# U ni te d S ta te s Co ur t of A pp ea ls

For the Eig hth Circu it

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No. 1 7- 11 40

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Uni te d S ta te s o f Am eri ca

Pla in ti ff - App el le e

v.

Ant ho ny Mark ei th Kin g

Defe nd an t - Ap pe ll an t

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No. 1 7- 19 76

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Uni te d S ta te s o f Am eri ca

Pla in ti ff - App el le e

v.

Kris te n L. Rai ne s, (o rig in al ly nam ed Kris ti n L. Rai ne s)

Defe nd an t - Ap pe ll an t

App eal s fr om

Uni te d S ta te s Di st ric t Co ur t

fo r th e Eas te rn Dis tri ct of Ark an sa s - Li tt le Ro ck

__ __ __ __ __ __Su bm it te d: Marc h 1 3, 2 01 8

Fi le d: Aug us t 2 , 20 18

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Befo re WOL LMAN, SHEPHERD, and ERICKSON, Ci rcu it Ju dg es

.

__ __ __ __ __ __

ERICKSON, Ci rcu it Ju dg e.

Thi s co ns ol id at ed ap pe al ari se s ou t of th e op erat io n of a “ pi ll m il l” co nd uc te d

un de r th e gu is e of a le gi ti m at e cl in ic

. Ant ho ny Mar ke it h Kin g an d Kris te n L. Rai ne s

were ch arg ed in a co ns pi racy to di st rib ut e sc he du le d co nt ro ll ed su bs ta nc es wit ho ut

an effe ct iv e pr es cri pt io n in vi ol at io n of 21 U.S.C. §§ 84 1( a)(1 ), (b )(1 )(C)

, (b )(1 )(E),

an d 84 6. R a i n e s w a s al so ch arg ed wit h two co un ts of di st rib ut io n of a sc he du le d

co nt ro ll ed su bs ta nc e wit ho ut an effe ct iv e pr es cri pt io n, in vi ol at io n of 21 U.S.C. §§

84 1( a)(1 ), (b )(1 )(C) , and (b) (1 )(E).

Kin g pl ed gu il ty to th e co ns pi racy ch arg e. The di st ric t co ur t 1 pu t Kin g at a ba se

of fen se le ve l of 26, th en ad de d a fou r-p oi nt en ha nc em en t fo r act in g as an or ga ni zer

or le ad er and su bt ract ed two po in ts fo r acce pt an ce of res po ns ib il it y . Kin g t he n ha d

an of fen se le ve l of 28

, cri m in al hi st or y cat eg or y I, wit h a Gui de li ne s ran ge of 78 -9 7

mo n t h s

. The co ur t se nt en ced Kin g to 12 0 m on th s’ im pr is on m en t, va ry in g up war d

du e to th e n at ur e o f Kin g’s ro le in th e co ns pi racy.

Rai ne s pr oc eed ed to tri al an d was co nv ic te d on th e co ns pi racy ch arg e an d

acq ui tt ed on th e di st rib ut io n ch arg es

. The di st ric t co ur t fo un d Rai ne s to be at of fen se

le ve l 26 (aft er ap pl y in g a two -p oi nt en ha nc e men t f o r ab us e of po si ti on of tru st ),

1 The Hon or ab le Ja m es M. Mo od y

, Uni te d St at es Dis tri ct Ju dg e fo r th e East ern

Dis tri ct of Ark an sa s.

-2

-cri m in al hi st or y cat eg or y I, w i t h a Gui de li ne s ran ge of 63 -7 8 m on th s. The co ur t

se nt en ced Rai ne s t o 7 0 m on th s’ im pr is on m en t.

Rai ne s ap pe al s he r co nv ic ti on an d se nt en ce, cl ai m in g: 1) th e co ur t im pr op erl y

ad m it te d ev id en ce at tri al , 2 ) th e co ur t erre d in in st ru ct in g th e jury, 3) th e e v i d e n ce

was in su ffi ci en t to su st ai n a co nv ic ti on

, an d 4) he r se nt e n c e i s s u b st an ti ve ly

un reas on ab le

. K i n g c h a l le ng es th e reas on ab il it y of hi s se nt en ce. W e affi rm th e

di st ric t co ur t i n a ll res pe ct s.

I. Ba ck gr ou nd

Arte x Med ic al Cl in ic op en ed in Lit tl e Ro c k

, A r k a n s as

, in Ju ne of 20 14

.

Pat ie nt s at Arte x freq ue nt ly rece iv ed pr e s c r ip ti on s fo r hydro co do ne an d/ or Xan ax

.

Arte x o p e r a t e d o n a cas h- fee ba si s, whe re pa ti en ts wou ld pa y $2 00 in cas h pr io r to

be in g ev al ua te d. Ant ho ny Kin g wor ke d as a “ recr ui te r” fo r th e cl in ic

. Kin g recr ui te d

pa ti en ts fr o m acro ss Ark an sa s to th e cl in ic

. Pat ie nt s were req ui red to si gn a “ pa in

co nt ract ” in whi ch th ey ag reed to op io id tre at m en t be fo re th ey were se en or di ag no se d

by m ed ic al st aff.

Kris te n Rai ne s be ga n work in g as an Adva nc ed Prac ti ce Regi st ered Nur se fo r

Arte x i n J ul y

of 2 01 4. Fro m

ne arl y th e ti m e sh e was hi red un ti l t he cli ni c cl os ed in

Sep te m be r of 20 14

, Rai ne s was th e on ly em pl oyee of Arte x pre se nt on a da il y ba si s

who was l ic en se d t o wri te pre sc rip ti on s fo r hydro co do ne an d Xan ax

.

The Dru g Enfo rcem en t Adm in is tra ti on an no un ced th at dr u g s co nt ai ni ng

hydro co do ne wou ld be co m e Sch ed ul e I I d r u g s on Octo be r 6, 20 14

, whi ch le d to

Arte x c l o s i n g it s do or s at th e en d of Sep te m be r. Sh or tl y aft er Arte x cl os ed

, it s

o p e r at or s (in cl ud in g Kin g) op en ed KJ Med ic al Cl in ic

. Bec au se of hydro co do ne ’ s

ne w sc he du li ng

, Arte x em pl oyed two do ct or s as pr es cri bi ng ph y si ci an s. The ne w

cl in ic op erat ed si m il arl y to th e o l d c l i ni c—p at ie nt s wou ld walk -in an d pa y ei th er

-3

-$2 00 fo r a pa in ev al ua ti on or $1 50 fo r tre at m en t fo r a “ co ug h.” In earl y Nov em be r of

20 14 , Rai ne s b eg an work in g a t KJ

.

