Prosecutors Must Prove Ill Intent in ‘Pill Mill’ Cases

In a unanimous decision, the US Supreme Court set aside the convictions of two physicians accused of violating the Controlled Substances Act (1970) and running “pill mills.”

The cases were sent back to their respective jurisdictions to be reheard in order to consider whether the juries were properly instructed. If they were not, said the court, it needs to be considered whether those improper directions affected the outcome.

At issue in the case, wrote Justice Stephen Breyer in the court’s opinion, was a legal doctrine known as mens rea, or criminal intent. The two cases were consolidated into one case, Xiulu Ruan v. United States. The defendants in the case were Xiulu Ruan, MD, a Mobile, Alabama–based pain medicine specialist, and Shakeel Kahn, MD, a pain medicine specialist who practiced in Fort Mohave, Arizona, and Casper, Wyoming.

Three Supreme Court justices disagreed with using the mens rea legal doctrine but ultimately agreed with the court’s opinion.

Agreeing with the decision but not the legal doctrine it used, Justice Samuel Alito wrote that to practice medicine, a practitioner must “act for a medical purpose ― which means aiming to prevent, cure, or alleviate the symptoms of a disease or injury ― and must believe that the treatment is a medically legitimate means of treating the relevant disease or injury.”

Still, Alito wrote, “A doctor who makes negligent or even reckless mistakes in prescribing drugs is still ‘acting as a doctor’ — he is simply acting as a bad doctor.”

Ruan and Kahn were charged with and ultimately convicted of violating the federal regulation that allows prescribers to write prescriptions for controlled substances, “but only if the prescription is ‘issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice,’ ” according to the Supreme Court’s opinion.

In Ruan’s trial, the jury was instructed that a “doctor violates §841 [of the Controlled Substances Act] when ‘the doctor’s actions were either not for a legitimate medical purpose or were outside the usual course of professional medical practice,’ ” per the Supreme Court’s opinion. Ruan was convicted and sentenced to more than 20 years in prison and was ordered to pay millions of dollars in restitution.

NBC News reported that Ruan and Kahn “ran lucrative ‘pill mills,’ flooding their patients with prescriptions for fentanyl and other serious pain management medications, according to prosecutors’ allegations.”

Ruan and his partner, James Crouch, MD, were convicted of overprescribing medications at their clinic and a pharmacy, according to NBC News. The Associated Press reported that Ruan and Crouch grossed $20 million between 2012 and 2015.

During Kahn’s trial, the jury was instructed that it shouldn’t convict if its members found that the physician acted in “good faith,” which was defined as “an attempt to act in accordance with what a reasonable physician should believe to be medical practice,” according to the Supreme Court’s opinion. Kahn was convicted and sentenced to 25 years in prison.

The Associated Press reported that Jessica Burch, of Lake Havasu City, Arizona, was one of Kahn’s patients; Burch died as a result of an overdose in 2015. Over 6 years, Kahn wrote nearly 15,000 prescriptions for controlled substances, totaling nearly 2.2 million pills; nearly half of the prescriptions were for oxycodone, according to the AP’s reporting.

Aine Cryts is a veteran health IT and healthcare writer based out of Boston.

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