Court Opinion

ID: 4588300
Source: CourtListenerOpinion
Date Created: 2020-11-20 10:06:20.641053+00
Date Added: 2024-06-11T07:50:02.914354
License: Public Domain

If this opinion indicates that it is “FOR PUBLICATION,” it is subject to
                 revision until final publication in the Michigan Appeals Reports.

                          STATE OF MICHIGAN

                           COURT OF APPEALS

In re DAVID PETER JANKOWSKI, D.O.

                                                                    UNPUBLISHED
 DEPARTMENT OF LICENSING AND                                        November 19, 2020
 REGULATORY AFFAIRS,

                Petitioner-Appellee,

 V                                                                  No. 348760
                                                                    LARA Bureau of Professional
                                                                    Licensing, Board of Osteopathic
                                                                    Medicine and Surgery
                                                                    Disciplinary Subcommittee
 DAVID PETER JANKOWSKI, D.O.,                                       LC No. 17-013679

                Respondent-Appellant.

Before: MARKEY, P.J., and METER and GADOLA, JJ.

PER CURIAM.

        Respondent appeals as of right a final order, issued by the Board of Osteopathic and
Surgical Medicine Disciplinary Subcommittee, a Board operating under the Michigan Department
of Licensing and Regulatory Affairs (LARA) Bureau of Professional Licensing. The Disciplinary
Subcommittee concluded that respondent violated MCL 333.16221(a) (negligence or failure to
exercise due care), MCL 333.16221(b)(i) (incompetence), MCL 333.16221(b)(vi) (lack of good
moral character), and MCL 333.16221(c)(iv) (prescribing or administering drugs for other than
lawful diagnostic or therapeutic purposes), all of which are provisions of the Public Health Code,
MCL 333.1101 et seq., fined respondent $25,000, and suspended his license to practice medicine
for three years. We affirm.

                                       I.    BACKGROUND

       In June 2017, the Bureau of Professional Licensing filed an administrative complaint
against respondent, a licensed osteopathic physician. The complaint alleged that respondent’s

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prescribing practices, patient treatments, and documentation practices violated the Public Health
Code. More specifically, the four-count complaint indicated that the Michigan Automated
Prescription System (MAPS), a database that’s used to track controlled substances, reflected that
from January 1, 2015 through June 19, 2017, respondent wrote 23,906 controlled-substance
prescriptions, more than 70% of which were for certain commonly abused and diverted controlled
substances, and he dispensed nearly 21% of the prescriptions he wrote in 2016 and nearly 17% in
2017. The complaint further outlined observations made following the review of records regarding
respondent’s care of nine specific patients during the same timeframe, and alleged that defendant
had committed the violations outlined above.

         Several witnesses testified at hearings held between August 2017 and August 2018.
Pharmacy specialist investigator Janice Waldmiller, who was involved in the investigation into
respondent’s prescribing practices, testified that of the over 50,000 prescribers in Michigan,
respondent was the 73rd highest prescriber of all controlled substances in 2015 and was 58th in
2016. Waldmiller further testified that “highly abused and diverted medications,” including
oxymorphone, OxyContin, oxycodone-acetaminophen, alprazolam, Clonazepam, Hydrocodone,
Percocet, and Norco, comprised over 75% of respondent’s overall controlled substance prescribing
in 2015 and over 71% in 2016 through August 25. Waldmiller also noted instances of patients
receiving controlled substances from multiple physicians, the amount of medications prescribed,
and drug screen results that were inconsistent with medications the patients received from
pharmacies. Waldmiller explained that these practices were inconsistent with “the CDC guidelines
[that] indicated that less than 15 morphine equivalent dosing was appropriate. But anything greater
than 90 morphine equivalent dosing, the practitioner should weigh . . . the risks and benefits . . .
because that’s where we get into potential overdose due to respiratory depression.” Waldmiller
also noted that the number of prescriptions respondent wrote for abused and diverted drugs
decreased after an investigation was started.

