# Lon F. Alexander, M.D.; Decision and Order

> Briefs, arguments, decisions, and more.

URL: https://www.frixlaw.com/law-library/documents/fr%3A2017-23339

## Record

- **Collection:** Federal Register
- **Document type:** Notice
- **Published:** October 26, 2017
- **Citation:** 82 FR 49704

## Text

DEPARTMENT OF JUSTICE
Drug Enforcement Administration
[Docket No. 16-17]
Lon F. Alexander, M.D.; Decision and Order

On February 4, 2016, the Deputy Assistant Administrator, of the then Office of Diversion Control, issued an Order to Show Cause to Lon F. Alexander, M.D. (hereinafter, Respondent), of Hattiesburg, Mississippi. ALJ Ex. 1, at 1. The Show Cause Order proposed the denial of Respondent's application for a DEA Certificate of Registration as a practitioner, on the ground that his “registration is inconsistent with the public interest.”
Id.
(citing 21 U.S.C. 823(f)).

As for the Agency's jurisdiction, the Show Cause Order alleged that Respondent had previously held a registration which he surrendered for cause on January 16, 2014.
Id.
The Order further alleged that on January 9, 2015, Respondent applied for a new registration as a practitioner in schedules II through V, at the proposed registered address of 36 Bridgefield Turn, Hattiesburg, Mississippi.
Id.

As for the substantive grounds for the proceeding, the Show Cause Order raised multiple allegations to the effect that, on numerous occasions in 2011 through 2013, Respondent violated federal and state law by issuing controlled substance prescriptions to his wife “that were nontherapeutic, were for other than a legitimate medical purpose, and were issued outside of the usual course of [his] professional practice.”
Id.
at 1-3. The Show Cause Order alleged that Respondent “repeatedly issued” prescriptions for schedule IV controlled substances which included zolpidem tartrate, alprazolam, and diazepam, “when she was concurrently being issued prescriptions for the same or similar class of drugs by her own psychiatrist, which [he] did without [the] psychiatrist's knowledge or permission.”
Id.
The Order further alleged that Respondent's “actions dramatically increased the chances of [his] wife's dependency, overdose, or diversion of those controlled substances, while also potentially complicating her psychiatric condition.”
Id.
(citing 21 CFR 1306.04; Miss. Admin. Code Part 2640, Ch. 1, r. 1.7, 1.10, and 1.16; Miss. Code Ann. Sec. 73-25-29(3) & (13)).
1

1

See also
ALJ Ex. 1, at ¶¶ 5-6.

The Show Cause Order also alleged that on various occasions from 2011 through 2013, Respondent violated federal and state law by issuing his wife prescriptions for hydrocodone, then a schedule III narcotic, as well as other controlled substances, which were also nontherapeutic, for other than a legitimate medical purpose, and were outside the usual course of professional practice.
Id.
at 2-3. Specifically, the Show Cause Order alleged that “[o]n at least one occasion in 2011,” Respondent issued prescriptions for hydrocodone and diazepam “to [his] wife concurrently with another prescription [for clonazepam] issued by her . . . psychiatrist,” and that he did so “without her psychiatrist's knowledge or permission.”
Id.
at 2. The Order again alleged that Respondent's “actions dramatically increased the chances of [his] wife's dependency, overdose, or diversion of . . . controlled substance[s], while also potentially complicating her psychiatric condition.”
Id.
(citing same authorities as above).

Next, the Show Cause Order alleged additional instances of non-therapeutic prescribing by Respondent to his wife in that, “[o]n at least four different occasions in 2013,” he “repeatedly issued . . . prescriptions for hydrocodone . . . zolpidem tartrate . . . and alprazolam . . . when she was concurrently being issued other controlled substances prescriptions for the same or similar drugs, as well as amphetamines, by her . . . psychiatrist, which [he] did without his knowledge or permission.”
Id.
at 2-3. As with the previous allegations, the Order alleged that Respondent's “actions dramatically increased the chances of her dependency, overdose, or diversion of those controlled substances, while also potentially complicating her psychiatric condition.”
Id.
at 3 (citing same authorities as above).

The Show Cause Order also alleged that “[o]n at least fifteen different occasions between 2011 and 2013, [Respondent] violated state and federal law by issuing” to his wife prescriptions for hydrocodone, and/or zolpidem, and/or alprazolam, “without conducting any examination of [his] wife (or documenting such in her file) or noting the . . . prescriptions in her patient chart.”
Id.
(citing same authorities as above). The Show Cause Order then alleged that “[o]n at least nine occasions between 2011 and 2013, [Respondent] violated state and federal law by issuing” to his wife prescriptions for these drugs, “without conducting sufficient examinations of [her] (or documenting such in her file).”
Id.
(citing same authorities as above).

Finally, the Show Cause Order alleged that Respondent “engaged in conduct which may threaten public health and safety . . . by attempting to mislead DEA investigators.”
Id.
(citing 21 U.S.C. 823(f)(5)). Specifically, the Government alleged that, “on February 2, 2016, [Respondent] turned over to DEA in response to an administrative subpoena a record purporting to be the patient file” of his wife.
Id.
The Order alleged that the file “contained false entries” in that it contained “repeated reference to conversations with and attempts to contact [his wife's] treating psychiatrist” and that “DEA's investigation . . . indicate[s] that these statements and others presented as part of the purported patient file are false.”
Id.

Following service of the Show Cause Order, Respondent, through his counsel, requested a hearing on the allegations. ALJ Ex. 2. The matter was placed on the docket of the Office of Administrative Law Judges and assigned to ALJ Charles Wm. Dorman. Following pre-hearing procedures, the ALJ conducted an evidentiary hearing in Jackson, Mississippi on June 29-30, 2016, at which both parties elicited testimony from witnesses and submitted various documents for the record. Following the hearing, both parties submitted briefs of their proposed findings of fact, conclusions of law, and argument.

On September 20, 2016, the ALJ issued his Recommended Decision. Therein, with respect to Factors Two (Respondent's experience in dispensing controlled substances) and Four (compliance with applicable laws related to controlled substances), the ALJ found that the Government had proved that Respondent violated 21 CFR 1306.04, Mississippi Code Sec. 73-25-29(3) and 73-25-29(13), as well as Mississippi Administrative Rules 1.7, 1.10, and 1.16 when he issued numerous controlled substance prescriptions to his wife.

Specifically, the ALJ found that during 2011, Respondent issued nine zolpidem, two alprazolam, seven hydrocodone, and one diazepam prescription(s) in violation of these provisions. R.D. at 39-40. The ALJ also found that during 2012, Respondent issued five alprazolam prescriptions, and that during 2013, he issued 11 alprazolam prescriptions in violation of these provisions.
Id.
at 41-43. The ALJ further found that in 2013, Respondent issued five hydrocodone prescriptions and one zolpidem prescription in violation of these provisions.
Id.
at 44.

In addition to the above, the ALJ found that between 2011 and 2013,

Respondent prescribed hydrocodone 11 times, zolpidem 12 times, and alprazolam five times without documenting the prescriptions or a prior examination in his wife's patient file in violation of various provisions of Mississippi law and administrative rules.
Id.
at 46. He also found that on nine occasions when Respondent did document a prescription in his wife's file, he failed to include information required by state rules such as a medical history, examination results, or a diagnosis.
Id.
at 47-48 (citing Miss. Admin. Rule 1.4). The ALJ further concluded that “nothing in . . . Respondent's file for his wife necessarily indicates that [he] ever conducted any type of physical or mental status examination of his wife prior to prescribing controlled substances to her.”
Id.
at 48. He thus found proved the “allegation that the Respondent failed to conduct examinations and/or lacked adequate documentation of examinations of his wife” in violation of various provisions of Mississippi law and administrative rules.
Id.
at 49.

Turning to Factor Five (such other conduct which may threaten public health or safety), the ALJ rejected the allegation that Respondent attempted to mislead DEA investigators by providing to them the patient file containing false entries to the effect that he had made his wife's psychiatrist aware of the prescriptions.
Id.
at 49-52. The ALJ reasoned that it appeared that Respondent created the file “as he was treating his wife,” that he “did nothing more than turn over his file when ordered to do so by the . . . subpoena,” and that there was “[n]o evidence . . . that, after the DEA subpoenaed the file, [he] created false entries or altered the file he already maintained.”
Id.
at 51.

The ALJ nonetheless concluded that “Factors Two and Four weigh substantially in favor of denying . . . Respondent's application because he prescribed controlled substances to his wife for illegitimate and nontherapeutic purposes, outside the scope of professional practice, and because he did not appropriately document examinations of, any prescriptions to, his wife.”
Id.
at 52. The ALJ thus found “that the Government has made a
prima facie
case . . . that the Respondent's registration would be inconsistent with the public interest.”
Id.

The ALJ acknowledged that “[t]o rebut the Government's
prima facie
case, the Respondent must both accept responsibility for his actions and demonstrate that he will not engage in future misconduct.”
Id.
(citation omitted). The ALJ explained that a “[a] respondent
must
express remorse for all acts of documented misconduct, and
may
be required to acknowledge the scope of his misconduct.” R.D. 52 (citations omitted);
see also id.
at 54. The ALJ also explained that “[a]cceptance of responsibility and remedial measures are assessed in the context of the egregiousness of the violations and the [DEA's] interest in deterring similar misconduct by [the] Respondent in the future as well as on the part of others.”
Id.
at 52 (internal quotations and citations omitted).

The ALJ concluded that “Respondent's misconduct was egregious” in that he “repeatedly and wrongfully prescribed addictive, dangerous, and potentially harmful controlled substances to his wife for approximately three years,” which “interfered with his wife's treatment and could have caused her to overdose, lose consciousness, or die.”
Id.
at 53. The ALJ nonetheless concluded that Respondent had accepted responsibility for his misconduct in prescribing outside the usual course of practice because, by “[s]imply acknowledging that he failed to properly document his treatment of his wife, [he] admitted to practicing outside the usual scope of professional practice.”
Id.
at 54.

The ALJ also acknowledged Respondent's testimony “that he did not think that his actions increased his wife's chances of dependency, overdose, or diversion,” and that “[t]he Government's argument that that Respondent did not accept responsibility for putting his wife at risk is also understandable.”
Id.
The ALJ reasoned, however, that “a respondent is not required to admit to every single component of an allegation in order to accept responsibility.”
Id.
The ALJ then noted that in a proceeding before the Mississippi Board, “Respondent acknowledged that his prescriptions were probably hurting his wife and keeping her from getting appropriate treatment.”
Id.

As for the Government's contention that Respondent did not specifically acknowledge his misconduct in “failing to conduct examinations and/or conduct insufficient examinations prior to issuing” the prescriptions, the ALJ noted that this “is technically correct.”
Id.
at 54-55. The ALJ, however, rejected the Government's contention, reasoning that “the Government overlooks the central concern of this case, which is that the Respondent wrote prescriptions for his wife when he should not have.”
Id.
at 55. The ALJ then explained that “[i]n his view, the Respondent's acceptance of responsibility for failing to examine his wife before writing her a prescription is subsumed in his general acceptance of responsibility.”
Id.

While the ALJ acknowledged that Respondent declined “to admit that he violated federal laws because he did not want to speculate on what statutes he might have violated” and “testif[ied] that he did not know whether the prescriptions were outside the scope of his professional practice as the DEA defines those terms,” the ALJ reasoned that Respondent was not required to “identify the specific federal code provisions he violated, or interpret federal laws and apply them to his circumstances.”
Id.
at 56. The ALJ further explained that he found Respondent's remorse to be “sincere and that his commitment to adhere to all regulations governing controlled substances is genuine.”
Id.
at 56-57.

The ALJ further found that Respondent had undertaken “reasonable and appropriate” remedial measures.
Id.
at 59. As for the Agency's interest in specific deterrence, the ALJ suggested that it “might be negligible,” reasoning that Respondent “thoroughly understands that if he engages in any further misconduct he will face immediate sanctions from the” Physicians Health Program and the State Board “that will end his medical career.”
Id.
at 59. And while the ALJ noted that “Respondent's conduct was egregious,” he reasoned that the circumstances were unique because “every allegation of misconduct . . . involved . . . Respondent prescribing to only his wife.”
Id.
at 60. The ALJ then explained that Respondent's testimony in a State Board proceeding to the effect that his prescribing “was not a matter of judgment but a matter of the heart[] merits some consideration.”
Id.
The ALJ thus recommended that Respondent's application be granted subject to various conditions.
Id.
at 61-62.

The Government filed Exceptions to the Recommended Decision. In its Exceptions, the Government contended that the ALJ committed error in concluding that Respondent has sufficiently accepted responsibility for his misconduct. Exceptions, at 3-15. The Government also contended that the ALJ committed error in concluding that Respondent is entitled to a new registration notwithstanding the egregiousness of his misconduct.
Id.
at 16-20. The Government thus argues that I should deny Respondent's application.
Id.
at 20. Respondent did not file a response to the Government's Exceptions.

Thereafter, the ALJ forwarded the record to me for final agency action. Having considered the record in its

entirety including the Recommended Decision, the parties post-hearing briefs and the Government's Exceptions, I adopt the ALJ's findings of fact (while making several additional findings as to prescriptions) and legal conclusions with respect to paragraphs two through ten of the Show Cause Order. I conclude, however, that the Government's Exception to the ALJ's legal conclusion that Respondent has sufficiently accepted responsibility for his misconduct is well taken. Accordingly, I deny his application. I make the following factual findings.

Findings of Fact

Respondent's Registration and Licensure Status

Respondent is a neurosurgeon licensed by the Mississippi State Board of Medical Licensure. R.D. 3 (citing Stipulation of Fact No. 4); Tr. 481-82. Respondent also previously held a DEA Certificate of Registration, pursuant to which he was authorized to dispense schedule II through V controlled substances as a practitioner. GX 1, at 1. However, on January 17, 2014, Respondent surrendered this registration for cause.
Id.
According to Respondent, he agreed to surrender his registration at the time of the State Board hearing that suspended his medical license. Tr. 485. On January 9, 2015, Respondent applied for a new practitioner's registration seeking authority to dispense controlled substances in schedules II through V, at a registered address in Hattiesburg, Mississippi. R.D. 3 (citing Stipulation of Fact No. 1).

