# Dawn Evert, N.P.; Decision and Order
On February 25, 2025, the Drug Enforcement Administration (DEA or Government) issued an Order to Show Cause and Immediate Suspension of Registration (OSC/ISO) to Dawn Evert, N.P., of Pueblo, Colorado (Registrant). Request for Final Agency Action (RFAA), Exhibit (RFAAX) 1, at 1. The OSC/ISO informed Registrant of the immediate suspension of her DEA Certificate of Registration, No. ME1730870, pursuant to 21 U.S.C. 824(d), alleging that Registrant's continued registration is “an imminent danger to the public health or safety.” *Id.* (quoting 21 U.S.C. 824(d)). The OSC/ISO also proposed the revocation of Registrant's registration, alleging that her registration is inconsistent with the public interest. *Id.* (citing 21 U.S.C. 823(g)(1)(B) and (D), 824(a)(4)).
More specifically, the OSC/ISO alleged that Registrant unlawfully prescribed controlled substances to four patients, which included prescribing dangerous combinations of controlled substances, failing to establish a medical justification for the prescribing of controlled substances, and failing to sufficiently monitor patients receiving controlled substance prescriptions. *Id.* at 1-2. The OSC/ISO alleged that the issuance of these prescriptions violated both state and federal law. *Id.* at 3. (citing 21 U.S.C. 823(g)(1)(D)). [^1]
[^1] According to the OSC/ISO and Agency records, Registrant's registration expired on August 31, 2025. RFAAX 1, at 3. The fact that a registrant allows her registration to expire during the pendency of an administrative enforcement proceeding does not impact the Agency's jurisdiction or prerogative under the Controlled Substances Act to adjudicate the OSC/ISO to finality. *Jeffrey D. Olsen, M.D.,* 84 FR 68474, 68476-79 (2019).
On April 29, 2025, the Government submitted an RFAA requesting that the Agency issue a default final order revoking Registrant's registration. RFAA, at 3. [^2] After carefully reviewing the entire record and conducting the analysis as set forth in more detail below, the Agency grants the Government's request for final agency action and revokes Registrant's registration.
[^2] The RFAA states that “the Administrator is authorized to render the Agency's final order, without . . . making any finding of fact in this matter.” RFAA, at 3 (citing 21 CFR 1301.43(c), (f), and 1301.46). However, 21 CFR 1316.67 requires that the Administrator's final order “set forth the final rule and findings of fact and conclusions of law upon which the rule is based.” *See JYA LLC d/b/a Webb's Square Pharmacy,* 90 FR 31244, 31246 n.7 (2025).
**I. Default Determination**
Under 21 CFR 1301.43, a registrant entitled to a hearing who fails to file a timely hearing request “within 30 days after the date of receipt of the [OSC] . . . shall be deemed to have waived their right to a hearing and to be in default” unless “good cause” is established for the failure. 21 CFR 1301.43(a) & (c)(1). In the absence of a demonstration of good cause, a registrant who fails to timely file an answer also is “deemed to have waived their right to a hearing and to be in default.” 21 CFR 1301.43(c)(2). Unless excused, a default is deemed to constitute “an admission of the factual allegations of the [OSC].” 21 CFR 1301.43(e).
Here, the OSC/ISO notified Registrant of her right to file a written request for hearing, and that if she failed to file such a request, she would be deemed to have waived her right to a hearing and be in default. RFAAX 1, at 10 (citing 21 CFR 1301.43). Here, Registrant did not request a hearing. RFAA, at 1-2. [^3] Thus, the Agency finds that Registrant is in default and therefore is deemed to have admitted to the factual allegations in the OSC/ISO. 21 CFR 1301.43(e).
[^3] Based on the Government's submissions in its RFAA, the Agency finds that service of the OSC/ISO on Registrant was adequate. Specifically, the Government attached evidence that Registrant was personally served with the OSC/ISO on February 26, 2025, and signed a Form DEA-12 confirming receipt of the OSC/ISO. RFAAX 2, at 1.
