Humphreys v. DEA ( 1996 )


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  •                                                                                                                            Opinions of the United
    1996 Decisions                                                                                                             States Court of Appeals
    for the Third Circuit
    9-17-1996
    Humphreys v. DEA
    Precedential or Non-Precedential:
    Docket 96-3099
    Follow this and additional works at: http://digitalcommons.law.villanova.edu/thirdcircuit_1996
    Recommended Citation
    "Humphreys v. DEA" (1996). 1996 Decisions. Paper 75.
    http://digitalcommons.law.villanova.edu/thirdcircuit_1996/75
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    UNITED STATES COURT OF APPEALS
    FOR THE THIRD CIRCUIT
    NO. 96-3099
    EARL A. HUMPHREYS, M.D.,
    Petitioner
    v.
    DRUG ENFORCEMENT ADMINISTRATION,
    Respondent.
    On Appeal from an Order of the Drug Enforcement Administration dated
    January 23, 1996
    (AH 16752)
    Argued July 26, 1996
    BEFORE:   BECKER, STAPLETON, AND MICHEL, Circuit Judges.
    (Opinion Filed September 17, 1996)
    Robert A. Felkay, Esquire (argued)
    John A. Tumolo, Esquire
    Professional Office Building
    430 Blvd. Of The Allies
    Pittsburgh, PA 15219
    Attorney for Earl A. Humphreys, M.D.
    John C. Keeney, Esquire,
    Theresa M.B. Van Vliet, Esquire,
    Hope P. McGowan, Esquire (argued)
    Narcotic and Dangerous Drug Section
    Criminal Division
    Post Office Box 27312
    Washington, D.C. 20038
    Attorneys for Drug Enforcement Administration
    OPINION OF THE COURT
    MICHEL, Circuit Judge.
    Earl A. Humphreys, M.D. ("Humphreys") appeals from an order of
    the Drug Enforcement
    Administration ("DEA"), dated January 23, 1996, in which the Deputy
    Administrator of the DEA ordered that
    Humphreys' DEA certificate of registration be revoked and any pending
    application for renewal of the registration
    be denied. Earl A. Humphreys, M.D.; Revocation of Registration, 
    61 Fed. Reg. 2840
     (1996). Because the DEA
    abused its discretion in failing to consider Humphreys' privacy defense
    and, on the present record, arbitrarily
    revoked his registration, we vacate and remand.
    BACKGROUND
    Humphreys is a Pittsburgh doctor specializing in gastroenterology
    and internal medicine and who, prior
    to this proceeding, had practiced for over 35 years without any
    disciplinary actions being taken against him. On
    April 12, 1995, a Deputy Assistant Administrator of the DEA issued to
    Humphreys an Order to Show Cause why
    the DEA should not revoke Humphreys' certificate of registration under 
    21 U.S.C. § 824
    (a)(4) and deny any
    pending application under 
    21 U.S.C. § 823
    (f) as being inconsistent with
    the public interest. Specifically, the
    Order to Show Cause alleged that "from the early 1980s to mid-1993,
    [Humphreys] prescribed controlled
    substances to at least four individuals without a legitimate medical need
    and with knowledge that these individuals
    were not the ultimate recipients of the controlled substances."
    The DEA's action was precipitated by Humphreys' personal and
    professional relationship with former
    Pennsylvania Supreme Court Justice Rolf Larson ("Larson") and the criminal
    investigation of Larson.
    Humphreys acted as Justice Larson's personal physician for approximately
    the past 20 years. In 1993, based on
    the findings and recommendations of a grand jury, Larson was charged with
    one count of conspiracy to commit
    "Acquisition or Obtaining of Possession of a Controlled Substance by
    Misrepresentation, Fraud, Forgery,
    Deception, or Subterfuge" and numerous other violations of law. Humphreys
    was named as an unindicted co-
    conspirator in the conspiracy count and received immunity in return for
    his testimony against Larson.
