combination of a benzodiazepine and an opioid are significant as they
are highly sought after by the black market and are dangerous to the
patient. Tr. 39. The Respondent also prescribed a large number of
combinations of the highly sought after ``Holy Trinity,'' which
includes a narcotic, a muscle relaxant and a benzodiazepine--96% of his
prescriptions during that three-year period.\*D\ Tr. 40, 42-43. These
highly addictive and highly dangerous combinations were prescribed over
a long period of time. Tr. 40-41.
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\*D\ To be clear, the DI did not testify that 96% of the
prescriptions that Respondent issued were issued in the ``Holy
Trinity'' combination. Rather, DI testified that 96% of Respondent's
issued controlled substance prescriptions were for either
hydrocodone (a narcotic), alprazolam (a benzodiazepine), or
carisoprodol (a muscle relaxant). Tr. 42.
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Due to these red flags, on September 26, 2018, DEA sent an
undercover agent (UC) to the Respondent's clinic--posing as a
prospective patient. Tr. 43. The first attempt was foiled as the clinic
was closed. The second attempt occurred on October 30, 2018. Tr. 44,
75-76. The clinic was again closed. The third attempt occurred on
November 6, 2018. UC complained of back pain and shoulder pain and
sought help from Dr. Rabadi. Dr. Rabadi declined to help the UC--
explaining that he was not taking new patients and that he was an
internist and not a pain specialist. Tr. 45, 75-76. Ultimately, DEA
obtained five search warrants, four of which were

[[Page 30566]]

executed on February 21, 2019. Tr. 46, 76-77. The fifth was served on
February 22, 2019. Tr. 74. They were served on his clinic, on his home
and on two safety deposit boxes at two separate banks. Tr. 46. DEA
seized 1.2 million dollars in cash at his home.\4\ Dr. Rabadi was home
when the search warrant was served. Tr. 77. He agreed to be interviewed
regarding his prescribing practices. Tr. 77. At his clinic, DEA seized
patient files and some prescriptions for S.B., B.C., M.B., J.C., D.D.,
J.M. and K.S. Tr. 49-50. Additional prescriptions and fill stickers
were obtained from pharmacies.\5\ Tr. 50-55; GX 1-15. Thereafter, in
January 2020, DEA issued an administrative subpoena to the Respondent
for any and all updated medical records and prescriptions for the noted
patients. Tr. 55-56.\6\ In all, DEA obtained twenty-seven files or
updated files. Tr. 78.
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\4\ The Respondent objected to the evidence of the cash seizure
as irrelevant and immaterial. The objection was carried. Tr. 47-49.
[I find that this evidence, while useful to understanding the course
of DEA's investigation, is immaterial to the ultimate issue in this
case, which is whether or not Respondent issued controlled substance
prescriptions that were outside the usual course of professional
practice and beneath the standard of care. Accordingly, I have not
considered this information in making my decision.]
\5\ DI noted record-keeping deficiencies on the part of some of
the pharmacies, Tr. 51-55, but clarified they were not a negative
reflection on the Respondent. Tr. 79-80.
\6\ The Government authenticated Government Demonstrative
Exhibits 1-8, which were summary charts for each of the seven
subject patients containing the subject prescriptions and patient
files consistent with the seized and stipulated to records. Tr. 57-
73.
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Dr. Timothy Munzing

Dr. Munzing is a physician licensed in California and holds a DEA
Certificate of Registration there. Tr. 86-87; GX 23. Dr. Munzing
graduated from UCLA Medical School in 1982. Tr. 89. He completed his
internship and residency in family medicine at the Kaiser Permanente
Medical Center in Los Angeles in 1985. Tr. 89. He then went to Kaiser
Permanente Orange County, where he has been employed for the last 35
years in the family medicine department. He is also available as a
consultant. Tr. 90.
In his family medicine practice, he takes care of his patients from
``cradle to grave.'' Tr. 90. Most of his present patients are adults.
Tr. 90. Twenty-five percent of his work is spent treating his patients.
Tr. 92. In his clinical practice, he has prescribed controlled
substances, including opioids and benzodiazepines. Tr. 92. Thirty-two
years ago Dr. Munzing founded a family medicine practice residency
program, and continues to be the residency director for twenty-four
residents. Tr. 90. He also sits on the National Accreditation Board for
Family Medicine Residency. He is a member of the American Medical
Association, the California Medical Association, and the American
Academy of Family Physicians, to name a few. Tr. 91; GX 23. He also
serves as a full clinical professor at the University of California
Irvine, and at the Kaiser Permanente School of Medicine. Tr. 91. He has
been called as an expert witness by the California Medical Board for
the past ten years, and by federal law enforcement for the past six
years. Tr. 623. Dr. Munzing has been qualified approximately thirty-
five times to offer his expert opinion for the California Medical
Board, DEA, FBI, and the Department of Justice, including his opinion
on the standard of care for prescribing controlled substances, and
whether a prescription was issued for a legitimate medical purpose in
the usual course of professional practice. Tr. 92-94, 623. He has
testified as an expert in five or six prior DEA Administrative
hearings. Most of his opinions have related to illegal prescribing of
opioids. Tr. 95. Internal rules of Kaiser Permanente prevent him from
testifying on behalf of physicians. Tr. 624. Dr. Munzing estimated he
had received approximately $20,000 for his time on the instant case at
$400 per hour. Tr. 624.
He is familiar with the California standard of care for prescribing
controlled substances. Tr. 94. The California standard of care is
informed by publications by the California Medical Board. Tr. 95-97; GX
20 at 59-61, GX 21. In particular, ``The Laws Governing the Practice of
Medicine by Physicians and Surgeons,'' sets out minimum requirements
for care, including history and physical examination, assessment of
pain, physical and psychological functioning, substance abuse history,
treatment plan, and maintaining accurate and complete records. Tr. 374-
80. In forming his opinions in this case, Dr. Munzing reviewed the
medical records and prescriptions for the subject patients. Tr. 100-01.
Dr. Munzing was qualified, without objection, as an expert in
California medical practice, including the applicable standards of care
in California for the prescribing of controlled substances within the
usual course of the professional practice of medicine. Tr. 101-02.
Dr. Munzing explained that the standard of care is generally ``what
a responsible, knowledgeable physician can do'' under similar
circumstances. Tr. 102-03. In prescribing controlled substances this
would include performing a physical examination, taking a history,
including both a medical history and a psychological and substance
abuse history, attempting to obtain prior medical records, formulating
a diagnosis, evaluating risk factors for the controlled medications
including the risk of abuse, discussing the risks with the patient to
obtain informed consent, developing a customized treatment plan with
goals and objectives, documenting all of the above in the medical
record, and providing ongoing monitoring of the patient and of his
treatment, including urine drug screens (UDS) and alternate therapies.
Tr. 103-112, 114-25, 128-35. Ongoing and comprehensive documentation is
critical for accurate evaluation of a patient's condition and
treatment. Tr. 142-50. The goal is to maximize function, while
minimizing risk. Tr. 139-40. Compliance with all relevant California
statutes and regulations is also required by the standard of care. Tr.
104. It requires addressing, resolving and documenting red flags. Tr.
112. Dr. Munzing identified the FDA ``black box'' warning regarding
combining opioids with benzodiazepines, titled New Safety Measures
Announced for Opioid Analgesics, dated August 31, 2016. Tr. 151; GX 22
at 1-3, 4, 25, 40. The FDA specifically noted diazepam, Klonopin, and
Xanax should not be combined with opioids unless absolutely necessary,
and for no longer than absolutely necessary. Tr. 153-55.
Dr. Munzing testified that the higher the morphine milligram
equivalent (MME) prescribed, the increased risk of addiction and
overdose. Tr. 126-28. Prescribing controlled substances for
psychological illness requires an even greater emphasis on history, and
a more-focused physical exam [of the ``heart, lung, vital signs . . .
seeing if [there is] any evidence of some other medical diagnosis'' in
addition to the mental health disorder.] Tr. 136, 138-39, 141. The
General Anxiety Disorder screening tool, GAD-7, is a useful tool in
assessing a patient's level of anxiety. Tr. 136-37.
Dr. Munzing reviewed the patient files, prescriptions, and CURES
data for Patients S.B., M.B., B.C., J.C., D.D., J.M., and K.S. [and
concluded that the prescriptions at issue were ``not consistent with
the standard of care in the state of California.''] Tr. 156-57. Dr.
Munzing noted that the history for these seven patients was deficient.
Tr. 157. There was no indication prior medical records were obtained.
Tr. 157. The physical exams, if present, were missing key elements.
There were no documented CURES checks. Tr. 158.

[[Page 30567]]

Diagnoses appeared and disappeared. Opioids were prescribed at high
dosages. There was no indication of the necessary patient monitoring
and there was no documentation of informed consent. Tr. 159-60, 207.
Dr. Munzing summarized that none of the controlled prescriptions issued
for the charged patients were issued for a legitimate medical purpose
by a practitioner acting within the usual course of professional
practice. Tr. 620-21. According to Dr. Munzing, all of the relevant
prescriptions were issued outside the standard of care. Tr. 621.

Patient S.B.

As per the parties' stipulations, between February 2, 2017, and
January 30, 2019, S.B. was prescribed hydrocodone, carisoprodol,
Adderall and alprazolam. Tr. 162-63; GDX 1. Dr. Munzing characterized
the patient file as meager. He characterized the controlled substance
prescriptions as being outside the standard of care. Tr. 163, 207, 241-
44. For S.B.'s initial visit on August 3, 2016, she was diagnosed with
Generalized Anxiety Disorder (GAD), Attention Deficit Disorder (ADD),
and Fibromyalgia. Tr. 163-65; GX 1 at 62, 66. There were no supporting
findings from a physical examination or history for the fibromyalgia
diagnosis, which typically is reached after a certain number of tender
points are determined. Tr. 166. Similarly, there were no supporting
findings from a physical examination or history to support the GAD or
ADD diagnoses. Tr. 166-71, 241-44. There was no physical functioning
level documented nor mental functioning level documented. Tr. 171.
Without sufficient evaluation and supporting documentation for the
three diagnoses, Dr. Munzing deemed the diagnoses inappropriate. Tr.
241-44. Without an appropriate diagnosis, there was no legitimate
medical purpose for the controlled substance prescriptions. Tr. 172,
207, 241-44. Similarly, there was no documented treatment plan. Tr.
241-44. On February 2, 2017, S.B. presented to the clinic suffering
from fibromyalgia and ADD. Tr. 173; GX 1 at 59. The Respondent
diagnosed her with fibromyalgia-opioid dependent, refusing detox, and
ADD. He prescribed hydrocodone, carisoprodol, and Adderall. Tr. 173-74.
Again, there was no medical history justifying the diagnosis. The
physical exam conducted on February 2, 2017, consisted of blood
pressure, cardiovascular, heart and lung, all of which were normal.
Again, the physical exam was insufficient to justify the fibromyalgia
and ADD diagnoses. Tr. 175. There was no documentation of the pain
level, or functionality level, to justify continued controlled
substance prescribing. Tr. 175-76. For the progress notes of June 28,
2017, the Respondent diagnosed her with fibromyalgia-opioid dependent,
refusing detox, and ADD. He prescribed hydrocodone, carisoprodol, and
Adderall. Tr. 177. Again, there was no medical history justifying the
diagnoses. There was no documentation of the pain level, or
functionality level, to justify continued controlled substance
prescribing. Tr. 177-78; GX 1 at 57. Again, blood pressure and heart
and lung exams were performed. Tr. 177. There was insufficient medical
evidence to justify the three diagnoses. Tr. 177-78. For the progress
note for December 21, 2018, S.B. presented with eczema and
fibromyalgia. Tr. 179; GX 1 at 49. The Respondent diagnosed her with
fibromyalgia-opioid dependent, refusing detox. She was prescribed
hydrocodone. No history was recorded. Again, blood pressure and heart
and lung exams were performed. Tr. 180. There was no documentation of
the pain level or functionality level, to justify continued controlled
substance prescribing. Tr. 180. There was insufficient medical evidence
to justify the fibromyalgia diagnosis. Tr. 181. In the progress notes
for January 30, 2019, S.B. reported to the clinic with ADD and
rhinitis. Tr. 181; GX 1 at 47. She was prescribed Adderall for the ADD.
No medical history was taken. ADD patient progress was reported as
``stable.'' There was insufficient medical evidence to justify the ADD
diagnosis. Tr. 183. Dr. Munzing deemed the ADD diagnoses inappropriate.
Without an appropriate diagnosis, there is no legitimate medical
purpose for the controlled substance prescription. Tr. 185-86. During
the subject period of the Respondent's treatment of S.B., he never
obtained any prior medical records. Tr. 184. He never recorded a
history, which would justify his diagnoses for Fibromyalgia, GAD, or
ADD. Tr. 184-85. He never reported a sufficient physical or mental exam
to justify the Fibromyalgia, GAD, or ADD diagnoses. Id. He never
reported a sufficient evaluation to justify his diagnoses for
Fibromyalgia, GAD, or ADD. Id. The relevant controlled substance
prescriptions for S.B. were not issued within the California standard
of care, nor were they issued within the usual course of professional
practice. Tr. 186-87, 244.
Dr. Munzing observed that the diagnoses would come and go in the
records and were inconsistently reported, which is atypical for chronic
diagnoses. Tr. 188-97. A chronic disease, with symptoms that appear to
come and go would raise the question of whether the patient had the
disease at all. Tr. 192. Even a lessening of symptoms should cause
evaluation as to whether tapering of medication would be appropriate.
Tr. 196.
Dr. Munzing noted that the Respondent prescribed S.B. both
hydrocodone and Soma to treat Fibromyalgia on numerous occasions. Tr.
197-98. On other occasions, he prescribed the hydrocodone only without
documenting any explanation for changing the medication protocol, which
was beneath the California standard of care for documentation. Tr. 198-
201; GX 20 at 61. [Dr. Munzing testified that Respondent did not
establish a legitimate medical purpose for issuing to S.B. any of the
controlled substances at issue. Tr. 201.] Dr. Munzing noted that S.B.
was prescribed a dangerous, highly addictive combination of medications
that was popular for abuse and diversion; namely hydrocodone and Soma,
which are respiratory depressants, and Adderall. Tr. 202.
Another dangerous combination, hydrocodone, Adderall and Xanax was
prescribed March 1, 2017, April 2017, and June 2017. Tr. 203; GX 1. Dr.
Munzing noted this combination is referred to by drug abusers as the
``new Holy Trinity.'' Tr. 204. It includes the depressants, hydrocodone
and Soma, and is followed by the stimulant, Adderall, to counteract the
effects of the depressants. Again, the combination of hydrocodone and
Soma are the subject of the FDA ``black box'' warning. Tr. 205. The
high dosage of Xanax, 6 mg per day, heightens the risk of this already
dangerous combination. With Xanax and Adderall prescribed at their
highest commercially available dosage units, the danger and risk of
addiction are further increased. Tr. 205. Additionally, two mg tablets
of Xanax are popular for abuse and diversion. Tr. 217-18. On September
29, 2017, and monthly from July 2018, to July 2019, S.B. was prescribed
hydrocodone and Adderall. Besides the serious risk of addiction posed
by these two Schedule II medications, the hydrocodone was prescribed at
a daily dosage of 60 mg MME, which significantly increases the risk of
overdose and death. This risk was increased by its combination with
Adderall. Tr. 206-07. Dr. Munzing could not foresee any medical
condition in which this combination would be appropriate. Tr. 211-12.
Dr. Munzing noted that the medical records failed to disclose any
indication that the Respondent warned S.B. regarding the risks
associated with these dangerous combinations of controlled

[[Page 30568]]

substances. This failure precludes any informed consent by S.B. Tr.
207. The Declaration of Pain Medication Use document in the file, dated
August 3, 2016, which requires the patient to alert the Respondent if
the patient takes additional medications [(other than those prescribed
by Respondent)] because they could result in drug interactions, does
not put the patient on notice of the dangerous combinations prescribed
by the Respondent. Tr. 207-10; GX 1 at 67. Similarly, Dr. Munzing noted
the repeated notation within the patient records of ``SED,'' which Dr.
Munzing assumed meant, ``side effects discussed,'' was insufficient
documentation within the standard of care to establish that Respondent
discussed the various risks of these medication combinations. Tr. 210-
11; GX 1 at 59.
In March, April and June of 2017, the Respondent prescribed S.B.
Xanax at 6 mg per day, in excess of the FDA recommended daily limit of
4 mg per day. Tr. 212-15; GX 1 at 57, 58, 59. GX 22 at 40, 59-61. In
May of 2017, the Xanax was abruptly stopped. Tr. 216-17; GDX 1. And
abruptly restarted in June of 2017, and again stopped. Tr. 217. This is
very dangerous as the abrupt stoppage of Xanax without titration,
especially at this high dosage, can cause seizures, and restarting at
this high dosage can trigger an overdose, especially in conjunction
with the prescribed opioid. Tr. 212-18.
Dr. Munzing testified that regarding the monitoring of S.B., there
were no urine drug screens evident in the records, which the standard
of care would have required at least quarterly. Tr. 218-21; GX 1 at 44.
In the progress notes for February, March, April 2017, all the way to
January 30, 2019, the Respondent noted ``refusal to detox.'' Tr. 220-
21, 227-29; GX 1 at 58, 59. This is a huge red flag for opioid use
disorder and for diversion. However, the chart reflects the Respondent
did not take any necessary action, such as CURES monitoring, random
pill count, UDS, counseling, or titration. Rather, he simply prescribed
the same levels of medications she was on, PRN. Tr. 222-23. The
Respondent's course of action was outside the California standard of
care. Tr. 223, 229. Respondent's medical file for S.B. contained a June
2017 report from Dr. F., an orthopedic surgeon who saw S.B. for
reported neck and back pain. According to Dr. F's report, S.B. reported
her past medical history as only ``anxiety.'' Tr. 229; GX 1 at 30, 32,
36-42, 56. She did not report Fibromyalgia or ADD. Tr. 229-30. S.B.
further reported to Dr. F. that she was not then taking any medication
for pain, which is contrary to the Respondent's medical records and
prescription evidence. Tr. 231-32. Dr. F.'s report was part of S.B.'s
disability application, claiming disability as of June 15, 2017. A
report from Chiropractor B.H. is also included in the disability
packet. Tr. 235. Dr. B.H. reports the disability was caused by
``accident or trauma,'' which is inconsistent with what the patient
reported to Dr. F. and to the Respondent. Tr. 236. There is no
indication within the Respondent's records for S.B. that he ever
discussed, with S.B. or with Dr. F., the discrepancies revealed by Dr.
F.'s report. Tr. 233-37.
Contemporaneous to the preparation of the disability claim, Dr.
Rabadi ordered a series of radiologic tests on S.B., none of which were
related to the Respondent's diagnosis of fibromyalgia. The progress
notes from August 17, 2017, say that S.B. presented with ``overactive
thyroid, gait disturbance.'' Tr. 237-40; GX 1 at 5, 7, 9, 11, 13, 16,
17, 56. Dr. Rabadi ordered an MRI of the brain to rule out MS, a
thyroid ultrasound to rule out hyperthyroidism, an MRI of the lumbar
spine, and an MRI of the thoracic spine. The MRI of the cervical spine
was ordered by Dr. F. Tr. 241.
[Dr. Munzing, summarizing his opinions based on his review of the
entire file for S.B., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for S.B.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded S.B.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with S.B., never
appropriately monitored S.B. and failed to appropriately respond to red
flags of diversion. Tr. 241-44. Accordingly, Dr. Munzing opined that
each of the relevant prescriptions Respondent issued to S.B. were
issued without a legitimate medical purpose, outside the usual course
of professional practice and beneath the standard of care in
California. Tr. 244.]

Patient M.B.

