United States v. Ahuja
United States v. Ahuja
Opinion of the Court
RULING RE: MOTION FOR PARTIAL SUMMARY JUDGMENT (DOC. NO. 74)
I. INTRODUCTION
Plaintiff, the United States (“the Government”), brings this action against defendant, Dr. Ajay S. Ahuja, M.D. (“Dr. Ahuja”), pursuant to the Controlled Substances Act (“CSA”), 21 U.S.C. § 801 et. seq. The action includes twenty-three counts of alleged violations of the CSA and its related regulations.
Dr. Ahuja filed a Motion for Partial Summary Judgment (“Mot. for Summ. J.”) (Doc. No. 74), as to four of the counts, numbered XIX through XXII. Each of these four counts alleges that Dr. Ahuja prescribed or otherwise dispensed con
Dr. Ahuja argues that the Government lacks power to bring an action against a physician for acting outside the usual course of professional practice by failing to maintain a patient chart. Mot. for Summ. J. at 3. Dr. Ahuja bases his argument on the Supreme Court decision Gonzales v. Oregon, 546 U.S. 243, 126 S.Ct. 904, 163 L.Ed.2d 748 (2006). See Mot. for Summ. J. at 3-4. For the reasons set forth below, Dr. Ahuja’s Motion for Summary Judgment is DENIED.
II. FACTUAL BACKGROUND
The parties agree as to very little. The parties agree Dr. Ahuja is a physician. Form 26(f) Report of Parties’ Planning Meeting (Doc. No. 33) at 2. The parties agree Dr. Ahuja is registered as a practitioner with the United States Department of Justice Drug Enforcement Administration (“DEA”) and authorized to handle controlled substances. Answer (Doc. No. 36) at 1, ¶¶ 2-3; Compl. at 1, ¶¶ 2-3.
DEA Diversion Investigator Marcie Johnson (“Johnson”) has written the following: Dr. Ahuja’s dispensing records reveal Dr. Ahuja dispensed controlled substances to two of the Recipients, to whom the parties refer as Jane Doe #1 and John Doe #1.
Based on a review of patient records, the Government’s proffered medical expert, Dr. Adam E. Perrin, M.D. (“Dr. Per-rin”) opines that Dr. Ahuja dispensed controlled medications outside the normal course of professional practice and without a legitimate medical purpose. Dr. Perrin’s Expert Medical Opinion (“Perrin Op.”) (Doc. No. 74-2) at 7. Dr. Perrin states that Dr. Ahuja “clearly did not adhere to accepted practice standards as [ ] pertains to the safe and proper distribution of controlled medications.” Id. at 9. Dr. Perrin indicates that a physician ought to document a controlled substance prescription in the medical record. Id. at 8. Dr. Perrin states that, when prescribing or otherwise dispensing controlled substances, a physician should keep “[ajccurate and complete documentation.” Id at 8. According to Dr. Perrin, a physician has a responsibility to record in a chart the reason he prescribes a controlled substance, and the fact that he examined the patient when making the prescription. Dr. Perrin Deposition (“Per-rin Dep.”) (excerpts in Doc. No. 74-3 and Doc. No. 75-5) at 79. Dr. Perrin describes Dr. Ahuja’s patient records as “cursory.” Perrin Op. at 7. Dr. Ahuja’s proffered medical expert, Dr. Gerald J. Hansen, M.D. (“Dr. Hansen”), states, however, that “[i]t is possible for a physician to provide care to a patient that is within the accepted standards of care, and even excellent care, without full or partial documentation.” Dr. Hansen Letter (Doc. No. 75-7).