    The criminal conspiracy charge against Larson, and DEA's
    regulatory investigation of Humphreys,
    stemmed from Larson's attempts to keep his mental health problems out of
    public sight. Beginning in the 1960's,
    Larson visited psychiatrists and psychologists for the treatment of
    clinical depression and anxiety. These doctors
    prescribed various tranquilizers and antidepressants, which Larson paid
    for out of his own pocket in order to
    preserve his privacy. Beginning in 1981, however, Larson revised his
    method of assuring his privacy: he asked
    Humphreys to prescribe various controlled drugs for Larson in the name of
    certain of Larson's employees
    (secretaries and a law clerk). From the early 1980's to mid-1993,
    Humphreys wrote approximately 34
    prescriptions for drugs in this manner, including prescriptions for
    Valium, Diazepan, Ativan, and Serax. It is
    undisputed that the individuals named on the prescriptions always gave the
    prescription drugs to Larson and did
    not take the medications themselves or resell them. It is also undisputed
    that Humphreys was aware of Larson's
    diagnosed condition, that he believed each medication he prescribed was
    for an appropriate medical purpose, and
    that he prescribed the substances in appropriate medical dosage amounts
    and at acceptable time intervals.
    Moreover, although Humphreys did not examine Larson each time he
    prescribed drugs, Humphreys did examine
    Larson before the first prescription and approximately every six months
    thereafter. Although Humphreys was
    aware that Larson was continuing to see other doctors, Humphreys was not
    aware of any other medications
    prescribed by Larson's other doctors and did not attempt to coordinate his
    prescriptions with those of these other
    doctors. Humphreys received no money for writing these prescriptions.
    After receiving the Order to Show Cause, Humphreys and his
    attorney each filed a response to the
    Order. Humphreys' primary defense was that, by prescribing the medication
    in the names of Larson's close
    associates, he was attempting to protect Larson's privacy in a manner
    common and acceptable in standard medical
    practice for famous patients with mental conditions. Humphreys
    waived his right to a hearing, as he was recovering from a stroke.
    On January 23, 1996, the Deputy Administrator entered his Final
    Order, based on the investigative
    record and Humphreys' written statement. The Deputy Administrator
    acknowledged that he could revoke
    Humphreys' registration only if continued registration would be
    inconsistent with the public interest pursuant to
    the five factors set forth in 
    21 U.S.C. § 823
    (f). The Deputy
    Administrator considered, discussed and relied upon
    each of the five factors except for factor three – Humphreys' conviction
    record under Federal or State laws
    relating to controlled substances, which, because he had none, was not a
    relevant factor – and, based upon these
    factors, determined that the public interest would be best served by
    revoking Humphreys' registration. The
    Deputy Administrator did not discuss, and apparently did not consider,
    Humphreys' privacy defense. Humphreys
    appealed, and this court granted a stay of the Order pending our
    disposition of this appeal. We have jurisdiction
    to hear this appeal under 
    21 U.S.C. § 877
     (1994).
    ANALYSIS
    The Standard of Review
    Agency decisions, such as the Deputy Administrator's Order, may
    be set aside only if arbitrary,
    capricious, an abuse of discretion or otherwise not in accordance with the
    law. 
    5 U.S.C. § 706
    (2)(A) (1994). "As
    a reviewing court, we must accord proper deference to the DEA's expertise
    but must nonetheless make a
    'searching and careful inquiry' of the record to determine whether the
    agency's decision was based on a
    consideration of the relevant factors and whether there was a clear error
    of judgment." Trawick v. DEA, 
    861 F.2d 72
    , 76 (4th Cir. 1988) (affirming revocation of registration)
    (citation omitted).
    The Regulatory Framework
    The Controlled Substances Act, as amended by the Dangerous Drug
    Diversion Control Act of 1984, Pub.
    L. No. 98-473, Title II, § 511, 
    98 Stat. 2073
    , requires that any person
    who dispenses controlled substances must
    first obtain a certificate of registration from the Attorney General. 
    21 U.S.C. §§ 822
    (a), 823(f) (1994). The
    Attorney General has delegated the authority to deny, revoke or suspend
    registrations to the Administrator of the
    DEA. 
