Opinion ID: 64036
Heading Depth: 1
Heading Rank: 2

Heading: illegal dispensation of controlled substances

Text: Armstrong and Dr. Cullins argue that because the Government failed to present expert testimony regarding what the professional standard of care should be for a physician prescribing controlled substances to chronic pain patients, there was insufficient evidence for the jury to find beyond a reasonable doubt that Appellants' conduct was outside the course of professional conduct.
In evaluating whether the evidence produced at trial is sufficient to support a jury conviction, this Court examines whether a rational jury, viewing the evidence in the light most favorable to the prosecution, could have found the essential elements of the offense to be satisfied beyond a reasonable doubt. See United States v. Miles, 360 F.3d 472, 476-77 (5th Cir.2004). In reviewing the evidence, all reasonable inferences are drawn in favor of the jury's verdict. Id. This Court does not evaluate whether the jury's verdict was correct, but rather, whether the jury's decision was rational. Id. If the evidence gives `equal or nearly equal circumstantial support to a theory of guilt or innocence, we must reverse the conviction, as under these circumstances a reasonable jury must necessarily entertain a reasonable doubt.' United States v. Rivera, 295 F.3d 461, 466 (5th Cir.2002) (internal citations omitted).
The evidence presented at trial, viewed in the light most favorable to the Government, supports the jury's guilty verdicts as to Armstrong and Dr. Cullins on the conspiracy charge under § 846 (count one) and on the substantive violations under § 841 (counts 2-27). Even without expert testimony, the Government demonstrated at trial that Armstrong and her co-conspirators organized and ran a continuous scheme of delivering controlled substances to a high volume of individuals for profit rather than a valid medical purpose. Although Armstrong and Dr. Cullins argue that the Government did not meet its evidentiary burden because it did not put on expert testimony, expert testimony is not always required in order to show that a physician is acting for other than proper medical purposes [in violation of § 841]. United States v. Chin, 795 F.2d 496, 503 (5th Cir.1986) (citing United States v. Rosen, 582 F.2d 1032, 1037 n. 10 (5th Cir. 1978)). While expert testimony may be both permissible and useful, a jury can reasonably find that a doctor prescribed controlled substances not in the usual course of professional practice or for other than a legitimate medical purpose from adequate lay witness evidence surrounding the facts and circumstances of the prescriptions. United States v. Rogers, 609 F.2d 834, 839 (5th Cir.1980). There are § 841 cases in which the trier of fact does not need outside, specialized knowledge to understand the evidence or determine the facts. [10] See United States v. Word, 806 F.2d 658, 663-64 (6th Cir.1986) (finding that expert testimony about the usual course of professional conduct and legitimate medical purposes may help a jury, it was not necessary on the facts of the case on appeal); United States v. Smurthwaite, 590 F.2d 889, 892 (10th Cir.1979) (finding expert testimony unnecessary to prove prescriptions were outside of professional practice where evidence included visits less than five minutes in length, charging patients per prescriptions, little or no physical examination of patients at initial or follow-up visits, and defendant had some knowledge that prescriptions pills were used for parties rather than weight-loss); United States v. Larson, 507 F.2d 385, 387 (9th Cir.1974) (similar). Jurors have had a wide variety of their own experiences in doctors' care over their lives, thus and expert testimony is not necessarily required for jurors to rationally conclude that seeing patients for as little as two or three minutes before prescribing powerful narcotics is not in the usual course of professional conduct. There are also undoubtably situations where evidence as to the usual course of professional conduct might be essential proof of the Government's case. But here there is ample evidence of conduct outside the usual course of any professional practice and/or without medical purpose. Specifically, the Government presented evidence of: (1) long-term rather than short-term treatment, which conflicted with the clinics' own medical guidelines regarding chronic pain management; [11] (2) an extremely high volume of patients seen each day (as many as 300 patients in a four-to-six hour time frame); (3) short durations for patient visits; [12] (4) a lack of individualization of the prescriptions; [13] (5) prescriptions prepared in advance requiring only the doctor's signature; (6) phony pre-printed doctor's medical comments placed in patient files; (7) a lack of meaningful physical examination on initial and repeat visits; [14] (8) a lack of required documentation of a physical injury; (9) false documentation and outdated MRIs presented by patients and accepted by treating physicians who continued to dispense the trinity drugs; (10) sham physical therapy sessions; [15] (11) a cash-only payment policy; and (12) clinic-hopping among