        David Aaron Cooke, M.D., was certified by the American Board of Internal Medicine and
spent “approximately two-thirds of [his] time in general internal medicine primary care practice
and approximately one-third of [his] time in specialty pain management care through the
University of Michigan Anesthesia Back and Pain Center.” He acknowledged that he was not a
member of the American Pain Society or the American Academy of Pain Medicine, and he did not
practice interventional pain medicine. Dr. Cooke indicated that the 2016 CDC Guideline for
Prescribing Opioids for Chronic Pain (CDC Guidelines) was “currently the most authoritative
statement” in regard to a standard of care for prescribing controlled substances in Michigan for the
period at issue. He explained that the CDC was not the first organization to make the
recommendations, but the most recent, that the CDC Guidelines memorialized what had been the
standard of care for prescribing controlled substances for at least the previous five years, and that
the principles underlying the CDC Guidelines had also been previously published in leading
medical journals. He suggested that the CDC Guidelines were voluntary rather than prescriptive
standards based on emerging evidence, and recognized that they stated that they were intended for
primary care physicians treating patients with chronic pain in outpatient settings. He was not
aware of whether the CDC Guidelines had been adopted by LARA, the Michigan Board of
Medicine, the Michigan Board of Osteopathic Medicine and Surgery, the American Pain Society,
the American Academy of Pain Medicine, the American Society of Anesthesiologists, or the
Federation of State Medical Boards. Moreover, Dr. Cooke agreed that one of the recommendations

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in the CDC Guidelines was that a primary care physician consult with a pain management
specialist before prescribing controlled substances exceeding 90 MED.

         Dr. Cooke indicated that, generally, prescribers should be cautious about escalating to
higher doses of opioids because increased doses placed patients at higher risk, and that a physician
should avoid co-prescribing benzodiazepines with opioids and other respiratory depressants. He
testified that the CDC Guidelines indicated that a doctor should rarely prescribe amounts
exceeding 90 morphine equivalent dosing (MED), and should do so only after careful
consideration and documentation of the reasons. He explained that a physician must carefully
consider and document the risks and benefits of and the patient’s response to the medications. He
further explained that studies had shown a clear relationship between opioid risk and death, and
relationships between use of multiple respiratory suppressants and death. He also stated, “The risk
to the patient is much higher when a patient is taking both a benzodiazepine and an opioid in
combination. They both depress the drive to breathe. When you start adding in higher doses of
multiple drugs from each class . . . the risk goes up exponentially.” He clarified that the “[r]isk of
death increases as MED increases as well as the number and doses of other respiratory depressants
such as Xanax, Soma, and others are added in. They all progressively increase risk and that is true
whether the patient is tolerant or not.”

        Dr. Cooke opined that respondent did not meet the applicable standard of care for
prescribing pain medication. More specifically, he found some of respondent’s initial and
subsequent evaluations of the nine patients insufficient, and he did not see evidence of
comprehensive treatment plans. Moreover, he opined that respondent prescribed opioids in very
high and potentially fatal doses above the recommended limits in the CDC Guidelines, and failed
to properly document the rationale for the prescriptions. Also, he expressed concern about the
combination of drugs that respondent was prescribing or that his patients were otherwise taking,
noting that nearly all the subject patients were receiving at least three different controlled
substances and, in some cases, five or six different prescriptions. He was concerned that there was
no documentation showing that respondent and the patient recognized the risks of combining the
prescribed medications. However, Dr. Cooke also observed that between 2015 and June 2017,
there was a “substantial decrease” in the amount of benzodiazepine and carisoprodol prescriptions
issued by respondent. He further noted that, in several cases, he did not see evidence that the
patients had improved in a meaningful way but medications were being continued or escalated.
Dr. Cooke testified that he would have expected to see documented reasons for changing
medications when that occurred. Also, he noted that several patients had instances where drug
screen results were not consistent with what had been prescribed or showed the presence of illicit
drugs.

        Respondent’s expert, Thomas S. Nabity Jr., M.D., had practiced pain medicine and
physical medicine rehabilitation since 2006 and was board-certified in Physical Medicine and
Rehabilitation and in the subspecialty of pain medicine. He worked for the Michigan Neurology
Association where about 90% of his patients had pain complaints. He testified that he was familiar
with the medical literature and research in the treatment and care of patients with chronic pain, and
explained that in treating a chronic pain patient, a physician had to consider how to combat a
patient’s pain while taking into consideration issues of misuse and addiction. According to Dr.
Nabity, this process included identifying patients that had painful disorders, whether through
trauma or occurring over time, identifying a diagnosis, working through the risks and benefits of

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the prescription for the patient, and incorporating drug therapy into a comprehensive plan that
looked at behavior therapy, interventional pain, procedures, nonopiate alternate pain medication,
and lifestyle changes. Dr. Nabity noted that because of the subjective nature of pain, physicians
had little evidence to guide them about dosing strategies for prescribing opioids for chronic pain
therapy.

