Opinion ID: 3153469
Heading Depth: 2
Heading Rank: 7

Heading: Dr. Azmat’s Expert

Text: Dr. Thomas Simopoulos testified as Dr. Azmat’s expert witness in pain management. After reviewing the patient files maintained by Dr. Azmat, Dr. Simopoulos concluded that Dr. Azmat obtained suitable medical histories, conducted appropriate physical exams, obtained patients’ prescription histories, and created suitable treatment plans. He stated that, in his opinion, Dr. Azmat prescribed controlled substances in each case for a legitimate medical purpose and in the regular course of medical treatment. Dr. Simopoulos explained that there was no standard measure for how much pain medication a doctor should prescribe, and Dr. Azmat appeared to be exercising clinical judgment when he provided patients with strong opioids in large supply. Dr. Simopoulos stated that there was no evidence of addictive patient behavior in Dr. Azmat’s medical records. Furthermore, it did not seem that 18 Case: 14-13703 Date Filed: 11/10/2015 Page: 19 of 60 Dr. Azmat was acting like a drug dealer because he was examining patients and decreasing their medications, rather than simply handing them prescriptions upon arrival. The fact that Dr. Azmat prescribed all of his patients oxycodone was not unusual because oxycodone is one of the most commonly prescribed opioids. Speaking generally about pain management, Dr. Simopoulos stated that a typical patient examination includes a discussion of the patient’s medical history and a physical exam. The physical should include looking at the patient’s body, testing the range of motion, and assessing any weakness. A physician should assess whether patients are accurately describing their level of pain, but there is no way for the physician to be sure whether the patient is telling the truth. It is common for patients to try to fool doctors in order to obtain medication. It is also typical that patients seeking pain management physicians are already medicated, and it may be necessary to keep providing such patients with high dosages of medications because they have built up drug tolerances from sustained use. Finally, Dr. Simopoulos stated that many small medical clinics deal in cash, and it is not unusual for a doctor to prescribe medication based on a complaint of pain together with an MRI showing an injury. On the other hand, Dr. Simopoulos stated that, when a patient travels a great distance to visit a pain clinic, or claims that he is already taking a medication but that medication does not show up in a urine sample because (1) the patient is not 19 Case: 14-13703 Date Filed: 11/10/2015 Page: 20 of 60 taking the pills as prescribed and has run out or (2) the patient is diverting the pills to another person, the treating doctor should be cautious of addiction. Similarly, while requiring patients to sign opioid agreements is a standard practice, requiring the patient to sign the agreement before seeing a doctor implies that opioid treatment is part of the clinic’s “treatment protocol.” Dr. Simopoulos also described several approaches, other than medication, that pain management doctors use to treat chronic pain patients. In his medical practice, when he encounters a patient with an addiction, he refers the patient to an addiction specialist. Having reviewed the trial evidence, we turn to the issues on appeal. IV. UNLAWFUL DISPENSATION OF CONTROLLED SUBSTANCES As a threshold issue, Dr. Azmat advances a statutory interpretation argument, contending that his writing prescriptions, even if for illegal purposes, did not constitute “dispensing” them under 21 U.S.C. § 841(a)(1). Thus, Dr. Azmat argues that, as a matter of law, he is not guilty of (1) unlawfully dispensing controlled substances, in violation of § 841(a)(1), or (2) conspiring to illegally dispense controlled substances, in violation of §§ 841(a)(1) and 846. We review the statute and then our relevant case law. A. 21 U.S.C. §§ 802 and 841(a)(1) Except as authorized by the Controlled Substances Act (“CSA”), it is “unlawful for any person knowingly or intentionally to manufacture, distribute, or 20 Case: 14-13703 Date Filed: 11/10/2015 Page: 21 of 60 dispense . . . a controlled substance.” 