Patrick W. Stodola, M.D.; Revocation of Registration, 20727-20736 [E9-10245]

Agencies

• Drug Enforcement Administration
• Department of Justice

[Federal Register Volume 74, Number 85 (Tuesday, May 5, 2009)]
[Notices]
[Pages 20727-20736]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-10245]


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DEPARTMENT OF JUSTICE

Drug Enforcement Administration

[Docket No. 07-24]


Patrick W. Stodola, M.D.; Revocation of Registration

    On February 7, 2007, the Deputy Assistant Administrator, Office of 
Diversion Control, Drug Enforcement Administration, issued an Order to 
Show Cause to Patrick W. Stodola, M.D. (Respondent), of Chicago, 
Illinois. The Show Cause Order proposed the revocation of Respondent's 
DEA Certificate of Registration, AS2352653, as a practitioner, and 
proposed the denial of his pending application to renew his 
registration, on the ground that his ``continued registration is 
inconsistent with the public interest.'' Show Cause Order at 1.
    The Show Cause Order specifically alleged that while Respondent is 
licensed as a physician only in Illinois, he prescribed controlled 
substances, via the internet, to persons located in twenty-six other 
States. Id. The Order alleged that Respondent's prescribing constituted 
the unauthorized practice of medicine because he did not possess the 
licenses required to practice medicine (and prescribe) in these States, 
and that the prescriptions he authorized ``were not issued in the usual 
course of professional practice as required by 21 CFR 1306.04.'' Id. at 
1-2.
    On March 14, 2007, Respondent filed a request for a hearing and the 
matter was placed on the docket of the Agency's Administrative Law 
Judges. Following pre-hearing procedures, a hearing was held on October 
16, 2007, in Chicago, Illinois. At the hearing, both parties elicited 
testimony and introduced documentary evidence for the record. Following 
the hearing, both parties submitted briefs containing their proposed 
findings of fact, conclusions of law and argument.
    On September 16, 2008, the ALJ issued her recommended decision 
(ALJ). In evaluating Respondent's experience in dispensing controlled 
substances and record of compliance with applicable laws, the ALJ 
concluded that Respondent had violated the medical practice standards 
adopted by multiple States which specifically require that a physician 
physically examine a patient before prescribing a drug to him/her. ALJ 
at 33-34. The ALJ further concluded that Respondent had violated the 
laws of numerous States by prescribing to their residents without 
holding the requisites licenses to practice medicine and/or dispense 
controlled substances. Id. at 34. While the ALJ found that Respondent 
has retained his Illinois medical license and has not been convicted of 
a crime, she further found that Respondent has ``refus[ed] to 
acknowledge his wrongdoing.'' Id. at 32 & 34. The ALJ thus 
``conclude[d] that Respondent is unwilling or unable to accept the 
responsibilities inherent in a DEA registration,'' and recommended that 
his registration be revoked and that any pending applications be 
denied. Id. at 35.
    Respondent did not file exceptions to the ALJ's decision.\1\ 
Thereafter, the record was forwarded to me for final agency action.
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    \1\ While the Government filed exceptions, the exceptions do not 
go to the merits of the proceeding.
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    Having considered the entire record in this matter, I adopt the 
ALJ's conclusions of law with respect to the public interest inquiry. I 
further adopt the ALJ's recommended sanction. Accordingly, I will 
revoke Respondent's registration and deny his pending application to 
renew the registration. I make the following findings.

Findings

    Respondent is the holder of DEA Certificate of Registration, 
AS2352653, which authorizes him to dispensing controlled substances in 
schedules II through V as a practitioner. According to Respondent's 
Certificate of Registration, the expiration date of his registration 
was February 28, 2006. It is undisputed, however, that Respondent filed 
a timely renewal application. I therefore find that Respondent's 
registration has remained in effect pending the issuance of this Order. 
See 5 U.S.C. 558(c).
    Respondent holds a medical license in Illinois. Tr. 85, 190-91. In 
his testimony, Respondent acknowledged that he is not licensed to 
practice medicine in any other State, id. at 85 & 191, and that he has 
never obtained a license to practice in any other State. Id. at 85. 
Moreover, Respondent does not hold a DEA registration for a location in 
any State other than Illinois. Id. at 191.
    In early 2006, Respondent read an advertisement which had been 
placed by Just USA Meds \2\ in the employment section of the Chicago 
Tribune's Web site. Id. at 165. Respondent called the phone number 
contained in the ad, and spoke with Challen Sullivan, Just USA's owner, 
who told him that his business ``was to be a provider of medical 
services,'' but not ``a dispenser or a vending machine of any 
particular medications.'' Id. at 87. Thereafter, Respondent entered 
into an agreement with the entity under which Just USA Meds would 
arrange for customers, who were seeking controlled substances, to speak 
with him by telephone. Id. at 14. Respondent was paid $20 per 
consultation and would typically issue a controlled-substance 
prescription for the patient upon the conclusion of the consultation. 
Id. The prescriptions were then sent to pharmacies which had entered 
into arrangements with Just USA Meds to dispense the drugs to its 
customers.
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    \2\ In this decision, Just USA Meds will also be referred to as 
``Just USA.''
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    According to Respondent, a customer would contact Just USA Meds, 
identify himself, and provide a copy of the credit card which he 
intended to use to pay his bill. Id. at 91. Respondent asserted that a 
customer would then be interviewed by an employee of Just USA Meds, who 
would ask him the name of his doctor, what other drugs he was taking, 
and whether he would agree not to seek drugs from another source if 
Respondent (or the other doctors engaged by Just USA Meds) issued a 
prescription for him. Id. at 92. Just USA would then contact the 
customer's credit card company to verify whether the card was valid and 
to request a pre-charge for the anticipated amount of the services and 
drugs being provided. Id. After Just USA obtained the pre-charge, the 
customer would then be scheduled for a consultation with Respondent or 
another physician. Id. at 104.
    Respondent admitted that he did not physically examine any of the 
persons who were referred to him by Just USA Meds. Tr. 18 (testimony of 
DI); id. at 84 (testimony of Respondent).\3\ Rather, Respondent 
asserted that the customers were required to send in medical records 
including the documentation of a physical exam which had to be less 
than one year old. Id. at 97-98. He also maintained that persons who 
claimed ``some sort of structural harm'' were

