Court Opinion

ID: 4566050
Source: CourtListenerOpinion
Date Created: 2020-09-16 18:06:37.461229+00
Date Added: 2024-06-11T12:49:02.353863
License: Public Domain

09/16/2020

                                          DA 18-0268
                                                                                       Case Number: DA 18-0268

                  IN THE SUPREME COURT OF THE STATE OF MONTANA

                                          2020 MT 237

STATE OF MONTANA,

              Plaintiff and Appellee,

         v.

CHRIS ARTHUR CHRISTENSEN,

              Defendant and Appellant.

APPEAL FROM:            District Court of the Twenty-First Judicial District,
                        In and For the County of Ravalli, Cause No. DC-15-171
                        Honorable Jeffrey H. Langton, Presiding Judge

COUNSEL OF RECORD:

                For Appellant:

                        Joshua S. Van de Wetering, Van de Wetering Law Offices,
                        Missoula, Montana

                        Laura Reed, Attorney at Law, Missoula, Montana

                For Appellee:

                        Timothy C. Fox, Montana Attorney General, C. Mark Fowler, Assistant
                        Attorney General, Helena, Montana

                        Bill Fulbright, Ravalli County Attorney, Thorin Geist, Deputy County
                        Attorney, Hamilton, Montana

                                                    Submitted on Briefs: April 1, 2020
                                                               Decided: September 16, 2020

Filed:

                                 'ig-6--4c
                        __________________________________________
                                          Clerk
Chief Justice Mike McGrath delivered the Opinion of the Court.

¶1       Chris Arthur Christensen appeals a judgment following a jury trial in Montana’s

Twenty-First Judicial District Court, in which Christensen was found guilty of two counts

of Negligent Homicide, felonies, in violation of § 45-5-104, MCA; nine counts of Criminal

Endangerment, felonies, in violation of § 45-5-207, MCA; and eleven counts of Criminal

Distribution of Dangerous Drugs, felonies, in violation of § 45-9-101, MCA. We affirm

in part and reverse in part.

¶2       We restate the issues on appeal as follows:

         Issue One: Whether the State proved beyond a reasonable doubt that Christensen
         committed Criminal Distribution of Dangerous Drugs with respect to eleven
         patients.

         Issue Two: Whether the State proved beyond a reasonable doubt that Christensen
         committed Criminal Endangerment as to his treatment of nine patients.

         Issue Three: Whether the State proved beyond a reasonable doubt that Christensen
         committed Negligent Homicide for the overdose deaths of Kara Philbrick and Gregg
         Griffin.

                   FACTUAL AND PROCEDURAL BACKGROUND

¶3       Christensen is a general physician who has practiced in California, Washington,

Idaho, and most recently, Montana. Although Christensen is not a pain specialist, he

considers himself to have a special interest in managing chronic pain.1                  In 1992,

     Chronic pain is defined as “a state in which pain persists beyond the usual course of an acute
     1

disease or healing of an injury, or that may or may not be associated with an acute or chronic
pathologic process that causes continuous or intermittent pain over months or years.” Montana
Board of Medical Examiners, Guidelines for the Use of Controlled Substances for the Treatment
of Pain, Sec. III, at *4 (Mar. 27, 2009).

                                                2
Christensen began operating a general practice in Kellogg, Idaho, and commenced treating

more chronic pain patients. Christensen prescribed to patients narcotics like Methadone, a

long-acting synthetic opioid agonist, and Dilaudid (hydromorphone hydrochloride), a

short-acting opioid analgesic that modifies patients’ psychologic interpretation of and

physiologic response to pain.2 Christensen often administered prescriptions for opioids in

conjunction with benzodiazepines like Diazepam (Valium), Lorazepam (Ativan), and

Alprazolam (Xanax), used for treating anxiety, muscle spasms, and depression.

Benzodiazepines are classified as Schedule IV controlled substances pursuant to the DEA.

Scheduled narcotics may only be prescribed by a physician or other medical professional

with a DEA license. See, e.g., 21 U.S.C. § 829.

¶4       In 1997, the Idaho Board of Medicine filed a complaint against Christensen, alleging

he prescribed excessive and inordinate amounts of controlled substances, that he prescribed

these drugs to addicted persons, and that he was operating outside the accepted standards

of medical practice established by the Idaho medical community. In 1998, Christensen

entered into a stipulation with the Board, agreeing to certain restrictions on his medical

license, prohibiting Christensen from writing prescriptions for controlled substances to

chronic pain patients for longer than 90 days. Christensen did not admit any liability or

wrongdoing.

     2
    These drugs are classified as Schedule II narcotics pursuant to the Drug Enforcement Agency
(“DEA”), the most potent medications that possess a known medical use in the United States. The
DEA has recognized that these drugs have a high potential for abuse which may lead to severe
psychological or physical dependence.
                                              3
¶5       In 2000 and 2001, the Idaho Board of Medicine filed two additional petitions

alleging Christensen violated his 1998 stipulation by continuing to prescribe controlled

substances in contravention of the restrictions placed on his medical license. The second

petition further alleged that Christensen’s prescriptions resulted in the overdose deaths of

at least five of his patients and at least six patient hospitalizations. Christensen again did

not admit any liability but agreed to surrender his medical license for two years and to

probation for five years if in the future he decided to reopen an Idaho practice. Christensen

further agreed to a stipulation prohibiting him from writing prescriptions for controlled

substances longer than 30 days and that he would engage in at least six months of

school-specific education regarding chronic pain treatment before he could resume practice

in Idaho.3

¶6       Christensen did not return to practice in Idaho, but in 2005, opened Big Creek

Family Medicine, a general practice, in Victor, Montana. Christensen’s medical license

was active and unrestricted, but he was prohibited from writing prescriptions for controlled

substances because he had not yet reacquired his DEA license. Christensen eventually

moved his practice to Florence, Montana. On August 26, 2011, Christensen was issued a

     3
      In 2006, Christensen was also indicted for criminal charges in United States District Court
for the District of Idaho for the death of one of his patients, alleging that Christensen knowingly
and intentionally distributed Schedule II and Schedule IV controlled substances outside the scope
of a professional practice and for no legitimate medical purpose in violation of U.S.C. § 841(a)(1).
See United States v. Christensen, No. CR-06-017-N-EJL, 2008 U.S. Dist. LEXIS 102370, at *2
(D. Id. Dec. 18, 2008). In 2009, the case was tried in Idaho and resulted in a hung jury. In 2010,
the case was retried, and Christensen was acquitted.

                                                 4
new DEA license. Christensen did not accept insurance payments for services and instead

accepted payment by cash or check.

¶7     In 2012, approximately six months after Christensen reacquired his DEA

prescription-writing authority, pharmacists in the surrounding areas reported concerns to

the Ravalli County Sheriff’s Office regarding large opioid prescriptions issued from

Christensen. On April 1, 2014, the Missoula High Intensity Drug Trafficking Area Task

Force (“Task Force”) obtained three search warrants from Montana’s Twenty-First Judicial

District Court, authorizing a search of Christensen’s business and residence for evidence

related to criminal distribution of dangerous drugs.

¶8     The Task Force thereafter consulted with the Ravalli County Attorney’s Office and

selected eleven patients among approximately 4,700 patients treated by Christensen. These

patients included Kara Philbrick and Gregg Griffin, who each died from prescription drug

overdoses shortly after obtaining prescriptions from Christensen, as well as Heather

Sutherland, Daniel Lieberg, Erica Cummings, Jennifer Hiscoe, Jacqueline Golden,

Michelle Jessop, Paul Peterson, Todd Gore, and Ryan Marchand. The County Attorney’s

Office alleged that between July 1, 2011, and April 1, 2014, Christensen distributed

dangerous drugs outside the course of a professional practice to these eleven patients.

