Opinion ID: 6330205
Heading Depth: 4
Heading Rank: 1

Heading: The Drug-Involved Premises Convictions

Text: The four defendants were each charged with one to three counts of maintaining a druginvolved premises under 21 U.S.C. § 856(a)(1). They were also charged for these offenses under 18 U.S.C. § 2, which imposes liability under an aiding and abetting theory. Hofstetter was convicted of three counts, Clemons of two, and Newman and Womack of one each. All four defendants argue that there was insufficient evidence to support their convictions. To support a conviction under § 856(a)(1), the government needed to prove, beyond a reasonable doubt, that the defendants “knowingly open[ed], lease[d], rent[ed], use[d], or maintain[ed] any place, whether permanently or temporarily,” for the purpose of illegally distributing controlled substances. United States v. Elenniss, 729 F. App’x 422, 428 (6th Cir. 2018) (quoting 21 U.S.C. § 856(a)(1)); see also United States v. Russell, 595 F.3d 633, 644 (6th Cir. 2010).
First, the government submitted significant circumstantial evidence that would allow a reasonable jury to conclude that the defendants knew they maintained or used the clinics to distribute controlled substances illegally. For example, none of the clinics accepted insurance, and each charged a flat cash fee of $300 to $350 per appointment. Third parties often paid other patients’ fees, and groups of patients sometimes arrived together in a single car, often from outof-county. The waiting rooms were frequently crowded to standing room only, and patients commonly waited hours for appointments. Additionally, former patients testified that they went to the clinics while exhibiting symptoms of drug withdrawal, appearing “high” or “junked out.” (Trial Tr., R. 922, PageID 66038–40; Trial Tr., R. 923, PageID 66206.) The signs of addiction were “obvious.” (Trial Tr., Nos. 20-6245/6426/6427/6428 United States v. Hofstetter, et al. Page 16 R. 921, PageID 65599.) One witness said the parking lot “looked more like . . . a place where people go to get high versus go to obtain a prescription.” (Trial Tr., R. 924, PageID 66518–19.) A former staff member testified that, on his first day, he found a crowd of people waiting for the Lenoir City clinic to open, who were “all talking to each other about [which provider] . . . would get them the most medicine.” (Trial Tr., R. 936, PageID 74712, 74722–23.) The Gallaher View and Lovell Road clinics received complaints that the clinics’ customers engaged in petty crimes and drug deals and discarded syringes in the clinic parking lots. The clinics also allegedly fostered criminal activity among the staff members, who engaged in kickback schemes from pharmaceutical companies and drug-testing laboratories in return for their business. Staff members also accepted bribes from patients in return for their help in passing drug tests or skipping long wait times. Other former staff members quit the clinics shortly after being hired. For example, a former physician’s assistant quit after just six weeks on the job. She testified: “You go into a clinic like that, and you see all of the irregularities. You see all of the different things happening. You look at the patients. You put it all together. . . . [T]hat place did not follow medical standard of care.” (Trial Tr., R. 919, PageID 65328–29.) She drew these conclusions without having any previous pain management experience. Former clinic medical directors echoed these concerns, sometimes raising them with Hofstetter directly. For example, former medical director Dr. Marc Valley prepared a report outlining all the problems of the clinics—including prescriptions that had “no purpose in chronic pain management” and diagnoses that did not support the use of controlled substances. (Gov’t Trial Ex. 498, R. 1188-7, PageID 81135.) His report concluded: “This clinic fits all criteria for the definition of ‘Pill Mill.’ . . . . [T]his is the most egregious example of inappropriate medical oversight and opioid management that I have ever seen.” (Id. at PageID 88136–37.) He gave the report to Hofstetter. It is true, as the defendants emphasize, that some of the government’s witnesses testified only about one particular clinic and not about the others. Other witnesses did not know or interact with each defendant. And still others did not notice illegal or concerning activity at the Nos. 20-6245/6426/6427/6428 United States v. Hofstetter, et al. Page 17 clinics. But we cannot reweigh the evidence, reevaluate witness credibility, or prioritize our judgment over the jury’s, so these discrepancies do not counsel in favor of reversal. Callahan, 801 F.3d at 616. It is also true that the government did not produce any direct evidence that Clemons, Womack, and Newman knowingly used the clinics for the purpose of illegal drug activity. But this is irrelevant. Circumstantial evidence, on its own, is sufficient to sustain a conviction. LaVictor, 848 F.3d at 456. And here, there is certainly enough circumstantial evidence to support the jury’s conclusion that the defendants “would know that the clinics in this case were pill mills, and by choosing to associate themselves with the clinics, . . . [they] agreed to assist in the diversion of opioids to drug addicts and drug dealers.” (Trial Tr., R. 885, PageID 60983.)