In 2008, Respondent referred himself to the Betty Ford Center, “when [he] realized [he] had a problem with prescription medicines” and spent 90 days in treatment. Tr. 487. According to Respondent, “[o]nce [he] went to the Betty Ford Center, [he] disclosed to the MPHP [Mississippi Physician's Health Program] and ultimately the [B]oard of [M]edicine that [he] was now a participant.”
Id.
at 488.

In May 2008, Respondent entered into a Recovery Contract Agreement (hereinafter, recovery contract, contract, or RCA) with the MPHP. GE 14, at 13. The RCA's terms included that he completely abstain from mood-altering addictive substances, that he not treat himself or his family, that he undergo random drug screens, and that he be honest.
Id.; see also
R.D. at 4.
2

2
The ALJ noted that these facts, which are based on the testimony of Dr. Hambleton, the Director of the MPHP, at Respondent's January 15, 2015 Board Hearing, are “
not
necessarily proven by a preponderance of the evidence.” R.D. 4. The Director was, however, placed under oath in the State Board proceeding. GE 14, at 11. He also testified in this proceeding and explained that with the exception of its duration, the terms of Respondent's current RCA (which “is his fourth contract”) are the same as they were for his previous contracts. Tr. 452. Notably, his current contract requires that, “[o]ther than cases of medical emergencies, I agree to abstain from the use of any mood-altering, addictive, or potentially addictive prescription medication, including amphetamine preparations, without written permission from MPHP.” RX C, at 2. The RCA's terms also state that “I agree not to prescribe, dispense or administer to family members or myself any drug having addiction-forming or addiction-sustaining liability.”
Id.

In March 30, 2012, Respondent tested positive for Tramadol. He then returned to the Betty Ford Center for one month, after which he was discharged with a diagnosis of opioid dependence. GE 14, at 14-16. The MPHP did not, however, withdraw its advocacy on his behalf, and on June 11, 2012, Respondent entered into a new RCA which contained the same terms as the previous RCA, including the prohibition on prescribing to family members.
Id.
at 16-17.

On September 10, 2012, Respondent met with the Mississippi Professionals Health Committee due to its concerns that he had “missed callings for random drugs screens,” had failed to attend Caduceus meetings, failed to continued his aftercare therapy, failed to pay his bill for the drug screen testing, and had “fail[ed] to turn in his support group attendance records.”
Id.
at 19-20. According to Dr. Hambleton's testimony at the second State Board hearing, the committee “warned [Respondent] very carefully that any future noncompliance would result in [the] potential loss of [the] MPHP['s] advocacy” and “that this was really his last chance to demonstrate that he could do what was necessary to prove that he's safe.”
Id.

While Respondent was compliant with the issues raised by the committee, the committee was unaware that Respondent had been violating his RCA by writing controlled substance prescriptions for his wife.
Id.
at 20-21. According to Dr. Hambleton, he did not know that Respondent had been calling in controlled substance prescriptions for his wife until the State Board informed him on October 7, 2013.
Id.
Dr. Hambleton also testified in the State Board proceeding that Respondent did not disclose this information to his “treatment providers at Betty Ford, to our committee, or [to] our staff at MPHP.”
Id.

On October 15, 2013, the MPHP, having concluded that Respondent's “continued practice of medicine represent[ed] a definite threat to the public health” withdrew its advocacy on behalf of Respondent. GE 14, at 23. Eight days later, the Board issued Respondent an order of prohibition which barred him from practicing medicine until further notice. GE 13, at 5.

Thereafter, Respondent was charged with two counts of violating the State's Medical Practice Act, including violating an existing Board Order, Stipulation or Agreement,
see
Miss. Code Ann. Sec. 73-25-29(13), and engaging in unprofessional conduct, by engaging in dishonorable or unethical conduct. GE 14, at 5;
see also
Miss. Code Ann. Sec. 73-25-29(8)(d) (unprofessional conduct includes “[b]eing guilty of any dishonorable or unethical conduct likely to deceive, defraud or harm the public”).

On January 16, 2014, the Board held a hearing on the allegations at which Respondent appeared. As the record of the hearing shows, the allegations were based on Respondent's violations of his RCA, particularly in his prescribing of controlled substances to his wife. Also at issue was his lack of honesty in failing to disclose his prescribing to his treatment providers as well as the MPHP committee and the MPHP's staff. GE 14, at 21.

Following the hearing, the Board found Respondent guilty on both counts and suspended his medical license for one year, after which he was entitled to petition the Board for reinstatement of his license.
Id.
at 91. The Board ordered that he “successfully complete multidisciplinary treatment at a treatment facility approved in advance by the MPHP,” as well “establish a provisional contract [and] take those steps necessary to obtain affiliation and advocacy with the MPHP.” GE 13, at 7-8.

On January 15, 2015, Respondent appeared before the Board seeking reinstatement. At the hearing, Dr. Hambleton (the MPHP Medical Director) testified in support of Respondent's petition, stating that he “complied with all of our requirements and he's begun the treatment process at Acumen.”
Id.
at 13. Dr. Hambleton further expressed his “belief . . . that he will comply with his contract.”
Id.
At the conclusion of the testimony, the Board reinstated Respondent's medical license.
Id.
at 15.

The DEA Investigation

At some point not clearly established on the record, a DEA Diversion Investigator (DI) assigned to the Jackson, Mississippi office opened an investigation into Respondent's

prescribing practices.
3

Tr. 31, 90. As the DI explained, Respondent's “history with the Medical Board . . . gave us pause, so we began an investigation into . . . his prescribing habits.”
Id.
The DI testified that he had access to the Board's investigation, Tr. 22 & 32, and obtained reports from the State's Prescription Monitoring Program showing Respondent's controlled substance prescribing.
Id.
at 22-23. Specifically, the DI obtained a “Prescriber Activity Report” showing Respondent's prescriptions from January 1, 2011 through December 31, 2013. Tr. 24; GX 10. The DI also obtained a PMP report using the various names of Respondent's wife for the same period. Tr. 29; GX 11. Of note, however, GX 10 contains a number of prescriptions which Respondent issued to his wife which are not listed on GX 11.
4

3
Earlier in his testimony, the DI stated that the investigation was prompted by Respondent's 2015 application. Tr. 31. Yet later in his testimony, the DI stated that the case was opened earlier, after the Board provided DEA “with documentation regarding his history with them.” Tr. 90. The DI explained that “[w]hen we obtain information from the Medical Board, whether or not somebody's applied for a DEA license or not, we have to document that information . . . the different allegations that the Board has made[,] or evidence that they may have against a physician.”
Id.
at 90-91.

4
According to the DI, when calling in the prescriptions, Respondent used “several different variations of” his wife's name. Tr. 38.

In reviewing the PMP reports, the DI found it suspicious that Respondent was prescribing controlled substances to his wife as “she was seeing a psychiatrist, Dr. Mark Webb, during that timeframe.” Tr. 30. The DI “noticed multiple prescriptions” which Respondent authorized for drugs that his wife “was receiving” from Dr. Webb.
Id.
at 31. The DI further explained that he was “aware that [Respondent] was married to . . . Ms. Alexander, so [I] knew there was a pretty good assumption that he was aware that she was receiving these medications, because she had seen Dr. Webb for such a long time.”
Id.
at 32. According to the DI, during a phone conversation with Respondent's wife “[s]he advised that she needed the medications” and that Respondent had written “her some prescriptions, but that she didn't feel like that was a problem.”
Id.
at 33. Respondent's wife also told the DI that “she didn't know if her husband had patient files . . . for her [but] that he did prescribe some prescriptions to her.”
5

Id.
at 34.

5
According to the DI, during this conversation, he told Respondent's wife (who holds a DEA registration as a Nurse Practitioner) that she appeared to be obtaining controlled substances “from multiple doctors, including her husband” and that he “would potentially be asking her to surrender her DEA license because of that.” Tr. 33-34. The DI testified that shortly after this conversation, he was contacted by Respondent's counsel, who advised that he was also representing Respondent's wife and was told “not to contact her anymore unless there, you know.”
Id.
at 34. The DI did not clarify what conditions Respondent's counsel asserted during this conversation.
Id.
The DI did not subsequently speak to Respondent's wife.
Id.

Thereafter, the DI visited Dr. Webb and “asked him if he was aware” that Respondent's wife was “receiving these prescriptions from” Respondent.
Id.
Dr. Webb “said that he was not” and asked the DI to “look into it further.”
Id.
Following the visit, the DI served a subpoena on Dr. Webb and obtained his patient file for Respondent's wife.
Id.
at 35; GX 3, at 1-2. Dr. Webb's file for Respondent's wife was entered into evidence as GX 5. Tr. 68-75.

The DI also obtained some of “the hard copy prescriptions from several different pharmacies throughout” the State.
6

Tr. 35-36. The DI presented the prescriptions to Dr. Webb and asked him: “were these authorized? Did you know?”
Id.
at 36. Dr. Webb “again maintained that he did not” know about the prescriptions.
Id.

6
According to the DI, he provided the pharmacies with the prescription numbers, Respondent's wife's name, and her date of birth. Tr. 38.

The DI also served a subpoena on Respondent for “[a]ny and all charts, files and/or documents, written, typed or computerized, relating to” his wife. GX 4, at 1. A ten-page exhibit of Respondent's Medical Progress Notes for his wife was entered into evidence as GX 6. Tr. 67.

Dr. Webb's Testimony

The Government called Dr. Mark Webb as a fact witness. Dr. Webb testified that he has practiced psychiatry in Mississippi since 1990 and that Respondent's wife has been his patient since November 2000.
Id.
at 102, 105. Dr. Webb acknowledged that he prescribes both controlled and non-controlled substances and that for most of the patients who are treated with controlled substances, he prescribes only “two weeks' worth of medications” so that “it's a tighter leash.”
Id.

According to Dr. Webb, he has “known [Respondent] for a long time” and the two “referred patients back and forth in the 90s and the early 2000[s].”
Id.
at 110. Dr. Webb testified that he saw Respondent's wife at his request.
Id.
He also testified that during the 2011 through 2013 period, his medication regimen for Respondent's wife was to prescribe “an anti-depressant,” an Attention Deficit Disorder (ADD) medication such as Adderall XR, a sleeping medication such as Ambien or Restoril, and an anxiety medication such as Xanax or Clonazepam.
Id.
at 204.

Dr. Webb testified that while he and Respondent “talked a lot in the 90s and the early 2000s,” they have “talked less and less over the last 10 years.”
Id.
at 110. Dr. Webb testified that his records show that he had talked to Respondent “about four times” in the period from January 2011 to December 2013.
Id.
at 111;
see also
GX 7, at 1 (memo prepared by Dr. Webb memorializing meeting with DEA noting that he had talked with Respondent on Dec. 20, 2011, Feb. 20, 2012, Sept. 4, 2012, and Aug. 5, 2013).

According to Dr. Webb, Respondent “would call me whenever he felt [his wife] was in a crisis . . . to give me that information and to . . . garner some help from me to her.” Tr. 110. Dr. Webb testified that he never had a discussion with Respondent about the latter's prescribing controlled substances to his wife.
Id.; see also id.
at 138. When then asked if Respondent had contacted him and told him that he had prescribed because his wife had “run out” and “need[ed] some” medication on a temporary basis, Dr. Webb answered “no” and explained that “that would not make a lot of sense,” because he (Dr.Webb) “would be the person authorized that needed to call that in.”
Id.
at 111. While Dr. Webb testified that there was an instance during which he “walked out to the car with [Respondent's wife] . . . and [Respondent] was in the car with their newborn son,” and they “chit-chatted [for] two seconds,” there was no discussion of Respondent's prescribing of controlled substances to his wife.
Id.
at 111-12;
see also
R.D. 16 (ALJ Finding of Fact No. 28). Dr. Webb also testified that he did not have a conversation with Respondent's wife about Respondent's prescribing to her until either late in 2015 or 2016. Tr. 174-75.

Dr. Webb testified that DEA Investigators showed him the ten pages of notes Respondent created with respect to the prescriptions he issued for his wife and that he compared them with the patient file he maintained on Respondent's wife.
Id.
at 116. However, “none of” the dates in the records created by Respondent “correspond[ed] to [Dr. Webb's] treatment records.”
Id.
at 16 (quoting GX 9 (memo created by Dr. Webb re: Feb. 25, 2016 meeting with DEA)). In his testimony, Dr. Webb adhered to his statement in the memo that he “did not speak to [Respondent] on these times in question and certainly would not have authorized him to call in medication for my patient.” GX 9; Tr. 117. As he testified, “[t]here's no reason for somebody else to call in the

prescriptions. That's my job.” Tr. 117. Subsequently, Dr. Webb reiterated that he did not authorize Respondent to issue any prescriptions to his wife during the relevant time frame.
Id.
at 119.

Respondent's Prescriptions for His Wife

The evidence shows that between January 1, 2011 and October 14, 2013 (when his medical license was suspended), Respondent issued the following controlled substances prescriptions for his wife.
7

7
The “fill dates” are used to identify these prescriptions because some of the prescriptions are not dated or bear illegible dates.

1. January 9, 2011, eight tablets of alprazolam (Xanax) 1 mg, one tablet to be taken twice day, a four-day supply. GE 10, at 85; GE 11, at 14; GE 29, at 1-2. The record does not establish when Dr. Webb had last prescribed alprazolam to Respondent's wife.
8

Respondent did not document the prescription in the patient file he maintained for his wife.
See generally
GE 6. Nor did he inform Dr. Webb that he had issued the prescription.

8
The ALJ found that this prescription overlapped with a 30-day prescription for zolpidem tartrate (Ambien) from Dr. Webb, which was filled on January 8, 2011. R.D. 16. Given that Dr. Webb testified that he was prescribing both Xanax for anxiety and Ambien for sleep to Respondent's wife simultaneously, the record does not establish that these were overlapping prescriptions.

