What Happened

A Missouri physician who owned a newly opened methadone clinic diluted the clinic's bulk methadone supply with saline and water to hide a shortage from the DEA.

Dr. Sunil G. Chand owned Best Medical LLC, a family medicine practice in Leadington, Missouri, and decided in 2020 to open a methadone clinic to treat patients with narcotic use disorders. He caused Best Medical to obtain a DEA registration authorizing it to operate as a narcotic treatment program and to store and dispense Schedule II controlled substances, including methadone. On April 6, 2021, the clinic received twelve 1,000-milliliter bottles of methadone oral concentrate, and the clinic opened the next day to treat patients with oral, liquid doses.

By April 22, 2021, Dr. Chand became aware that methadone was missing. Rather than reporting the loss to the DEA within one business day as required, he waited several days and then instructed the clinic's clinical director to submit a DEA Form 106 that inaccurately reported only 1,075 milliliters lost. Dr. Chand then came into the closed clinic on a Sunday and added saline and water to the remaining methadone supply to mask the shortfall. He pleaded guilty on February 3, 2023, in federal court in St. Louis to one count of adulterating a drug with intent to defraud or mislead, and agreed to surrender his DEA registration. The charge carried a maximum penalty of three years in prison and a $250,000 fine, with sentencing scheduled for May 2023.

What Went Wrong

A clinic owner was able to conceal a controlled-substance loss from the DEA and adulterate the remaining supply before the truth came out. Key failures included:

  • The clinic's required loss reporting was routed through and controlled by the same owner who had an incentive to understate the shortage.
  • The mandatory one-business-day DEA loss reporting window was missed without any internal escalation forcing timely disclosure.
  • No independent verification of the clinic's methadone stock volume was performed before the falsified DEA Form 106 was submitted, allowing an inaccurate loss figure to go out the door.
  • Physical access to the bulk methadone supply was not restricted or monitored outside of normal clinic hours, allowing the owner to dilute it unsupervised on a Sunday when the clinic was closed.

How It Could Have Been Prevented

  • Separate the duties of discovering a controlled-substance loss from the duties of reporting it, so no single individual controls both the count and the DEA disclosure.
  • Enforce the DEA's one-business-day loss reporting requirement with an internal escalation trigger that does not depend on the owner's initiative.
  • Independently verify bulk controlled-substance volumes against distributor shipment records before any loss report is filed.
  • Restrict and log after-hours access to bulk narcotic treatment program stock, and require a witness for any access when the clinic is closed.

Related Guidance

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