The si gn s th at KJ was no t op erat in g as a le gi ti m at e m ed ic al es ta bl is hm en t were

ap pa ren t. Rec ep ti on is ts at th e cl in ic gu id ed pa ti en ts ’ an swe r s o n qu es ti on na ire s to

m ak e th em ap pr op ria te can di da te s fo r co nt ro ll ed su bs ta nc e pr es cri pt io ns

. Pat ie nt s

were in st ru ct ed to fil l th ei r pr es cri pt io ns on ly at pa rti cu la r ph arm aci es

. Pat ie nt s were

req ui red t o s i g n fo rm s at te st in g th at th ey were no t in vo lv ed in an y go ve rn m en t

in ve st ig at io n in to th e cl in ic

. Pat ie nt s were gi ve n an “ en tra nc e nu m be r” in th e pa rk in g

lo t ne ar th e bu il di ng an d were on ly al lo wed in si de in li m it ed nu m be rs

. Upo n en try

pl ai nt iff s wer e ch eck ed for weap on s b y an arm ed sec ur it y

gu ard

.

The cl in ic ’s un or th od ox m et ho ds ex te nd ed to pa ti en t ev al ua ti on s an d th e

pr es c r i p t i on of m ed ic at io ns

. Doc to rs at th e cl in ic wou ld pr e-fi ll pr es cri pt io ns fo r

hydro co do ne an d Xan ax

. Nur se s wou ld t h e n c o n d u ct in -p ers on ev al ua ti on s of th e

pa ti en ts an d c om

pl et e th e p re-f

il le d p res cri pt io ns ov er t he ph y si ci an ’s si gn at ur e.

Rai ne s le ft KJ in earl y Ja nu ary of 2 0 1 5

. K i ng co nt in ue d recr ui ti ng pa ti en ts

un ti l May of 20 15

, w h e n th e cl in ic was rai de d by th e DEA. Fo ll owi ng th e rai d,

Rai ne s an d Kin g were c h arg ed in a co ns pi racy to di st rib ut e co nt ro ll ed su bs ta nc es

.

Rai ne s was al so ch arg ed wit h tw o c o u n ts of di st rib ut io n of a co nt ro ll ed su bs ta nc e

wit ho ut an effe ct iv e p res cri pt io n.

At tri al th e go ve rn m en t pr es en te d ev id en ce fro m co op erat in g co -co ns pi rat or s,

co nf id en ti al in fo rm an ts

, an d an ex pe rt m ed ic al wit ne ss

. St el la Gre e n

, a c o w o rk er

nu rs e, te st ifi ed th at u s i n g pr e-s ig ne d pr es cri pt io ns was st an da rd pr oc ed ur e fo r th e

cl in ic

. Sev eral ot he r wit ne ss es al so te st ifi ed th at th e cl in ic rel ie d on pr e-s ig ne d

pr es cri pt io ns

.

-4

-The go ve rn m en t in tr oduc ed ev ide nc e fr om a co nf ide nti al inf

o rm an t who vi si te d

th e cl in ic in Nov em

be r of 20 14

, Ja nu ary of 20 15

, an d Mar ch o f 2 0 1 5

. R a in es was

wor ki ng at t he cli ni c du rin g th e ti m e pe rio d of th e fir st two vi si ts , bu t n ot th e th ird

.

Th e in fo rm an t te st ifi ed th at on each vi si t pr os pe ct iv e pa ti en ts were to ld to ta k e a

nu m be r, ge t in li ne

, an d wait to rece iv e a pr es cri pt io n. Sh e de sc rib ed th e at m os ph ere

as ch ao ti c, wit h pa ti en ts arg ui ng ab ou t who wou ld ge t in si de to fil l th ei r pr es cri pt io n.

Sh e te st ifi ed th at on he r fir st vi si t whe n sh e ha nd ed he r pa pe rwo rk in an d m ark ed

on ly a “ 5” on th e pa in sc al e, a de sk cl erk as ke d he r to ch an ge he r an swe r to a “ 10 ” or

el se sh e wou ld be un ab le to se e a do ct or

. The go ve rn m en t in tro du ced a vi de o ta ke n

du rin g th e in fo rm an t’s th i r d v i si t to th e cl in ic

. The in fo rm an t te st ifi ed th at th e

co nt en ts of th e vi de o were si m il ar in m an y way s to he r ex pe rie nc e du rin g he r fir st two

tri ps to th e cl in ic

. A co wor ke r te s t i f i e d th at Rai ne s wou ld ha ve walk ed th ro ug h or

se en th e sa m e are as th at th e v id eo was t ak en in as a n o rd in ary pa rt o f he r wor kd ay

.

A m ed ic al ex pe rt, Dr. Carl os Ro m an

, te st ifi ed reg ard in g st an da rd s of pr act ic e

in th e fie ld of pa in m an ag em en t, gu id el in es fo r pr es cri bi ng m ed ic at i o n s

, a n d “ red

fla gs ” th at in di cat ed po te nt ia l pa in ki ll er ab u s e

. D r

. R om an ha d twen ty y ears of

ex pe rie nc e in th e m ed ic al pr of es si on an d ha d se rv ed on th e Ark an sa s St at e Med ic al

Bo ard Rev ie w Co m

m it te e si nc e 20 05

, in cl ud in g as ch ai rm an

. Dr. Ro m an al so se rv ed

as th e Ch ie f of Pai n Man ag em en t at St. Vin cen t In fir m ary in Lit tl e Ro ck

, Ark an sa s.

Dr. Ro m an no te d th at th e Arte x “ pa in co nt ract ” an d KJ’s si gn ed fo rm p r oh ib it in g

pa ti en ts fro m pa rti ci pa ti ng in la w en fo rcem en t act iv it y were no t typic al fo r a

le gi ti m at e m ed i c a l es ta bl is hm en t. He al so te st ifi ed reg ard in g th e Pres cri pt io n

M o ni to rin g Pro gr am (“ PMP ”) da ta of fere d by th e Uni te d St at es as ev i d e n c e o f

irr eg ul ar pr es cri pt io n act iv it y

. The da ta was su bm it te d to th e tri al co ur t in a su m m ary

ch art fo rm show ing hy dr oc odon e an d X an a x pr es cri pt io ns al le ge dl y writ te n by Rai ne s

whi le wor ki ng at Arte x. The or ig in al ve rs io ns of th e pr es cri pt io ns refe ren ced in th e

ch art were als o su bm it te d to th e co ur t. Of ap pr ox im at el y 11 2 pat ie nt fil es fro m KJ,

21 co nt ai ne d pa pe rwo rk si gn ed by Rai ne s, al on g wit h pr es cri pt io ns be ari ng Rai ne s’s

ha nd writ in g a nd a ph y si ci an ’s si gn at ur e.