2. January 31, 2011, 30 tablets of zolpidem tartrate (Ambien) 10 mg, a 15-day supply. GE 10, at 19; GE 11, at 14. Notably, on January 8, 2011, Respondent's wife had refilled a prescription issued by Dr. Webb on August 31, 2010 for 60 tablets, this being a 30-day supply. GE 11, at 14. Thus, if taken as directed, the refill of Dr. Webb's prescription should have last Respondent's wife until February 7, 2011. On February 3, 2011 (only three days later), Dr. Webb prescribed 60 units of zolpidem 10 to Respondent's wife. GE 11, at 13. GE 5, at 112. Respondent did not document the prescription in the patient file he maintained for his wife. GE 6. Nor did he inform Dr. Webb that he issued the prescription.

3. February 7, 2011, 20 tablets of hydrocodone/acetaminophen (Lorcet) 7.5-650, a three-day supply. GE 10, at 23; GE 11, at 13;
see generally
Tr. 373-74 (testifying that her husband prescribed hydrocodone for her once in 2011). Other than on one occasion in June/July 2013, which is discussed below, Dr. Webb did not prescribe hydrocodone to Respondent's wife. Moreover, the PMP report does not list any hydrocodone prescriptions that were issued by any other provider until November 30, 2011. GE 11, 11. Respondent did not document this prescription in the patient file he maintained on his wife.
See generally
GE 6. He also did not disclose the prescription to Dr. Webb.

4. March 30, 2011, 30 tablets of zolpidem tartrate (Ambien) 10 mg, with a dosing instruction of one tablet at bedtime but “may repeat for early,” a 15-30-day supply. GE 10, at 85; GE 11, at 13; GE 30, at 1-2. Notably, the zolpidem prescription which Dr. Webb issued on February 3, 2011 (RX #949559) provided for multiple refills, as it was refilled by Respondent's wife on April 9, 2011, May 23, 2011, and July 7, 2011. GE 11, at 13; Tr. 254-55. Respondent did not document the prescription in the patient file he maintained on his wife. GE 6. Nor did he inform Dr. Webb that he issued the prescription.

5. April 8, 2011, 15 tablets of hydrocodone/acetaminophen (Lorcet) 10-650, one tablet every six hours as needed, a three-day supply. GE 10, at 85; GE 11, at 13; GE 31, at 1-2. As explained above, other than in June/July 2013, Dr. Webb did not prescribe this drug to Respondent's wife, and no other physician prescribed hydrocodone to her until November 30, 2011. Respondent did not document the prescription in the patient file. GE 6. He also did not disclose the prescription to Dr. Webb.

6. May 6, 2011, 30 tablets of zolpidem tartrate (Ambien) 10 mg, one tablet at bedtime but “may repeat,” a 30-day supply. GE 10, at 85; GE 11, at 13; GE 32, at 1-2. As discussed above, Respondent's wife still had refills available for 60 dosage units based on the prescription issued by Dr. Webb on February 3, 2011, and eventually refilled the prescription on May 23, 2011. GE 11, at 13; Tr. 255. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose the prescription to Dr. Webb.

7. May 14, 2011, 14 tablets of hydrocodone/acetaminophen (Lorcet) 10-650, a two-day supply. GE 10, at 19; GE 11, at 13. As explained above, other than in June/July 2013, Dr. Webb did not prescribe this drug to Respondent's wife, and no other physician prescribed hydrocodone to her until November 30, 2011. Respondent did not document the prescription in the patient file. GE 6. Nor did he disclose the prescription to Dr. Webb.

8. June 28, 2011, 30 tablets of zolpidem tartrate (Ambien) 10 mg, a 30-day supply. GE 10, at 84; GE 11, at 12. Respondent's wife still had a refill available for 60 dosage units based on the prescription issued by Dr. Webb on February 3, 2011, and eventually refilled the prescription on July 7, 2011. GE 11, at 12. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose it to Dr. Webb.

9. July 15, 2011, prescription (assigned RX # 4002009 by the pharmacy) for 28 tablets of hydrocodone-acetaminophen (Lorcet) 10-650, a five-day supply. GE 10, at 64. This prescription also authorized a refill, which Respondent's wife obtained on July 29, 2011.
Id.
As explained above, other than in June/July 2013, Dr. Webb did not prescribe this drug to Respondent's wife, and no other physician prescribed hydrocodone to her until November 30, 2011. Respondent did not document the prescription in the patient file. GE 6. Nor did he disclose the prescription to Dr. Webb.

10. July 31, 2011, 12 tablets of zolpidem 10 mg, one tablet at bedtime, a 12-day supply, with one refill. GE 10, at 84; GE 11, at 12; GE 33, at 1-2. As found above, on July 7, 2011, Respondent's wife obtained a refill of a prescription for 60 zolpidem issued by Dr. Webb, which, if taken as directed, should have lasted her until August 6, 2011 (this being in addition to the 30 zolpidem prescription Respondent issued on June 28, 2011). GE 11, at 12; Tr. 251-53. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose the prescription to Dr. Webb.

11. August 13, 2011, 20 tablets of alprazolam (Xanax) 1 mg, one-half to one tablet, to be taken twice a day, a 10-20-day supply. GE 22, at 1-2.
9

Notably, on August 4, 2011, Respondent's wife had refilled a prescription issued by Dr. Webb for 45 alprazolam 2 mg, a 15 day supply. GE 11, at 12. Thus, if taken as directed, this refill should have lasted Respondent's wife until August 19, 2011. Moreover, on August 16, 2011, Dr. Webb issued Respondent's wife a new prescription for 90 alprazolam 2mg, a 30-day supply.
Id.
Respondent did not document the prescription in his wife's patient file.
See generally
GE 6.
10

Nor

did he disclose the prescription to Dr. Webb.

9
Although this prescription was filled on August 13, 2011,
see
GE-22, at 2, it does not appear on Mrs. Alexander's PMP.
See
GE-11, at 12. However, a copy of the prescription and the fill sticker is in the record. GE 22.

10
The Respondent's patient file for his wife mentions a prescription for 20 tablets of Xanax, 2 mg, dated July 13, 2011.
See
GE-6, at 1. The patient file says he prescribed Xanax because “Jill out of Xanax—in Philadelphia—Has had twitching—[illegible] Dr. Webb has not called back.” GE-6, at 1. Dr. Webb, however, had no notes in his file about any attempt by the Respondent to contact him on July 13, 2011.
See
Tr. 126. However, neither the

PMP reports, nor the copies of the prescriptions, support a finding that Respondent issued an alprazolam prescription on or about this date.

12. August 28, 2011, 12 tablets of zolpidem tartrate (Ambien) 10 mg, a 12-day supply. GE 10, at 19. Notably, on August 16, 2011, Respondent's wife had obtained and filled a new prescription from Dr. Webb for 60 zolpidem, a 30-day supply. GX 11, at 12. If taken as directed, Dr. Webb's prescription should have lasted Respondent's wife until September 15, 2011. Moreover, as found above, Respondent had also provided a refill when he issued the July 31, 2011 prescription (RX# 443737), and this refill was still available to his wife on August 28, 2011. GE 11, at 12. Respondent did not document the prescription in the patient file.
See generally
GE 6. He also did not disclose the prescription to Dr. Webb.

13. September 6, 2011, 12 tablets of zolpidem tartrate (Ambien) 10 mg, a 12-day supply, this being a refill authorized by Respondent's July 31, 2011 prescription. GE 11, at 12. As discussed in the preceding paragraph, Dr. Webb's August 16, 2011 prescription should have lasted Respondent's wife until September 15, 2011. In addition, Respondent's August 28, 2011 prescriptions provided his wife with additional medication in excess of what Dr. Webb had prescribed. As found above, Respondent did not document the original prescription in the patient file nor disclose it to Dr. Webb.
See generally
GE 6.

14. September 28, 2011, 16 tablets of hydrocodone/apap 10/650, a four-day supply with one refill.
See
GE 10, at 64. As explained above, other than in June/July 2013, Dr. Webb did not prescribe this drug to Respondent's wife, and no other physician prescribed hydrocodone to her until November 30, 2011. Respondent did not document the prescription in the patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

15. October 11, 2011, 20 tablets of zolpidem tartrate (Ambien) 10 mg, one tablet at bedtime, a 20-day supply. GE 10, at 84; GE 11, at 11; GE 34, at 1-2; Tr. 249. Of note, on September 19, 2011, Respondent's wife had refilled Dr. Webb's August 16, 2011 prescription and obtained 60 tablets, a 30-day supply. GE 11, at 12. If taken as directed, the September 19 refill should have lasted Respondent's wife until October 19. GE 11, at 12; Tr. 248-49. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose it to Dr. Webb.

16. October 20, 2011, 16 tablets of hydrocodone-acetaminophen (Lorcet) 10-650, a four-day supply, this being a refill of the September 28, 2011 prescription. GE 10, at 64. As explained above, other than in June/July 2013, Dr. Webb did not prescribe this drug to Respondent's wife, and no other physician prescribed hydrocodone to her until November 30, 2011. As found above, Respondent did not document the prescription or the refill in the patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

17. November 13, 2011, 18 tablets of clonazepam 2mg, a six-day supply. GE 10, at 19. Notably, on November 3, 2011, Respondent's wife had refilled a prescription issued by Dr. Webb on October 19, 2011 for 45 dosage units, a 15 day supply. GE 11, at 11. If taken as directed, the November 3 refill should have lasted Respondent's wife until November 18, 2011. Moreover, on November 15, 2011, only two days after filling the prescription she obtained from her husband, Respondent's wife obtained a further refill of Dr. Webb's prescription for 45 dosage units of clonazepam. GE 11, at 11. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose it to Dr. Webb.

18. November 25, 2011, 10 tablets of clonazepam 2 mg, a three-day supply. GE 10, at 63. If taken as directed, by itself, the November 15, 2011 refill should have lasted Respondent's wife until November 30, 2011. Respondent did not document the prescription in the patient file. GE 6. Nor did he disclose it to Dr. Webb.

19. November 29, 2011, four tablets of hydrocodone/acetaminophen (Lorcet) 10-650 mg, one tablet to be taken four to six times a day, a one-day supply. GE 26. Respondent did not document the prescription in the patient file. GE 6. He also did not disclose the prescription to Dr. Webb.

20. Also on November 29, 2011, one Diastat Acudial, 5-7.5-10 mg kit. GE 10, at 92; GE 11, at 11; GE 28, at 1. Diastat Acudial is a rectal suppository of diazepam, which is also a benzodiazepine and a schedule IV controlled substance.
11

Tr. 260-61; 21 CFR 1308.14(c). Respondent did not document the prescription in the patient file.
See
GX 6. Nor did he disclose it to Dr. Webb.

11
Dr. Chambers, the Government's Expert testified that this prescription “is a bit puzzling because it's clear she's taking oral meds and usually that's reserved for people who can't take” the oral form of the drug. Tr. 259.

21. December 5, 2011, 10 tablets of hydrocodone-acetaminophen (Lorcet) 10-650, a three-day supply. GE 10, at 63. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose it to Dr. Webb.

22. December 27, 2011,
12

30 tablets of zolpidem tartrate (Ambien) 10 mg, one tablet a day at bedtime, a 30-day supply. GE 10, at 80; GE 21, at 1-2. However, on December 16, 2011, Respondent's wife had obtained a refill of Dr. Webb's August 16, 2011 prescription for 60 dosage units, a 30-day supply. GE 11, at 11. Thus, if taken as directed, the December 16 refill should have lasted Respondent's wife until January 15, 2012. In Respondent's patient file for his wife, he documented: “Jill not sleeping. Holiday schedule at Mississippi Neuropsychiatric—stress of house repossession and moving in with mother-in-law. Erratic. Bugs. Ambien 10 mg #30 [one to two orally at bedtime]. No response on-call dr.” GE 6, at 1. Respondent did not disclose the prescription to Dr. Webb.

12
The Government established that this was a Tuesday. Tr. 190.

23. January 7, 2012, 28 tablets of zolpidem 10 mg, a 28-day supply. GE 10, at 63. As found above, on December 16, 2011, Respondent's wife had obtained a refill of Dr. Webb's prescription and obtained medication that should have lasted her until January 15, 2012. Moreover, on December 27, 2011, she filled the prescription Respondent wrote her for 30 more tablets. Respondent's patient file for his wife does not document the issuance of a zolpidem prescription on this date, but rather on January 10, 2012.
See generally
GE 6. That entry states: “Jill Philadephia at M-I-L house,” “Pills discarded—tension—No vehicles (Bankruptcy).” GE 6, at 2. The entry then lists a prescription for 30 Ambien 10 mg, with a dosing instruction of one tablet by mouth per day.
Id.
Moreover, Respondent did not disclose the prescription to Dr. Webb.

24. January 16, 2012, 30 tablets of alprazolam (Xanax) 2 mg, to be taken “as directed.”
13

GE 23, at 1-2. However, on January 5, 2012, Respondent's wife had refilled a prescription (Rx# 976879) issued by Dr. Webb for 45 tablets, a 15-

day supply, and that prescription had an additional refill remaining which Respondent's wife obtained on February 14, 2012. GE 11, at 10. In his wife's patient file, Respondent wrote: “Dr. Webb wants Jill to come in. Difficult [with] transportation—Will Rx 10 day supply til 1/26/12—Webb aware—Xanax 2 mg #30 [two orally three times a day].” GE 6, at 2. Dr. Webb testified, however, that neither Respondent nor Respondent's wife ever told him about any prescription issued by Respondent.
14

Tr. 115-17, 119, 138, 174-75;
see also
R.D. 16 (Finding of Fact No. 28).