         Dr. Nabity was familiar with different recommendations as to limiting dosages, such as
those identified by the American Society of Interventional Pain Physicians (ASIPP), the American
Pain Society, the CDC Guidelines, and different insurance companies. He indicated that ASIPP’s
recommendation of 300 MED was the highest ceiling, while the CDC Guidelines’
recommendation of 90 MED was the lowest ceiling. However, he indicated that there was
disagreement about the importance or validity of the MED standard, and he opined that the
standard of care for treating chronic pain did not have a high dose limit. He indicated that when
he first began practicing medicine, the standard was that opiates were the last line of treatment and
that one would start with low doses and titrate upward to pain control, but over time there had been
a change in the standard of care with regard to MED levels, and continuing to escalate dosages of
opiates until pain relief was achieved was no longer the standard of care. He claimed that the
absolute MED limit was still being debated. He also opined that the standard of care allowed use
of benzodiazepines on a long-term basis in chronic pain patients.

        Dr. Nabity suggested that the CDC Guidelines and the standard of care were not the same
thing; the CDC Guidelines were merely recommendations based on a review of a large number of
patients in large numbers of situations, whereas the standard of care was an acceptable practice
regarding how an individual was treated and managed. He noted that the CDC Guidelines were a
voluntary recommendation rather than a prescriptive standard, and intended for primary care
physicians. He suggested that the CDC Guidelines were merely a guide for the change in
prescribing practices.

        According to Dr. Nabity, respondent’s treatment for each of the nine patients and his
documentation in the patient charts fell within the standard of care applicable during the time of
care. He described the nine patients as “very complicated cases,” all involving chronic pain, and
stated that all but one of the patients had suffered traumatic injuries. He noted that the patients
had a history of multiple surgeries, and that chronic pain patients often also experienced anxiety
and depression. He further noted that the patient records contained lab tests, drug screens,
diagnostic imaging, neuropsychological exams, and referrals to various specialists. He opined that
this information suggested that respondent was following a comprehensive treatment plan,
including a full exploration of available treatment options, and was not simply prescribing
medications to his patients. Dr. Nabity also noted that respondent regularly checked reports from
MAPS before patients were started on opiates.

        Dr. Nabity also testified that respondent’s controlled-substance agreement form contained
informed consent information discussing that his treatments were done to assist in pain control,
that there were risks associated with treatment, and that the patient was required to comply with
certain expectations to maintain their pain medication prescriptions. He opined that this was
sufficient evidence to support a conclusion that the patients were aware of potential risks. In his
opinion, there was no evidence presented that any of respondent’s patients had experienced
respiratory depression or overdose, and there was evidence that only one patient showed addictive

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behavior, which respondent addressed by terminating care. Dr. Nabity further noted that within
the previous year, respondent had worked to bring prescription levels down, and had also sought
additional consultations to assist individual patients. Dr. Nabity opined that it was reasonable for
respondent to make changes to medications after considering the patients’ conditions; he stated
that finding a balance that worked for each patient was more important than the level of morphine
equivalent dosing prescribed.

        Dr. Nabity testified that a pain management physician should stop prescribing controlled
substances based on inconsistencies in drug screen results when the provider believes that the harm
outweighs the benefit derived from the prescription. Moreover, he indicated that when a drug
screen identifies an illicit drug, a discussion should take place about the propriety of the patient’s
referral to a substance abuse specialist.

         Based on his review of the medical records, Dr. Nabity opined that respondent met the
minimal standards of care. Dr. Nabity disagreed with Dr. Cooke’s suggestion that respondent’s
initial history taking for the patients was deficient and Dr. Cooke’s assessment that the records
lacked clinical rationales and decisions. He opined that the charting was sufficient to assess
whether the patients had received functional benefit from controlled substances. He also noted
that respondent had recommended neuropsychological and surgical consults when appropriate.