21 U.S.C. § 841(a)(1). The CSA contains definitions in § 802 and defines “dispense” as follows: The term “dispense” means to deliver a controlled substance to an ultimate user or research subject by, or pursuant to the lawful order of, a practitioner, including the prescribing and administering of a controlled substance and the packaging, labeling, or compounding necessary to prepare the substance for such delivery. Id. § 802(10) (emphasis added). “The terms ‘deliver’ or ‘delivery’ mean the actual, constructive, or attempted transfer of a controlled substance.” Id. § 802(8) (emphasis added). Thus “dispense” means constructive transfer of a controlled substance to a user by prescribing it. In contrast, “‘administer’ refers to the direct application of a controlled substance to the body of a patient or research subject by (A) a practitioner (or, in his presence, an authorized agent), or (B) the patient or research subject at the direction and in the presence of the practitioner.” Id. § 802(2). Finally, “‘distribute’ means to deliver (other than by administering or dispensing) a controlled substance.” Id. § 802(11). B. Dr. Azmat’s Arguments Dr. Azmat advances two interpretations of § 841(a)(1) and its attendant definitions in § 802. He first claims that a doctor who writes a prescription for an illegitimate purpose is guilty of unlawful “distribution” of a controlled substance, not unlawful “dispensation.” Dr. Azmat argues that, in order to “dispense” a 21 Case: 14-13703 Date Filed: 11/10/2015 Page: 22 of 60 controlled substance, under the definition stated in § 802(10), the “practitioner” must “deliver” the controlled substance to the user. According to Dr. Azmat, “delivery” occurs only when a practitioner (1) prescribes and administers the controlled substance, and/or (2) packages, labels, or compounds the controlled substance. Dr. Azmat contends that writing a prescription does not complete the physical exchange of medication, and thus a prescription does not “dispense” it. Next, Dr. Azmat argues that a physician can never be guilty of unlawfully “dispensing” a controlled substance because § 802(10) presupposes that “delivery” occurs by means of a “lawful order.” If the order is not lawful, the offense is “distribution.” C. Circuit Precedent Dr. Azmat’s arguments wholly fail in light of our prior decisions. In United States v. Leigh, the former Fifth Circuit held for the first time that “a doctor who administers or prescribes a controlled substance is, for the purposes of the statute, dispensing it . . . .” 3 487 F.2d 206, 208 (5th Cir. 1973) (emphasis added). Our subsequent decisions have followed this precedent, and this Court has consistently affirmed defendants’ convictions for unlawfully “dispensing” controlled substances–by virtue of writing prescriptions–on the ground that “prescribing” 3 We have adopted as binding precedent all decisions of the former Fifth Circuit handed down prior to October 1, 1981. Bonner v. City of Prichard, 661 F.2d 1206, 1209 (11th Cir. 1981) (en banc). 22 Case: 14-13703 Date Filed: 11/10/2015 Page: 23 of 60 constitutes “dispensing.” See, e.g., United States v. Joseph, 709 F.3d 1082, 1088, 1098, 1105 (11th Cir. 2013) (upholding a physician’s convictions for unlawfully dispensing and distributing controlled substances by means of writing prescriptions); United States v. Ignasiak, 667 F.3d 1217, 1219, 1227-29 (11th Cir. 2012) (upholding the sufficiency of the evidence for a physician’s convictions for unlawfully dispensing controlled substances by virtue of writing prescriptions); United States v. Thompson, 624 F.2d 740, 741-42 (5th Cir. 1980) (stating that a doctor is properly indicted for unlawful dispensation when he prescribes a controlled substance outside of the usual course of professional practice and not for a legitimate medical purpose). Moreover, this Court has explicitly rejected Dr. Azmat’s theory that “dispensing” is always a lawful activity. See Joseph, 709 F.3d at 1098 (“We reject the argument that, under the Act, all acts to dispense prescriptions are lawful and all acts to distribute prescriptions are unlawful.”). Notably, other circuits agree that issuing written prescriptions to patients that enable them to obtain controlled substances constitutes “dispensing” under § 841(a)(1). United States v. Roya, 574 F.2d 386, 393 (7th Cir. 1978) (“Thus, ‘dispense’ includes constructive transfers which encompass Roya’s actions of issuing written prescriptions to patients entitling them to purchase the substances from a pharmacy”); United States v. Tighe, 551 F.2d 18, 21 (3d Cir. 1977) (“[W]e hold that by placing a prescription for a controlled substance, issued outside of the 23 Case: 14-13703 Date Filed: 11/10/2015 Page: 24 of 60 usual course of medical practice, in the hands of an ultimate user a physician completes the offense of dispensing under 21 U.S.C. § 841(a)(1).”). These circuits rely on a constructive-delivery theory. See Roya, 574 F.2d at 393; Tighe, 551 F.2d at 21 (“[A] prescription is the written representation of the drug and enables its possessor to claim physical custody and control over the drug prescribed.”). This Court has implicitly relied on this constructive-delivery reasoning in our prior decisions and we expressly do so now: When a physician writes a patient a prescription for a controlled substance, the physician is constructively transferring the controlled substance to the patient, thereby accomplishing the delivery required for dispensation under § 802(10). See 21 U.S.C. § 802(8) (stating that the statutory term “delivery” includes the constructive transfer of a controlled substance). 