Prescription Drug History and the Mental and Physical Evaluation

To help prevent prescription drug abuse and protect the health and safety of Pennsylvania citizens, Pennsylvania’s Prescription Drug Monitoring Program (PA PDMP) collects information on all filled prescriptions for controlled substances. This information helps health care providers safely prescribe controlled substances and helps patients get the treatment they need.

PA PDMP’s new initiative seeks to integrate the PDMP system with the electronic health records (EHRs) and pharmacy management systems of all eligible health care entities in Pennsylvania.

As well, as of July 7, 2017, the Pennsylvania Prescription Drug Monitoring Program is sharing data with 11 other states and D.C. Interstate sharing of data helps prescribers and pharmacists get a more complete picture of their patients’ controlled substance prescription histories, regardless of which state they filled their prescription in.

In New jersey, on May 1, 2017, the emergency rules that went into effect on March 1, 2017 were readopted by the Attorney General and the Board of Medical Examiners.  These rules concern limitations on prescribing, administering, or dispensing of controlled dangerous substances, with specific limitations for opioid drugs, and establish special requirements for the management of acute and chronic pain.  These limitations and requirements apply to physicians, podiatrists, physician assistants, and certified nurse midwives.

These new rules affect how professional licensees prepare for Mental and Physical Examinations (MPE). If you have read my other blogs, you should understand the MPE is a compelled medical doctor Drug and Alcohol evaluation investigating a licensee’s potential impairment and continued ability to practice their profession safely. Licensing board orders compelling MPEs require professionals to provide their medical records. The lookback period for medical treatment and care depends on the nature and extent of a licensee’s medical needs.

Historical surgeries (dental orthopedic, or OB/GYN for example) typically reveal a prescription history.  It is these prescriptions of which the MPE expert is interested. The new PA PDMP discussed above is now a means through which the MPE expert (a medical doctor with access to the database) can learn of a licensee’s prescription drug history.

As a medical doctor, the MPE expert has access to licensees’ historic prescription drug use.  The MPE medical experts can review the  PA PDMP database similar to a treating physician who has a legal obligation to check the PA PDMP  before writing a prescription or a pharmacist prior to dispensing a medication.  The licensee who does not bring corroborative prescription records or provides a false historical record severely taints their credibility in the MPE.

 

Call me to discuss your MPE ordered through your Pennsylvania licensing Board.

 

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To Testify or Not – A Licensee’s Hearing Rights

The confluence of administrative and criminal procedure is a significant issue I confront defending licensee disciplinary cases.  Sometimes, during a hearing, or a pre-complaint investigatory meeting, a licensee is asked — almost expected — to give a statement.  During a hearing, with a criminal case pending, a licensee sometimes must strategically choose or not to testify.  This issue was recently addressed in the case of Blair Anthony Hawkins v. Bureau of Prof’l & Occupational Affairs, 2017 Pa. Commw. Unpub. LEXIS 112 (Commw. Ct. Feb. 16, 2017).

In that matter, after the Department presented its evidence, Hawkins argued that the Board denied him a full and fair hearing when it failed to continue the hearing until after the resolution of the criminal case, thus resulting in Hawkins’ decision to invoke his Fifth Amendment right against self-incrimination before the Board.  However, Hawkins was not forced to testify.  Hawkins invoked his 5th Amendment Rights against self-incrimination.

A hearing was held on January 8, 2016, at which Petitioner renewed his request for a continuance until after the criminal charges were resolved. The Board denied the continuance request. Therefore, Hawkins asserted his Fifth Amendment right against self-incrimination and did not answer any questions.  This looks horrible in a hearing.

Prior to the hearing, the parties exchanged pre-hearing statements, identified witnesses and exhibits, and participated in a pre-hearing conferences. On the day before the hearing, Petitioner requested a continuance via email, until Hawkins’ criminal charges were resolved. The Department opposed the continuance request. The Board denied the continuance, noting that Petitioner had previously been granted a continuance, had indicated that he was available for the hearing on January 8, 2016, had participated in a pre-hearing conference a few days prior, and had failed to identify an emergent reason for requiring a continuance.

Initially, the continuance request was handled improperly.  Either at a pre-hearing conference, or in a separate motion to continue the hearing, counsel for Hawkins should have sought a continuance much sooner, with greater vigor.  Counsel, not Hawkins, put his client in the trap the licensee board prosecutors set.  The Board prosecutor set the trap, showed the trap to counsel, and counsel messed up the case.  The matter should have been continued way before the hearing until after the criminal case had resolved.