Armstrong's clinics. [16] Dr. Guenther also testified that each time he attempted to discuss clinic problems with Armstrong, such as the lack of physical therapy or clinic-hopping, Armstrong told him that she would take care of it, although no changes were made, and on one such occasion Armstrong suggested Dr. Guenther simply stop taking notes. Such evidence demonstrates conduct outside of the usual course of professional practice. And although the Government failed to present expert testimony regarding the recognized practices of chronic pain management facilities, the jury did hear from fact witnesses about their discomfort with the clinics' operations. Dr. Hope Ewing testified that within an hour of meeting Armstrong about bringing her pain management patients to the clinics, she had a strong feeling that this was not a suitable place for pain management, because she was told that she would have to see six to seven patients an hour, which she believed was insufficient for pain management. The Government also presented testimony of two physicians detailing the irregularities that caused them to stop working at the clinics. Dr. Michael Hunter, who quit after only a month at the clinics, stated that Armstrong told him that she gave prescriptions to patients because they expected to receive them. After seeing Armstrong in the parking lot exchanging money with a patient for whom he had refused to write a prescription, Dr. Hunter believed that patients were getting drugs without seeing a doctor. Dr. Gilbert Mason, who departed after six weeks, testified that he felt pressured by Armstrong to write prescriptions and to see more patients. [17] Additionally, Dr. Cullins admitted at trial that she had: (1) made poor medical judgments; (2) identified patients as clinic hoppers; (3) issued multiple prescriptions for overlapping treatment periods to patients; (4) violated the Louisiana Pain Management Standards; and (5) been warned in March by Armstrong that the DEA might be sending in undercover agents since it had publicly shut down some other pain clinics. Despite having previously caught DEA informant Buckeridge clinic hopping and noting the word jumper multiple times in the clinics' files, Dr. Cullins continued to see Buckeridge and write her trinity drug prescriptions. Dr. Cullins even signed two post-dated prescriptions, seized from one of the pharmacies on April 11, 2005. The prescriptions purported to have been written April 23, 2005, but were filled by the pharmacy on April 9, 2005. Further, an analysis of prescriptions written by Dr. Cullins was presented to the jury. It showed that Dr. Cullins was seeing and prescribing the trinity drugs for several hundred patients a day, with a high of 302 in one day. Although Dr. Cullins offered explanations for her conduct, the jury was entitled to reject most of her explanations. [18] Yet Armstrong and Dr. Cullins contend that in this case expert testimony was necessary because the facts and circumstances surrounding the prescriptions could not establish that they acted outside the scope of professional practice in dispensing the controlled substances. Appellants' reliance on two cases from other circuits, United States v. Bek, 493 F.3d 790 (7th Cir.2007), and United States v. Cuong, 18 F.3d 1132 (4th Cir.1994), as support for this proposition is misplaced. In Bek, the Seventh Circuit addressed a sufficiency of the evidence challenge to convictions for illegally dispensing controlled substances to three deceased patients because they were unavailable to testify at trial. Bek, 493 F.3d at 799. That court reversed only one substantive count where the Government did not present expert testimony, medical records, or other evidence regarding the deceased patient's condition or the doctor's treatment of her. Id. In fact, the court recited the evidence presented that it considered sufficient to satisfy the criminal standard to convict a practitioner under § 841(a)(1), reflecting many of the same facts in the present case, such as uniform and careless medical exams and a disregard for signs of drug abuse. See id. Similarly in Cuong, the Fourth Circuit reversed multiple § 841 convictions where the Government failed to present testimony from any of the patients to whom the illegal dispensations were made. 18 F.3d at 1142-43. Thus, Bek and Cuong propose that evidence regarding the particular patient visit or treatment giving rise to the § 841 charge should be presented at trial in order for a conviction on the charge to withstand a motion for acquittal. See id. In this case, all of the substantive § 841 counts (counts 2-27) were based on occasions in which practitioners dispensed controlled substances to either DEA informant Buckeridge or undercover DEA Agent David Gauthreaux. Because both testified at trial as to each of their clinic visits and the treatment they received, recordings of the visits with Dr. Cullins were played for the jury, and medical records were introduced into evidence respecting counts 2-27, the reasoning of neither Bek nor Cuong would require acquittal. Therefore, we are not persuaded that expert testimony was required to establish criminal liability on the facts of this case.