After a review of M.B.'s patient file, CURES report and related
prescriptions, Dr. Munzing observed that between January 5, 2018, and
November 20, 2019, the Respondent prescribed hydrocodone and Adderall.
Tr. 245. As with patient S.B., Dr. Munzing characterized the patient
file as containing ``very little'' information. Tr. 245-47. The
Respondent never obtained prior medical records of M.B. Tr. 288. Dr.
Munzing observed that none of the subject prescriptions were within the
California standard of care. Tr. 248, 289.
On April 19, 2006, M.B. presented for his first visit. Tr. 248-49;
GX 3, p. 88, 91. In his ``Comprehensive History and Physical
Examination,'' the Respondent reported that M.B. presented with
symptoms of ``chronic back pain, left knee pain, dyslipidemia.'' Tr.
249-50. However, there are no appropriate diagnoses relating to the
back and knee pain and therefore no legitimate medical purpose for
prescribing hydrocodone.\*E\ Tr. 250-51, 258. To address the reported
pain, the Respondent prescribed hydrocodone. Tr. 252. The file fails to
evidence sufficient history to justify the pain prescriptions under the
standard of care. Tr. 252-54. The file fails to evidence any physical
exam to justify the pain prescriptions under the standard of care.\*F\
Tr. 254-55, 258, 287. The file fails to evidence any treatment plan or
goals, or past drug abuse to justify the pain prescriptions under the
standard of care. Tr. 254-55, 258, 287.
---------------------------------------------------------------------------

\*E\ Dr. Munzing clarified that ``knee pain and back pain are
really symptoms, and chronic back pain is essentially, you have a
symptom that's there ongoing.'' Tr. 250. He further testified that
these symptoms are not diagnoses, though Respondent treated them as
such, and that the distinction is important because the way knee and
back pain are treated differs ``depending on the more specific
diagnoses or diagnosis causing the symptoms.'' Tr. 251.
The Government's attorney and Dr. Munzing agreed about the
importance of this distinction and the Government's attorney
apologized in advance that he might refer to certain symptoms as
diagnoses as ``shorthand,'' even though they both understood what he
meant. Id.
\*F\ Dr. Munzing testified, ``there was no back exam. There was
no knee exam. Again, heart, lung, abdomen. There is a head, ear,
eyes exam. . . . He, once again, did a testicular and a rectal exam.
But there is no back and knee exam evident.'' Tr. 256.
---------------------------------------------------------------------------

Although M.B. declared on a ``Declaration of Pain Medication Use''
form that he had no prior drug abuse in August 2009, which was three
years after his first visit, such static declaration does not satisfy
the physician's ongoing responsibility under the standard of care to
monitor this issue [to determine whether the patient is ``currently
using drugs.''] Tr. 259-61; GX 3 at 93.
On July 9, 2013, M.B. presented with ADD and neck pain. Tr. 261-62;
GX 3 at 46. He was prescribed Adderall for the ADD. Tr. 262. Again, the
records reveal there was no history taken to support the diagnosis or
justify the prescriptions for Adderall. Tr. 262. There was no evident
evaluation done by the Respondent. Tr. 287. There was no treatment
plan. Tr. 263. Although

[[Page 30569]]

there was a diagnosis related to the neck pain, there was no history or
physical exam evident in the file. Tr. 263-64. The Respondent never
established a legitimate medical purpose for hydrocodone. Tr. 264. On
September 6, 2013, M.B. presented with ADD. Tr. 264-65; GX 3 at 46. He
was prescribed Adderall for the ADD, but at double the dosage of the
previous visit without any reported justification. Tr. 264-65.
Dr. Munzing testified that on January 5, 2018, M.B. presented to
the clinic. Tr. 265-66; GX 3 at 37. He was prescribed hydrocodone and
Adderall. There was no medical history, assessment of M.B.'s response
to treatment, evaluation of pain or functioning, substance abuse
history, diagnoses, rationale for establishing a legitimate medical
purpose for prescribing or to justify continuing the medication
regimen. Tr. 265-66. On March 6, 2018, M.B. presented to the clinic
with ``ADD and opioid dependency.'' Tr. 266-67; GX 3 at 36. Absent was
any report of pain. He was diagnosed with ``Opioid dependency, refusing
detox.'' Tr. 267. Hydrocodone as treatment for opioid dependency is not
a legitimate medical purpose and is outside the usual course of
professional practice. Tr. 268. He was prescribed hydrocodone, which
not only is outside the standard of care, but is illegal in
California.\*G\ Tr. 267-68. Dr. Munzing observed that the Respondent
prescribed hydrocodone repeatedly to address his diagnosis of opioid
dependency until November 20, 2019. Tr. 268-69. On November 20, 2019,
M.B. presented with ADD and back pain. Tr. 269; GX 3 at 27. He was
prescribed Adderall, and his hydrocodone was increased. Tr. 270. No
medical history was taken or updated. No response to treatment or
patient functionality was included. Although vital signs were taken, no
physical or mental exam was performed. Tr. 270-71. There was no
appropriate diagnosis for the back pain. Tr. 272. There was no
evaluation for ADD, such as mental functioning. Tr. 271, 274, 287-88.
The Respondent never obtained a sufficient history to support the
diagnosis for ADD. Tr. 273. There was no appropriate diagnosis for ADD.
Tr. 272.
---------------------------------------------------------------------------

\*G\ As written, this language suggests that there is a specific
California law prohibiting hydrocodone prescriptions for individuals
who are opioid dependent and refusing detox. The Government did not
introduce specific evidence of any such law. However, the
Government, through Dr. Munzing's testimony, has established that
opioid dependency is not a legitimate medical purpose for
prescribing hydrocodone and that such prescriptions are outside the
usual course of professional practice. Furthermore, the Government
has established that prescribing without a legitimate medical
purpose and outside of the usual course of professional practice is
a violation of Cal. Health & Safety Code Sec. 11153(a).
Accordingly, I agree that the conduct is illegal and have moved the
sentence for clarity.
---------------------------------------------------------------------------

[Dr. Munzing, in summary, testified that Respondent never took a
proper medical or mental health history and never conducted a
sufficient physical or mental health examination for M.B.'s relevant
diagnoses; therefore, he never made an appropriately supported
diagnosis. Tr. 273-74. Accordingly,] the Respondent never established a
legitimate medical purpose to prescribe either hydrocodone or Adderall
to M.B. throughout the reported treatment. Tr. 274. Dr. Munzing opined
that such prescriptions were not issued in the usual course of
professional practice, were not for a legitimate medical purpose, and
were outside the standard of care. Tr. 274-75.
Dr. Munzing noted the inconsistency of the various diagnoses.
Diagnoses would come and go within the records. Tr. 275-278; GX 3 at
35, 37, 43, 67. Although the recorded diagnoses were always treated
with hydrocodone, the diagnoses varied greatly; [in 2009, it was
prescribed for shoulder pain, in 2013, it was prescribed for neck pain,
in 2014, it was prescribed for back pain, in 2018, it was prescribed
for opioid dependency, and sometimes there was no diagnosis whatsoever
given for the hydrocodone prescribed. Tr. 275-78.] Yet no explanation
for the changing diagnoses is included in the file, as required by the
standard of care. Tr. 278-80.
Dr. Munzing noted the serious dangers occasioned by the combination
of Adderall and hydrocodone by reference to his testimony regarding
S.B.'s similar prescriptions.\7\ Tr. 281. Dr. Munzing deemed this
combination of medications for over ten years inappropriate and unsafe.
Tr. 284. The only semblance of a warning to M.B. regarding these
dangerous combinations appeared in a 2009 ``Controlled Substance
Therapy Agreement.'' For the same reasons as Patient S.B., Dr. Munzing
deemed the signed form wholly insufficient to satisfy the California
standard of care in this regard. Tr. 281-82; GX 3 at 92. Similarly, the
notation within the file, ``SED'' was insufficient to satisfy the
standard of care. Tr. 283. Dr. Munzing also testified that there was
never a UDS ordered for M.B., which was necessary under the standard of
care for any patient receiving opioids, but especially for a patient
who has refused opioid detox. Tr. 284-85. A patient diagnosed with
opioid dependency and refusing detox is also a red flag of abuse and
diversion. Such red flag was not appropriately addressed by the
Respondent repeatedly as to M.B. Tr. 285-87; GX 3 at 36.
---------------------------------------------------------------------------

\7\ On September 29, 2017, and monthly from July 2018, to July,
2019, S.B. was prescribed hydrocodone and Adderall. Besides the
serious risk of addiction posed by these two Schedule II
medications, the hydrocodone was prescribed at a daily dosage of 60
mg MME, which significantly increases the risk of overdose and
death. This risk was increased by its combination with Adderall. Tr.
206-07. Dr. Munzing could not foresee a medical condition in which
this combination would be appropriate. Tr. 211-12.
---------------------------------------------------------------------------

[Dr. Munzing, summarizing his opinions based on his review of the
entire file for M.B., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for M.B.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded M.B.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with M.B., never
appropriately monitored M.B. for medication compliance and failed to
appropriately respond to red flags of diversion. Tr. 287-89.
Accordingly, Dr. Munzing opined that each of the relevant prescriptions
Respondent issued to M.B. were issued without a legitimate medical
purpose, outside the usual course of professional practice and beneath
the standard of care in California. Tr. 289-90.]

Patient B.C.

Dr. Munzing reviewed the subject prescriptions, patient file and
CURES report for Patient B.C., which he described as containing ``very
little.'' Tr. 290-92; GDX 3. He opined that the subject controlled
substance prescriptions issued for hydrocodone, Xanax and Adderall,
from January 25, 2017, to December 19, 2019, were all issued outside
the California standard of care. Tr. 290-92, 335-38. B.C. presented on
March 27, 2014, with GAD and back pain. Tr. 293-94; GX 5 at 48, 55.
B.C. was diagnosed with GAD and back pain, refusing detox. He was
prescribed Xanax (6 mg per day) for the GAD, and hydrocodone for the
back pain, refusing detox. Tr. 294. Dr. Munzing reiterated the risks
involved in prescribing 6 mg of Xanax per day. Tr. 295.
The records failed to disclose the minimum history necessary under
the standard of care to appropriately diagnose ``back pain'' and GAD
[or to prescribe controlled substances to treat those conditions.] Tr.
295-96. Other than limited vital signs, the records failed to disclose
the minimum physical examination necessary under the

[[Page 30570]]

standard of care to appropriately diagnose ``back pain,'' or to justify
a hydrocodone prescription. Tr. 296-97. Dr. Munzing could not remember
seeing any prior medical records in the Respondent's subject files. Tr.
297. There were no entries in B.C.'s file indicating physical or mental
functioning. Tr. 298, 335-38. There was no treatment plan indicated.
The Declaration of Pain Medication Use, signed by B.C. at his first
visit, as discussed previously, is insufficient to evaluate B.C. and to
establish informed consent for the controlled substances prescribed.
Tr. 299-300. There was insufficient medical evidence to support either
diagnosis. Tr. 298, 335-38. Accordingly, there was no legitimate
medical purpose for either controlled substance prescription. Tr. 299,
335-38.
B.C. presented on May 20, 2014, with ADD and was prescribed
Adderall. Tr. 301-02; GX 5 at 47. The ADD diagnosis was deficient, as
no history was developed, no mental functioning was assessed, the
medical evidence was deficient, and a treatment plan was lacking. The
Respondent failed to establish a legitimate medical purpose for
prescribing Adderall. Tr. 302. Additionally, starting B.C. on 30 mg of
Adderall twice daily is a very high dosage, and extremely inappropriate
to an Adderall naive patient, which is not developed within the patient
file. Tr. 302-03.
According to Dr. Munzing, B.C. presented on January 25, 2017, with
ADD, opioid dependency and GAD. Tr. 303; GX 5 at 33. He was diagnosed
with ADD for which he was prescribed Adderall, and GAD for which he was
prescribed Xanax (6 mg per day). Tr. 304. Pain levels were not reported
at this visit. The diagnoses were unsupported by sufficient medical
history, medical evaluation, response to treatment, patient
functionality, and medical evidence. Tr. 304-06. He failed to establish
a legitimate medical purpose for both Adderall and Xanax. Tr. 306, 335-
38. The Respondent further diagnosed, ``Opioid dependency, refusing
detox'' for which the Respondent again prescribed hydrocodone. Tr. 306.
Hydrocodone as treatment for opioid dependency is not a legitimate
medical purpose and is outside the usual course of professional
practice. Tr. 307. Prescribing hydrocodone for opioid dependence is not
only outside the standard of care, but it is illegal in California. Tr.
307. A patient diagnosed with opioid dependency and refusing detox is
also a red flag of abuse and diversion. Such red flag was not addressed
by the Respondent repeatedly as to B.C. Tr. 306-07; GX 5, at 33.
On July 31, 2018, B.C. presented with ADD, back pain and GAD. Tr.
308; GX 5 at 28. He was diagnosed with ADD for which he was prescribed
Adderall (60 mg per day), ``back pain, opiate dependent, refusing
detox'' for which he was prescribed hydrocodone, and GAD for which he
was prescribed Xanax (6 mg per day). Tr. 308. There was no medical
history supporting the prescriptions. There was no indication how the
patient was responding to treatment and no indication that a physical
exam was performed to support the diagnoses or justify the
prescriptions. Tr. 308-09, 335-38. There was no reference to pain
levels or physical functionality. Tr. 309-10. There was no reference to
mental functioning with respect to the ADD and GAD diagnoses. Though
three diagnoses were recorded, Dr. Munzing testified that none of them
were appropriate. Tr. 309-10. Neither did Respondent establish a
legitimate medical purpose for the three controlled substance
prescriptions. Tr. 311.
B.C. presented on December 19, 2019, with ADD and back pain, which
were also his diagnoses, and for which he was prescribed Adderall (60
mg per day) and hydrocodone. Tr. 311-12; GX 5 at 20. The record is
lacking documentation of a medical history, any updated medical
history, the patient's state of health, how he is responding to
treatment, a physical exam, pain levels, mental or physical
functioning, appropriate rationale for continued treatment, and
information relating to drug abuse. Tr. 312-13, 335-38. As a result,
the three diagnoses are without sufficient medical evidence. Tr. 313.
Dr. Munzing testified that each of the controlled substance
prescriptions were issued without a legitimate medical purpose, outside
the usual course of professional practice, and beneath the standard of
care. Tr. 313-16, 335-38.
Dr. Munzing noted the inconsistency of diagnoses throughout B.C.'s
records and the dual prescribing of hydrocodone, sometimes for opioid
abuse, sometimes for skeletal pain, and sometimes for both, without
explanation in the record. Tr. 316-19; GX 5 at 31, 32, 33. [Dr. Munzing
explained that it ``would be important to document [what is] going on
here.'' Tr. 318.] Dr. Munzing noted the GAD and ADD diagnoses appear
and disappear within the record, as do their treatment medications
without explanation. Tr. 319-24; GX 5 at 27, 31, 32, 33. Dr. Munzing
deemed it highly unlikely that ADD and GAD were appropriate
diagnoses.\*H\ Tr. 322, 324.
---------------------------------------------------------------------------

\*H\ Dr. Munzing's opinion regarding the credibility of any
assigned diagnosis is not particularly relevant to my analysis.
Here, the standard of care requires that a diagnosis be based on a
patient's history and physical examination. See infra, The Standard
of Care for Prescribing. Accordingly, where, as here, Dr. Munzing
has testified that the diagnosis was not adequately supported by the
patient's history and physical examination, then I find that, based
on his expert testimony, the diagnosis is inadequate to serve as the
basis for the prescribed prescriptions. This is true whether or not
a practitioner acting in the usual course of professional practice
could have properly reached the same diagnosis for that individual.
---------------------------------------------------------------------------

Dr. Munzing also testified that the Respondent prescribed B.C. a
combination of hydrocodone, Adderall and Xanax. Tr. 327; GDX 3. Dr.
Munzing could not conceive of a medical condition warranting this
dosage, duration, and combination of medications, noting Adderall is
counter-indicated for GAD, and combining Xanax with an opioid
represents a dangerous combination that is contrary to an FDA black box
warning and CDC guidance. Tr. 327-29, 332-33; GDX 3. A further concern,
as detailed earlier in his testimony, is reflected by the repeated
combination of hydrocodone and Adderall by the Respondent. Tr. 329-30;
GDX 3. These dangerous combinations were prescribed without an
established legitimate medical purpose, outside the usual course of
professional practice, without sufficient warnings and informed
consent, without sufficient patient monitoring, and without regard to
obvious red flags. Tr. 330-35.
[Dr. Munzing, summarizing his opinions based on his review of the
entire file for B.C., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for B.C.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded B.C.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with B.C., never
appropriately monitored B.C. for medication compliance and failed to
appropriately respond to red flags of diversion. Tr. 335-37.
Accordingly, Dr. Munzing opined that each of the relevant prescriptions
Respondent issued to B.C. were issued without a legitimate medical
purpose, Tr. 330, outside the usual course of professional practice and
beneath the standard of care in California. Tr. 330, 338.]

[[Page 30571]]

Patient J.C.

Dr. Munzing reviewed the subject prescriptions issued from January
16, 2018, to December 30, 2019, patient records and CURES data relating
to Patient J.C. Tr. 381-82; GDX 4. Dr. Munzing opined that none of the
subject prescriptions issued to J.C. were issued within the California
standard of care. Tr. 382. J.C. presented to the Respondent's clinic on
May 18, 2009, with a headache and GAD. Tr. 383-384; GX 7, at 216, 233.
He was prescribed hydrocodone for migraine and Xanax for GAD and
remained on this medication regimen for a long period. As to the
migraine diagnosis, insufficient medical history was obtained, symptom
evaluation was absent, no neurological exam was conducted, no
evaluation of functioning level was made, no treatment plan was
evident, and no evaluation of possible drug abuse was provided. Tr.
384-90. In short, there was insufficient medical evidence to support
the diagnoses of migraines and GAD, nor was there a legitimate medical
purpose to prescribe hydrocodone and Xanax. Tr. 386-88.
[On August 17, 2009, J.C. signed a ``Declaration of Pain Medication
Use'' form indicating that he had no prior drug abuse, and Dr. Munzing
testified that there is no record of J.C. ever being asked about
illicit substance abuse again. Tr. 389-90. Dr. Munzing testified that
the 2009 Declaration was an insufficient inquiry to cover Respondent's
prescribing during the relevant period. Id.]
J.C. presented on July 21, 2016, with ``GAD, chronic back pain,
consented for H&P.'' Tr. 390; GX 7 at 189. He was diagnosed with GAD
and back pain--refusing detox for which he was prescribed Xanax and
hydrocodone, respectively. Tr. 390-91. There was no updated history
taken for either diagnosis, no physical exam, no treatment plan, no
response to treatment, no pain or functioning level evaluations, no
discussion regarding drug abuse, and no rationale for continued
treatment, as required by the standard of care. Tr. 390-94. There was
deficient medical evidence to support either diagnosis. The Respondent
did not establish a legitimate medical purpose to prescribe the
controlled substances. Tr. 393-94. J.C. presented on January 16, 2018,
with GAD and back pain for which he was diagnosed with GAD and back
pain, opiate dependent, refused detox. Tr. 394-95; GX 7 at 180. He was
prescribed Valium for the GAD (Klonopin was discontinued), and
hydrocodone for back pain, although no explanation was given for
substituting the Valium for the Klonopin. Tr. 395. There was no medical
history included in the records, no response to treatment, no physical
exam, no pain or functioning evaluation, no drug abuse history,
rendering each diagnosis inappropriate. Tr. 395-97. Without a
legitimate medical purpose, there was no appropriate rationale for
continued treatment with controlled substances. Tr. 396-98. J.C.
presented on February 16, 2018, with ``opioid dependency, GAD,'' yet
without the previously noted back pain. Tr. 398; GX 7, 9. There was no
reference to pain. He was diagnosed with ``Opioid dependency, refusing
detox'' for which he was prescribed hydrocodone, which again, is
outside the usual course of professional practice and illegal in
California. Tr. 398-400. The diagnosis for opioid dependency that was
treated with hydrocodone appeared repeatedly in the records. Tr. 399.
J.C. presented on May 6, 2019, however no treatment notes for this
visit are evident in the file. Tr. 401; GX 4, GX 7 at 168.
On April 9, 2019, J.C. presented with GERD and back pain for which
he was prescribed hydrocodone. Tr. 402. However, there was no medical
history included in the records, no response to treatment, no adequate
physical exam, no pain or functioning evaluation, no mental health
history, and no drug abuse history, which rendered the back pain
diagnosis inappropriate. Tr. 402-04. Without a legitimate medical
purpose, there was no appropriate rationale for continued treatment
with controlled substances. Tr. 402-04. On December 30, 2019, J.C.
presented with GERD and GAD. Tr. 404; GX 7, p. 171. He was prescribed
Valium for the GAD. However, there was no appropriate medical history
included in the records, no response to treatment, no documented
evaluation for GAD or functioning evaluation, no mental health history,
and no drug abuse history, rendering the GAD diagnosis inappropriate
from January 16, 2018, to December 30, 2019. Tr. 404-08, 425-28.
Without a legitimate medical purpose, there was no appropriate
rationale for continued treatment with controlled substances. Tr. 408,
425-28. Such prescriptions, from January 16, 2018, to December 30,
2019, were issued outside the standard of care, without legitimate
medical purpose and outside the usual course of professional practice.
Tr. 408, 425-28.
Dr. Munzing noted the inconsistency of diagnoses throughout J.C.'s
records, and the dual prescribing of hydrocodone for opioid abuse,
migraines, and for skeletal (sometimes neck, sometimes back) pain,
without documenting an explanation for the changes in the record. Tr.
410-14; GX 7 at 188, 189, 205, 214, 215. [There was never any
discussion regarding ``where one condition was going and another was
coming from'' as Dr. Munzing agreed ``would be important for a
practitioner acting within the standard of care to understand'' and to
document. Tr. 414.] Dr. Munzing noted the skeletal pain diagnoses
appears and disappears within the record. Tr. 414-15. Dr. Munzing
suspected the skeletal pain complaints were not legitimate. Tr. 415; GX
7 at 188, 189, 205, 214, 215. Dr. Munzing noted the Respondent had
prescribed a combination of hydrocodone and Valium monthly between
January 2018 and January 2019 without a legitimate medical purpose. Tr.
416-17; GX 4. Combining Valium with an opioid represents a dangerous
combination and is contrary to an FDA black box warning and to CDC
guidance, especially with the Valium at its highest available strength.
Tr. 417. Dr. Munzing could not envision a condition for which this
medication regimen would be appropriate treatment. Tr. 418. These
dangerous combinations were prescribed without an established
legitimate medical purpose, outside the usual course of professional
practice, without sufficient warnings and informed consent, without
sufficient patient monitoring,\*I\ and without addressing obvious red
flags. Tr. 418-23; GX 7 at 19, 25, 27, 180, 225.
---------------------------------------------------------------------------

\*I\ Dr. Munzing testified that given the prescribed combination
of medications and how ``highly sought after [they are] in the drug
abusing community,'' it would have been ``[v]itally important'' to
conduct appropriate ongoing monitoring, which was not done and was
therefore outside the standard of care here. Tr. 421.
---------------------------------------------------------------------------

[Dr. Munzing, summarizing his opinions based on his review of the
entire file for J.C., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for J.C.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded J.C.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with J.C., never
appropriately monitored J.C. for medication compliance and failed to
appropriately respond to red flags of diversion. Tr. 424-27.
Accordingly, Dr. Munzing opined that each of the relevant prescriptions
Respondent issued to J.C. were issued without a legitimate medical
purpose, outside the usual course of professional

[[Page 30572]]

practice and beneath the standard of care in California. Tr. 428.]