[[Page 20728]]

required to forward imaging documentation such as a CT scan, MRI, or X-
Ray, and that if the person did not have a physical that met the above 
requirement, the person was sent an eleven to twelve-page-long form, 
which was to be taken to a doctor in his/her community to ``have the 
history and physical completed.'' Id. at 98. Relatedly, Respondent 
claimed that for those customers who found it inconvenient to go to a 
doctor's office, Just USA Meds used a company which sent a nurse to the 
customer's home to obtain a medical history and perform a physical. Id. 
at 100.
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    \3\ Respondent did not even physically examine those persons he 
prescribed to who resided in the Chicago area. See GX 34 at 24 
(resident of Chicago); GX 39 at 63 (resident of Highland Park, Il.); 
Id. at 133 (resident of Arlington Heights, Il.); Id. at 171 
(resident of Hoffman Estates, Il.).
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    Respondent further maintained that he kept copies of each 
customer's medical records. Id. Respondent did not, however, produce 
any of these records at the hearing.
    Respondent also asserted that the phone consultations he conducted 
were probing and would take between twenty to thirty minutes to 
complete.\4\ Id. at 105. Relatedly, he maintained that Just USA Meds 
``scolded [him] a couple of times in the beginning'' because the 
consultations took too much time. Id. According to Respondent, the
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    \4\ The prescription records suggest that this testimony 
stretches the limits of credulity. According to GX 35, on February 
9, 2006, Respondent would have performed approximately thirty 
consultations, and the following day, he would have performed 
approximately thirty-three consultations. Respondent would thus have 
spent between ten and seventeen hours a day consulting. While this 
is not out of the realm of possibility, it seems most unlikely. 
However, because most (if not all) of Respondent's prescribings were 
illegal regardless of how long the consultations lasted for, it is 
unnecessary to determine whether this testimony is credible.

consultations were inquiries concerning the history and physical, 
which was in front of me, the nature and extent of the medications 
and therapies that they had already received, their response to any 
medications that they had already received, what medications other 
than what they were requesting they were already taking, how their 
condition affected them, and I usually used two or three different 
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tests inquiring from them to find out the nature of their problem.

Id. at 104. Respondent also maintained that he asked the customer to 
rate their pain ``on a scale of 1 to 10,'' whether he/she had 
previously ``taken hydrocodone,'' and if so, how it affected the 
customer's pain level and whether the drug had caused various adverse 
events. Id. at 105. Respondent maintained that ``those were all 
discussed by me each and every time,'' and that ``[t]here were no 
exceptions.'' Id.
    Relatedly, Respondent asserted that the consultations ``were 
meaningful interviews that took as long or longer than is customarily 
had in a physician's office with the patient physically in front of 
them,'' and ``that the interviews were comprehensive and medically 
appropriate.'' Id. at 106. According to Respondent, ``probably about 90 
percent of the patients who were inquiring were requesting some sort of 
pain relief.'' Id. Respondent also asserted that he would ``sometimes'' 
negotiate with the customers to ``alter their request'' for drugs and 
or ``to use some other medicine.'' \5\ Id.
    According to various prescription records which were entered into 
evidence, Respondent issued in excess of three hundred controlled-
substance prescriptions for Just USA, the overwhelming majority 
(approximately eighty-five to ninety percent) of which were for 
combination drugs containing hydrocodone, a schedule III controlled 
substance, and acetaminophen. See GXs 34, 35, & 39; 21 CFR 1308.13(e). 
Invariably, the prescriptions were for those formulations which 
contained the stronger concentrations (7.5 or 10 mg.) of hydrocodone. 
See GXs 34, 35, & 39.
    As I have noted in numerous other decisions, these drugs are highly 
popular with drug abusers. See Southwood Pharmaceuticals, Inc., 72 FR 
36487, 36503 (2007) (noting 2004 survey of National Institute of Drug 
Abuse found that ``9.3 percent of twelfth graders reported using 
Vicodin, a brand name Schedule III controlled substance without a 
prescription in the previous year''); William R. Lockridge, 71 FR 
77791, 77796 (2006) (noting that in 2002, the abuse of hydrocodone 
products resulted in more than 27,000 emergency room visits).\6\ 
Respondent also issued smaller numbers of prescriptions for Didrex 
(benzphetamine, a schedule III controlled substance), as well as 
various schedule IV drugs including alprazolam, diazepam, Ambien 
(zolpidem) and phentermine. See GXs 34, 35, & 39; see also 21 CFR 
1308.13(b)(2); Id. 1308.14(c) & (e).
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    \5\ The prescriptions records, however, cast doubt on the 
credibility of this testimony. As found above, Respondent invariably 
issued prescriptions for combination drugs which contained either 
7.5 or 10 mg. of hydrocodone (rather than those drugs which contain 
only 5 mg.), and rarely issued prescriptions for such non-controlled 
drugs which are used to treat pain such as Tramadol and Fioricet.
    The various prescription records entered into evidence show that 
Respondent also wrote a miniscule number of prescriptions for non-
controlled drugs including Soma (carisoprodol), Tramadol, and 
Fioricet (a combination of butalbital, acetaminophen and caffeine).
    \6\ In his testimony, Respondent asserted that drugs containing 
hydrocodone are not addictive or ``dangerous.'' Tr. 158-59. As found 
above, combination hydrocodone drugs are among the most highly 
abused controlled substances. I therefore reject Respondent's 
testimony as self-serving.
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    As the prescriptions records indicate, the customers were located 
throughout the United States, and the overwhelming majority of them 
resided in States other than Illinois. See GXs 34, 35, & 39. More 
specifically, the records in evidence show, inter alia, that Respondent 
issued hydrocodone prescriptions in the following amounts: forty-eight 
to residents of Texas, forty to residents of California, nineteen to 
residents of North Carolina, thirteen to residents of both Ohio and of 
Virginia, ten to residents of Indiana, nine to residents of Colorado, 
eight to residents of both Massachusetts and Mississippi, seven to 
residents of Georgia, six to residents of Missouri, and four to 
residents of Oklahoma.\7\ See generally GXs 34, 35, & 39.
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    \7\ The Government also introduced into evidence the sworn 
declaration of George Van Komen, M.D. GX 41. Respondent, however, 
objected to the admission of the exhibit on the ground that the 
declaration was testimonial in nature and that he was unable to 
cross-examine Dr. Van Komen. Tr. 58-59. The ALJ overruled 
Respondent's objection and admitted the declaration. Id. at 59.
     I do not rely on the exhibit, however, because it is unclear 
whether the declaration was properly admitted. While the Government 
provided notice of its intent to use the Declaration in its 
Supplemental Prehearing Statement, the Statement does not disclose 
the substance of the Declaration. Moreover, the record does not 
establish whether a copy of the Declaration was provided to 
Respondent in advance of the hearing. While hearsay is admissible in 
these proceedings, a testimonial declaration must be timely provided 
to the other party in order to afford it with the opportunity to 
determine whether to request a subpoena of the witness.
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    As early as March 2006, Respondent spoke with a DEA Diversion 
Investigator to inquire as to why the Agency had not approved his 
renewal application. Tr. 87. During the conversation, the DI asked him 
``what [he] was doing to make a living as a doctor.'' Id. Respondent 
told the DI that he worked at several clinics and ``had some 
telemedicine internet practice going.'' Id. The DI then told Respondent 
``that there might be a problem with that.'' Id. Respondent nonetheless 
continued his prescribing for Just USA Meds until January 2007. Id. at 
178.\8\
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    \8\ The record suggests that Respondent had additional 
discussions with DEA Investigators in both May and September 2006 
regarding his practices. The record does not, however, establish 
with reasonable specificity the content of these discussions.
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    Throughout the hearing, Respondent maintained that his 
``prescribing was appropriate.'' Id. at 99. Furthermore, on cross-
examination, Respondent acknowledged that he found evidence that Just 
USA Meds had used his name and registration to back-date several 
prescriptions which had been dispensed before he commenced working for 
the