**II. Applicable Law**
As the Supreme Court stated in *Gonzales* v. *Raich,* 545 U.S. 1 (2005), “the main objectives of the [Controlled Substances Act (CSA)] were to conquer drug abuse and control the legitimate and illegitimate traffic in controlled substances.” 545 U.S. at 12. *Gonzales* explained that:
Congress was particularly concerned with the need to prevent the diversion of drugs from legitimate to illicit channels. To effectuate these goals, Congress devised a closed regulatory system making it unlawful to manufacture, distribute, dispense, or possess any controlled substance except in a manner authorized by the CSA. . . . The CSA and its implementing regulations set forth strict requirements regarding registration, labeling and packaging, production quotas, drug security, and recordkeeping.
*Id.* at 12-14.
According to the CSA's implementing regulations, prescriptions may only be issued by an individual practitioner who is “[a]uthorized to prescribe controlled substances by the jurisdiction in which he is licensed to practice his profession” and has either been issued a DEA registration or is exempted from registration under DEA regulations. 21 CFR 1306.03. Furthermore, a lawful controlled substance order or prescription is one that is “issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.” 21 CFR 1306.04(a). A “practitioner must establish and maintain a *bona fide* doctor-patient relationship in order to act `in the usual course of . . . professional practice' and to issue a prescription for a `legitimate medical purpose.' ” *Dewey C. MacKay, M.D.,* 75 FR 49956, 49973 (2010).
Colorado state law similarly requires that prescriptions for controlled substances only be issued in the course of legitimate professional practice. Colo. Rev. Stat. 12-255-120(1)(s); RFAAX 1, at 3. Colorado law also forbids “[A]ny action by any person who . . . [h]as acted in a manner inconsistent with the health or safety of persons under his or her care.” *Id.* 12-255-120(1)(c); RFAAX 1, at 2. In addition, Colorado law requires a practitioner or the practitioner's designee in ordinary circumstances to query the database the Colorado State Board of Pharmacy maintains of prescription drugs (Prescription Drug Monitoring Program or “Colorado PDMP”) before prescribing an opioid or benzodiazepine to a patient. *Id.* 12-280-404(4)(a), (a.5) (requirement to query the Colorado PDMP before prescribing an opioid or benzodiazepine); RFAAX 1, at 3.
**III. Findings of Fact**
In light of Registrant's default, the factual allegations in the OSC/ISO are deemed admitted. [^4] 21 CFR 1301.43(e). Accordingly, Registrant admits to each of the following facts. Specifically, Registrant admits that between January 2023 and November 2024, she issued numerous prescriptions for Schedule II and IV controlled substances to four patients, including a law enforcement officer operating in an undercover capacity (UC). RFAAX 1, at 3. Registrant admits that these prescriptions were not for a legitimate medical purpose, nor were they issued in the usual course of professional practice. *Id.*
[^4] According to the Controlled Substances Act (CSA), “[f]indings of fact by the [DEA Administrator], if supported by substantial evidence, shall be conclusive.” 21 U.S.C. 877. Here, where Applicant is found to be in default, all the factual allegations in the OSC are deemed to be admitted. These uncontested and deemed admitted facts constitute evidence that exceeds the “substantial evidence” standard of 21 U.S.C. 877; it is unrebutted evidence.
**1. Prescribing to UC**
On September 18, 2023, UC visited Registrant's office and the visit was audio recorded. RFAAX 1, at 4. Registrant admits that she did not perform a sufficient initial evaluation and examination, including the taking of a comprehensive history of UC's past substance use history. *Id.* Registrant also admits that she failed to appropriately address the red flags of abuse and diversion exhibited by UC during the September 18, 2023 appointment. *Id.* For example, UC stated to Registrant that they had previously obtained “some blues” [^5] from an acquaintance. *Id.*
[^5] “Blues” is a street term for pills containing oxycodone (a Schedule II opioid). RFAAX 1, at 4.