         Following the hearings, the administrative law judge (ALJ) issued his proposal for
decision, concluding that respondent was subject to discipline under MCL 333.16221(a)
(negligence or failure to exercise due care), MCL 333.16221(b)(i) (incompetence), MCL
333.16221(b)(vi) (lack of good moral character), and MCL 333.16221(c)(iv) (prescribing or
administering drugs for other than lawful diagnostic or therapeutic purposes). The ALJ made
specific findings of fact with respect to each of the nine patients. With regard to the standard of
care, the ALJ recognized the differing expert opinions, but stated, “The CDC Guideline and the
underlying studies reference [sic] therein reflect the standard of care for a pain management doctor
during the same time periods relevant to this case.” The ALJ found that respondent had “made
significant changes in his prescribing practices starting in September 2016 through September
2017, during which time he wrote fewer prescriptions for controlled substances and reduced
dosages for some patients.” The ALJ specifically determined that respondent violated MCL
333.16221(a) and (b)(i), but not solely for writing prescriptions that exceeded 90 or 120 MEDs;
rather, it was for failing to document his underlying rationale for exceeding those thresholds and
for writing combination prescriptions. The ALJ noted that all nine patients had also been
prescribed a benzodiazepine along with the opioids, and none of the medical records included
documentation about the inherent risk of this combination. According to the ALJ, this “strongly
supports” a conclusion that respondent violated the standard of care requiring documented
reasoning for both prescribing chronic opioid therapy in high doses, along with benzodiazepines,
and in some cases multiple other controlled substances. The ALJ noted that as of 2010, and
certainly after March 2016, the literature was well-established regarding the dangers of MEDs
greater than 120, with or without other controlled substances.

        The ALJ further concluded that “the totality of the evidence” supported a finding that
respondent lacked good moral character because he ranked in the top 30 prescribers statewide for
several commonly abused and diverted controlled substances while only working 25 to 30 hours
per week. And, in 2015, respondent wrote an average of approximately 200 controlled substance

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prescriptions each week. The ALJ noted that respondent prescribed opioids and benzodiazepines
for a relative without assessing him for substance abuse, reviewing his MAPS reports, or
administering urine drug screens, and injected him with testosterone without testing to determine
a need for the treatment. Finally, the ALJ concluded that the high doses of opioids with
benzodiazepines and other dangerous combinations of drugs were not for legitimate therapeutic
purposes. This conclusion was based on respondent’s persistent disregard for the risks inherent in
his prescribing practices, and the lack of documentation regarding those risks or their disclosure
to his patients.

        The Disciplinary Subcommittee entered a final order adopting the ALJ’s proposal for
decision. In addition to suspending respondent’s medical license for three years for violating MCL
333.16221(a), (b)(i), (b)(vi), and (c)(iv), the Subcommittee required that respondent apply for
reinstatement of his license and pay a $25,000 fine before doing so. This appeal followed.

                                  II.     STANDARD OF REVIEW

       This Court reviews a final order in a disciplinary case under the Public Health Code as
follows:

           All final decisions, findings, rulings and orders of any administrative officer or
           agency existing under the constitution or by law, which are judicial or quasi-
           judicial and affect private rights or licenses, shall be subject to direct review by
           the courts as provided by law. This review shall include, as a minimum, the
           determination whether such final decisions, findings, rulings and orders are
           authorized by law; and, in cases in which a hearing is required, whether the
           same are supported by competent, material and substantial evidence on the
           whole record. [Dep’t of Community Health v Risch, 274 Mich. App. 365, 371;
           733 NW2d 403 (2007), quoting Const 1963, art 6, § 28.]

“When reviewing whether an agency’s decision was supported by competent, material, and
substantial evidence on the whole record, a court must review the entire record and not just the
portions supporting the agency’s findings.” Risch, 274 Mich. App. at 372. Evidence is substantial
if a reasonable mind would accept it as “sufficient to support a conclusion.” Id. Substantial
evidence requires “more than a scintilla of evidence,” but “may be substantially less than a
preponderance.” Id. (quotation marks and citation omitted). However, this Court generally will
not disturb administrative findings of fact, especially when they are based on credibility
determinations, “because it is not the function of a reviewing court to assess witness credibility or
resolve conflicts of evidence.” Id. Indeed, this Court “may not set aside factual findings supported
by the evidence merely because alternative findings could have been supported by evidence on the
record . . . .” Id. at 373. “Moreover, an appellate court must generally defer to an agency’s
administrative expertise.” Dep’t of Community Health v Anderson, 299 Mich. App. 591, 598; 830
NW2d 814 (2013).

                                          III.    ANALYSIS

       Respondent first argues that the Disciplinary Subcommittee’s final order should be
reversed because absent any expert testimony or evidence as to “the actual, relevant and applicable

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standard of care and how that standard was breached, there was no competent, material, and
substantial evidence on which the Disciplinary Subcommittee could have ruled that [respondent]
violated the Public Health Code in any way.” The crux of respondent’s argument is that the 2016
CDC Guidelines and other literature cited by Dr. Cooke as the applicable standard of care apply
to primary care physicians and not chronic pain management practitioners like respondent. This
argument is unavailing.