[[Page 20729]]

entity. Id. at 170. Respondent testified that he did not authorize this 
use of his registration which he discovered ``within the first couple 
of weeks'' after he started working for Just USA. Id. at 169.
    Respondent failed to report the incident to the Agency, asserting 
that Just USA had told him that ``only one or two'' prescriptions had 
been back dated. Id. at 170. Respondent admitted, however, that he 
``had no way of confirming'' the validity of Just USA's representation 
that the backdating had occurred in ``only one or two instances.'' Id.
    Respondent also maintained that on multiple occasions, he engaged 
in due diligence to determine whether his conduct was legal. Respondent 
contends that shortly after he entered into his arrangement with Just 
USA, he was sent a document entitled ``Ordering and Registration 
Instructions,'' which indicated the procedures which the ``patients'' 
were required to complete to purchase drugs which included providing a 
copy of an identification card, medical records, and physician reports, 
etc. RX 7A. Moreover, the document listed seven States that Just USA's 
pharmacies did not ship to including Arizona, Kentucky, Missouri, 
Nevada, Pennsylvania, South Carolina, and Tennessee. Id. In his 
testimony, Respondent maintained that Just USA had sent this document 
to him after he asked how he would know that he was permitted to 
prescribe to residents of States other than Illinois. Tr. 95. 
Respondent further claimed that Just USA told him that it had ``already 
done an examination of the law, and we do not service'' the above 
States, because they ``required a face-to-face meeting between the 
prescribing doctor and the patient,'' or the State prohibited an out-
of-state doctor from prescribing to its residents, or the State did not 
permit telemedicine. Id. at 95-96; see also id. at 184. According to 
Respondent, ``it was good enough for me that they had ruled out certain 
states that it was not appropriate to go to.'' \9\ Id. at 96.
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    \9\ Respondent subsequently stated that after he stopped working 
for Just USA he learned that there were two or three other States 
(in addition to the seven States listed in RX 7A) where his 
prescribing was illegal. Tr. 161.
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    On cross-examination, however, the Government identified multiple 
instances in which Respondent had issued prescriptions to patients who 
lived in these States. See Tr. 186-90. More specifically, the 
Government identified controlled prescriptions Respondent issued to 
residents of Arizona (GX 39 at 6), Kentucky (id. at 21), Missouri (id. 
at 23), Nevada (id. at 75), Pennsylvania (id. at 67), and South 
Carolina (id. at 182). When confronted with this evidence, Respondent 
did not ``know how that happened'' and claimed that he ``wasn't aware 
that it happened.'' Id. at 194.
    Respondent admitted, however, that the customer's names and 
addresses were in the medical records, which he claimed he had access 
to. Id. at 196. He also admitted that ``in most instances,'' he did not 
look at where the customer lived, id., but instead relied on the 
employees of Just USA to screen out the customers. Id. at 200-01.
    Respondent also entered into evidence an Agency document which 
stated that it was clarifying DEA's ``policies regarding the dispensing 
and prescribing of controlled substances as they pertain to the 
internet.'' RX 7C. This document specifically noted the prescription 
requirement of Federal law, see 21 CFR 1306.04(a), and made explicit 
reference to the Agency's 2001 Guidance Document, Dispensing and 
Purchasing Controlled Substances over the Internet, 66 FR 21181. The 
document further stated: ``As noted in the guidance document, it is 
unlikely that such a relationship could be established through the use 
of an online questionnaire completed by a consumer prior to the 
purchase of controlled substances.'' RX 7C, at 1.
    The Agency's 2001 Guidance expressly stated that ``[u]nder Federal 
and state law, for a doctor to be acting in the usual course of 
professional practice, there must be a bona fide doctor/patient 
relationship.'' 66 FR at 21182. Continuing, the Guidance observed that 
``[f]or purposes of state law, many state authorities, with the 
endorsement of medical societies, consider the existence of the 
following four elements as an indication that a legitimate doctor/
patient relationship has been established: A patient has a medical 
complaint; A medical history has been taken; A physical examination has 
been performed; and Some logical connection exists between the medical 
complaint; the medical history, the physical examination, and the drug 
prescribed.'' Id. at 21182-83. The Guidance further stated that 
``[c]ompleting a questionnaire that is then reviewed by a doctor hired 
by the internet pharmacy could not be considered the basis for a 
doctor/patient relationship.'' Id. at 21183.
    Of further relevance, the Guidance explained that ``[o]nly 
practitioners acting in the usual course of their professional practice 
may prescribe controlled substances. These practitioners must be 
registered with DEA and licensed to prescribe controlled substances by 
the State(s) in which they operate.'' Id. at 21181 (emphasis 
added).\10\
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    \10\ Respondent also cites a ``Flow Chart,'' RX 7B, which was 
prepared by Just USA Meds Pharmacy and which sets forth the 
purported process by which customers obtained drugs as evidence of 
his having engaged in due diligence. The document does not set forth 
any legal advice and is merely cumulative of Respondent's testimony 
as to the procedures used by Just USA to process customer orders.
    Respondent also submitted a document which contains several e-
mail messages from July 27 and 28, 2006, which discuss an e-
prescribing initiative introduced in Illinois, one of which 
originated from Mudri Associates, a DEA Consultancy. RX 7E. 
Respondent asserts that this evidence establishes that he contacted 
the consultant ``following [its] inspection of all of the procedures 
followed by [J]ust USA * * * [and] the pharmacies with which [J]ust 
USA had arrangements.'' Resp. Br. (Pt. II) at 14. The e-mail does 
not, however, discuss any issue other than various proposals that 
were part of an Illinois patient safety initiative.
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    As further support for his contention that he performed due 
diligence in attempting to ascertain whether his prescribing practices 
were legal, Respondent introduced into evidence a document which 
appears to be a legal opinion (dated June 21, 2006) prepared by a 
Tampa, Florida-based lawyer.\11\ See RX 7D. In stating the issue, the 
opinion noted that ``[a]s your Pharmacy and Prescribing Doctors are 
located within the States of Florida, this Memorandum's analysis 
focuses on Florida law as well as Federal law concerning appropriate 
prescribing standards.'' Id. at 6. Continuing, the opinion observed 
that ``[t]he state laws and professional standards concerning 
telemedicine and prescribing practices vary from state to state, and 
because I am licensed to practice in the State of Florida, this 
Memorandum's analysis is limited to Florida law as well as Federal law 
concerning appropriate prescribing standards.'' Id. The opinion further 
noted that it ``specifically'' did not address such issues as 
``physician and pharmacy licensure.'' Id.
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    \11\ The text of the letter appears to have been cut and 
inserted into various internet-based text messages which occurred 
between Respondent and Challen Sullivan, the owner of Just USA Meds. 
See RX 7-D; Tr. 119 & 125-26. Nor does the text of the memorandum 
appear in the exhibit in the order that is customarily used by 
lawyers in preparing legal opinions for their clients. See id.
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    As for its legal conclusions, the opinion stated that 
``[p]rescribing standards vary dramatically from state to state and in 
some instances vary within a particular state for the prescription of 
specified pharmaceutical items (e.g., some states have heightened 
standards for prescribing controlled substances and diet drugs).'' Id. 
at 1.\12\