On October 5, 2023, UC visited Registrant's office again and Registrant prescribed UC oxycodone 10 mg (21 tablets). *Id.* Registrant admits that she prescribed UC this controlled substance without maintaining sufficient clinical documentation, without conducting an appropriate medical examination and evaluation, without establishing a legitimate diagnosis, and without performing necessary and consistent monitoring. *Id.* Registrant failed to establish a proper medical justification for the treatment of UC with oxycodone and failed to assess UC's risk factors for adverse outcomes. *Id.* Registrant admits that she failed to appropriately address the red flags of abuse and diversion exhibited by UC during this visit. *Id.* at 5. Specifically, UC stated to Registrant that they had obtained “blues” from a friend. *Id.* Registrant admits that she falsified UC's patient record associated with this visit by documenting performance of a test that she, in fact, did not conduct. *Id.* Registrant further admits that she did not review the Colorado PDMP prior to issuing UC the prescription for oxycodone. *Id.*
On October 18, 2023, UC called Registrant's office and spoke with an unidentified individual who answered the line. *Id.* at 5. UC asked the unidentified individual who answered the telephone to ask “Evert” for another prescription of oxycodone. *Id.* On the same day, Registrant issued a second prescription to UC for oxycodone 10 mg (21 tablets). *Id.* Registrant admits that she prescribed UC this controlled substance without maintaining sufficient clinical documentation, without conducting an appropriate medical examination and evaluation, without establishing a legitimate diagnosis, and without performing necessary and consistent monitoring. *Id.* Registrant failed to establish a proper medical justification for the treatment of UC with oxycodone and failed to assess UC's risk factors for adverse outcomes. *Id.* Registrant admits that she did not review the Colorado PDMP prior to issuing UC the prescription for oxycodone. *Id.*
On November 6, 2023, UC called Registrant's office and spoke with an unidentified individual who answered the phone. *Id.* UC asked the person who answered the phone for a refill of their prescription from “Evert” for oxycodone. *Id.* On that same day, Registrant issued a third prescription to UC for oxycodone 10 mg (28 tablets). *Id.* Registrant admits that she prescribed UC this controlled substance without maintaining sufficient clinical documentation, without conducting an appropriate medical examination and evaluation, without establishing a legitimate diagnosis, and without performing necessary and consistent monitoring. *Id.* at 6. Registrant failed to establish a proper medical justification for the treatment of UC with oxycodone and failed to assess UC's risk factors for adverse outcomes. *Id.* Registrant admits that she did not review the Colorado PDMP prior to issuing UC the prescription for oxycodone. *Id.*
**2. Prescribing to J.S.**
Registrant admits that between January 2023 and November 2024, Registrant issued numerous prescriptions for controlled substances to individual J.S., including hydrocodone 5 mg and hydrocodone 10 mg (a Schedule II opioid), as well as diazepam 5 mg and diazepam 10 mg (a Schedule IV benzodiazepine). *Id.* Registrant also admits that she prescribed these controlled substances without sufficient clinical documentation, without conducting an appropriate medical examination and evaluation, without establishing a legitimate diagnosis, and without performing necessary and consistent monitoring. *Id.* Registrant further admits that she failed to monitor and review Colorado PDMP information when prescribing these opioids and benzodiazepines between January 1, 2023, and November 30, 2024. *Id.* at 7. Registrant admits and the Agency finds unrebutted evidence that these controlled substance prescriptions were not issued for a legitimate medical purpose, nor in the usual course of professional practice. *Id.*
**3. Prescribing to R.N.**
Registrant admits that between January 2023 and September 2024, Registrant issued numerous prescriptions for controlled substances to individual R.N., including the following Schedule II opioids: oxycodone 20 mg, oxycodone 30 mg, morphine sulfate 60 mg (a Schedule II opioid), and morphine sulfate 100 mg. *Id.* Registrant also prescribed diazepam 5 mg and diazepam 10 mg. *Id.* Registrant admits that she prescribed these controlled substances without sufficient clinical documentation, without conducting an appropriate medical examination and evaluation, without establishing a legitimate diagnosis, and without performing necessary and consistent monitoring. *Id.* Registrant further admits that she failed to review Colorado PDMP information when prescribing these opioids and benzodiazepines between January 1, 2023, and November 30, 2024. *Id.* at 8. Registrant admits and the Agency finds unrebutted evidence that these controlled substance prescriptions described above were not issued for a legitimate medical purpose, nor in the usual course of professional practice. *Id.*