Patient D.D.

Dr. Munzing reviewed the subject prescriptions issued from January
4, 2018, to February 12, 2019, patient records and CURES data relating
to Patient D.D. Tr. 428-29; GDX 5. Dr. Munzing opined that none of the
subject prescriptions issued to D.D., which were for hydrocodone, Soma,
and Xanax, were within the California standard of care. Tr. 430. Again,
the records contained ``very little information.'' Tr. 429. D.D.
presented on July 9, 2008, with GAD and back pain. Tr. 430-31 GX 9 at
74. For the GAD, he was prescribed Valium. For back pain, he was
prescribed hydrocodone and Soma. Tr. 431. The medical records reflect
that D.D. refused an MRI and refused referral to orthopedist or a pain
specialist. Tr. 431. According to Dr. Munzing, each refusal is a red
flag, and suggestive of drug-seeking behavior. Tr. 432. [``Those are
huge red flags. [For] someone who truly wants to be treated for back
pain to be refusing kind of ways to try to improve that or to better
diagnose it through an MRI or an evaluation from a subspecialist are
just enormous red flags and certainly brings in the distinct
possibility [he] is here seeking drugs rather than really trying to get
his pain managed.'' Tr. 432.] Instead of addressing the red flags, the
Respondent prescribed opioids. Tr. 432. The Respondent's response was
the same throughout the subject treatment of D.D., a total of nine and
a half years. Tr. 433.
According to Dr. Munzing, there was no appropriate medical history
included in the records, no response to treatment, no physical exam,
insufficient patient monitoring, no evaluation for GAD, no functioning
evaluation, no mental health history, no drug abuse history, no
discussion of risk factors and informed consent, and no patient
monitoring, rendering the GAD and back pain diagnoses inappropriate
from July 9, 2008, to January 4, 2019. Tr. 433-38; GX 9 at 37, 39, 41,
43, 44. Without a legitimate medical purpose, there was no appropriate
rationale for continued treatment with controlled substances. Tr. 434-
48. Such prescriptions, from July 9, 2008, to January 4, 2019,\*J\ were
issued outside the standard of care, without legitimate medical purpose
and outside the usual course of professional practice. Tr. 434-48.
---------------------------------------------------------------------------

\*J\ Only the prescriptions issued between January 4, 2018, and
February 12, 2019, were alleged in the OSC and are relevant to my
decision.
---------------------------------------------------------------------------

[On January 11, 2019, D.D. was diagnosed with GERD and ``back
pain--opiate dependent refusing detox.'' Tr. 439. This is the last time
Respondent prescribed D.D. both hydrocodone and Soma, but the medical
records again reflected a lack of appropriate medical history, response
to treatment, an appropriate physical examination, assessment of pain
or physical functionality, an appropriate diagnosis, or an established
legitimate medical purpose for the prescriptions. Tr. 439-40. On
February 12, 2019, Respondent prescribed D.D. hydrocodone to treat
opioid dependency--refusing detox without there being any mention of
pain. Dr. Munzing testified that this was outside the standard of care
for all of the reasons he had previously testified. Tr. 441-42. Dr.
Munzing testified that at no point during the treatment period did
Respondent ever obtain a sufficient history to establish a diagnosis
for back pain or support prescribing of hydrocodone and that the
prescriptions for hydrocodone and Soma were not issued within the usual
course of professional practice and were outside the standard of care.
Tr. 443-44.'']
Dr. Munzing noted a period of over a year when no diagnosis for GAD
appeared in D.D.'s records, from May 10, 2017, to September 19, 2018,
and the 30 mg daily dose of Valium was stopped. Tr. 447-48. Then on
September 19, 2018, the Respondent was placed on 6 mg of Xanax, which
is a very high dosage especially for the beginning dosage. [Dr. Munzing
testified that Respondent failed to obtain sufficient medical evidence
upon which to base a GAD diagnosis. Tr. 446.] Compounding this
dangerous dosage of Xanax, D.D. was prescribed hydrocodone in
combination, which heightened the risk of overdose [without any warning
from Respondent regarding the dangers of the controlled substances
being prescribed.] Tr. 446, 448-50, 458. [Dr. Munzing testified that
there was no established legitimate medical purpose for prescribing
Xanax to D.D. Tr. 446.]
Dr. Munzing noted the inconsistency of diagnoses throughout D.D.'s
records and the dual prescribing of hydrocodone and Soma for
fibromyalgia, opioid abuse, and skeletal pain (namely back pain or neck
pain), without a documented explanation in the record. Tr. 450-56; GX 9
at 43, 51, 64, 70; GDX 5. Dr. Munzing noted the skeletal pain diagnoses
appear and disappear within the record. Tr. 450-56. Dr. Munzing
suspected the skeletal pain complaints were not legitimate. Tr. 456; GX
9 at 43, 51, 64, 70. Prescribing Soma with hydrocodone presents
considerable risks to the patient. Each are respiratory depressants,
which presents a significant risk of overdose, [and each is highly
abused.] Tr. 458. [Dr. Munzing also reiterated the risks of prescribing
both hydrocodone and Xanax together. Tr. 458. Dr. Munzing testified
that in 2009, D.D. signed ``the same controlled substance therapy
agreement we've seen with the previous four patients,'' and it was
insufficient notice of the risks of using controlled substances for the
reasons already discussed. Tr. 458-59. Dr. Munzing further testified
that the record is lacking any documentation that Respondent adequately
warned D.D. of the risks of the controlled substances he was taking,
particularly in light of the various combinations and high dosages. Tr.
459-60.]
D.D. presented on March 23, 2019, with opioid dependency, refusing
detox, which is a red flag. He was again prescribed hydrocodone and
Soma. Tr. 463; GX 9 at 42, 43. [Dr. Munzing reiterated his testimony
that hydrocodone is not an appropriate treatment for opioid dependency
and added that neither is Soma. Tr. 454-55. Accordingly, Dr. Munzing
testified, every relevant prescription for hydrocodone and/or Soma that
was issued to treat opioid dependency was issued outside the standard
of care. Tr. 455.] The Respondent failed to address this red flag
repeatedly, instead prescribing Soma and hydrocodone. Tr. 465.
[Dr. Munzing, summarizing his opinions based on his review of the
entire file for D.D., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for D.D.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded D.D.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with D.D., never
appropriately monitored D.D. for medication compliance and failed to
appropriately respond to red flags of diversion. Tr. 465-68.
Accordingly, Dr. Munzing opined that each of the relevant prescriptions
Respondent issued to D.D. were issued without a legitimate medical
purpose, outside the usual course of professional practice and beneath
the standard of care in California. Tr. 468.]

Patient J.M.

Dr. Munzing reviewed the subject prescriptions and fill stickers
issued from January 10, 2017, to December 31,

[[Page 30573]]

2019, patient records and CURES data relating to Patient J.M. Tr. 469-
70; GDX 6. [Again Dr. Munzing testified there was ``very little
information'' in the patient's medical records. Tr. 470.] Dr. Munzing
opined that none of the subject prescriptions issued to J.C., namely
for hydrocodone, Xanax and Soma, were issued within the California
standard of care. Tr. 470-71.
On May 13, 2007, J.M. presented with hypertension, back pain, GAD,
dyslipidemia and insomnia. Tr. 470-72; GX 7 at 104, 111. He was
diagnosed with hypertension, back pain, GAD, dyslipidemia and insomnia.
He was prescribed hydrocodone for back pain and Xanax (6 mg per day)
for GAD. Tr. 472. Xanax and hydrocodone were recurring prescriptions.
As discussed, the high dosage of Xanax was a concern to Dr. Munzing, as
well as its combination with an opioid. Tr. 473.
According to Dr. Munzing, there was no appropriate medical history
included in the records, no response to treatment, no physical exam of
the back or other areas of issue, insufficient patient monitoring, no
evaluation for GAD, no treatment plan, no pain or functioning
evaluation, no mental health history, no ongoing drug abuse history or
monitoring, no discussion of risk factors and informed consent, and no
patient monitoring, which rendered the GAD and back pain diagnoses
inappropriate from May 13, 2007, to January 13, 2017. Tr. 473-76, 478,
481-83, 485-500. The MRI dated May 30, 2007, and its ``mild'' findings,
did not independently satisfy the Respondent's obligations or justify
the subject prescriptions. Tr. 479-80, 485-87; GX 11 at 14, 16, 17, 22,
26, 31, 37, 41, 42, 115. [Dr. Munzing testified that for the five
visits between January 10, 2017, through March 27, 2017, there is so
little documentation that Dr. Munzing cannot tell whether the records
reflect ``actual visits'' or just ``documentation of a refill of the
medication.'' Tr. 482-85. This is because, according to Dr. Munzing,
the records lack examination or history notations, documentation of the
dose or strength prescribed, diagnoses, nothing to meet the standard of
care for prescribing hydrocodone and Xanax for that period. Tr. 482-85.
The first prescription for Soma during the relevant time period was
on April 13, 2017, and according to Dr. Munzing, the medical note said
``Xanax number 90, Soma number 50SED, and then a signature'' with
absolutely nothing else recorded and none of the elements of the
standard of care met. Tr. 485-86. Dr. Munzing testified specifically
about selected office visits. On April 25, 2018, Respondent's records
for J.M. contain information suggesting an office visit occurred, but
they continue to have the same deficiencies. That day, J.M. was not
diagnosed with pain, but with GAD and opioid dependence--refusing
detox, which was treated with hydrocodone. Tr. 487. Dr. Munzing
reiterated his concern that hydrocodone is not appropriate treatment
for opioid dependence and was inappropriate each time it was prescribed
for that purpose. Tr. 488. Dr. Munzing testified about the November 19,
2018 visit during which J.M. was prescribed Xanax for GAD and Soma for
back pain; the February 20, 2019 visit during which he was prescribed
Xanax for GAD and hydrocodone for back pain; and the December 31, 2019
visit during which he was prescribed Xanax for GAD and was not
diagnosed with back pain. Tr. 489, 492-93, 495. Dr. Munzing again
testified, amongst other things, that for each of these visits, there
was an insufficient medical history or physical examination to make the
diagnoses, there was no information regarding the response to
treatment, pain level, or functionality, and there was no legitimate
medical purpose established for the prescriptions at issue. Tr. 489-91,
493-97.] Without a legitimate medical purpose, there was no appropriate
rationale for the controlled substance prescriptions, or to continue
treatment with controlled substances. Tr. 473-76, 478, 485-500, 505;
GDX 7.
There were also red flags left unaddressed by the Respondent. J.M.
refused to see a pain specialist, which gives rise to the suspicion
that he is not concerned about getting better, but just getting
medicated. Tr. 476-77.\*K\ Dr. Munzing noted that there were gaps in
prescribing hydrocodone and Soma without any required explanation for
changes to the medication regimen. Tr. 500-04; GX 11 at 36, 37, 40, 41,
42, 76. He observed that the hydrocodone was prescribed either for back
pain or for opioid dependence. Tr. 504. However, as with the other
patients, the required evaluation for the diagnoses coming and going
and explanation for treatment is lacking. This further diminishes any
medical legitimacy for prescribing hydrocodone. Tr. 504.
---------------------------------------------------------------------------

\*K\ Omitted for relevance.
---------------------------------------------------------------------------

Additionally, on multiple occasions the Respondent prescribed a
very addictive and dangerous combination of medications including an
opioid and a benzodiazepine. Tr. 558-60. Even more concerning, he added
a muscle relaxant, to this already dangerous combination to form the
``Holy Trinity,'' which is a favorite drug combination for abuse. Tr.
505-10. Dr. Munzing could not conceive of a medical condition in which
the trinity combination would represent appropriate treatment. Tr. 512.
This trinity of medications was prescribed to J.M. repeatedly. GDX 6.
The file fails to reveal whether appropriate warnings were given to
J.M. in connection with this dangerous combination. Tr. 511; GX 11 at
113. The CURES report reveals that 40 Xanax prescriptions (totaling
3600 dosage units and 7200 mgs) were issued to J.M. over a period of 22
months between January 2017 and November 2018. This means that
Respondent was issuing a Xanax prescription to Respondent every 16 days
on average for an average total of 10.5 mgs per day. Tr. 512-17, 527-
28; GX 7, 17, 18. Ten and a half mgs per day is considerably greater
than the maximum 4 mg per day recommended for treatment of anxiety. The
CURES report lists two different dates of birth for J.M., as well as
two different spellings of his first name. Tr. 517-18, 547-49; GX 18. A
CURES search would be name and date of birth specific, so a search by
one name and date of birth would not reveal prescriptions filed under
the alternate name and date of birth. Tr. 526. The main sources of the
CURES report information are two pharmacies, Reliable Rexall and
Northridge Pharmacy. Tr. 518-19. Despite the fact that J.M. was using
different names and dates of birth at different pharmacies, which was a
considerable red flag suggesting abuse or diversion, the Respondent did
not address these issues. Tr. 519-20, 525-26. Even if J.M. or the
pharmacies were the source of the alternate dates of birth and
alternate first names, with due diligence, the Respondent would have
discovered that a search by a single name and date of birth would only
include half of the Xanax prescriptions the Respondent issued to J.M.
Tr. 521-26, 549-50. [Dr. Munzing testified that there is ``nothing in
the notes'' addressing this red flag.'' Tr. 550.] Additionally, two
prescriptions, one written by the Respondent and one called in by the
Respondent on the same day, contain two different dates of birth. Tr.
533-34.
The CURES report also reveals J.M. was alternating the filling of
the Xanax prescriptions between the two pharmacies--which could
indicate that he was trying to hide the bi-monthly frequency of the
prescriptions. Tr. 520; GX 17, 18. Dr. Munzing noted this was a
suspicious prescribing practice by the Respondent. Tr. 530; GX 17, #
425 & 575.\8\ He would issue two prescriptions

[[Page 30574]]

on the same day to J.M., one for hydrocodone and one for Xanax. He
would issue a written prescription for hydrocodone, which J.M. would
invariably fill at Northridge Pharmacy, but would call in the Xanax
prescription to Reliable pharmacy. Tr. 531-33, 535-45, 550-58; GX 11 at
32, 33, 35, 36, 38, 40, 41, GX 12 at 5, 6, 10, 11, 14, 22, 24, 27, 33,
34; GX 13, at 20, 25, 27, 32, 34; GX 17, 18 #473, #474, #994, #1120,
#1228, #1386, #1472, #1553, #2102, #2229, #2341, #2342. Dr. Munzing
testified that this could have been an attempt to avoid the suspicion
generated by the opioid/benzodiazepine combination if filled at a
single pharmacy. Tr. 532-33, 557-60. There was an additional suspicious
circumstance related to a Xanax prescription. The Respondent wrote in
his medical notes that the medication should be taken once every eight
hours, but the call-in information to the pharmacy was once every six
hours. Tr. 543-45, 554, 556-57. [Dr. Munzing testified ``[there is] not
consistency between what [Respondent is] telling the pharmacist and
what [he is] documenting in the progress note.'' Tr. 545.]
---------------------------------------------------------------------------

\8\ These are prescription numbers.
---------------------------------------------------------------------------

The red flag of refusing to detox was repeatedly evident within
J.M.'s patient file. Tr. 562; GX 11 at 37. He was diagnosed with
``Opioid dependency, refusing detox'' for which he was prescribed
hydrocodone, which again, is outside the usual course of professional
practice and illegal in California. Tr. 563-64. The diagnosis for
opioid dependency being treated with hydrocodone appeared repeatedly in
the records. The Respondent never addressed this red flag. Tr. 564.
[Dr. Munzing, summarizing his opinions based on his review of the
entire file for J.M., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for J.M.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded J.M.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with J.M., never
appropriately monitored J.M. for medication compliance and failed to
appropriately respond to red flags of diversion. Tr. 564-67.
Accordingly, Dr. Munzing opined that each of the relevant prescriptions
Respondent issued to J.M. were issued without a legitimate medical
purpose, outside the usual course of professional practice and beneath
the standard of care in California. Tr. 567-68.] \*L\
---------------------------------------------------------------------------

\*L\ This text replaces the ALJ's summary paragraph for
consistency.
---------------------------------------------------------------------------

Patient K.S.