                                             5
¶9       On October 19, 2017, the State filed the final Amended Information in Montana’s

Twenty-First Judicial District Court,4 accusing Christensen of two counts of Negligent

Homicide, felonies, in violation of § 45-5-104, MCA, for the deaths of Philbrick and

Griffin; nine counts of Criminal Endangerment, felonies, in violation of § 45-5-207, MCA,

for nine patients; and eleven counts of Criminal Distribution of Dangerous Drugs, felonies,

in violation of § 45-9-101, MCA.

¶10      A jury trial was held October 23, 2017, through November 20, 2017. Christensen

was found guilty on all counts. On March 8, 2018, the District Court issued its Judgment

and Commitment, sentencing Christensen to 20 years in the Montana State Prison with ten

years suspended. The District Court stayed Christensen’s sentence until resolution of his

appeal to the Montana Supreme Court. Christensen appeals. Additional facts specific to

Christensen’s arguments are included below.5

                                STANDARDS OF REVIEW

¶11      A grant or denial of a motion to dismiss in a criminal case is a question of law which

we review de novo. State v. Ashmore, 2008 MT 14, ¶ 7, 341 Mont. 131, 176 P.3d 1022.

A district court’s denial of a motion to dismiss based on insufficiency of the evidence is

     4
      On August 19, 2015, the State filed an Information in Montana’s Twenty-First Judicial
District Court, charging Christensen with two counts of Negligent Homicide, nine counts of
Criminal Endangerment, 306 counts of Criminal Distribution of Dangerous Drugs in violation of
§ 45-9-101(2), MCA; an additional 82 counts of Criminal Distribution of Dangerous Drugs, in
violation of § 45-9-101(4), MCA; and one count of Criminal Possession of Dangerous Drugs.
     5
     In addition to the arguments below, Christensen argues on appeal that the District Court
improperly imposed a fine at sentencing because he is “effectively bankrupt.” However, in its
Judgment and Commitment, the District Court did not impose a fine. Christensen’s argument is a
non-issue and we therefore do not address its merits on appeal.
                                               6
reviewed for an abuse of discretion. State v. Miller, 1998 MT 177, ¶ 21, 290 Mont. 97,

966 P.2d 721. We review de novo whether sufficient evidence supports a conviction. State

v. Polak, 2018 MT 174, ¶ 14, 392 Mont. 90, 422 P.3d 112. When reviewing a challenge

to the sufficiency of the evidence, this Court determines whether, after reviewing the

evidence in the light most favorable to the prosecution, any rational trier of fact could have

found the essential elements of the crime beyond a reasonable doubt. State v. LaMere,

2003 MT 49, ¶ 13, 314 Mont. 326, 67 P.3d 192.

¶12     Generally, this Court will not address issues raised for the first time on appeal. State

v. Longfellow, 2008 MT 343, ¶ 19, 346 Mont. 286, 194 P.3d 694. However, this Court

possesses the inherent authority to invoke plain error review for claimed errors that

implicate a criminal defendant’s fundamental constitutional rights when failing to review

the claimed error may result in a manifest miscarriage of justice, leave unsettled the

question of the fundamental fairness of the trial or proceedings, or compromise the integrity

of the judicial process. State v. Taylor, 2010 MT 94, ¶ 12, 356 Mont. 167, 231 P.3d 79.

¶13     We review de novo a District Court’s interpretation of statute, determining whether

the trial court’s interpretation is correct. State v. Sutton, 2018 MT 143, ¶ 11, 391 Mont.

485, 419 P.3d 1201. A statute is presumed constitutional unless it conflicts with the

constitution, in the judgment of the court, beyond a reasonable doubt. State v. Stock, 2011

MT 131, ¶ 19, 361 Mont. 1, 256 P.3d 899. The party challenging the constitutionality of a

statute bears the burden of proof; if any doubt exists, it must be resolved in favor of the

statute. Mont. Cannabis Indus. Ass’n v. State, 2016 MT 44, ¶ 12, 382 Mont. 256, 368 P.3d

1131.

                                               7
¶14    A district court has broad discretion in determining whether evidence is relevant and

admissible. State v. Duffy, 2000 MT 186, ¶ 43, 300 Mont. 381, 6 P.3d 453. We review a

district court’s evidentiary rulings, including the admissibility of character evidence, for an

abuse of discretion. State v. Kaarma, 2017 MT 24, ¶ 11, 386 Mont. 243, 390 P.3d 609

(citing State v. Huerta, 285 Mont. 245, 254, 947 P.2d 483, 489 (1997)).

¶15    Jury instructions in a criminal case are reviewed for an abuse of discretion to

determine whether the instructions, as a whole, fully and fairly instruct the jury on the law

applicable to the case. State v. Dunfee, 2005 MT 147, ¶ 20, 327 Mont. 335, 114 P.3d 217.

To constitute reversible error, any mistake in instructing the jury must prejudicially affect

the defendant’s substantial rights. Kaarma, ¶ 7.

                                       DISCUSSION

¶16    Issue One: Whether the State proved beyond a reasonable doubt that Christensen
       committed Criminal Distribution of Dangerous Drugs with respect to eleven
       patients.

¶17    Christensen raises multiple issues regarding his prosecution and conviction for

criminal distribution of dangerous drugs. Before discussing the merits as to the issues

raised, we provide a chronological factual summary of relevant pretrial motions, testimony

presented at trial, evidentiary issues, and jury instructions.

Pretrial Motions

¶18    On March 21, 2016, the State filed its first pretrial motion for an order confirming

how the offense of Criminal Distribution of Dangerous Drugs, § 45-9-101, MCA, would

be interpreted at trial, requesting the court adopt the State’s proposed jury instructions with

regard to this offense. The State’s motion asserted that pursuant to § 45-9-101(1), MCA,

                                               8
the writing of a prescription constitutes a “sale, barter, exchange, or giving away of

dangerous drugs,” and the professional practice exemption for physicians and medical

professionals, pursuant to § 45-9-101(6), MCA, was inapplicable because Christensen was

acting outside the course of his professional practice. In support of its motion and proposed

jury instructions, the State relied on a Ninth Circuit Court of Appeals case, United States

v. Feingold, 454 F.3d 1001 (9th Cir. 2006).

¶19    Christensen, at the time appearing pro se, did not file a timely answer brief

responding to the State’s motion, but did file a motion to stay the proceeding until he

obtained appropriate legal representation. On July 25, 2016, the court issued an opinion

and order on multiple pretrial motions, noting that Christensen’s failure to file an answer

brief within the time allowed constituted an admission that the motion was well taken. The

court granted the State’s motion on the proposed jury instructions for criminal distribution,

finding the proposed instructions correctly instructed the jury on the law.

¶20    On January 18, 2017, Christensen filed a motion to dismiss all charges. With respect

to the drug distribution charges, Christensen asserted that Montana’s criminal distribution

statute, § 45-9-101, MCA, did not prohibit “prescribing” of dangerous drugs, and

§§ 45-9-101(6) and 102(8), MCA, exempted the actions of physicians acting in the course

of a professional practice from prosecution. On April 5, 2017, the District Court issued an

order denying Christensen’s motion to dismiss. The court also held that it already ruled on

the issue when it granted the State’s motion for proposed jury instructions.