-5

-Dr. Ro m an te st ifi ed th at he be li ev ed th e reco rd s in di cat ed a fai lu re to pu rs ue

a le gi ti m at e m ed ic al pu rp os e. He ba se d hi s revi ew on al l of th e fil es av ai la bl e fro m

Arte x, te n fil es ch os en at ran do m fr o m KJ, an d el ev en fil es id en ti fie d as rel at in g to

pa ti en ts Rai ne s trea te d at KJ. He no te d th at pa ti en ts ha d con si st en tl y m ark ed ei th er

a “9 ” or “ 10 ” on th e pa in sc al e. He fu rth er rem ark ed th at th e pa ti en ts ’ an swe rs to

an xi et y an d de pr es s io n qu es ti on na ire s were ou ts id e th e no rm al bo un da ry fo r

tre at m en t by a pa in sp eci al is t an d in di cat ed su ic id al te nd en ci es

. I n p a r t i cu la r, he

no te d th at se ve ral of th e fil es rai se d co nc ern s th at m ed ic al tre at m en t ha d be en li m it ed

to t h e p res cri pt io n of op io id s whe n th e al le ge d ci rcu m st an ces wou ld ha ve req ui red

m or e de ta il ed an d th or ou gh care

. He al so co m m en te d on an au di o reco rd in g fro m an

in fo rm an t pa ti en t in w h i c h Rai ne s refe rred to Xan ax by th e st reet te rm “ ba rs .” He

no te d t ha t u si ng st reet ter m s i s n ot no rm al in m ed ic al pra ct ic e.

Dur in g th e jury in st ru ct io n co nf eren ce, Rai ne s req ue s t e d a “ go od fai th ”

in st ru ct io n, p ro po si ng th e fo ll owi ng lan gu ag e:

Wh e n y ou co ns id er th e go od fai th de fen se

, it is th e de fen da nt ’ s

be li ef th at is im

po rta nt

. It i s t he si nc eri ty o f th e de fen da nt ’s b el ie f th at

de te rm in es if he or s h e a c t ed in go od fai th

. If th e de fen da nt ’s be li ef is

un reas on ab le

, y ou m ay co ns id er th at in de te rm in in g hi s or he r si nc eri ty

of be li ef, b ut an un reas on ab le be li ef s in cere ly hel d i s g oo d fa it h.

The tri al jud ge de cl in ed to pr ov id e th e i n s t ru ct io n. The tri al jud ge pr ov id ed an

in st ru ct io n o n wi ll fu l b li nd ne ss ov er Ra in es ’s ob jecti on

.

Ra i n e s was co nv ic te d on th e co ns pi racy ch arg e an d acq ui tt ed on th e

su bs ta nt iv e di st rib ut io n ch arg es

. At se nt en ci ng th e di st ric t co u r t f o u nd Rai ne s

res po ns ib le fo r 12 5,9 40 pi ll s of hydro co do ne an d 15 1,0 76 pi ll s of Xan ax

. The co ur t

al so ap pl ie d an en ha nc em en t fo r ab us e of po si ti on of tru st

. Rai ne s was se nt en ced to

a te rm of 70 m o n t h s ’ i m pr is on m en t to be fo ll owe d by th ree y ears of su pe rv is ed

rel eas e.

-6

-The di st ri c t c o u rt ap pl ie d a se nt en ce en ha nc em en t to Kin g fo r be in g an

or ga ni zer o r l e a d e r an d al so ap pl ie d a red uc ti on fo r acce pt an ce of res po ns ib il it y

.

Kin g was se nt en ced to a te rm of 12 0 m on th s’ im pr is on m en t to be fo ll owe d by th ree

y ears of s up erv is ed rel eas e.

II

. Dis cus si on

A. Ev id enti ar y Rul in gs

“ Fed eral Ru le of Ev id en ce 4 03 all ows a di st ric t co ur t t o e xc lu de ev id en ce ‘ if

it s pr ob at i v e v a l u e i s su bs ta nt ia ll y ou twei gh ed by a da ng er of

. . . un fai r pr ejud ic e,

co nf us in g th e is su es

, m is le ad in g th e jury, u n d u e de la y

, was ti ng ti m e, or ne ed le ss ly

pr es en ti ng cu m

u l a t i v e ev id en ce.’” Dav is v. W hi te

, 85 8 F.3 d 11 55

, 11 59 (8 th Ci r.

20 17 ). W e gi ve gr eat de fere nc e to th e di st ric t co ur t’s Ru le 40 3 de te rm in at io ns an d

wil l rev ers e it s ev id en ti ary ru li ng s on ly fo r a “ cl ear an d pr ejud ic ia l ab us e of

d i s c ret io n.” Qui gl ey v. W in te r

, 59 8 F.3 d 93 8, 94 6 (8 th Ci r. 20 10 ). “ [A] di st ri c t

co ur t’s di sc ret io n in de te rm in in g th e ad m is si bi li ty of ev id en ce is ‘part ic ul arl y br oa d

in a co ns pi racy tri al .’ ” Uni te d St at es v. Dard en

, 70 F.3 d 15 07

, 15 39 (8 th Ci r. 19 95 )

(q uo ti ng Uni te d St at es v. Wi ll is , 9 97 F.2 d 40 7, 41 4 (8 th Ci r. 19 93 )). Rai ne s rai se s

a se rie s o f ob

jecti on s t o e vi de nt ia ry

de ci si on s m ad e b y

th e d is tri ct co ur t.

1. Th e Pre sc ri

pt io n Mo ni to ri ng

Pro gr am Da ta Su mmar ie s

Rai ne s cl ai m s th e P MP da ta is in ad m is sa bl e be cau se it is of qu es ti on ab le

rel ia bi li ty an d is un fai rly pr ejud ic ia l. The PMP da ta was co rro bo rat ed by se ve ral ot he r

pi eces of ev id en ce, in cl ud in g cro ss -ref eren ces to pa rti cu la r da y s on whi ch Rai ne s

wor ke d, pa ti en t si gn -in lo gs fo r th os e da y s, an d ha rd co pi es of th e act ua l pr es cri pt io ns

of fere d to th os e pa ti en ts

. T hose co rr ob or at in g el em en ts pr ov id ed su ffi ci en t rel ia bi li ty

-7

-fo r th e PMP su m m a r i es

. 2 Co nt rary to Rai ne s’s as se rti on

, it was no t un fai rly

pr ejud ic ia l fo r t h e P M P s um m ari es to in cl ud e on ly th os e pr es cri pt io ns fo r th e

pa rti cu la r su bs ta n c e s a l l eg ed in th e co ns pi racy. The di st ric t co ur t di d no t ab us e it s

di sc ret io n b y

ad m it ti ng th e PMP ev id en ce. 3

2. Exp er t Ph

ys ic ia n T es ti mon y

Rai ne s ob jects to th e ad m is si on of Dr. Ro m an ’s ex pe rt ph y si ci an te st im on y on

th e gr ou nd s th at it was ba se d on bo th a la ck of pe rs on al kn owl ed ge an d an in ad eq ua te

rev ie w of th e pr es cri pt io n reco rd s. Ru l e 7 0 2 o f th e Fed eral Ru le s of Evi de nc e

go ve rn s th e ad m is si on of ex pe rt te st im on y

. “ W e rev ie w a di st ric t co ur t’s de ci si on to

a dm it ex pe rt te st im on y fo r an ab us e of di sc ret io n.” Ro bi ns on v. GEICO G e n

. I n s

.