[[Page 20730]]

Moreover, in addition to its discussion of Florida law, the opinion 
notes that ``[o]ther states have adopted statutes specifically relating 
to prescribing standards and the business of Internet pharmacy--often 
requiring a face to face physical examination and making non-compliance 
a crime subject to heavy penalties. These statutes are usually more 
comprehensive in requiring compliance by all of the website operators, 
physicians and pharmacies involved. Most sophisticated and established 
Internet pharmacy operators avoid conducting business in these more 
restrictive states.'' Id. at 4 (emphasis added).\13\
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    \12\ The opinion provides a lengthy discussion of Florida's 
standards, and appears to conclude that under Florida law and 
regulations, a physician need not have personally performed a 
physical examination in order to prescribe a drug (other than a diet 
drug). Id. at 2-3. However, as found above, Respondent prescribed to 
residents of numerous other States.
    \13\ The opinion also observed that the American Medical 
Association's ``standards suggest that the physician must personally 
conduct the physical examination,'' RX 7D at 3, and while suggesting 
that the AMA's positions were inconsistent, quoted another AMA 
guideline which states in relevant part: ``Licensure: Physicians who 
prescribe medications via the Internet across state lines, without 
physically being located in the state(s) where the patient 
(clinical) encounter(s) occurs, must possess appropriate licensure 
in all jurisdictions where patients reside.'' Id. at 4.
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    The opinion also discussed Federal prescribing standards. In 
discussing this Agency's 2001 Guidance, the opinion states that 
``[a]lthough the DEA acknowledges that state law ultimately controls 
the issue of whether a prescription is written in the usual course of 
professional practice, the DEA feels that the weight of legal and 
professional authority requires the [four] elements [set forth in the 
Guidance] to be present in order to establish a bona fide doctor/
patient relationship.'' Id. The letter then quoted verbatim the four 
elements set forth in the Guidance.
    Furthermore, the opinion also noted that ``DEA has in some 
instances over the past year informally challenged some pharmacies and 
medical professionals participating in a Medical Records Based 
Prescribing pharmacy business. The DEA has asserted in such instances 
that in its opinion Medical Records Based Prescribing does not meet 
applicable local legal standards which require that an adequate 
physician-patient relationship exists for the prescription.'' RX 7D at 
5.
    The opinion, however, rejected the Agency's view as to the legality 
of Medical Records Based Prescribing, citing among other things, its 
author's ``understanding that the three largest drug wholesalers * * * 
have concluded that the DEA does not have a legal basis for making 
these assertions,'' the 2003 failure of Congress to enact the Ryan 
Haight Internet Pharmacy Consumer Protection Act (which prohibits a 
practitioner's prescribing to a person he/she has not physically 
examined),\14\ and the December 2005 testimony of Agency officials to 
Congress to the effect that the Controlled Substances Act does not 
provide a statutory definition of ``what constitutes a valid `doctor/
patient' relationship.'' Id. at 5. The opinion thus concluded that 
``the Websites' Medical Records Based Prescribing Procedures appear to 
comply with the DEA's published rules and Federal law.'' Id.\15\
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    \14\ On October 15, 2008, the President signed into law the Ryan 
Haight Online Pharmacy Consumer Protection Act of 2008, Public Law 
No. 110-425, 122 Stat. 4820 (2008). Section 2 of the Act prohibits 
the dispensing of a prescription controlled substance ``by means of 
the Internet without a valid prescription,'' and defines, in 
relevant part, the ``[t]he term `valid prescription' [to] mean [ ] a 
prescription that is issued for a legitimate medical purpose in the 
usual course of professional practice by * * * a practitioner who 
has conducted at least 1 in-person medical evaluation of the 
patient.'' 122 Stat. 4820. Section 2 further defines ``[t]he term 
`in-person medical evaluation' [to] mean [ ] a medical evaluation 
that is conducted with the patient in the physical presence of the 
practitioner, without regard to whether portions of the evaluation 
are conducted by other health professionals.'' Id. These provisions 
do not, however, apply to Respondent's conduct.
    \15\ Respondent also cites a December 1, 2006 rulemaking which 
amended DEA regulations to require that a practitioner obtain a 
separate registration for each State in which he practices, and a 
December 22, 2006, memo written by the same Tampa-based attorney 
regarding the applicability of the new rule to internet prescribers. 
See RX 7G. In light of the fact that almost (if not) all of the 
actual prescriptions which are in evidence in this matter were 
issued by Respondent prior to his having reviewed either of these 
documents, I find it unnecessary to make any findings based on them.
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Discussion

    Section 304(a) of the Controlled Substances Act (CSA) provides that 
a registration to ``dispense a controlled substance * * * may be 
suspended or revoked by the Attorney General upon a finding that the 
registrant * * * has committed such acts as would render his 
registration under section 823 of this title inconsistent with the 
public interest as determined under such section.'' 21 U.S.C. 
824(a)(4). Moreover, section 303(f) of the CSA provides that ``[t]he 
Attorney General may deny an application for [a practitioner's] 
registration if he determines that the issuance of such registration 
would be inconsistent with the public interest.'' 21 U.S.C. 823(f). In 
making the public interest determination, the Act requires the 
consideration of the following factors:

    (1) The recommendation of the appropriate State licensing board 
or professional disciplinary authority.
    (2) The applicant's experience in dispensing * * * controlled 
substances.
    (3) The applicant's conviction record under Federal or State 
laws relating to the manufacture, distribution, or dispensing of 
controlled substances.
    (4) Compliance with applicable State, Federal, or local laws 
relating to controlled substances.
    (5) Such other conduct which may threaten the public health and 
safety.