In reviewing the choice to testify or not, the Board looked to prior case law.  In Herberg v. Commonwealth, State Board of Medical Education & Licensure, 42 A.2d 411, 412 (Pa. Cmwlth. 1982), a physician’s medical license was revoked and the physician argued that during the hearing before the board, his rights pursuant to the Fourteenth and Fifth Amendments of the United States Constitution were violated. The physician invoked his Fifth Amendment right against self-incrimination so that his testimony before the board could not be used in a later criminal proceeding.  Commonwealth Court determined that:

‘[T]here [is nothing] inherently repugnant to due process in requiring the doctor to choose between giving testimony at the disciplinary hearing, a course that may help the criminal prosecutors, and keeping silent, a course that may lead to the loss of his license.'[A]bsent a finding that a physician was forced to testify against himself, a medical disciplinary board was not constitutionally required to stay its proceedings until the criminal prosecutions against the doctor were over.

In Hawkins, the licensee was called as a witness, chose not to testify, and was not forced to testify. Thus, Hawkins’ Fifth Amendment right against self-incrimination was not violated because the Board honored his choice not to testify. Further, due process rights are not violated simply because a decision on whether to testify is arduous. See PSI Upsilon v. University of Pennsylvania, 591 A.2d 755, 760 (Pa. Super. 1991). Hawkins made what was assuredly a hard decision not to testify; however, making this decision did not result in a violation of his due process rights. See Herberg, 42 A.2d at 413. The Board did not err or abuse its discretion when it held Hawkins’ disciplinary hearing prior to his criminal proceeding, thus making Hawkins choose between testifying or asserting his privilege against self-incrimination.

Call me to talk about your case, investigators wanting you to give a pre-complaint statement, and how to handle your up coming hearing.

 

Pennsylvania’s Stregthening Disciplinary Enforcement Environment

My law practice focuses on defending professional licensee disciplinary actions based upon criminal convictions, professional competence, and/or drug and alcohol addiction and professional impairment. I write blogs about Pennsylvania professional licensing disciplinary actions.  Recently, I reviewed all of Pennsylvania’s licensing board disciplinary actions for October and November of 2016. My case load is consistent with the disciplinary orders I reviewed; the cases reflect a stiffening enforcement environment for each of Pennsylvania’s 29 licensing boards.

In November 2016 Bureau of Professional and Occupational Affairs’ 29 professional licensing boards entered 135 different disciplinary orders.  Board orders range from accountancy, real estate, architecture, chiropractic, massage therapy, nursing, the numerous medical fields, social workers, to veterinary medicine. Of the 135 actions, 41 or 30% of the prosecutions were against non-Pennsylvania practicing licensees. Of the remaining 94 actions (70%), 30 cases or 31% were taken against licensees in Philadelphia and its five surrounding counties. The October 2016 statistics are about the same.

The consistency in the prosecutions is staggering. Many licensees are not represented by counsel. Many orders or settlements include significant civil penalty fines. In the dental profession, there is an increase in petitions for immediate temporary suspensions, pending hearings, on the grounds that the licensee’s practice constitute an immediate and clear danger to the public health and safety. Throughout the medical professions, including pharmacy, numerous disciplinary actions are based upon misdemeanor or felony Drug Act convictions.  Accountancy and real estate board prosecutions center on fraud issues.  The statistics suggest one main point; over 60 percent of cases are from the Philadelphia area and out of state but all of which prosecutions are based upon criminal convictions or drug impairment issues.  These types of disciplinary cases can be fought and penalties reduced.  Many licensees do not think so and either do not have any counsel or they hire the wrong, incompetent counsel.  This is a mistake.

A significant aspect of my practice is reflected in the disciplinary orders. Whether a medical doctor, osteopathic doctor, or nurse, almost one half of disciplinary actions are based upon allegations of inability to practice a profession with reasonable skill and safety to patients by reasons of a mental or physical illness or condition stemming from a dependence upon alcohol or drugs that impairs judgment or coordination. Fighting these cases and contesting any allegation of drug or alcohol impairment is mandatory to keep your license.  DO NOT TAKE THESE ALLEGATIONS LIGHTLY.  DO NOT GO TO THESE ASSESSMENTS WITH OUT AN ATTORNEY.  See my other blogs on this issue.  The orders of discipline clearly reflect licensees incompetently fighting their case without counsel.  I have written extensive blogs on the importance of having an attorney.

A significant percentage of enforcement actions are based upon in or out-of state guilty pleas to either misdemeanors or felonies under the Drug Act or felonies (typically sexual assault) involved in the professional practice. The Boards are collaterally prosecuting every licensee convicted of any offense involving drugs, the violations of norms of practice of that specific profession, or crimes of moral turpitude. The criminal offense, whether drugs, DUI, or a practice related sexual offense does not have to occur in Pennsylvania. Having the right criminal attorney fighting the underlying criminal prosecution is paramount to avoiding collateral licensing prosecution.  I handle all of these criminal cases in Pennsylvania and New Jersey.  Call me to discuss the underlying criminal charges.