Co

. , 44 7 F.3 d 10 96

, 11 00 (8 th Ci r. 20 06 ) (ci ti ng Uni te d St at es v. Cawt ho rn

, 42 9 F.3 d

79 3, 79 9 (8 th Ci r. 20 05 )). Ru le 70 2 req ui res on ly th a t an ex pe rt “ po ss es s

‘kno wled ge

, sk il l, ex pe rie nc e, tra in in g, or ed uc at io n’ su ffi ci en t to ‘ass is t’ th e tri er of

fact

, whi ch is ‘sati sf

ie d whe re ex pe rt te st im on y ad va nc es th e tri er of fact ’s

2 Rai ne s’s rel ia nc e on Uni te d St at es v. Jo ne s

, 57 0 F.2 d 76 5, 76 9 (8 th Ci r. 19 78 ),

is m is pl aced

. In th at cas e we he ld th at sp eci fic pr es cri pt io ns in tro du ced in to ev id en ce

bu t no t ad dr es se d in th e rel ev an t in di ct m en t sh ou ld ha ve be en ba rred on Ru le 40 4( b)

an d 40 3 gr ou nd s. Here th ere is no Ru le 40 4( b) pr ob le m

, as th e PMP su m m ari es on ly

co nt ai n pr es cri pt io ns rel at in g to th e ch arg ed co ns pi racy. See United States v. Ali

, 799

F.3d 1008, 1 0 2 6 (8th Cir. 2015) (evidence is intrinsic in a conspiracy if it “com pletes the

story or provides a total picture of the charged crim e”). The su m m ari es al so do no t po se

th e Ru le 40 3 pr ob le m s we id en ti fie d in Jo ne s

, as th ey are acco mp a n i e d b y o th er

e v i d e n ce be y on d m ere qu an ti ty an d do no t in cl ud e pr es cri pt io ns rel at in g to “ ot h e r

cl ai m s o f wro ng do in g.” See 57 0 F .2d 76 5, 7 68 -6 9.

3 Rai ne s’s rem ai ni ng ob

jecti on s to th e PMP da ta were am pl y ad dr es se d vi a he r

ab il it y to cro ss -ex am in e wit ne ss es reg ard in g th e co ns tru ct io n of th e PMP ch art s. See

W at ki ns v. So wde rs

, 44 9 U.S. 34 1, 34 9 (1 98 1) (“ [U]nde r ou r ad ve rs ar y s ys t e m of

jus ti ce, cro ss -ex am in at io n ha s al way s be en co ns id e r e d a m os t effe ct iv e way to

as cert ai n t ru th .”).

-8

-un de rs ta nd in g t o an y de gr ee.’” Id

. (qu ot in g 2 9 C H A R LE S A LA N W R IG H T & V IC T O R

J A M E S G O LD

, F E D E R A L P R A C T IC E A N D P R O C E D U R E : E V ID E N C E § 6 26 5 (1 99 7) ); se e

al so Po ls ki v. Quig le y Co rp

. , 53 8 F .3d 83 6, 8 39 (8t h C ir. 2 00 8) (qu ot in g Lau zo n v.

Sen co Pro ds

., In c.

, 27 0 F.3 d 68 1, 68 6 (8 th Ci r. 20 01 )) (ex pl ai ni ng th at di st ric t co ur ts

sh ou ld ap pl y th ree- pa rt te st to ex pe rt te st im on y by ad dr es si ng rel ev an cy

, rel ia bi li ty,

an d t he qu al ifi cat io ns of t he wit ne ss ).

Here Dr. Ro m an ’s te st im on y reg ard in g st an da rd s of m ed ic al care an d th e PMP

da ta sa ti sf

ie d Ru le 70 2’s req ui rem en t s

. D r

. Ro m an was well qu al ifi ed to te st ify

co nc ern in g st an da rd s of pr act ic e in th e fie ld of pa in m an ag em en t, in cl ud in g warn in g

si gn s reg ard in g ab us e of pa in m ed ic at io n or di ve rs io n of m ed ic at io n. And gi ve n Dr.

Ro m an ’s “p e r so na l kn owl ed ge [an d] ex pe rie nc e,” he was a rel ia bl e so ur ce of

te st im on y on st an da rd s of m ed ic al care an d th e im po rt of th e PMP ch art s. See Uni te d

St at es v. Hol m es

, 75 1 F

. 3 d 8 46

, 85 0 (8 th Ci r. 20 14 ) (q uo ti ng Kum ho Tire Co

. v.

Carm ic ha el

, 52 6 U.S. 13 7

, 1 4 7 ( 19 99 )) (ex pl ai ni ng th at th e “ rel ev an t rel ia bi li ty

co nc ern s m ay fo cu s up on pe rs on al kn owl ed ge or ex p e r i e n c e”). W hi le Dr. Ro m an

ack no wled ge d th at he co ul d no t de fin it iv el y st at e th at an y pa rti cu la r pr es cri pt io n was

il le g i t i mat e ab se nt m or e in fo rm at io n, hi s op in io n on th e ge ne ral op erat io n of th e

cl in ic ba se d on th e accu m ul at ed ev id en ce w a s st il l rel ev an t. On th e who le

, Dr.

Ro m an ’s op in io n on th e PMP ch art s “ ad va nc e[d ] th e tr ie r of fact ’s u nd ers ta nd in g”

of th e cl in ic al pr act ic es at KJ an d Arte x an d ho w th ey di ffer ed fro m or di na ry m ed ic al

faci li ti es

. The tri al co ur t di d no t ab us e it s di sc ret io n by a d mi t t i ng Dr. Ro m an ’s

te st im on y

.

3. Tes ti mon y fr om Cl in ic Co wo rk

er

St el la Green te st ifi ed reg ard in g he r pe rs on al kn owl ed ge of th e ge ne ral pr act ic e

of th e cl in ic

. As a fel lo w nu rs e, Green ha d di rect kn owl ed ge of t he cli ni c’s ge ne ral

op erat in g pr act ic es

. W hi le G r e e n t es ti fie d ab ou t he r own ob se rv at io ns an d

kn owl ed ge

, it was ci rcu m st an ti a l e v i d en ce of Rai ne s’s kn owl ed ge of or wil lfu l

-9

-bl in dn es s to th e na tu re of th e cli ni c. Defen se co un se l was gi ve n th e op po rtu ni ty t o

cro ss -ex am in e Green reg ard in g he r pe rs on al kn owl ed ge (o r la ck th ereo f) of Rai ne s’s

sp eci fic act io ns

. Tha t op po rtu nit y suf fi ci en t ly en su red th e rel ia bi li ty of th e te st im on y

.