        We first note that the 2016 Guidelines were not admitted at any time during these
proceedings. Nonetheless, neither party disputes that they are intended for primary care
physicians. The issue at hand, therefore, is whether they also apply to pain management physicians
with respect to the prescribing of pain medication.

        All information relevant to the 2016 Guidelines was presented via testimony. Dr. Cooke
indicated that they were not the first or only recommendation, but were the most recent. He further
indicated that the CDC Guidelines memorialized what had been the standard of care for prescribing
controlled substances for at least the previous five years, and that the principles underlying the
CDC Guidelines had also been previously published in leading medical journals. Moreover, Dr.
Cooke recognized that although other guidelines existed, it was clear that prescribers should be
cautious about escalating to higher doses of opioids because increased doses placed patients at
higher risk, and that a physician should avoid prescribing both benzodiazepines and opioids or
other respiratory depressants. Dr. Cooke testified that the CDC Guidelines indicated that a doctor
should rarely prescribe amounts exceeding 90 MED, and should do so only after careful
consideration and documentation of the reasons. He also explained that a physician must carefully
consider and document the risks, benefits, and patient’s response to medications. Additionally,
throughout these proceedings, pharmacy specialist Waldmiller testified that the CDC Guidelines
served as a guide when she reviewed prescribing practices of physicians. The combined testimony
of Dr. Cooke and Waldmiller supports a conclusion that the CDC Guidelines were the accepted
standard of care regarding prescribing pain medication at the relevant time.

        On the other hand, Dr. Nabity testified that he was aware of the 2016 CDC Guidelines and
the industry’s evolution toward caps on pain medication. Nonetheless, he suggested that the 2016
Guidelines were not in place during respondent’s treatment of the nine patients whose records he
reviewed. He described a standard of care that followed very loose guidelines and allowed
virtually unlimited doses of pain relief as well as drug combinations.

        The ALJ recognized the differing expert opinions, but stated, “The CDC Guideline and the
underlying studies reference [sic] therein reflect the standard of care for a pain management doctor
during the same time periods relevant to this case.” This conclusion indicated that the ALJ found
Dr. Cooke’s and Waldmiller’s testimony credible in terms of what was applicable during the
relevant time frame. As noted above, this Court generally will not disturb administrative findings
when they are based on credibility determinations “because it is not the function of a reviewing
court to assess witness credibility or resolve conflicts of evidence.” Risch, 274 Mich. App. at 372.

        Our review of the ALJ’s determination reflects that the ALJ’s analysis was consistent with
the use of the CDC Guidelines as a benchmark to evaluate respondent’s conduct. Following his
review of the record and testimony, the ALJ determined that respondent did not adequately justify
concurrent prescriptions, did not adequately address the risk of abuse or diversion with patients,

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and failed to justify the high level of medications prescribed. Those conclusions are supported by
Dr. Cooke’s testimony. Moreover, a disciplinary subcommittee may rely on its own expertise in
determining violations of the Public Health Code. Anderson, 299 Mich. App. at 600. In that regard,
this Court has previously concluded that a disciplinary subcommittee does not require expert
testimony to determine that a respondent was negligent or lacking in good moral character when
the conduct lacked basic elements of professional integrity. Sillery v Bd of Med, 145 Mich. App.
681, 688-689; 378 NW2d (1985). Therefore, even without Dr. Cooke’s testimony, the Board could
have determined, using its own expertise, that the evidence demonstrated that respondent engaged
in violations of the Public Health Code. The Board’s decision was supported by competent,
material, and substantial evidence on the record.

        Respondent argues that the final order is not supported by competent, material, and
substantial evidence to establish that he violated MCL 333.16221(a) or (b)(i) through negligence
and incompetency because the record amply supports that respondent exercised due care in
treating his patients and in documenting the course of their care. We disagree.

       MCL 333.16221(a) provides:

       (a) Except as otherwise specifically provided in this section, a violation of general
           duty, consisting of negligence or failure to exercise due care, including
           negligent delegation to or supervision of employees or other individuals,
           whether or not injury results, or any conduct, practice, or condition that impairs,
           or may impair, the ability to safely and skillfully engage in the practice of the
           health profession.