Out-of-state licensee’s disciplinary actions reveal a pattern of significantly harsher disciplinary outcomes. Apparently many of these licensees’ indefinite or automatic suspensions are based upon decisions to not contest the Pennsylvania disciplinary action or licensees fighting their case without counsel. Either choice is the worst possible way to address a Pennsylvania based disciplinary action. Every out-of-state licensee should fight each and every disciplinary action.

Please call me to discuss the heightened enforcement environment in Pennsylvania and your pending disciplinary action. Do not attempt to handle these cases on your own. Pennsylvania’s licensing board prosecuting attorneys are much more familiar with appropriate potential negotiating positions then the licensee. The number of professionals I represent before the various boards, and my current pending case load with the same prosecutor on your case, uniquely positions me to fight your case.

Expanded Psychology Board Disciplinary Authority

On June 23, 2016 the General assembly approved act 2016–53. This is a new provision in the the Psychology Board Act.  It became effective August 23, 2016.  This an amendment to the Psychology Board’s authority in disciplining it’s licensees. The specific section in bold states:

(b) When the board finds that the license or application for license of any person may be refused, revoked, restricted or suspended under the terms of subsection (a), the board may:

(1) Deny the application for a license.

(2) Administer a public reprimand.

(3) Revoke, suspend, limit or otherwise restrict a license as determined by the board.

(4) Require a licensee to submit to the care, counseling or treatment of a physician or a psychologist designated by the board.

(5) Suspend enforcement of its findings thereof and place a licensee on probation with the right to vacate the probationary order for noncompliance.

(6) Restore a suspended license to practice psychology and impose any disciplinary or corrective measure which it might originally have imposed.

(7) Take other action as the board in the board’s discretion considers proper, including precluding a suspended licensee from engaging in counseling or any other form of mental health practice.

The import of the new (b)(7) provision cannot be under stated. The legislature has given the Board authority to take “other action” within the “Board’s discretion it considers proper”. This is just about anything.  The case law discussing licensing boards authority to discipline their licensees is clear.

Appellate review of a discretionary Board action is limited to determining whether constitutional rights have been violated, an error of law committed, or necessary findings of fact are supported by substantial evidence. 2 Pa.C.S. § 704; Cassella v. Pennsylvania Board of Medicine, Bureau of Professions and Occupations, 119 Pa. Commonwealth Ct. 394, 547 A.2d 506 (1988); DePanfilis v. State Board of Pharmacy, 121 Pa. Commonwealth Ct. 526, 551 A.2d 344 (1988). The State Board of Nursing is the ultimate fact finder and may accept or reject the testimony of any witness in whole or in part.

The proper review of an agency’s action, assuming that it is not defective under the self-explanatory requirements of § 704 of the Administrative Agency Law, 2 Pa. Cons. Stat. § 704, is not whether its order was reasonable, but whether it was made in accordance with law, i.e., whether it was made in bad faith, and whether it was fraudulent or capricious. A reviewing court may interfere in an agency decision only when there has been a manifest and flagrant abuse of discretion or a purely arbitrary execution of the agency’s duties or functions. Slawek v. Commonwealth, State Bd. of Med. Educ. & Licensure, 526 Pa. 316, 318, 586 A.2d 362, 363 (1991).

Where a full and complete record is made of the proceedings before the State Board of Nursing, a reviewing court must affirm the adjudication unless it is in violation of the constitutional rights of the appellant or not in accordance with the law, the procedural provisions of the local agency law are violated, or a finding of fact of the State Board of Nursing necessary to support its adjudication is not supported by substantial evidence. Section 754 of the Administrative Agency Law, 2 Pa. C.S. § 754. The emphasis here is that is a full and complete record is a necessity.

Substantial evidence means that the evidence required to support the finding of an administrative agency must be “such relevant evidence as a reasonable mind might accept as adequate to support the conclusion.”  Civil Service Com. V. Poles, 132 Pa. Commw. 593, 573 A.2d 1169, 1172 (1990); Gallagher v. Philadelphia State Board of Pharmacy, 16 Pa. Commw. 279, 330 A.2d 287, 289 (Pa. Commw. Ct. 1974).

It is imperative that counsel is present at any hearing to insure the trial evidence objections are properly set forth int he record.  In many cases, Board discretionary action can only be limited by insuring the evidence at the hearing is minimized against the licensee.  Or on Appeal, reviewing the record, to insure the Board decision is made in accordance with the facts presented at the hearing. Any decision based on facts outside of the record is not proper. Please call to discuss you psychology license disciplinary issues.

 

 

Major US Supreme Court DUI Decision and Pennsylvania Licensees

On June 23 the United States Supreme Court decided  BIRCHFIELD v. NORTH DAKOTA, three consolidated cases addressing important substantive and procedural legal issues regarding driving under the influence (“DUI”) cases.  In each case, the North Dakota motorist, lawfully arrested or under investigation for drunk driving, was convicted of a separate crime or otherwise received an enhanced criminal penalty for refusing to submit to a warrantless blood test measuring the alcohol in their bloodstream.