4 D. Statutory Interpretation Anew Alternatively, even viewing Dr. Azmat’s interpretations on a clean slate, we would conclude that they are unsupported by the CSA’s language. The more natural reading of § 802(10) is that “dispensing” occurs when a practitioner 4 But see United States v. Black, 512 F.2d 864, 866 (9th Cir. 1975) (holding that a physician who wrote unlawful prescriptions was guilty of “distributing” controlled substances–as opposed to “dispensing”–because the term “‘dispense’ expressly contemplates a ‘lawful order,’” meaning that a “‘practitioner’ who dispenses does not violate the Act”); United States v. Badia, 490 F.2d 296, 297-99 (1st Cir. 1973) (holding that a doctor was properly convicted of “distributing” controlled substances–based on his act of selling prescriptions–because “distribution” is the “[d]elivery of controlled substances outside the course of professional practice or research,” whereas “dispensation” is limited to the delivery of a controlled substance “by a physician who is acting in the course of professional practice or research”). 24 Case: 14-13703 Date Filed: 11/10/2015 Page: 25 of 60 “delivers” a controlled substance to a user. See id. § 802(10). In turn, the “delivery” may be a constructive transfer and may be carried out by various methods including (1) prescribing the medication, (2) administering the medication, (3) packaging, labeling, or compounding the medication as necessary to prepare it for delivery, or (4) other methods not listed in the § 802(10) statute. See id.; Stansell v. Revolutionary Armed Forces of Colom., 704 F.3d 910, 915 (11th Cir. 2013) (noting that the term “‘include’ is merely illustrative”). In addition to the fact that Dr. Azmat’s reading of § 802(10) twists the statute’s plain language, his argument falls on its own sword. Dr. Azmat asserts that prescribing a medication does not complete the “delivery” required by § 802(10). Dr. Azmat then claims that because a prescription does not “deliver” a controlled substance, a doctor who writes a prescription does not dispense a “controlled substance”–rather, the doctor “distributes” the controlled substance. One obvious flaw in this argument is that the term “deliver” also appears in the definition of “distribution.” See 21 U.S.C. § 802(11). As there is a presumption that a “term is used to mean the same thing throughout a statute,” Barber v. Thomas, 560 U.S. 474, 483-84, 130 S. Ct. 2499, 2506 (2010) (quotation marks omitted), Dr. Azmat’s interpretation would compel us to conclude that “delivery,” as used in the offense of unlawful “distribution,” does not include writing a prescription, either. Therefore, contrary to Dr. Azmat’s assertion, under 25 Case: 14-13703 Date Filed: 11/10/2015 Page: 26 of 60 his own framework, the act of prescribing a controlled substance without a legitimate medical purpose can never be criminal under § 841(a)(1). As we are hard pressed to decide that Congress did not intend to criminalize this act, we have further reason to reject Dr. Azmat’s arguments. V. SUFFICIENCY OF EVIDENCE OF UNLAWFUL DISPENSATION Having reaffirmed that prescribing a controlled substance is “dispensing,” we turn to the sufficiency of the evidence as to Dr. Azmat’s convictions for unlawfully dispensing controlled substances and conspiring to unlawfully dispense controlled substances. Having outlined the trial evidence above, we readily conclude that the evidence supported the jury’s verdict on these charges. A. Standard of Review We review the sufficiency of the evidence de novo when, as here, the defendant has preserved his claim by moving for a judgment of acquittal. United States v. Jiminez, 564 F.3d 1280, 1284 (11th Cir. 2009). We examine “whether the evidence, when viewed in the light most favorable to the government, and accepting reasonable inferences and credibility choices by the fact-finder, would enable the trier of fact to find the defendant guilty