Opinion ID: 867984
Heading Depth: 1
Heading Rank: 1

Heading: sufficiency of the evidence

Text: Robert’s first argument on appeal is that there was insufficient evidence to support his convictions. He makes several claims in support of this argument. First, he argues that the government only proved that he was a bad or reckless doctor. He suggests that his practice was merely “sloppy” because he has multiple sclerosis. Second, he argues that the court improperly allowed the jury to find “guilt by association or as a result of a pattern.” Third, he argues that the evidence was insufficient because the government never established the appropriate standard of care and how much he deviated from that standard. This Court reviews a challenge to the sufficiency of the evidence de novo, viewing the evidence and making all reasonable inferences in the light most favorable to the government. United States v. Garcia, 405 F.3d 1260, 1269 (11th Cir. 2005). We must affirm the convictions “unless, under no reasonable construction of the evidence, could the jury have found the appellants guilty beyond a reasonable doubt.” Id. 3 Case: 11-15268 Date Filed: 05/15/2013 Page: 4 of 19 “[A]lthough [Robert] was convicted of both substantive fraud counts and dispensing controlled substances counts, the convictions are inextricably intertwined . . . . Thus, we evaluate the sufficiency of the evidence for the fraud and dispensing counts together . . . focusing upon the requirements under the CSA.” United States v. Ignasiak, 667 F.3d 1217, 1227 (11th Cir. 2012). To convict a physician licensed to prescribe controlled substances, such as Robert, under § 841 “it [is] incumbent upon the government to prove that he dispensed controlled substances for other than legitimate medical purposes in the usual course of professional practice, and that he did so knowingly and intentionally.” Id. at 1228 (quotation marks omitted); see also United States v. Tobin, 676 F.3d 1264, 1282 (11th Cir. 2012). There was ample evidence to support Robert’s convictions. Our precedent establishes that “conduct where an inordinately large quantity of controlled substances was prescribed, . . . large numbers of prescriptions were issued, . . . no physical examination was given, . . . . [and] that [the physician] knew or should have known that his patients were misusing their prescriptions” suggests that a defendant distributed a prescription without a legitimate medical purpose and outside the usual course of professional practice. United States v. Joseph, 709 F.3d 1082, 1104 (11th Cir. 2013) (quotation marks and alterations omitted). There was evidence that Robert engaged in this type of conduct. A Drug Enforcement 4 Case: 11-15268 Date Filed: 05/15/2013 Page: 5 of 19 Administration diversion investigator testified that between 2004 and 2008, Robert wrote 43,051 prescriptions for controlled substances. See Ignasiak, 667 F.3d at 1229 (finding that there was sufficient evidence in part based on the fact the defendant had “written more than 43,000 prescriptions for controlled substances over a five year period”). Also, a pharmacist testified that Robert typically prescribed the same three controlled substances to each patient and rarely prescribed any other medications. An expert who reviewed Robert’s files stated that there was scant initial history of the patients and “typically there was no documented evidence of any physical exam being done.” The government also pointed to circumstantial evidence that Robert knew or should have known that at least some of his patients were misusing their prescriptions. For example, there was evidence that “patients beg[a]n to demonstrate . . . aberrant behavior . . . with their use of their medicines” such as “coming back on . . . multiple episodes early,” and that some family members had called Robert’s office to ask him to stop writing prescriptions to addicted patients. Our review of the record also reveals other evidence supporting Robert’s convictions. For example, there was evidence that he continued to prescribe controlled substances to patients he knew had experienced withdrawal symptoms or who had overdosed in the past. Cf. Ignasiak, 667 F.3d at 1223 (noting, as a positive, the fact that the doctor had stopped prescribing controlled substances to a 5 Case: 11-15268 Date Filed: 05/15/2013 Page: 6 of 19 patient who became addicted and almost overdosed). Robert had a pattern of writing the same prescriptions for different patients, which could support a finding that there was not a “logical relationship between the drugs prescribed and treatment of the condition.” United States v. Rosen, 582 F.2d 1032, 1036 (5th Cir. 1978). 2 The government also presented an expert in prescribing controlled substances, Dr. Parran. He reviewed the medical files of patients who were the subject of the indictment, as well as other patient files. Dr. Parran testified that “the prescribing on [each charged] occasion was done in a way that was inconsistent with the usual course of medical practice and for other than legitimate medical purpose.” Unlike the trial in United States v. Tran Trong Cuong, 18 F.3d 1132 (4th Cir. 1994), which Robert suggests is analogous, Dr. Parran specifically discussed the medical file of each patient charged in the indictment, including those who did not testify, commented on the prescriptions they received, and made individual assessments about their treatment. See id. at 1141. “Further, the fact the jury acquitted [Robert] of several counts . . . sufficiently minimizes the risk identified in Cuong that [Robert’s] jury merely convicted him based only upon ‘guilt by association.’” Ignasiak, 667 F.3d at 1229 (quoting Cuong, 18 F.3d at 1142). Certainly the case would have been stronger if Dr. Parran had examined 2 In Bonner v. City of Prichard, 661 F.2d 1206 (11th Cir. 1981) (en banc), we adopted as binding all decisions of the former Fifth Circuit handed down before October 1, 1981. Id. at 1209. 6 Case: 11-15268 Date Filed: 05/15/2013 Page: 7 of 19 more of the charged patients or more of the charged patients testified, but we easily conclude there was sufficient evidence to support the jury’s guilty verdicts. See id. at 1228–29. Finally, despite Robert’s protests to the contrary, there was also sufficient evidence regarding the appropriate standard of care. For example, Dr. Parran testified generally about the usual course of professional practice. Also, and significantly, the 2002–2011 executive director for the Florida Board of Medicine told the jury about the Florida Statutes that authorized physicians to prescribe controlled substances and set out the standard of care. He testified as well as to the Florida Board of Medicine’s rules regarding the prescription of controlled substances. On cross-examination, he read into evidence parts of Florida Administrative Code Rule 64B8-9.013, which address the use of controlled substances for pain management. From this testimony together with the evidence of Robert’s prescribing practices, the jury could have fairly concluded that Robert “prescribed controlled substances not in the usual course of his medical practice and was acting other than for a legitimate medical purpose.” Joseph, 709 F.3d at 1103 (quotation marks omitted).