All three state court cases results depended upon the proposition that criminal laws ordi­narily may not compel a motorist to give evidence against themselves in the form a blood sample or breath test unless a warrant authorizing such testing is issued by a magistrate.  The specific issue considered was how the search-incident-to-arrest doctrine applies to breath and blood tests incident to DUI arrests. The court ruled while compelled evidence from breath tests are constitutional based upon the limited inconvenience and invasion of privacy to the motorist, compelled blood tests are unconstitutional for those same reasons.

In Pennsylvania, 75 Pa C.S.A. § 1547 of the motor vehicle laws addresses motorists’ civil license suspension consequences for refusing to submit to a DUI investigation breath or blood test. Depending on how many refusals the operator of the car has previously engaged, a driver’s license suspension based upon a breath or blood test refusal starts at one year and may escalate. The court ruled that these civil collateral consequence license suspension for refusing the test remains constitutional. “Our prior opinions have referred approvingly to the gen­eral concept of implied-consent laws that impose civil penalties and evidentiary consequences on motorists who refuse to comply.”The Birchfield case did not question the constitutionality of those civil collateral consequence refusal laws, and the Supreme Court limited its ruling stating that “nothing should be read to cast doubt on them.”

In 2015 the Supreme Court ruled that the natural dissipation of alcohol from the bloodstream does not always constitute an exigency justifying the warrantless taking of a blood sample. That was the holding of Missouri v. McNeely, 569 U. S. ___, where the State of Mis­souri was seeking a per se rule that “whenever an officer has probable cause to believe an individual has been driving under the influence of alcohol, exigent circum­stances will necessarily exist because BAC evidence is inherently evanescent.”  This case set the stage for Birchfield, where the individual defendant’s objected to being criminally penalized for not submitting to the warrantless blood draw or were criminally penalized when the warrantless blood draw produced evidence that was used against them in trial.

Pennsylvania’s DUI statute, 75 Pa.C.S.A.§3802D, provides for enhanced criminal penalties for refusing to submit to a breath or blood test stemming from a DUI investigation. DUI offenders with multiple prior DUI convictions faced enhanced license suspensions and jail sentences based upon the same refusal. In Birchfield, after reviewing all of the prior case law regarding car stops, privacy concerns, and search incident to arrest case law, the court held that motorists cannot be deemed to have consented to submit to a blood test on pain of committing a criminal offense.  Motorists can not be compelled criminally to give evidence against themselves without a warrant signed by an independent magistrate.
The court has finally drawn a constitutional line in the sand limiting the extent to which a state may utilize driving-on-our-roads informed consent laws to compel motorists to give evidence against themselves so the state may investigate and prosecute them for criminal conduct. In Pennsylvania, this will mean enhanced criminal penalties associated with refusing a blood test, not breathalyzer, in any criminal DUI prosecution may no longer be constitutionally permissible.  Please call to discuss your DUI charge, your medical or professional license issue and potential discipline on your license from stemming from your first or subsequent DUI.

The VRP and the “Letter of Concern” — They Are Not Concerned!

I have written about this issue many times.  I, though, continue my one attorney crusade against the PHMP improperly offering a drug and alcohol treatment-abstinence program to vulnerable licensees who neither suffer from drug or alcohol addiction nor are incapable of safely practicing their profession.  By this I mean offering any professional enrollment in the Voluntary Recovery Program “VRP” whether or not they suffer from an addiction or impairment.