    21 U.S.C. § 824
     (1994); 
    28 C.F.R. § 0.100
    (b).
    Prior to 1984, the DEA could revoke a registration for only three
    reasons: (1) falsification of an
    application; (2) felony conviction related to controlled substances; and
    (3) suspension, revocation or denial of a
    state license. In 1984, with the enactment of the Dangerous Drug
    Diversion Control Act, Congress added a
    fourth reason for which a registration could be revoked, namely, a finding
    that the physician had committed "such
    acts as would render his registration under section 823 of this title
    inconsistent with the public interest as
    determined under such section . . . ." 
    21 U.S.C. § 824
    (a) (1994). In
    determining whether registration would be
    inconsistent with the public interest, the DEA must consider the following
    factors:
    (1) The recommendation of the appropriate State licensing
    board or
    disciplinary authority.
    (2) The applicant's experience in dispensing, or
    conducting research
    with respect to controlled substances.
    (3) The applicant's conviction record under Federal or
    State laws
    relating to the manufacture, distribution, or dispensing of
    controlled
    substances.
    (4) Compliance with applicable State, Federal, or local
    laws relating
    to controlled substances.
    (5) Such other conduct which may threaten the public
    health and
    safety.
    
    21 U.S.C. § 823
    (f) (1994). The five factors are independent, and the
    Deputy Administrator may revoke a
    registration based on one factor or a combination of several factors.
    Henry J. Schwartz, M.D., 
    54 Fed. Reg. 16,422
    , 16,424 (1989).
    The DEA bears the burden of proving that registration would not be in
    the public interest. See Shatz v.
    United States Dep't of Justice, 
    873 F.2d 1089
    , 1091 (8th Cir. 1989) ("We
    think the burden of persuasion and
    production on the issue whether registration would be in the public
    interest was correctly placed on the
    Administrator as an initial matter. Once the Administrator produced
    evidence of the state medical board's
    actions, the DEA investigation and the drug-related felony conviction, the
    burden of production only then shifted
    to Shatz to rebut this evidence.").
    Applicability of the Statute to Humphreys and its Application
    Humphreys raises two primary issues on appeal: whether 
    21 U.S.C. § 824
    (a) can apply to the facts of
    this case and, if so, whether the DEA properly applied the five public
    interest factors to his case and properly
    considered his privacy defense.
    Initially, we may easily dispose of Humphreys' contention that 
    21 U.S.C. § 824
    (a) was never meant to
    apply to physicians in his circumstances. Citing Trawick, 
    861 F.2d at 76
    ,
    Humphreys argues that the legislative
    history of the 1984 amendment indicates it was meant to apply only in
    egregious cases and was specifically
    directed to those physicians who prescribed controlled substances to
    addicts, who then could either use the drugs
    themselves or resell them in order to purchase different drugs, such as
    heroin. Humphreys argues that his actions
    did not fall within the category of egregious cases. Certainly, there is
    no allegation here of sales to addicts.
    However, Humphreys, while relying on selected language in the Trawick
    opinion, has ignored not only
    the holding of the Trawick decision, but other language as well. In
    Trawick, a dentist was indicted on state felony
    drug charges, including conspiracy to distribute and distribution of
    cocaine, based on acts not related to his
    patients. 
    861 F.2d at 73-74
    . The dentist pled guilty only to misdemeanor
    possession of cocaine as part of a plea
    bargain. 
    Id. at 74
    . Following his conviction, the DEA revoked his
    registration as being inconsistent with the
    public interest. 
    Id.
     The Court of Appeals noted that the legislative
    history of the public interest standard was much
    as Humphreys now suggests, but concluded that the dentist there could not
    "avoid the plain statutory language of
    the amendment merely by showing that Congress, in enacting it was largely
    concerned with a situation different
    from the instant case." 
    Id. at 76
    . Reasoning that a court must uphold
    any reasonable agency construction of a
    statute it is entrusted to enforce, the court concluded it was reasonable
    to interpret the statute to authorize
    revocation based on a misdemeanor drug conviction. 
    Id. at 75-76
    .