“Negligence is a well-recognized legal concept which describes conduct that falls below a standard
of reasonable or due care. A failure to exercise due care contemplates an abdication of
responsibilities or carelessness in executing one’s duties.” Sillery, 145 Mich. App. at 686. Further,
MCL 333.16221(b)(i) authorizes disciplinary action for incompetence. Incompetence is defined
as “a departure from, or failure to conform to, minimal standards of acceptable and prevailing
practice for a health profession, whether or not actual injury to an individual occurs.” MCL
333.16106(1).

        The crux of respondent’s argument is that the standard of care adopted by the ALJ was
incorrect. With that pretext, respondent argues that Dr. Nabity’s testimony about the ways in
which respondent met the standard of care was sufficient to establish that respondent was not
negligent or incompetent. However, as noted above, this Court defers to the ALJ’s credibility
determination. Furthermore, Dr. Cooke presented significant testimony regarding various
concerns regarding respondent’s failure to adequately justify concurrent prescriptions, to address
the risk of abuse or diversion with patients, and to justify changes and high levels of medications
prescribed. Dr. Cooke’s testimony, coupled with the ALJ’s own conclusions, establish that
sufficient competent evidence was presented to establish that respondent violated MCL
333.16221(a) and (b)(i), so as to support the Subcommittee’s final order.

        Respondent further argues that the final order is not based on sufficient competent evidence
to establish that he lacked good moral character, thereby violating MCL 333.16221(b)(vi). “Good
moral character” means “the propensity on the part of the person to serve the public in the licensed

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area in a fair, honest, and open manner.” MCL 338.41(1). Respondent asserts that the ALJ’s
conclusion that he lacked good moral character was based only on statistical data that respondent
ranked in the top 30 prescribers statewide for several commonly abused and diverted controlled
substances. Respondent asserts that this data does not support the ALJ’s conclusion because a
pain management physician would be more likely than other providers to prescribe controlled
substances and treat a population with significant medical conditions. However, this argument
ignores the ALJ’s conclusion that respondent demonstrated a lack of good moral character when
he prescribed opioids and benzodiazepines to his relative without assessing for substance abuse,
reviewing MAPS, or administering drug screens. Further, the ALJ noted that respondent injected
his relative with testosterone without testing to determine the need for the injection, and continued
to prescribe medications to patients despite numerous inconsistent urine drug screen results
showing the medications were not being taken. The ALJ concluded that respondent
“demonstrate[d] a pattern of prescribing practices, lack of documentation, and a disregard for the
significant risks to his patients” that demonstrated a lack of openness and honesty. Given the
ALJ’s multiple reasons for concluding that respondent lacked good moral character, and the
support in the medical records for these reasons, we hold that the ALJ’s conclusion was supported
by sufficient competent evidence.

        Lastly, respondent argues that competent, material, and substantial evidence did not
establish that respondent violated MCL 333.16221(c)(iv). MCL 333.16221(c)(iv) identifies
violations of the Public Health Code that include “selling, prescribing, giving away, or
administering drugs for other than lawful diagnostic or therapeutic purposes.” Respondent argues
that there is no proof that he acted for some illicit purpose beyond treating his patients. We
disagree.

        Once again, the crux of respondent’s argument is that a violation of an incorrect standard
of care is insufficient to establish a violation of the Public Health Code. However, as noted above,
the ALJ did not err by adopting the 2016 CDC Guidelines as the relevant standard of care.
Nonetheless, while it was indeed undisputed by both experts that the patients at issue had severe,
chronic pain, there was significant testimony presented by Dr. Cooke regarding the frequency at
which respondent prescribed medications without a documented discussion regarding the
associated risks and benefits. In that regard, the record supports a conclusion that respondent
frequently prescribed a high level of substances without documenting any justification, and on
some occasions without any prior testing to confirm the need for the medications. Additionally,
on several occasions respondent continued to prescribe these substances despite receiving drug
screen results that were inconsistent for the medications prescribed, and prescribed medications to
a relative without reviewing MAPS or requiring drug screens. These acts were sufficient to
establish a violation of the relevant standard of care.

        In sum, we conclude that when viewed as a whole, the record before this Court contains
sufficient competent, material, and substantial evidence to support the ALJ’s and the Disciplinary
Subcommittee’s ruling that respondent was negligent, was incompetent, lacked a good moral
character, and dispensed medications for other than legitimate or therapeutic purposes.

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Affirmed.

                   /s/ Jane E. Markey
                   /s/ Patrick M. Meter
                   /s/ Michael F. Gadola

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