See Uni te d S ta te s v. W il de r , 5 97 F.3 d 93 6, 94 4 (8 th Ci r. 20 10 ) (ex pl ai ni ng th at th e

fact -fi nd er is th e fin al arb it er of wit ne ss cred ib il it y ). Add it io na ll y

, “ [w]here ev id en ce

do es no t ha ve a su bs ta nt ia l in flu en ce on th e ve rd ic t be cau se it is cu m ul at iv e, th ere is

no pr ejud ic e.” Dav is

, 85 8 F.3 d at 11 59

. Green ’s te st im on y was co rro bo rat ed by ot he r

ev id en ce of

fere d th ro ug h th e co ur se of th e tri al

, pa rti cu la rly th at th e cl in ic rel ie d on

pr e-s ig ne d p res cri pt io ns . Adm it ti ng th e te st im on y was n ot an ab us e o f di sc ret io n.

4. Vi de ot ap e b

y a n In fo rma nt

Rai ne s cl ai m s th at th e di st ric t co ur t ab us ed it s di sc ret io n by ad m it ti ng a

vi de ot a p e o f a vi si t by a co nf id en ti al in fo rm an t th at to ok pl ace whi le sh e was no t

em pl oyed by th e cl in ic

. The vi de o was of fere d as ci rcu m st an ti al ev id en ce of Rai ne s’s

kn owl ed ge o f o r w il lfu l bl in dn es s to th e na tu re of th e cl in ic

. W hi le Rai ne s di d no t

wor k at th e cl in ic at th e t i me t h e vi de o was ta ke n, th e in fo rm an t who cap tu red th e

vi de o t es ti fie d t ha t t he co nt en ts were similar to he r pr io r vi si ts to th e cli ni c—wh ic h

di d oc cu r whi le Rai ne s was em pl oyed by th e cl in ic

. Oth er te st im on y co rro bo rat ed

t h a t R a i n e s wou ld ha ve vi ewed th e sa m e area s of th e cl in ic sh own on th e vi de o a s

pa rt o f he r or di na ry

work da y

.

W e ne ed no t de ci de whe th er ad m is si o n of th e vi de o was erro r, as “ im pr op er

ad m is si on of ev id en ce whi ch is cu m ul at iv e of m at te rs sh own by ad m is si bl e ev id en ce

is ha rm le ss erro r.” Id

. (q uo ti ng W il so n v. Ci ty of Des Mo in es

, 44 2 F.3 d 63 7, 64 4 (8 th

Ci r. 20 06 )). The sc en e de pi ct ed in th e vi de o was cum ul at iv e of an d co ns is te nt wit h

ex te ns iv e te st i m on y pu t be fo re th e jury reg ard in g th e da y -to -d ay at m os ph ere at th e

cl in ic . If th ere i s an y

erro r, it is ha rm le ss

.

-1 0-B. Ju ry Ins truc tio ns

“ W e rev ie w th e di st ric t cou rt’s jury in st ru ct io ns for ab us e o f di sc ret io n,” an d

“ wil l affi rm if th e in st ru ct io ns

, ta ke n as a who le

, fai rly an d ad eq ua te ly su bm it te d th e

i s s u e s to th e jury.” Uni te d St at es v. Katz

, 44 5 F.3 d 10 23

, 10 30 (8 th Ci r. 2 0 0 6 )

(q uo ti ng Uni te d St at es v. Garci a

- G o n o n

, 4 3 3 F.3 d 58 7, 59 1 (8 th Ci r. 20 06 )). “ A

de fen da nt is en ti tl ed to a sp eci fic jury in st ru ct io n ‘ th at co nv ey s th e su bs ta nc e of hi s

req ue st if hi s req ue st is ti m el y

, it is su pp or te d by ev id en ce in th e cas e, an d is a co rrec t

st at em en t of th e la w.’ ” Uni te d St at es v. Cru z-Zu ni ga

, 57 1 F.3 d 72 1, 72 5 (8 th Ci r.

20 09 ) (q uo ti ng Uni te d St at es v. W hi te he ad

, 17 6 F. 3 d 10 30

, 10 37 (8 th Ci r. 19 99 )).

A de fen da nt “ is no t en ti tl ed to a pa rti cu la rly-word ed in st ru ct io n whe n th e in st ru ct io ns

act ua ll y gi ve n b y th e tr ia l co ur t ad eq ua te ly an d co rrec tl y co ve r th e su bs ta nc e o f th e

req ue st ed in st ru ct io n.” Id

. (q uo ti ng Uni te d St at es v. Lon g

, 97 7 F.2 d 12 62

, 12 72 (8 th

Ci r. 19 92 )). “ W e rev ie w th e di st ric t co ur t’s de ni al of a pr op os ed jury in st ru ct io n fo r

ab us e of di sc ret io n, rev ers in g ‘onl y if th e di st ric t co ur t’s al le ge d erro ne ou s fai lu re to

gi ve a pa rti cu la r in st ru ct io n was pre jud ic ia l.’” Id

. (qu ot in g W hi te he ad , 17 6 F .3d at

10 37 ).

Rai ne s arg ue s th at th e di st ric t cou rt sh ou ld no t ha ve pr ov id ed th e jury wit h a

wil lfu l bl in dn es s in st r

u c ti on

. An in st ru ct io n on wil lfu l bl in dn es s is es pe ci al ly

ap pr op ria te “ whe n th e de fen da nt de ni es an y kn owl ed ge of a cri m in al sc he m e de sp it e

st ro ng ev id en ce to th e co nt rary.” Uni te d St at es v. Si gi ll it o , 7 59 F.3 d 91 3, 93 9 (8 th

Ci r. 20 14 ) (q uo t i n g U n i t e d S ta te s v. Lewis

, 55 7 F.3 d 60 1, 61 3 (8 th Ci r. 20 09 )).

Rai ne s to ok th e st an d to pr ot es t th at sh e la ck ed act ua l kn owl ed ge of th e sc he m e. The

ev id en ce su pp or ts a th eo ry th at an y la ck of un de rs ta nd in g of the na tu re of th e cl in ic

a s a p il l m il l co ul d on ly ha ve be en he ld by refu si ng to ta ke no te of th e ob vi o u s

.

In cl ud in g a wil lfu l bl in dn es s in st ru ct io n was well wit hi n th e d i s t r i c t co ur t’s

di sc ret io n.