Dr. Munzing reviewed the subject prescriptions and fill stickers
issued from January 19, 2018, to January 31, 2019, patient records and
CURES data relating to Patient K.S. Tr. 469-70; GDX 8. [Again Dr.
Munzing testified there was ``very little'' information in the medical
records. Tr. 569.] Dr. Munzing opined that none of the subject
prescriptions issued to K.S., namely hydrocodone, Xanax and Adderall,
were issued within the California standard of care. Tr. 568-70. K.S.
presented on June 21, 2007, with ``back pain'' for which he was
prescribed hydrocodone and Soma. Tr. 570; GX 13 at 117. Although the
Respondent noted he would get an MRI for the lumbar spine, no such MRI
appears in the records. Tr. 571. There was no medical history included
in this record regarding back pain, no treatment plan, no response to
treatment, no physical exam of the back or musculoskeletal area, no
pain or functioning evaluation, no ongoing drug abuse history,
rendering the back pain diagnosis inappropriate. Tr. 570-74. Without a
legitimate medical purpose, there was no appropriate rationale for
continued treatment with controlled substances for back pain. Tr. 571-
74.
[On August 5, 2009, K.S. signed a ``Declaration of Pain Medication
Use'' form indicating that he had no prior drug abuse, and Dr. Munzing
testified that there is no record of K.S. ever being asked about
illicit substance abuse again. Tr. 575. Dr. Munzing testified that the
2009 Declaration was an insufficient inquiry to cover prescribing at
any point in time when Respondent was treating K.S. Tr. 576.]
On May 1, 2012, K.S. presented with GAD and neck pain. Tr. 576; GX
14 at 80. He was diagnosed with GAD and neck pain, and prescribed Xanax
for GAD and hydrocodone for the neck pain, refusing detox. Tr. 577.
K.S. was prescribed a combination of hydrocodone and Xanax frequently
throughout his treatment. This combination of an opioid and a
benzodiazepine is dangerous, beneath the standard of care and
represents a red flag unresolved by the Respondent throughout the
records. Tr. 578-79. There was no medical history supporting the
prescriptions. There was no indication of how the patient was
responding to treatment. There was no treatment plan and no indication
a physical exam was performed to support the diagnoses or justify the
prescriptions. Tr. 579-81. There was no reference to pain levels or
physical functionality. There was no reference to mental functioning
with respect to the GAD diagnosis. There was no appropriate diagnosis
for the GAD and neck pain. Respondent did not establish a legitimate
medical purpose for the controlled substance prescriptions. Tr. 580-81.
According to Dr. Munzing, K.S. presented on November 18, 2013, and
was prescribed Adderall (60 mg per day) with no documented evaluation
for or diagnosis of any condition that Adderall may treat. Tr. 581-82;
GX 14 at 70. There is also no medical history, physical exam, or
treatment plan, and accordingly, the subject prescription is without a
legitimate medical purpose.\*M\ Tr. 582.
---------------------------------------------------------------------------

\*M\ This sentence was modified for clarity.
---------------------------------------------------------------------------

On January 19, 2018, K.S. presented with GAD, back pain and
ADD.\*N\ Tr. 583, 599; GX 14 at 41. For GAD, the Respondent prescribed
Xanax. For back pain--opioid dependent, refusing detox, the Respondent
prescribed hydrocodone; and for ADD, Adderall. Tr. 584. The record is
missing any medical history, any updated medical history, the patient's
state of health, how he is responding to treatment, a physical exam,
pain levels, mental or physical functioning assessment, appropriate
rationale for continued treatment, and information relating to drug
abuse. Tr. 583-86. As a result, the treatment is without sufficient
medical evidence. Tr. 584-86. Accordingly, the subject charged
prescriptions are without a legitimate medical purpose. Tr. 586.
---------------------------------------------------------------------------

\*N\ Dr. Munzing testified that Respondent did not obtain
sufficient medical evidence to diagnose K.S. with ADD at any point
between the November 2013 visit and the January 2018 visit. Tr. 583.
---------------------------------------------------------------------------

On February 27, 2018, K.S. presented with ADD, opioid dependency
and GAD. Tr. 586-87, 599-600; GX 14 at 39, 40. He was diagnosed with
ADD, opioid dependency-refusing detox, and GAD. Back pain was not
reported, nor was any report of pain made. At the April 30, 2018 visit,
again, back pain was not reported, nor was any report of pain made. Tr.
601. Throughout the records, the Respondent failed to explain the
appearance and disappearance of back pain. Tr. 601-02. Again, beneath
the standard of care and against the law in California, K.S. was
prescribed hydrocodone for opioid dependency, which Dr. Munzing
testified was neither appropriate nor legal. Tr. 587-88. On November
28, 2018, K.S. presented with opioid dependency and GAD for which

[[Page 30575]]

he was diagnosed with opioid dependency-refusing detox and GAD, and for
which he was prescribed hydrocodone and Xanax respectively. Tr. 588-
589; GX 14 at 33; GDX 8. Again, beneath the standard of care and
contrary to the law in California, K.S. was prescribed hydrocodone for
opioid dependency. Tr. 588-89. And again, the medication regimen
included the dangerous combination of an opioid and benzodiazepine. The
record is missing any medical history, any updated medical history, the
patient's state of health, how he is responding to treatment, a
physical exam, pain levels, mental or physical functioning, any
evaluation for GAD, appropriate rationale for continued treatment, and
information relating to drug abuse. As a result, the treatment is
without sufficient medical evidence. Tr. 588-89. Accordingly, the
subject charged prescriptions were issued without a legitimate medical
purpose, outside the usual course of professional practice, and beneath
the standard of care. Tr. 590.
On December 11, 2018, K.S. presented with ADD and eczema for which
he was diagnosed with ADD and eczema. Tr. 591; GX 14 at 33. For ADD, he
was prescribed Adderall. [Dr. Munzing testified that the Adderall
prescription lacked a legitimate medical purpose for the same reasons
as the prior prescriptions he had just discussed. Tr. 591-93.] On
January 31, 2019, K.S. presented with and was diagnosed with back pain
and stomatitis. Tr. 593-94; GX 14 at 31. For the back pain he was
prescribed hydrocodone. [Again, Dr. Munzing testified that the
hydrocodone prescription lacked a legitimate medical purpose for the
same reasons as the prior prescriptions he had just discussed. Tr. 594-
95.]
A review of the entirety of K.S.'s subject medical records reveals
that the Respondent never obtained any prior medical records. Tr. 596,
619. The record is missing an adequate prior medical history, any
updated medical history, the patient's state of health, how he is
responding to treatment, a physical exam, pain levels, mental or
physical functioning, any evaluation for GAD, appropriate rationale for
continued treatment, and information relating to drug abuse. As a
result, the treatment is without sufficient medical evidence. Tr. 598-
99, 620. Accordingly, the subject charged prescriptions were issued
without a legitimate medical purpose, outside the usual course of
professional practice, and beneath the standard of care. Tr. 597-98,
619-20.
[Dr. Munzing testified that, similar to the other patients,
Respondent prescribed hydrocodone to K.S. for back pain, then neck
pain, then for opioid dependency, and sometimes for a combination of
these reasons, without any documentation regarding these changes or the
coming and going of the pain issues as would be required by the
standard of care. Tr. 598-602.] Dr. Munzing also noted the
inconsistency of the GAD diagnoses throughout the records. Tr. 602-05;
GX 14 at 31, 42, 47, 48. With the GAD diagnoses appearing and
disappearing within the records and without any explanation, Dr.
Munzing observed there is no medical evidence it was a medically
legitimate diagnosis. Tr. 605-09; GX 8. Similarly, ADD was
inconsistently diagnosed with Adderall inconsistently prescribed. Tr.
605-06; GX 14 at 34, 35; GX 8. With the ADD diagnoses appearing and
disappearing within the records and without any explanation, Dr.
Munzing observed there is no medical evidence it was a medically
legitimate diagnosis. Tr. 609.
Dr. Munzing noted the Respondent prescribed a dangerous combination
of medications, including hydrocodone, Adderall and Xanax, which was
prescribed from January 2018, through August 2018. Tr. 609-10. Dr.
Munzing noted it is referred to by drug abusers as the ``new Holy
Trinity.'' Tr. 610. Additionally, the combination of an opioid and a
benzodiazepine is present in August, October and November 2018. Tr.
610-11. The records fail to reveal that the appropriate warnings were
conveyed to K.S., or that informed consent was obtained. Tr. 611-13; GX
8. Dr. Munzing could not conceive of a medical condition warranting the
dangerous combinations of medications prescribed. Tr. 614. [Dr. Munzing
also noted that Respondent failed to properly monitor medication
compliance, and conducted no urine drug screens, as was required by the
standard of care in California. Tr. 614.]
Dr. Munzing noted the Respondent's failure to resolve red flags,
including K.S.'s diagnosis of opiate dependency with refusal to detox,
the dangerous combinations of medications, and high dosages of
controlled medications. Tr. 615-18, 620; GX 14 at 39, 40, 41. The
refusal to detox is a major red flag for opioid use disorder and for
diversion. However, the Respondent did not take any necessary action,
such as CURES monitoring, UDS, counseling, or titration. Rather, he
simply prescribed the same levels of medications she was on, PRN. Tr.
615-17. The Respondent's course of action was outside the California
standard of care.
[Dr. Munzing, summarizing his opinions based on his review of the
entire file for K.S., testified that Respondent never took a proper
medical or mental health history, never conducted a sufficient physical
or mental health examination for K.S.'s relevant diagnoses, never made
an appropriately supported diagnosis, never recorded K.S.'s pain and
functionality level, never documented an appropriate treatment plan
with goals or objectives, never appropriately documented discussion of
the risks of the prescribed controlled substances with K.S., never
appropriately monitored K.S. for medication compliance and failed to
appropriately respond to red flags of diversion. Tr. 617-20.
Accordingly, Dr. Munzing opined that each of the relevant prescriptions
Respondent issued to K.S. were issued without a legitimate medical
purpose, outside the usual course of professional practice and beneath
the standard of care in California. Tr. 620.
In summarizing the entire body of evidence he reviewed in this
matter, Dr. Munzing opined that each of the controlled substance
prescriptions at issue in this matter were issued ``outside the
standard of care'' and that Respondent's prescribing of high dosages of
these controlled substances ``absolutely'' constituted clear excessive
prescribing. Tr. 621.]

Respondent's Case-in-Chief

The Respondent presented his case-in-chief through the testimony of
one witness, the Respondent, Fares Rabadi, M.D.

Fares Rabadi, M.D.

Dr. Rabadi attended medical school in the former Soviet Union. Tr.
626. He underwent a three-year residency training in internal medicine
at State University of New York School of Medicine and Biomedical
Science in Buffalo, New York. Tr. 627. According to Respondent, he is
currently licensed to practice medicine in New York (inactive),
California, and Indiana. Tr. 627. He has been licensed in California
since September 25, 1998. His first two years practicing in California
were spent working at another medical group. For the past twenty-years
he has had his own practice. Tr. 628. He is a member of the American
Medical Association (AMA), the American College of Physicians, a Master
of the College of Physicians, the American Society of Internal
Medicine, the Los Angeles Medical Association and Arab American Medical
Association. Tr. 628. He is affiliated with the U.S.C. Keck School of
Medicine, and is on the volunteer faculty with the UCLA's David Geffen
School of Medicine. He teaches family

[[Page 30576]]

medicine residents at the Northridge Hospital. Tr. 628-29.
Dr. Rabadi was familiar with the federal regulations, the
California Health and Safety Code, and the California Business and
Professional Code cited in the Order to Show Cause. Tr. 630. Dr. Rabadi
was familiar with the Government Exhibits 1-19 (records relating to the
prescribing to the charged patients), and 20 (The [California] Guide to
the Laws Governing the Practice of Medicine by Physicians and
Surgeons). Tr. 630. He was specifically familiar with pages 59-60
relating to pain management. Tr. 630; GX 20. He was also familiar with
the Guidelines for Prescribing Controlled Substances. Tr. 630; GX 21.
In his medical career Dr. Rabadi has treated thousands of patients,
including hundreds of pain patients. At the time of the issuance of the
Order to Show Cause, Dr. Rabadi had 300-400 patients of which 175-200
were pain management patients. Tr. 631, 792. In both 2017 and 2018, he
estimated he treated 400 to 500 patients. Tr. 803. In 2019, he
estimated he saw 400 patients, and less than 200 in 2020.\9\ Tr. 804.
---------------------------------------------------------------------------

\9\ There was some confusion in the transcript as to the total
number of patients in 2019. The Respondent estimated 400 total
patients for 2019, but later agreed it was approximately 200 total
patients in 2019. Tr. 804. [Respondent also testified at the hearing
that ``I have close to 550-600 patients'' suggesting that was his
total number of patients at the time of the hearing in September
2020. Tr. 792. He testified that he had 175-200 patients who were
specifically pain patients up until the time of the OSC which was
dated March 2020. I note that the exact number of patients that
Respondent was treating at any given time has little relevance to my
decision in this matter, other than as it relates to his ability to
accurately recall the undocumented details of each medical visit to
which he testified.]
---------------------------------------------------------------------------

Dr. Rabadi described his protocol upon a patient's first visit to
his clinic prior to the issuance of a prescription. Tr. 631. The
patient initially fills out paperwork. His office verifies insurance
coverage. The patient is weighed and then sent to an examination room.
Dr. Rabadi enters the room, greets the patient and sits on a stool ``so
[his] eyes are with the same level as the patient's eyes.'' \*O\ Tr.
632. Dr. Rabadi determines how the patient was referred to him. Dr.
Rabadi then takes the patient's history, which begins with the
patient's main complaint. Dr. Rabadi disagreed with Dr. Munzing's
estimate that a diagnosis is 85% based on the patient's history. Dr.
Rabadi believed it was upwards of 95% based on history. Tr. 635-36. The
Respondent conceded history is critical to understanding the patient's
condition and how to treat the patient. Tr. 804. He inquires about
family history and their medical issues. Dr. Rabadi then inquires
regarding social history, surgeries and present pain. He inquires into
habits, such as smoking, and past and present use of illegal drugs. He
then probes any allergies, including allergies to medications. If a
patient has no allergies, he reports NKDA. Tr. 635. Following history,
Dr. Rabadi testified he ``starts going in depth about the main
complaint,'' with an eye toward isolating the ultimate medical source
of the malady, and whether the symptoms are resolved with medication.
Tr. 635-37. Regarding complaints of ``back pain,'' for example, Dr.
Rabadi testified that he will review previous diagnoses, probe the
source and triggers for the pain, explore any nerve restrictions, and
discuss the success of different past treatment methods. Tr. 638-40. If
pain medication management was the only treatment that alleviated the
pain, Dr. Rabadi would explore the history of that treatment and its
efficacy. [Respondent testified that ``after [he] complete[s] the
history in general, and organ-specific where the complaint is, then [he
does the] physical examination.'' Tr. 641.]
---------------------------------------------------------------------------

\*O\ Modified for clarity.
---------------------------------------------------------------------------

Dr. Rabadi testified that the physical exam he performs for all
patients starts with the head. He examines the skull. He explores
headaches, noted in the records as, ``HEENT.'' Tr. 641. He then checks
the eyes, the ears, and the mouth. Tr. 642. He moves down to the neck,
checking for issues with the veins of the neck. He then checks the
efficiency of the heart's pumping and its rhythm. Next, he checks the
lungs. Moving down to the abdominal cavity, he palpates the liver and
spleen for abnormal size. Tr. 643. He then checks the remaining organs
of the abdomen and the bowel for irregularities. Tr. 643. He then
checks the extremities for circulation issues, often noting in the
records, ``No ECC'' (edema, clubbing or cyanosis). He then checks for
skin issues. Finally, he performs a neurological examination, including
a mini mental-state exam and their orientation as to time and space.
Tr. 643-45. He checks their reflexes, their cranial nerves. Tr. 645. He
decides if further radiologic testing is necessary. Tr. 651-52. For men
aged 17-35, he offers a testicular exam to check for cancer. For men
over 50, he offers a rectal exam to determine indications of prostate
and colorectal cancer. The complete exam takes from 30-40 minutes.
Then, Dr. Rabadi formulates his diagnosis, [though he noted that ``the
patient many times comes with a diagnosis already.''] \*P\ Tr. 647. He
then establishes a treatment plan. Tr. 649. He discusses the treatment
plan with the patient and obtains informed consent. Tr. 658. For
patients experiencing pain, he explains the mechanism of pain, the
modalities of pain and the type of pain; chronic pain, acute pain,
malignant pain, post-traumatic pain, rheumatological pain, psychogenic
pain, and neuropathic pain.\10\ Tr. 668. For patients receiving pain
medication prescriptions, Dr. Rabadi explains the medications, their
side effects, including addiction, overdose and death, and cautions
patients not to operate machinery or use heavy equipment. Tr. 668-70.
[When asked whether he had ever prescribed a controlled substance for a
patient without having this discussion about the dangers, he responded,
``Absolutely not. Absolutely not. Absolutely not.'' Tr. 669.] Dr.
Rabadi assures his patients that if they take the medication as
prescribed, they will not overdose. Tr. 670.\11\ He typically sees his
pain patients monthly. Tr. 672.
---------------------------------------------------------------------------

\*P\ At this point in his testimony, Respondent stated, ``[T]he
Government seized more than 223 charts . . . they returned more than
200. . . . And now, they are focusing and fixating on these seven
charts. So, they're just looking at the charts and some notes and
immediately demonizing an astute clinician who's been in the medical
field for 41 years without a blemish to my reputation and career.
And now, I'm just portrayed as I'm just feeding the addicts; I'm
just distributing his medications.'' Tr. 648-49. I note that for the
purposes of this Decision, I presume that all prescriptions issued
by Respondent that are not at issue in this cases were legitimate.
\10\ Dr. Rabadi contrasted these classifications with those he
indicated were described by Dr. Munzing, mild, moderate and severe.
Tr. 667-68.
\11\ As I understand Dr. Rabadi's testimony, Dr. Rabadi noted
that an unnamed study found that dosages 5-6 times higher than that
recommended by the FDA were safe. This highly specific evidence was
not noticed prehearing, was not reasonably anticipated by the
Government, and will not be considered.
---------------------------------------------------------------------------

For return visits, Dr. Rabadi is focused on the specific reason for
their visit. Tr. 673. This explains why Dr. Munzing's noted diagnoses
would appear and disappear from month to month. Tr. 673. Dr. Rabadi
does not make note each month of long-term chronic conditions. Tr. 673.
If a patient has new symptoms, Dr. Rabadi will focus on these new
symptoms and tailor his examination to these symptoms, although at
least two organ systems are always examined. Tr. 674. At least every
three months blood pressure is checked. Tr. 675. Dr. Rabadi explained
that much depends on the physician's judgment. Guidelines are
essentially recommendations. Following the guidelines does not make the
Respondent a good doctor. The most important thing is to perform with
knowledge, with care and in good faith, placing the interest of the
patient as the Respondent's top priority. Tr. 676.

[[Page 30577]]

If patients' symptoms subsided and they did not finish their
medication, Dr. Rabadi would not prescribe more medication. He would
wait until the medication was finished. This explains why prescriptions
would sometimes stop and restart from month to month. Tr. 673.
For patients on pain medication and desiring to continue on pain
medication, he discusses the options of detox and referral to a pain
specialist. Tr. 650. All of his patients on pain medications are
required to sign a ``Controlled Substance Agreement.'' Tr. 658. Dr.
Rabadi also verbally tells patients that they cannot obtain pain
medication from different physicians, and they cannot go to different
pharmacies for refills. Tr. 660. If a patient overdoses, or is arrested
selling medications, he is banned from further treatment. Tr. 660. Dr.
Rabadi has little sympathy for reports of lost or stolen medication.
Tr. 661.
In the United States, the patient ``is in the driver's seat.'' The
patient's wishes are granted unless they are asking for something
illegal or abnormal. Treatment cannot be forced on them. Tr. 650. When
a patient reports that he has received extensive radiologic testing and
has exhausted medical treatment and surgeries for his injury and wishes
to remain on pain medications, the only option is to prescribe those
medications or to drop the patient, which Dr. Rabadi did not view as an
ethical option.*\Q\ Tr. 651. No one deserves to be in pain. Tr. 664-65,
670. If chronic pain patients were dropped from the practice, they may
turn to buying illegal drugs off the street. Tr. 663. Dr. Rabadi was
realistic as to most of his pain patients. Some had been on pain
medications for 10, 15 and 20 years and were chemically dependent on
them. Tr. 662. The goal was not to make them pain free, which would be
impossible. It was to minimize the pain, and maximize their
functionality without making them a slave to the medications. Tr. 662,
664. For acute pain, Dr. Rabadi typically restricted pain medication to
one week. Tr. 662.
---------------------------------------------------------------------------

*\Q\ Respondent testified, ``[i]f the patient tells me, `Look,
I've already been with pain specialists; I've already seen a couple
of specialists; I already had three-four MRIs; I already had
surgery; I'm on this medication for years, and it's working for me,'
then it comes down to one of two options. Either I tell him I will
fill his prescription or I kick him out of my office. And I don't
think it is ethical to do that latter approach.'' Tr. 651.
---------------------------------------------------------------------------

Dr. Rabadi noted that almost all of his patients work full time in
the motion picture industry doing hard labor and suffer serious and
sometimes recurring injuries. Tr. 647, 663. They have had long term
injuries with surgeries, and have been on pain medication for a long
period of time prior to coming to see him, and are still able to
function. Tr. 647-48, 663.
Regarding the use of pain scales in diagnosing, Dr. Rabadi noted
their limitations--it is purely subjective to each patient. Tr. 658-59.
Regarding the high doses of medications he prescribed, Dr. Rabadi
agreed with Dr. Munzing that starting patients on such high doses was
dangerous. Tr. 640. However, if the patients were acclimated to such
high doses, prescribing lower doses would be ineffectual and
potentially dangerous. Tr. 656-58. If Dr. Rabadi was just starting
treatment for ADD, for example, he would start the patient on .25 mg of
Xanax per day. Tr. 657.