The VRP does this by targeting professionals charged for the first time with a DUI or other minor alcohol or drug related summary offenses.  These professionals received the VRP “letter of concern” at a very vulnerable time.  Especially nurses who must report criminal charges with in thirty (30) days of arrest, not conviction. However, first time DUI offenders are typically eligible for Pennsylvania’s ARD pre-trial diversion program.   As such, there will be no conviction.  Professionals receiving the “letter of concern” while the DUI prosecution is just starting are terrified of losing their license. Many unilaterally, without consultation of licensing counsel like me, go to the VRP assessment and then sign a PHMP consent agreement thinking it saves their license while the prosecution is pending. It only makes the problems worse.
The 2006 case Wittorf v. State Board of Nursing, 913 A.2d 956 (Pa. Cmwlth. 2006) is on point. Wittorf voluntarily entered the VRP to save his license after a first time DUI offense.  (If he had competent counsel he would not have entered the VRP to start and his license would never have been affected.) Soon after, however, the rigors of the abstinence-based PNAP administered PHMP became clear.  Work and life affected Wittorf’s ability to comply with every condition of the program.  He sought to exit the program.  Wittorf claimed he did not suffer from a drug or alcohol addiction that rendered him an impaired nurse. Wittorf presented numerous witnesses at the hearing supporting his lack of addiction and any professional impairment. Wittorf lost his petition to exit the VRP and have his license returned to non-probationary status.
Wittorf forgot he signed the standard PHMP agreement/contract and Board Consent Agreement.  Each document contains admissions that the signatory is an alcoholic (or drug addict) and such impairs their ability to practice their professional safely. This is the only legal fact upon which the Court needed to rely in denying Wittorf’s motion.  By signing the agreements Wittorf (and every other licensee in the same position) stipulates to both their addiction and impairment when asking to voluntarily enter the VRP.  One must do so to be eligible for the VRP.  Its the worst thing to do.
Every VRP “letter of concern” includes the personal data information sheet and medical authorization releases. Do not sign any of these documents if you wish to retain your medical, nursing for other professional  license.  Do not go to the requested assessment as one is not legally required. If you are reading this blog or column, you should call me immediately.
If you are reading this blog after being charged with a DUI and compelled to go to a COAD (Council on Addictive Diseases) assessment, hire competent counsel to handle your licensing issue along with the DUI. This is because typically the mandatory ARD DUI COAD assessors are the local PHMP referred VRP assessors. Once that assessor learns that DUI ARD applicant sitting in front of them is also a professional licensee – especially nurses and doctors – the assessment turns into a VRP assessment that I advise my clients to avoid.  Being prepared for this assessment, similar to be prepared for the Mental and Physical Evaluations (see my other blogs int he archives), is just as important.
The only way I can fight against the unfair tactics of the VRP is by representing as many professionals as I can.  These are trained but incompetent unlicensed case workers implements are highly structured regulatory process.  They have no authority to deviate from any condition of the program.
The PHMP, PMP, VRP, PNAP case workers deal with these issues every day and have honed their trapping skills over the years.  I read the same case workers names on every VRP and PHMP “letters of concern”.  This is the first time you have read this letter.  You need experienced counsel who has honed his skills to battle these experienced case workers.  Call me.

PHMP’s NEW TRICK – License Inactive Documents

Pennsylvania’s monitoring program, PHMP has instituted a new trick in their playbook. Now, with every PHMP questionnaire and data sheet, PHMP/PNAP caseworkers are including a voluntary license inactivation document. WHAT IS THIS? DON’T SIGN IT.

This is a new attempt to limit voluntary recovery program (“VRP”) participants from changing their mind before the Board enters a consent agreement formally accepting them into the VRP. In essence, most potential monitoring program targets/enrollees are actually INeligible for the VRP. Most do not suffer from any drug or alcohol addiction that renders them unable to perform their profession.  The caseworkers just pressure them to admit this.

These VRP participants, however, mistakenly sign the contract, get stuck with a false bills of goods, contact counsel and seek to change their minds. I TELL ALMOST EVERYONE TO WITHDRAW FROM THE PROGRAM, DO NOT ADMIT TO ANY IMPAIRMENT AND FIGHT FOR THEIR MEAL TICKET.  NEVER ADMIT ANY IMPAIRMENT.

If the licensee signs this new form, voluntarily rendering their license inactive, there is no point in changing their mind to go back to work. They can’t because their license is now inactive.  Formal Board action is required to reactivate that license. While the same PHMP Mental and Physical evaluation (SEE MY OTHER BLOGS) will take place, the licensee now cannot work during this 3-7 MONTH process. This is compared to not signing the form, not going into the program, fighting the case, and working pending the PHMP evaluation with an expert, not a cracker jack box assessor!

My prior blogs discuss why almost every licensee should not voluntarily enroll in the monitoring program. The blogs discuss the burdens of proof and difficulty of complying with all confirms and conditions of the monitoring program. GO READ THEM.

Importantly, there is a 6-8 MONTH time lag between the initial PHMP/PNAP “letter of concern” contact with the licensee and when a formal signed board approved consent agreement binds a licensee into the PHMP. Remember, this is a voluntary process. Prior to an executed professional license board FORMAL consent agreement being entered, EVERY licensee (doctor, nurse, pharmacist) is free to change their mind and withdraw from the program.

If a licensee signs a voluntarily inactive agreement, the program is no longer voluntary. If the licensee signs a voluntary license inactive document, changing their mind and withdrawing from the PHMP — because of the bait and switch tactics of the caseworkers quickly reveal themselves — signing an agreement to have a license deemed inactive handcuffs the licensee into the program.

Remember,  the VRP is just that; voluntary. Every licensee must acknowledge a drug or alcohol addiction and that renders them incapable of safely practicing their profession. If a licensee does not suffer from a potential drug or alcohol abuse or dependence disorder and/or are capable of safely practicing your profession, DON’T SIGN ANY DATA QUESTIONNAIRE, PHMP CONTRACT AND, ESPECIALLY, AN AGREEMENT TO VOLUNTARILY RENDER A LICENSE INACTIVE. Once the license is inactive, whether you change your mind about the program or not, withdrawing from the program does not allow a licensee to work.