¶21    On August 9, 2017, the District Court issued its first set of trial stipulations. The

State and Christensen agreed to jury instructions prohibiting each party from discussing

                                              9
potential sentences that may be imposed in this case. On September 8, 2017, the State filed

a motion in limine seeking in part to preclude Christensen from presenting testimony or

evidence from 28 former patients regarding personal medical experiences with

Christensen. On September 22, 2017, Christensen filed a response to the State’s motion in

limine, arguing that M. R. Evid. 406, Habit and Routine Practice, permitted admission of

such testimony because the issue concerned his prescribing practices. On the same date,

Christensen also filed a motion in limine, seeking in part to exclude from trial as irrelevant

(1) any reference to criminal charges in Idaho for which he stood trial and was acquitted

and any reference to events underlying the charges and acquittal; and (2) any reference to

the Idaho Medical Board’s actions taken against Christensen.

¶22    On October 16, 2017, the District Court issued an order granting the State’s motion

in limine to preclude testimony or evidence of Christensen’s former patients, finding the

proposed testimony did not fall within M. R. Evid. 406(b) as evidence of a routine practice

and was irrelevant as to Christensen’s treatment of the eleven patients. On October 18,

2017, the court granted Christensen’s motion in limine to preclude any reference to

criminal charges in Idaho except for purposes of impeachment and rebuttal. However, the

court denied Christensen’s motion to preclude any reference to the actions taken by the

Idaho Medical Board against Christensen, finding such evidence was admissible for non-

propensity purposes to show knowledge and absence of a mistake or accident, and that this

evidence was not unfairly prejudicial.

                                             10
Trial

Opening Statements

¶23     In opening statements, the State referenced the Idaho Board of Medicine’s

complaints filed against Christensen stemming from allegations that Christensen

overprescribed opioids outside the accepted standards of medical practice and that at least

five of his patients died of a drug overdose and another six had been hospitalized. The

State also explained that as to both complaints, “[Christensen] never admitted any

liability[,]” but that “he did agree to surrender his medical license for a period of two years,

and he agreed that if he was going to come back to Idaho that he would be on probation for

five years.”

State’s Case

        Idaho Charges

¶24     On October 26, 2017, in regard to scheduled testimony from Jean Uranga, the

attorney representing the Idaho Board of Medicine at the time Christensen was investigated

in Idaho, the court conferred with each party regarding the admissibility of the proposed

testimony under M. R. Evid. 404(b). Christensen’s counsel objected to the introduction of

allegations contained in the Idaho Board cases, and specifically, the introduction of the

complaints themselves as exhibits as irrelevant and unduly prejudicial. The State countered

that the evidence was admissible under M. R. Evid. 404(b) to show Christensen was on

notice for the crimes in the present case. Christensen’s counsel acknowledged that

questioning as to the underlying allegations was permissible to some extent, that he was

not surprised by the State’s efforts to admit this evidence, and acknowledged the State

                                              11
provided him this proposed evidence before trial. The court ultimately prohibited the State

from introducing the complaints as exhibits and limited the State’s questioning of Uranga

to only general allegations in the complaint and the number of patients involved in the

Idaho investigation, while barring detailed questioning as to specifics.

¶25    Uranga testified that Christensen was investigated by the Idaho Board of Medicine

in 1997 for allegedly violating community standards of care in Idaho for providing

narcotics to patients without treating their primary conditions, not conducting physical

examinations, not offering referrals, and providing narcotics to patients with drug

addictions. Uranga further testified that in 2000, the Board filed a petition, alleging that

Christensen overprescribed opioids to 28 patients, 23 who received prescriptions for

opioids and benzodiazepines, and that the Idaho Board concurrently filed an immediate

suspension of his prescription-writing authority for intentionally, knowingly, flagrantly,

and repeatedly violating the stipulation and order signed with the Board. Uranga testified

that Christensen did not admit any liability but agreed to surrender his Idaho license to

practice medicine and his ability to prescribe any controlled substances for two years.

       Chronic Pain and Opioid Risks

                                             12
¶26      The State presented extensive expert testimony from Dr. Ajay Wasan,6 Dr. Brett

Bender,7 Dr. Vince Colucci,8 Dr. Patrick Danaher,9 and Dr. Elena Furrow10 as to the nature

of “chronic pain” and the risks and efficacy of treating chronic pain with opioids. Experts

testified that chronic pain is the result of prolonged pain which causes the nervous system

to act in a negative, dysfunctional state and triggers a negative emotional interpretation of

that pain. Experts further testified that opioids cannot serve as the dominant treatment for

chronic pain because they may cause increased pain symptoms, carry a high risk of

addiction, and offer limited effectiveness. Experts also testified that opioids may cause

dangerous interference with electrical conduction signals in the heart and are subject to

build-up in the system, increasing the risk of respiratory depression, sleep apnea, and death,

particularly when taken in combination with benzodiazepines.

         Standard of Care

¶27      At trial, the State introduced into evidence the 2009 Montana Board of Medical

Examiners Guidelines for the Use of Controlled Substances for the Treatment of Pain.11

   6
    Dr. Wasan is a medical doctor, pain specialist, and psychiatrist at the University of Pittsburgh
Medical Center.
   7
       Dr. Bender treats chronic spine and pain patients at St. Patrick’s Hospital in Missoula.
   8
       Dr. Colucci is a doctor of pharmacy operating a professional practice at St. Patrick’s Hospital.
   9
      Dr. Danaher, a doctor of osteopathic medicine (“DO”) licensed to practice in Montana, was
a blind expert in the case and did not review any of the patient medical files prior to testifying.
   10
     Dr. Furrow is a family physician who operates a training program for addiction and opioid
dependence in Missoula.
   11
      Dr. Bender testified on cross-examination that these guidelines first became prominent
around 2005 and that he refers to these guidelines when treating chronic pain patients. Dr. Bender
                                                   13
Section I of these guidelines provides in part: “the inappropriate treatment of pain includes

nontreatment, undertreatment, overtreatment, and the continued use of ineffective

treatments[,]” and, “All physicians should become knowledgeable about assessing

patients’ pain and effective methods of pain treatment, as well as statutory requirements

for prescribing controlled substances.” Section I also provides, “[T]he Board expects that

physicians incorporate safeguards into their practices to minimize the potential for the

abuse and diversion of controlled substances.”

¶28      In addition, Dr. Bender, Dr. Danaher, Dr. Ravitz,12 Dr. Furrow, and Dr. Wasan

testified as to standards of practice for physicians when treating chronic pain patients.