Based on review of Dr. Ahuja’s patient records, Dr. Perrin opines that Dr. Ahuja violated a medical code of ethics by the way Dr. Ahuja prescribed controlled medications to family members. Perrin Op. at 7. Dr. Perrin states that an ethical concern exists when physicians prescribe for family members—especially when physicians prescribe controlled substances. Perrin Dep. at 96. Dr. Perrin reports concern within the medical establishment over the ethics of treating family members generally. Per-rin Op. at 8. Dr. Hansen opines, however, that whether it is proper for a physician to treat a family member depends on the situation. Dr. Hansen Deposition (“Hansen Dep.”) (Doc. No. 75-6) at 47. Dr. Hansen says that to treat a family member does not necessarily create a conflict. Id. at 58. Dr. Hansen states that a physician who treats a family member is “supposed to” maintain a patient chart for the family
III. STANDARD OF REVIEW
On a motion for summary judgment, the burden is on the moving party to establish that there are no genuine issues of material fact in dispute and that he is entitled to judgment as a matter of law. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 256, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986); White v. ABCO Engineering Corp., 221 F.3d 293, 300 (2d Cir. 2000). Once the moving party has met its burden, in order to defeat the motion, the nonmoving party must “set forth specific facts showing that there is a genuine issue for trial,” Anderson, 477 U.S. at 255, 106 S.Ct. 2505, and present such evidence as would allow a jury to find in its favor, Graham v. Long Island R.R., 230 F.3d 34, 38 (2d Cir. 2000).
In assessing the record to determine whether there are disputed issues of material fact, the trial court must resolve all ambiguities and draw all inferences in favor of the party against whom summary judgment is sought. See Anderson, 477 U.S. at 255, 106 S.Ct. 2505; Graham, 230 F.3d at 38. Summary judgment “is properly granted only when no rational finder of fact could find in favor of the non-moving party.” Carlton v. Mystic Transp., Inc., 202 F.3d 129, 134 (2d Cir. 2000). “When reasonable.. persons, applying the proper legal standards, could differ in their responses to the question” raised, on the basis of the evidence presented, the question must be left to the finder of fact. Sologub v. City of New York, 202 F.3d 175, 178 (2d Cir. 2000).
IV. CSA STANDARD
A physician violates the CSA when he dispenses a controlled substance “outside the usual course of professional practice.” See United States v. Moore, 423 U.S. 122, 124, 96 S.Ct. 335, 46 L.Ed.2d 333 (1975). Such a violation arises because the CSA prohibits dispensing a controlled substance without authorization, see 21 U.S.C. § 841(a)(1); or without a valid prescription or medical purpose, see 21 U.S.C. §§ 829(a-c); 842(a)(1).
The phrase “professional practice” implies normal and proper physician behavior, as determined by generally-accepted standards: for a physician to act “in the course of his professional practice” means to act “strictly within the appropriate
The term ‘professional practice’ refers to generally accepted medical practice; a practitioner is not free deliberately to disregard prevailing standards of treatment. In short, the doctor must act in the good faith belief that his distribution of the controlled substance is for a legitimate medical purpose and in accordance with the usual course of generally accepted medical practice.
United States v. Vamos, 797 F.2d 1146, 1151 (2d Cir. 1986) (citations omitted).
Whether a practitioner acted outside the usual course of professional practice is generally a question of fact. See United States v. Riccio, 43 F.Supp.3d 301, 308 (S.D.N.Y. 2014) (“Whether the prescriptions filled here were issued in the usual course of practice, pursuant to a bona fide physician patient relationship, is a question to be argued before and resolved by the jury.”); United States v. ALN Corp., No. CIV.A. 3:92-407, 1993 WL 402803, at *2 (D.Conn. Sept. 20, 1993) (stating that whether practitioner acted in accordance with what he reasonably believed proper medical practice was a question of fact).
A practitioner acts outside his professional practice when he behaves more as a “pusher” than as a physician. See Moore, 423 U.S. at 142-43, 96 S.Ct. 335 (holding that a jury could find a physician exceeded the bounds of professional practice when he failed to properly examine patients, ignored test results, dispensed controlled substances outside a clinic environment, failed to take precautions against drug misuse and diversion, let patients decide dosage, and based fee on drug quantity). A physician also acts outside professional practice when he issues a prescription for an individual who is not under his direct care. United States v. Salcedo, No. 02-CV-1095 (FB) (WP), 2003 WL 21196843, at *2 (E.D.N.Y. Feb. 19, 2003).