-1 1-Rai ne s al so cl ai m s th e di st ric t co ur t sh ou ld ha ve pr ov id ed he r pr op os ed go od

fai th in st ru ct io n. The go ve rn m en t bo re t he bu rd en of es ta bl is hi ng th at Rai ne s’s

act io ns were no t fo r le gi ti m at e m ed ic al pu rp os es in th e us ua l co ur se of med i cal

pr act ic e. See Uni te d St at es v. Sm it h

, 57 3 F.3 d 63 9, 64 7- 49 (8 th Ci r. 20 09 ) (d is cu ss in g

m ean in g of “ us ua l co ur se of pr of es si on al pr act ic e”). A m ed ic al pr of es si on al ’s go od

fai th m ay be rel ev an t to a jury’ s de te rm in at io n of whe th er th e do ct or act ed ou ts id e th e

bo un ds of m ed ic a l pr act ic e or wit h a le gi ti m at e m ed ic al pu rp os e whe n pr es cri bi ng

na rco ti cs

. See id

. (di sc us si ng a go od fai th in st ru ct io n i n a cas e in vo lv in g § 84 1)

.

Rai ne s’s go od fai th in st ru ct io n was un warra nt ed he re be cau se it m is st at ed th e

ap pl ic ab le la w. Rai ne s ’s i n s t r uc ti on in co rrec tl y su gg es te d th at th e st an da rd fo r

ap pr op ria te m ed ic al pr act ic e was su bjec ti ve

, rat he r th an ob jecti ve

. See id

. at 64 8- 49

(q uo ti ng Uni te d St at es v. Mo or e

, 42 3 U.S. 12 2, 14 3 (1 97 5) ) (in te rn al qu ot at io n m ark s

om it te d) (ex pl ai ni ng th at if “ a su bjec ti ve st an da rd were to pr ev ai l, it wou ld al lo w an

in di vi du al [m ed ic al pr of

es si on al ] to de fin e th e pa ram et ers of hi s or he r pr act ic e an d

effe ct iv el y sh ie ld th e pr act it io ne r fro m cri m in al li ab il it y de sp it e th e fact th at th e

pr act it io ne r m ay

be act in g a s n ot hi ng m or e th an a ‘larg e-s cal e p us he r’”).

Mo re im po rta nt ly, th e in st ru ct io ns as a w h o l e de sc rib ed th e sp eci fic in te nt

ne ces sa ry to co m

m it th e cri m e an d co ve r th e sa m e gr ou nd th e go od fai th in st ru ct io n

wou ld co ve r. Und er th es e ci rcu m st an ces th ere is no erro r. Uni te d St at es v. Bro wn

,

47 8 F.3 d 92 6, 92 8 (8 th Ci r. 20 07 ). H e r e th e jury in st ru ct io ns on co ns pi racy

ad eq ua te ly se t ou t th e req ui red el em en ts of kn owl ed ge an d in te nt

. The di st ric t co ur t

di d n ot ab us e it s d is cret io n b y refu si ng to pro vi de a go od fai th in st ru ct io n.

C. Suff

ic ie ncy of t he Ev id ence

Rai ne s ch al le ng es th e su ffi ci en cy of th e ev id en ce pr es en te d at tri al

. W e rev ie w

“ th e su ffi ci en cy of th e ev id en ce de no vo

, vi ewin g ev id en ce in th e li gh t m os t fav or ab le

to th e jury’ s ve rd ic t, res ol vi ng co nf li ct s in th e go ve rn m en t’s fav or

, an d acce pt in g al l

-1 2-reas on ab le in fere nc es th at su pp or t th e ve rd ic t.” Uni te d Sta te s v . Till m an , 76 5 F .3d

83 1, 83 3 (8 th Ci r. 20 14 ) (q uo ti ng Uni te d St at es v. Harri s- Tho m ps on

, 75 1 F.3 d 59 0,

59 8 (8 th Ci r. 20 14 )). “ A de fen da nt ch al le ng in g th e su ffi ci en cy of th e ev id en ce i n a

co ns pi racy cas e ha s a he av y bu rd en .” Uni te d St at es v. Man n

, 70 1 F.3 d 27 4, 29 6 (8 th

Ci r. 20 12 ) (q uo ti ng Uni te d St at es v. Mi ck el so n

, 37 8 F.3 d 81 0, 82 1 (8 th Ci r. 20 04 )).

“ [I]n ev al ua ti ng th e su ffi ci en cy of ev id en ce to su st ai n a ve rd ic t, ci rcu m st an ti al

ev id en ce m

us t be tre at ed no di ffer en tl y th an di rect ev id en ce.” Uni te d St at es v.

You ng

, 75 3 F.3 d 75 7, 78 3 (8 th Ci r. 20 14 ) (ci ti ng Uni te d St at es v. Lam

, 33 8 F.3 d 86 8,

87 1 (8 th Ci r. 20 03 )). W e wil l o ve rtu rn th e ve rd ic t on ly i f no reas on ab le jury co ul d

ha ve fo un d th e de fen da nt gu il ty be y on d a reas on ab le do ub t. Uni te d St at es v. Co lt on

,

74 2 F.3 d 34 5, 34 8 (8 th Ci r. 20 14 ) (q uo ti ng Uni te d St at es v. Bel l

, 47 7 F.3 d 60 7, 61 3

(8 th Cir . 20 07 )).

To co nv ic t Rai ne s of con sp ira cy

, th e go ve rn m en t ne ed ed to sh ow th at (i) two

or m or e pe rs on s ag reed to di st rib ut e co nt ro ll ed su bs ta nc es wit ho ut an e f f e c t i ve

pr es cri pt io n, (ii ) th e de fen da nt kn ew th e ag reem en t’s pu rp os e, an d (ii i) th e de fen da nt

kn owi ng ly and vo lu nt ari ly joi ne d th e ag reem en t. See Uni te d S ta te s v . Hans en , 79 1

F.3 d 86 3, 87 0- 72 (8 th Ci r. 20 15 ) (ap pl y in g co ns pi racy el em en ts to m ai l/ wire frau d

cas e). No ex p l i c i t a g r e em en t is req ui red ; “ a ta ci t or im pl ic it un de rs ta nd in g” is

su ffi ci en t. Uni te d St a t e s v

. W el ls

, 64 6 F.3 d 10 97

, 11 02 (8 th Ci r. 20 11 ). Eve n a

m in or pa rti ci pa to r y r o l e in th e co ns pi racy wil l su st ai n a co nv ic ti on on ce an

un de rlyin g co ns pi racy ha s be en es ta bl is h e d

. S e e U ni te d St at es v. Lop ez

, 44 3 F.3 d

10 26

, 10 30 (8 th Ci r. 20 06 ) (en ba nc ). A jury ve r d i c t m ay be ba se d “ so le ly on th e

te st im on y of co op erat in g wit ne ss es .” Til lm an

, 76 5 F.3 d a t 8 34 (q uo ti ng Uni te d St at es

v. Sm it h

, 63 2 F.3 d 10 43

, 10 46 (8 th Ci r. 20 11 )). W hi le th e “ go ve rn m en t m ay no t rel y

so le ly on th e jury’ s di sb el ie f of a de fen da nt ’s de ni al s to mee t i t s b ur de n of pr oo f,”

whe n th ere is “ ot he r co rro bo r a t i v e ev id en ce of gu il t, th e jury can pr op erl y dr aw an

in fere nc e of gu il t fro m it s di sb el ie f of th e d e f e nd an t’s de ni al s.” Uni te d St at es v.