**4. Prescribing to M.J.**
Registrant admits that between February 2023 and September 2024, Registrant issued prescriptions for controlled substances to individual M.J. on approximately a monthly basis. *Id.* These prescriptions included one and, at times, two of the following opioids per month: oxycodone 5 mg, oxycodone 10 mg, oxycodone 30 mg, morphine sulfate 15 mg, and morphine sulfate 30 mg. *Id.* Registrant also prescribed approximately monthly prescriptions for diazepam 10 mg. *Id.* Registrant admits that she prescribed these controlled substances without sufficient clinical documentation, without conducting an appropriate medical examination and evaluation, without establishing a legitimate diagnosis, and without performing necessary and consistent monitoring. *Id.* Registrant further admits that she failed to review Colorado PDMP information when prescribing these opioids and benzodiazepines. *Id.* at 9. Registrant admits and the Agency finds unrebutted evidence that these controlled substance prescriptions described above were not issued for a legitimate medical purpose, nor in the usual course of professional practice. *Id.*
**5. Expert Review**
DEA retained an independent medical expert to review materials, including Registrant's medical records for UC and individuals J.S., R.N., and M.J. *Id.* at 9. Based on Registrant's deviations from the standard of care, the medical expert concluded, and the Agency finds, that the prescriptions for controlled substances Registrant issued violated minimal medical standards applicable to the practice of medicine in Colorado. *Id.*
Accordingly, the Agency finds unrebutted record evidence that Registrant prescribed controlled substances, including dangerous combinations of controlled substances, to UC and three other individuals, without conducting an appropriate medical examination, establishing a medical justification for the prescribing of controlled substances, and querying the PDMP to monitor patients receiving controlled substance prescriptions. *Id.* at 1-2.
**IV. Public Interest Determination**
**A. Legal Background on Public Interest Determinations**
When the CSA's requirements are not met, the Attorney General “may deny, suspend, or revoke [a] registration if . . . the [registrant's] registration would be `inconsistent with the public interest.' ” *Gonzales* v. *Oregon,* 546 U.S. 243, 251 (2006) (quoting 21 U.S.C. 824(a)(4)). In the case of a “practitioner,” Congress directed the Attorney General to consider five factors in making the public interest determination. *Id.;* 21 U.S.C. 823(g)(1)(A-E). [^6]
[^6] The five factors are:
(A) The recommendation of the appropriate State licensing board or professional disciplinary authority.
(B) The [registrant's] experience in dispensing or conducting research with respect to controlled substances.
(C) The [registrant's] conviction record under Federal or State laws relating to the manufacture, distribution, or dispensing of controlled substances.
(D) Compliance with applicable State, Federal, or local laws relating to controlled substances.
(E) Such other conduct which may threaten the public health and safety.
The five factors are considered in the disjunctive. *Gonzales* v. *Oregon,* 546 U.S. at 292-93 (Scalia, J., dissenting) (“It is well established that these factors are to be considered in the disjunctive” (quoting *In re Arora,* 60 FR 4447, 4448 (1995))); *Robert A. Leslie, M.D.,* 68 FR 15227, 15230 (2003). Each factor is weighed on a case-by-case basis. *David H. Gillis, M.D.,* 58 FR 37507, 37508 (1993). Any one factor, or combination of factors, may be decisive, *David H. Gillis, M.D.,* 58 FR at 37508, and the Agency “may give each factor the weight . . . deem[ed] appropriate in determining whether a registration should be revoked or an application for registration denied.” *Morall,* 412 F.3d. at 185 n.2 (Henderson, J., concurring) (quoting *Robert A. Smith, M.D.,* 70 FR 33207, 33208 (2007)); *see also Penick Corp.* v. *Drug Enf't Admin.,* 491 F.3d 483, 490 (D.C. Cir. 2007).