Armstrong argues that counts 2-27 must fail because she is not registered to dispense controlled substances under the CSA and therefore cannot be held liable as a principal for substantively violating § 841. In response, the Government contends that the jury convictions should stand with Armstrong charged and convicted as both a principal and an aider and abetter. The Government also asserts that because Armstrong was a nurse during the conspiracy, she meets the definition of practitioner under the CSA and could be prosecuted for illegal dispensing without relying on the conduct of a registrant to establish liability.
We review the sufficiency of an indictment de novo. United States v. Lucas, 516 F.3d 316, 342 (5th Cir.2008). Again, we evaluate the sufficiency of evidence supporting a jury conviction by determining whether a rational jury, viewing the evidence in the light most favorable to the prosecution, could have found the essential elements of the offense to be satisfied beyond a reasonable doubt. See Miles, 360 F.3d at 476-77.
Armstrong was indicted on twenty-six counts of substantively violating § 841 of the CSA. Specifically, it was charged that she, along with her clinics and pharmacies, aided and abetted by the registered physicians she employed, illegally dispensed controlled substances outside the scope of professional practice. Section 841 states:  Except as authorized by this subchapter, it shall be unlawful for any person knowingly or intentionally. . . to manufacture, distribute, or dispense, or possess with intent to manufacture, distribute, or dispense, a controlled substance. 21 U.S.C. § 841 (emphasis added). The basic proscription in § 841 applies to any person except those authorized by this subchapter such as physicians registered with the Attorney General pursuant to 21 U.S.C. § 822. The Supreme Court in United States v. Moore limited the scope of the § 841 exception by holding that an authorized physician who issues prescriptions outside the usual course of professional practice is subject to punishment under § 841(a)(1) just as any other drug pusher. Moore, 423 U.S. 122, 138, 142-43, 96 S.Ct. 335, 46 L.Ed.2d 333 (1975). Thus, Armstrong contends that a charge for dispensing controlled substances outside the scope of professional practice only applies against registered physicians. Armstrong argues that because she was charged with illegally dispensing, and she is not a physician registered under the CSA, the substantive counts of the indictment fail. Armstrong argues that the law against dispensing applies only to registered physicians, citing United States v. Albert, 675 F.2d 712 (5th Cir.1982). In Albert, this Court rejected the argument that laypersons could not conspire to dispense drugs illegally because they were not able to dispense drugs in the first instance, relying on the rule that a person may be guilty of conspiring although incapable or committing the substantive offense. Id. at 715. Although this Court in Albert appeared to accept the assertion that the law against dispensing applies only to medical practitioners, id. (the [co-conspirator laypersons] need not themselves be able to dispense drugs), its dicta is not controlling. However, an examination of the CSA definitions of dispense, distribute, practitioner, and administer, [19] causes us to reject the Government's assertion that Armstrong may be convicted as a principal under § 841. The logical reading of the statutory definitions of dispense and distribute that led this Court in United States v. Leigh to determine a doctor writing illegal prescriptions must be charged with dispensing rather than distributing, counsels that a non-registrant who does not write prescriptions but otherwise acts to provide drugs would not properly be charged with dispensing rather than distributing. See Leigh, 487 F.2d 206 (5th Cir.1973) (holding reaffirmed by United States v. Harrison, 628 F.2d 929 (5th Cir.1980)). On each of the substantive counts, Armstrong was charged and convicted pursuant to both 21 U.S.C. § 841(a) and 18 U.S.C. § 2, as both a principal and an aider and abettor, or-the more correctly descriptive in this case-a commander or inducer. See Adam H. Kurland, To Aid, Abet, Counsel, Command, Induce, or Procure the Commission of an Offense: A Critique of Federal Aiding and Abetting Principles, 57 S.C. L.Rev. 85, 87 (2005) (discussing the confusion caused by using the traditional phrase aid and abet to describe conduct captured by 18 U.S.C. § 2's extension of liability to those who cause illegal acts to be done). Section 2(b) states: Whoever willfully causes an act to be done which if directly performed by him or another would be an offense against the United States, is punishable as a principal. 