Id.
    ``[T]hese factors are * * * considered in the disjunctive.'' Robert 
A. Leslie, M.D., 68 FR 15227, 15230 (2003). I may rely on any one or a 
combination of factors, and may give each factor the weight I deem 
appropriate in determining whether to revoke an existing registration 
or to deny an application to renew a registration. Id. Moreover, I am 
``not required to make findings as to all of the factors.'' Hoxie v. 
DEA, 419 F.3d 477, 482 (6th Cir. 2005); see also Morall v. DEA, 412 
F.3d 165, 173-74 (D.C. Cir. 2005).
    Having considered all of the factors, I acknowledge that the record 
contains no evidence that the State of Illinois has taken action 
against Respondent's medical license (factor one) or that Respondent 
has been convicted of an offense related to controlled substances 
(factor two).\16\ The record contains, however, an abundance of 
evidence that Respondent's experience in dispensing controlled 
substances (factor two) and record of compliance with applicable 
Federal and State laws (factor four) is characterized by his repeated 
violation of the CSA's prescription requirement, as well as numerous 
state laws and regulations prohibiting the unlicensed practice of 
medicine and setting the standards for prescribing a drug.
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    \16\ This Agency has long held that a State's failure to take 
action against a practitioner's authority to dispense controlled 
substances is not dispositive in determining whether the granting of 
an application for registration would be consistent with the public 
interest. See Mortimer B. Levin, 55 FR 8209, 8210 (1990). I further 
note that the absence of a criminal conviction is not dispositive of 
the public interest inquiry. See, e.g., Edmund Chein, 72 FR 6580, 
6593 n.22 (2007).
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    Moreover, I reject Respondent's contention that his conduct should 
be excused because he engaged in due diligence in attempting to 
ascertain the legal requirement for his prescribing. Even if I was to 
recognize such a defense in the context of a prescribing practitioner, 
the record establishes that Respondent's efforts were half-baked at 
best, and that when he did receive information that his activities were 
likely illegal, he ignored it. Finally, while Respondent eventually 
ceased his internet-related prescribing activities, his testimony 
manifests that he has not accepted responsibility for his misconduct, 
but rather blames others.

[[Page 20731]]

    I therefore conclude that Respondent's continued registration would 
be ``inconsistent with the public interest.'' 21 U.S.C. 823(f). 
Accordingly, Respondent's registration will be revoked and his 
application to renew his registration will be denied.

Factor Two and Four--Respondent's Experience in Dispensing Controlled 
Substances and Record of Compliance With Applicable Controlled 
Substance Laws

    The primary issue in this case is whether the prescriptions 
Respondent issued pursuant to his agreement with Just USA Meds were 
lawful prescriptions under the CSA. Under a longstanding DEA 
regulation, a prescription for a controlled substance is not 
``effective'' unless it is ``issued for a legitimate medical purpose by 
an individual practitioner acting in the usual course of his 
professional practice.'' 21 CFR 1306.04(a). This regulation further 
provides that ``an order purporting to be a prescription issued not in 
the usual course of professional treatment * * * is not a prescription 
within the meaning and intent of [21 U.S.C. 829] and * * * the person 
issuing it, shall be subject to the penalties provided for violations 
of the provisions of law relating to controlled substances.'' Id. As 
the Supreme Court recently explained, ``the prescription requirement * 
* * ensures patients use controlled substances under the supervision of 
a doctor so as to prevent addiction and recreational abuse. As a 
corollary, [it] also bars doctors from peddling to patients who crave 
the drugs for those prohibited uses.'' Gonzales v. Oregon, 546 U.S. 
243, 274 (2006) (citing United States v. Moore, 423 U.S. 122, 135, 143 
(1975)).
    Under the CSA, it is fundamental that a practitioner must establish 
a bona fide doctor-patient relationship in order to act ``in the usual 
course of * * * professional practice'' and to issue a prescription for 
a ``legitimate medical purpose.'' Moore, 423 U.S. at 141-43. At the 
time of the events at issue here, the CSA generally looked to state law 
to determine whether a doctor and patient have established a bona fide 
doctor-patient relationship. See Kamir Garces-Mejias, 72 FR 54931, 
54935 (2007); United Prescription Services, Inc., 72 FR 50397, 50407 
(2007); Dispensing and Purchasing Controlled Substances Over the 
Internet, 66 FR at 21182-83; but see n.14, supra (discussing the Ryan 
Haight Act).
    Moreover, shortly after the CSA's enactment, the Supreme Court 
explained that ``[i]n the case of a physician [the Act] contemplates 
that he is authorized by the State to practice medicine and to dispense 
drugs in connection with his professional practice.'' Moore, 423 U.S. 
at 140-41 (emphasis added). Accordingly, ``[a] physician who engages in 
the unauthorized practice of medicine'' under state laws ``is not a 
`practitioner acting in the usual course of * * * professional 
practice' '' under the CSA. United Prescription Services, 72 FR at 
50407 (quoting 21 CFR 1306.04(a)). This rule is supported by the plain 
meaning of the Act, which defines the ``[t]he term `practitioner' [to] 
mean [ ] a physician * * * licensed, registered, or otherwise 
permitted, by the United States or the jurisdiction in which he 
practices * * * to * * * dispense * * * a controlled substance,'' 21 
U.S.C. 802(21), and ``[t]he term `dispense' [to] mean [ ] to deliver a 
controlled substance to an ultimate user * * * by, or pursuant to the 
lawful order of, a practitioner.'' Id. Sec.  802(10). See also id. 
Sec.  823(f) (``The Attorney General shall register practitioners * * * 
to dispense * * * if the applicant is authorized to dispense * * * 
controlled substances under the laws of the State in which he 
practices.'').
    A controlled-substance prescription issued by a physician who lacks 
the license or other authority required to practice medicine within a 
State is therefore unlawful under the CSA. See 21 CFR 1306.04(a) (``An 
order purporting to be a prescription issued not in the usual course of 
professional treatment * * * is not a prescription within the meaning 
an intent of'' the CSA); cf. 21 CFR 1306.03(a)(1) (``A prescription for 
a controlled substance may be issued only by an individual practitioner 
who is * * * [a]uthorized to prescribe controlled substances by the 
jurisdiction in which he is licensed to practice his profession[.]'').
    The record establishes that in issuing the prescriptions for Just 
USA's customers, Respondent repeatedly violated the CSA's prescription 
requirement. 21 CFR 1306.04(a). This is so for two reasons: (1) 
Respondent prescribed without establishing a valid doctor-patient 
relationship in violation of the medical practice standards of numerous 
States because he failed to physically examine the patients, and (2) 
Respondent's prescribing typically constituted the unauthorized 
practice of medicine in the States where the patients were located 
because he was licensed to practice medicine (and authorized to 
prescribe) only in Illinois. Furthermore, Respondent issued unlawful 
prescriptions even where various States had either enacted laws and 
regulations, rendered decisions in adjudications, or issued policy 
statements making clear that his prescribing practices were illegal.
    For example, as found above, Respondent issued forty hydrocodone 
prescriptions to residents of California. In 2000, California enacted 
Cal. Bus. & Prof. Code Sec.  2242.1,\17\ which specifically prohibits 
the prescribing or dispensing of a dangerous drug ``on the Internet for 
delivery to any person in this state, without an appropriate prior 
examination and medical indication therefore, except as authorized by 
Section 2242.'' Moreover, the statute, which provides for a fine or 
civil penalty of twenty-five thousand dollars for a violation, further 
directs that ``[i]f the person or entity that is the subject of an 
action brought pursuant to this section is not a resident of this 
state, a violation of this section shall, if applicable, be reported to 
the person's or entity's appropriate professional licensing 
authority.'' Id. at (e).
---------------------------------------------------------------------------

    \17\ This statute was effective January 1, 2001.
---------------------------------------------------------------------------

    Relatedly, in 2003, the Medical Board of California revoked a 
physician's medical license for engaging in the same type of 
prescribing practices as Respondent did here. See In re John Steven 
Opsahl, M.D., Decision and Order, at 3 (Med. Bd. Cal. 2003) (available 
by query at https://publicdocs.medbd.ca.gov/pdl/mbc.aspx). In Opsahl, 
the Medical Board expressly found that ``[b]efore prescribing a 
dangerous drug, a physical examination must be performed.'' Id. 
Continuing, the Board found that ``[a] physician cannot do a good faith 
prior examination based on a history, a review of medical records, 
responses to a questionnaire and a telephone consultation with the 
patient, without a physical examination of the patient.'' Id. Finally, 
the Board found that:

    Medical indication means having a condition that warrants 
specific treatment. It is determined after the physician takes a 
history, performs a physical examination and makes an assessment 
about the patient's condition. * * * A physician cannot determine 
whether there is a medical indication for prescription of a 
dangerous drug without performing a physical examination.