13
While neither PMP report contains an entry for an alprazolam prescription issued by Respondent for his wife on this date, Government Exhibit 23 contains a copy of the prescription and the fill sticker showing that on January 16, 2012, Respondent issued, and his wife filled a prescription for 30 alprazolam 2 mg. Notwithstanding that the prescription appears to be dated “1/16/11,” the fill sticker states that the prescription was written on “01/16/12.” GX 23, at 1-2.

14
January 16, 2012 was a Monday. Tr. 190.

25. February 26, 2012, 20 tablets of diazepam 5 mg, a six-day supply. GX 11, at 10. Of note, on February 23, 2012, Respondent's wife had obtained and filled a new prescription from Dr. Webb for 45 alprazolam 2 mg, a 15-day supply; this prescription (Rx# 982872) also authorized three refills.
Id.
at 10-11. Diazepam and alprazolam are both benzodiazepines and are used to treat anxiety. Tr. 259. Dr. Webb did not prescribe diazepam to Respondent's wife.
See generally
GE 11; Tr. 204; GX 5. Respondent did not document the prescriptions in his wife's patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

26. March 4, 2012, 30 tablets of zolpidem10 mg, a 30-day supply. GE 10, at 13; GE 11, at 10. Of note, on February 23, 2012, Respondent's wife obtained and filled a prescription from Dr. Webb for 30 zolpidem, a 15-day supply. GE 11, at 10. If taken as directed, Dr. Webb's prescription should have lasted Respondent's wife until March 9, 2012. Moreover, Dr. Webb's Feb. 23 prescription provided for two refills, the first of which Respondent's wife obtained on March 19, 2012, respectively. GE 11, at 10. Respondent did not document the prescription in the patient file.
See generally
GE 6. Nor did he disclose the prescription to Dr. Webb.

27. March 12, 2012, 12 tablets of alprazolam (Xanax) 2 mg, one tablet to be taken three times a day, a four-day supply. GE 10, at 80; GE 20. As found above, on February 23, 2012, Dr. Webb issued a prescription for 45 tablets of alprazolam 2 mg, a 15-day supply, which authorized three refills. GE 11, at 9-10. In the patient file, Respondent wrote: “Out of Xaax [sic] x 5 days—Jerky & twitching—feels like Extreme anxiety—digging at arms [-] delusional parasitosis? Will give 4 day supply—[illegible] talk to Dr. Webb—Xaax [sic] 2 mg #12,” followed by the dosage instruction of one tablet by mouth, three times a day.” GE 6, at 3. Respondent's wife had available a refill of Dr. Webb's February 23 prescription which she could have filled on this date (without being early) but which she did not fill until March 19, 2012. GE 11, at 10. Respondent did not disclose the prescription to Dr. Webb.

28. March 12, 2012, 30 tablets of zolpidem 10 mg, 30-day supply. GE 10, at 80. As found above, on March 4, 2012, Respondent prescribed 30 zolpidem (a 30-day supply) for his wife which she filled the same day. GE 11, at 10. If taken as directed, Respondent's March 4 prescription should have lasted until April 3, 2012. Also, Dr. Webb's Feb. 23, 2012 prescription (for 30 tablets) authorized multiple refills and Respondent's wife obtained a refill on March 19, 2012.
Id.
Respondent did not document the prescription in his wife's patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

29. April 1, 2012, 24 tablets of zolpidem tartrate (Ambien) 10 mg, a 24-day supply. GE 10, at 13; GE 11, at 10. Putting aside that Respondent's March 4 prescription should have lasted through April 3, 2012, as found above, Respondent's wife obtained 30 tablets on March 12 when she filled his prescription and another 30 tablets on March 19, when she refilled Dr. Webb's Feb. 2, 2012 prescription. GE 11, at 10. Respondent did not document the prescription in his wife's patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

30. April 2, 2012, 120 units of hydrocodone-homatropine syrup (Hycodan), one teaspoon every four to six hours as needed. GE 19, at 1-2.
15

Respondent did not document the prescription in his wife's patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

15
Although this prescription does not appear on either of the PMP reports, the Government produced both the prescription and the fill sticker showing that the drug was dispensed on April 2, 2012.
See
GE 19, at 2.

31. June 18, 2012, 20 tablets of alprazolam (Xanax) 2 mg, one tablet to be taken twice a day, a 10-day supply. GE 10, at 75; GE 11, at 9; GE 15, at 1-2; Tr. 262. Respondent's wife still had a refill remaining on Dr. Webb's Feb. 23, 2012 prescription for 45 alprazolam, which she filled on July 5, 2012. GE 11, at 9. Respondent did not document the prescriptions in his wife's patient file.
See generally
GE 6. Nor did he disclose the prescription to Dr. Webb.

32. July 17, 2012, 20 tablets of alprazolam (Xanax) 2 mg, one tablet twice a day, a 10-day supply. GE 10, at 13; GE 11, at 9;
see
Tr. 262-63. As noted above, on July 5, 2012, Respondent's wife obtained 45 tablets (15 days) of alprazolam when she refilled Dr. Webb's prescription. GE 11, at 9. In a note (dated July 14, 2012) in his wife's patient file, Respondent wrote: “she had done very well without medicine—even though extremely stressful living conditions. . . . 4 month no meds—depressed, crying, jittery—Has been in contact [with] Dr. Webb. . . . She feels self harm—but no SI. Xanax 2 mg #20 6 day supply.” GE 6, at 4; Tr. 130. Respondent did not disclose the prescription to Dr. Webb, and Dr. Webb did not talk to the Respondent's wife on July 14, 2012.
See generally
GE 5; Tr. 131. Dr. Webb also testified that neither Respondent nor Respondent's wife ever told him about any prescription issued by Respondent. Tr. 115-17, 119, 138, 174-75;
see also
R.D. 16 (Finding of Fact No. 28).

33. August 13, 2012, 30 tablets of hydrocodone/acetaminophen, 10-650, one tablet every four hours, a five-day supply. GE 10, at 80; GE 11, at 9; GE 16, at 1. Respondent did not document the prescription in his wife's patient file.
See
GE 6. Nor does the PMP report show that any other doctor prescribed hydrocodone to Respondent's wife between December 22, 2011 and December 16, 2012. GE 11, at 8-10. Respondent did not disclose the prescription to Dr. Webb.

34. October 5, 2012, 12 tablets of alprazolam (Xanax) 2 mg, a four-day supply. GE 10, at 22; GE 11, at 9. On September 24, 2012, Dr. Webb prescribed and Respondent's wife filled a prescription for 45 alprazolam 2 mg, a 15-day supply, which also provided for two refills. GE 11, at 9. If taken as directed, Dr. Webb's prescription should have lasted until October 9, 2012. In his wife's patient file, Respondent wrote: “Dr. Webb Rx Xanax—She is out 2 days early—Laceration/cutting—severe anxiety & depression—arms excoriated No return call from weekend MD—I have to leave to work out of town Xanax 2 mg #12 Walgreens 3-4 day supply through weekend.” GE 6, at 5. While the note also appears to state “aware -,” Dr. Webb did not have any notes in his file regarding any calls from Respondent on October 5, 2012, Tr. 131, and I find that Respondent did not disclose the prescription to Dr. Webb. I also find that Respondent's wife did not disclose the prescription. Tr. 174-75.

35. December 22, 2012, 15 capsules of Dextroamphetamine-Amphetamine ER 20 mg, a five-day supply. GE 11, at 8. While Dr. Webb had prescribed this drug to Respondent's wife,
see id.,
Respondent did not disclose the prescription to Dr. Webb. Nor did

Respondent document the prescription in his wife's patient file.
See
GE 6.

36. January 11, 2013, 10 tablets of alprazolam (Xanax) 2 mg, a three-day supply. GE 10, at 21; GE 11, at 8. According to the PMP report, on January 10, 2013, Respondent's wife refilled a prescription issued by Dr. Webb
16

(Rx #996307) for 45 tablets of alprazolam 2 mg, a 15-day supply.
Id.
If taken as directed, the January 10 refill provided enough medication to last Respondent's wife until January 25. The PMP report also shows that on December 30, 2012, Respondent's wife had refilled a different prescription issued by Dr. Webb
17

(RX #2703928) for 45 tablets of alprazolam 2 mg, a 15-day supply.
Id.
If taken as directed, the December 30 refill provided enough medication to last Respondent's wife until January 14, 2013. Respondent did not document the prescription in his wife's patient file.
See generally
GE 6. Nor did he disclose the prescription to Dr. Webb.

16
The prescription was originally issued on July 26, 2012 and provided five refills. GE 11, at 8.

17
The prescription was originally issued on November 6, 2012. GE 11, at 8.

37. January 11, 2013, six capsules of temazepam, a three-day supply. GE 11, at 8. According to the PMP report, on January 10, 2013, Respondent's wife refilled a prescription issued by Dr. Webb for 30 capsules of the drug, a 30-day supply.
Id.
If taken as directed, the January 10 refill provided enough medication to last Respondent's wife until February 9, 2013. Respondent did not document the prescription in his wife's patient file.
See
GE 6. Nor did he disclose the prescription to Respondent.

38. January 23, 2013, 15 tablets of alprazolam 2 mg, to be taken “as directed.”
18

GE 17; GE 10, at 79; GE 11, at 7. An entry in Respondent's file (dated January 20, 2013) states “Jill has opened sore on nose,” “arms—del. parastosis [sic]—arms,” “cutting—Anxiety/depression,” “Out of her Xanax—inconsolable,” “weekend—No return from on-call,” “Xanax #15,” “will contact Dr. Webb in Am,” “No HI/SI,” and a dosing instruction of “TID prn.” GE 6, at 5. Dr. Webb's patient file for his wife does not document a call from the Respondent on or near this date.
See
GE 5; Tr. 131-32. I therefore find that Respondent did not disclose the prescription to Dr. Webb.

18
Both the prescription label and the PMP report list this as being a 30-day supply.
See
GE 17; GE 10, at 79. However, according to Respondent's note in the file, the dosing instruction was take the drug three times a day as needed.

39. January 23, 2013, 30 tablets of hydrocodone/apap 10-650, a five-day supply. GE 11, at 7. Respondent's wife had obtained prescriptions on December 16, 2012 for 20 tablets for hydrocodone/apap 7.5/500 (a two-day supply) and on December 18, 2012 for 20 tablets of hydrocodone/apap 10/500 (a five-day supply) from Dr. Pecunia. GE 11, at 8. However, she was not regularly being prescribed hydrocodone.
See generally
GE 11. Respondent did not document the prescription in his wife's patient file.
See
GE 6. Nor did he disclose the prescription to Dr. Webb.

40. February 5, 2013, eight tablets of alprazolam 2 mg, a two-day supply. GE 10, at 86; GE 11, at 7; GE 40, at 2. In his wife's patient file, Respondent wrote: “Agitated—open sore on nose & hair line—Back from attempted trip—weathered out—returned with tons of anxiety—ran out of meds while OOT
19

—Minneapolis.” GE 6, at 6. The note further states: “Xanax #8 CVS Hattiesburg Zoloft #7” and “Filled Dr. Webb in on Travel—Jill did.” GE 6, at 6. Respondent did not, however, disclose the prescriptions to Dr. Webb.

19
The ALJ presumed, with reason, that “OOT” is an abbreviation for “out of town.” R.D. 22 n.32.

41. February 27, 2013, 10 tablets of alprazolam 2 mg, a three-day supply. GE 6, at 6; GE 10, at 86; GE 11, at 7. On February 19, 2013, Respondent's wife filled a prescription written by Dr. Webb for 45 alprazolam 2 mg, a 15-day supply. GE 5, at 70; GE 11, at 7. If taken as directed, Dr. Webb's prescription should have provided Respondent's wife with enough medication to last until March 6, 2013. In his wife's patient file, Respondent wrote: “Anxious about marital situation—sores on nose/forehead will not heal—No HI/SI—out of her meds early—Out of Xanax,” “Xanax #10 [one orally three times a day] CVS Hardy St (enough for weekend) (Monday: Dr. Webb refilled for her).” GE 6, at 6.

42. March 27, 2013, 14 tablets of alprazolam (Xanax) 2 mg, one tablet to be taken three times a day as needed, a five-day supply, which was filled the next day.
20

GE 36; GE 10, at 86; GE 11, at 7. On March 19, 2013, Respondent's wife had refilled a prescription issued by Dr. Webb for 45 alprazolam 2 mg, a 15-day supply. GE 11, at 7. If taken as directed, the refill of Dr. Webb's prescription should have provided Respondent's wife with enough medication to last until April 3, 2013. A note dated “3/28/13” in his wife's patient file, states: “Marital/physical/mental stress. Sky high Marriage Workshop in Montana just accentuated—depilitating hairline—[illegible] meds needs plastic surg[ery] to fix—Out of Xanax early—rebound anxieties—self-harm—Xanax #14—CVS Hardy St.” GE 6, at 7. The note also includes the following addendum: “Dr. Webb aware—he called in Restoril/Zoloft & the Xanax (3/30/13).”
Id.
Dr. Webb, however, was not aware of this prescription. Tr. 132-33; 174-75. Further, Dr. Webb's file contains no documentation of any contact by Respondent around March 28 through 30. Tr. 133;
see generally
GE 5; GE 7-9. Notably, Respondent did not note what dose of Xanax he prescribed or the dosing instructions.
See
GE 6, at 7;
see
Tr. 266, 287-88.

20
Although the PMP entry (as well as Respondent's note) are dated March 28, 2013, the prescription was written on March 27.
See
GE 36, at 1.

43. May 10, 2013, 14 tablets of alprazolam (Xanax) 2 mg, one tablet to be taken three times a day as needed, a four-day supply. GE 10, at 86; GE 11, at 7; GE 37, at 1-2. On April 30, 2013, Respondent's wife obtained a refill of a prescription issued by Dr. Webb for 45 alprazolam 2 mg, a 15-day supply. GE 11, at 7; Tr. 267. If taken as directed, the refill of Dr. Webb's prescription should have provided Respondent's wife with enough medication to last until May 15, 2013. Respondent did not document the prescription in his wife's patient file. GE 6. Nor did he disclose the prescription to Dr. Webb.