beyond a reasonable doubt.” United States v. Monroe, 866 F.2d 1357, 1365 (11th Cir. 1989). A conviction must be affirmed unless there is “no reasonable construction of the evidence” from 26 Case: 14-13703 Date Filed: 11/10/2015 Page: 27 of 60 which the jury could have found the defendant guilty beyond a reasonable doubt. United States v. Garcia, 405 F.3d 1260, 1269 (11th Cir. 2005). In order to secure a conviction for unlawful dispensation under § 841(a)(1), the government must prove that the defendant “dispensed controlled substances for other than legitimate medical purposes in the usual course of professional practice, and that he did so knowingly and intentionally.” Ignasiak, 667 F.3d at 1227. To establish a conspiracy in violation of § 846,5 the government must prove beyond a reasonable doubt that: (1) there was an agreement between two or more people to commit a crime (in this case, unlawfully dispensing controlled substances in violation of § 841(a)(1)); (2) the defendant knew about the agreement; and (3) the defendant voluntarily joined the agreement. Monroe, 866 F.2d at 1365. The existence of an agreement may “be proved by inferences from the conduct of the alleged participants or from circumstantial evidence of a scheme.” United States v. Mateos, 623 F.3d 1350, 1362 (11th Cir. 2010) (quotation marks omitted). A conspiracy conviction will be upheld if “the circumstances surrounding a person’s presence at the scene of conspiratorial activity are so obvious that knowledge of its character can fairly be attributed to him.” United States v. Figueroa, 720 F.2d 1239, 1246 (11th Cir. 1983). 5 Section 846 provides that “[a]ny person who attempts or conspires to commit any offense defined in this subchapter shall be subject to the same penalties as those prescribed for the offense, the commission of which was the object of the attempt or conspiracy.” 21 U.S.C. § 846. 27 Case: 14-13703 Date Filed: 11/10/2015 Page: 28 of 60 B. Analysis Simply put, there was overwhelming evidence that Dr. Azmat knowingly and voluntarily joined an agreement to unlawfully dispense controlled substances. See Monroe, 866 F.2d at 1365. First, from the testimony concerning Dr. Azmat’s conduct, the jury reasonably could infer that Dr. Azmat was participating in the conspiracy. See Mateos, 623 F.3d at 1362. Before Dr. Azmat accepted the position, LeFrancois told Dr. Azmat that he had previous experience in a Florida pill mill and East Health Center would be the same kind of operation. LeFrancois also explained that patients would be expecting oxycodone. Dr. Azmat’s response to LeFrancois was that he had experience in pain management and could “take care of everything.” As noted earlier, Dr. Azmat also admitted to Investigator Sikes that many of the people who he saw were addicted to oxycodone, and he consistently referred to them as “customers” instead of “patients.” Moreover, Dr. Azmat’s interactions with the patients suggested that he was involved in the conspiracy. Investigator Sikes testified that Dr. Azmat prescribed 196 out of his 238 patients medications, and that 96 percent of the prescriptions were for oxycodone. The eight testifying patients generally reported that Dr. Azmat’s examinations were brief and sometimes involved no physical component. They described themselves as addicts during their testimony, and they stated that Dr. Azmat did not review their patient history forms before prescribing 28 Case: 14-13703 Date Filed: 11/10/2015 Page: 29 of 60 medications and appeared to ignore medical concerns–like high blood pressure— that could not justify prescribing opioids. Dr. Kennedy concluded that Dr. Azmat’s decision to prescribe controlled substances to each of the 25 patients included in the indictment was illegitimate. All of the witnesses with medical backgrounds also testified that there was an abundance of red flags that should have tipped off any doctor that his patients were seeking pills. These signs included the facts that: patients were traveling from out-of-state; patients appeared to be lying about whether they were already taking controlled substances; patients’ MRIs were unremarkable and obtained without a doctor’s referral; patients appeared to be inflating their pain levels; and patients consented to opioid treatment before coming into the examination room. Indeed, upon learning some of this information about East Health Center’s clientele, Drs. Ross and Hatmaker both declined employment and contacted law enforcement officials because they were suspicious of the clinic’s activities. In addition, the jury could reasonably