Diversion Case Studies

Rutland pharmacy technician's registration revoked after alleged theft and consumption of a narcotic cough syrup

The State filed a Request for Summary Suspension dated October 8, 2009 alleging that a pharmacy technician employed in Rutland stole and drank Tussionex, a schedule III narcotic-containing mixture, in May 2009. The technician's registration had lapsed on July 31, 2009, and the Board of Pharmacy found emergency action was needed because she could obtain employment with access to narcotics. Following the hearing, the Board revoked her registration effective as of the hearing date.

Anesthesiologist diverted controlled substances from his workplace for personal use

The Maryland Board of Physicians took reciprocal action based on a finding by the Oregon Medical Board that a physician had substance abuse issues and diverted controlled dangerous substances (CDS) from his workplace for personal use. The Maryland Board reprimanded the physician and suspended his license until it is reactivated by the Oregon Medical Board.

Tucson hospital reached civil settlement with the United States after DEA investigation of missing controlled substances

On March 27, 2009 the United States reached a civil settlement with a Tucson hospital following a DEA audit and investigation that began after several doses of controlled substances were found missing from the hospital in early 2004. Under the settlement, the hospital committed to fund $1,000,000 over five years, beginning in fiscal year 2009/2010, to establish a three-part drug abuse prevention initiative for the Tucson community. The settlement resolved the government's claims and is not a finding of liability.

Delaware nurse used a physician's DEA number to obtain Xanax for herself; licenses later permanently revoked

In late 2008 a Delaware nurse illegally obtained a physician's Drug Enforcement Administration number, impersonated the physician, and ordered Xanax prescriptions in her own name. She was arrested in December 2008 and pled guilty in February 2009 to one count of Obtaining a Controlled Substance by Deception. The Delaware Board of Nursing suspended her licenses in May 2011, finding she had diverted, possessed, obtained and administered prescription drugs to herself without authorization, and permanently revoked them in October 2013 after finding she worked as a nurse for roughly eight months while suspended. A 2015 gubernatorial pardon of the conviction did not restore her eligibility; the Board's 2017 denial of her reapplication was affirmed by the Superior Court in September 2017 and by the Delaware Supreme Court in 2018.

General practice physician accused of self-administering narcotics and writing prescriptions to family and staff without medical records

Bowie, MD

A Maryland general practice physician was summarily suspended after the Board's investigation found evidence of addiction to controlled substances, a narcotics overdose, and a pattern of writing prescriptions to family members and office staff without keeping medical records. Patients were also allegedly permitted to create and retain their own medical records. The action was an emergency summary suspension based on investigative findings, not a final adjudicated finding.

Gaston County general practitioner's license revoked after felony conviction for prescribing controlled substances without a legal medical purpose

A general practitioner in Bessemer City was convicted of a felony in North Carolina state court for prescribing controlled substances without a legal medical purpose. Following the conviction, the North Carolina Medical Board issued a notice of revocation of the physician's medical license on November 20, 2008. The Board's report does not identify the specific drugs involved.

Vermont-licensed nurse charged over diversion of opioids prescribed to a New Hampshire nursing home resident

The State of Vermont filed a Specification of Charges dated January 30, 2008 against a Vermont-licensed nurse, alleging unprofessional conduct for diversion of opioids prescribed to a resident of the New Hampshire nursing center where the nurse was employed. The charges cite statutes and board rules covering failure to comply with practice laws, inability to practice competently by reason of drug use, and habitual intemperance or addiction to habit-forming drugs. The excerpt available does not show how the Board resolved the charges.

Unlicensed resident removed narcotic patches from nursing home patient

Baltimore, MD

The Board permanently revoked eligibility for licensure and stated that any application for licensure, registration, or certification will not be accepted. The action concerned an unlicensed first-year resident in a hospital residency program who posed as a licensed physician, entered a nursing home, and unlawfully removed narcotic-eluding patches from a ventilator-dependent patient. Date of action: July 25, 2007.