These experts identified four primary guidelines to which physicians must adhere when

treating chronic pain patients, including: (1) comprehensive initial assessments through

diagnostic tests and review of medical records to diagnose the underlying cause of pain

and identify risk factors of opioid treatment; (2) providing holistic treatment plans;

(3) careful patient monitoring; and (4) comprehensive documentation.

             a. Initial Assessment

¶29      Section II of Montana’s Medical Board guidelines provides a list of criteria for

evaluating a physician’s treatment of pain, requiring physicians to obtain patients’ medical

histories and physical examinations, evaluate and document this information in patients’

also testified that the Center for Disease Control published guidelines in 2016, after Christensen’s
practice closed, stating that physicians should not prescribe more than 90 morphine milligram
equivalents of opioids.
   12
        Eric Ravitz, DO, is a family physician practicing in Missoula.
                                                 14
medical records, and document current and past treatments for pain, underlying diseases

or medical conditions, and histories of substance abuse.           Similarly, Dr. Danaher,

Dr. Bender, and Dr. Wasan testified that in their own practices, prior to administering

medications, patients must undergo comprehensive initial evaluations, which includes

review of past medical records, patient interviews, physical examinations, and imaging

studies such as X-rays, CT scans, CAT scans, and MRIs. Based on this collective

information, treating physicians must identify and accurately diagnose the underlying

cause of chronic pain. Dr. Danaher and Dr. Wasan also testified that patients never receive

opioids the first visit but must first submit to psychological assessments and other referrals

to identify any red flags suggesting the possibility of opioid abuse. If opioids are

determined as a potential source of treatment, patients must undergo an electrocardiogram

(“EKG”) during the initial assessment phase and at least every year to ensure that opioids

will not have a negative effect on heart and respiratory health.

          b. Treatment Plan

¶30    Section II of Montana’s Medical Board guidelines further provides that physicians

should create a treatment plan outlining treatment objectives and are encouraged to discuss

with patients the risks of using controlled substances. Physicians are also encouraged to

use a written agreement outlining patient responsibilities in instances which a patient is at

a high risk for substance abuse. Dr. Danaher, Dr. Wasan, and Dr. Bender explained that

this treatment plan must be catered specifically to the etiology of the patient based on

information acquired in the initial assessment. Dr. Wasan testified that the standard of care

for this treatment plan is “multimodal,” requiring a physician to utilize four basic

                                             15
methodologies—(1) medications, and specifically, non-opioid medications as much as

possible, (2) injections such as nerve blocks13 and prolotherapy,14 (3) physical therapy, and

(4) psychiatric care to combat depression and anxiety.

¶31     Dr. Danaher testified that a treatment plan utilizing only opioid and benzodiazepine

medications does not meet the standard of care for the pain community due to risks of

abuse. Dr. Bender and Dr. Ravitz testified that if the treatment plan involves the use of

opioid medications, physicians must explain instructions and warnings, and utilize a

consent form, known as the “opioid agreement,” detailing the risks and potential side

effects of opioid use. Dr. Wasan stated that this opioid agreement is the “cornerstone” of

good opioid care and is critical to the success of the treatment plan.

               c. Monitoring

¶32     Section II of Montana’s Medical Board guidelines also encourages physicians to

periodically review pain treatment procedures, use objective evidence to monitor

treatments, and routinely consider other therapeutic treatments available, including

referrals for additional evaluations, particularly for patients at risk of opioid misuse.

Similarly, Dr. Wasan, Dr. Danaher, and Dr. Bender all testified that the treatment plan must

be revised at each successive meeting to effectively manage pain and ensure treatment

objectives are being targeted. Once opioids are prescribed, careful monitoring and short

   13
      Nerve blocks are medications often administered as injections to block pain from nerve
receptors.
   14
      Prolotherapy is a procedure in which a natural irritant is injected into the soft tissue of an
injured joint to stimulate the body’s healing response.
                                                16
interval follow ups are necessary to determine patient responses to medications and identify

any aberrant behavior, utilized through random urine drug screens, pill counts, and

restrictions to filling scripts at only one pharmacy. Dr. Wasan testified that if a patient is

overusing or misusing opioid prescriptions, it may indicate that the medications are not

working effectively to treat pain and are instead being used to feed tolerance or addiction.

Dr. Wasan stated that in such instances, physicians must consider moving away from using

opioid treatments, perform additional assessments, and modify treatment plans.

              d. Documentation

¶33    Section II of Montana’s Medical Board guidelines further advises physicians to

maintain accurate and complete records of: medical histories; physical examinations;

diagnostic and lab results; evaluations and consultations; treatment objectives; discussions

of risks and benefits of treatments; informed consent obtained; treatments; medications

prescribed, including date, type, dosage, and quantity; instructions and agreements for

using medications; and periodic reviews. Dr. Wasan and Dr. Ravitz testified that it is

within the standards generally accepted in the medical community to maintain

comprehensive summaries in patient files when treating chronic pain patients and is

“crucial” to guide follow-up treatments. Dr. Ravitz explained that in classical medical

documentation, he utilizes S.O.A.P. notes in patient files—an acronym referring to four

benchmarks of documentation: Subjective notes, such as patient descriptions of pain and

symptoms; Objective notes regarding diagnostic tests performed, such as vital signs,

temperature, blood pressure, physical examinations, and imaging results; Assessment,

referring to the physician’s valuation of both subjective and objective findings that

                                             17
correlates to the physician’s ultimate diagnosis as to the underlying cause of pain; and Plan,

referring to the corresponding treatment plan.

        Christensen’s Treatment of Patients

¶34     The jury heard testimony from all nine surviving patients15 regarding treatment

received from Christensen. Dr. Ravitz, Kara Philbrick’s treating physician prior to her

treatment with Christensen, and Jerry Price, Philbrick’s husband, offered testimony on

behalf of Philbrick.       Sharon Griffin, Gregg Griffin’s mother, Ryan Marchand,

Christensen’s risk assessment management and addiction counselor, and Dr. Furrow,

Griffin’s former treating physician, testified on behalf of Griffin.

           a. Addiction Disclosures

¶35     Cummings, Golden, Jessop, and Gore all testified that they heard about Christensen

by word-of-mouth, that you could “basically get anything,” and he “prescribed out the

medications that you asked for.” Cummings, Golden, Hiscoe, Lieberg, Sutherland, Jessop,

Peterson, and Gore all testified that they were already suffering from drug or opioid

addictions at the time they first saw Christensen. Golden, Hiscoe, Lieberg, Jessop,

Peterson, and Gore did not explicitly disclose their addictions to Christensen during their

   15
       Erica Cummings, the State’s first witness and a former patient of Christensen, was
prosecuted in a separate case for criminal distribution of dangerous drugs and negligent homicide.
Cummings ultimately pleaded guilty to criminal distribution and criminal endangerment. As part
of her plea agreement with the State, in exchange for dropping the negligent homicide charges,
she agreed to testify against Christensen in this case. During cross-examination, in an effort to
show bias, Christensen’s counsel sought to impeach Cummings based on the penalties she would
have potentially received if she did not agree to testify against Christensen. The State objected.
The court sustained the objection, explaining that the line of questioning “suggest[s] to the jury
what penalties [Christensen] might be facing, and that would be improper.” Christensen’s counsel
was permitted to question her about her actual sentence received based on the plea agreement.
                                               18
first or subsequent appointments. However, Ryan Marchand testified that he performed a

risk assessment with Lieberg and noted that he “was pretty open about the issues that he’s

had in his past[,]” and “it was pretty obvious that he would continue to struggle, to use

chemicals to deal with emotional issues as they arose . . . .”

¶36     Sutherland testified that she disclosed to Christensen on her initial visit in 2005 that

she was getting opioid withdrawal counseling and in 2012, after moving back to Montana,

testified she told Christensen she was on a Suboxone16 program. Marchand testified that

he performed a risk assessment on Sutherland, that Sutherland was open about her struggles

with addiction, and that she told Marchand that her grandmother had to keep her

medications locked up. Similarly, Cummings testified that she told Christensen during her

first meeting that she was addicted to Methadone. Marchand testified he performed a risk

assessment for Cummings and noted on her assessment form that she posed a “severe risk”

with using opioid therapy.

¶37     Both deceased patients, Griffin and Philbrick, also had long histories with substance

abuse at the time they saw Christensen. Sharon Griffin and Dr. Furrow testified that Griffin

had a long history with Methadone abuse, previously served a stint in a drug rehabilitation

center in Kalispell and was treated with Suboxone therapy for eight years prior to seeing

Christensen because of his Methadone addiction. Dr. Ravitz and Price testified that

Philbrick was an alcoholic, was routinely drinking large quantities of vodka at the time she

   16
      Suboxone (buprenorphine and naloxone) is a DEA Schedule III narcotic used to treat opioid
addiction.
                                               19
received treatment from Dr. Ravitz, and that in 2006, Philbrick overdosed from prescription

drugs.