have concluded that Dr. Azmat had knowledge of the conspiracy due to his presence at East Health Center. See Figueroa, 720 F.2d at 1246. Many witnesses testified that the clinic did not look like a legitimate medical office. It had minimal medical supplies and the patients looked like addicts or “zombies.” Dr. Azmat also had some awareness of the clinic’s unusual marketing tactics, believed that the patients paid in cash, knew that 29 Case: 14-13703 Date Filed: 11/10/2015 Page: 30 of 60 he did not have the proper medical malpractice insurance, and accepted his salary in daily cash installments. Finally, both expert witnesses testified that Dr. Azmat’s records showed that he prescribed each patient listed in the indictment oxycodone, hydrocodone, and/or alprazolam. Dr. Kennedy concluded that the prescriptions in each case were not dispensed for a legitimate medical purpose or in the usual course of professional practice. We do not disturb the fact-finder’s reasonable credibility determinations, and here, the jury credited Dr. Kennedy’s professional opinions over Dr. Simopoulos’s conclusion that Dr. Azmat was acting appropriately under medical standards. See Monroe, 866 F.2d at 1365. The totality of this evidence was more than sufficient for the jury to determine that Dr. Azmat was aware that East Health Center was a pill mill and knowingly entered the conspiracy to dispense controlled substances, as evidenced by his unprofessional interactions with the patients and unwarranted prescriptions for opioids. Of course, there was countervailing testimony suggesting that Dr. Azmat’s patients had real injuries, that he was attempting to wean them off narcotics and was not overprescribing pills, that he was following medical guidelines but was simply fooled by people who lied about their prescription needs, and that he was attempting to bring East Health Center into compliance with 30 Case: 14-13703 Date Filed: 11/10/2015 Page: 31 of 60 official requirements. 6 However, the jury made a reasonable choice in finding that Dr. Azmat’s motives were not altruistic, and that Dr. Azmat knew that East Health Center was not a legitimate medical clinic and that the customers were addicts coming for opioids, not for medical purposes. See id. There was voluminous evidence supporting the jury’s conspiracy conviction, and we will not set it aside. For the same reasons, the 49 counts of conviction for substantive illegal dispensation to individual patients were supported by overwhelming evidence. The evidence was uncontroverted that Dr. Azmat dispensed controlled substances, and the jury reasonably concluded that Dr. Azmat knowingly and intentionally did so outside of the usual course of professional practice and for other than a legitimate medical purpose. See Ignasiak, 667 F.3d at 1227; Garcia, 405 F.3d at 1269. VI. SUFFICIENCY OF EVIDENCE OF CONSPIRACY TO LAUNDER MONETARY INSTRUMENTS The jury also found Dr. Azmat guilty of conspiracy to commit promotional money laundering under 18 U.S.C. § 1956(a)(1)(A)(i), which is a violation of § 1956(h). See 18 U.S.C. § 1956(h) (making it illegal to conspire to commit any money laundering offense described in § 1956). Promotional money laundering is 6 This testimony was also susceptible to an interpretation that Dr. Azmat was a sophisticated actor who attempted to give his actions an air of legitimacy in case the state investigated the clinic. 31 Case: 14-13703 Date Filed: 11/10/2015 Page: 32 of 60 using funds from an unlawful activity to promote the carrying out of said unlawful activity. United States v. Esquenazi, 752 F.3d 912, 935 (11th Cir.), cert. denied, 135 S. Ct. 293 (2014). Specifically, the indictment charged Dr. Azmat with conspiring to use the proceeds from unlawfully dispensing controlled substances to promote the pill mill’s illegal activities. In order to obtain a conviction for conspiracy to commit promotional money laundering, the government must prove beyond a reasonable doubt that (1) two or more persons agreed to promotionally launder money; and (2) the defendant, knowing the unlawful plan, voluntarily joined the conspiracy. United States v. Johnson, 440 F.3d 1286, 1294 (11th Cir. 2006). “The existence of an agreement may be proven by circumstantial evidence, including inferences from the conduct of the alleged participants or from circumstantial evidence of a scheme. Indeed, the government may establish knowledge of an illegal agreement by showing that the defendant knew the essential object of the conspiracy.” United States v. Silvestri, 409 F.3d 1311, 1328 (11th Cir. 2005). A. Evidence