Ree d

, 29 7 F.3 d 78 7, 78 9 (8 th Ci r. 20 02 ) (q uo ti ng Uni te d St at es v. Dav id so n

, 12 2 F.3 d

53 1, 53 6 (8 th Ci r. 19 97 )). “ [W] il lfu l bl in dn es s m ay se rv e as th e ba si s fo r kn owl ed ge

-1 3-if, ‘in li gh t of ce r t a i n ob vi ou s fact s, reas on ab le in fere nc es su pp or t a fin di ng th at a

de fen da nt ’s fai lu re to in ve st ig at e i s e q u i v al en t to bu ry in g on e’s he ad in th e sa nd .’ ”

Uni te d St at es v. Ch av ez-Al va rez

, 5 9 4 F.3 d 10 62

, 10 67 (8 th Ci r. 20 10 ) (q uo ti ng

Uni te d St at es v. Fl or ez

, 36 8 F.3 d 10 42

, 1 0 4 4 ( 8 t h Ci r. 20 04 )) (in te rn al qu ot at io n

m ark s o m it te d)

.

The ev id en ce i n t hi s ca se was o ve rwh el m in g t ha t Ra in es was i nv ol ve d i n t he

co ns pi racy. The jury was pr es en te d wit h ex te ns iv e ev id en ce th at Arte x an d KJ were

no t ru n as le gi ti m at e m ed ic al en te rp ris es

. Rai ne s do es no t co nt es t th e ex is te nc e of a

co ns pi racy; rat he r, sh e cla im s t he ev id en ce was in su ffi ci en t to pr ov e sh e joi ne d th e

co ns pi racy an d ha d kn owl ed ge of it s pu rp os e. Rai ne s co nt in ue d to wor k at th e cl in ic

de sp it e ob vi ou s si gn s th at th e cl in ic was a pi ll m il l. Rai ne s’s de ci si on to wor k at th e

cl in ic de sp it e th e c l in ic ’s ob vi ou sl y il le gi ti m at e na tu re is read il y se en as a “ ta ci t or

im pl ic it un de rs ta nd in g” of he r ro le in th e sc he m e. Giv en th e ev id en ce, a reas on ab le

jury cou ld eas il y

fin d R ai ne s g ui lt y

be y on d a reas on ab le do ub t.

D. Sent enci ng Deci si on s

Rai ne s an d Kin g rai se a nu m be r of ch al le ng es to th e di st ric t co ur t’s se nt en ci ng

de ci si on s. W e “ rev ie w a ll se nt en ces —wh et he r in si de , ju st ou ts id e, or si gn ifi c an tl y

ou ts id e th e Gui de li ne s ran ge —u nd er a de fere nt ia l ab us e-o f-d is cret io n st an da rd .”

Uni te d St at es v. St on e

, 8 7 3 F.3 d 64 8, 64 9 (8 th Ci r. 20 17 ) (ci ti ng Gall v. Uni te d

St at es

, 55 2 U.S. 38

, 41 (2 00 7)

. W e “ fir st en su re th at th e di st ric t co ur t co m m it te d no

si gn ifi can t pr oc ed ur al erro r, su ch as fai li ng to cal cu la te (o r im pr op erl y cal cu la ti ng )

th e Gui de li ne s ran ge

, tre at in g th e Gui de li ne s as m an da to ry

, fai li ng to co ns id er th e §

35 53 (a) fact or s, se le ct in g a se nt en ce ba se d on cl earl y erro n e o u s f a c ts

, or fai li ng to

ad eq ua te ly ex pl ai n th e ch os en se nt en ce— in cl ud in g an ex pl an at io n fo r an y de vi at io n

fro m th e Gui de li ne s ran ge .” Uni te d St at es v. Sm it h , 57 3 F .3d 63 9, 6 58 -5 9 (8 th Ci r.

20 09 ) (q uo ti ng Gall , 5 52 U.S. a t 50 -5 1)

. If th ere i s n o pr oc ed ur al erro r, we rev ie w

-1 4-th e su bs ta nt iv e reas on ab le ne ss of th e se nt en ce. Id

. (q uo ti ng Uni te d St at es v. Alv iz oTruji ll o , 52 1 F .3d 10 15 , 10 17 (8t h C ir. 2 00 8) ).

1. Dr ug Qua nt it y Ca lc ul at io ns

Rai ne s ch al le ng es th e di st ric t co ur t’s dr ug qu an ti ty cal cu la ti on s. Dru g qu an ti ty

de te rm in at i o n s “ are fact ua l fin di ng s, whi ch we rev ie w fo r cl ear erro r, ap pl y in g th e

pr ep on de ran ce-o f-t he -ev id e n c e s t an da rd .” Uni te d St at es v. W al ke r

, 68 8 F.3 d 41 6,

42 0 (8 th Ci r. 20 12 ) (ci ta ti on om it te d) (in te rn al qu ot at io n m ark s om it te d)

. The di st ric t

co ur t’s fact ua l de te rm in at io ns wil l st an d “ un le s s t h e de ci si on is un su pp or te d by

su bs ta nt ia l ev id en ce, is ba se d on an erro ne ou s vi ew of th e ap pl ic ab le la w, or in li gh t

of th e en ti re reco rd

, we are le ft wit h a fir m an d de fin it e co nv ic ti on th at a m is ta ke ha s

be en m ad e.” Co lt on

, 74 2 F.3 d at 34 8 (q uo ti ng Uni te d St at es v. Mi ll er

, 51 1 F.3 d 82 1,

82 3 (8 th Cir . 20 08 )).