V. DISCUSSION
Counts XIX through XXII allege Dr. Ahuja violated the CSA by dispensing controlled substances to Recipients outside the course of professional practice. Compl. at 6-7. Evidence that Dr. Ahuja may have dispensed outside professional practice includes evidence suggesting that: (1) Dr. Ahuja dispensed controlled substances to the Recipients, see Decl. ¶¶ 14-15; Investigation Rep. ¶ 23; (2) Dr. Ahuja gave investigators inaccurate and inconsistent answers regarding his patient treatment, charting, and dispensing practices, see Decl. ¶¶ 13, 16-17; Investigation Rep. ¶¶ 21-22, 25; (3) Dr. Ahuja lacked a patient chart for some of the Recipients for the period when he dispensed said Recipients controlled substances, see Decl. ¶¶ 14, lb-17; (4) Dr. Perrin believes physicians should record in patient charts when dispensing, see Perrin Dep. at 79; (5) two Recipients were Dr. Ahuja’s relatives, see Investigation Rep. ¶¶ 21, 23; (6) Dr. Perrin believes dispensing controlled substances to relatives creates an ethical concern, see Perrin Dep. at 96; (7) concern exists within the medical community about the ethics of treating relatives generally, see Perrin Op. at 8; (8) Dr. Hansen believes that physicians should keep a patient chart when treating family members and should ideally note controlled substance prescriptions in said chart, see Hansen Dep. at 48; and (9) Dr. Perrin believes Dr. Ahuja dispensed without a legitimate medical purpose and outside the usual course of professional practice, see Perrin Op. at 7.
The Motion for Summary Judgment does not explicitly assert that no
Dr. Ahuja’s argument fails because it misapplies Gonzales. Gonzales held only that the Attorney General lacked power under the CSA to define legitimate medical practices so as to directly oppose state law. See 546 U.S. at 258, 126 S.Ct. 904 (“[H]e is not authorized to make a rule declaring illegitimate a medical standard for care and treatment of patients that is specifically authorized under state law.”); see also United States v. Feingold, 454 F.3d 1001, 1011 n. 2 (9th Cir. 2006) (describing Gonzales as “holding that the Attorney General lacked authority to declare illegitimate a medical standard for care ... that was specifically authorized under state law”). Specifically, Gonzales concluded that the CSA’s prescription requirement did not authorize the Attorney General’s interpretive rule, which intentionally countered Oregon’s physician-assisted suicide regime by declaring suicide not a legitimate medical purpose. 546 U.S. at 253-54, 274-75, 126 S.Ct. 904. The interpretive rule that Gonzales invalidated had sought to put an interpretive gloss on section 1306.04 of title 21 of the Code of Federal Regulations. Id. at 254, 126 S.Ct. 904. Gonzales did not invalidate section 1306.04 itself. See, e.g., id. at 250, 126 S.Ct. 904 (quoting the regulation’s professional practice requirement without stating or implying invalidity); United States v. Joseph, 709 F.3d 1082, 1088 (11th Cir. 2013) (citing section 1306.04(a) when affirming conviction of physician and others for dispensing outside “the usual course of his professional practice”). The Government thus retains the power to enforce the CSA against physicians who dispense controlled substances outside professional practice. The Second Circuit has made clear that the Government retains such power after Gonzales, holding that, “[a] doctor may be convicted of unlawful ... dispensation of a controlled substance if his activities fall outside the usual course of professional practice.” United States v. Quinones, 635 F.3d 590, 594 (2d Cir. 2011) (internal quotation marks omitted).