Registered nurse diverted a Schedule II controlled substance from the workplace

The board database records that a registered nurse diverted a Schedule II controlled substance from the workplace and had a substance abuse notation. The matter was resolved by an amended memorandum of agreement, and the nurse relocated to Nebraska.

Pennsylvania practical nurse's license revoked for misappropriating drugs

The Pennsylvania State Board of Nursing revoked a practical nursing license and assessed a $2,000 civil penalty in May 2007. The board's published action states findings of unprofessional conduct, misappropriation of drugs, presenting an immediate and clear danger to public health and safety, and criminal convictions. Revocation is a final disciplinary action rather than a temporary measure. The notice does not identify the practice setting or the drugs involved.

Pennsylvania nurse disciplined for misappropriation and non-medical use of a controlled substance

The Pennsylvania State Board of Nursing entered an agreed disciplinary action in May 2007 against a nurse holding both practical and professional licenses. The stated grounds were unprofessional conduct for failing to conform to a quality standard of the profession, misappropriating property from an employer or patient, and using a controlled substance for other than an acceptable medical purpose. The licensee agreed to an indefinite suspension of at least one year, immediately stayed in favor of probation, paid a $1,000 civil penalty, and agreed to complete eight hours of continuing education. Because the suspension was stayed, the licensee remained able to practice under probationary terms.

Nevada pharmacy technician refilled hydrocodone prescriptions for herself; registration revoked

The Nevada State Board of Pharmacy revoked a pharmaceutical technician's registration at its February 22, 2007 meeting. Board staff reported that the technician had been terminated from employment after allegedly authorizing and refilling hydrocodone prescriptions for herself without a physician's authorization. The technician did not appear at the hearing despite receiving notice, and the Board proceeded to revocation.

Nevada hospital pharmacy technician created fictitious nurse account to pull narcotics from dispensing cabinets

A hospital pharmacy technician created a fictitious nurse in the hospital pharmacy computer system and gave that account full access to the hospital's automated dispensing cabinets, according to a Nevada State Board of Pharmacy disciplinary report for a February 22, 2007 Board meeting. The hospital noticed that the fictitious user was logged on whenever the technician was also logged on. The report states the technician pried open cabinet compartments to remove Schedule II and III narcotics for personal use, was arrested and convicted of a gross misdemeanor, and was ordered to pay $7,796.20 in restitution and serve two years probation. The technician did not appear at the Board hearing.

Hospital anesthesiologist diverted controlled dangerous substances from medication management system and falsified patient records

Berlin, MD

A physician admitted to addiction to certain controlled dangerous substances and diverted the drugs from a hospital medication management system, placing false information in patient medical records to do so. The Board concluded that the public health, safety, or welfare imperatively required emergency action based on the diversion, abuse of prescription medications, and providing professional services while under the influence. The Board summarily suspended the physician’s license.

Virginia-licensed pharmacist self-administered diverted phentermine on duty; suspension stayed by consent order

According to a Maryland Board of Pharmacy order, a pharmacist's Virginia license was indefinitely suspended after he diverted phentermine HCl 37.5 mg, a Schedule IV controlled substance, and self-administered it while on duty. In lieu of a formal hearing, he entered a consent order with the Commonwealth of Virginia on or about May 22, 2006, and the Virginia Board stayed the indefinite suspension at that time. The order also recites that he pled guilty to prescription fraud and was placed on supervised probation for one year. The Maryland Board later opened its own investigation after learning of the Virginia suspension.

Kansas practical nurse convicted of obtaining prescription drug by fraud; license reinstated under stayed suspension

A Kansas licensed practical nurse was convicted in January 2006 of a misdemeanor for obtaining a prescription-only drug by fraudulent means and was placed on probation that included a drug treatment program. After the nurse applied in September 2007 to reinstate a lapsed license, the nurse and the Kansas State Board of Nursing entered a consent agreement in which the board's counts included fraud or deceit, inability to practice safely due to drug or alcohol abuse, and diverting drugs, supplies or property of a patient or agency. The agreement reinstated the license subject to a suspension that is stayed while the nurse remains in compliance with its conditions, and it is reportable as discipline on future renewals.

