Diversion Case Studies

Charges announced in alleged opioid distribution network run from a Morris County physician's office

On August 5, 2022 the Acting Attorney General announced charges in what prosecutors describe as an opioid distribution network operated from a Morris County physician's office. The Acting Attorney General said that medical office employees who use their trusted positions to divert prescription opioids pose a grave risk to public health. The release lists four defendants and their counsel. The charges are allegations and had not been adjudicated at the time of the announcement.

Hospice nurse admitted diverting oxycodone and Oxycontin from two patients

Watertown, WI

The Board of Nursing adopted a stipulation and found that a registered nurse at a hospice center diverted controlled substances from two patients. The findings state that the nurse picked up prescriptions, signed for oxycodone and Oxycontin, delivered fewer tablets than she signed for, and set up e-prescribing requests without physician orders; she admitted to police that she diverted prescription medication from the patients. The Board suspended her nursing license for an indefinite period, stayed the suspension on compliance with treatment and monitoring conditions, and restricted her from working in settings with access to controlled substances.

New Mexico pharmacy settles federal claims after DEA inspections could not account for over 24,000 controlled-substance doses

A retail pharmacy in Peralta agreed to pay $50,000 to the United States to resolve civil penalty claims under the Controlled Substances Act. DEA on-site inspections found the pharmacy could not account for 24,422 doses of controlled substances, most of them opioid analgesics, along with 112 additional record-keeping violations and four dispensing violations. The settlement resolves civil claims and is not a finding of liability. The pharmacy owner had earlier surrendered the pharmacy's DEA registration, and the pharmacy later closed.

Missouri Nurse License Revoked Over Hospital Opioid Diversion and Unauthorized Badge Access

St. Louis, Missouri

The Missouri State Board of Nursing revoked a registered nurse's license after finding she diverted morphine and hydromorphone at Mercy Hospital East by extracting drug residue from vials and refilling them with saline to conceal the theft, then continued to access the hospital numerous times after being suspended, before a circuit court later ordered the board to issue a probated license instead.

Eastern Idaho nurse practitioner consented to civil judgment over hydrocodone prescriptions written for a third party

A nurse practitioner in eastern Idaho consented to a civil judgment in the U.S. District Court for the District of Idaho after admitting to unlawfully prescribing narcotics on more than 15 occasions. The government's complaint alleged that hydrocodone prescriptions were written in one patient's name and then handed to a third party to fill and use. The court found the practitioner civilly liable for violating the Controlled Substances Act and ordered a $30,000 fine.

North Carolina Hospital Nurse Sentenced for Tampering With Hydromorphone Vials

Winston-Salem, North Carolina

A contract nurse working in the pre/post-procedure unit at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina, opened sealed container packages of injectable hydromorphone from an automated medication dispensing/monitoring system, removed and injected the drug herself, then refilled the vials with saline and reglued the caps before returning them to circulation for use on surgical patients. The scheme ran from July through November 2020. She was convicted of tampering with a consumer product and sentenced to 54 months in prison, three years of supervised release, and a $3,000 fine. This is a separate federal case from an earlier Virginia prosecution of the same nurse for diverting drugs at a different hospital.

Nursing home licensed practical nurse convicted of diverting 638 narcotics pills from residents

Georgiana, AL

A licensed practical nurse employed at a Georgiana nursing home was convicted after pleading guilty to four counts of second-degree theft of property. The investigation determined the nurse diverted 638 narcotics pills, including hydrocodone, oxycodone, tramadol and lorazepam, from residents for whom the medications were intended. The thefts occurred between November 5, 2020, and January 19, 2021. Sentencing was set for July 7, with a possible sentence of one to 10 years imprisonment and up to a $15,000 fine for each conviction.

Emergency room nurse sentenced to probation for diverting fentanyl from a Lincoln hospital pharmacy

Lincoln, NE

A former emergency room nurse at CHI Health St. Elizabeth in Lincoln resigned in July 2022 after hospital investigators found 55 discrepancies among more than 200 fentanyl checkouts from the pharmacy between May and June 2022, according to a Nebraska State Patrol investigation. Investigators said 2.65 mg of fentanyl was unaccounted for, and in some cases the nurse checked out the drug without a doctor's order or reported administering it within five minutes of patient discharge. After denying stealing or using the drug, the nurse's urine tested positive for fentanyl; she later pleaded guilty to acquiring a controlled substance by fraud and was sentenced to three years of probation. She gave up her nursing license.