Patient S.B.

Patient S.B. remained a patient of Dr. Rabadi's. Tr. 708-09. She
was prescribed hydrocodone, Xanax and Adderall. Tr. 709. Dr. Rabadi
believed his prescription practice concerning S.B. was within the
California standard of care. Tr. 709. Dr. Rabadi began his treatment of
S.B. on August 3, 2016. Tr. 718. She presented as a 29 year-old female
to establish care for the treatment of ongoing conditions of GAD,
fibromyalgia, and ADD. Tr. 719. As per Dr. Rabadi's policy, as detailed
in his earlier testimony, he took a complete history.*\R\ Tr. 719-20.
He performed a complete physical examination [``head to toe including
every organ and system,''] reviewed her existing diagnoses of GAD and
ADD, and her medication history in general and specifically for those
diagnoses. Tr. 720, 722-24. He obtained her pain level with and without
medication. Without medication her subjective pain level was eight.
With medication, it was one to two, which permitted her to function and
perform daily activities. Tr. 721. The Respondent conceded that the
detailed findings of the complete physical exam are not reflected in
his chart, but noted he was a clinician with 41-years of experience,
and not a medical student. Tr. 810. Tr. 810. [He testified that he
inquired regarding any behavioral and psychological issued S.B. might
have. Tr. 722.] Dr. Rabadi noted that patients with ADD are six times
more likely to have other psychiatric conditions as people without ADD.
Tr. 722. Ultimately, Dr. Rabadi concurred with the previous physician's
diagnoses of ADD, GAD, and fibromyalgia. Tr. 724, 728. To obtain
informed consent to prescribe controlled substances to S.B., the
Respondent executed the ``pain management contract.'' Tr. 728-29. The
patient reads it and signs it. The Respondent then goes over the
contract in detail with the patient. The Respondent then explains that
the medications are meant to help the patient, not to cause side
effects or addiction, although they tend to cause chemical dependence.
Tr. 729. The Respondent then goes over all the alternative treatments,
but in the end, it is the patient's decision as to the treatment she
will receive. Tr. 729. If the Respondent objected to every patient's
choice of treatment, there would no medical care. If a patient says she
is on medication and it permits her to function, the Respondent will
continue that treatment. Tr. 729-30. S.B. indicated she had been
through several alternate treatments, including, occupational therapy,
physical therapy, hydrotherapy, yoga and meditation. Tr. 731, 805.
---------------------------------------------------------------------------

*\R\ Respondent testified both generally and specifically to
S.B. that he ``take[s] personally a very lengthy history. [He]
spend[s] close to 60 minutes in the first visit the patient comes.''
Tr. 719, 721.
---------------------------------------------------------------------------

The Respondent conceded the list of prior therapies was not in his
progress notes. Tr. 805-06, 808. The Respondent explained its absence
as maybe he ``did not feel it was crucial to be documented,'' as he
memorizes what the patient tells him.*\S\ Tr. 806. Respondent testified
that including references to prior, concluded treatment was irrelevant
as the prior treatment was concluded and the patient had moved on to
the new treatment. Tr. 807-08. The Respondent testified to S.B.'s prior
treatment from memory. Tr. 808. The Respondent explained that, as he
still maintained handwritten records and saw up to 20 patients a day,
with new patients taking an hour and returning patients taking up to 20
minutes each, he did not have the luxury of documenting in detail. Tr.
807, 849. So, the basic information is reflected in his written notes,
while the rest he remembers; ``I rely on my photographic memory.'' Tr.
808-09. The

[[Page 30578]]

Respondent conceded that ``maybe'' it was ``inappropriate'' of him not
to more thoroughly detail this information in the charts. Tr. 809. But
with handwritten charts he was only able to include the ``main ideas.''
His notes are simply to remind him of the matters. Tr. 810-11. He keeps
his notes as brief as possible to remind him in the future. Tr. 815.
---------------------------------------------------------------------------

*\S\ Respondent testified that, ``the record is probably missing
these things, because maybe at the time of the documentation I did
not feel that was crucial to be documented. As soon as the patient
disclosed that to me, I memorize it. I remember it. You've seen how
several years later I still remember it. . . . I did not feel I have
to clutter my charts with, you know, this information.'' Tr. 806-07.
Respondent further testified that he does not have electronic
medical records, he is ``still writing . . . And when I see 15, 20
patients a day . . . There [are] only 24 hours a day. I don't have
the luxury to write ten pages on each patient. . . . [W]hat's
pertinent, what's your diagnosis, what's your main exam, and what's
your treatment is reflected there. The rest I remember. I don't need
to write it.'' Tr. 807-08.
---------------------------------------------------------------------------

Respondent testified that S.B. further reported that she had been
on the same dosage of medications for several years to good effect. Tr.
731-32. [Respondent testified that ``medically it is very inappropriate
when a patient is stable at [a] certain dose, to start cutting the dose
because [the] patient will regress'' and either] suffer withdrawal
symptoms or have severe pain.*\T\ Tr. 732. Prior to each prescription,
the Respondent discussed side effects, and changes in status. Tr. 733.
---------------------------------------------------------------------------

*\T\ Modified for clarity.
---------------------------------------------------------------------------

The Government sought to test the Respondent's ``photographic
memory'' by asking to confirm that, consistent with his direct
testimony, he only treated S.B. with hydrocodone, Xanax and Adderall.
Tr. 810-13. The Respondent confirmed his direct testimony. Tr. 812. The
Government reminded the Respondent that he prescribed Soma as well,
[but Respondent testified that he did not mention it on direct because
it ``was not [an] ongoing prescription. Maybe the patient got it once
or twice over the course of the years.''] Tr. 813.
Although the Respondent testified he developed a treatment plan for
each of his patients, the Government pointed out, and the Respondent
agreed, that S.B.'s treatment plan and objectives were not documented
in her chart. Tr. 813-14.
Although the Respondent testified he did not introduce any of his
subject patients to controlled substances, the chart reflects he did
prescribe Soma to S.B. for the first time. Tr. 816-17; GX 1 at 61, 62.
The Respondent remembered during cross-examination that, although not
in the chart, S.B. told him she had been on Soma previously. Tr. 817-
19.

Patient J.M.\12\
---------------------------------------------------------------------------

\12\ In transcript pages 734-43, Patient J.M. is discussed.
However, due to some confusion with patient initials, the Respondent
described his treatment of J.M. as M.B. within the transcript. Tr.
774. [All of the questions and responses for pages 734-43 referred
to this patient as ``M.B.''; however the factual information that
was being discussed was actually applicable to ``J.M.'' The error
was not discovered until Respondent was questioned about the patient
whose initials were actually M.B. The parties entered ``a
stipulation that Dr. Rabadi's [prior] testimony as to M.B., the
second patient discussed, is actually applied or attributed to
Patient J.M.'' Tr. 774-75. This exchange did not fill me with
confidence that Respondent's testimony reflected his true
recollection of the specific actions he took with regard to the
specific patient being discussed. Rather, Respondent seemed to
testify to the policies and procedures he followed in the regular
course and assumed that those policies and procedures were followed
with regard to all the named patients.]
---------------------------------------------------------------------------

J.M. has been a patient for thirteen years. Tr. 734. The Respondent
has prescribed him Xanax, Soma and hydrocodone. The Respondent believed
his treatment of J.M. was within the California standard of care. J.M.
first presented on May 14, 2007, with chronic pain syndrome, which
sometimes manifests as back pain, and neck pain, and GAD. Tr. 735; GX
11 at 104. The Respondent took a history. J.M. had been involved in a
motor vehicle accident injuring his back, neck and lumbar spine.
Additionally, he suffered from GAD and hypertension. Tr. 736. The motor
vehicle accident as the source of the injury was not documented. Tr.
853. J.M. had seen an orthopedic surgeon, although it was not
documented in the chart. Tr. 853. Without medication, J.M. reported
severe pain of 10 or 11 of 10. With medication, he reported pain levels
of three of ten, which permitted him to function and to work full time;
the pain levels were not documented in the chart. Tr. 736, 854-55. J.M.
reported prior treatments and medication. He had received physical
therapy, occupational therapy, hypnosis and acupuncture to no avail
prior to turning to chronic pain management, although these previous
therapies were not documented in the chart. Tr. 737, 854. His present
medication protocol delivered the best results with the least side
effects. Tr. 737. The Respondent probed his psychological history,
which included an all-consuming fear.
The Respondent performed a comprehensive physical exam ``head to
toe.'' Tr. 739. To obtain informed consent to prescribe J.M. controlled
substances, the Respondent went over the pain management contract,
which J.M. also read and signed. The Respondent cautioned J.M. about
diversion and red flags of doctor shopping and pharmacy hopping, which
would result in discharge. Tr. 739-40. The Respondent noted that J.M.
is a very well-respected man. He's very well-known in the community.
Tr. 740.\13\ The Respondent then discussed the beneficial aspects of
the pain medication and potential negative effects if abused.
Respondent testified that J.M. never gave any indication he represented
a risk of diversion. Tr. 741. Prior to seeing the Respondent, J.M. was
on a higher MME of opioids. He was able to reduce the dosages to the
level he was on when he first saw the Respondent. He remains on that
dosage. Again, he is able to function and work full-time on this
dosage. Tr. 742. The Respondent noted that J.M. would sometimes try to
avoid taking his medication, even if he suffered pain, as explanation
for the breaks in prescribing. Tr. 743.
---------------------------------------------------------------------------

\13\ J.M.'s prestigious background will not be considered. It is
an unnoticed matter that the government would have no way of
checking or countering. [It is also completely irrelevant to my
decision in this case.]
---------------------------------------------------------------------------

The Respondent denied ever using a different first name for J.M.,
or using a different birth date for him [and attributed any mistake to
the pharmacy.] Tr. 778-82.

Patient B.C.

Patient B.C. has been a patient of the Respondent since March 27,
2014. Tr. 750-51. Patient B.C. has been prescribed hydrocodone, Xanax
and Adderall. Tr. 749. The Respondent obtained a complete history, a
complete physical exam and then probed the complaint that brought him
to the Respondent, which was right shoulder and chronic back pain. Tr.
751. Without medication, B.C. reported pain at seven or eight, and with
medication at one or two. Tr. 752. As far as his medication history,
B.C. had been on pain medication for years following a neurosurgical
procedure to treat a herniated disc with radiculopathy.\14\ Tr. 752. To
obtain informed consent, the Respondent discussed the pain management
contract, which B.C. read and signed. Tr. 752-53. The Respondent then
discussed side effects of the medication [including ``addiction,
overdose, and death.'' Tr. 753.] B.C. is a married man with three
children. He works full time. He gave the Respondent no indication he
was a risk for diversion. Tr. 753.
---------------------------------------------------------------------------

\14\ The Government objected to B.C.'s prior treatment history,
which was not noticed in the RPHS. I ruled it was reasonably
anticipated. The Respondent cited to specific treatment from a prior
physician. The contested evidence is reflected in GX 5 at 14, so the
Government was certainly not surprised by the evidence.
---------------------------------------------------------------------------

Regarding prior alternate treatment, B.C. reported that he has
tried surgery, physical therapy and acupuncture, but that only pain
medication therapy alleviates his pain to the extent he can function.
Tr. 754. At each visit, the Respondent reviewed B.C.'s progress and
believed B.C.'s condition warranted the medication he was prescribed.
Tr. 754, 757. Although the Respondent remembered discussing B.C.'s pain
levels on March 27, 2014, and that it was one or two on medication, he
conceded it was not documented in the

[[Page 30579]]

chart. Tr. 832-34; GX 5 at 48. Although the Respondent remembered B.C.
reporting he had a herniated disc, this report was not documented in
the chart. Tr. 836. Neither were B.C.'s reported prior surgery,
physical therapy, acupuncture, or occupational therapy documented. Tr.
837.

Patient J.C.

Patient J.C. presented on May 18, 2009, with chronic back pain,
ulcerative colitis and GAD. Tr. 759-60, 761-62. He was prescribed
hydrocodone, and Xanax, sometimes substituted with Valium. Tr. 759. The
Government pointed out to the Respondent that there were visits during
which several other controlled substances were prescribed. Tr. 842-46;
GX 7 at 181, 214, 215.
He had suffered multiple injuries, and had been immobile for some
time. However, the Respondent did not document the injuries or the
immobility in the chart, nor did the file contain any prior medical
records.\15\ Tr. 839, 842; GX 7 at 216. He had undergone physical
therapy, occupational therapy, and finally pain management, which
permitted him to resume working full-time. Tr. 760. These alternate
treatments and therapies and prior surgeries were not documented within
the chart. Tr. 840. The Respondent could not remember if J.C. mentioned
his prior surgeries at the first or second visit.*\U\ Tr. 840. The
Respondent performed a full exam on J.C. Tr. 760-61. His GAD resulted
from his ulcerative colitis. Tr. 762.
---------------------------------------------------------------------------

\15\ The Respondent again explained the difficulty in obtaining
prior medical records. Tr. 842.
*\U\ Respondent testified, ``[w]hether he mentioned the surgery
the very first visit, that I cannot tell you yes or no at this point
because it's not in my notes. So I'm just second guessing myself.''
Tr. 841.
---------------------------------------------------------------------------

The Respondent obtained informed consent to prescribe controlled
substances by explaining the pain contract; afterwards, J.C. read it
and signed it. Tr. 763. The Respondent explained the dangers of
overdose. Tr. 764. The Respondent had no concerns about J.C. diverting
his medication. Tr. 764-65. On the basis of J.C.'s considerable
injuries and condition, the Respondent felt J.C.'s medication protocol
was fully justified. Tr. 765. The Respondent denied ever intentionally
misspelling J.C.'s first name.*\V\ Tr. 765-66. Although the Respondent
remembered J.C. reporting that he had seen two previous doctors,
including a pain physician, that report was not reflected in the chart.
Tr. 841-42. Although the Respondent remembered performing a complete
mental health evaluation on J.C., it is not documented in the chart.
Tr. 842.
---------------------------------------------------------------------------

*\V\ There was no allegation that Respondent misspelled J.C.'s
name, but the OSC did allege that Respondent ``used a variant
spelling of Patient J.M.'s first name.'' OSC, at 13. Accordingly,
Respondent's testimony that he never intentionally misspelled J.C.'s
first name is not relevant to this hearing other than it caused me
to again question whether Respondent's testimony reflected his true
recollection of the specific actions he took with regard to the
specific patient being discussed. See supra n.12.
---------------------------------------------------------------------------

Patient D.D.

Patient D.D. first presented on July 9, 2008, with GAD and severe
back pain, although the source of the back injury was not documented.
Tr. 767-68, 850; GX 9 at 74. Over the course of treatment, the
Respondent prescribed hydrocodone, Xanax and Soma. Tr. 850. The
Respondent added that he probably prescribed Valium, as well,
explaining he was remembering from 13 years ago. Tr. 850. The
Respondent remembered D.D. was prescribed Valium, hydrocodone and Soma
the first visit. Tr. 851-52. The Respondent believes his treatment was
within the standard of care in California. The Respondent took a
complete medical history, family history, personal history and
medication history. Tr. 768. The family history was not documented in
the chart. Tr. 848. The Respondent explained that the family history
was not documented because it was non-contributory to his assessment.
Tr. 848. There were no heart conditions in his family, etc. Tr. 849.
The Respondent did document that D.D. was married, which he deemed
contributory. Tr. 849. D.D. had a dirt bike accident, which shattered
his shoulder and fractured several ribs, although the accident as the
source of the injury was not documented.*\W\ Tr. 850. He underwent
physical therapy and occupational therapy after treatment by an
orthopedic surgeon, although neither was documented within the chart.
Tr. 769, 771, 850-51. It was several years before he reached the
medication regimen he was on when he first reported to the Respondent.
The Respondent performed a full physical exam. He established informed
consent with the pain contract and discussion of side effects and
overdose, as with all his patients. Tr. 770. He verbally cautioned D.D.
regarding diversion and other red flags. Again, D.D. gave no indication
of diversion. Tr. 771. Respondent testified that alternative treatments
were discussed. Tr. 771.
---------------------------------------------------------------------------

*\W\ Respondent testified that, ``whether it is specifically
dirt bike as opposed to car accident, as opposed to falling off the
second story, this has become, there is a good reason for the back
pain. That's the whole thing, why I did not mention specifically
dirt bike injury.'' Tr. 850.
---------------------------------------------------------------------------

Patient M.B.

Patient M.B. presented on April 19, 2006, with severe back pain,
left knee pain and history of dyslipidemia. Tr. 782. The Respondent
obtained a full medical history, medication history, pain level, and
performed a complete head to toe physical exam. Tr. 783. The Respondent
discovered M.B. had chronic back pain related to an injury, a
manageable knee injury, and dyslipidemia. Tr. 784. Although the
Respondent maintains he obtained a complete medical history as to the
back pain and chronic knee pain, he concedes it is not detailed in the
chart. Tr. 820-23. [He testified, ``[maybe . . . I should have
documented more. I'm not going to say anything to that.'' Tr. 821.] He
was already on hydrocodone, previously prescribed, when M.B. first saw
the Respondent.
The Respondent obtained informed consent in the same manner as
described for his earlier patients. Tr. 784. He discussed alternative
forms of treatment with M.B., however M.B. had exhausted those.*\X\
M.B. had physical

[[Page 30580]]

therapy, and perhaps acupuncture, but the Respondent could not quite
remember. Tr. 827. The Respondent conceded he did not document these
therapies in the chart. Tr. 828. The Respondent monitored M.B.
throughout his treatment. Tr. 785. The Respondent believed his
prescribing was justified on the basis of M.B.'s medical conditions,
level of chronic pain and present level of functioning, working in a
welding factory lifting heavy things.*\Y\ Tr. 786, 832. The Respondent
conceded that he did not document M.B.'s degree of pain, but minimized
the value of the subjective pain scale. Tr. 823-24. The Respondent
conceded there were no imaging reports in M.B.'s chart, but explained
that these patients were from the movie business. They were treated by
a Health Maintenance Organization (HMO) from which it is almost
impossible to obtain records. Tr. 829.
---------------------------------------------------------------------------

*\X\ Specifically, when asked whether he considered alternative
forms of treatment for M.B., Respondent testified: ``I do. We do
discuss that. However, patient's already been through those. Again,
the common denominator in my practice is unique thing . . . because
these patients [have] been there, done that. They had surgeries,
they had imaging, they had already physical therapy, activation,
acupuncture, medication. I told you some of them had hypnosis, water
pool or water therapy. Everything was done. But still . . . for the
sake of clarity I have to discuss everything. The patient will tell
me, Doctor, I've done that, I've been there, and this is what works
for me right now.'' Tr. 785. On cross examination when asked
specifically whether M.B. told Respondent that he had tried each of
these forms of alternative treatment, Respondent replied ``[n]ot
necessarily all of this. I always ask questions, what alternative
therapy did you discuss.'' Tr. 825. When directed to identify
specifically which forms of alternative treatment M.B. had tried,
Respondent testified, ``I don't want to misspeak. I'm not sure if he
had . . . acupuncture or not. But I know for a fact he had physical
therapy.'' Tr. 827. I find this testimony illustrative of two
concerns I have with Respondents testimony. First, it appears that
Respondent's testimony does not always reflect an independent
recollection of the undocumented events that occurred between him
and the specific patients being discussed. Even where Respondent
seems to be testifying about a specific patient, it morphs into
testimony about his patients collectively rather than as
individuals. This sort of collective focus that appears throughout
Respondent's testimony causes me to question Respondent's
credibility--specifically whether he remembers the events that
occurred at each specific visit for each specific patient that he
discussed in the absence of medical records documenting these
events. Indeed, Respondent testified that ``[o]ver [his] career,
[he] worked [with] about 5,000 patients.'' Tr. 792. And at the time
of the hearing he had ``close to 550-600 patients'' and prior to the
order to show cause he ``had between 175-200 [pain] patients.'' Id.
Secondly, I am concerned that Respondent's ``photographic memory''
may not be as reliable as he portrays it, particularly where, as
here, there is no documentation in support of his memory.
*\Y\ On cross-examination Respondent testified ``the patient is
in motion picture but he has also something that he does on the side
that has to do [with] welding iron or something like that as well.''
Tr. 832.
---------------------------------------------------------------------------

Patient K.S.