Moreover, while the Agency is required to consider each of the factors, it “need not make explicit findings as to each one.” *MacKay* v. *Drug Enf't Admin.,* 664 F.3d 808, 816 (10th Cir. 2011) (quoting *Volkman* v. *U.S. Drug Enf't Admin.,* 567 F.3d 215, 222 (6th Cir. 2009)); *Jones Total Health Care Pharmacy, LLC* v. *Drug Enf't Admin.,* 881 F.3d 823, 830 (11th Cir. 2018); *Hoxie* v. *Drug Enf't Admin.,* 419 F.3d 477, 482 (6th Cir. 2005). “In short, . . . the Agency is not required to mechanically count up the factors and determine how many favor the Government and how many favor the registrant. Rather, it is an inquiry which focuses on protecting the public interest; what matters is the seriousness of the registrant's misconduct.” *Jayam Krishna-Iyer, M.D.,* 74 FR 459, 462 (2009). Accordingly, as the Tenth Circuit has recognized, Agency decisions have explained that findings under a single factor can support the revocation of a registration. *MacKay,* 664 F.3d at 821.
The Government has the burden of proof in this proceeding. 21 CFR 1301.44(e) (revoking or suspending a registration).
**B. Registrant's Registration Is Inconsistent With the Public Interest**
While the Agency has considered all the public interest factors of 21 U.S.C. 823(g)(1), [^7] the Government's evidence in support of its *prima facie* case is confined to Factors B and D. RFAAX 1, at 3. Evidence is considered under Factors B and D when it reflects compliance or non-compliance with laws related to controlled substances and experience dispensing controlled substances. *Kareem Hubbard, M.D.,* 87 FR 21156, 21162 (2022).
[^7] As to Factor A, there is no record evidence of disciplinary action against Registrant's state medical license. 21 U.S.C. 823(g)(1)(A). State authority to practice medicine is “a necessary, but not a sufficient condition for registration.” *Robert A. Leslie, M.D.,* 68 FR at 15230. Therefore, “[t]he fact that the record contains no evidence of a recommendation by a state licensing board does not weigh for or against a determination as to whether continuation of the Respondent's DEA certification is consistent with the public interest.” *Roni Dreszer, M.D.,* 76 FR 19434, 19444 (2011). As to Factor C, there is no evidence in the record that Registrant has been convicted of any federal or state law offense “relating to the manufacture, distribution, or dispensing of controlled substances.” 21 U.S.C. 823(g)(1)(C). However, as Agency cases have noted, “the absence of such a conviction is of considerably less consequence in the public interest inquiry” and is therefore not dispositive. *Dewey C. MacKay, M.D.,* 75 FR at 49973. As to Factor E, the Government's evidence fits squarely within the parameters of Factors B and D and does not raise “other conduct which may threaten the public health and safety.” 21 U.S.C. 823(g)(1)(E). Accordingly, Factor E does not weigh for or against Registrant.
Here, Registrant's noncompliance with state and federal law reflects his experience prescribing with respect to controlled substances. *See supra* Section III. Moreover, the Agency finds unrebutted record evidence that between January 2023 and November 2024 Registrant unlawfully prescribed controlled substances, including dangerous combinations of controlled substances, to UC and three other individuals, without conducting an appropriate medical examination, establishing a medical justification for the prescribing of controlled substances, and querying the PDMP to monitor patients receiving controlled substance prescriptions. Further, an independent medical expert reviewed Registrant's medical records and controlled substance prescriptions and found that Registrant's prescribing violated minimal medical standards in Colorado. Accordingly, the unrebutted record evidence supports the Agency's finding that between January 2023 and November 2024 Registrant committed violations of both Colorado state law and federal controlled substance regulations, namely 21 CFR 1306.04(a), Colo. Rev. Stat. 12-280-404(4)(a) & (a.5), and Colo. Rev. Stat. 12-255-120(1)(c) & (s).
The Agency further finds that after considering the factors of 21 U.S.C. 823(g)(1), Registrant's registration is “inconsistent with the public interest.” 21 U.S.C. 824(a)(4). Accordingly, the Government satisfied its *prima facie* burden of showing that Registrant's continued registration would be “inconsistent with the public interest.” 21 U.S.C. 824(a)(4). The Agency also finds that there is no mitigating evidence to rebut the Government's *prima facie* case. Thus, the only remaining issue is whether, in spite of the public interest determination, Registrant can be trusted with a registration.