The government is not trying to establish a per se rule that [a certain method of dispensing is] invalid; rather, it is prosecuting the defendants under the rule established in Moore that prescribing drugs outside the usual scope of professional practice is illegal. The government is making no attempt, as in Gonzales, to unilaterally define which practices fall outside that scope; rather, it intends to leave that question where it has been for over 30 years—with the jury.
United States v. Quinones, 536 F.Supp.2d 267, 271 (E.D.N.Y. 2008).
Second, unlike in Gonzales, no conflict exists with state law here. Dr. Ahuja bases the Motion for Summary Judgment on the argument that the Government cannot sue him for failing to maintain patient charts. Mot. for Summ. J. at 3. Dr. Ahuja concedes, however, that Connecticut regulations require physicians to keep such charts. See Reply at 6 (“Public Health Codes §§ 19a-14-40 & 19a-14-41 discuss a physician’s obligation to maintain a patient chart.”). Gonzales does not preclude the Government from arguing that a physician’s dispensing of controlled substances without recording in a patient chart falls outside the scope of professional practice, at least for a physician in a state that requires such charts. To the contrary, a conflict between Dr. Ahuja’s dispensing practices and Connecticut’s public health codes may be used as evidence that Dr. Ahuja violated the CSA. See United States v. Prejean, 429 F.Supp.2d 782, 799-800 (E.D.La. 2006) (agreeing with the Government’s argument “that Gonzales v. Oregon does not disturb the body of case law that holds that violations of state regulations of medical practice may be evidence supporting a conviction under 21 U.S.C. § 841”).
The premise of the Motion for Summary Judgment is false because it mischaracter-izes the Government’s case. The Motion for Summary Judgment implies that the Government intends to prove Dr. Ahuja violated the CSA solely by failing to maintain patient charts. See, e.g., Mot. for Summ. J. at 8. The Government actually treats charting deficiencies as just one purported fact in support of its allegation that Dr. Ahuja dispensed- outside professional practice. See Pl.’s 56(a)(3) ¶ 7. Other purported facts that the Government considers material to proving Dr. Ahuja dispensed outside professional practice include that Dr. Ahuja dispensed to family members, see id. ¶ 3, 10; dispensed to himself, see id. ¶ 3, 28; and responded inconsistently and inaccurately to investigators, see id. ¶ 2, 9. Additionally, even if professional practice does not require charting, a
Courts have previously accepted inadequate patient charting as one piece of evidence that a physician may have prescribed outside professional practice. For instance, in a conviction for prescribing outside professional practice, the Ninth Circuit stated that testimony “overwhelmingly demonstrated” a physician’s “disregard for proper prescribing practices” when such testimony included the fact that the physician “never recorded the medical basis for prescribing [] controlled substances in his patients’ medical charts.” See Feingold, 454 F.3d at 1004. Similarly, the Third Circuit affirmed a physician’s conviction for prescribing outside professional practice when an expert had testified as to deficiencies including that (1) the physician lacked old patient charts, (2) existing patient charts lacked information regarding work-up or diagnostic evaluations, and (3) existing patient charts had insufficient information on patient histories and physical examinations. See United States v. Maynard, 278 Fed.Appx. 214, 217 n. 1 (3d Cir. 2008).
The court finds that nothing in Gonzales or other case law forbids the Government from presenting Dr. Ahuja’s allegedly inadequate patient charting practices as evidence of a CSA violation, and the court notes that other courts have properly allowed this type of evidence in the past.
VI. CONCLUSION
The court is concerned regarding the defense counsel’s pleadings. For example, the defense counsel writes that the Government “avers that, in failing to maintain an adequate chart, the Defendant has per se acted outside the scope of a ‘legitimate medical practice.’ ” Reply at 1 (citing “Plaintiff’s Objection, p.8”). After thoroughly searching page eight of-the Plaintiffs Memorandum in Opposition to the Motion for Summary Judgment (Doc. No. 75-3) and reading the rest of said document, the court finds no such averment. The court expects in the future when the defense counsel files, that he will be aware of his obligations. See Fed. R. Civ. P. 11.