Id.\18\
---------------------------------------------------------------------------

    \18\ Dr. Opsahl's prescribing practices involved ``verifying 
patient identity,'' ``obtaining and reviewing medical records,'' 
``having direct contact with the patient, though personal contact 
was not required,'' and ``having an opportunity for follow-up.'' 
Decision at 4. Opsahl prescribed both non-controlled and controlled 
drugs including combination drugs containing hydrocodone, 
benzodiazepines, schedule three drugs containing codeine, as well as 
Ambien, phentermine, and phendimetrazine. Id. at 6.

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[[Page 20732]]

    Moreover, prior to Respondent's engaging in internet-based 
prescribing, the Medical Board of California had issued numerous 
Citation Orders to out-of-state physicians for internet prescribing to 
California residents. These Orders invariably cited not only the 
physicians' failure to perform ``a good faith prior examination,'' but 
also their lack of ``a valid California Physician and Surgeon's License 
to practice medicine in California.'' Citation Order, Martin P. Feldman 
(Aug. 15, 2003); see also Citation Order, Harry Hoff (Jun. 17, 2003); 
Citation Order, Carlos Gustavo Levy (Jan. 28, 2003); Citation Order, 
Carlos Gustavo Levy (Nov. 30, 2001). Moreover, the Board had issued 
several press releases setting forth its position that internet 
prescribing is unlawful. See GX 11 at 9 (Feb. 2004 Action Report) 
(``The Board has taken action against California physicians and 
licensees from other states for prescribing over the Internet without a 
good faith prior exam, and continues to investigate cases as it becomes 
aware of the practice.''); Record Fines Issued by Medical Board to 
Physicians in Internet Prescribing Cases (News Release Feb. 10, 2003) 
(available at https://www.mbc.ca.gov/board/media/releases_2003_02-10_internet_drugs.html). Respondent thus clearly violated both California 
law and the CSA in issuing these prescriptions.
    Respondent issued forty-eight prescriptions for hydrocodone drugs 
to residents of Texas. Respondent did not, however, hold a Texas 
medical license. See Tex. Occ. Code Sec.  155.001; see also id. Sec.  
151.056(a) (``A person who is physically located in another 
jurisdiction but who, through the use of any medium, including an 
electronic medium, performs an act that is part of a patient care 
service initiated in this state, * * * and that would affect the 
diagnosis or treatment of the patient, is considered to be engaged in 
the practice of medicine in this state and is subject to appropriate 
regulation by the board.''); 22 Tex. Admin. Code Sec.  174.4(c) 
(``Physicians who treat and prescribe through the Internet are 
practicing medicine and must possess appropriate licensure in all 
jurisdictions where patients reside.'').
    Respondent also lacked the state registration required to prescribe 
a controlled substance. See Tex. Health & Safety Code Sec.  481.061(a) 
(requiring state registration to dispense); id. Sec.  481.063(d) 
(requiring as a condition for registration that ``a practitioner [be] 
licensed under the laws of this state''). Respondent thus also violated 
Texas law, and the CSA, in prescribing controlled substances to that 
State's residents. See Moore, 423 U.S. at 140-41 (``In the case of a 
physician [the CSA] contemplates that he is authorized by the State to 
practice medicine and to dispense drugs in connection with his 
professional practice.'') (emphasis added); United Prescription 
Services, 72 FR at 50407 (``A controlled-substance prescription issued 
by a physician who lacks the license [or other authority required] to 
practice medicine within a State is * * * unlawful under the CSA.''); 
21 U.S.C. 802(10) (defining `` `dispense' [to] mean[ ] to deliver a 
controlled substance to an ultimate user * * * by, or pursuant to the 
lawful order of, a practitioner'').
    Respondent issued nineteen prescriptions for drugs containing 
hydrocodone to North Carolina residents. Respondent did so 
notwithstanding that under North Carolina law, ``prescribing medication 
by use of the Internet or a toll-free telephone number, shall be 
regarded as practicing medicine'' in the State and subjects the 
practitioner to North Carolina law ``and appropriate regulation by the 
North Carolina Medical Board.'' N.C. Gen. Stat. Ann. Sec.  90-18(b). 
North Carolina law further provides that ``[n]o person shall practice 
medicine * * * nor in any case prescribe for the cure of diseases 
unless the person shall have been first licensed and registered to do 
so.'' Id. Sec.  90-18(a). Moreover, if ``the person so practicing 
without a license is an out-of-state practitioner who has not been 
licensed and registered to practice medicine and surgery in this State, 
the person shall be guilty of a Class I felony.'' Id.\19\
---------------------------------------------------------------------------

    \19\ While North Carolina exempts from these requirements an 
out-of-state practitioner who ``on an irregular basis, consults with 
a resident registered physician,'' Respondent does not maintain that 
he was consulting with a North Carolina physician. N.C. Gen. Stat. 
Ann. Sec.  90-18(c)(11).
---------------------------------------------------------------------------

    In addition, in February 2001, the North Carolina Medical Board 
issued a Position Statement entitled: Contact With Patients Before 
Prescribing. GX 25 at 11. Therein, the Board stated ``that prescribing 
drugs to an individual the prescriber has not personally examined is 
inappropriate except as noted * * * below.'' Id. The Board further 
explained that ``[b]efore prescribing a drug, a physician should make 
an informed medical judgment based on the circumstances of the 
situation and on his or her training and experience. Ordinarily, this 
will require that the physician personally perform an appropriate 
history and physical examination, make a diagnosis, and formulate a 
therapeutic plan, a part of which might be a prescription.'' Id. While 
the North Carolina Board recognized that it may be appropriate to 
prescribe to a patient without having performed a physical exam ``under 
certain circumstances,'' none of these apply to Respondent.\20\ I thus 
conclude that Respondent violated both North Carolina law and the CSA 
in prescribing to the State's residents.
---------------------------------------------------------------------------