“[F ]o r p ur

po se s of cal cu la ti ng dr ug qu an ti ty in a dr ug co ns pi racy cas e, ‘t h e

di st ric t co ur t m ay co ns id er am ou nt s fro m dr ug tra ns act io ns in whi ch th e de fe n d a nt

was no t d ire ct ly in vo lv ed if th os e de al in gs were pa rt of th e sa m e co ur se of c on du ct

or sc he m e.’” Id

. at 34 9 (ci ti ng Uni te d St at es v. Brad le y

, 64 3 F.3 d 11 2 1

, 11 26 (8 th

Ci r. 20 11 )). Thi s i nc lu de s “ al l t ran sa ct io ns kn own or r eas on ab ly fores eeab le to th e

de fen da nt th at were m ad e in fu rth eran ce of th e co ns pi racy.” Id

. (ci ti ng Uni te d St at es

v. Pl an cart e-Vaz qu ez

, 4 50 F.3 d 84 8, 85 2 (8 th Ci r. 20 06 )). “ The co ur t m ay m ak e a

sp eci fic nu m eri c de te rm in at io n of qu an ti ty ba se d on im pr eci se ev id en ce

. . . so lo ng

as th e reco rd refl ect s a ba si s for th e co ur t’s de ci si on .” Uni te d St at es v. Ro ach , 1 64

F.3 d 4 03 , 41 3- 14 (8t h C ir. 1 99 8)

.

The di st ric t co ur t’s dr ug qu an ti ty cal cu la ti on s in cl ud ed a n um be r of pi ll s

di rect ly at tri bu ta bl e to Rai ne s, as well as pi ll s fro m ot he r tra ns act io ns by th e pi ll m il l.

The reco rd am

pl y pr ov id es a ba si s fo r th e di st ric t co ur t’s cal cu la ti on

. The jury fo un d

be y on d a reas on ab le do ub t th at Rai ne s ha d kn owl ed ge of th e co ns pi racy. Giv en th e

-1 5-“p i ll m il l” na tu re of th e co ns pi racy, th e dr ug qu an ti ti es in vo lv ed were reas on a b l y

fo res eeab le to Rai ne s. Th e d is tri ct co ur t di d no t cl earl y err in m ak in g it s dr ug

qu an ti ty calcu la ti on s.

2. Th e Abu se of

Tru st Enh an cemen t

“ To warra nt an ab us e-o f-t ru st en ha nc em en t, t he go ve rn m en t m us t pro ve by a

pr ep on de ran c e of th e ev id en ce th at , ‘(1 ) de fen da nt oc cu pi ed a po si ti on of

. . . t ru st

,

an d (2 ) de fen da nt us e d t h i s po si ti on in a m an ne r th at si gn ifi can tl y faci li ta te d th e

co m m is si on or co nc eal m en t of th e of fen se .’ ” Uni te d St at es v. W al ke r

, 81 8 F.3 d 41 6,

42 3 (8 th Ci r. 20 16 ) (q uo ti ng Uni te d St at es v. Mi el l

, 66 1 F. 3 d 9 9 5, 99 8 (8 th Ci r.

20 11 )) (em

ph as is rem ov ed fro m o r i gi na l). “ W e rev ie w th e le ga l co m po ne nt of th e

ab us e of tru st de te rm in at io n de no vo an d th e di st ric t co ur t’s fact ua l fin di ng s fo r cl ear

erro r.” Id

. (qu ot in g Uni te d St at es v. An de rs on , 34 9 F .3d 56 8, 5 73 (8t h C ir. 2 00 3) ).

The di st ric t co ur t pr op erl y fo un d th at Rai ne s’s ro le as a m ed ic al pro fes si on al

m ean t sh e se rv ed in a po si ti on of tru st

. See Uni te d Stat es v. Ste ll a , 59 1 F .3d 23

, 29

(1 st Ci r. 20 09 ) (h ol di ng th at reg is te red nu rs e se rv e d in a po si ti on of pu bl ic tru st ).

And Rai ne s’s rol e as a m ed ic al pro fes si on al “ si gn ifi can tl y faci li ta te d” he r ab il it y to

ai d th e co ns pi racy, whi ch rev ol ve d aro un d th e il le gi ti m at e di sp en si ng of dr ug s. The

di st ric t co ur t d id no t er r in it s d et erm in at io n.

3. S ub st an ti ve Rea so na bl en es s o f t he Se nt en ces

A se nt en ci ng co ur t “ ab us es it s di sc ret io n if it fai ls to co ns id er a rel ev an t fact or

th at sh ou ld ha ve rece iv ed si gn ifi can t weig ht

, gi ve s si gn ifi can t weig ht to an im pr op er

or irr el ev an t fact or

, or co ns id ers on ly th e ap pr op ria te fact or s bu t co m m it s a cl ear erro r

of jud g men t i n weig hi ng th os e fact or s.” Uni te d St at es v. W at so n

, 48 0 F.3 d 11 75

,

11 77 (8 th Ci r. 20 07 ) ( c i t i n g Uni te d St at es v. Haack

, 40 3 F.3 d 99 7, 10 04 (8 th Ci r.

-1 6-20 05 )). A se nt en ce wit hi n th e Gui de li ne s ran ge is pr es um pt iv el y reas on ab le

. Id

. (ci ti ng Uni te d S ta te s v . Lin co ln , 41 3 F .3d 71 6, 7 18 (8t h C ir. 2 00 5) ).

Rai ne s’ s w ith in- G uid el ine s se nte nc e w as subs ta nti ve ly reas on ab le

. The di st ric t

co ur t ad eq ua te ly ex pl ai ne d it s se nt en ce, ev en no ti ng th at it was a pp ro pr ia te wit h o r

wit ho ut th e ex is te nc e o f th e Gui de li ne s i n l ig ht of th e qu an ti ty o f dr ug s th at Rai ne s

ha d he lp ed en te r he r co m

m un it y

. The di st ric t co ur t’s de ci si on no t to weig h m it ig at in g

fact or s as he av il y as Rai ne s “ wou ld ha ve pr efer red do es no t jus ti fy rev ers al .” Uni te d

St at es v. Br id ge s , 56 9 F .3d 37 4, 3 79 (8t h C ir. 2 00 9)

.

Kin g’s se nt en ce was al so su bs ta nt iv el y reas on ab le

. T h e d i s t ric t co ur t

art ic ul at ed it s op in io n th at Kin g’s ro le as a recr ui te r who co nn ect ed us ers fro m acro ss

th e st at e of Ark an sa s wit h th e pi ll m il l de s e rv ed a st ro ng er se nt en ce th an th at

co nt em pl at ed by th e Gui de li ne s. The co ur t no te d th at th e se nt en ce was de si gn ed to

ad dr es s th e ne ed s of the pa rti cu la r of fen de r, gi ve n Ki ng ’s dai ly vio la ti on of th e la w

an d th e da m ag e cau se d to t h e c o mm un it y

. Und er th es e ci rcu m st an ces

, an up ward

va ria nc e o f 23 m on th s was no t an ab us e o f di sc ret io n.

II I. Con cl us io n

W e aff irm th e jud gm en ts of t he di st ric t co ur t.

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