Patient K.S. presented on June 21, 2007, with chronic back pain. He
was later diagnosed with ADD. He was prescribed hydrocodone, Soma and
sometimes Adderall. Tr. 788-89, 861; GX 14 at 110. The Respondent added
that he may have also prescribed Xanax, but it is difficult to be sure
with hundreds of patients and treatment dating back fifteen years. Tr.
859. Even with a ``good memory, sometimes you just miss something.''
Tr. 859. Additionally, he noted that many times patients do not
disclose all of their medications at the initial visit, if they have
plenty and do not then need them to be refilled. So, he is not always
aware of all of their medications at the initial visit. Tr. 860-62.
The Respondent believed his prescribing was within the standard of
care for California. Tr. 788. The Respondent obtained a full medical
history, medication history, pain level, and performed a complete head-
to-toe physical exam. Tr. 789. The Respondent discovered K.S. had
chronic back pain related to a bike accident for which he had been
treated by several doctors for several years, although the bike
accident as the source of the injury and treatment by other doctors was
not documented. Tr. 789, 856-57, 859. Additionally, there were no
records from prior treatment in the patient's records. Tr. 857.
Although the Respondent explained that he requested the prior medical
records, none were provided. The Respondent explained that his request
for records is simply faxed to the previous physician's office. Tr.
857-58. Its absence from the file was probably because a staffer forgot
to file it. Tr. 858. The Respondent did not contest the Government's
observation that no requests for previous medical records were in any
of the seven patient files. Tr. 859. K.S. was already on hydrocodone
when K.S. first saw the Respondent. The Respondent obtained informed
consent [and disclosed the potential side effects including the risk of
death] in the same manner as described for his earlier patients.*\Z\
Tr. 790. He discussed alternative forms of treatment with K.S. K.S. was
obtaining physical therapy prior to seeing the Respondent and continued
physical therapy after beginning treatment with the Respondent. Tr.
791. The Respondent monitored K.S. throughout his treatment. Tr. 791.
K.S. presented no indications of diversion. The Respondent has treated
K.S. for thirteen years during which time K.S. got married and had
three children. Tr. 790-91.
---------------------------------------------------------------------------

*\Z\ Specifically, when asked whether he had a conversation with
this patient involving informed consent, Respondent testified:
``Yes, I did. And, as usual, he read the entire contract, understood
it. Indicated that [he] understood, both verbally and signed it.
Then I . . . explain[ed] the potential side effects of these
medications that include from my explaining with sedation and
constipation, all the way to addiction, overdose, and possible
death. And I indicate always to my patients on the last two, the
overdose and the death, is on you, because you can cause it
yourself, or you could use this medication indefinitely and never
have any problem. . . .'' Tr. 790; see also Tr. 670-71, 753, 770.
Once again, Respondent begins his testimony purporting to have a
specific recollection of his 2007 conversation with K.S., but then
he turns to general language, which more supports a general
assumption that he had the conversation. See, e.g., Respondent's use
of ``as usual, he,'' which is ambiguous because, while all of
Respondent's patients purportedly receive the contract, K.S. is only
purported to have received it once.
---------------------------------------------------------------------------

The Respondent noted that, to the best of his knowledge, none of
his thousands of patients have suffered any harm from his medication
treatment. Tr. 793. [Respondent testified that a combination of an
opiate, muscle relaxant, and benzodiazepine, when ``used in the right
dosages for the right indications, and used as prescribed by a
knowledgeable M.D., . . . are safe to use in combination therapy.'' Tr.
797.] The Respondent disagreed with Dr. Munzing's assertion that he
could perceive of no medical condition justifying the dangerous
combinations of medications identified herein. Tr. 794-800. The
Respondent conceded the potential danger of individual pain
medications, and the potential increase in risk in combination with
other medications. However, according to him, if patients are
responsible and take the medications as prescribed for the indications
intended, these combinations are fairly safe. Tr. 800.\16\
---------------------------------------------------------------------------

\16\ Although the government objected to this opinion by the
Respondent, I overruled its objection. A general disagreement by the
Respondent of the government expert's opinion is certainly
reasonably anticipated. The Respondent did not cite to any unnoticed
medical practice guide, medical theories or other basis for his
contrary opinion. The government was readily able to confront the
Respondent's opinion. The Respondent's opinions were not considered
expert opinions.
---------------------------------------------------------------------------

The Respondent recognized his obligations to follow all federal and
state rules concerning the practice of medicine, including the
directives of the California Board of Medicine. Tr. 862. California's
Compliance with Controlled Substance Laws and Regulations includes a
provision on records. Tr. 864; GX 20 at 61. According to Respondent, it
mandates that, the physician and surgeon should keep accurate and
complete records according to the items above between the medical
history and physical examination, other evaluations and consultations,
treatment plan objectives, informed consent, treatments, medications,
rationale for changes in the treatment plan or medications, agreements
with the patient, and periodic reviews of the treatment plan. Tr. 864-
65. The provision further requires, ``[a] medical history and physical
examination must be accomplished . . . this includes an assessment of
the pain, physical and psychological function.'' Tr. 866; GX 20 at 59.
The Respondent assured the tribunal that the necessary assessments were
made, but not fully documented. Tr. 866-67. The Respondent, [while
again conceding that there was no documentation,] made the same
assurances for the requirements as to ``Treatment Plan Objectives,''
``Informed Consent,'' and ``Periodic Review,'' noting these Guidelines
were published in 2013.\17\ Tr. 867-72. [As justification for not
documenting a treatment plan, Respondent testified that he was
``carrying the same treatment [plan] and no change and the patient is
stable,'' but that ``[i]f [he] changed the treatment plan'' it would be
important to document. Tr. 874. Contrary to Respondent's testimony, the
treatment plan did change when on February 2, 2017, the Respondent
prescribed Soma to S.B. Tr. 875; GX 1 at 59. By March 1, 2017, Soma had
been discontinued, yet the chart reflected no rationale for

[[Page 30581]]

that change in medication regimen. Tr. 876-77. As the Respondent varied
his prescribing between Soma and Xanax, he conceded he did document the
reason for the variation in medication. Tr. 878-83. The Respondent
conceded he did not document the rationale for the change in medication
for J.M. or K.S. as well. Tr. 885. Similarly, the Respondent conceded
he did not document pain level, function level and quality of life for
any of the seven charged patients. Tr. 885-87; GX 20 at 61. The
Respondent reiterated that, to his knowledge, none of his patients
exhibited red flags or violated the pain agreement. Tr. 888-89.
---------------------------------------------------------------------------

\17\ See Tr. 950-52. Dr. Munzing testified credibly that the
2013 version was the 7th edition and the basic requirements have not
changed over the years.
---------------------------------------------------------------------------

[Respondent testified somewhat extensively and flippantly regarding
his thoughts on California law's documentation requirements. ``I am not
going to just say, okay, write in the chart I told the patient hello,
they said hello, I said, okay, what did you have for breakfast? I am
not going to document all that, there is no reason. It is just
excessive wrecking [sic.] havoc on the documentation. . . .
[E]verything was addressed, everything was talked about, and every
exam, every consent, everything was done by the book. I am a
perfectionist. I am a perfectionist.'' Tr. 871.]

Rebuttal Testimony

Diversion Investigator
DI identified a CURES Audit Report for the Respondent's
Registration number. Tr. 893-94; GX 24. The audit report shows each
time the Respondent accessed CURES to run a query on patients. Tr. 894.
This particular audit included data from January 1, 2016, through
January 13, 2020. DI also identified GX 25, which was a CURES Audit
Report run on the DEA Registration of Dr. B.S., which included the
patient M.B., a patient common to the Respondent. Tr. 904. Between
October 10, 2018, and September 11, 2020, Dr. B.S. prescribed Suboxone
\18\ to M.B. Tr. 909; GX 24, 25, 25B. On March 15, 2019, the Respondent
accessed CURES and would have observed M.B. was receiving Suboxone from
Dr. B.S. Tr. 910; GX 24. DI identified GX 26, an additional CURES Audit
Report for Dr. B.S.2, which spanned from January 2017, to September
2020, and which shared a common patient with the Respondent, J.M. Tr.
911-13; GX 26, 26B. Dr. B.S.2 similarly prescribed Suboxone to J.M.
from January 2017 to August 2020. Tr. 913. The CURES Audit of the
Respondent demonstrated he accessed the CURES database during the
period J.M. was prescribed Suboxone by Dr. B.S.2, which would have been
evident by this review. Tr. 914.
---------------------------------------------------------------------------

\18\ Buprenorphine.
---------------------------------------------------------------------------

Dr. Munzing
Dr. Munzing repeatedly gave his opinion regarding the credibility
of the Respondent's testimony. I find that Dr. Munzing's opinion as to
the Respondent's credibility is beyond Dr. Munzing's qualified
expertise. Accordingly, those opinions will not be considered
herein.\19\
---------------------------------------------------------------------------

\19\ [Omitted for brevity.]
---------------------------------------------------------------------------

Dr. Munzing opined on the importance of documentation within
medical records, including medical history and pain levels. Tr. 917,
936-38. He noted that documentation was not just for the then treating
physician. It was important for other physicians, perhaps years later,
who may treat the patient in an emergency room setting. [Dr. Munzing
testified that ``[t]rue, and accurate, and thorough documentation is
vitally important for patient safety. It's also part of the standard of
care.'' Tr. 917.] He reiterated that the elements identified in the
Board of Medicine's Guidelines on documentation are part of the
standard of care. Tr. 917-18; GX 20 at 59, 60, 61. He noted the lapse
in documentation regarding the history, pain levels, mental health
exams, and treatment plans the Respondent testified he performed or
obtained for each patient. Tr. 916, 921-22. [Specifically, Dr. Munzing
testified that ``practically none of the information that Respondent
mentioned [during his testimony] was documented.'' Tr. 916.] Dr.
Munzing observed that the examination described by the Respondent for
fibromyalgia was medically deficient and inconsistent with the standard
of care, as it did not include a musculoskeletal exam. Tr. 918-20. Dr.
Munzing observed that the standard of care applies equally to
electronic records as to written records. It does not matter whether
the physician documents electronically or in writing, the standard
remains the same. Tr. 922.
Regarding the Respondent's testimony that he would continue
patients on medication prescribed by previous physicians if they
reported they were doing well on the medication, Dr. Munzing opined
that Respondent needed to conduct an ``independent evaluation'' and
``verify what [the patient is] saying'' *\AA\ to comply with the
standard of care. Tr. 923-27, 928-29. Dr. Munzing observed that the
Respondent's warnings regarding the potential for overdose were not
consistent with the standard of care. Tr. 927. Dr. Munzing believed the
Respondent's undocumented verbal caution that overdose was a potential
risk if the patients took the medication other than as directed was
misleading, because there were risks even if the medication were taken
as prescribed, and it was beneath the standard of care. Tr. 927, 929-
31.
---------------------------------------------------------------------------

*\AA\ For example, Dr. Munzing testified that Respondent could
have checked CURES or urine drug tests to verify what the patients
were saying or could have asked the patients to bring copies of
their prior medical records in with them. Tr. 923-24. Dr. Munzing
testified that it is outside the standard of care in California to
simply take a patient at their word when they say that they are
receiving certain controlled substances in certain doses. Tr. 928-
29.
---------------------------------------------------------------------------

Regarding the Respondent's explanation that he only documented the
condition of which the patient was complaining, and did not document
all the medications the patients were already on when coming to his
clinic, Dr. Munzing opined such practice was inconsistent with the
standard of care. Tr. 932. Dr. Munzing testified that the documentation
was not just to remind the treating physician, but to alert any
physician who may treat the patient. Tr. 931-34. Dr. Munzing also
criticized the Respondent's handling of situations in which patients
reported they still had medication remaining from the previous month.
Rather than simply refraining from prescribing additional medication,
Dr. Munzing indicated that that situation should trigger a discussion
with the patient and evaluation whether the existing level of
medication is appropriate, or whether titration is warranted. Tr. 933-
36. Dr. Munzing deemed the Respondent's prescribing 10 mg a day of
Xanax to J.M. to treat GAD and undocumented panic attacks as excessive
and beneath the standard of care. Tr. 938-39. Dr. Munzing deemed the
Respondent's reluctance to reduce the opioid dosage lest the patient
suffer pain or withdrawal symptoms misguided. Tr. 941. Titration of
high opioid dosage of high risk patients or exploration of alternate
treatment is consistent with the standard of care. Tr. 941. Dr. Munzing
was critical of the Respondent's handling of J.M. and S.B. after
discovering they were being prescribed Suboxone by other physicians.
Tr. 941-48. Suboxone is typically prescribed for opioid use disorder or
addiction. Tr. 943. It directly violates the Respondent's pain contract
for these patients, yet the Respondent took no action and continued to
prescribe opioids. Tr. 947.

[[Page 30582]]

The Facts 20
---------------------------------------------------------------------------

\20\ [The contents of the original footnote are omitted due to
my omission of the Joint Stipulations. The parties agreed to Joint
Stipulations numbered 1-38. See ALJX 3, Govt Prehearing, at 1-14 and
ALJX 13, Resp Supp. Prehearing, at 1. The RD included many of the
stipulated facts between the parties, but appears to have
inadvertently left some out. See RD, at 54-67. I have omitted the
joint stipulations from this decision in the interest of brevity,
but I incorporate fully herein by reference Joint Stipulations 1-38.
Where there is a reference to the Joint Stipulations herein, the
numbering aligns with the numbering in the Government's Prehearing
Statement, GX3, at 1-14.]
---------------------------------------------------------------------------

Findings of Fact

The factual findings below are based on a preponderance of the
evidence, including the detailed, credible, and competent testimony of
the aforementioned witnesses, the exhibits entered into evidence, and
the record before me.
During the hearing conducted, via video teleconference, from
September 28, 2020, to September 30, 2020, the Government established
the following facts through evidence, testimony, or stipulation
(``Proposed Findings of Fact'' or ``PFF''):

I. Investigatory Background

1. DI has been employed by DEA as a Diversion Investigator for
three years. Tr. 33.
2. DEA began investigating Respondent in April of 2018, after
receiving a February 2018 report issued by the Department of Health and
Human Services indicating that Respondent's prescribing habits
presented a high-risk for overprescribing. Tr. 37-38.
3. DEA monitored California's prescription drug monitoring program,
known as CURES, and identified several red flags regarding Respondent's
prescribing. Tr. 35, 38. CURES reports obtained by DEA were admitted
into evidence as GX 16, 17, 18, and 19. Tr. 16-18; see also Joint
Stipulation Nos. 31-34. Among other things, DEA found that; (1)
Respondent frequently prescribed opioids at their maximum strength, Tr.
38-39; (2) Respondent frequently prescribed patients a combination of
an opioid and a benzodiazepine, Tr. 39; (3) Respondent issued
prescriptions for a combination of an opioid, a benzodiazepine, and
carisoprodol--a combination that is highly sought after on the illicit
market, and is known as ``the Holy Trinity,'' Tr. 40; (4) Respondent
prescribed high doses of controlled substances to patients for long
periods of time, Tr. 40-41; (5) between November 20, 2015, and November
21, 2018, Respondent issued approximately 9,000 prescriptions for
controlled substances, Tr. 39; GX 16; GX 17; GX 18; (6) Over half of
those 9,000 prescriptions were for hydrocodone, and approximately 96
percent of these prescriptions were for either hydrocodone, alprazolam,
or carisoprodol--which together make up the ``Holy Trinity'' cocktail.
Tr. 39, 42-43; GX 16; GX 17; GX 18.
4. DEA obtained medical files from Respondent, pursuant to a
federal search warrant executed at Respondent's medical clinic in
February of 2019, and pursuant to an administrative subpoena issued to
Respondent in January of 2020. Tr. 46, 49, 49, 55-56. These included
medical files for Patients S.B., M.B., B.C., J.C., D.D., J.M., and K.S.
(admitted as GXs 1, 3, 5, 7, 9, 11, and 14; Tr. 16-18).
5. DEA also obtained prescriptions for the above-mentioned patients
(see PFF ] 4) from its search of Respondent's clinic, and from
pharmacies at which these prescriptions were filled (admitted as GXs 2,
4, 6, 8, 10, 12, and 15; Tr. 16:15-18:3). DEA also obtained fill
stickers for certain prescriptions issued to Patient J.M. from one of
the pharmacies at which Patient J.M. filled prescriptions Respondent
issued to Patient J.M. (admitted as GX 13; Tr. 16:15-18:3).

II. The Government Expert's Qualifications

6. Dr. Munzing's curriculum vitae was admitted into evidence as GX
23; Tr. 89. He is a licensed physician in the State of California, who
has worked in the field of family medicine for nearly forty years. Tr.
89.
7. Dr. Munzing received his medical degree from the University of
California, Los Angeles, in 1982, and did his residency at Kaiser
Permanente Medical Center in Los Angeles. Tr. 89. He then began working
in the family medicine department of Kaiser Permanente Orange County,
where he has been for the last thirty-five years, twice serving as
president of the medical staff at the hospital. Tr. 89, 94. He has a
DEA COR and an active clinical practice, prescribing, inter alia,
opioids, benzodiazepines, and other controlled substances when
indicated. Tr. 91-92.
8. In addition to his clinical practice, Dr. Munzing teaches
extensively to physicians, serving as the director of the Kaiser
Permanente Orange County family medicine residency program. Tr. 90.
Further, he is a full clinical professor at University of California,
Irvine. Tr. 91. He also sits on the National Accreditation Board for
Family Medicine Residency, which accredits all of the residency
programs in the United States of America. Tr. 90-91.
9. Dr. Munzing has been called upon to provide opinions about the
prescribing of other medical professionals, and he has been qualified
as an expert witness in over 30 cases, including in DEA administrative
hearings. Tr. 93-94.
10. As a licensed California physician who has been practicing in
California for nearly 40 years, Dr. Munzing is familiar with the
standard of care for prescribing controlled substances in California.
He also has reviewed publications by the Medical Board of California
that inform his understanding of the standard of care, including the
``Guide to the Laws Governing the Practice of Medicine by Physicians
and Surgeons (7th Edition)'' (admitted as GX 20, Tr. 16-18), and the
``Guidelines for Prescribing Controlled Substances for Pain,''
(admitted as GX 21, Tr. 16). In addition, he is familiar with the FDA's
black box warning regarding the risks of overdose and death posed by
concurrently taking opioids and benzodiazepines, and the FDA labels for
benzodiazepines including Klonopin, Valium, and Xanax (admitted as GX
22, Tr. 16-18). Further, Dr. Munzing reviewed several laws and
regulations that informed his understanding of the standard of care.
Tr. 99.
11. Dr. Munzing was qualified as an expert in California medical
practice, including, but not limited to, applicable standards of care
in California for the prescribing of controlled substances within the
usual course of the professional practice of medicine. Tr. 102.

III. The Standard of Care for Prescribing Controlled Substances in
California

12. Dr. Munzing testified that the standard of care in California
first requires that, before prescribing controlled substances, a
practitioner perform a sufficient evaluation of the patient, including,
a medical history and appropriate physical examination. Tr. 103.
a. In the context of treating a patient with controlled substances
for pain, the standard of care in the state of California requires the
following:
i. Medical history: The practitioner must obtain detailed
information about the pain, including where the pain is, how long a
patient has had it, how severe the pain is, the impact of the pain on
the patient's functionality and activities of daily living, and any
previous diagnoses and treatments the patient has received for the
pain. The practitioner must also seek to obtain any relevant prior
medical records and imaging. Tr. 114-115.

