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Criminal intent key to conviction of pill-mill doctors, high court rules

The ruling puts extra burdens on the government to prove doctors knowingly provided addictive painkillers against medical advice.

WASHINGTON (CN) — The government will now have to prove criminal intent when convicting medical doctors facing charges for prescribing addictive painkillers, the Supreme Court said in a unanimous decision on Monday. 

The case before the court concerns three doctors fighting convictions sentencing them to decades in prison for their prescription of painkillers.

Between 2011 and 2015, Xiulu Ruan and John Patrick Couch ranked as the top prescribers of a certain kind of fentanyl, writing almost 300,000 prescriptions for the schedule II drug and other controlled substances like oxycodone and morphine from their clinic in Mobile, Alabama. The two doctors mostly wrote these prescriptions for common ailments and sometimes did so without seeing the patients.

Shakeel Kahn had a patient overdose two days after he wrote high-dose prescriptions for oxycodone, carisoprodol, and alprazolam in exchange for $1,250. 

Doctors can distribute controlled substances if they're “acting in the usual course of his professional practice,” under the Controlled Substances Act. Consolidated before the high court, the cases asked what it means for doctors to be acting in good faith and how it should affect pill mill doctors' prosecutions. 

The justices heard oral arguments in the case in March considering the court’s own precedents and how the wording of the statutory text could help delineate the line between prescribing medicine and dealing drugs. 

Each of the doctors was convicted for prescribing controlled substances not as authorized. The high court ruled Monday the government must prove doctors knew they were providing a substance in an unauthorized manner.  

“The question before us concerns the state of mind that the Government must prove to convict these doctors of violating the statute,” Justice Stephen Breyer wrote for the majority. “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.” 

Breyer wrote that in these prosecutions, a lack of authorization is what separates guilty and nonguilty convictions. 

“In other words, authorization plays a ‘crucial’ role in separating innocent conduct — and, in the case of doctors, socially beneficial conduct — from wrongful conduct,” Breyer wrote. “Applying §841’s ‘knowingly or intentionally’ mens rea to the authorization clause thus ‘helps advance the purpose of scienter, for it helps to separate wrongful from innocent acts.’”

The court rejected the government’s arguments and said their standard would use the mental state of “reasonable” doctors, not the mental state of the doctor facing criminal liability. 

“The Government’s standard would turn a defendant’s criminal liability on the mental state of a hypothetical ‘reasonable’ doctor, not on the mental state of the defendant himself or herself,” Breyer wrote. 

Justice Samuel Alito — joined in full by Justice Thomas and in part by Justice Barrett — agreed with the court’s judgment but thought the opinion created a confusing precedent to follow. 

“In criminal law, the distinction between the elements of an offense and an affirmative defense is well-known and important,” Alito wrote. “In these cases, however, the Court recognizes a new hybrid that has some characteristics of an element and some characteristics of an affirmative defense. The consequences of this innovation are hard to foresee, but the result may well be confusion and disruption. That risk is entirely unnecessary.” 

The Department of Justice and Lawrence Robbins, an attorney for Ruan with the firm Robbins Russell, did not respond to requests for comment. 

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