18 U.S.C. § 2(b) (emphasis added). The historical and statutory note for § 2 further states that [o]ne who puts in motion or assists in the illegal enterprise or causes the commission of an indispensable element of the offense by an innocent agent or instrumentality, is guilty as a principal even though he intentionally refrained from the direct act constituting the completed offense. Thus pursuant to § 2(b) Armstrong, a non-registrant, may be convicted for either aiding and abetting or willfully causing the dispensing of controlled substances beyond the scope of professional practice. The evidence must prove that Armstrong had the mental state necessary to violate the underlying criminal statute and that she willfully caused another to commit the necessary act. See United States v. Levy, 969 F.2d 136, 141 (5th Cir.1992) (noting that § 2(b) does not require shared criminal intent; only the defendant charged need have criminal intent, and the individual whom defendant caused to perform the criminal act may be innocent). Because Dr. DeLoach and Dr. Guenther were charged with illegal dispensing but entered plea bargains with the Government and did not go to trial, Armstrong was convicted on twelve counts (counts 4, 6, 9-10, 12-13, 15-16, 19, 21, and 25-26) where the registrant who was charged was not tried. Examining the record, there is evidence sufficient for a rational jury to have convicted Armstrong for these counts under 18 U.S.C. § 2 regardless of whether a non-registrant may be convicted of illegally dispensing controlled substances. [20] See United States v. Neal, 951 F.2d 630, 633 (5th Cir.1992) (Aiding and abetting is not a separate offense, but it is an alternative charge in every indictment, whether explicit or implicit.); United States v. Smith, 584 F.2d 731, 734 (5th Cir.1978) (stating that it is beyond controversy, [that pursuant to § 2(b)] the accused may be convicted as causer, even though not legally capable of personally committing the act forbidden by a Federal statute). The evidence supported a jury conclusion that the prescriptions in those counts were in fact issued without a legitimate medical purpose or beyond the scope of professional practice, and that Armstrong aided or induced the writing of such prescriptions. More problematic are five additional counts (11, 14, 17, 20, and 27) where Armstrong was convicted but Dr. Cullins, the defendant physician, was tried and acquitted. The facts and proceedings of this case stands in contrast to Standefer v. U.S., where the Supreme Court upheld petitioner's conviction for aiding and abetting even though the alleged principal had been acquitted. 447 U.S. 10, 25, 100 S.Ct. 1999, 64 L.Ed.2d 689 (1980) (noting that symmetry of results may be intellectually satisfying but is not required). The principal had been acquitted in an earlier trial, and the jury instructions given in Standefer's trial required the jury to find his co-defendant guilty of the substantive offense in order to convict Standefer of aiding and abetting him. Id. at 13 n. 6, 20 n. 14. Here, however, the same jury that convicted Armstrong considered the guilt of and acquitted Dr. Cullins. The jury concluded that there was at least reasonable doubt whether the prescriptions Dr. Cullins wrote on those five occasions were illegitimate. Thus, as to these counts, there was no crime for Armstrong to have abetted. See Standefer, 447 U.S. at 20 n. 14, 100 S.Ct. 1999 (distinguishing instant case, where the Government proved the co-defendant had committed the substantive violation, from cases holding that there can be no conviction for aiding and abetting someone to do an innocent act) (citing Shuttlesworth v. Birmingham, 373 U.S. 262, 265, 83 S.Ct. 1130, 10 L.Ed.2d 335 (1963)); cf. United States v. Yost, 24 F.3d 99, 104 (10th Cir.1994) (All that is required for a conviction based on 18 U.S.C. § 2 is a finding that the [defendant] aided someone in committing the crime.); United States v. Martin, 747 F.2d 1404, 1407 (11th Cir.1984) (noting that one must aid or abet or procure someone else to commit a substantive offense). Even on a theory that Armstrong caused or induced non-culpable Dr. Cullins to write the prescriptions, it is whether they were written without a legitimate purpose or outside the course of professional conduct that differentiates dispensing from illegal dispensing. On these counts there is no evidence that Armstrong signed the prescriptions herself or otherwise was aware, even if Dr. Cullins was not, that