[[Page 30583]]

ii. Physical examination: The practitioner must look at the area of
pain unclothed for any swelling, redness, or mass. Tr. 116-17. The
practitioner must palpate the affected area and identify areas of
particular tenderness or pain. Tr. 117-18. The practitioner also is
required to test a patient's range of motion, as well as the patient's
neurological conditions via targeted tests for the area affected by
pain (e.g., tendon reflexes, and strength tests for the affected area).
Tr. 118-19.
b. In the context of treating a patient with controlled substances
for mental health conditions, the standard of care in the state of
California requires the following:
i. Medical history: The practitioner must inquire into the
patient's condition, including symptoms the patient is experiencing,
when the patient experiences symptoms, how those symptoms impact the
patient's functionality and activities of daily living, when the
condition began, and if there is a family history of mental health
issues. The practitioner must also seek to obtain any relevant prior
medical records. Tr. 136-38.
ii. Physical examination: The practitioner must conduct a limited
and focused general examination, including heart, lungs, and vital
signs, [to rule out other possible medical diagnosis.] Tr. 138-39.
13. As part of the medical history, the practitioner must inquire
into the patient's history of, and/or current use or abuse of, tobacco,
drugs, or alcohol, as well as into any family history of use or abuse
of tobacco, drugs, or alcohol. Tr. 120-21, 142.
14. Based on the history and physical examination, the standard of
care requires the practitioner to assign a diagnosis to the patient.
Tr. 103. An appropriate history and physical examination are crucial to
arriving at an appropriate diagnosis. Tr. 121-22, 141. Without an
appropriate diagnosis, a practitioner cannot establish a legitimate
medical purpose to prescribe. Tr. 124, 141. [The standard of care
requires the diagnosis to be documented in the record. Tr. 122.]
15. Next, the standard of care requires the practitioner to develop
a customized and documented treatment plan for the patient with goals
and objectives. Tr. 109-110. The practitioner must relay that plan to
the patient, inform the patient of the risks *\BB\ and benefits of
treatment with controlled substances, as well as potential alternative
treatments, and obtain the patient's informed consent for the
treatment. Tr. 103-04, 124-25. When prescribing high dosages of
controlled substances, this discussion of risks must include risks of
addiction, overdose, and death. Tr. 126-27. ``All of [this] needs to be
documented'' in the medical record. Tr. 135.
---------------------------------------------------------------------------

*\BB\ The practitioner must determine the risk posed to a
patient by controlled substances due to the patient's overall health
history--as well as the potential for substance abuse or addiction.
Tr. 103, 109. This text, which appeared in the RD originally, has
been relocated for clarity.
---------------------------------------------------------------------------

a. In the context of treating a patient with controlled substances
for pain, the standard of care in the state of California requires that
a treatment plan contain goals and objectives for pain management, such
as maximizing benefit to function and minimizing pain, while also
minimizing the risk to the patient from the controlled substances
prescribed. Tr. 131.
b. In the context of treating a patient with controlled substances
for mental health conditions, the standard of care in the State of
California still requires that the treatment plan contain goals and
objectives for the patient. Tr. 143.
c. With respect to risks of medications, Dr. Munzing explained that
practitioner should only co-prescribe opioids and benzodiazepines when
``absolutely necessary,'' and should do so for ``[n]o longer than
absolutely necessary and typically in as low doses as possible to . . .
decrease the risk.'' Tr. 154-55.
16. As treatment progresses, the standard of care requires a
physician to monitor the patient. Tr. 104, 132. A practitioner must
periodically update the patient's medical history, conduct further
physical examinations, and obtain updated information regarding the
etiology of a patient's state of health. Tr. 106-08. The practitioner
must periodically review the course of treatment, ascertain how the
patient is responding thereto, determine if continued treatment is
appropriate or if the treatment plan needs to be modified, and document
the rationale for any modifications. Tr. 108-09, 206; GX 20 at 61. The
practitioner must also periodically re-inquire into the patient's use
or abuse of tobacco, drugs, or alcohol. Tr. 259-60.
17. The practitioner must also periodically conduct updated
physical examinations, both brief general examinations to ensure that
the patient is healthy enough to continue receiving controlled
substances, as well as focused examinations of the area for which pain
is being treated to help in determining how the patient is responding
to treatment. Tr. 111-12.
18. When prescribing controlled substances, the standard of care in
California also requires a practitioner to monitor medication
compliance, including thorough reviews of CURES, Tr. 132, periodic
urine drug screening, Tr. 133, and/or pill counts. Id. The practitioner
must address any red flags of abuse or diversion. Tr. 112.
19. In addition, the standard of care requires that a practitioner
document all of these above steps in detail. See, e.g., Tr. 104, 109,
110, 112, 122, 135, 144. Such documentation is critically important as
it: (1) enables the practitioner to recall important facts about the
patient's state of health and treatment, Tr. 145, 146; and (2) allows
other practitioners who may also see the patient to see these facts.
Tr. 145-146.
20. Appropriate documentation is a well-known, fundamental
requirement in the medical community. Tr. 146. [According to Dr.
Munzing, ``[t]he general mantra in medicine [is] . . . if [it is] not
documented, it [did not] happen.'' Tr. 148. Thus, it is not credible
that a practitioner who consistently failed to document these basic
elements for a patient actually performed them. Tr. 148-50.
21. The practitioner must also comply with all relevant California
laws.

IV. Respondent's Improper Prescribing of Controlled Substances

A. Patient S.B.

i. Patient S.B.'s Initial Visit
22. Between February 2, 2017, and January 30, 2019, Respondent
issued Patient S.B. the controlled substance prescriptions listed in
Joint Stipulation No. 10. See ALJ Ex. 3 at 2-3. During this time,
Respondent diagnosed Patient S.B. with fibromyalgia, GAD, and ADD. GX 1
at 47-59.
23. Respondent's initial encounter with Patient S.B. took place on
August 3, 2016. GX 1 at 62, 66; Tr. 164-65. At that visit, Respondent
diagnosed Patient S.B. with fibromyalgia, GAD, and ADD. GX 1 at 62; Tr.
165. Respondent prescribed Patient S.B. hydrocodone for fibromyalgia,
Xanax for GAD, and Adderall for ADD. GX 1 at 62; Tr. 165. At this
initial visit, Respondent failed to:
a. Take an appropriate medical history, GX 1 at 62; Tr. 166-68;
b. address Patient S.B.'s pain or functionality levels, GX 1 at 62;
Tr. 171;
c. conduct an appropriate physical examination, GX 1 at 62; Tr.
166, 168-71;
d. establish appropriate diagnoses, and therefore to establish
legitimate medical purposes for hydrocodone, Xanax, or Adderall, Tr.
171-72; or
e. establish and document a treatment plan with goals and
objectives, GX 1 at 62; Tr. 172-73.

[[Page 30584]]

ii. Continued Controlled Substance Prescribing Violations
24. Throughout the entire course of treatment, Respondent never
obtained a proper medical history of Patient S.B., never recorded
Patient S.B.'s pain or functionality levels, never obtained prior
medical records for Patient S.B.--nor does Patient S.B.'s medical file
reflect Respondent requested such records--failed to periodically
update Patient S.B.'s medical history as treatment progressed, and
never conducted a sufficient physical examination for fibromyalgia. See
generally GX 1; Tr. 241-43.
25. None of Respondent's diagnoses of Patient S.B. for which he
prescribed controlled substances were based on sufficient clinical
evidence. Tr. 243.
26. Over the course of his treatment of Patient S.B., Respondent's
diagnoses of Patient S.B. for ADD, GAD and fibromyalgia came and went
without explanation or comment. See generally GX 1; Tr. 188, 193-95.
Fibromyalgia and ADD are chronic diagnoses. Tr. 188, 193. These erratic
diagnoses were outside of the standard of care, [especially since these
diagnoses,] including those made between February 2, 2017, and January
30, 2019, [were not supported by an adequate medical history and
physical examination].*\CC\ Tr. 191-92; 195-97.
---------------------------------------------------------------------------

*\CC\ I have made this change for S.B. and each of the
subsequent patients for legal clarity pursuant to supra n. *HH.
---------------------------------------------------------------------------

27. Respondent sometimes prescribed Patient S.B. both hydrocodone
and Soma, and sometimes only hydrocodone, for fibromyalgia. See GX 1 at
47-59; Tr. 197:3-17. Respondent never documented any rationale for
changing Patient S.B.'s course of medication in violation of the
California standard of care. See GX 1 at 47-59; PFF ] 16; Tr. 199-200.
28. Respondent never documented an appropriate treatment plan with
goals and objectives for Patient S.B., never documented an appropriate
rationale for continued treatment of Patient S.B. with controlled
substances, and failed to properly discuss the risks and benefits of
the controlled substances he prescribed to Patient S.B. See generally
GX 1; Tr. 243.
29. Respondent also prescribed Patient S.B. the following dangerous
combinations of controlled substances that put Patient S.B. at serious
risk of adverse medical consequences, including addiction, overdose,
and death. Tr. 203-05:
a. Hydrocodone, Adderall, and Soma on February 2, 2017, May 8,
2017, June 2, 2017, August 1, 2017, August 30, 2017, November 6, 2017,
and January 23, 2018. ALJ Ex. 3 at 2-3.
b. Hydrocodone, Adderall, and Xanax on March 1, 2017, April 4,
2017, June 28, 2017. ALJ Ex. 3 at 2-3.
c. Hydrocodone and Adderall on September 29, 2017, July 2018, and
in August 2018, September 2018, October 2018, and November 2018. ALJ
Ex. 3 at 3.
30. Respondent's prescriptions to Patient S.B. for Xanax between
February 2, 2017, and January 30, 2019, were all for 6 mg of Xanax per
day. GX 1 at 57-59; Tr. 212-13. The maximum recommended dosage for
Xanax for treatment of GAD is 4 mg per day, according to the FDA label
for Xanax. GX 22 at 59; Tr. 213. Prescribing such high dosages of Xanax
placed Patient S.B. at risk of potentially lethal withdrawal, and
presented risks of diversion. Tr. 217, 218-19. The fact that Respondent
prescribed Xanax to Patient S.B. concurrently with opioids, see ALJ Ex.
3 at 2-3, dramatically increased her risk of overdose and death. Tr.
217-18.
31. Respondent noted, on fifteen occasions between February 2,
2017, and December 21, 2018, that Patient S.B. was opioid dependent and
refusing detoxification. GX 1 at 49-59. Refusal to detoxify is a
significant red flag of abuse or diversion, indicating the prescriber
feels the patient needs to detoxify, but the patient refuses. Tr. 221-
22. Respondent never addressed this red flag, but simply continued to
prescribe the patient opioids on an as-needed basis. GX 1 at 49-59; Tr.
222. Prescribing opioids to the patient on an as-needed basis when a
patient is refusing detoxification is particularly inappropriate,
because any prescribed opioids must be carefully controlled. Tr. 223.
32. Patient S.B. provided inconsistent information to other
providers; she told an orthopedic surgeon during a June 28, 2017 visit
that she had only a past medical history of anxiety (with no mention of
fibromyalgia or ADD), and she did not disclose taking any medications
when she was receiving hydrocodone, Soma, Adderall, and Xanax from
Respondent. See GX 1 at 30, 57. Patient S.B. also informed the
orthopedic surgeon that she had no history of trauma, see GX 1 at 30,
but reported to the California Employment Development Department that
she was disabled as a result of accident or trauma that had occurred on
June 15, 2017, see GX 1 at 40. These inconsistent reports were
significant red flags of abuse or diversion. Tr. 230, 231-32.
Respondent, however, never addressed these red flags. Tr. 233, 235-37.
33. Respondent never conducted a urine drug screen on Patient S.B.
in violation of the California standard of care. Tr. 219:13-16; PFF ]
18; see generally GX 1.
34. None of the controlled substance prescriptions Respondent
issued to Patient S.B. between February 2, 2017, and January 30, 2018,
were issued for a legitimate medical purpose, or by a practitioner
acting within the usual course of professional practice. Tr. 244.
Indeed, according to Dr. Munzing, no patient should receive the drugs
that Respondent prescribed to Patient S.B. in the dosages, durations,
and combinations that Respondent prescribed. Tr. 211-12.

B. Patient M.B.

35. Between January 5, 2018, and November 20, 2019, Respondent
issued to Patient M.B. the controlled substance prescriptions listed in
Joint Stipulation No. 13. See ALJ Ex. 3 at 4-5. During this time,
Respondent diagnosed Patient M.B. with back pain, ADD, and opioid
dependency. GX 3 at 24-37.
i. Patient M.B.'s Initial Visit and the First Diagnosis for ADD
36. Respondent's initial encounter with Patient M.B. took place on
April 19, 2006. GX 3 at 84, 91; Tr. 248-49. At that visit, Respondent
diagnosed Patient M.B. with chronic back pain, chronic left knee pain,
and dyslipidemia. GX 3 at 84; Tr. 250-51. Respondent prescribed Patient
M.B. hydrocodone for chronic back and left knee pain. GX 3 at 84. At
this initial visit, Respondent failed to:
a. Take an appropriate medical history, GX 3 at 84; Tr. 252-54;
b. address Patient M.B.'s pain or functionality levels, GX 3 at 84;
Tr. 257;
c. conduct an appropriate physical examination, GX 3 at 84; Tr.
254-56, 257;
d. establish appropriate diagnoses for back pain and knee pain and
therefore to establish a legitimate medical purpose to prescribe
hydrocodone, Tr. 258; or
e. establish and document a treatment plan with goals and
objectives, GX 3 at 84; Tr. 258.
37. Respondent first diagnosed Patient M.B. with ADD on July 9,
2013, and prescribed 30 mg of Adderall per day. GX 3 at 46. No history
was taken, nor evaluations performed, for ADD other than a note saying
Patient M.B. presented as a ``40 yom with ADD, neck[ ]pain.'' GX 3 at
46; Tr. 262. Nothing supported Respondent's diagnosis for ADD, and he
did not establish a legitimate medical purpose to prescribe Adderall.
Tr. 263. Nor did

[[Page 30585]]

he establish and document a treatment plan with goals and objectives
for the Adderall. GX 3 at 46; Tr. 263.
ii. Continued Controlled Substance Violations
38. Throughout the entire course of treatment, Respondent never
obtained a proper medical history of Patient M.B., recorded Patient
M.B.'s pain or functionality levels, or obtained prior medical records
for Patient M.B.--nor does Patient M.B.'s medical file reflect
Respondent requested such records--failed to periodically update
Patient M.B.'s medical history as treatment progressed, and never
conducted a sufficient physical examination for pain. See generally GX
3; Tr. 287-88.
39. None of Respondent's diagnoses of Patient M.B. for which he
prescribed controlled substances between January 5, 2018, and November
20, 2019, were based on sufficient medical evidence. Tr. 288.
40. Over the course of his treatment of Patient M.B., Respondent
frequently changed without comment the diagnoses for which he
prescribed Patient M.B. hydrocodone. See generally GX 3; Tr. 275-78.
These erratic diagnoses were outside of the standard of care,
[especially because these diagnoses], including those made between
January 5, 2018, and November 20, 2019, [were not supported by an
adequate medical history and physical examination.] Tr. 278-80.
41. Other than inquiring into smoking and alcohol use at Patient
M.B.'s initial visit, see GX 3 at 84, Respondent did not inquire about
current or past substance abuse until over three years later, on August
11, 2009, when he had Patient M.B. sign a form stating ``I have no
history of drug abuse, nor was I treated for drug or substance abuse in
the past.'' GX 3 at 94. Patient M.B. was never asked about substance
abuse again--something the California standard of care required
Respondent to do. PFF ] 16; Tr. 261; see generally GX 3.
42. Respondent never documented an appropriate treatment plan with
goals and objectives for Patient M.B., never documented an appropriate
rationale for continued treatment of Patient M.B. with controlled
substances, and failed to properly discuss the risks and benefits of
the controlled substances he prescribed to Patient M.B. See generally
GX 3; Tr. 288-89.
43. Respondent also prescribed Patient M.B. dangerous combinations
of hydrocodone and Adderall approximately monthly from January 2018,
until July 2019, and once again on November 20, 2019. ALJ Ex. 3 at 4-5.
These combinations put Patient M.B. at serious risk of adverse medical
consequences, including addiction, overdose, and death. Tr. 105-06,
281.
44. Respondent noted, on at least 11 occasions between March 6,
2018, and February 4, 2019, that Patient M.B. was opioid dependent, and
refusing detoxification. GX 3 at 30, 32-36. Respondent never addressed
this red flag, but simply continued to prescribe the patient
hydrocodone on an as-needed basis. GX 3 at 30, 32-36; see also Tr. 286-
87.
45. Indeed, Respondent frequently prescribed Patient M.B.
hydrocodone as a treatment for the patient's opioid dependency,
including on March 6, 2018, May 1, 2018, August 16, 2018, September 13,
2018, October 11, 2018, November 7, 2018, and January 2, 2019. GX 3 at
30, 32-36.
46. Opioid dependency does not create a legitimate medical purpose
to prescribe hydrocodone. To the contrary, treating a patient's opioid
dependency with hydrocodone is outside of the standard of care and
outside the usual course of professional practice. Tr. 267-69.
47. Respondent never conducted a urine drug screen on Patient M.B.,
in violation of the California standard of care. Tr. 284; PFF ] 18; see
generally GX 3.
48. None of the controlled substance prescriptions Respondent
issued to Patient M.B. between January 5, 2018, and November 20, 2019,
were issued for a legitimate medical purpose or by a practitioner
acting within the usual course of professional practice. Tr. 289-90.
According to Dr. Munzing, there is nearly no situation in which a
patient should receive the drugs that Respondent prescribed to Patient
M.B. from January 5, 2018, to November 20, 2019, in those dosages,
durations, and combinations, and Patient M.B. did not present any such
situation. Tr. 283-84.