44. May 13, 2013, 12 tablets of alprazolam (Xanax) 2 mg, one tablet to be taken three times a day, a four-day supply. GE 10, at 21; GE 11, at 7; GE 41, at 1-2. Respondent wrote in his wife's patient file: “Out of Xanax 2 days early—she says repeated [illegible] calls—no answer—No healing on face/arm—repeated re-openings. I am scheduled OOT next 4 days—Xanax #12 [once orally three times a day].” GE 6, at 8. Respondent had already prescribed a four-day supply of Xanax to his wife on May 10; additionally, Respondent's wife still should have had two days' worth of Xanax left from Dr. Webb's April 30 refill. GE 11, at 7; Tr. 267. Respondent did not disclose the prescription to Dr. Webb. While the note also states that Respondent prescribed “Ambien 10 for sleep,” GE 6, at 8, the record does not contain a zolpidem prescription with this date.

45. May 20, 2013, 20 tablets of zolpidem 10 mg, one tablet at bedtime, a 20-day supply. GE 10, at 85; GE 11, at 7; GE 38, at 1-2. Respondent's patient file contains no note for a prescription issued on this date. GE 6, at 8. On May 23, 2013, Dr. Webb prescribed 30 du of another sleep medication, Restoril 30 mg (temazepam), with five refills, to Respondent's wife. GE 5, at 102; GE 11, at 6; Tr. 133-34. Moreover, the PMP report shows that Dr. Webb had been prescribing temazepam with refills to Respondent's wife beginning on July 26,

2012 and had not issued a zolpidem prescription to her since February 23, 2012, which she last refilled more than a year earlier on April 12, 2012. GE 11, at 7-10. Respondent did not discuss the prescription with Dr. Webb. Tr. 133. In an entry dated “5/23,” Respondent wrote: “Dr Webb—started Zoloft & Buspar—And [R]estoril[.] Ambien discarded—only Restoril.” GE 6, at 8. As also found above, Respondent had previously prescribed temazepam for his wife on January 11, 2013. GE 11, at 8.

46. July 1, 2013, 20 tablets of hydrocodone/acetaminophen (Lorcet), 10-650, a five-day supply.
21

GE 10, at 93; GE 11, at 6; GE 27, at 1. In his wife's patient file, Respondent wrote: “Her mother in hospital in Jackson—dying—in ICU/hospice—she had
seizure
—injured shoulder/rib finger. Fractured teeth. Would not go to ER—Lorcet 10/650 #20,” which was followed by illegible handwriting. GE 6, at 9; Tr. 134. Respondent did not discuss those injuries with Dr. Webb at any point; further, Respondent's wife had an appointment with Dr. Webb on July 1. Tr. 134. While Dr. Webb did not prescribe any medications to Respondent's wife at this visit, she did fill a prescription for 90 capsules of Adderall XR 20 (amphetamine), which Dr. Webb issued on June 28, 2013. GE 11, at 6; Tr. 273. Also, on June 28, 2013, she had obtained from Dr. Webb and filled new prescriptions for 45 alprazolam 2 mg, a 15-day supply, and 30 temazepam 30 mg, a 30-day supply. GE 11, at 6.

21

See
GE-14, at 59 (admitting to calling in a prescription for Lorcet in July).

47. July 7, 2013, 12 tablets of alprazolam (Xanax) 2 mg, one tablet to be taken twice a day, a six-day supply. GE 35, at 1-4;
see
GE 10, at 41; GE 11, at 6; Tr. 268-69. However, if taken as directed, the June 28 alprazolam prescription from Dr. Webb should have provided enough medication to last Respondent's wife until July 13, 2013. In his wife's patient file, Respondent wrote: “She is out of her Xanax early. Dr. Webb is aware of the tremendous stress of her mother's illness. No return call on-call MS Neuro [illegible] Xanax #12/Lorcet #12 Walgreens.” GE 6, at 9; Tr. 135. Dr. Webb's file for Respondent's wife does not document a call from Respondent on this date.
See generally
GE 5; GE 7-9; Tr. 135.

48. July 7, 2013, 12 tablets of hydrocodone/apap 10-650 mg, one tablet to be taken four to six times a day, a two-day supply. Respondent's note in his wife's patient file does not discuss his reason for prescribing hydrocodone.
See
GE 6, at 9. Respondent did not disclose the prescription to Dr. Webb.

49. July 25, 2013, 12 tablets of hydrocodone/apap, 10-650, one tablet every six hours as needed, a three-day supply. GE 10, at 21; GE 11, at 5; GE 42, at 1-2. Respondent did not document this prescription in his wife's patient file.
See generally
GE 6. He also did not disclose the prescription to Dr. Webb.

50. July 29, 2013, eight tablets of alprazolam 2 mg, one tablet to be taken three times a day as needed, a two-day supply. GE 10, at 85; GE 11, at 5; GE 39, at 1-2. The PMP shows that on July 19, 2013, Respondent's wife had obtained a refill of a prescription issued by Dr. Webb for 45 alprazolam 2 mg, a 15-day supply. GE 11, at 6. If taken as directed, the refill should have provided Respondent's wife with enough medication to last until August 3, 2017. In his wife's patient file, Respondent wrote: “Out of Xanax—buried her mother—funeral—Dr. Webb back Thursday. Xanax #8 [once orally three times a day].” GE 6, at 9; Tr. 136. Dr. Webb testified that he did not receive any message or have any contact with Respondent on this day, Tr. 136, and there is nothing in Dr. Webb's file for Respondent's wife that indicates that he was contacted by Respondent around July 29, 2013.
See
GE 5; GE 7-9. I find that Respondent did not disclose the prescription to Dr. Webb.

51. August 15, 2013, 14 tablets of hydrocodone/apap 10-650, one tablet every four to six hours as needed, a two-day supply. GE 10, at 21; GE 11, at 5; GE 43, at 1-2. Respondent did not document the prescription in his wife's patient file.
See generally
GE 6. Nor did he disclose the prescription to Dr. Webb.

52. August 22, 2013, 15 tablets of alprazolam (Xanax), 2 mg, one tablet to be taken three times a day, a five-day supply. GE 10, at 67; GE 11, at 5; GE 24, at 1-2. According to the PMP report, Dr. Webb issued his last alprazolam prescription to Respondent's wife on July 31, 2013 for 45 tablets, a 15-day supply, and the PMP report contains no entry for any refill of this prescription. GE 11, at 1-5. The PMP report further shows that on August 5, 2013, Dr. Webb had re-commenced prescribing clonazepam, a different benzodiazepine. GE 11, at 5;
see also
GE 5, at 71. In an entry in his wife's patient file dated “8/24/13,” Respondent wrote: “Following [her mother's] death, she has been very labile. Dr. Webb has tried multiple medications. Jill is very morose, often cannot stop crying. Denies SI/HI—No self-harm this month.” GE 6, at 10. Continuing, the note states: “Multiple Rx & calls to Dr. Webb. Could not reach this weekend—Rx: Xanax #12 [once orally three times a day]” and “[w]ill update Dr. Webb.” GE 6, at 10; Tr. 136-37. However, there is nothing in Dr. Webb's file for Respondent's wife that indicates that he was contacted by the Respondent around August 22, 2013 and Dr. Webb testified that Respondent never disclosed any of the prescriptions.
See
GE 5; Tr. 137. I find that Respondent did not disclose the prescription to Dr. Webb.

53. September 5, 2013, 24 tablets of alprazolam (Xanax), 2 mg, an eight-day supply. GE 10, at 21; GE 11, at 5. The Respondent recorded in his wife's patient file: “Will not leave room—depressed—needs to get back with Dr. Webb—anorexic—very anxious/depressed—Xanax #20 [once orally three times a day].” GE 6, at 10. Respondent did not disclose the prescription to Dr. Webb.

Dr. Webb's Testimony Regarding Respondent's Prescriptions

Asked if there were “any risks” in Respondent's wife “receiving prescriptions from someone other” than himself, Dr. Webb testified that “this particular patient . . . has some severe problems[,] and takes a high dose of medication. . . . my concern is that I'm keeping a close tab on it, but if there's somebody out there writing that I don't know about, that's dangerous.”
Id.
at 120. Dr. Webb explained that Respondent's prescribing was dangerous because “you're going above the maximum dose that should be prescribed and more medicines can lead to sedation, more sedation, difficulty, death, loss of balance, falls, poor judgment, things like that.”
Id.
at 121.

Dr. Webb also explained that the prescriptions “interfered with [my] treatment for her, because I wasn't seeing the real patient, because there's a ghost writer out there that I don't know about.”
Id.
Dr. Webb testified that “I have certain timed prescriptions and if that timed prescription is getting gapped . . . by another prescription, it's distracting me from my decisionmaking.”
Id.
He also testified that this would “[m]ost definitely” interfere with his decisionmaking, in that “[if] she was out of . . . my medicines, then I would hear a distressed phone call . . . and I would need to reorient my treatment for her [by] put[ting] her in the hospital.”
Id.
at 122.

In a July 13, 2011 entry in Respondent's wife patient file, which documents a prescription for 20 Xanax 2mg, but for which there is no corresponding prescription in either the PMP reports or the other exhibits,

Respondent wrote: “Dr. Webb has not called back.” GX 6, at 1. Regarding this entry, Dr. Webb testified that there are “five other [ ]” practitioners that work at his clinic and the phones are covered 24 hours a day, seven days a week. Tr. 124. Moreover, his clinic has an answering service for after office hours and weekends.
Id.
at 125. Dr. Webb testified that Respondent's note did not state what time the call to him had been placed and he maintained that he “always called patients back.”
Id.
at 126.

Dr. Webb further testified that the file did not contain a note “from the answering service or the secretary that on [this date] a message was left.”
Id.
Dr. Webb then testified that his “file contains every telephone message notation that is given to our office” and that “the actual notes written by the office staff are kept,” and that there are no notes for this date.
22

Id.
The closest phone message by date are two messages on July 21, 2011 from Respondent's wife; the earlier message states “please call asap” and the later message states “urgent out of med.” GE 5, at 137. Notably, the PMP shows that on the same day, Dr. Webb issued to Respondent's wife a new prescription for 45 alprazolam 2 mg. GE 11, at 12.

22
On cross-examination, Dr. Webb acknowledged that the clinic's answering service would not necessarily page the on-call doctor just for a patient “who needs a normal refill.” Tr. 156. However, Dr. Webb maintained that if a patient was out of medicine early and in distress, the answering service would pass this message on to the doctor.
Id.
at 157, 182. He also testified that “[i]t's our policy to call everybody back.”
Id.
at 183.

Dr. Webb further testified that to the best of his recollection, all of the phone call messages “should be” in the patient file for Respondent's wife.
Id.
at 159. Dr. Webb testified that he did not “find it odd” that there was “only [in the words of Respondent's counsel] a handful of . . . call notes in her file.”
Id.
at 160. Putting aside that there are 48 such notes in the patient file, Dr. Webb explained that Respondent's wife “typically kept pretty good contact. Knowing that I'd be in the daytime, she's in the medical field, she knows night time phone calls . . . aren't very productive . . . [b]ecause you're unlikely to have your doctor on call.”
Id.
He also testified that Respondent's wife had not expressed any dissatisfaction with her being able to reach him other than when he was not on call during a weekend.
Id.
at 184.

Dr. Webb further testified that his practice has not received complaints about the clinic's “on call service” and “the inability to connect with a doctor” or to “get a request fulfilled by a doctor.”
Id.
at 161. The ALJ specifically found that Dr. Webb's testimony was credible. R.D. 8.

The Government also asked Dr. Webb about Respondent's note dated “1/16/12” (prescription No. 24). The note appears as follows:

Dr. Webb wants Jill to come in

Difficult s transportation

Will Rx 10 day supply til

1/26/12—Webb aware—

Xanax 2 mg # 30

[ ] po TID prn

GX 6, at 2, Tr. 126. Dr. Webb testified that he was not sure if the prescription referenced in the note was “attached to the January 16 or January 26th note.” Tr. 127. He then testified that he had no contact with Respondent's wife on January 16, 2012,
23

but that on January 26, 2012, he called in a prescription for 45 Xanax 2 mg, three tablets a day.
Id.
at 127-28;
see also
GX 5, at 69. He also had no contact with Respondent on January 26, 2012.
24

Tr. 128.

23
With respect to Respondent's wife, Dr. Webb testified that early in his treatment of her, she lost a bottle of Xanax which prompted him “to shorten the leash and give smaller amounts.”
Id.
at 162.

24
Dr. Webb also identified other instances in which Respondent made notes in his wife's file documenting phone calls but Dr. Webb's file contained no record that the call was made to his office.
See
Tr. 129-33,137. These include notations for Feb. 18, 2012 (“called answering service for Dr. Webb No response—weekend Dr”); Oct. 5, 2012 (“No return call from weekend doctor”); Jan. 20, 2013 (“No return from on call” and “Will contact Dr. Webb in AM”); Mar. 28, 2013 (“Dr. Webb aware.”); Aug. 24, 2013 (“Will update Dr. Webb”). The record, however, does not establish whether these notations were intended to document that Respondent or his wife had placed the call and/or notified, or intended to notify Dr. Webb.

The Government also asked Dr. Webb about an entry Respondent made on July 7, 2013, which states in part: “She's out of her Xanax early. Dr. Webb is aware of the tremendous stress of her mother's illness. No return on call.” GX 6, at 9;
see also
Tr. 135. As found above, on this date, Respondent prescribed to his wife 12 Xanax and 12 Lorcet. GX 6, at 9; GX 11, at 6. Notably, the PMP report shows that Respondent's wife had refilled a prescription issued by Dr. Webb on May 23, 2013 for 45 Xanax (15 day supply) on June 21, 2013, and had obtained and filled a new prescription for 45 Xanax (15 day supply) on June 28, 2013.
25

GX 11, at 6. After again noting that there was no record of any call to the clinic or its answering service by Respondent on this date, Dr. Webb testified that the fact that Respondent's wife was out of her Xanax early would concern him “[b]ecause it lets me know that she's using more than prescribed and would . . . ha[ve] me wondering whether we need to put her in the hospital, to monitor her, or [if] there [are] other issues going on.” Tr. 135-36.