¶38      Price testified that on March 13, 2013, he attended Philbrick’s first and only meeting

with Christensen. Price testified Philbrick told Christensen that she was on Fentanyl,

Zoloft, and Valium, and disclosed in her initial questionnaire that she used alcohol.

Similarly, Dr. Furrow testified that while Griffin first obtained a Methadone prescription

from Christensen on February 22, 2012, Griffin had previously met with Christensen in

2008 to obtain a medical marijuana card and indicated on a questionnaire that he was on

Suboxone treatment. On March 21, 2012, Marchand evaluated Griffin, and noted Griffin

posed a “high risk” for opioid abuse and dependency, was a “high risk” for developing

problems on long-term opioid therapy, and Marchand recommended “high monitoring.”

Marchand’s notes also provided that Griffin was on Suboxone therapy and that Griffin

wished to discuss further Suboxone treatment with Christensen.

                b. Legitimate Medical Issues

¶39      Trial testimony established that ten of the patients had legitimate pain at the time of

their first appointments with Christensen. Cummings was suffering from a hip injury;

Peterson, a professional golfer, suffered from a knee problem; Golden reported that she

suffered from rheumatoid arthritis in her hands; Hiscoe suffered from a degenerative bone

disease, neck fusion, a bad shoulder, arthritis in her back, and depression stemming from

her son’s death; Lieberg suffered a back injury from falling down a flight of stairs;

Sutherland was suffering from endometriosis and pain in her right hip; Gore suffered from

                                               20
a back injury stemming from collegiate football and prior military service; and Marchand

testified that he had a severe spinal cord injury from a mountaineering accident.

¶40    Sharon Griffin testified that Griffin suffered from a wrist injury from a nail gun,

broke an ankle from a construction accident, and previously received an arthroscopic

procedure for a knee injury. Price testified that Philbrick had a back injury from falling off

a horse when she was 12 and a misdiagnosed wrist injury. Only Jessop testified that she

was not in any pain at the time she went to see Christensen but did testify that in 1995 she

suffered an injury to her throat from a barbed wire fence while riding an ATV. Jessop

testified she told Christensen that pain from this incident was the reason for her coming to

Christensen.

               c. Initial Assessments

¶41    Many patients reported that meetings with Christensen, including initial

appointments, were no longer than a few minutes to a half hour. Christensen’s preliminary

examinations were very limited in nature or altogether nonexistent. Cummings testified

that he only had her touch her toes and “poked around” her back. She also testified that he

talked briefly about prolotherapy as an option but that she told him she was not interested.

She testified that Christensen did not conduct any urine or blood tests, did not conduct an

EKG, did not discuss the risk of opioid use, and did not recommend addiction or treatment

counseling. Similarly, Peterson testified that he only filled out one piece of paper at his

first visit and listed his cause of pain as “chronic pain” and a family history of

“fibromyalgia.” His first visit was only 10 minutes, and Christensen felt around his knees,

performed no diagnostic tests, and diagnosed him with “chronic pain.” Christensen

                                             21
purportedly told him he would treat his pain with pain pills, and offered no referrals for

surgery, alternative treatments, and did not discuss chemical dependency.

¶42    Golden testified Christensen performed a cursory exam on her back by pushing on

it and asked if it “hurt.” He told her she should eventually do an MRI but never followed

up on this suggestion. Christensen did not talk about the dangers or risks of opioid use,

ask for medical records, or utilize blood draws or urine screens. Similarly, Hiscoe testified

that Christensen did not perform any real physical exam or any diagnostic tests, discuss

with her any diagnosis or offer alternative treatments, did not provide a chemical

dependency evaluation, and the entire meeting was only 10 minutes.

¶43    Lieberg testified that Christensen met with him for only 20-25 minutes and

performed a basic checkup. Christensen diagnosed Lieberg with “chronic pain,” but only

briefly examined his back and did not perform any imaging tests. Sutherland testified she

received only one X-ray for pneumonia but did not receive one for her hip. Jessop said

that she first saw Robin Rice, Christensen’s physician assistant (“PA”), who explained pain

management to her and told her she needed to get her medical records. She testified no

diagnostic tests or imaging tests were conducted, there was no conversation about chemical

dependency, or a discussion as to a treatment plan. Marchand testified that he brought in

a binder with his past medical records for his first visit and provided a history of surgeries.

He testified that Christensen briefly looked through some of these records and made some

photocopies, but that Christensen did not conduct an in-depth physical examination.

¶44    Gore, a drug addict and drug dealer working in the Bakken oil fields in North

Dakota, testified that he came to his first meeting with a faulty back brace and cane to

                                              22
facilitate acquisition of prescription drugs. He previously had back surgery at a V.A.

hospital in North Dakota, but he did not obtain his V.A. records until his third appointment.

He was never asked to get a new MRI. Christensen only briefly checked his back and

observed his scar. Price testified that Christensen did not review any of Philbrick’s past

medical records, that he did not sign any of her release records to obtain past medical

records, that there was no physical exam aside from looking at her wrist, and that there was

no blood tests or EKG performed.

                 d. Prescriptions

¶45    All eleven patients received opioid prescriptions from Christensen on the first visit.

Cummings testified that she left her first visit with Christensen for a prescription of 80 or

90 mg of Methadone per day, as well as a prescription for Dilaudid and Ativan. She

testified that Christensen never discussed with her the risks of combining opioids with

benzodiazepines. Christensen also asked her if she owed anyone Methadone. Peterson

testified that he received a prescription for Dilaudid and Methadone at his first visit, that

he was to take “as needed,” and that Christensen did not explain the side effects of the

prescriptions.      Peterson testified that the quantity of his prescriptions went up

“significantly” until he was eventually taking 14 pills per day, and that “I always felt I was

prescribed way too much medication.”           Peterson was later prescribed Xanax for

sleeplessness. He testified that Christensen never discussed the risks of taking opioids and

benzodiazepines together or discussed the long-term effects of using these drugs.

Christensen also never set a date for having to stop. Peterson testified that at least once,

                                             23
Christensen used street slang to reference these drugs and referred to the street value of

these drugs.

¶46    Golden testified that she received a prescription for three Methadone per day on her

first visit and eventually received prescriptions for Xanax. She testified that Christensen

never discussed the dangers or risks of opioid use or the risks of combining Methadone and

Xanax. Hiscoe testified that she received prescriptions for Methadone, Hydromorphone,

and Xanax from Christensen, and eventually also received Hydrocodone. Over time, she

began receiving higher quantities of drugs until she was taking 100 mg of Methadone per

day in addition to Hydromorphone, Dilaudid, and Xanax.

¶47    Lieberg testified that he received Hydrocodone on his first visit. Eventually, he

received injections of prolotherapy on two separate occasions. Lieberg testified he later

received prescriptions for Oxycodone, Fentanyl Patches, and Dilaudid. He testified that he

paid in cash or traded manual labor for prescriptions. Lieberg testified that eventually he

was taking 10 pills of 10 mg Hydrocodone in addition to 6 pills of 30 mg Oxycodone per

day. Sharon Lieberg, a registered nurse for 47 years, testified that Lieberg received

prescriptions on two separate occasions for 300 pills, and another for 180 pills. She

testified that she had never seen prescriptions for drugs of that quantity prescribed before.