    Likewise, here there is nothing unreasonable
    about the DEA's interpretation of the statute as authorizing revocation
    based on Humphreys' allegedly unlawful
    and irregular prescription of controlled substances in the names of
    individuals other than his patient, Larson. As
    discussed below, however, the DEA's application of the statute to the
    precise situation facing Humphreys is so
    deficient as to be an abuse of discretion.
    The Privacy Defense
    In a combined discussion of factors two and four under 
    21 U.S.C. § 823
    (f), the two factors upon which
    the Deputy Administrator relied most heavily, the Deputy Administrator
    emphasized that Humphreys had engaged
    in a course of conduct during approximately a 12-year period that clearly
    violated federal drug prescribing
    regulations. Specifically, the Deputy Administrator concluded that
    Humphreys' conduct violated 
    21 C.F.R. § 1306.04
    (a), which provides that a prescription for a controlled substance
    "must be issued for a legitimate medical
    purpose by an individual practitioner acting in the usual course of his
    professional practice." The Deputy
    Administrator concluded that these factors weighed in favor of revoking
    Humphreys' registration, as Humphreys'
    long practice of issuing prescriptions in the names of individuals unknown
    to him and not under his care would not
    meet this criterion.
    The central deficiency in the Deputy Administrator's decision is his
    complete failure to discuss the one
    and only defense raised by Humphreys: that prescribing antidepressants
    and other such drugs for a famous patient
    in the name of another individual in order to preserve the privacy of the
    patient was, in fact, the "usual course" of
    medical practice in circumstances such as these and that, therefore,
    Humphreys did not violate the federal
    regulation. Humphreys squarely and intelligibly raised this defense
    before the Deputy Administrator, as before
    us.
    Specifically, Humphreys, too ill to appear in person, wrote in a
    letter responding to the DEA Order to
    Show Cause that "[t]he psychiatrist and the neurologist at the trial for
    Justice Larson testified that they probably
    would have done the same thing and might have even used the same
    medications. They indicated that it is
    common practice, especially in psychiatric patients, to do this."
    Additionally, Humphreys' attorney wrote the
    following:
    Separate and apart from Dr. Humphrey's [sic] opinion is the
    sworn testimony of Gerald
    Sandson, M.D. given in the case of Commonwealth of Pennsylvania
    v. Rolf Larson at
    #9313844, in which this psychiatrist completely concurred with
    the need for privacy in
    the treatment of Justice Larson. . . . Testimony at trial
    showed that psychiatric patients
    suffer a stigma in society, and that public figures bear even
    greater burden.
    During the case of Commonwealth of Pennsylvania vs. [sic]
    Larson, it was established
    without contradiction, that on a daily basis, psychiatrists on
    the staffs of at least
    Allegheny General Hospital and the Western Psychiatric Institute
    prescribed drugs in
    names of people for whom the prescriptions were not intended
    because privacy was an
    essential part of the treatment of the patient. No prosecutions
    were ever brought for
    any of these doctors or hospitals.
    Humphreys' attorney also asserted that the sworn testimony at the Larson
    trial also established that privacy was an
    essential part of Larson's treatment, that privacy was the reason the
    drugs were prescribed in the names of others,
    and that the manner and method of Larson's treatment were not inconsistent
    with generally accepted medical
    standards.
    The Deputy Administrator apparently failed to consider any of this
    evidence, stating instead only that "the
    trial transcript from Justice Larson's trial was not a part of the
    investigative record, and the Respondent did not
    attach a copy of the referenced sections to his Reply." It is true that
    Humphreys failed to include the Larson trial
    transcripts he cited in the DEA record. Humphreys should have submitted
    these transcripts to the DEA for
    inclusion in the record. However, while the record did not contain these
    trial transcripts, the Deputy
    Administrator was clearly aware of the trial and referred specifically to
    Humphreys' testimony at a pre-trial
    hearing in the Larson case.
    Thus, the Deputy Administrator did have before him, and took notice of,
    Humphreys' sworn testimony, observing
    that
    beginning in 1981 and continuing until 1993, [Humphreys] had
    issued prescriptions for
    Schedule IV controlled substances intended for Justice Larson's
    use, but he had issued
    the prescriptions in the name of third-parties. . . .
