Justices Side With Two Doctors Snared in Opioid ‘Pill Mill’ Case 

WASHINGTON — In a unanimous ruling the Supreme Court said on Monday that prosecutors must prove doctors knowingly misprescribed drugs to secure convictions against them for the unlawful distribution of controlled medicines, like opioids.

The decision came down in a case brought by two doctors, Xiulu Ruan and Shakeel Kahn, who were sentenced to decades in prison for unlawfully prescribing opioids to patients at their medical clinics in Alabama and Arizona.

Both men were convicted under the Controlled Substances Act, which makes it a crime for any person to “knowingly or intentionally” dispense a controlled substance.

Under the law, there is an exception for a licensed health care professional who is allowed to dispense some of the drugs with a prescription, but the prescription must be issued for a legitimate medical purpose.

Between January 2011 and May 2015, Ruan’s clinic, Physicians Pain Specialists, issued nearly 300,000 controlled substance prescriptions netting the practice more than $3 million. 

According to federal prosecutors, more than half of the drugs prescribed were so-called Schedule II drugs — among the most dangerous drugs on the market. 

They include opioids such as fentanyl, hydrocodone, morphine and oxycodone, all of which can be used to treat pain, but are also known to be highly addictive. 

The clinic was raided by the FBI and Ruan was charged with running a “pill mill” that prescribed controlled substances for no legitimate medical purpose. 

Kahn’s arrest came after a three-year investigation by the Board of Pharmacy, where he ran another clinic, after questions were raised about the large amount of painkillers he was prescribing.

State and federal law enforcement eventually took over the investigation, and Kahn and his brother Nabeel were charged with distributing millions of opioids and laundering the proceeds.

Ruan and Kahn’s cases were consolidated for the Supreme Court. 

Ruan was sentenced to 21 years in prison in 2017 after being found guilty of running what the Justice Department called a pill mill, while Shakeel Kahn of Wyoming was sentenced to 25 years in prison in 2019 for crimes including drug distribution resulting in death. 

“Dr. Kahn testified that he would not have issued prescriptions to individuals that he knew to be selling their medication,” his lawyer told the justices during oral arguments on March 1. 

A lawyer for Ruan, meanwhile, argued that the doctors can’t be convicted under the law without regard to whether they “reasonably believed” the prescriptions fell within the usual course of professional practice.

But the U.S. Supreme Court was having none of this argument.

Deputy Solicitor General Eric Feigin told the justices that lawyers for the doctors were “really asking this court to transform their [federal] registrations, which are premised on the idea that they’re actually practicing medicine, into licenses to, at their own subjective views, violate the general rule that drug pushing is illegal.”

“They want to be free of any obligation even to undertake any minimal effort to act like doctors when they prescribe dangerous, highly addictive and, in one case, lethal doses of drugs to trusting and vulnerable patients,” Feigin said.

In essence, the justices were asked to decide what threshold doctors had to cross in handing out prescriptions to go from providing care to drug trafficking.

Ultimately, the justices concluded intent matters for the doling out of prescriptions to be considered criminal.

The court found that in these cases, intent matters for prescribing to be considered criminal. 

“In each of these two consolidated cases, a doctor was convicted under §841 for dispensing controlled substances not ‘as authorized,’” said Justice Stephen Breyer, writing for the court. “The question before us concerns the state of mind that the government must prove to convict these doctors of violating the statute. 

“We hold that the statute’s ‘knowingly or intentionally’ mens rea applies to authorization. After a defendant produces evidence that he or she was authorized to dispense controlled substances, the government must prove beyond a reasonable doubt that the defendant knew that he or she was acting in an unauthorized manner, or intended to do so,” he said.

Despite coming to that conclusion, the justices did not throw out the convictions of the two physicians.

Instead, it told appeals courts to review the jury instructions from the original criminal cases to see if they comported with the new ruling and to determine whether any instructional error that was made was harmless.

Dan can be reached at [email protected] and @DanMcCue