That’s another important aspect of these PHMP contracts. PHMP/PNAP/PHP/SARPH agreements require licensees agrees to abide by any terms and conditions imposed by their caseworker. Some caseworkers compel not working in the licensee’s profession for a short period of time. Nonetheless, previously, the license was still active. Now, if a licensee signs that inactive agreement, the caseworker has ultimate control over the licensee, their career, their profession, and their wallet.

The case worker has the licensee’s professional career by the neck and will not let go until licensee completely satisfy them. TRUST ME, THE CASE WORKER AND PHMP case managers are not and never act as the licensee’s “advocate.” Their allegiance is to the board, their job, and their pay check, not the licensee’s.

With a license inactive, the caseworker must file a formal board document asking for re-activation prior to even them even being able to permit the licensee to work (even when in the PHMP). The Boards sit on these requests for multiple months.  As such, these voluntary inactive documents further extend and strengthen the caseworkers’ control over the licensee. It is inappropriate, unacceptable and could be deemed it illegal to compel a licensee to sign a interactive document as part of PHMP contract.

Remember, enrollment in the PHMP does not constitute discipline of a license. Only after the Board accepts the PHMP contract in the form of a consent agreement has discipline been entered. Opting out of the PHMP prior to Board approval does not constitute discipline and the licensee’s license is not restricted in any manner. If the licensee withdrawals from the PHMP and has not signed any license inactive document, they can go to work right away.

If the licensee agrees to sign the interactive document request, there’s no difference between withdrawing from the PHMP or not, as they will not be able to work until the license is reactivated. DON’T SIGN THIS NEW DOCUMENT WITHOUT LEGAL COUNSEL. DON’T SIGN THIS DOCUMENT UNDER ANY CIRCUMSTANCES, NO MATTER WHAT.

Pharmacists’ Corresponding Responsibility

What is a pharmacist’s “corresponding responsibility”? Corresponding responsibility requires pharmacists to refuse dispensing prescriptions to people they know or have reason to know that the presented prescription 1) is a fake or illegal, 2) is written not based upon a valid medical reason, and 3) while properly secured is being consumed incorrectly or abusively. Pharmacists can lose their license for violating this corresponding responsibility!

The pain medication overdose epidemic stemming in part from properly secured medications dispensed to injured athletes of high school and college sports departments, and now society as a whole, has created huge pressure on state and federal authorities. Their secondary response (aside from prosecuting the prescription writing doctors) is to target the pharmacist and pharmacy dispensing the schedule II medication. Stripping pharmacists of their professional licenses (state and federal DEA dispensing authority) for violating their corresponding responsibility is the new battled ground in the war against drug addiction and dependence.

Federal and state prosecutors are bringing professional license disciplinary prosecutions against pharmacy owners and the pharmacists by claiming violations of their corresponding responsibility. Prosecutors seek to portray these pharmacists as mere conduits for bad doctors selling prescriptions. The process begins when a doctor is charged with selling prescriptions. Either set up and targeted in a sting or simply being caught by Federal DEA investigators, these doctors are typically criminal charged federally and go to jail. While the doctor’s license is emergently revoked during the pendency of their federal criminal prosecution, the DEA and the state pharmacy investigators turn their attention to the pharmacy which was filling (dispensing) that bad doctor’s prescriptions.  Mandatory monthly regulatory compliance audits of the same pharmacies, which pharmaceutical suppliers and health insurance prescription plans must conduct, corroborate the specific pharmacists who were filing the fake, fraudulent, or abusive prescriptions.

21 CFR §1306.04, Purpose of issue of prescription, the Code of Federal Regulations, CFR) states

(a) A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription within the meaning and intent of section 309 of the Act (21 U.S.C. 829) and the person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.

Pennsylvania’s Drug Act counterpart is 28 Pa. Code § 25.52, which states:

(a) A prescription for a controlled substance must be issued for a legitimate medical purpose by a licensed practitioner in the usual course of professional practice. The responsibility for proper prescribing of controlled substances is upon the practitioner but a corresponding responsibility rests with the pharmacist who dispenses the medication and interprets the directions of the prescriber to the patient.
(b) A prescription may not be issued by a practitioner to obtain controlled substances for use in his routine office practice nor for general dispensing to his patients.
(c) A prescription may not be issued for the dispensing of controlled substances listed in any schedule to a drug dependent person for the purpose of continuing his dependence upon such drugs, nor in the course of conducting an authorized clinical investigation in a narcotic dependency rehabilitation program.

What are pharmacists to look for in fake or fraudulent prescriptions? A list of red flags that present to a pharmacist reasons not to fill a prescription include:

1) Some patients, in an effort to obtain additional amounts of legitimately prescribed drugs, alter the practitioner’s prescription, to secure high drug amounts by:

a) providing a different call back number to verify the prescription,
b) calling in their own prescriptions and give their own telephone number as a call-back for confirmation, and
c) stealing legitimate prescription pads from practitioner’s offices and/or hospitals and prescriptions are written using fictitious patient names and addresses.