York, Pennsylvania Personal Care Home Nurse Sentenced for Stealing a Hospice Patient's Oxycodone

York, Pennsylvania

A licensed practical nurse who administered a personal care home for senior citizens in York, Pennsylvania diverted oxycodone prescribed to a Medicare hospice patient in her care and falsified medical records to conceal the theft. She was sentenced to one year of probation and a $525 fine for theft in connection with health care and permanently surrendered her nursing license.

Baltimore Pharmacy and Pharmacist Settle Red-Flag Dispensing Allegations

Baltimore, Maryland

Ketan K. Dankhara, a Baltimore pharmacist, and his pharmacy, Falls RX, LLC d/b/a Ultra Care Pharmacy Baltimore, entered a federal consent decree resolving civil allegations that they filled fraudulent controlled-substance prescriptions while ignoring obvious red flags. Investigators found that a single individual repeatedly presented prescriptions for multiple different people for the same drug, strength, and quantity from the same prescriber, including prescriptions written by an OB/GYN for patients who were biologically male. Dankhara also falsely indicated on at least one prescription that he had verified it directly with the prescriber. A federal judge approved the consent decree under which Dankhara and the pharmacy paid a $15,000 civil penalty and agreed to specific red-flag identification and documentation procedures before filling similar prescriptions going forward.

Western Pennsylvania pharmacy owner sentenced in prescription drug fraud scheme

A pharmacist who owned and operated four pharmacies in the Pittsburgh region was sentenced in federal court in May 2022 on convictions for obtaining controlled substances by fraud, misbranding of drugs, and health care fraud conspiracy. The guilty plea was entered in September 2021. The court imposed one year in prison, two years of supervised release, a $10,000 fine, and $649,524 in restitution.

Dearborn physician pleaded guilty to conspiring to distribute hydrocodone without medical necessity

A Dearborn physician pleaded guilty in federal court to conspiracy to distribute controlled substances and agreed to forfeit approximately $37,000 in cash seized from the office. According to court records cited by the U.S. Attorney's Office, the physician admitted prescribing 12,500 dosage units of hydrocodone outside the course of professional practice and without legitimate medical need. Sentencing was set for August 22, 2022.

Pharmacy technician reinstated after taking a controlled substance from a pharmacy for personal use

In an order entered by the executive director on May 3, 2022, a pharmacy technician who applied for reinstatement of registration was recorded as having taken a controlled substance from the pharmacy for personal use on 06/06/2019, conduct tied to a prior board order. The Board granted reinstatement and imposed three years' probation.

Wisconsin Pharmacy Settles Controlled Substance Dispensing and Recordkeeping Violations

Cadott, Wisconsin

Cadott Miller Pharmacy in Cadott, Wisconsin agreed to pay $20,000 to resolve allegations that it dispensed dangerous drug combinations with no legitimate medical purpose, filled prescriptions with no valid Rx on file, and allowed unauthorized early refills. DEA had already served an immediate suspension order in December 2019, and the pharmacy surrendered its registration in January 2020. The settlement was announced April 29, 2022.

Missoula Hospital Nurse Sentenced for Diverting Fentanyl and Hydromorphone

Missoula, Montana

A registered nurse at Community Medical Center in Missoula diverted fentanyl and hydromorphone for her own use over several months. Coworkers grew suspicious after observing her acting furtively near patients, including filling syringes with her back turned and later asking a colleague to witness her disposal of medication vials. When supervisors confronted her, she admitted stealing narcotics and using them; a search of her bag turned up unmarked used syringes and alcohol-swab wrappers, and a urine sample tested positive for fentanyl. She pleaded guilty to unlawfully obtaining controlled substances by fraud, deception, and subterfuge and was sentenced to two years of probation and a $2,000 fine.

Ulster County Dentist Pleads Guilty to Fraudulently Obtaining Oxycodone in a Patient's Name

Stone Ridge, New York

Vivian Letizia, a dentist in Stone Ridge, New York, submitted a fraudulent oxycodone prescription in December 2019 using one of her dental patient's name and date of birth, then filled it at a Woodstock pharmacy for her own consumption while knowing she was not treating that patient. She pleaded guilty in April 2022 and agreed to surrender her medical license and her eligibility for a DEA registration.

Jacksonville Hospital ICU Nurse Pleads Guilty to Tampering With Patients' Fentanyl

Jacksonville, Florida

A registered nurse in the neurological intensive care unit of a Jacksonville hospital removed fentanyl from syringes intended for critically ill ICU patients, replaced it with saline, and reglued tamper-evident caps back onto the syringes with adhesive she obtained from the hospital. A hospital pharmacist discovered a syringe with a damaged cap after her shift and, reviewing dispensing records, found she had checked out and then cancelled fentanyl transactions 24 times in one month, a pattern no other nurse on the unit showed. Confronted the next day, she admitted diverting the drug for personal use since the previous summer; investigators later found needles, saline syringes, and adhesive in her bag. She pleaded guilty to tampering with a consumer product.