    [Humphreys] had never met these
    individuals, and they were not his patients. . . . [Humphreys]
    testified that he
    examined Justice Larson about every six months, but not
    necessarily prior to issuing
    each of the prescriptions. Rather, Justice Larson would
    telephone [Humphreys] and tell
    him what substances he wanted and in whose name to issue the
    prescription. . . .
    [Humphreys] was aware of Justice Larson's diagnosed condition .
    . . and that it was
    [his] belief that every medication he prescribed for Justice
    Larson was for a legitimate
    medical purpose. [Humphreys] testified that he had prescribed
    the substances in
    legitimate medical dosage amounts and at appropriate time
    intervals. He states that he
    prescribed these controlled substances in this manner in order
    to preserve his patient's
    privacy . . . .
    Indeed, nearly the entirety of the administrative record consists of items
    from Larson's criminal trial, including
    hearing transcripts and a copy of the complaint, and newspaper reports
    regarding the trial.
    We are troubled by the fact that the Deputy Administrator went
    outside the papers submitted by
    Humphreys for evidence supporting his decision, such as Humphreys' pre-
    trial testimony – evidence that actually
    indicated that Humphreys acted out of concern for Larson's privacy - yet
    failed to obtain the public trial
    transcripts of Dr. Sandson and others from the very same trial, which were
    cited by Humphreys in his support, or
    to otherwise consider Humphreys' privacy defense. Such failure is
    especially egregious where, as here, the record
    is devoid of any evidence, in the form of affidavits, medical treatises or
    anything else, that would support a
    conclusion that doctors do not prescribe drugs in the name of proxies for
    famous patients with mental disorders in
    the "usual course" of their medical practice. Nor have we been able to
    locate any previous published DEA or
    court decision in which such privacy concerns were raised and rejected.
    Indeed, at oral argument the DEA
    representative acknowledged that she was unaware of any other proceeding
    in which such a privacy defense had
    been raised.
    An agency's action is arbitrary and capricious if the agency
    "entirely failed to consider an important
    aspect of the problem, offered an explanation for its decision that runs
    counter to the evidence before the agency,
    or is so implausible that it could not be ascribed to a difference in view
    or the product of agency expertise."
    Natural Resources Defense Council, Inc. v. United States Envtl. Protection
    Agency, 
    790 F.2d 289
    , 297-98 (3rd
    Cir. 1986)(quoting Motor Vehicle Mfrs. Ass'n. v. State Farm Mutual, 
    463 U.S. 29
    , 43 (1983)) (emphasis added),
    cert. denied sub nom. Chicago Ass'n. of Commerce & Indus. v. National
    Resources Defense Council, Inc., 
    479 U.S. 1084
     (1987); see also Shane Meat Co. v. United States Dep't of
    Defense, 
    800 F.2d 334
    , 336 (3d Cir. 1986)
    ("Failure of the agency to address an important aspect of the issue under
    consideration may be fatal to its
    conclusion."). Here, the decision of the Deputy Administrator, lacking any
    analysis of Humphreys' privacy defense, is arbitrary and capricious.
    In short, the Deputy Administrator both failed to evaluate and
    address Humphreys' defense and to resolve
    the conflict created by the arguments and evidence before him. See Kent
    v. Schweiker, 
    710 F.2d 110
    , 114 (3d
    Cir. 1983) (stating, in reference to the substantial evidence test, that
    "[a] single piece of evidence will not satisfy
    the substantiality test if the Secretary ignores, or fails to resolve, a
    conflict created by countervailing evidence.").
    Humphreys and other trial witnesses asserted that such prescribing
    occurred in the "usual course," and there is no
    contrary evidence in the record. Thus, there is a conflict between the
    record evidence and the Deputy
    Administrator's tacit assumption about the "usual course" of medical
    practice. The Deputy Administrator
    nevertheless failed to resolve or even acknowledge this conflict. He
    neither gave any reasons for rejecting
    Humphreys' assertions about the "usual course," nor cited any evidence
    supporting the conclusion that Humphreys
    did not act in the "usual course." That he avoided this conflict is all
    the worse given his failure to review the
    public testimony that Humphreys and his attorney specifically cited,
    summarized and asserted would corroborate
    Humphreys' position.