Alarmed by these prescriptions, she met with Christensen and told him Lieberg had a

history of drug abuse, bipolar disorder, and an autoimmune disorder.           In response,

Christensen prescribed Lieberg Fentanyl to help wean him off his prescriptions. Only days

later, Christensen increased his Fentanyl prescription to 100 mg per day before eventually

prescribing him most of the medications he was taking before.

                                             24
¶48      Sutherland testified that in 2012, her first visit back to Christensen, she received a

prescription for Methadone in lieu of Suboxone. Sutherland testified that she was

eventually prescribed 1000 Methadone pills per prescription. For approximately nine

months, she was instructed to take up to 600 mg of Methadone, eight to ten Dilaudid, and

six Xanax per day, alongside medication for muscle spasms. Jessop testified that her first

visit she told Christensen what medications worked for her pain and what she needed and

“that’s what I walked out with.” She received prescriptions for Dilaudid, Xanax, Soma,17

and eventually Methadone. She testified that the risks of these drugs were never explained.

She testified at the highest point, she was taking 20 Dilaudid, four Methadone, and five or

six Soma per day, in addition to a Methadone with each Dilaudid, plus a Xanax to go to

bed. She also testified that on two separate occasions she received Adderall pills directly

from Christensen.

¶49      Gore testified that he received Dilaudid on his first meeting with Christensen even

though it was not requested. Eventually he was prescribed Xanax and Methadone.

Marchand testified that he was prescribed Methadone and Dilaudid on his first visit with

Christensen. He testified his Methadone and Dilaudid prescriptions were increased over

time and eventually was also prescribed Xanax. Marchand said that Christensen did not

discuss any risks associated with combining Xanax with opioids like Methadone and

Dilaudid. Marchand was also eventually prescribed Adderall after he told Christensen he

was having trouble staying awake and focusing due to his Methadone prescription.

   17
        Soma (carisoprodol) is used as a muscle relaxant.
                                                 25
¶50     Price testified that at her first appointment, Philbrick asked Christensen for a

prescription for Methadone at a specific amount and her request was granted. He also

prescribed Philbrick Dilaudid for “breakthrough pain”18 and a medical marijuana

certificate. Dr. Ravitz testified Christensen’s prescription indicated that Philbrick was

supposed to increase her Methadone dosage from 30 mg to 90 mg per day over a six-day

period. Dr. Ravitz testified that he had prescribed Philbrick Fentanyl only days earlier.

Price testified that Christensen provided a four-day taper off the Fentanyl. Price also

testified that they went to the Osco drug pharmacy and had a hard time filling the

Methadone prescription. Price testified that on March 15, 2013, two days later, he found

Philbrick dead.

¶51     Dr. Furrow testified that Griffin received Methadone from Christensen on his first

visit. She testified that Christensen did not contact her regarding Griffin’s treatment. On

March 2, 2012, Griffin’s second visit with Christensen, he received a prescription for 200

pills of Methadone in addition to Xanax and was to take 60 or 70 mg of Methadone per

day. On March 30, 2012, Griffin attended Big Creek Family Medicine; he did not have an

actual appointment but obtained a refill of a prescription for 200 Methadone pills. Sharon

Griffin testified that on April 2, 2012, she found Griffin dead from a drug overdose.

               e. Monitoring

¶52     Patient testimony also reflected that Christensen’s follow-up appointments were

consistently brief, that Christensen rarely conducted follow-up tests or assessments, and

   18
       Dr. Colucci testified that breakthrough pain refers to unexpected flare ups of pain that are
often treated with short-acting opioids like Dilaudid.
                                                26
often only refilled prescriptions.    Cummings testified that Christensen never again

performed any physical exams or diagnostic tests, never discussed goals to address her

underlying hip pain, or a timeline for weaning off opioids. She testified that once

Christensen offered her prolotherapy, but she declined. She testified that once Christensen

performed a pill count and another time a urine test, which she failed for having

unprescribed Adderall in her system. Christensen responded by providing her a

prescription for Adderall. Cummings also testified that on another occasion she was

required to meet with Marchand after a neighbor called Christensen and told him she was

selling her pills. Christensen told her he did not have any reason for concern and did not

make changes to her prescriptions.      He also recommended Cummings only fill her

prescriptions at a pharmacy in Corvallis, Montana, because it was the only pharmacy that

would fill his prescriptions. Eventually she stopped seeing Christensen because she was

arrested for criminal distribution of dangerous drugs and negligent homicide.

¶53    Peterson testified that follow-up visits with Christensen were shorter each time, that

there were no additional physical exams or evaluations, and that follow-up appointments

were used only to refill his prescriptions. He testified that Christensen never discussed a

timeline to discontinue opioid treatment. He testified he was never subject to pill counts,

urinalysis tests, and only once received an EKG, but did engage in physical therapy

treatments at Christensen’s office on two occasions. Peterson stated that within four weeks

of treatment he believed he was addicted to opioids and feared overdosing. He testified he

asked Christensen if he could begin to taper off opioids, but Christensen responded, “we

                                             27
need to continue treatment as we are doing now.” Peterson entered a drug rehabilitation

program after Christensen’s practice shut down.

¶54    Similarly, Golden testified Christensen never discussed alternatives to opioids, did

not request past medical records, perform blood draws, or utilize urine tests, and only once

performed an EKG. She testified that on one occasion Christensen sent a letter stating he

was going to terminate her treatment contract because she was being reported to authorities

for abusing opioids. She testified she appeared at a scheduled visit anyway and continued

to see Christensen for another year with no change in her prescriptions. She also met once

with a counselor in his practice for an evaluation but testified that Christensen told her

everything seemed good and he would not modify her prescriptions. Eventually, Golden

moved to Oregon to quit opioids and began using methamphetamine to cope with

withdrawals.

¶55    Hiscoe testified that her follow-up appoints were only five to ten minutes, that

Christensen never again performed any physical exams, attempted to treat her underlying

condition, discussed goals or plans for treatment, or discussed the risks of using opioids

while suffering from depression. She testified that once she asked Christensen as to

whether she should be concerned about mixing opioids with benzodiazepines. Christensen

told her that it was mostly a concern for patients not used to taking those kinds of

medications. She also testified her drug addiction was most severe when she was seeing

Christensen and that on multiple occasions, her children found her unconscious and unable

to function, but that she did not disclose these events to Christensen.

                                             28
¶56    Lieberg testified that Christensen never discussed any options for alternative

treatments. Subsequent visits were only 20 minutes each time, there were no other physical

exams other than prolotherapy, and he was never referred to any specialists. Lieberg

testified that there was once a discussion about obtaining a chemical dependency

evaluation, which he received, but the results were never discussed. He stated that on

several occasions he could not fill his prescriptions because the number of pills was too

high. Lieberg’s mother testified that eventually, Lieberg tried to commit suicide. She

responded by reporting Christensen to the DEA.

¶57    Sutherland testified that she once inquired as to her drug tolerance, and Christensen

responded only that her tolerance was “pretty high.” She was also asked to see a chemical

dependency counselor in his office, but the results were never discussed. She stated that

she was never provided a recommendation for addiction treatment or counseling. She also

stated that only the Corvallis pharmacy would fill her prescriptions. Eventually she quit

seeing Christensen when Child Protective Services took away her daughter “because of the

state that I was in.”