25
Respondent's wife also obtained a refill of the June 28, 2013 prescription for 45 Xanax on July 10, 2013, and a refill of the May 23, 2011 prescription (which also was for 45 Xanax) on July 19, 2013. GX 11, at 6; Tr. 144.

An entry in Respondent's file dated July 29, 2013 states: “Out of Xanax—buried her mother—funeral—Dr Webb back Thursday Xanax #8” and includes dosing instructions of “po TID.” GX 6, at 9. As found above, the PMP report shows that Respondent issued his wife a prescription for eight Xanax 2 mg. GX 11, at 5. The PMP report also shows, however, that Respondent's wife refilled prescriptions for 45 Xanax (15 day supply) issued by Dr. Webb on both July 10 and 19, 2013. GX 11, at 6.
Id.
Dr. Webb testified that he spoke with Respondent's wife on July 30, 2013, and prescribed more Xanax to her and referred her to a psychologist. Tr. 136. According to the PMP report, Dr. Webb issued Respondent's wife a prescription for 45 Xanax on July 31, 2013. GX 11, at 5.

Dr. Webb testified that in his view “gap filling . . . means that there's a prescription that is used to get [the patient] to the next authorized refill.” Tr. 138. Dr. Webb then cited stolen medication as an example of when a gap fill would be appropriate.
Id.
Dr. Webb also testified that if a doctor sets up a regimen of refills, the patient “needs to follow that timeline. And so, if they're short on set refills, that's a problem.”
Id.
at 139.

On cross-examination, Respondent's counsel asked Dr. Webb about a statement he wrote in a memo he prepared following a January 11, 2016 meeting with DEA personnel in which he noted that Respondent's “prescriptions consisted of large quantities of controlled medications such as Xanax, [h]ydrocodone, [and] Ambien.” Tr. 151;
see also
GX 8. Asked how he concluded that the prescriptions were for large quantities, Dr. Webb explained that “[t]hey appeared to be more than just a day or so” and that while “some were less than 10 . . . my recollection was that more, most of them were more than 10” tablets. Tr. 151.

Dr. Webb subsequently explained that he had Respondent's wife “up to max doses of all prescriptions . . . that I had her on” and that “[a]nything over was a potentially large impact.”
Id.
at 152. He added that “[m]aybe the number isn't large, but the potential impact is large.”
Id.
Asked by Respondent's counsel if he “agree[d] that compared to [his] prescribing, the number of controlled substances prescribed by [Respondent] was relatively small,” Dr. Webb answered “correct,” but then added that it was “[m]ore than I prescribe and moving into . . . above my max and serious harm.”
26

Id.
at 152-53.

26
As found above, the evidence shows that Respondent issued a number of prescriptions, especially for zolpidem, that provided quantities that were for periods considerably longer than two to three days. Specifically, Respondent authorized prescriptions on May 20, 2013, for 20 dosage units (du) of zolpidem (a 20 day supply); on April 1,

2012, for 24 du of zolpidem (24 days); on March 4, 2012, for 30 zolpidem (30 days); on October 11, 2011, for 20 du of zolpidem (20 days); on July 31, 2011, for 12 du (12 days) plus a refill; on June 28, 2011, for 30 du (30 days); on May 6, 2011, for 30 du (30 days); on March 30, 2011, for 30 du (15 days), and on January 31, 2011, also for 30 du (15 days). GX 11, at 7, 10-14. He also authorized prescriptions on July 7, 2013, for 12 du of alprazolam (6 day supply); on March 28, 2013, for 14 du of alprazolam (5 days); and on both July 17, 2012 and June 18, 2012, for 20 du of alprazolam (10 days). GX 11, at 6-7, 11.

Dr. Webb testified that he had been “very careful in regimenting” the prescriptions he issued for Respondent's wife based on his “years of working with her” and her visit in either 2002 or 2009 (or both years) when “she went to Sierra Tucson” to be evaluated for Xanax abuse. Tr. 146-47. According to Dr. Webb, Sierra Tucson did not diagnose her as being addicted or abusing controlled substances.
Id.
at 164. While he “was not aware” that she was “overtly abusing,” Dr. Webb testified that she “[s]he had been early . . . sometimes on her prescriptions.”
Id.
at 185. Dr. Webb also cited “the severity of her illness” as a reason for why he generally limited the prescriptions to 15 days.
27

Id.

27
Dr. Webb testified that he “feel[s] that . . . she's primarily a psychiatric disorder first, and then medication difficulty second, rather than the other way around.”
Id.
at 165;
id.
at 194-95.

Dr. Webb subsequently testified that “[s]ince I did not know about the other prescriptions out there, it did not appear to be as big of an issue. She was early a day or two here and there. But, yes, substance dependence was on the radar.”
Id.
at 194. On still further questioning by the Government, Dr. Webb testified that if he had known about Respondent's prescriptions to his wife during the 2011-2013 period, this “would have” changed his opinion as to whether she was abusing controlled substances.
Id.
at 196-97. On questioning by the ALJ, Dr. Webb testified that “[k]nowing what [he] know[s] today . . . I would have suggested” that she undergo “in-patient” treatment to address both “her primary . . . and secondary problem[s].”
Id.
at 197.

Asked about the notes he maintained for his phone conversations with Respondent's wife, which typically were no more than one or two lines, Dr. Webb maintained that he and Respondent's wife “always had in-depth conversations” and that “[t]hey were usually fairly long, like 20, 30, 45 minute phone conversations.”
Id.
at 169. He also testified that his notes met the standard for documentation. Dr. Webb acknowledged, however, that he is “not perfect” and that there may have been some phone calls that he had with Respondent's wife “that were not noted.”
Id.
at 203.

Dr. Webb acknowledged that psychiatrists do not typically prescribe opioids such as hydrocodone; he testified that he had “written maybe less than five [prescriptions] in my last 20 years.”
Id.
at 170-71. Asked why he issued the June 28, 2013 prescription for 10 tablets of hydrocodone/acetaminophen 10/650 mg,
see
GX 11, at 6, Dr. Webb testified that the prescription was filled “at Beemon, so potentially she had come up from Hattiesburg.” Tr. 171. Continuing, Dr. Webb testified: “[t]hat was right around her mother's death, mother's sickness, and maybe she told me she was out of her medicine potentially. I'd want to see my note if I put it in there.”
Id.
Subsequently, Dr. Webb added that Respondent's wife had undergone a procedure by a different doctor and received hydrocodone about nine or ten days earlier, but he could not otherwise recall the circumstances.
Id.
at 172. Dr. Webb then admitted that this prescription “certainly could” interfere with the treatment being provided by the other doctor.
Id.
However, he explained that Respondent's wife “was out of town from her treating . . . physician, and out of her opiate for pain relief.”
Id.
at 186. Moreover, this was the only instance in which he prescribed hydrocodone or any other opioid to her.
Id.
at 200-01.

Dr. Webb testified that he did not have a conversation with Respondent's wife about Respondent's prescribing controlled substances to her until either late 2015 or 2016, after he was contacted by the Diversion Investigator.
Id.
at 175. Dr. Webb testified that he “believe[d] at times” that Respondent was trying to help his wife and that “[t]hey have had lots of difficulty.”
Id.
at 177. Based on the four phone calls he had with Respondent during the 2011 through 2013 period and because Respondent would “[t]ypically call if there would be a crisis,” Dr. Webb acknowledged that Respondent's wife was often in crisis.
Id.
at 178.

On subsequent questioning, Respondent's counsel suggested that just as the other doctors in his practice can appropriately prescribe gap fills to his patients because they can access the patient's file and see “abuse issues in the patient file . . . someone living with the patient can assess that person.”
Id.
at 196. Dr. Webb took issue with this suggestion, explaining that “the difficulty with living with someone is that you're not potentially an expert.”
Id.

Dr. Webb testified that Respondent's notes did not contain a patient history and specific diagnosis.
Id.
at 188. As for whether the notes contained evidence of an examination, Dr. Webb explained that, “other than the subjective notes that are listed, no.”
Id.

The Testimony of the Government's Expert

The Government called R. Andrew Chambers, M.D., to testify as an expert in psychiatry, the proper prescribing of controlled substances and their effects on patients, and on addiction; the ALJ accepted Dr. Chambers as an expert in these areas. Tr. 246. Dr. Chambers obtained his B.S. degree in Chemical Physics from Centre College, Danville, Kentucky in 1991 and his M.D. degree from the Duke University School of Medicine in 1996. GX 12, at 1. Thereafter, he completed a residency in psychiatry at the Yale University School of Medicine in 2002 and a fellowship in addiction psychiatry at the Indiana University (IU) School of Medicine in 2012.
Id.
From 2002 through 2003, he served as an Assistant Professor of Psychiatry, Division of Substance Abuse at Yale; from 2003 through 2009, he served as an Assistant Professor of Psychiatry at the Indiana University School of Medicine; and since 2010, he has been an Associate Professor of Psychiatry with Tenure at the IU School of Medicine.
Id.
Also since 2012, Dr. Chambers has been the Director of the Fellowship Training Program in Addiction Psychiatry at the IU School of Medicine.
Id.

Dr. Chambers has had appointments in the Department of Psychiatry at various hospitals including the West Haven (Connecticut) VA Hospital, Yale New-Haven Hospital, Connecticut Mental Health Center, and Indiana University Health Hospitals. GX 12, at 2. He is board certified in general adult psychiatry and addiction psychiatry. Tr. 227-28. He has also been published in the areas of psychiatry and addiction “on the order of 50 times” in peer-reviewed journals, published in multiple textbooks, and made a number of presentations to professional conferences.
Id.
at 229-30; GX 12, at 3-7, 11-18.

Dr. Chambers testified that treating patients with mental illness and addiction is his “bread and butter work.” Tr. 231. He testified that he is “familiar with and utilize[s] a broad range of pharmacotherapies for both mental illness and addiction, as well as psychotherapies for both mental illness and addiction” and that “the vast majority of [his] patients have both mental illness and addiction.”
Id.
at 231-32. He testified that he is familiar with the prescribing of controlled

substances to psychiatric patients, the risks of controlled substances, and the typical practices undertaken by psychiatrists to mitigate the risks or dangers of the diversion of controlled substances.
Id.
He further testified that he is familiar with the standards for prescribing controlled substances in Mississippi, as well the circumstances under which a doctor may fail to conduct himself in a manner that comports with a legitimate medical purpose or is within the course of proper professional practice.
Id.
at 233.

While Dr. Chambers had never previously testified in a proceeding based on the Mississippi law and the State Board's rules,
id.
at 240, he testified that he had reviewed the State's laws and rules.
Id.
at 236. He further testified that the Mississippi provisions on prescribing controlled substances are “fairly universal.”
Id.
at 237. Dr. Chambers explained “that the codes around the country are informed by the medical profession . . . and there are universal, fairly universal ethical standards, evidence-based standards that are scientific that then inform the code.”
Id.
at 240. Dr. Chambers subsequently cited the Patient Record provisions of the State Board's Rule 1.4 as one such standard that is accepted across the medical profession.
Id.
at 244.

Turning to Respondent's October 11, 2011 prescription for 20 zolpidem (No. 15 above), Dr. Chambers noted that the refill obtained by Respondent's wife on September 19 was for 30 days and should have lasted until October 19.
Id.
at 249. Dr. Chambers testified that Respondent's October 11 prescription was “a problem.”
Id.
As to why, Dr. Chambers explained: “[t]his is a prescription for a controlled substance that is coming from a separate source that's occurring on top of a prescription from the primary psychiatrist, and the combination of these kinds of controlled substances could have serious consequences.”
Id.
Dr. Chambers further explained that “Ambien and other benzoate medications have central nervous system effects that can cause oversedation, memory disturbances, and, if taken in combination with other drugs, especially opioids, death.”
Id.
at 250. While Dr. Chambers testified that 10 milligrams (the dose prescribed by Respondent) “is not the maximum dose of Ambien that can be prescribed,” a patient obtaining the drug from another source “would be of concern.”
Id.
Dr. Chambers explained that the concern would be driven by the “the size of the dose, the nature of the drug,” as well as “the fact the primary physician who is prescribing the drug . . . would not . . . necessarily [be] aware” that the patient was obtaining the drug “from a separate source.”
Id.

According to Dr. Chambers, when a patient is obtaining a drug from other sources, “it can create a great deal of confusion on the part of the primary prescriber about the effects or side effects of the drug and the mental status of the patient.”
Id.
at 250-51. Continuing, Dr. Chambers testified that “there are also synergistic overdose risks of being on both doses at the same time. . . . It's obviously not the dose that the primary prescriber wants because they would have prescribed that dose if that's what they wanted.”
Id.
at 251. Dr. Chambers then explained that “the same concerns” were raised by the zolpidem prescription Respondent wrote on July 31, 2011 because the refill his wife obtained on July 7, 2011 of Dr. Webb's prescription for 30 days of zolpidem should have lasted for another week.
Id.
at 252.

Dr. Chambers identified several instances in which Dr. Webb's prescriptions “overlapped” with those of Respondent.
28

These included the zolpidem prescription (for 30 tablets/30 days) which Respondent issued on May 6, 2011 and the refills obtained on both April 9, 2011 and May 23, 2011 by Respondent's wife of Dr. Webb's Feb. 3, 2011 prescription for 60 tablets (a 30-day supply). Tr. 255. Dr. Chambers testified that while “[t]he one before is a relatively minor overlap[,] about one or two days, which is fairly insignificant, . . . the secondary overlap is more significant.”
Id.
The prescriptions presented the same concerns of danger to the patient and confusion for the doctor.
Id.