there was no legitimate medical purpose for the prescriptions. Cf. Smith, 584 F.2d at 734 (holding that defendant could properly be convicted of failure to maintain records required of a licensed dealer, when he, a non-licensed employee of the dealer, knowingly sold and delivered firearms without noting the required personal information of the purchaser); also Cuong, 18 F.3d at 1142 (A defendant is entitled to individual consideration of every count in an indictment by the jury and evidence sufficient to convict on each count beyond a reasonable doubt, if he is to be convicted.). Considering that the jury found at least reasonable doubt that Dr. Cullins had issued the prescriptions other than for a legitimate medical purpose in the course of professional conduct, we find insufficient evidence for the jury to have reasonably concluded on these charges that they in fact were illegitimate prescriptions and Armstrong knew so. [21] Therefore, we reverse Armstrong's convictions for counts 11, 14, 17, 20, and 27. [22]
Armstrong and Dr. Cullins both challenge the sufficiency of the jury instructions administered by the district court. Appellants argue that the instructions did not correctly state the law, instead allowing conviction based on a civil negligence standard and exposing Appellants to criminal conviction for malpractice. Specifically, Appellants challenge the district court's instruction to the jury that it could find them guilty of violating 21 U.S.C. § 841 if they prescribed controlled substances either without a valid medical purpose or beyond the scope of professional practice. They assert that this disjunctive standard effectively permitted conviction for negligence because it eliminated the mens rea of the crimelack of a legitimate medical purposeand eviscerated any good faith defense that Armstrong mounted. Finally, Dr. Cullins argues that the good faith instruction did not cure the district court's refusal to charge in the conjunctive because (1) it applied only the substantive counts and not to the conspiracy, and (2) it was couched as a defense rather than as an element of the Government's case. In response, the Government argues that the instructions, taken as a whole, properly apprised the jury of the applicable law. The Government asserts that this Court has sustained illegal dispensing convictions using similar phraseology adopted by the district court in this case. The Government points to the fact that nowhere in the plain text of the three provisions that govern the dispensing of controlled substances, 21 U.S.C. §§ 841 and 822(b) and 21 C.F.R. § 1306.04, is there a double statutory element permitting conviction only if a prescription is issued for both no legitimate medical purpose and also outside the usual course of professional practice. The Government also notes that many courts, including the Fifth Circuit in United States v. Fuchs, 467 F.3d 889 (5th Cir.2006), have recognized that the two clauses legitimate medical purpose and usual course of professional conduct are often used interchangeably. [23] Finally, the Government notes that Dr. Cullins did not object to the good faith jury instruction below, and that the instruction, which mirrored a good faith instruction approved by this Court's precedent, was not in plain error. Moreover, the Government contends that because the jury charge properly linked the substantive § 841 instruction back into the instruction for conspiracy, the good faith charge in the former was legally sufficient.
A properly objected-to instruction is reviewed for abuse of discretion. Fuchs, 467 F.3d at 900. Whether an instruction misstated an element of a statutory crime is reviewed de novo. United States v. Guidry, 406 F.3d 314, 321 (5th Cir.2005) (citation omitted). In conducting that review, this Court consider[s] whether the jury instruction, taken as a whole, is a correct statement of the law and whether it clearly instructs jurors as to the principles of the law applicable to the factual issues confronting them. Guidry, 406 F.3d at 321 (emphasis added). [24] A single instruction to a jury should not be judged in isolation. Id. Any error in the jury instruction is subject to harmless error review. United States v. Patterson, 431 F.3d 832, 837 (5th Cir.2005); see FED. R. CRIM. P. 52(a) (standard for harmless error review). The failure to object timely to a jury instruction is subject to plain error review. See Fuchs, 467 F.3d at 901 (the court will reverse only if (1) there was an error, (2) that was clear and obvious, and (3) that affected the defendant's substantial rights causing a miscarriage of justice).