For the reasons set forth above, the court DENIES Dr. Ahuja’s Motion for Partial Summary Judgment (Doc. No. 74).
SO ORDERED.
. The discussion below includes only factual issues relevant to Counts XIX through XXII.
. John Doe #1' may refer to Dr. Ahuja himself. Compare Compl. at 6 (alleging Dr. Ahuja dispensed four ounces of Guaifenesin with Codeine to John Doe #1 on February 6, 2014, and told investigators he lacked a patient chart for John Doe #1) with Investigation Report (Doc. No. 74-1) ¶ 134 (“Ahuja dispensed a bottle of Guaifenesin with Codeine to himself on 02/06/2014 and admitted to Investigators that he does not maintain a patient chart for himself.”).
. The Declaration refers to this Recipient as John Doe #2. Decl. ¶ 16. As Dr. Ahuja's Motion for Summary Judgment reveals, John Doe #2 is Dr. Ahuja's son. See Compl. at 6-7 (containing Count XXI which details Dr. Ahu-ja’s five prescriptions to John Doe #2); Mot. for Summ. J. at 8 (directing court to compare Government’s description of five prescriptions to Dr. Ahuja's son with Count XXI).
.The Declaration refers to this Recipient as John Doe #3. Decl. ¶ 17. As Dr. Ahuja’s Motion for Summary Judgment reveals, John Doe #3 is Dr. Ahuja's brother. See Compl. at 7 (containing Count XXII which details three of Dr. Ahuja's prescriptions to John Doe #3); Mot. for Summ. J. at 8 (directing court to compare Government’s description of prescriptions to Dr. Ahuja’s brother with Count XXII). The Investigation Report also lists a fourth prescription to Dr. Ahuja's brother on September 25, 2013, see Investigation Rep. ¶ 23; but the Complaint did not include this
. The Declaration says "the time period referenced in the complaint.” Decl. ¶¶ 14, 16-17. Counts XIX, XXI, and XXII of the Complaint reference dates ranging from early 2012 to late 2013. Compl. at 6-7.
. Counts XIX through XXII of the Complaint cite section 841(a)(1). Compl. at 6-7. Counts XIX through XXII of the Trial Memorandum, however, cite sections 829 and 842(a)(1). Trial Memorandum (Doc. No. 73) at 31-33, n.84-87. The Government is ordered to file a notice as to which section(s) it is proceeding under.
. The Reply also states that Gonzales, "concluded that the CSA does not regulate the practice of medicine outside the criminal context.” Reply at 4. The Reply fails to cite to a page in Gonzales for this proposition. Id. at 4. The court cannot find language in Gonzales limiting the CSA’s power over medicine to criminal enforcement. To the contrary, Gonzales described the interpretive rule it struck down as one that “declares certain conduct criminal.” 546 U.S. at 262, 126 S.Ct. 904. Moreover, Gonzales merely struck down an interpretive rule because it exceeded the CSA, see id. at 274-75, 126 S.Ct. 904; Gonzales did not strike down any part of the CSA, see, e.g., id. at 274-75, 126 S.Ct. 904 (referencing the CSA’s prescription requirement without stating or implying invalidity). Thus, the CSA civil penalty provision survives. See 21 U.S.C. § 842 (c). Civil penalties apply to certain medical practice violations, including dispensing without a valid prescription. See, e.g., 21 U.S.C. §§ 829, 842(a)(1),(c). While not common, civil CSA enforcement against physicians does occur. See, e.g., United States v. Butterbaugh, No. C14-515, 2015 WL 4660096, at *1 (W.D.Wash. Aug. 5, 2015); United States v. Paskon, No. 4:07-CV-1161, 2008 WL 2039233, at *1 (E.D.Mo. May 12, 2008); Salcedo, 2003 WL 21196843, at *2.
Reference
- Full Case Name
- United States v. Ajay S. AHUJA, M.D.
- Status
- Published