    It may well be that the testimony referred to by Humphreys and his
    attorney does not, in fact, establish
    that Humphreys was merely engaging in the "usual course" of practice.
    Here, however, the Deputy Administrator
    improperly failed to consider Humphreys' privacy concerns and failed to
    determine whether Humphreys' privacy
    concerns brought his otherwise allegedly improper prescribing conduct
    within the "usual course." Failing to
    analyze the privacy defense was an abuse of discretion. Absent such
    analysis, it was arbitrary and capricious to
    revoke Humphreys' registration in reliance on the second and fourth
    factors of 
    21 U.S.C. § 823
    (f).
    We neither disregard nor minimize the substantial deference to
    which such agency decisions are always
    entitled. See Pennsylvania Funeral Directors Ass'n. v. Federal Trade
    Comm'n., 
    41 F.3d 81
    , 85 (3d Cir. 1994)
    ("The arbitrary and capricious standard is very deferential."). We also
    recognize that we must not simply
    substitute our judgment for that of the agency. Shane Meat Co., 
    800 F.2d at 336
    . However, this is not simply a
    case where we disagree with the Deputy Administrator's application of
    relevant mitigating aspects of the statutory
    factors to settled facts. See 
    Id.
     (reversing district court decision
    finding an administrative decision arbitrary and
    capricious where the agency decision gave consideration to the relevant
    mitigating factors). Rather, here the
    agency improperly failed even to consider the defense put forth by
    Humphreys. The case must be remanded for
    proper consideration of that defense.
    Proceedings on Remand
    In addition to the Deputy Administrator's improper reliance on
    factors two and four in the absence of a
    consideration of Humphreys' privacy defense, the Deputy Administrator's
    remaining discussion of the 
    21 U.S.C. § 823
    (f) factors contains several additional inconsistencies and problems
    which should be addressed and corrected
    on remand.
    First, as to factor one, the "recommendation" of the appropriate
    state licensing board or professional
    disciplinary authority, section 823(f)(1), the Deputy Administrator noted
    that the Pennsylvania Bureau of
    Professional and Occupational Affairs had issued a Show Cause order
    alleging that Humphreys had engaged in a
    12-year pattern of issuing prescriptions to individuals who were not his
    patients that, if proven, would violate state
    law and might justify revoking his medical license. At the time of DEA's
    decision, however, the only evidence in
    the record pertaining to the state investigation indicated merely that the
    Show Cause order had issued and that
    Pennsylvania bore the burden of proving the charges by a preponderance of
    the evidence. We have no indication
    whether Humphreys advanced the same defense there as here or what ruling,
    if any, Pennsylvania made on any
    such defense. On remand, the DEA should determine whether Pennsylvania,
    in fact, met its burden and what
    actions, if any, have actually been taken against Humphreys. If none,
    then the Deputy Administrator should
    consider whether, by merely issuing the Order to Show Cause, Pennsylvania
    authorities have made any
    "recommendation" within the meaning of section 823(f)(1). Only if the
    Deputy Administrator properly concludes
    Pennsylvania has made a "recommendation" of revocation or other punitive
    action may any weight adverse to
    Humphreys be given under factor one. Although in this decision the Deputy
    Administrator only gave limited
    weight to factor one, it is not clear any weight at all is appropriate.
    Second, we note that, as applied by the Deputy Administrator, any
    weight under factor two, which
    concerns "experience with dispensing . . . controlled substances," is
    entirely dependent on the violation of a
    federal regulation found by the Deputy Administrator under factor four.
    That is, if Humphreys violated the
    federal regulation, that he did so for over 12 years is an aggravating
    factor. However, if his conduct was indeed
    in the "usual course," its duration is irrelevant.