¶58    Jessop testified that she never had any subsequent physical exams and that her

prescriptions were simply refilled every two weeks. She testified that there was no other

treatment plan other than how many pills per day she was to take and that there was never

any discussion as to alternative forms of treatment or addiction counseling. She also stated

that only one urinalysis test was conducted and there was never a discussion about the

results. She testified that on multiple occasions she told Christensen her medications were

lost, stolen, or dropped in the toilet, and that he never documented the instances or modified

                                             29
her prescriptions. She also testified it was evident that she was a drug addict, that she was

taking heroin and methamphetamine on the side, and that she lost nearly 40 pounds

throughout the course of her treatment from Christensen. She stopped seeing Christensen

in 2012 after she was arrested for stealing one of Christensen’s prescription pads and was

forging his signature to obtain prescription drugs.

¶59     Gore testified that on subsequent visits he was never asked to get a new MRI for his

back. He stated that it became difficult to fill his prescriptions because of the quantity of

drugs he was receiving. Eventually, to obtain a three-month prescription, Gore testified

that he was required to see an addiction counselor and complete a urinalysis test. He used

someone else’s urine to pass the test. He was also given two different pill counts for

Dilaudid and Roxicet.19 He stated that he was never given another physical exam, urine

test, or pill count. He also stated that Christensen occasionally used street slang to refer to

the names and prices of the drugs he was administered.

¶60     Marchand testified that over two years, Christensen never conducted additional

physical exams other than one instance following a slip and fall accident at another

employer. Marchand testified that he would receive prescriptions for three months at a

time, and at each appointment, Christensen would only refill his prescriptions. He testified

that prescriptions were just ready at the front desk or he would pass them along directly

“when he had time to write them out.” Marchand testified that eventually he believed he

was addicted to opioids and that he could not function safely.

   19
       Roxicet (Oxycodone and Acetaminophen) is a combination of opioid and non-opioid pain
relief medications.
                                              30
       Expert Testimony Regarding Christensen’s Treatment Practices

¶61    Dr Ravitz, Dr. Bender, Dr. Furrow, and Dr. Wasan each reviewed some or all the

patient medical files and offered testimony as to Christensen’s treatment in relation to the

standard of care. Dr. Wasan testified that Christensen’s treatment of all nine surviving

patients—Cummings, Peterson, Hiscoe, Golden, Sutherland, Lieberg, Jessop, Gore, and

Marchand—fell below or far below the accepted standards of practice recognized in the

medical community because Christensen always prescribed high dose opioids, often in

conjunction with benzodiazepines, on the very first visit; Christensen administered these

prescriptions without proper assessments, review of existing medical files, referrals to

properly diagnose underlying conditions, consideration of non-opioid treatments, or

comprehensive treatment plans; and Christensen routinely failed to monitor patients’ use

of heavy dose prescriptions through adequate pill counts or blood or urine tests despite the

presence of red flags. Dr. Wasan noted these red flags included Hiscoe’s depression,

anxiety, and PTSD; Lieberg’s history of opioid abuse and Cummings’ addiction history

disclosures, both of which Dr. Wasan described as the “equivalent of giving someone a

loaded gun”; track marks on Jessop’s arms from intravenous drug use; patients’ misuse of

prescriptions and reports of lost or stolen prescriptions; and Gore’s back brace and crutch,

which he opined suggested exaggerating or faking symptoms.

¶62    Experts also testified that Christensen’s treatment of Philbrick and Griffin did not

meet the standards of care in the medical community.             Dr. Ravitz testified that

Christensen’s medical files for Philbrick did not adhere to the standards expected in the

medical community and would not achieve a passing grade for a second-year medical

                                            31
student. Dr. Ravitz further testified there was no documented evidence Christensen

performed a full assessment on Philbrick because there was no review of her medical

history, evidence of a physical exam, imaging tests, or evidence of a treatment plan.

Dr. Ravitz and Dr. Wasan testified that Christensen’s increase of Philbrick’s Methadone

prescription to 90 mg per day over a six-day period fell well below the standard of care

because Philbrick had a history of addiction and alcohol abuse and there were no written

warnings, specific instructions to discontinue Fentanyl, short-interval follow ups, or efforts

to obtain past medical files.

¶63    Dr. Furrow and Dr. Wasan reviewed Christensen’s medical file for Gregg Griffin

and testified that there was not an acceptable reason to prescribe Griffin high-dose opioids

and benzodiazepines at the beginning of treatment when Griffin had successfully used

Suboxone therapy for eight years. Both experts testified this prescription was “dangerous,”

undermined Griffin’s addiction treatment, and put him at a severe risk of overdose or

addiction.   Dr. Furrow testified that Christensen’s medical file did not have any

documentation or offer any changes to his prescriptions based on Marchand’s assessment,

which placed Griffin at a “high risk” for abuse. Dr. Furrow further testified there was no

documentation regarding advice, suggestions, warnings, or discussions with Griffin

concerning his opioid medication, and that Christensen’s limited documentation did not

conform to the standard of care in the medical community.

                                             32
Christensen’s Defense20

¶64     Christensen presented expert testimony from Dr. Forrest Tennant, a Los Angeles

physician and doctor of public health who operates a clinic for intractable pain patients.

Dr. Tennant testified that from 2001 until 2016, known as the “Decade of Pain,” federal

efforts sought to encourage every physician and family doctor to engage in widespread

opioid prescriptions to treat pain. Dr. Tennant testified that during this period, there was

no maximum limit of opioids that could be prescribed, that opioids were considered a first

line of defense to treat chronic pain, that doctors did not need to provide a diagnosis before

prescribing opioids, and dosages were between the physician and patient to determine.

Dr. Tennant further testified that until 2015 or 2016, the prevailing medical opinion was

that it was okay to prescribe benzodiazepines and opioids together.

¶65     Dr. Tennant also reviewed all eleven of the patient files in the case and opined as to

whether Christensen was operating within the course of a professional practice and whether

Christensen was prescribing opioids for a legitimate medical purpose. He testified that

   20
       Prior to Christensen’s witnesses testifying, the State notified the court as to issues regarding
the scope of Christensen’s lay witness testimony in relation to Gayle Christensen, Christensen’s
wife and a physical therapist and business manager of Christensen’s practice, and Francie Paddock,
a receptionist and bookkeeper in Christensen’s practice from 2010 to 2012. Christensen sought to
elicit testimony from Gayle and Paddock regarding how Christensen’s practice operated,
availability of alternative pain management modalities, and pricing of treatment to suggest
Christensen was acting within the course of a professional practice. The State objected to the
relevance of this potential line of questioning. The court sustained the objection, stating that
anything that these witnesses observed, experienced, or witnessed in regards to the alleged victims
or that was applicable to all patients during the period they were treated was permissible and
relevant evidence, but opinion evidence as to whether or not Christensen was a “good doctor” and
acting in the course of his practice was too broad and impermissible. Christensen’s counsel argued
that this testimony should be admitted because it concerned an element of an affirmative defense—
that Christensen was at all times acting within the course of a professional practice—and stated
that this limiting instruction would “substantially gut the defense” and constituted reversible error.
                                                  33
Christensen’s medical charts were about “60 to 70 percent there” relative to what was

required, but that it did not take him outside the course of a professional practice even

though he found them “unsatisfactory.” He testified that the Montana standards, which are

based on the National Federation of Medical Board21 standards, are “very vague” and

Christensen had great latitude to treat these patients. He also testified that the eleven patient

cases were “very complex,” that Christensen “did what he thought was right,” and that

Christensen was operating within the standard of practice at the time.                 However,

Dr. Tennant also testified that Christensen was “way over his head” and “totally

unqualified,” that his care was “atrocious” and “laughable” based on present standards, and

that his “setting and style were never going to allow the kind of care that would be

appropriate in the family practice setting.”