28
This particular overlap involved Respondent's zolpidem prescription of March 30, 2011 for 30 tablets (a 15-day supply) (Rx No. 4 above) and an April 9 dispensing of a zolpidem prescription. Tr. 254-55. Dr. Chambers testified that “on April 9, 2011, Dr. Webb issue[d] the same med for a 30-day supply. So now you have an example of Webb unknowingly overlapping a controlled substance with Dr. Alexander that happened on 3-30.”
Id.
at 255. The PMP report shows, however, that the latter event did not involve the issuance of a new prescriptions but a refill of Dr. Webb's February 3, 2011 prescription.
See
GE 11, at 13. Nonetheless, Respondent's prescription still created an overlap.

Dr. Chambers subsequently testified that it does not matter whether Dr. Webb's prescriptions were new prescriptions or refills because the prescription “is essentially an instruction both to the pharmacist and the patient for the daily dosing and the number of days that the patient should follow that dosing.”
Id.
at 257. Dr. Chambers then testified that “[r]efills is [sic] just a way to communicate to the patient and the pharmacist . . . that you're allotting the schedule out in monthly, usually monthly allotments, and then it starts over.”
Id.
Continuing, Dr. Chambers explained that “the bottom line is that when the doctor writes the prescription and the pharmacist records it . . . there's a complete understanding of what's expected. There should be no haziness on the part of the doctor or the pharmacist or the patient . . . about the expected rate of consumption . . . from the start to finish, whether it be a 30-day supply or a 30-day supply with two refills.”
Id.
at 257-58.

Next, the Government questioned Dr. Chambers about the combination of prescriptions/refills that Respondent's wife filled on November 28-29, 2011.
Id.
at 258-59. Specifically, on November 28, 2011, she refilled a prescription issued by Dr. Webb for 45 clonazepam (15 days) as well as filled a new prescription issued by Webb for 90 capsules of Adderall. GX 11, at 11. The next day, she filled prescriptions for a one-day supply of Diastat Acudial (a rectal suppository of diazepam) and a one-day supply (four tablets) of hydrocodone/apap 10/650.
Id.

Dr. Chambers noted that the Diastat prescription “is a bit puzzling because it's clear [Respondent's wife] is taking oral meds and usually [Diastat] [is] reserved for people who can't take [drugs] oral[ly].”
Id.
He then testified that “it's a very high risk and potentially lethal combination one day after receiving a 15-day supply of” clonazepam and “also a stimulant” from Dr. Webb.
Id.
Dr. Chambers then testified that “[t]he combination of an opioid and a benzodiazepine is causing an unprecedented epidemic of death in the United States . . . because when the two drugs are together they synergistically suppress consciousness and breathing and the central nervous system.”
Id.

Addressing the prescriptions which Respondent issued on both June 18 and July 17, 2012, for 20 du of alprazolam 2 mg (both being for a 10-day supply),
29

each of which was filled on the date of issuance, as well as the refill she obtained on July 5, 2012 of Dr. Webb's prescription for 45 du (15 days), Dr. Chambers testified that the prescriptions had different dosing instructions and overlapped.
Id.
at 262-63. Dr. Chambers then testified that “we don't know what she was actually taking, but if she was actually taking the dose per both doctor's directions, she would be taking 10 milligrams of [alprazolam] a day . . . which would render me unconscious.”
Id.
at 263. As another example of Respondent's issuance of an alprazolam

prescription which resulted in “nearly a week of overlap of the same dose by two different doctors” and raised “the same concern,” Dr. Chambers identified Respondent's March 28, 2013 prescription for 14 dosage units (three tablets a day), which overlapped with a refill his wife obtained on March 19, 2013 for 45 tablets (also three tablets a day).
30

Id.
at 266.

29

See
prescription Nos.31 and 32 above.

30
Other examples of overlapping prescriptions involved Respondent's May 10 and May 13, 2013 prescriptions (Nos. 43 and 44 above) for 14 and 12 dosage units of alprazolam 2 mg, which overlapped with the refill his wife obtained on April 30, 2013 of Dr. Webb's prescriptions for 45 du (15 days) of alprazolam 2 mg. Tr. 267. According to Dr. Chambers, even Respondent's May 10 and May 13 prescriptions overlapped, and that on May 13, “what you actually have here is a triple compounding of the dosing based on the disposition dates and the way the drugs were instructed to be taken.”
Id.
Dr. Chambers then explained that “that is a very dangerous dose that would normally never be prescribed outside an intensive care unit.”
Id.
at 267-68.

Another such example is Respondent's July 29, 2013 alprazolam prescription which provided eight tablets (TID). Dr. Chambers testified that Respondent's prescription provided a dosing instruction of eight milligrams a day, Tr. 271, which is supported by the PMP report which lists the prescription as providing a two-day supply. GE 11, at 5. However, the dosing instruction on the actual prescription was TID, or one tablet, three times a day. GX 39, at 1-2. Nonetheless, the prescription overlapped with the refill Respondent's wife obtained on July 19, 2013 for Dr. Webb's prescription for 45 tablets (15 days), and on July 31, 2013, she obtained a new prescription from Dr. Webb for 45 tablets (15 days). GE 11, at 5. However, even if Respondent's prescription only had a dosing instruction of 3 tablets a day, if she took the medications as prescribed by both Dr. Webb and Respondent for the period in which the prescriptions overlapped, she would have taken six tablets a day or 12 milligrams. Tr. 272.

Addressing Respondent's July 7, 2013 prescriptions (Nos. 46 and 47) for 12 du of hydrocodone/apap 10/650 (two-day supply) and 12 alprazolam 2 mg (six-day supply), Dr. Chambers characterized the latter prescription as “remarkable,” explaining that “it's prescribed at the same time [Respondent] also prescribed hydrocodone, an opioid medication, also on the same day, again introducing the risk of a potentially lethal overdose.”
Id.
at 268-69. Dr. Chambers noted that Respondent's prescribing was “also occurring in the context of” an amphetamine (Adderall XR) prescription for 30 days issued by Dr. Webb “six days” earlier.
Id.
at 269. Dr. Chambers then testified that if Respondent's wife was “taking as prescribed, she's doing what street people call a speedball, which is essentially an amphetamine/opioid combination with a . . . benzodiazepine garnish.”
Id.
Dr. Chambers also noted that on July 1, 2013, the same day that Respondent's wife filled the Adderall
31

prescription, Respondent had also issued her a prescription for 20 hydrocodone/apap 10/650, which she filled that day.
Id.
at 269-70. Dr. Chambers noted that this hydrocodone prescription was “a higher dose than what Dr. Webb did.”
Id.
at 273. He explained that “there's a combination of multiple overlaps of multiple classes of addictive substances that can produce overdose and severe psychiatric disturbances from two different physicians who are apparently in no communication.”
Id.
Continuing, he explained that “in [his] experience, when you see all three of those [classes of] drugs represented and you have multiple physicians contributing to it . . . that indicates a patient who is in serious trouble iatrogenically . . . meaning harmed being caused through medical practice.”
Id.
at 274.

31
Dr. Chambers explained that while Adderall is “used for a number of clinical indications, including attention deficit disorder [and] narcolepsy . . . [i]t also has significant street value” and is “basically a cousin of methamphetamine.” Tr. 270.

Asked if he had “reach[ed] a conclusion” as to whether Respondent's prescriptions were issued “within the usual course of professional conduct,” Dr. Chambers testified:

I did. It is not [the] usual course of clinical conduct for someone with mental illness or someone without mental illness to be prescribed these combinations of drugs and to have these combinations being prescribed by different individuals who—one of who—where there's not communication or awareness that it's happening. So it's not only not usual clinical practice, but the reason it's not usual is because it's dangerous for patients and harmful. So it's actually not only is it not usual, it's essentially malpractice.

Id.
at 275. On further questioning, Dr. Chambers testified that the Respondent's prescribing was not “legitimate medical practice” and the prescriptions were “non-therapeutic.”
Id.
Dr. Chambers further testified that “[b]ased on the entirety of the evidence [he] reviewed,” Respondent's prescribing did not comply with either the Controlled Substances Act or the standards of the Mississippi Administrative Code, including the State's requirements for patient records.
Id.
at 276, 278.

Addressing the patient file Respondent maintained on his wife, Dr. Chambers testified that “there is a paucity of data to support the diagnosis or the prescription . . . that the note is built around. There's a lack of physical or mental status exam that normally would be in a note like this to justify and direct the use of controlled substances.”
Id.
at 277. Dr. Chambers further observed that in comparing the patient file with the PMP data, “about 40 percent of the prescriptions” had “no corresponding note at all. There's no data. There's no diagnosis, no detailing of what was prescribed.”
Id.
He also observed that “there are instances where the dosing or type of the drug is left out of the record.”
Id.
at 278.

Dr. Chambers identified Respondent's entry dated January 16, 2012 (Prescription No. 24) as one such example. Tr. 278. As found above, on this date, Respondent prescribed 30 alprazolam 2 mg “to be taken as directed” and wrote in the note: “Dr. Webb wants Jill to come in. Difficult [with] transportation—will Rx 10 day supply till 1/26/12—Webb aware—Xanax 2 mg” with a dosing instruction of “po TID.” GE 6, at 2.

Dr. Chambers testified that “this note does not have a diagnosis. It doesn't have an examination to justify . . . why that prescription happened at that dose . . . was he aware of what the prescription was from another doctor? Was he continuing? Was there any plan to taper it?” Tr. 279. Dr. Chambers added that “he's kind of writing as if the reason he's doing it is because the patient can't get to Dr. Webb, and he's documenting that Webb is aware . . . but in review of Webb's chart, there no indication that Webb was ever aware that this kind of stuff was going on.”
Id.
When then asked if a 10-day supply is “unusual for . . . a gap fill,” Dr. Chambers answered:

. . . I think it's unusual for one doctor to be gap filling another regardless of what the duration is, especially when there's no knowledge that that's happening. So any duration is odd, I think. I guess the longer the number of days the more concerning it is because you're dispensing bigger doses. I mean, she's got 30 tabs. That's quite a bit.

Id.
at 280.

Addressing Respondent's note of February 18, 2012, Dr. Chambers acknowledged that it contained “a little bit more of what you could call a clinical assessment” in that Respondent described his wife's symptoms.
Id.
at 281. Dr. Chambers observed, however, that the note did not indicate “how many he prescribe[d].”
Id.
As for Respondent's statement that his wife was “[o]ut of her Xanax for . . . 10 days” and “[o]ut of her Ambien for a week,” GE 6, at 3, Dr. Chambers testified:

It's not clear exactly what that means, but I take it to mean that he is prescribing because she's been out. And so, first of all, why is she out? Is it because she's using it too rapidly? It's just not clear. But he is filling the gap with an unclear amount and then suggesting by my read . . . [that] he's documenting he's contacting Dr. Webb,

informing them of this gap fill, the best I could tell.

But what's beginning to emerge here in this note and does come in later is that he is becoming—Dr. Alexander is becoming aware that she's running out and I assume prematurely because when you look at the PDMP data from Dr. Webb, Dr. Webb is not creating gaps. . . . He is not leaving her hanging with no medication a whole lot of times.

Id.
at 281-82.

Continuing on to the next note (March 12, 2012), Dr. Chambers testified that this was “the first time I've seen a diagnosis in the chart.”
Id
at 282. He then explained that “delusional parasitosis is a non-specific psychotic symptom,” and that while it can be caused by “a primary delusional illness . . . more commonly [it] is a sign of severe drug withdrawal” including “benzodiazepine . . . or even opiate withdrawal.”
Id.
at 282-83. Dr. Chambers testified that the behavior documented in the chart (jerking, twitching, and delusional parasitosis) “suggests extreme discomfort” and “could suggest vital sign changes [and] impending catastrophic withdrawal.”
32

Id.
at 283. Dr. Chambers observed, however, that Respondent did not obtain his wife's blood pressure and pulse or perform a mental status exam.
Id.
at 284.

32
Dr. Chambers further criticized Respondent because “the standard of care for the treatment of acute withdrawal” requires as part of “the basic response to get a blood pressure or a pulse,” and “[i]f these measures aren't taken, people die routinely.”
Id.
at 284.

Respondent's note of July 14, 2012 documents a prescription for 20 alprazolam 2 mg, a “6 day supply,” and states, among other things, that his wife had been off medications for four months and had been staying with her mother-in-law. GE 6, at 4. Regarding the note, Dr. Chambers testified that “I don't know that she's even around when this prescription happens. It's just not clear where . . . she [is]. There's no evidence that she's even in front of him on July 14, and that's also a concern.” Tr. 285.

Dr. Chambers observed that, in the October 5, 2012 note (“[s]he is out 2 days early”), Respondent documented that his wife was “actually overusing the prescription that Dr. Webb ha[d] provided her. So he's documenting evidence that she's demonstrating abuse of these drugs and then he . . . say[s], `[s]he's lacerating and cutting herself, severe anxiety and depression, arms excoriated. No return call from a weekend doctor. I have to leave to work out of town.'”
Id.
After criticizing Respondent for “abandoning the patient,” who was self-mutilating and in a “potentially life threatening withdrawal,” Dr. Chambers testified that Respondent's “leaving for the weekend and leaving her with more medication unsupervised” is “of grave concern.”
Id.

Dr. Chambers offered similar testimony regarding Respondent's May 13, 2012 note.
See id.
288 (“So again he's now creating a track record in his . . . notation that the patient is essentially out of control and abusing Xanax and injuring herself. His response is to attempt to prescribe a combo of Xanax and Ambien . . . .).

Respondent's February 27, 2013 note states that his wife was “[a]nxious about marital situation.” As to the note, Dr. Chambers testified that “it's not considered a normal medical practice” to treat family members and “that when it comes to controlled substances it's a whole different ball game” when the prescription is “for a family member.”
33

Id.
at 286-87.