A defendant need not lease or own the building to “maintain” it under the second element. Russell, 595 F.3d at 644. Instead, “control, duration, acquisition of the site, renting or furnishing the site, repairing the site, supervising, protecting, supplying food to those at the site, and continuity” all evince “maintenance.” Id. (emphasis added). The government submitted sufficient evidence to show that Hofstetter supervised the clinics. She oversaw the clinics as office manager and part owner by administering daily operations and managing personnel. She controlled the clinics by instructing staff to modify medical records and directing employees without medical licenses to attend to patients. The record also sufficiently supports a finding that Clemons, Newman, and Womack “used” the clinics for the purpose of distributing controlled substances illegally. Section 856(a)(1) “uses the disjunctive conjunction ‘or’ between the listed alternative ways of violating the statute, [so] § 856(a)(1) is violated simply by using a place for the commission of the specified drug crimes; proof that the defendant ‘maintain[ed]’ the premises, which is a separate way of violating the statute, is not necessary for conviction.” United States v. Facen, 812 F.3d 280, 289 (2d Cir. 2016). Thus, whether the government proved that Clemons, Newman, and Womack “maintained” the premises is not the sole inquiry; we must also consider whether the defendants used the premises for the purpose of illegal drug distribution. Nos. 20-6245/6426/6427/6428 United States v. Hofstetter, et al. Page 18 The government showed that Clemons, Newman, and Womack each used the clinics to write hundreds of prescriptions for opioids and benzodiazepines during their tenures at the clinics, and in roughly the same proportion: 54 to 57 percent of their prescriptions were for oxycodone, 24 to 33 percent for oxymorphone, and 8 to 14 percent for morphine. Non-opioid, non-benzodiazepines accounted for less than three percent of their prescriptions. Drawing the evidence in the light most favorable to the prosecution, the jury could have reasonably concluded that Hofstetter maintained the clinics, and Clemons, Newman, and Womack used the clinics, to distribute drugs illegally.
To prove the last element, the government was required to show that each defendant “was significantly motivated to maintain [or use] the premises for drug-related purposes.” United States v. Serrano-Ramirez, 811 F. App’x 327, 339 (6th Cir. 2020); see also Russell, 595 F.3d at 642 (finding that a defendant maintains or uses a place “for the purpose of” distributing drugs if the “drug distribution was a significant or important reason”). There must also be sufficient evidence that the controlled substances were distributed illegally, or “without a legitimate medical purpose.” United States v. Chaney, 921 F.3d 572, 591 (6th Cir. 2019). Sufficient evidence supports this element as to each defendant. When Hofstetter opened her own clinic with Tipton at Lovell Road, she instructed her staff to solicit patients that had been discharged from other pain clinics for signs of drug abuse, such as displaying “track marks” or testing positive for illegal drugs. (Trial Tr., R. 906, PageID 76749.) Hofstetter used this strategy to build much of the initial patient base at Lovell Road. The government also submitted evidence that Hofstetter prioritized profit over patient care: she limited appointments to 15 minutes, she instructed staff members with no medical training to fill out patient charts, and she generally focused on getting “the patients . . . in there and paying their fee.” (Trial Tr., R. 906, PageID 76794.) Sufficient evidence also supports the jury’s finding that Clemons, Newman, and Womack used the clinics for the purpose of distributing opioids unlawfully. In addition to the number of opioid prescriptions that they issued (in the same proportions, described above), Dr. John Everett Nos. 20-6245/6426/6427/6428 United States v. Hofstetter, et al. Page 19 Blake—an anesthesiologist and pain management physician—testified that high-dose opioids accounted for the vast majority of treatment offered at the clinics, and that none of the opioid prescriptions he reviewed in about 90 patient files were written for a legitimate medical purpose. Another expert witness testified that none of the files he reviewed contained the necessary elements of a medical chart, noting that medical histories and results from physicals, diagnoses, and treatment plans all fell below the standard of care. See infra part II.D.ii. And former patients testified that they visited the clinics to obtain opioids to feed their addictions or to resell. Moreover, former staff member Stephanie Puckett testified that she and another staff member participated in one of the pharmaceutical kickback schemes, where they received a payout each time they prescribed a specific pain cream. Because Puckett and the other staff member could not write prescriptions themselves, they asked Clemons, Newman,4 and Womack to participate in the scheme and, according to Puckett, all three women agreed. Womack even allegedly signed a blank prescription for the pain cream, so that Puckett could copy it and place them in the file of every Womack patient with insurance. Clemons, Newman, and Womack highlight that some of the clinics’ former patients testified that they did experience chronic pain and needed medication to control it. But this argument does not change our analysis because: [W]e look at a provider’s reason for issuing the prescription when determining whether it was issued for a legitimate medical purpose, rather than the patient’s underlying conditions . . . a [provider] prescribing opioid painkillers to anyone walking through the door is not saved if a person happens to have an underlying condition that could justify the prescription. Chaney, 921 F. 3d at 590–91 (collecting similar cases). Clemons, Newman, and Womack also emphasize that some witnesses testified that the defendants acted professionally and ethically with respect to prescriptions. And Dr. Blake testified that reasonable minds could differ as to the standard of care offered by the providers, in 4Newman disputes that the trial record supports an inference of her involvement in this scheme. Specifically, she highlights Puckett’s recross-examination testimony as demonstrating that Newman was not involved. Newman’s argument, however, distorts the scope of the recross-examination, and a reasonable jury could have viewed Puckett’s testimony as implicating Newman. Nos. 20-6245/6426/6427/6428 United States v. Hofstetter, et al. Page 20 part because the Tennessee guidelines at the time did not limit the amount of medication that could be prescribed to a patient. In essence, with these challenges, Clemons, Newman, and Womack ask us to weigh some testimonies over others and to assess witness credibility, which we may not do when considering the sufficiency of the evidence on appeal. Emmons, 8 F.4th at 478. There was sufficient evidence for a reasonable jury to conclude that the evidence proved each element of this offense, and we affirm the defendants’ convictions.