    Third, the DEA found that Humphreys' "prescribing of controlled
    substances to Justice Larson merely
    upon his request, without seeing him, examining him, or otherwise making a
    medical evaluation prior to issuing
    the prescription, demonstrated behavior such that the patient's demands
    seemed to replace the physician's
    judgment. . . . Such uncontroverted actions on the part of the Respondent
    are preponderating evidence that he
    has dispensed controlled substances in violation of federal law." We have
    reviewed the administrative record and
    see nothing in the current record that would support this particular
    finding. While there is some evidence
    indicating Larson would call Humphreys and request prescriptions for
    certain drugs or request a change in his
    prescription, there is absolutely no testimony indicating Humphreys failed
    to exercise his own medical judgment
    when prescribing medication for Larson. We do not mean to say that the DEA
    might not be able to prove this fact
    at a later date upon an expanded record – only that it has not done so on
    this record. Indeed, if anything, the
    current record indicates Humphreys, in fact, was exercising independent
    medical judgment. Specifically,
    Humphreys stated that he would have adjusted the drugs accordingly had he
    become aware that other drugs were
    being prescribed to Larson by other doctors. Humphreys also testified
    that it was his belief that every medication he prescribed for Larson was
    medically appropriate. In addition, the
    testimony of Larson himself indicates Humphreys exercised his own
    judgment. Specifically, Larson testified
    Humphreys performed a full physical evaluation before prescribing drugs
    for the first time, that the drugs were
    later changed due to side effects, and that Humphreys was the "ultimate
    decider" of what particular drugs to
    prescribe. Thus, it remains unclear how factor four can weigh against
    Humphreys in this regard.
    Fourth, the Deputy Administrator found, under factor five, that
    the public was at risk from the potential
    diversion of controlled substances by both Larson, who could have received
    duplicative prescriptions for
    controlled substances, and the employees named on the prescriptions, who
    were prescribed medication they did
    not intend to ingest and for which they themselves lacked a medical need.
    The Deputy Administrator's inferences
    of a threat of public harm are overly broad and only weakly, if at all,
    supported by the present record. Indeed, the
    Deputy Administrator admitted that no such diversion in fact occurred.
    The conclusion that substantial risk for
    diversion existed because Larson or the secretaries and the law clerk
    might resell the drugs, under these
    circumstances, is so unlikely as to be unsustainable. The secretaries and
    law clerk in whose names the
    prescriptions were written were, after all, trusted employees and
    responsible adults. They obtained the drugs at
    Larson's specific requests and under his instruction. Moreover, Larson
    was aware of what drugs he should
    receive from each of these individuals and when he should receive them,
    having contacted Humphreys each time
    to tell Humphreys which name to use for a particular prescription. Any
    deviation would have been quickly
    noticed and, presumably, dealt with appropriately. That such trusted
    employees were at risk because they might
    take the drugs themselves or endangered others because they might attempt
    to resell them, rather than turn them
    over to Larson, is "implausible". See Natural Resources Defense Council,
    
    790 F.2d at 297-98
    .
    It is true, as the Deputy Administrator noted, that the
    pharmacist filling a prescription could not have
    checked any available computer data bank for conflicting prescriptions for
    Larson, since the prescriptions for
    Larson were not in his name. However, the DEA did not establish that the
    pharmacy or pharmacies patronized by
    Larson had such a system in place during the relevant time period.
    Moreover, if Larson frequented more than
    one pharmacy, the DEA has not shown that problems would have been detected
    even if all of Larson's
    prescriptions had been written in his own name.
    Our discussion of the need on remand to correct the deficiencies
    in the decision under review should not
    be construed in any way as suggesting that Humphreys either is or is not
    entitled to retain his DEA registration.
    We intimate no view on that issue. Rather, we hold only that the Deputy
    Administrator failed to properly
    analyze the evidence and decide the issues and must do so on remand.
    Conclusion
    Because the DEA utterly failed to consider Humphreys' defense and
    improperly analyzed some of the
    evidence, its analysis was so inadequate and prejudicial to Humphreys as
    to constitute an abuse of discretion and
    render the revocation order an arbitrary and capricious agency action.
    Therefore, we vacate and remand.