33
Dr. Chambers also testified that there is a prohibition against a psychiatrist treating a spouse for two reasons. Tr. 293. According to Dr. Chambers, the first reason is that the practice of psychiatry requires “getting inside the mind of the patient” and “is a very invasive process” and that “romantic and sexual . . . motives will contaminate the clarity of the practitioner. . . . A psychiatrist who is falling in love with his patient will begin to take actions that benefit . . . him or her rather than the patient.”
Id.
at 293-94. The second reason is that “there is an implicit power differential” between “a psychiatrist and a patient” and that “to exploit that power differential on a patient who's vulnerable with mental illness through romantic or erotic counter-transference is regarded fairly much as a cardinal sin in psychiatry.”
Id.
at 294. Continuing, Dr. Chambers testified that in “many cases, these are patients who have already suffered physical and sexual abuse previously” and are “susceptible” to more abuse “later on.” Thus, if a “psychiatrist engages in a sexual relationship with a patient . . . the very real danger is [that] there could . . . be a revictimization . . . of the patient.”
Id.
at 295.

Dr. Chambers also testified, however, that “[t]his standard is actually not true for other branches of medicine” such as family practice.
Id.
at 294.

Dr. Chambers offered similar testimony with respect to Respondent's March 28, 2012 note, which states: “Marital/physical/mental stress sky high—Marriage workshop in Montana just accentuated” and “Out of Xanax early—rebound anxiety—self harm.” GE 6, at 7. Dr. Chambers testified that he found that entry was “interesting because the marital, physical and mental stress . . . involves him, and he's prescribing this medication to somebody who is in acute distress that's ultimately related to the medication.” Tr. 287. Dr. Chambers also testified that Respondent's notation of a prescription for “Xanax # 14” “is incomplete” because it does not state “the dose” or the patient's instructions.
Id.

Subsequently, the Government asked Dr. Chambers to address “the situation where” a primary care doctor is prescribing to a patient who is also being treated by a psychiatrist.
Id.
at 291. Dr. Chambers testified that in his “own practice,” if a new patient is receiving psychoactive medication from another physician, he “will call them to stop that because you can't have two chefs in the kitchen.”
Id.
Dr. Chambers then explained:

If you have two chefs in the kitchen, this is the kind of stuff that can happen as you get chaos and harm and polypharmacy and no one understanding what is the illness versus what is [sic] the side effects of the medications, and it can lead to escalation of mental illness, addiction, and even death.

Id.

Finally, on direct examination, Dr. Chambers testified that “[a] competent psychiatrist would document [in the patient's chart] if they knew that another doctor was prescribing controlled substances that were overlapping or representing a threat.”
Id.
at 298. A competent psychiatrist would also “take action to stop it or to stop their practice.”
Id.

On cross-examination, Dr. Chambers agreed that “[i]n many cases,” Respondent prescribed the same drugs to his wife as were prescribed by Dr. Webb.
Id.
at 307. Dr. Chambers also acknowledged that he had not examined Respondent's wife and that “someone who sees her in person” is in a better position to evaluate her than a person who only reads her chart.
Id.
at 310. After accusing Dr. Chambers of making a “serious allegation []” when he testified that Respondent's “wife was going through withdrawal” and which “could be interpreted as she was abusing controlled substances,” Respondent's counsel asked Dr. Chambers whether he or Dr. Webb was in a better position to make that determination.
Id.
Dr. Chambers answered that Dr. Webb was, but noted that he “was looking at data from” Respondent and “had the ability to look at two charts.”
Id.
at 310-11;
see also id.
at 319 (Q. You don't know if she was exhibiting physical characteristics that correspond to drug addiction. A. I can only go on what I've read.”).

Asked by Respondent's counsel if “providing gap fills necessarily mean[s] there's a drug abuse issue,” Dr. Chambers answered that “[i]t can mean.”
Id.
at 311. After Respondent's counsel asserted that “[i]t can . . . it's not definitive,” Dr. Chambers answered: “I don't see gap filling happen[ing] in this case. There is no gap filling going on. There's overlaying.”
Id.
After Respondent's counsel asserted that Dr. Webb “ha[d] categorized the same

evidence . . . as gap filling,” Dr. Chambers testified: “[i]t would surprise me if he's seen the same evidence . . . It would surprise me because that's not what I see in the data.”
34

Id.

34
As found above, while Dr. Webb testified that gap filling “means a prescription that is used to get you to the next authorized refill” and gave various examples, including “something that would speak to a need for more medication,” his testimony was clear that with the exception of a prescription issued by “one of my on call doctors,” a gap fill by another provider was not appropriate. Tr. 138-39, 192, 195-96.

Assuming facts not in evidence, Respondent's counsel then asked Dr. Chambers if “somebody who sees [the patient] regularly five or six times a week as a patient
35

or someone who's paid to review her patient file” is “in a better position” to diagnose a patient as a substance abuser.
Id.
While Dr. Chambers agreed that a psychiatrist who saw the patient is in a better position to evaluate a patient, in response to the question of whether “it would not surprise [him] that Dr. Webb concluded that [Respondent's wife] didn't have a substance abuse issue,” Dr. Chambers explained that “[i]t wouldn't” because Dr. Webb is “not an addiction psychiatrist.”
Id.
at 312-13. When subsequently asked by Respondent's counsel if he “disagree[d] . . . with the doctor that's seen her for 15 years five to six times a week with his diagnosis,” Dr. Chambers answered that he did.
36

Id. See also id.
at 319 (Q. “So it's better to leave it to the psychiatrist who sees her five to six times a week over a 15-year period to make that decision.” A. “Well, not always. Not always, right.”).

35
Dr. Webb's patient file contains progress notes for 10 visits by Respondent's wife during the years 2011 through 2013. GX 5, at 42-53. Thus, contrary to the premise of the question, there is no evidence that Dr. Webb saw Respondent's wife “five or six times a week as a patient.” Tr. 311.

36
While the ALJ admitted only Dr. Webb's chart for Respondent's wife during the years 2011 through 2013, Tr. 74, here again, there is no evidence in the entire record that Dr. Webb saw Respondent's wife five to six times a week.

Dr. Chambers acknowledged that Respondent's and Dr. Webb's dosing of alprazolam were “often in the same ballpark.”
Id.
at 317. However, Dr. Chambers explained that, while “taken separately both of the [doctors'] dose ranges might be acceptable, . . . if they're . . . overlapping, that's when you get into the danger.”
Id.
Dr. Chambers acknowledged, however, that “[n]o one” knows how much of the drug Respondent's wife was taking.
Id.
at 318.

Respondent's counsel then asked Dr. Chambers if “you're saying that she was addicted or . . . was abusing controlled substances . . . wouldn't . . . the individual who prescribed her over 1500 doses of controlled substance in one year . . . be more responsible for that versus the individual who prescribed 200 doses of controlled substances a year?”
Id.
at 320. Dr. Chambers answered: “but what we're seeing here, that's not what happened. We're seeing two people prescribing [to] one person.”
Id.
Continuing, Dr. Chambers explained that “it could be a totally different picture if . . . only Dr. Webb” was prescribing but he had “no idea what that whole trajectory would look like” and whether “[s]he might be more stable.”
Id.
Dr. Chambers held to his earlier testimony that having two physicians prescribe to Respondent's wife was “creating chaos that could actually cause the treatment to get even worse” and “to evolve in the wrong direction.”
Id.
at 321.

After Dr. Chambers acknowledged that “Dr. Webb prescribed a significant amount of controlled substances, Respondent's counsel asked him if he “was aware that in 2011 [Respondent] only prescribed 128 dosage units to her?”
37

Id.
at 321. After answering “yes,” Dr, Chambers added that “Dr. Alexander prescribed about 20 percent of the controlled prescriptions and Dr. Webb about 70 percent on average over three years.
Id.

37
This, too, is a misstatement of the evidence. Rather, the evidence shows that during 2011, Respondent issued prescriptions for 206 dosage units of zolpidem, 151 dosage units of hydrocodone, 28 dosage units of clonazepam, 28 dosage units of alprazolam, and one kit of Diastat acudial.

Respondent's counsel also misstated the evidence when he asked Dr. Chambers if he was “aware [that] in 2012 Dr. Webb prescribed approximately 1720 dosage units of controlled substances versus the 132 that [Respondent] prescribed] to” is wife. Tr. 321. Rather, the evidence shows that Respondent prescribed 112 du of zolpidem, 94 du of alprazolam, 20 du of diazepam, 30 du of hydrocodone, 15 du of Adderall, as well as Hycodan cough syrup.

Following questions about the relative amounts of controlled substances prescribed by Dr. Webb and Respondent, Respondent's counsel asked Dr. Chambers if Respondent's wife had “a substance abuse issue, . . . isn't it logical that Dr. Webb would have as much, if not more, responsibility for that?”
Id.
at 322. Dr. Chambers disagreed, explaining: “not necessarily because Dr. Webb is not aware that . . . two doctors [were] putting drugs into one person.”
Id.
While Dr. Chambers acknowledged that there is evidence in Dr. Webb's chart “that he had discussions” with Respondent about his wife, he found “no evidence at all . . . that [Dr. Webb] knew that [Respondent] was also prescribing controlled substances.”
Id.

Dr. Chambers testified that he did not see any notation in Dr. Webb's patient file that he was aware that Respondent's wife “was running out early and that [Dr. Webb] was filling earlier.”
Id.
at 328. Asked if he would be surprised that Dr. Webb testified that he was aware that Respondent's wife was getting early refills, Dr. Chambers answered that he “would be” and explained that PMP “data doesn't really reflect [that] there was a great deal of early refill activity going on from Webb by himself,” and while “[t]here may be a few instances of it, [it was] not very frequent.”
Id.
at 329. Dr. Chambers explained that Dr. Webb's “prescribing shows a relative lack of overlap of his . . . prescriptions for controlled substances. And when I say `relative lack,' I mean maybe a day or two,” which is “not really significant because people have got to go to the pharmacy.”
Id.

Respondent's counsel then questioned Dr. Chambers about the alprazolam prescriptions which were issued by Dr. Webb and filled by Respondent's wife on May 14, June 10, July 4, July 21, August 4, and August 16, 2011, and whether the overlap between the prescriptions concerned him.
Id.
at 331. Dr. Chambers acknowledged that the June 10, 2011 filling created an overlap of three/four days and was “on the margin” as did the August 16, 2011 filling.
Id.
at 331-32. Dr. Chambers also acknowledged that the July 21 prescription “would concern me.”
Id.
at 332. Dr. Chambers offered similar testimony with respect to several alprazolam prescriptions that Respondent's wife filled on February 14 and 23, 2012, finding that the latter fill was “five days early” and “[t]hat's when the red flag begins to go up.”
Id.
at 332-33. Of note, however, several of these fills were actually refills of prescriptions written much earlier,
see
Tr. 333, and in any event, to the extent that Dr. Webb should have been aware that a previous prescription he issued had provided sufficient refills such that there was no reason to issue a new prescription on a particular date, Dr. Webb is not the respondent in this proceeding.
38

Likewise, while Respondent's counsel raised a series of questions as to whether the pharmacies that filled the prescriptions should not have dispensed various early refills,
id.
at 334-336, the

ALJ properly ruled that the conduct of the pharmacies is irrelevant.
Id.
at 336.

38
Specifically, Dr. Webb's February 3, 2011 alprazolam prescription, which was for a 30-day supply, see GE 5, at 111, authorized five refills, and Respondent's wife obtained refills which were authorized by this prescription on June 10 and July 4, 2011.
See
GE 11, at 12. However, on May 2, 2011, Dr. Webb issued Respondent's wife an additional prescription for 30 days of alprazolam. GE 11, at 13; GE 5, at 111.

Respondent's counsel subsequently asked Dr. Chambers if the hydrocodone prescription which Dr. Webb issued on June 28, 2013 concerned him.
Id.
at 338. Dr. Chambers testified that he did “have a concern in that [Dr. Webb] is concurrently prescribing two other benzodiazepines at the same time,” these being temazepam and alprazolam.
Id.
at 338-39. Dr. Chambers also acknowledged that the Adderall prescription issued by Dr. Webb on this date created “a speedball.”
Id.
at 339. Continuing, Dr. Chambers testified:

So that is a concern. When you step back from the record and you look at where—the opiate is the main threat actually, and when you look at the predominance of opiate prescribing over three years, the majority of it came from Dr. Alexander. So the number of opiates that were prescribed were quite rare. The incidents you're putting in there—you're pointing out is a concern, but . . . the relative frequency of which Webb did that was much, much, much lower than when Dr. Alexander [did] it, and that's interesting because, as you pointed out, Dr. Webb is prescribing . . . three or four times more number of prescriptions. So it's a matter of degree as well.

Id.
at 340.

Asked if it is within the usual course of professional practice for a psychiatrist to prescribe an opiate, Dr. Chambers testified that a psychiatrist “may treat pain on occasion.”
Id.
at 341. While Dr. Chambers then testified that he was surprised that Dr. Webb had testified that that he had written the June 28, 2013 hydrocodone prescription knowing that another physician was prescribing the drug to Respondent's wife and did so without consulting that physician, when Respondent's counsel asked Dr. Chambers if this called into question Dr. Webb's treatment of her, the ALJ properly sustained the Government's objection.
Id.
at 341-42.

Addressing the prescription for Diastat Acudial, a rectal suppository form of diazepam, Dr. Chambers testified that while Dr. Webb's file shows that Respondent's wife suffers from seizures, he did not see how administering Diastat would “be consistent with treating someone who was having a seizure.”
Id.
at 345. While Dr. Chambers testified that Valium (diazepam) and benzodiazepines “can be used to treat seizure disorder[s],” he added that these drugs “can also cause seizure disorders.”
Id.
at 346. Dr. Chambers subsequently testified that a rectal suppository might be used “to treat a seizure disorder if someone can't take [the drug] orally, meaning [the patient] would be in status epilepticus, like actively seizing and not conscious.”
Id.

Respondent's Testimony at the State Board Hearing Regarding His Reasons for Issuing the Prescriptions

At the January 2014 Board hearing which resulted in the suspension of his medical license, Respondent was asked to explain why he issued the prescriptions. GE 14, at 56. Respondent explained that his wife has a “fragile” psyc

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2017-23339. Public record. Not legal advice.