A Maryland Board case from Baltimore, MD found that a physician assistant with a problem with opiate dependency had filled prescriptions for himself for narcotic analgesics and benzodiazepines. Because the method ran through prescriptions and left cabinet stock, waste and counts out of it, a program built only around dispensing transactions would be expected to miss a practitioner who is both prescriber and patient. That is the lesson for program leads.
What the record shows
The drugs appear in the record only as classes, narcotic analgesics and benzodiazepines, and the setting only as practice.
The Board found that the physician assistant, who had a problem with opiate dependency, filled prescriptions for himself for those drugs. It found him guilty of providing professional services while using a narcotic or controlled dangerous substance and being addicted to narcotics or CDS, and of unprofessional conduct in the practice of medicine. These are findings, not allegations.
The sanction was a three-year suspension effective 12/15/1999, with 26 months stayed and 10 months active, followed by five years of probation subject to terms and conditions.
Everything below works from the one mechanism the record describes: a practitioner obtaining controlled substances for his own use through prescriptions written for himself. The full entry and its cited source are on the case page for Physician assistant self-prescribed narcotic analgesics and benzodiazepines while addicted to opiates, and this summary follows that entry.
The control that failed
Ordinary prescribing separates the person who decides that a controlled substance is needed from the person who receives it. A prescriber assesses a patient and writes the prescription, and a pharmacist fills it for that patient, so each step assumes two different people with a clinical relationship. When the prescriber is the patient, the independent assessment disappears, and the prescription need not look unusual in drug, dose or quantity.
This is our reading, not part of the record: the pharmacy would be expected to have been the last point where the arrangement could be seen, since prescriber and patient were the same person on the same prescription.
Fitness for duty was also in play. The Board's finding of providing professional services while using a narcotic or controlled dangerous substance means the use overlapped with practice, so a program could read the case as one in which the controls meant to identify an impaired clinician at work, such as peer observation and reporting, did not stop the practice.
For program leads, the controls most commonly measured, such as cabinet removals, waste witnessing and count reconciliation, sit downstream of a dispensing event inside a facility. A self-prescription filled at a pharmacy outside the facility would be expected to generate none of those transactions.
The earliest measurable signal
Among the detection indicators published on the site, the Provider prescribing z-score fits a self-prescribing method. It takes the provider's controlled-substance prescriptions per 100 visits, subtracts the peer mean and divides by the peer standard deviation, within specialty. The published starting threshold is a z of 3 or more for review and 2 to 3 for watch.
Our reading is that it would be expected to surface this method earliest. Each self-prescription adds to the count of controlled-substance prescriptions, and if no visit was documented for it, the visit count does not change, which pushes the ratio up against peers in the same specialty. Unlike the cabinet-based indicators, it looks at the prescribing step, the step the recorded method used.
The fit has limits. A practitioner who self-prescribes in small amounts might stay inside the watch band, so a program relying on this measure would need to review watch-band scores. The published typical false positives are pain, palliative or addiction medicine, an unusual panel mix, and very small panels, which makes specialty context important when reading any score. The indicator also depends on prescription data the program can see, so prescriptions filled outside the facility's own systems would appear only if the program has access to that data.
The indicators, with their computation, starting thresholds and ordinary false positives, are published on Drug Diversion KPIs, Detection Thresholds and Dashboards. Every threshold there is a starting point to tune against a local baseline, and a flag is a hypothesis, not a finding.
What a program should change
The first change is to treat self-prescribing of controlled substances as a reviewable event in its own right instead of waiting for a volume signal. Where a program can see prescriptions written by its own clinicians, a rule that flags any controlled-substance prescription on which prescriber and patient are the same person would be expected to catch the recorded method on its first occurrence. This rule is our suggestion and is not one of the published indicators.
Monitoring should also extend to every prescriber role, including physician assistants, because a program built around nursing and pharmacy transactions would be expected to have no view of a method that runs through prescriptions. Applying the Provider prescribing z-score to all prescriber roles, with the watch band reviewed, is the direct application of the published indicator to this mechanism.
Prescribing review can also be linked to fitness-for-duty processes. Since the Board found that this physician assistant provided professional services while using a controlled substance, a program could write into its procedure that a self-prescription flag triggers both a diversion review and an impairment assessment, so that neither proceeds without the other.
Finally, a program credentialing a clinician with a disciplinary history could ask to see the full order and set prescribing review to match its terms for the probation period, which in this case was five years.
For the qualitative warning signs that sit alongside these measurements, see the 15 red flags of drug diversion.
What the record does not establish
The record is short. It does not say how the self-prescribing was first detected, who brought it to the Board, how long it went on, how many prescriptions were filled, what quantities were involved, or which specific drugs within the two classes were obtained. It does not say which pharmacy or pharmacies filled the prescriptions, whether one or several were used, or whether any pharmacist questioned them, and it does not say whether anyone raised a concern about his practice.
It names no employer and describes the setting only as practice, so it does not say whether that practice had a diversion program, prescription monitoring or a rule on self-prescribing. It reports no patient harm and does not say whether any error occurred while he provided professional services while using a controlled substance. It records no criminal charge and no criminal outcome; the only outcome is the Board's finding and sanction. It does not list the probation terms or say whether the active suspension and probation were completed.
It also reports no prescribing volumes, visit counts, peer comparison or monitoring of his prescriptions, so it cannot show whether the Provider prescribing z-score or any other indicator would have fired. The indicator is offered here as the measure a program would be expected to rely on for this method, and it was not computed for this case.
Frequently asked questions
Was the physician assistant charged with a crime?
The record does not report any criminal charge. It is a Maryland Board action. The Board found him guilty of providing professional services while using a narcotic or controlled dangerous substance and being addicted to narcotics or CDS, and of unprofessional conduct in the practice of medicine. These are Board findings in a licensing matter. Whether any other authority took action is not part of the record.
What sanction did the Maryland Board impose?
A suspension for three years effective 12/15/1999, with 26 months stayed, leaving 10 months of active suspension. That is followed by probation for five years subject to terms and conditions. The record does not list those terms, so it does not say whether they included prescribing monitoring, treatment or testing. A program credentialing a clinician with this history could ask for the full order.
Why does a self-prescribing case matter to a hospital diversion program?
The recorded method ran through prescriptions for himself rather than through any dispensing transaction inside a facility. This is our reading, not part of the record: indicators built on cabinet removals, waste or counts would be expected to see nothing of it. The Provider prescribing z-score looks at the prescribing step, and a program that wants coverage of this method would need to apply it to every prescriber role.
Primary source: https://www.mbp.state.md.us/forms/june_2000.html. This article uses only what that record states; analysis is labelled as analysis.