of Agreement We are unpersuaded by Dr. Azmat’s argument that the government failed to prove beyond a reasonable doubt that he knowingly agreed with any of his codefendants to launder money. The trial testimony showed that several of his codefendants agreed to dispense controlled substances in exchange for cash and 32 Case: 14-13703 Date Filed: 11/10/2015 Page: 33 of 60 then use the cash paid by patients to pay for the clinic’s lease, pay salaries, rent a house in which employees would live, pay for additional overhead costs (such as maintenance and cable), and open a bank account. By spending profits on these activities, the scheme participants reinvested the money earned from unlawfully dispensing drugs into the activities of East Health Center. This enabled them to continue seeing pill-seeking patients and enrich themselves by dispending controlled substances in exchange for money. While Dr. Azmat may not have been aware of all of the uses of the clinic’s proceeds, it was reasonable for the jury to infer that he knew that the cash was used to pay salaries and cover the clinic’s operating costs. See Monroe, 866 F.2d at 1365. Dr. Azmat reported to the office each day, where he could see that there were amenities like cable television, and he received a cash salary. Dr. Azmat also witnessed Wise counting cash at the end of the day and knew that the patients paid in cash. From this evidence, the jury could have readily concluded that Dr. Azmat knew that the patients’ money–which they paid for illegal prescriptions–was used to pay his salary and the salaries of those around him, in addition to supplying the clinic and paying the lease. See id. Likewise, the jury easily could have concluded that, having already agreed with LeFrancois to dispense medications outside the course of his usual professional practice to patients paying money to the clinic, and 33 Case: 14-13703 Date Filed: 11/10/2015 Page: 34 of 60 by continuing to work and generate profits, Dr. Azmat had knowingly joined a conspiracy to launder money, in which illegal proceeds were used to “promote” East Health Center’s drug-dispensing activities. See id. B. Separate Offense Dr. Azmat also claims that he could not be convicted of conspiring to launder money because he did nothing other than receive the cash proceeds of the underlying criminal activity. Dr. Azmat maintains that his convictions for unlawfully distributing controlled substances encompass his acts of receiving money in exchange for writing prescriptions, and that his receipt of daily cash payments was not a separate money laundering offense. In other words, Dr. Azmat contends that his receipt of cash payments merged with his crime of unlawfully dispensing controlled substances, and to convict him of conspiracy to promotionally launder money would be punishing him twice for the same conduct. Dr. Azmat’s argument misses the mark, however, as he was not convicted of substantive money laundering. His conviction was for joining a conspiracy to launder money, in which his co-conspirators used the proceeds from his crime of illegally dispensing controlled substances to maintain East Health Center’s operations, in order to continue reaching more patients and enriching themselves from additional pill-for-cash exchanges. The government did not have to prove that Dr. Azmat personally reinvested the illegal proceeds into the clinic’s criminal 34 Case: 14-13703 Date Filed: 11/10/2015 Page: 35 of 60 activities. See Whitfield v. United States, 543 U.S. 209, 214, 125 S. Ct. 687, 691 (2005) (“Because the text of § 1956(h) does not expressly make the commission of an overt act an element of the conspiracy offense, the Government need not prove an overt act to obtain a conviction.”); Silvestri, 409 F.3d at 1328. It was enough that he knowingly entered an agreement in which his co-conspirators did, or planned to do, the reinvesting. See Johnson, 440 F.3d at 1294. C. Underlying Funds Were Illegally Generated Dr. Azmat further argues that his conviction for conspiracy to illegally launder the proceeds from dispensing controlled substances cannot stand because East Health Center did not violate the law by “dispensing” controlled substances, as stated in the indictment. However, as discussed above, the activities undertaken at East Health Center constituted unlawful dispensation of controlled substances. Thus, the funds were illegal proceeds from those crimes and the funds were used to promote the pill mill. Dr. Azmat has shown no reversible error as to his conviction for conspiracy to commit promotional money laundering.