2) Suspicious activity includes any combination of :

a) different hand writing,
b) different color ink in the prescription,
c) cross outs or incorrect spelling of patient, doctor, or drug names,
d) incorrectly dosing in strength and quantity of controlled substances,
e) patients showing up with prescriptions of other people,
f) incorrect, old, or wrong addresses and telephone numbers,
g) photo copied prescriptions,
h) Prescriptions that look “too good” or too legible,
i) quantities, directions, or dosages differ from usual medical usage,
j) prescriptions that do not possess correct standard abbreviations,
k) prescriptions that present with textbook presentations, and
l) directions that are written in full with no abbreviations.

3) Prescriptions not written for a valid medical condition present as follows:

a) a prescriber writes significantly more prescriptions (or in larger quantities) compared to other practitioners in the area.
b) patients appear too frequently – not on a monthly basis;
c) prescribers who write prescriptions for antagonistic drugs, such as depressants and stimulants, at the same time;
d) a number of people appear simultaneously, or within a short time, all bearing similar prescriptions from the same physician; and
e) people who are not regular patrons or residents of the community, show up with prescriptions from the same physician.

The manner and means of investigating what pharmacies and which pharmacists are failing perform their corresponding responsibility when dispensing schedule II prescriptions, for which doctors, patients, and drugs, is very easy. Historical reviews of drug company delivery records to pharmacists are now being conducted on bi-monthly. Drug manufacturers are routinely reporting to the state pharmacy board’s, DEA, and state attorney general narcotics enforcement officers suspect volume changes of schedule II narcotic orders, excessive increase in volume and ordering, and conducting their own investigation of doctors who are writing the prescription.

As a pharmacist, please call me to discuss allegations of your breach of your corresponding responsibility, how to defend it, and how we can protect your federal and state DEA dispensing licenses.

QUESTIONS THE PROFESSIONAL SHOULD ASK THEMSELVES BEFORE ENTERING PENNSYLVANIA’S PHMP

Should you expect your VRP case worker’s cooperation when you complete the PHMP (whether voluntary or not) three year program? Will your PMP, PNAP, SarPH case worker be your advocate? Will the program finish within the three year time? When will your licensing board hear your reinstatement application? These are all important questions for any professional considering Pennsylvania’s Voluntary Recovery Programs.

The answers to these questions constitute the basic assumptions each professional will posses and seek to understand prior to entering the PHMP. Whether doctor, nurse, pharmacist, or any other professional, understanding the full extent of your professional recovery program (they are almost all the same) prior to signing the enrollment contract is paramount to managing your expectations and experiences in the PHMP. See this link for the terms and conditions. http://www.dos.pa.gov/ProfessionalLicensing/OtherServices/ProfessionaHealthMonitoringPrograms/Documents/terms_and_conditions_for_participation.pdf

The first issue is how long is the PHMP. If you think your personalized PHMP will be only three years from the date you sign the VRP contract, you are wrong. See the terms and conditions link. http://www.dos.pa.gov/ProfessionalLicensing/OtherServices/ProfessionaHealthMonitoringPrograms/Documents/terms_and_conditions_for_participation.pdf.

Upon signing and submitting the contract to your case worker, your compliance is necessary. (You have now admitted an addiction which causes an impairment to practice safely. See my other blogs on why not to do that.) The three year period only commences upon your licensing board’s approval of that contract–thus becoming a board ordered agreement that they can enforce. However, what your PHMP caseworker intentionally omits telling you is that it takes 3, 6, or maybe 9 months for your licensing board to approve your enrollment contract. As such, the three-year term of the PHMP is really 39, 42, or 45 months. This becomes excruciatingly long.

Secondly, every professional expects their PHMP caseworker to advocate for their return to practice. Each enrollee hopes to have someone assist them navigate the complexities of the drug testing, treatment, and evaluations. Within several months of PHMP enrollment, whether your contract has received board approval, reality clashes with expectations. Every participant with whom I have spoken quickly realizes that “their advocate” — their PNAP or PHMP caseworker, is merely an enforcement officer. This enforcement officer does not help, but merely enforces the terms of the contract of sobriety into which you the professional has entered.

Your PNAP, PMP, PHMP, VRP case worker demands payment, drug testing, re-drug testing, and all medical records. They require retests and timely answers to all questions. East case worker will be the first to suggest a violation of the program and seek automatic and lengthy extensions for failing drug test for other program protocols. Your advocate becomes your violator, cop, the PHMP enforcer – not an advocate for you.

Lastly, if you have been drug free for 36 to 45 months, you the professional would think your compliance warrants license reinstatement without restriction. However, there are several additional steps in the process of which the case worker never discloses until the three year time period has run, thus delaying reinstatement longer.