Although a close question, the complete context of the jury charge properly apprised the jurors of the correct legal standards and burdens to be met by the prosecution. For the reasons discussed below, based on the relevant statutory language, regulation, Moore, and Fifth Circuit precedent, we conclude that these jury instructions, taken as a whole, provided a correct statement of the law. [25] To convict the defendants of illegally dispensing controlled substances in violation of 21 U.S.C. § 841(a)(1), the Government was required to prove (1) that [they] . . . dispensed a controlled substance, (2) that [they] acted knowingly and intentionally, and (3) that [they] did so other than for a legitimate medical purpose and in the usual course of [ ] professional practice. United States v. Norris, 780 F.2d 1207, 1209 (5th Cir.1986) (quoting United States v. Rosen, 582 F.2d 1032, 1033 (5th Cir.1978)). The third element is not expressly required by the text of § 841, but relevant regulations provide that a controlled substance can be dispensed by a prescription issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. 21 C.F.R. § 1306.04(a). The Supreme Court held in Moore, 423 U.S. at 138-43, 96 S.Ct. 335, that a registered physician could be charged and convicted under § 841 of the CSA for drug trafficking. Although the precise elements of a § 841 offense were not expressly addressed in Moore, the Supreme Court rejected the suggest[ion] that if a registrant could be reached under § 841, he could not be prosecuted merely because his activities fall outside the `usual course of practice.' Id. at 139, 96 S.Ct. 335. Under the Harrison Act, the predecessor to the CSA, [p]hysicians who stepped outside the bounds of professional practice could be prosecuted, id. at 132, 96 S.Ct. 335, and because Congress intended the CSA to strengthen rather than weaken prior drug laws, a defendant physician could still be convicted under § 841 for conduct that exceeded the bounds of professional practice. Id. Moreover, a logical reading of 21 C.F.R. § 1306.04, the applicable regulation, shows that liability is not conjunctive. See United States v. Hayes, 595 F.2d 258, 259 (5th Cir.1979) (stating that § 1306.04 defines the circumstances in which a registrant may be held to have violated the proscription against manufacturing, distributing, or dispensing a controlled substance contained in 21 U.S.C. § 841). The regulation states that for a prescription for a controlled substance to be effective[, it] must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. 21 C.F.R. § 1306.04. Both prongs are necessary for a prescription to be legitimate; one is not sufficient. Id. The logical converse is that a practitioner is unauthorized to dispense a controlled substance if the prescription either lacks a legitimate medical purpose or is outside the usual course of professional practice. See id.; see also United States v. Nelson, 383 F.3d 1227, 1233 (10th Cir.2004) (holding that the converse of the affirmative requirement of a medical purpose in usual course of practice would be if either was missing, not if both were missing). In other words, knowingly distributing prescriptions outside the course of professional practice is a sufficient condition to convict a defendant under the criminal statutes relating to controlled substances. [26] Specifically in the instant case, the district court instructed the jury in relevant part that: the defendants are charged with multiple violations of [§ 841(a)(1)] and [18 U.S.C. § 2], which provide that it is unlawful for any person knowingly or intentionally to illegally dispense controlled substances not for a legitimate medical purpose or outside the usual course of professional practice . . . . In order for you [sic] find each of the defendants guilty . . . the government would have to prove the following elements beyond a reasonable doubt as to each count . . . [f]irst, that the physician prescribed or dispensed the controlled substance alleged in the indictment; [s]econd, that the physician did so knowingly and intentionally; and [t]hird, that the physician prescribed or dispensed the controlled substance either without a legitimate medical purpose or outside the course of his or her professional practice. The district court then explained that for a prescription to be authorized under the CSA, it must be issued for a legitimate medical purpose by an individual acting in the usual course of his or her professional practice. Thus, the final element the government must prove beyond a reasonable doubt, is either that the physician prescribed or dispensed the drug other than for a legitimate medical purpose or that the physician dispensed the drug not in the usual course of medical practice. A controlled substance is prescribed by a physician in the usual course of professional practice, and therefore, lawfully, if the substance is prescribed by him or her in good faith, medically treating a patient in accordance with a standard of medical practice generally recognized and accepted in the United States. Good faith in this context means an honest effort to prescribe for a