What Happened
The pharmacist-in-charge at Ennis Pharmacy in Ennis, Montana filled hydrocodone prescriptions for himself under a physician's name and signature, without that physician ever seeing him as a patient or authorizing the prescriptions.
A routine DEA administrative inspection in 2019 turned up numerous prescriptions for Norco 10-325mg written in the pharmacist's own name. Investigators also found that he had altered a friend's legitimate prescription — doubling the strength from Norco 5-325mg to 10-325mg and increasing the quantity from 45 to 120 pills — before filling it himself as the on-duty pharmacist and mailing the drugs to the friend out of state.
He pleaded guilty to dispensing a controlled substance by a practitioner and to obtaining a controlled substance by misrepresentation, fraud, or forgery. In a separate civil case resolved earlier the same month, Ennis Pharmacy itself agreed to pay a $125,000 fine and make changes to its operating procedures.
What Went Wrong
- The pharmacist-in-charge filled his own prescriptions. No independent pharmacist reviewed or verified prescriptions written in his own name before he dispensed them to himself.
- Prescription authenticity wasn't verified with the prescriber. Prescriptions purportedly from a specific physician were filled without the pharmacy contacting that physician to confirm they had actually been issued.
- Altered prescriptions passed through unnoticed. A prescription whose strength and quantity had been changed after the fact was filled without any flag for tampering.
- The scheme was only caught by a routine outside inspection. Internal pharmacy controls did not surface the self-dealing; a DEA administrative inspection did.
How It Could Have Been Prevented
- Prohibit a pharmacist from filling or verifying prescriptions written in their own name; require an independent pharmacist to handle staff prescriptions.
- Call prescribers to confirm unusual or high-risk prescriptions before dispensing, especially when the pharmacist recognizes the "patient."
- Implement recurring self-audits of dispensing records for prescriptions naming pharmacy employees or their known associates.
- Reconcile prescription images/records against pharmacy management system quantities to catch post-issuance alterations.
Related Guidance
- Community Pharmacy Self-Assessment Checklist — Controls for retail pharmacy dispensing and staff prescriptions.
- 15 Red Flags of Drug Diversion — Indicators including self-prescribing and altered prescriptions.
- Regulatory Guide — DEA registrant recordkeeping and corresponding-responsibility obligations.
- Diversion Case Registry — Related pharmacist self-diversion cases.