DC nurse and nurse practitioner licenses revoked after oxycodone distribution conviction

Washington, DC

On April 8, 2022 the District of Columbia Board of Nursing revoked a licensee's registered nursing and nurse practitioner licenses, adopting a hearing panel's recommended decision of February 10, 2022 as its final order. The discipline rested on a federal conviction for distribution of oxycodone outside the legitimate practice of medicine. The licensee argued that the recommended decision relied on findings and evidence from a criminal proceeding then on appeal to the U.S. Court of Appeals for the District of Columbia Circuit, and that the contested evidence had previously been made known to the Board's former executive director and board attorney. The Board rejected the argument, holding that under the Health Occupations Revision Act a conviction means a judgment or other admission of guilt, so the U.S. District Court judgment was a sufficient basis for disciplinary action, and that the licensee could pursue relief later if the appeal succeeded.

Prisma Health Midlands Pays $1 Million in Record South Carolina CSA Settlement

Columbia, South Carolina

Prisma Health Midlands agreed to pay a record $1 million, the largest Controlled Substances Act settlement in South Carolina history, after DEA investigators found the hospital system failed to report thefts or significant losses of controlled substances within one business day over a three-year period. The probe began after two Prisma patients were arrested for distributing drugs obtained through the hospital pharmacy. Announced April 5, 2022.

Hilo Medical Center nurse charged with fentanyl theft and drug possession

Hilo, HI

A nurse at Hilo Medical Center was charged with several drug offenses, including felony drug possession, in connection with two incidents in April 2022 at the hospital. According to reports, the charges include two counts of obtaining a controlled substance by fraud, deceit, misrepresentation, embezzlement or theft, and two counts of promoting a dangerous drug involving alleged possession of fentanyl, including one-fourth ounce or more. The nurse appeared in Hilo Circuit Court, where a request for supervised release or a bail reduction was denied and bail was maintained at $55,000; the nurse later posted cash bail and was released. The text describes charges only; no finding or plea is reported.

Worcester County Nursing Home Nurse Pleads Guilty to Tampering With a Dementia Patient's Morphine

Northborough, Massachusetts

A registered nurse employed by a Worcester County, Massachusetts nursing home tampered with a bottle of morphine sulfate prescribed to a resident suffering from dementia, removing some of the drug and diluting the remainder with water during an overnight shift on a dementia care unit. A nurse on a later shift administered the diluted morphine to the patient before the tampering was discovered. She pleaded guilty to tampering with a consumer product and to obtaining a controlled substance by fraud and deception.

Danville Hospital Nurse Sentenced for Tampering with Fentanyl and Hydromorphone

Danville, Virginia

Emilee Kathryn Poteat, a registered nurse at Sovah Health-Danville, diverted fentanyl and hydromorphone from an AcuDose dispensing machine beginning in January 2020, popping the tops off vials and later denying the conduct to investigators twice. She pleaded guilty to tampering with a consumer product and making false statements, and was sentenced in March 2022 to 36 months in federal prison.

Mount Pleasant pharmacy technician charged with stealing OxyContin and Adderall from CVS pharmacy

Mount Pleasant, SC

In March 2022, a pharmacy technician at a CVS Pharmacy on Ben Sawyer Boulevard in Mount Pleasant, SC, allegedly stole tablets of OxyContin and Adderall from the pharmacy. According to DHEC, investigators determined responsibility based on an audit, video evidence, and a confession. The technician was charged with two counts of theft of a controlled substance in August 2023 and was booked into the Al Cannon Detention Center before being released on own recognizance.

Illinois Dentist Charged with Tampering with Patients' Fentanyl

Rochester, Illinois

Phillip Jensen, a Rochester, Illinois dentist, was indicted after allegedly piercing fentanyl vials before surgeries, removing half the drug for personal use, and refilling the vials with another solution before administering the diluted anesthesia to patients between December 2019 and August 2020. He faced eight counts of drug diversion and was arrested February 7, 2022.

Aspirar Pharmacy Pays $100K for Filling Invalid Opioid Prescriptions

Cary / Durham, North Carolina

Aspirar Pharmacy's Cary and Durham, North Carolina locations agreed to pay $100,000 to resolve allegations that from 2017-2018 they filled controlled-substance prescriptions written by a Duke University physician operating outside the scope of her limited faculty license. The pharmacy failed to confirm the validity of the physician's license before dispensing. The settlement was announced February 3, 2022.