patient's condition in accordance with the standards of medical practice generally recognized or accepted in this country. (emphasis added). The district court then explicitly highlighted the broad discretion afforded doctors in their medical practice: In making a medical judgment concerning the right treatment for an individual patient, physicians have discretion to choose among a wide range of available options. Therefore, in determining whether the defendant acted without a legitimate medical purpose, you should examine all of the physician's actions and the circumstances surrounding them. (emphasis added). This language describes lawful conduct as including a doctor's intentional effort to prescribe for the purpose of treating a patient's condition. As such, the district court essentially defined conduct in the usual course of professional practice as conduct that is intended for a legitimate medical purpose. Our reading of the jury charge is bolstered by the immediately following section of instruction, which, including factors identified in Rosen, 582 F.2d at 1036, and subsequent case law, lists several examples of the [t]ypes of behavior from which you [the jury] could infer that the physician was acting without a legitimate medical purpose or outside the usual course of professional practice. That the district court instructed that the same behavioral examples could support a conclusion that a doctor acted either outside the scope of professional practice or without a legitimate medical purpose indicates that the phrases, although listed disjunctively, were considered interchangeable. The jury instructions in this case reflect previously approved instructions. Implicit in the Supreme Court's reasoning in Moore is the acceptance of the single prong of outside the scope of a professional practice. See Moore, 423 U.S. at 138-43, 96 S.Ct. 335. It also suggested the propriety of a jury instruction stating that the defendant could be found guilty if the jury found beyond a reasonable doubt that he dispensed the controlled substance other than in good faith for detoxification in the usual course of a professional practice and in accordance with a standard of medical practice generally recognized and accepted in the United States. Id. at 139, 96 S.Ct. 335 (emphasis added). Notably, while the jury instructions were not the issue directly before the Moore court, they did not include the requirement that the Government prove beyond a reasonable doubt that the physician prescribed the controlled substance other than for a legitimate medical purpose. Id. In holding that the law requires an objective standard to determine what constitutes the usual course of professional practice, this Court's dicta in Norris, 780 F.2d at 1209, commented that an instruction to the jury to consider [w]hether [defendant] prescribed the drugs for what he subjectively considered a legitimate medical purpose was a correct statement of law. Id. What the Norris court refers to as the instruction requiring what he subjectively considered a legitimate medical purpose was that it was prescribed lawfully, if the substance is prescribed by him in good faith. Id. at n. 2. Furthermore, Norris approved jury instructions substantially the same as those in this case. See Norris, 780 F.2d at 1209 n. 2 (containing language identical to the good faith instruction given by the district court at Armstrong's trial). [27] In Fuchs, the defendant pharmacist challenged his convictions for dispensing a controlled substance not in the usual course of professional practice in violation of § 841(a)(1) based on the ground that the government was required to prove not only that he dispensed controlled substances outside the usual course of professional practice but also that he did so without a legitimate medical purpose. Fuchs, 467 F.3d at 899. Neither the indictment nor the jury instructions in Fuchs referred to legitimate medical purpose. Id. Under plain error review, the court did not find the instructions problematic, recognizing that this circuit's previous case law listed as a single element of a § 841(a)(1) offense that the dispensing be done other than for a legitimate purpose and in the usual course of his professional conduct. Id. (citing Rosen, 582 F.2d at 1033). The court in fact recognized that the phrases without a legitimate medical reason and beyond the course of professional practice have been used interchangeably. Id. (citing United States v. Outler, 659 F.2d 1306, 1308-09 (5th Cir. 1981) ([A] physician may be charged with a criminal violation of § 841(a) . . . whenever he or she prescribes a controlled substance without a legitimate medical reason. . . [T]he qualifying condition of the offense, i.e., the element of behavior beyond professional practice . . . .)). Thus, relying on Moore, the Fuchs court concluded that [u]nder current law, a medical professional `can be prosecuted under § 841 when [his] activities fall outside the usual course of professional practice.' Fuchs, 467 F.3d at 901 (quoting Moore, 423 U.S. at 124, 96 S.Ct. 335). Finally, looking to the holdings of other circuits that have addressed