Each participant must pass fitness for return to work evaluations. These evaluations delay full reinstatement for significant time periods. Case workers only schedule these evaluations at the end of the programs. A mix of participant and expert scheduling coordination, report generation and final approval by PHMP supervisors extent your PHMP enrollment many more months.  Thereafter, petitions to the board for reinstatement must be filed, for which hearings and decisions could take additional months. All the while, the professional must remain compliance in the program. None of this is explained to the unknowing and scared PHMP participant.

It is at the end of the PHMP 3 year time period when case worker manipulation is rampant. Specious drug test violations magically show up. Chain of custody protocols become suspicious. Allegations of participant “no showing” or lost samples for drug tests are routine. Case workers begin to unilaterally extend the PHMP time period by refusing to schedule fitness for work evaluations. Refusing to advocate for you the professional becomes the final delay tactic of choice.

If you have been in the program for drug and alcohol use and now you’re being required to undergo a mental health evaluation for no reason, they will seek to extend your enrollment for noncompliance. If you received drug treatment, but were not told you had a mental health diagnosis (anxiety otherwise unspecified) and you have not received any mental health treatment for three years because no one suggested it, recommend it, or require it, your case worker will attempt to delay your fitness for return to work for now a mental health evaluation. These are examples of your advocate refusing to advocate on your behalf.

Legal counsel is necessary to insure that the board understands the arbitrary and capricious nature of case workers’ lack of support, advocacy, or basic assistance in helping you get through the program. Frayed nerves, empty wallets, and frustration rule the professional PHMP participant’s day. Please call me to discuss missed drug tests, positive drug tests, or delayed scheduling of fitness to return to work evaluation. Please call me to discuss the abusive, obnoxious and demeaning caseworker treatment of you in your attempt to get back to your professional life. Lets file that petition for reinstatement and get you out of the PHMP in the time they suggested.

The PHMP program is only available to the following licensees:

Chiropractic
Dentistry
Medicine
Nursing: RN Law and PN Law
Occupational Therapy
Optometry
Osteopathic Medicine
Pharmacy
Physical Therapy
Podiatry
Psychology
Social Work, Marriage and Family Therapists and Professional Counselors
Speech-Language Pathology and Audiology
Veterinary Medicine

The Conflict between Legalizing Cannabis and the Professional Licensee

The wave of marijuana legalization is crashing across the country. I recently appeared on Art Fennel Reports, on the Comcast Network arguing against the legalization of the personal use of marijuana. I maintain this position in light of the extensive impact a positive blood test showing the presence of THC in one’s blood will have on the professional licensee.

In my television appearance my position rested solely upon the societal choice of selling and taxing cannabis to fund schools, similar to government support of gambling in the form of state lottery systems. I disagree with this type of regressive tax on our society’s neediest to fund government programs that wealthier individuals should support.  I also disagree with making cannabis more accessible to the children who will now attend school high on pot and be even less likely to learn or simply will not show up for school.  My position stands regardless for the fact that the war on drug has been lost. ( Importantly, everyone agrees the drug laws would not change for the illegal sale of cannabis. This means that incarceration levels and state level prison sentences would not be affected by legalizing personal use marijuana. )

As for the professional licensee (doctor, dentist, nurse, real estate agent, pharmacist, and/or ambulance tech) smoking cannabis or eating food made with marijuana will still present the THC drug in your blood.  Pennsylvania’s current driving after imbibing drug law, 75 Pa. C.S.A. § 3802(d), does not require intoxication or impairment to be guilty of driving while high. Getting high a day or two prior to a car crash or traffic violation that may/could evolve into a Pennsylvania DUI investigation could result in a blood draw showing THC in the blood. If the THC metabolite is present, one will be charged with DUI.

Importantly, if there is a car accident (either in the workplace and OSHA or the federal labor board investigates or after work hour on your private time) your blood may still be drawn. The presence of TCH in a licensee’s blood from private personal recreational cannabis smoking or eating, will also generate a State Board investigation. Obviously this investigation will be in addition to any criminal prosecution or work place employment related investigation.

Simply put, legally getting high on cannabis it is not worth the high cost associated with defending one against the state trying to revoke or discipline the professional licensee for such conduct.   The complications that arise from the two very simple scenarios overrides the benefits of legalization of marijuana. My prior blogs set forth the extensive administrative nightmare each license confronts when a state license board attempts to discipline or strip a licensee of their professional license.

Unfortunately, the people advocating for the legalization of marijuana do not consider the over lapping legal consequence the decades of civil penalties that have been erected to scare people into being safe in the work place (any work place with any type of license) and not show up at work (or use your professional license) high. It is these scare tactics and penalties that are are not being removed with the legalization of pot and with which a licensee may be confronted if caught on the “job” high.

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