C. Patient B.C.

49. Between January 25, 2017, and December 19, 2019, Respondent
issued to Patient B.C. the controlled substance prescriptions listed in
Joint Stipulation No. 16. See ALJ Ex. 3 at 5-7. During this time,
Respondent diagnosed Patient B.C. with back pain, GAD, ADD, and opioid
dependency. GX 5 at 17-33.
i. Patient B.C.'s Initial Visit and the First Diagnosis for ADD
50. Respondent's initial encounter with Patient B.C. took place on
March 27, 2014. GX 5 at 48, 55; Tr. 293:1-16. At that visit, Respondent
diagnosed Patient B.C. with GAD and back pain. GX 5 at 48; Tr. 294.
Respondent prescribed Patient B.C. hydrocodone for back pain and 6 mg
of Xanax for GAD. GX 5 at 48; Tr. 294. At this initial visit,
Respondent failed to:
a. Take an appropriate medical history, GX 5 at 84; Tr. 295:7-
296:15;
b. address Patient B.C.'s pain or functionality levels, GX 5 at 84;
Tr. 297-98;
c. conduct an appropriate physical examination, GX 5 at 84; Tr.
296:16-297;
d. establish an appropriate diagnosis for back pain or GAD as
necessary to establish a legitimate medical purpose to prescribe
hydrocodone or Xanax, Tr. 298-99; or
e. establish and document a treatment plan with goals and
objectives, GX 5 at 85; Tr. 299.
51. Respondent only inquired about Patient B.C.'s substance abuse
on March 27, 2014. See GX 5 at 48, 57; Tr. 296, 299. Patient B.C. was
never asked about substance abuse again--something the California
standard of care required Respondent to do. PFF ] 16; Tr. 300; see
generally GX 5.
52. Respondent first diagnosed Patient B.C. with ADD on May 20,
2014, and prescribed 60 mg of Adderall per day. GX 5 at 47. He took no
history, and performed no evaluations, for ADD, other than a note
saying ``Pt has ADD--give [A]dderall 30mg bid (SED).'' Id. Respondent's
diagnosis for ADD was unsupported; he did not establish a legitimate
medical purpose to prescribe Adderall, nor did he establish and
document a treatment plan with goals and objectives. GX 5 at 47; Tr.
302.
ii. Continued Controlled Substance Violations
53. Throughout the entire course of treatment, Respondent never
obtained a proper medical history of Patient B.C., never recorded
Patient B.C.'s pain or functionality levels, failed to periodically
update Patient B.C.'s medical history as treatment progressed, and
never conducted a sufficient physical examination for pain. See
generally GX 5; Tr. 335-36.
54. None of Respondent's diagnoses of Patient B.C. for which he
prescribed controlled substances between January 25, 2017, and December
19, 2019, were based on sufficient medical evidence. Tr. 336.
55. Over the course of his treatment of Patient B.C., Respondent's
diagnoses for pain, GAD, and ADD frequently came and went without
comment or explanation. See generally GX 5; Tr. 316-19; 319-21; 322-25.
Like chronic pain and GAD, ADD is a chronic condition. Tr. 167:13-16.
These erratic diagnoses were outside of the standard of care,
[especially since these

[[Page 30586]]

diagnoses,] including those made between January 25, 2017, and December
19, 2019, [were not supported by an adequate medical history and
physical examination.] Tr. 318-19; 321-22; 325-26.
56. Respondent never documented an appropriate treatment plan with
goals and objectives for Patient B.C., never documented an appropriate
rationale for continued treatment of Patient B.C. with controlled
substances, and failed to properly discuss the risks and benefits of
the controlled substances he prescribed to Patient B.C. See generally
GX 5; Tr. 337.
57. Respondent also prescribed Patient B.C. the following dangerous
combinations of controlled substances, which put Patient B.C. at
serious risk of adverse medical consequences, including addiction,
overdose and death. Tr. 326-30:
a. Hydrocodone, Adderall, and Xanax on January 25, 2017, April 18,
2017, June 19, 2017, and July 31, 2018. ALJ Ex. 3 at 5-6.
b. Hydrocodone and Xanax on May 19, 2017, and approximately monthly
from February 16, 2018, until July 3, 2018. ALJ Ex. 3 at 5-06.
c. Hydrocodone and Adderall on September 25, 2018, December 19,
2018, February 13, 2019, April 9, 2019, June 5, 2019, July 30, 2019,
October 25, 2019, and December 19, 2019. ALJ Ex. 3 at 5-7.
58. Respondent's prescriptions to Patient B.C. for Xanax between
January 25, 2017, and July 31, 2018, were all for 6 mg of Xanax per
day. GX 5 at 28-33. Such high dosages of Xanax placed Patient B.C. at
risk of potentially lethal withdrawal, and presented risks of
diversion. Tr. 294-95. The fact that Respondent prescribed Xanax to
Patient B.C. concurrently with opioids, see ALJ Ex. 3 at 5-6,
dramatically increased his risk of overdose and death. Tr. 295.
59. Respondent noted, on 19 occasions between January 25, 2017, and
February 13, 2019, that Patient B.C. was opioid dependent, and refusing
detoxification. GX 5 at 23, 25-33. Respondent never addressed this red
flag, but simply continued to prescribe the patient hydrocodone on an
as-needed basis. GX 5 at 23, 25-33; see also Tr. 333-34.
60. Indeed, Respondent frequently improperly and illegally
prescribed Patient B.C. hydrocodone as a treatment for the patient's
opioid dependency, including on January 25, 2017, June 19, 2017, July
17, 2017, March 26, 2018, May 11, 2018, July 3, 2018, August 28, 2018,
October 22, 2018, December 19, 2018, and February 13, 2019. GX 5 at 23,
25-33; Tr. 306-07.
61. Respondent never conducted a urine drug screen on Patient B.C.,
in violation of the California standard of care. Tr. 333; PFF ] 18; see
generally GX 5.
62. None of the controlled substance prescriptions Respondent
issued to Patient B.C. between January 25, 2017, and December 19, 2019,
were issued for a legitimate medical purpose or by a practitioner
acting within the usual course of professional practice. Tr. 289-90.
According to Dr. Munzing, there is nearly no situation in which a
patient should receive the drugs that Respondent prescribed to Patient
B.C. from January 25, 2017, to December 19, 2019, in those dosages,
durations, and combinations, and Patient B.C. did not present any such
situation. Tr. 337-38.

D. Patient J.C.

63. Between January 16, 2018, and December 30, 2019, Respondent
issued to Patient J.C. the controlled substance prescriptions listed in
Joint Stipulation No. 19. See ALJ Ex. 3 at 7-8. During this time,
Respondent diagnosed Patient J.C. with back pain, GAD, and opioid
dependency. GX 7 at 168-180.
i. Patient J.C.'s Initial Visit and the First Diagnosis for Back Pain
64. Respondent's initial encounter with Patient J.C. took place on
May 18, 2009. GX 7 at 216, 233; Tr. 383:1-384:5. At that visit,
Respondent diagnosed Patient J.C. with migraine headaches and GAD. GX 7
at 216; Tr. 384. Respondent prescribed Patient J.C. hydrocodone for
migraines and Xanax for GAD. GX 7 at 216; Tr. 384. At this initial
visit, Respondent failed to:
a. Take an appropriate medical history, GX 7 at 216; Tr. 385-86;
b. address Patient J.C.'s pain or functionality levels, GX 7 at
216; Tr. 387;
c. conduct an appropriate physical examination, GX 7 at 216; Tr.
386:16-387:3;
d. establish appropriate diagnoses for migraines or GAD and so
establish a legitimate medical purpose to prescribe hydrocodone or
Xanax, Tr. 387-88; or
e. establish and document a treatment plan with goals and
objectives, GX 7 at 216; Tr. 388.
65. Respondent first diagnosed Patient J.C. with back pain on July
21, 2016, and prescribed hydrocodone. GX 7 at 189. There was no history
taken, or evaluations performed, for back pain, other than a note
saying Patient J.C. presented as a ``39 yom with GAD, chronic back
pain.'' Id. Respondent's diagnosis for back pain was unsupported; he
did not establish a legitimate medical purpose to prescribe
hydrocodone, nor did he establish and document a treatment plan with
goals and objectives. Tr. 391, 392-93, 393-94.
ii. Continued Controlled Substance Violations
66. Throughout the entire course of treatment, Respondent never
obtained a proper medical history of Patient J.C., never recorded
Patient J.C.'s pain or functionality levels, never obtained prior
medical records for Patient J.C.--nor does Patient J.C.'s medical file
reflect Respondent requested such records--failed to periodically
update Patient J.C.'s medical history as treatment progressed, and
never conducted a sufficient physical examination for pain. See
generally GX 7; Tr. 424-26.
67. None of Respondent's diagnoses of Patient J.C. for which he
prescribed controlled substances between January 16, 2018, and December
30, 2019, were based on sufficient medical evidence. Tr. 426.
68. Over the course of his treatment of Patient J.C., Respondent
frequently changed without comment the diagnoses for which he
prescribed Patient J.C. opioids, as well as the opioids prescribed. See
generally GX 7; Tr. 409-14. These erratic diagnoses were outside of the
standard of care, [especially since those diagnoses,] including those
made between January 16, 2018, and December 30, 2019, [were not
supported by an adequate medical history and physical examination.] Tr.
414-15.
69. Other than inquiring into smoking and alcohol use at Patient
J.C.'s initial visit, see GX 7 at 216, Respondent did not inquire about
current or past substance abuse until August 17, 2009, when he had
Patient J.C. sign a form stating, ``I have no history of drug abuse,
nor was I treated for drug or substance abuse in the past.'' GX 7 at
227. Patient J.C. was never asked about substance abuse again--
something the California standard of care required Respondent to do.
PFF ] 16; Tr. 359-60; see generally GX 7.
70. Respondent never documented an appropriate treatment plan with
goals and objectives for Patient J.C., never documented an appropriate
rationale for continued treatment of Patient J.C. with controlled
substances, and failed to properly discuss the risks and benefits of
the controlled substances he prescribed to Patient J.C. See generally
GX 7; Tr. 426-27.
71. Respondent also prescribed Patient J.C. dangerous combinations
of hydrocodone and Valium approximately monthly from January 16, 2018,
until January 18, 2019, and once again on

[[Page 30587]]

May 6, 2019. ALJ Ex. 3 at 7-8. These combinations put Patient J.C. at
serious risk of adverse medical consequences, including addiction,
overdose, and death. Tr. 417-18.
72. Respondent noted, on 14 occasions between January 16, 2018, and
February 19, 2019, that Patient J.C. was opioid dependent, and refusing
detoxification. GX 7 at 173, 175-180. Respondent never addressed this
red flag, but simply continued to prescribe the patient hydrocodone on
an as-needed basis. GX 7 at 173, 175-80; see also Tr. 423-24.
73. Indeed, Respondent frequently improperly and illegally
prescribed Patient J.C. hydrocodone as a treatment for the patient's
opioid dependency, including on February 16, 2018, April 16, 2018, June
15, 2018, August 15, 2018, October 17, 2018, and December 13, 2018. GX
7 at 175-80; Tr. 398-400.
74. Respondent never conducted a urine drug screen on Patient J.C.,
in violation of the California standard of care. Tr. 421; PFF ] 18; see
generally GX 7.
75. None of the controlled substance prescriptions Respondent
issued to Patient J.C. between January 16, 2018, and December 30, 2019,
were issued for a legitimate medical purpose or by a practitioner
acting within the usual course of professional practice. Tr. 427-28.
According to Dr. Munzing, there is nearly no situation in which a
patient should receive the drugs that Respondent prescribed to Patient
J.C. from January 16, 2018, to December 30, 2019, in those dosages,
durations, and combinations, and Patient J.C. did not present any such
situation. Tr. 418-19.

E. Patient D.D.

76. Between January 4, 2018, and February 12, 2019, Respondent
issued to Patient D.D. the controlled substance prescriptions listed in
Joint Stipulation No. 22. See ALJ Ex. 3 at 9. During this time,
Respondent diagnosed Patient D.D. with back pain, GAD, and opioid
dependency. GX 9 at 37-43.
i. Patient D.D.'s Initial Visit
77. Respondent's initial encounter with Patient D.D. took place on
July 9, 2008. GX 9 at 74, 80; Tr. 430-31. At that visit, Respondent
diagnosed Patient D.D. with GAD and back pain. GX 9 at 74; Tr. 431.
Respondent prescribed Patient D.D. hydrocodone and Soma for back pain,
and Valium for GAD. GX 9 at 74; Tr. 431. At this initial visit,
Respondent failed to:
a. Take an appropriate medical history, GX 9 at 74; Tr. 433-34;
b. address Patient D.D.'s pain or functionality levels, GX 9 at 74;
Tr. 435-36;
c. conduct an appropriate physical examination, GX 9 at 74; Tr.
434-35;
d. establish appropriate diagnoses for back pain or GAD and so to
establish a legitimate medical purpose to prescribe hydrocodone, Soma,
or a benzodiazepine, Tr. 436:3-21; or
e. establish and document a treatment plan with goals and
objectives, GX 9 at 74; Tr. 436:22-25.
ii. Continued Controlled Substance Violations
78. Throughout the entire course of treatment, Respondent never
obtained a proper medical history of Patient D.D., never recorded
Patient D.D.'s pain or functionality levels, never obtained prior
medical records for Patient D.D.--nor does Patient D.D.'s medical file
reflect Respondent requested such records--failed to periodically
update Patient D.D.'s medical history as treatment progressed, and
never conducted a sufficient physical examination for pain. See
generally GX 9; Tr. 465-66.
79. None of Respondent's diagnoses of Patient D.D. for which he
prescribed controlled substances between January 4, 2018, and February
12, 2019, were based on sufficient medical evidence. Tr. 467.
80. Over the course of his treatment of Patient D.D., Respondent
frequently changed without comment the diagnoses for which he
prescribed Patient D.D. opioids. See generally GX 9; Tr. 450-56. These
erratic diagnoses were outside of the standard of care, [especially
since these diagnoses,] including those made between January 4, 2018,
[were not supported by an adequate medical history and physical
examination.] Tr. 453-56.
81. Other than inquiring into smoking and alcohol use at Patient
D.D.'s initial visit, see GX 9 at 74, Respondent did not inquire about
current or past substance abuse until over one year later, on August
28, 2009, when he had Patient D.D. sign a form stating ``I have no
history of drug abuse, nor was I treated for drug or substance abuse in
the past.'' GX 9 at 77. Respondent never asked Patient D.D. about
substance abuse again--something the California standard of care
required Respondent to do. PFF ] 16; see generally GX 9.
82. Respondent never documented an appropriate treatment plan with
goals and objectives for Patient D.D., never documented an appropriate
rationale for continued treatment of Patient D.D. with controlled
substances, and failed to properly discuss the risks and benefits of
the controlled substances he prescribed to Patient D.D. See generally
GX 9; Tr. 467.
83. Respondent also prescribed Patient D.D. the following dangerous
combinations of controlled substances, which put Patient D.D. at
serious risk of adverse medical consequences, including addiction,
overdose, and death, Tr. 457-58:
a. Hydrocodone and Soma approximately monthly from January 4, 2018,
through August 10, 2018, and October 16, 2018, through January 11,
2019. ALJ Ex. 3 at 9.
b. Hydrocodone and Xanax on September 19, 2018. ALJ Ex. 3 at 9.
84. Respondent noted, on 10 occasions between January 16, 2018, and
February 12, 2019, that Patient D.D. was opioid dependent and refusing
detoxification. GX 9 at 37, 39-43. Respondent never addressed this red
flag, but simply continued to prescribe the patient hydrocodone on an
as-needed basis. GX 9 at 37, 39-43.; see also Tr. 463-65.
85. Indeed, Respondent frequently illegally and improperly
prescribed Patient D.D. hydrocodone as a treatment for the patient's
opioid dependency, including on March 23, 2018, July 6, 2018, August
10, 2018, October 16, 2018, December 13, 2018, and February 12, 2019.
GX 9 at 37, 39-43; Tr. 454. Moreover, on all of those occasions except
February 12, 2019, Respondent also prescribed Patient D.D. Soma for his
opioid dependency. Soma is not indicated as a treatment for opioid
dependency, and prescribing it to treat opioid dependency is outside
the usual course of professional practice. GX 9 at 39-43; Tr. 454-55.
86. Although Patient D.D. presented a risk of abuse or diversion,
Respondent never conducted a urine drug screen on Patient D.D., in
violation of the California standard of care. Tr. 461-62; PFF ] 18; see
generally GX 9.
87. None of the controlled substance prescriptions Respondent
issued to Patient D.D. between January 4, 2018, and February 12, 2019,
were issued for a legitimate medical purpose or by a practitioner
acting within the usual course of professional practice. Tr. 468:4-16.
According to Dr. Munzing, there is nearly no situation in which any
patient should receive the drugs that Respondent prescribed to Patient
D.D. between January 4, 2018, and February 12, 2019, in those dosages,
durations, and combinations, and Patient D.D. did not present any such
situation. Tr. 460-61.

[[Page 30588]]

F. Patient J.M.

88. Between January 10, 2017, and December 31, 2019, Respondent
issued to Patient J.M. the controlled substance prescriptions listed in
Joint Stipulation No. 25. See ALJ Ex. 3 at 10-12. During this time,
Respondent diagnosed Patient J.M. with back pain, GAD, and opioid
dependency. GX 11 at 18-42.
i. Patient J.M.'s Initial Visit
89. Respondent's initial encounter with Patient J.M. took place on
May 14, 2007. GX 11 at 104, 111; Tr. 471. At that visit, Respondent
diagnosed Patient J.M. with, inter alia, back pain and GAD. GX 11 at
104; Tr. 472. Respondent prescribed Patient J.M. hydrocodone for back
pain and 6 mg of Xanax per day for GAD. GX 11 at 104; 472. At this
initial visit, Respondent failed to:
a. Take an appropriate medical history, GX 11 at 104; Tr. 473-74
b. address Patient J.M.'s pain or functionality levels, GX 11 at
104; Tr. 474-75;
c. conduct an appropriate physical examination, GX 11 at 104; Tr.
474;
d. establish an appropriate diagnosis for back pain and so
establish a legitimate medical purpose to prescribe hydrocodone or
Soma, Tr. 475; or
e. establish and document a treatment plan with goals and
objectives, GX 11 at 104; Tr. 475-76.
ii. Controlled Substance Violations
90. Throughout the entire course of treatment, Respondent never
obtained a proper medical history of Patient J.M., never recorded
Patient J.M.'s pain or functionality levels, never obtained prior
medical records for Patient J.M.--nor does Patient J.M.'s medical file
reflect Respondent requested such records--failed to periodically
update Patient J.M.'s medical history as treatment progressed, and
never conducted a sufficient physical examination for pain. See
generally GX 11; Tr. 564-66.
91. None of Respondent's diagnoses of Patient J.M. for which he
prescribed controlled substances between January 10, 2017, and December
31, 2019, were based on sufficient medical evidence. Tr. 566.
92. Over the course of his treatment of Patient J.M., Respondent
frequently changed without comment the diagnoses for which he
prescribed Patient J.M. hydrocodone. See generally GX 11; Tr. 502-03,
504. These erratic diagnoses were outside of the standard of care,
[especially since these diagnoses,] including those made between
January 10, 2017, [were not supported by an adequate medical history
and physical examination.] Tr. 503-04.
93. Other than inquiring into smoking and alcohol use at Patient
J.M.'s initial visit, see GX 11 at 104; Tr. 475, Respondent did not
inquire about substance abuse until over two years later, on September
21, 2009, when he had Patient J.M. sign a form stating ``I have no
history of drug abuse, nor was I treated for drug or substance abuse in
the past.'' GX 11 at 115. Respondent never asked Patient J.M. about
substance abuse again as required by the California standard of care.
PFF ] 16; Tr. 481-82; see generally GX 11.
94. Respondent never documented an appropriate treatment plan with
goals and objectives for Patient J.M., never documented an appropriate
rationale for continued treatment of Patient J.M. with controlled
substances, and failed to properly discuss the risks and benefits of
the controlled substances he prescribed to Patient J.M. See generally
GX 11; Tr. 566-67.
95. Respondent also prescribed Patient J.M. the following dangerous
combinations of controlled substances, which put Patient J.M. at
serious risk of adverse medical consequences, including addiction,
overdose, and death, Tr. 505-10:
a. Hydrocodone, Xanax, and Soma (a combination referred to by
illicit users as ``the Holy Trinity,'' Tr. 506) in May of 2018, and
November of 2018. ALJ Ex. 3 at 11.
b. Hydrocodone and Xanax on 26 occasions between January 25, 2017,
and February 20, 2019. ALJ Ex. 3 at 10-11.
96. These combinations of drugs are highly sought after for abuse
and diversion. Tr. 505-06, 510. Indeed, there is almost never any
medical justification for prescribing a combination of hydrocodone,
Xanax, and Soma. Tr. 507-08. Specifically, this combination was
prescribed on January 25, 2017, June 19, 2017, August 14, 2017,
September 14, 2017, October 17, 2017, November 6, 2017, November 20,
2017, January 25, 2018, February 7, 2018, February 23, 2018, March of
2018, April 9, 2018, April 25, 2018, May 23, 2018, June 11, 2018, June
27, 2018, July 11, 2018, July 25, 2018, August 29, 2018, September 17,
2018, October 17, 2018, December 5, 2018, December 21, 2018, January of
2019, February 6, 2019, and February 20, 2019.
97. Respondent's prescriptions to Patient J.M. for Xanax between
January 10, 2017, and February 20, 2019, were repeatedly for at least 6
mg of Xanax per day. GX 11 at 26-42; ALJ Ex. 3 at 10-11. Prescribing
such high dosages of Xanax placed Patient J.M. at risk of potentially
lethal withdrawal, and presented risks of diversion. Tr. 217, 218-19.
The fact that Respondent often prescribed Xanax to Patient J.M.
concurrently with opioids, see ALJ Ex. 3 at 10-11, dramatically
increased his risk of overdose and death. Tr. 217-18.
98. Indeed, between January 10, 2017, and November 2, 2018,
Respondent repeatedly issued Patient J.M. substantially early
prescriptions for Xanax--issuing Patient J.M. 40 prescriptions for 90
units of Xanax 2 mg, or a prescription approximately every 17 days. ALJ
Ex. 3 at 10-11. This provided Patient J.M. with over 10.5 mg of Xanax
per day, or more than double the maximum recommended daily dose of 4
mg. Id.; Tr. 513-15.
99. Further, between January 10, 2017, and November 2, 2018,
Patient J.M. alternated filling his Xanax prescriptions at one of two
different pharmacies. Tr. 520-21; GX 17; GX 18. This was a significant
red flag or abuse and diversion, indicating that Patient J.M. was
seeking to avoid the pharmacies detecting how m

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