**V. Sanction**
Where, as here, the Government has met the burden of showing that Registrant's continued registration is inconsistent with the public interest, the burden shifts to Registrant to show why she can be entrusted with a registration. *Morall,* 412 F.3d. at 174; *Jones Total Health Care Pharmacy, LLC* v. *Drug Enf't Admin.,* 881 F.3d 823, 830 (11th Cir. 2018); *Garrett Howard Smith, M.D.,* 83 FR 18882, 18904 (2018). The issue of trust is necessarily a fact-dependent determination based on the circumstances presented by the individual respondent. *Jeffrey Stein, M.D.,* 84 FR 46968, 46972 (2019); *see also Jones Total Health Care Pharmacy,* 881 F.3d at 833. Moreover, as past performance is the best predictor of future performance, the Agency requires that a registrant who has committed acts inconsistent with the public interest accept responsibility for those acts and demonstrate that she will not engage in future misconduct. *See Jones Total Health Care Pharmacy,* 881 F.3d at 833; *ALRA Labs, Inc.* v. *Drug Enf't Admin.,* 54 F.3d 450, 452 (7th Cir. 1995). The Agency requires a registrant's unequivocal acceptance of responsibility. *Janet S. Pettyjohn, D.O.,* 89 FR 82639, 82641 (2024); *Mohammed Asgar, M.D.,* 83 FR 29569, 29573 (2018); *see also Jones Total Health Care Pharmacy,* 881 F.3d at 830-31. In addition, a registrant's candor during the investigation and hearing is an important factor in determining acceptance of responsibility and the appropriate sanction. *See Jones Total Health Care Pharmacy,* 881 F.3d at 830-31; *Hoxie,* 419 F.3d at 483-84. Further, the Agency considers the egregiousness and extent of the misconduct as significant factors in determining the appropriate sanction. *See Jones Total Health Care Pharmacy,* 881 F.3d at 834 & n.4. The Agency also considers the need to deter similar acts by a registrant and by the community of registrants. *Jeffrey Stein, M.D.,* 84 FR at 46972-73.
Here, Registrant failed to answer the allegations contained in the OSC\ISO and did not otherwise avail herself of the opportunity to refute the Government's case. Thus, there is no record evidence that Registrant takes responsibility, let alone unequivocal responsibility, for the misconduct. Accordingly, she has not convinced the Agency that her future controlled-substance-related actions will comply with the CSA such that she can be entrusted with the responsibilities of a registration.
Further, the interests of specific and general deterrence weigh in favor of revocation. Registrant's conduct in this matter concerns the CSA's strict requirements regarding registration and recordkeeping and, therefore, goes to the heart of the CSA's “closed regulatory system” specifically designed “to conquer drug abuse and to control the legitimate and illegitimate traffic in controlled substances.” *Gonzales* v. *Raich,* 545 U.S. at 12-14. Permitting Registrant to maintain a registration under these circumstances would send a dangerous message that compliance with the law is not essential to maintaining a registration.
In sum, Registrant has not offered any credible evidence on the record that rebuts the Government's case for revocation of her registration, and Registrant has not demonstrated that she can be entrusted with the responsibility of registration. Accordingly, the Agency will order the revocation of Registrant's registration.
**Order**
Pursuant to 28 CFR 0.100(b) and the authority vested in me by 21 U.S.C. 824(a) and 21 U.S.C. 823(g)(1), I hereby revoke DEA Certificate of Registration No. ME1730870 issued to Dawn Evert, N.P. Further, pursuant to 28 CFR 0.100(b) and the authority vested in me by 21 U.S.C. 823(g)(1), I hereby deny any pending applications of Dawn Evert, N.P., to renew or modify this registration, as well as any other pending application of Dawn Evert, N.P., for registration in Colorado. This Order is effective December 1, 2025.
**Signing Authority**
This document of the Drug Enforcement Administration was signed on October 9, 2025, by Administrator Terrance Cole. That document with the original signature and date is maintained by DEA. For administrative purposes only, and in compliance with requirements of the Office of the Federal Register, the undersigned DEA Federal Register Liaison Officer has been authorized to sign and submit the document in electronic format for publication, as an official document of DEA. This administrative process in no way alters the legal effect of this document upon publication in the *Federal Register* .
Heather Achbach,
Federal Register Liaison Officer, Drug Enforcement Administration.