this question, we find additional support for upholding the jury instructions in this case. The Tenth Circuit addressed similar arguments in United States v. Nelson, 383 F.3d 1227, 1230-33 (10th Cir.2004). The Nelson court found Moore controlling on the point of whether a disjunctive jury instruction properly stated the law, [28] and relied on Moore and § 1306.04 to hold that the phrases may be listed in the disjunctive in the trial court's jury charge. See also United States v. Bek, 493 F.3d 790, 798 (7th Cir.2007) (approving disjunctive jury instructions; noting Government, to convict practitioner, must prove he prescribed controlled substances outside course of professional practice; opinion does not state that the prosecution must also prove that it was without legitimate medical purpose); United States v. Limberopoulos, 26 F.3d 245, 249-50 (1st Cir.1994) (finding that well-established case law mak[es] clear that the statute [§ 841] applies to a pharmacist's (or physician's) drug-dispensing activities so long as they fall outside the usual course of professional practice.). In addition, the Fourth Circuit has stated that requiring the prosecution to prove that the defendant physician acted for other than a legitimate medical purpose. . . plac[es] an even heavier burden on the government than otherwise required to establish criminal liability. United States v. McIver, 470 F.3d 550, 559 (4th Cir.2006) (citing United States v. Alerre, 430 F.3d 681, 690-91 (4th Cir.2005); Cuong, 18 F.3d at 1138). Appellants urge this court to instead adopt the reasoning of the Ninth Circuit in United States v. Feingold, 454 F.3d 1001 (9th Cir.2006). That court determined that outside the scope of professional practice was a mere malpractice standard and that even intentional malpractice would be inconsistent with Moore's description of a doctor violating § 841(a) as one acting as a drug pusher rather than a physician. Id. at 1010. Rather, the Feingold court asserted that Moore requires that a doctor's actions must completely betray any semblance of legitimate medical treatment, and thus criminal liability requires the higher showing that the practitioner intentionally has distributed controlled substances for no legitimate medical purpose and outside the usual course of professional practice. Id. (emphasis added). The court continued by stating that the jury instructions cited and implicitly accepted in Moore, as well as § 1306.04, support its interpretation of that standard. Id. at 1010-11. We are not persuaded by the reasoning of the Ninth Circuit in Feingold. As discussed, the jury instructions implicitly approved by Moore exclude any reference to medical purpose, and a logical reading of § 1306.04 supports the use of the disjunctive standard. Further, Feingold merely includes the language of the jury instruction cited in Moore followed by a conclusory statement that it indicates that the jury could convict under § 841(a) if the government proved that the practitioner intentionally prescribed drugs for no legitimate medical purpose. [29] Id. Armstrong and Dr. Cullins also argue that the legitimate medical purpose prong encompasses the necessary mens rea element of a § 841 offense, and without it, the doctor will be criminally convicted for malpractice. Appellants are mistaken. The mens rea of a § 841 offense is encompassed in the second and third element of the crime  whether the practitioner intentionally dispensed controlled substances without a legitimate medical purpose or outside the scope of professional practice. See Nelson, 383 F.3d at 1232-33. The charge as a whole in this case, including the good faith instruction, and instruction on the discretion afforded to doctors, made it clear that the jury had to make a finding with respect to Appellants' state of mind. These instructions distinguish a § 841 prosecution from a mere civil malpractice suit where a plaintiff may prevail regardless of a defendant doctor's good faith intent to act within the scope of medical practice. See McIver, 470 F.3d at 559-60 (finding that good faith is not a defense to a claim of medical malpractice) (citations omitted). Furthermore, the standard of proofbeyond a reasonable doubtadditionally protects practitioners from being exposed to criminal convictions on a mere civil standard. See United States v. Vamos, 797 F.2d 1146, 1153 (2d Cir.1986) (rejecting the assertion that the jury instructions in that case exposed the defendant to criminal liability for nothing more than mere malpractice by pointing out that in a criminal prosecution [a defendant] may be found guilty only upon proof beyond a reasonable doubt that he acted outside the scope of medical practice). Finally, Armstrong and Dr. Cullins also argue that the jury instruction regarding expert testimony compounded the error in instructing the jury that a finding of conduct outside the usual course of professional practice sufficed to convict under § 841. [30] They did not object below, and we find no clear error in the instruction. Taken as a whole, the jury charge was a correct statement of law and correctly presented the issues to the jury. [31]