    \20\ These circumstances ``may include admission orders for a 
newly hospitalized patient, prescribing for a patient of another 
physician for whom the prescriber is taking call, or continuing 
medication on a short-term basis for a new patient prior to the 
patient's first appointment.'' GX 25 at 11. The Board also noted 
that ``[e]stablished patients may not require a new history and 
physical examination for each new prescription, depending on good 
medical practice.'' Id.
---------------------------------------------------------------------------

    Respondent issued thirteen prescriptions for hydrocodone to Ohio 
residents. Ohio law defines `` `the practice of telemedicine' [to] 
mean[ ] the practice of medicine in this state through the use of any 
communication, including oral, written, or electronic communication, by 
a physician outside th[e] state,'' and authorizes ``[t]he holder of a 
telemedicine certificate [to] engage in the practice of telemedicine in 
this state.'' Ohio Rev. Code Ann. Sec.  4731.296(A) & (C). See also id. 
Sec.  4731.41 (``No person shall practice medicine and surgery, or any 
of its branches, without the appropriate certificate from the state 
medical board to engage in the practice.''). Moreover, under the 
regulations of the State Medical Board of Ohio, ``a physician shall not 
prescribe, dispense, or otherwise provide, or cause to be provided, any 
controlled substances to a person who the physician has never 
personally examined and diagnosed'' except for in limited situations 
not applicable here.\21\ Ohio Admin. Code Sec.  4731-11-09(A). I thus 
conclude that Respondent violated both Ohio law and the CSA in issuing 
prescriptions to Ohio residents.
---------------------------------------------------------------------------

    \21\ The exceptions are for ``institutional settings, on call 
situations, cross coverage situations, situations involving new 
patients,'' (but limited to where ``the physician has scheduled or 
is in the process of scheduling an appointment to examine the 
patient and the drugs are intended to be used pending that 
appointment''), ``protocol situations,'' ``nurses practicing in 
accordance with standard care arrangements, and hospice settings.'' 
Ohio Admin. Code Sec.  4731-11-09.
---------------------------------------------------------------------------

    Respondent issued thirteen prescriptions for hydrocodone to 
Virginia residents. Under Virginia law, it is ``unlawful for any person 
to practice medicine * * * in the Commonwealth without a valid 
unrevoked licensed issued by the Board of Medicine,'' Va. Code Ann. 
Sec.  54.1-2902; and ``[a]ny person shall be

[[Page 20733]]

regarded as practicing the healing arts who actually engages in such 
practice as defined in this chapter.'' Id. Sec.  54.1-2903; see also 
id. Sec.  54.1-2900 (the ``[p]ractice of medicine'' * * * means the 
prevention, diagnosis and treatment of human physical or mental 
ailments, conditions, diseases, pain or infirmities by any means or 
method''); id. Sec.  54.1-2929 (``No person shall practice * * * 
medicine * * * without obtaining a license from the Board of 
Medicine'').\22\ Furthermore, ``[a] prescription for a controlled 
substance may be issued only by a practitioner of medicine * * * who is 
authorized to prescribe controlled substances.'' Va. Code Sec.  54.1-
3303(A). Moreover, ``[t]he prescription shall be issued for a medicinal 
or therapeutic purpose and may be issued only to persons * * * with 
whom the practitioner has a bona fide practitioner-patient 
relationship.'' Id.
---------------------------------------------------------------------------

    \22\ Respondent does not claim that his prescribing came within 
one of the limited exceptions for out-of-state practitioners 
recognized by Virginia law. See Va. Code Ann. Sec.  54.1-2901(A)(7) 
(authorizing ``[t]he rendering of medical advice * * * through 
telecommunications from a physician licensed to practice medicine in 
* * * an adjoining state to emergency medical personnel acting in an 
emergency situation'').
---------------------------------------------------------------------------

    The Virginia statute also provides that ``a bona fide practitioner-
patient relationship means that the practitioner shall * * * perform or 
have performed an appropriate examination of the patient, either 
physically or by the use of instrumentation and diagnostic equipment 
through which images and medical records may be transmitted 
electronically; except for medical emergencies, the examination of the 
patient shall have been performed by the practitioner himself, within 
the group in which he practices, or by a consulting practitioner prior 
to issuing a prescription.'' Id. (emphasis added). I thus conclude that 
Respondent violated Virginia law and the CSA in prescribing to 
Virginia's residents.
    Respondent issued ten prescriptions for hydrocodone to Indiana 
residents. Under Indiana law, ``[i]t is unlawful for any person to 
practice medicine * * * in this state without holding a license or 
permit to do so.'' Ind. Code Sec.  25-22.5-8-1. Moreover, the practice 
of medicine includes the ``prescription * * * of any form of treatment, 
without limitation.'' Id. Sec.  25-22.5-1-1.1(a)(1)((B); see also 
id.Sec.  (a)(4).
    The Medical Licensing Board of Indiana has also adopted a 
regulation (similar to Ohio's), which provides that except for in 
limited situations, ``a physician shall not prescribe, dispense, or 
otherwise provide, or cause to be provided, any controlled substance to 
a person who the physician has never personally physically examined and 
diagnosed.'' 844 Ind. Admin. Code 5-4-1(a).\23\ This rule has been 
effect since October 2003. I thus conclude that Respondent violated 
Indiana law and the CSA in prescribing to Indiana residents.
---------------------------------------------------------------------------

    \23\ The exceptions are for ``institutional settings, on-call 
situations, cross-coverage situations, and situations involving 
advanced practice nurses with prescriptive authority.'' 844 Ind. 
Admin. Code 5-4-1(a). Respondent does not claim that his prescribing 
falls within any of these exceptions.
---------------------------------------------------------------------------

    Respondent issued nine prescriptions for hydrocodone to Colorado 
residents. In November 2000, the Colorado State Board of Medical 
Examiners issued a policy statement entitled ``Guidelines Regarding 
Prescribing for Unknown Patients.'' In this statement, the Colorado 
Board declared that:

    It is unprofessional conduct for a physician to provide 
treatment and consultation recommendations, including issuing a 
prescription via electronic or other means, unless the physician has 
obtained a history and physical evaluation of the patient adequate 
to establish diagnoses and identify underlying conditions and/or 
contra-indications to the treatment recommended/provided. Issuing a 
prescription on the basis of a questionnaire, Internet-based 
consultation, or a telephonic consultation, all without a valid pre-
existing patient/practitioner relationship does not constitute an 
acceptable standard of care.
    Before prescribing a drug, a physician should make an informed 
medical judgment based on the circumstances of the situation and on 
his/her training and experience. Ordinarily, this will require that 
the physician perform an appropriate history and physical 
examination, make a diagnosis, and formulate a therapeutic plan, a 
part of which might be a prescription.\24\
---------------------------------------------------------------------------

    \24\ The Colorado Board has also recognized limited exceptions 
similar to those adopted by Ohio and Indiana.