General practice physician summarily suspended after admitting cocaine use in violation of probation

Columbia, MD

A physician in general practice tested positive for cocaine, in violation of a consent order from April 2005. The physician admitted to using cocaine on the occasion that resulted in the positive test. The Board imposed a summary suspension of the physician's license.

Internist's reinstatement denied over past substance abuse and fraud in obtaining controlled dangerous substances

Annapolis, MD

The Board denied reinstatement of an internist's license and will not accept further applications for reinstatement for 5 years. The Board found that the physician failed to meet his burden of demonstrating the requisite qualities for reinstatement in light of the serious and recurrent nature of his past misconduct concerning substance abuse and fraud in obtaining controlled dangerous substances and submitting false statements when he obtained licensure in Maryland. Date of action: September 1, 2005.

Pathologist suspended for narcotic/CDS abuse and illegal prescribing

Owings Mills, MD

The Board concluded that a pathologist was guilty of unprofessional conduct in the practice of medicine, including being addicted to or habitually abusing narcotics or controlled dangerous substances, willfully making or filing a false report in the practice of medicine and when applying for licensure, and prescribing drugs for illegal or illegitimate medical purposes. The Board suspended the license for 5 years with terms and conditions, with probation for 5 years if the suspension is stayed. Date of action: August 24, 2005.

Nursing home nurse took Percocet from a resident's medication supply for personal use

Kennebunk, ME

A nurse at Kennebunk Nursing Center was found guilty by a jury of stealing narcotics from the facility where she worked as a nurse from February through May 2004. Evidence at trial showed she took 72 Percocet pills from a resident's supply of medication under the guise of medicating the resident and instead took the pills for her own use. She was sentenced to 9 months in jail with all but 5 days suspended and two years of probation, during which she must submit to random searches and drug testing.

Psychiatrist summarily suspended for prescribing controlled substances in others' names and picking up prescriptions

College Park, MD

The Board summarily suspended a psychiatrist's license on an emergency basis. The Board concluded that the public health, safety, and welfare required emergency action based on investigative findings that the physician engaged in unprofessional conduct, including inappropriate prescribing practices: prescribing large quantities of CDS in the names of 12 individuals for whom the physician could not provide medical records, and picking up the filled prescriptions himself. Date of action: June 13, 2005.

Physician removed hospital supplies to administer a controlled substance to a friend and falsified test records to conceal it

The Board found the physician guilty of unprofessional conduct and of willfully filing a false record, based on conduct including removing hospital supplies to administer a controlled dangerous substance intravenously to an addicted friend. The physician then had the friend's blood tested and had the results filed under the name of another inpatient to conceal the diversion. The Board revoked the physician's license.

Registered nurse diverted morphine and fentanyl from Children's Hospital of Wisconsin stock or waste

Milwaukee County, Wisconsin

A registered nurse employed at Children's Hospital of Wisconsin was found by the Board of Nursing to have diverted morphine and fentanyl from hospital stock or waste for personal use over four years until June 28, 2004, and to have consumed them at work without a prescription or other authority. The Board found this placed patients at risk but did not find actual harm. The nurse was criminally charged in Milwaukee County Circuit Court with unlawfully obtaining a controlled substance. The license was suspended for six months, then indefinitely, with treatment and monitoring conditions and a restriction on access to controlled substances.

General practice physician summarily suspended over alleged conspiracy to distribute Ecstasy and Phentermine

Baltimore, MD

The Maryland Board of Physicians summarily suspended a general practice physician's license, finding that public health, safety, or welfare imperatively required emergency action. The action was based on the physician's alleged activities involving conspiracy, possession, and intent to distribute Ecstasy and Phentermine, and the illegal manufacture, distribution, storage, and concealment of these controlled dangerous substances.

Family practice physician's license revoked after ingesting morphine in violation of probation

Catonsville, MD

The Maryland Board of Physicians revoked a family practice physician's license after finding he violated his July 2002 consent order and a rehabilitation contract by ingesting morphine. The physician was barred from applying for reinstatement for three years.