    GX 12 at 14. I thus conclude that Respondent acted outside of the 
course of professional practice in issuing the prescriptions to 
Colorado residents and violated the CSA.
    Respondent issued eight prescriptions for hydrocodone to 
Mississippi residents. In May 2000, the Mississippi State Board of 
Medical Licensure issued a policy statement on Internet Prescribing. 
See GX 21 at 6. The Mississippi Board advised that the ``[e]ssential 
components of proper prescribing and legitimate medical practice 
requires [sic] that the physician obtains a thorough medical history 
and conducts an appropriate physical examination before prescribing any 
medication for the first time.'' Id.
    Moreover, since 1997, Mississippi law has provided that ``no person 
shall engage in the practice of medicine across state lines 
(telemedicine) in this state, hold himself out as qualified to do the 
same, or use any title, word or abbreviation to indicate to or induce 
others to believe that he is duly licensed to practice medicine across 
state lines in this state unless he has first obtained a license to do 
so from the State Board of Medical Licensure and has met all education 
and licensure requirements as determined by the State Board * * *. '' 
Miss. Code Ann. Sec.  73-25-34(2). The statute specifically defines the 
terms ``telemedicine, or the practice of medicine across state lines,'' 
as including ``[t]he rendering of treatment to a patient within this 
state by a physician located outside this state as a result of 
transmission of individual patient data by electronic or other means 
from within this state to such physician or his agent.'' Id. Sec.  73-
25-34(1)(b).\25\ I thus conclude that Respondent violated Mississippi 
law and the CSA when he prescribed to the State's residents.
---------------------------------------------------------------------------

    \25\ Mississippi exempts an out-of-state physician from the 
licensure requirement when the physician provides an evaluation, 
treatment recommendation, or medical opinion at the request of ``a 
physician duly licensed to practice medicine in th[e] state,'' and 
the requesting physician ``has already established a doctor/patient 
relationship with the patient to be evaluated and/or treated.'' 
Miss. Code Ann. Sec.  73-25-34(3). Respondent, however, produced no 
evidence that any physician had ever requested that he evaluate a 
Just USA patient.
---------------------------------------------------------------------------

    Respondent also issued eight prescriptions for hydrocodone to 
residents of Massachusetts, whose law follows nearly verbatim the CSA's 
prescription requirement. Compare Mass. Gen. Laws ch. 94C, Sec.  19(a), 
with 21 CFR 1306.04(a). In December 2003, the Massachusetts Board of 
Registration in Medicine issued the following interpretation of the 
State's prescription law:

    [t]o satisfy the requirement that a prescription be issued by a 
practitioner in the usual course of his professional practice, there 
must be a physician-patient relationship that is for the purpose of 
maintaining the patient's well-being and the physician must conform 
to certain minimum norms and standards for the care of patients, 
such as taking an adequate medical history and conducting an 
appropriate physical and/or mental status examination and recording 
the results. Issuance of a prescription, by any means, including the 
Internet or other electronic process, that does not meet these 
requirements is therefore unlawful.

    Commonwealth of Massachusetts, Board of Registration in Medicine, 
Policy 03-06 INTERNET PRESCRIBING (Adopted Dec. 17, 2003).\26\ As the

[[Page 20734]]

Board's interpretation makes plain, Respondent acted outside of the 
usual course of professional practice when he prescribed controlled 
substances to residents of Massachusetts, and therefore violated both 
Massachusetts law and the CSA.
---------------------------------------------------------------------------

    \26\ The ALJ also concluded that Respondent was required to be 
licensed to practice medicine in Massachusetts and violated its law 
by prescribing to residents of that State. ALJ at 34. In light of 
the Massachusetts' Board clear interpretation as set forth in its 
policy on Internet Prescribing, I conclude that it is unnecessary to 
address whether Respondent also violated the State's provisions 
requiring a license and controlled substance registration which 
appear to allow an out-of-state practitioner to issue a prescription 
to a state resident in some instances. Id. Mass. Gen. Laws ch. 94C, 
18(c).
---------------------------------------------------------------------------

    Respondent issued seven prescriptions for hydrocodone for residents 
of Georgia. Under the rules of the Georgia Composite State Board of 
Medical Examiners, it is ``unprofessional conduct'' to ``[p]rovid[e] 
treatment and/or consultation recommendations via electronic or other 
means unless the licensee has performed a history and physical 
examination of the patient adequate to establish differential diagnoses 
and identify underlying conditions and/or contra-indications to the 
treatment recommended.'' Ga. Comp. R. & Regs. 360-3-.02(6).\27\ 
Moreover, Respondent violated Georgia law because he engaged in the 
unlicensed practice of medicine. See Ga. Code Ann. Sec.  43-34-
31.1.\28\ I thus conclude that Respondent violated the CSA in 
prescribing to Georgia residents.
---------------------------------------------------------------------------

    \27\ It is noted that the rule does ``not prohibit a licensee 
who is on call or covering for another licensee from treating and/or 
consulting a patient of such other licensee.'' Ga. Comp. R. & Regs. 
360-3-.02(6). Respondent did not maintain that he was covering for, 
or consulting with, other physicians who were treating the Georgia 
residents he prescribed to.
    \28\ This statute provides:
    (a) A person who is physically located in another state * * * 
and who, through the use of any means, including electronic * * * or 
other means of telecommunication, through which medical information 
or data is transmitted, performs an act that is part of a patient 
care service located in this state * * * that would affect the 
diagnosis or treatment of the patient is engaged in the practice of 
medicine in this state. Any person who performs such acts through 
such means shall be required to have a license to practice medicine 
in this state and shall be subject to regulation by the board.
    Ga. Code Ann. Sec.  43-34-31.1(a). While the statute includes 
exceptions when, inter alia, the physician ``[p]rovides consultation 
services at the request of a physician licensed in this state,'' or 
``[p]rovides consultation services in the case of an emergency,'' 
id. Sec.  43-34-31.1(b)(1) & (2), neither exception applies to 
Respondent.
---------------------------------------------------------------------------

    Respondent issued six prescriptions for hydrocodone to Missouri 
residents. Under Missouri law--which was last amended in 1998--it is 
``unlawful for any person not now a registered physician within the 
meaning of the law to practice medicine [or] * * * to engage in the 
practice of medicine across state lines * * * except as herein 
provided.'' Mo. Ann. Stat. Sec.  334.010(1). The statute defines ``the 
practice of medicine across state lines'' to mean in relevant part, 
``[t]he rendering of treatment to a patient within this state by a 
physician located outside this state as a result of transmission of 
individual patient data by electronic or other means from within this 
state to such physician or physician's agent.'' Id. Sec.  
334.010(2)(2). While the statute exempts from the licensure requirement 
an out-of-state physician who consults with a Missouri-licensed 
physician when the latter ``retains ultimate authority and 
responsibility for the * * * diagnoses and treatment * * * of the 
patient located within th[e] state,'' id. Sec.  334.010(3), Respondent 
makes no claim that his prescribing falls within this exemption.\29\ 
Respondent thus violated both Missouri law and the CSA when he 
prescribed to the State's residents.
---------------------------------------------------------------------------

    \29\ The Missouri statute contains two