¶66     Christensen also testified in his defense. Christensen explained that his philosophy

for treating chronic pain patients was to “commit[] to them for as long as you are going to

be in practice.” He testified that he often provided a list of medications to patients to

familiarize them with options and prices because many patients could not afford

comprehensive treatment. He also testified that he used lists of drugs and listened to patient

requests for certain drugs because he “subscribe[d] very much to the idea that if patients

have knowledge of what does or doesn’t work for them, that’s an appropriate starting

place.” Christensen explained that while patients asking for certain drugs could be

   21
      The Federation of State Medical Boards (“FSMB”) is a national non-profit organization
representing 71 state medical and osteopathic boards of the United States and its territories. The
FSMB licenses physicians, investigates complaints, disciplines medical practitioners violating the
law, conducts evaluations, and facilitates physician rehabilitation.
                                               34
considered a red flag, he was “more than willing to put aside that issue of whether the

patient had a preference by allowing a discussion of what had been used in the past.”

¶67     Christensen also testified that when the prescription drug registry22 became

available in Montana, he did not keep records of how many times he utilized the database.

He testified that his former P.A., Robin Rice, was “certainly more inclined to want the

reassurance that there wasn’t doctor shopping, multiple prescribers involved.” Christensen

also testified that when treating Sutherland, she admitted to him that “she had had a lot of

use of street drugs,” and “[s]he sought out whatever she could ger her hands on to treat the

pain.” He testified that this was a “red flag” but that it did not stop him from prescribing

opioids to her because “the underpinning idea behind management of chronic pain as a

progressive disorder is that if you can adequately control the pain, you can change the

outcome.” Christensen further testified that his treatment as to Sutherland was based

“entirely on that level of communication with the patient.” He stated that he was concerned

about the amount of opioids and medications he was prescribing to her but did not stop

prescribing Methadone because “at every point of making the decision whether I would

continue to use what I was using . . . there was a report that she was gaining, incrementally,

more and more ability to be on her feet . . . .”

   22
      The Montana Prescription Drug Registry is an online tool used to provide a list of controlled
substance prescriptions to health care providers to improve patient care and safety and identify
potential misuse, abuse, and/or diversion of controlled substances. In 2011, the Montana
Legislature authorized the use of The Montana Prescription Drug Registry, §§ 37-7-1501 through
1515, MCA. This registry became functional in 2012.
                                                35
¶68      On cross-examination, Christensen was questioned regarding his treatment of some

of his patients that overdosed in Idaho. Christensen stated that, “I was accused of having

a role in the death of several patients, most of whom were not under my care when they

died.” He also stated that after his second Board stipulation in Idaho, “I had 10 years to

reevaluate my prescription writing practices.” The State asked Christensen whether he had

the opportunity to reevaluate his prescription writing practices following the death of

Griffin. Christensen responded, “The outcome of any patient I treat needs to be taken into

account in terms of how I continue to treat other patients in a similar manner.” Finally,

Christensen admitted that he previously told the Task Force during the beginning of the

investigation in this case that “85 percent” of the pharmacies in the area would not fill his

prescriptions.

State’s Rebuttal

¶69      The State provided testimony from Mary Leonard, an investigator and subsequently

an associate director for the Idaho Board of Medicine. Leonard was assigned Christensen’s

case in 1999. Leonard testified that it was “not true” that most of the patients whom

Christensen treated in Idaho who died from overdoses were not under his care at that time.

Leonard testified that she received the information from these deaths, reviewed patient

medical records, pharmacy printouts, information from law enforcement, and coroners’

reports that showed Christensen’s names on pill bottles found within residences or place

of death of these patients.23 Of the five overdose deaths of which Christensen was notified

   23
        At trial, Christensen’s counsel objected to this testimony as inadmissible hearsay.
                                                  36
of in the disciplinary proceeding, Leonard testified that all five were under his medical care

and records reflect he prescribed all of them controlled substances. Leonard also testified

that all five of these patients were on a combination of opioids and benzodiazepines and

died from an overdose of those prescriptions.

¶70    Following Leonard’s testimony, Christensen’s counsel requested that the court have

a M. R. Evid. 404(b) instruction read as part of the final instructions. The State did not

object and the court included Instruction No. 28, Evidence of Other Acts, which addressed

the limited purpose for which the jury could use Christensen’s past conduct in Idaho.

Closing Arguments

¶71     During closing argument, the State referenced the Montana standards of practice,

stating that physicians do not meet these standards by “handing them opioids the first time

and saying there, I treated you.” The State also explained that in determining whether

Christensen could be convicted for criminal distribution, “It’s not about a physical

building. It’s about are you conducting yourself as a part of the professional practice.”

The State also opined that Christensen “is not just like all the [practitioners in Montana],

because all the others were practicing medicine[.]” The State offered that “The only

[patients] who went to [Christensen] because others wouldn’t—or they didn’t want to keep

going to the others, are the addicts, because the people doing it right made it too tough.”

¶72    The State further explained that the Idaho Board investigations were relevant

because “It’s the notice [Christensen] was put on. It’s what he learned and did not

change[,]” and “He was put on notice, if you do this people die. He did nothing to change.

He did it again. People died. It’s that simple.” The State told the jury, “What I’m asking

                                             37
you is to say to Dr. Christensen you cannot do that in Idaho, put your blinders on, come

over here in Montana, ignore everything you should have learned and do the same thing

here. Tell him that is criminal. It fits every definition. That is criminal.”

Jury Instructions

¶73    Prior to administering jury instructions, Christensen’s counsel objected to the

language in the State’s instruction as to criminal distribution, arguing that there was

nothing in the instruction about a nationwide standard of care, that the professional practice

exemption in § 45-9-101(6), MCA, must be read strictly such that Christensen may not be

prosecuted under the statute, and the State must at least follow Feingold if the case is to be

“legally viable” because Montana law does not prohibit Christensen’s conduct.

¶74    The final jury instructions included Instruction No. 23, Criminal Distribution of

Dangerous Drugs, which stated:

       [T]o convict a Defendant of criminal distribution of dangerous drugs, for
       each separate count the State must prove the following elements: (1) that the
       Defendant prescribed a dangerous drug to another; and (2) that the Defendant
       acted purposely or knowingly; and (3) the professional practice exemption
       does not apply to the Defendant’s conduct. If you find from your
       consideration of the evidence that each of these elements have been proved
       beyond a reasonable doubt, then you should find the Defendant guilty.

¶75    Jury Instruction No. 24 articulated the professional practice exemption:

       A practitioner who prescribes a dangerous drug to a patient is distributing
       that dangerous drug. However, a practitioner is exempt from prosecution
       and may not be convicted of criminal distribution of dangerous drugs if he
       delivers that prescription while acting in the course of a professional practice.

       The exemption does not apply if a practitioner purposely or knowingly
       prescribes a dangerous drug for no legitimate medical purpose while acting
       outside of the regular course of a professional practice.

                                              38
       You are not required to determine if any patient receiving a prescription had
       a legitimate medical condition. Rather, you must determine whether the
       Defendant had a legitimate medical purpose within the regular course of a
       professional practice when he delivered the particular prescription being
       considered.

       The legitimacy of the “medical purpose” is not determined merely by a
       practitioner’s sincere intent towards his patient. Instead, you are to determine
       from the evidence whether the Defendant made an honest effort to prescribe
       for a patient’s condition in accordance with the standard of medical practice,
       if any, that was generally recognized and accepted in the State of Montana
       during the time period in which the prescription occurred.

       Evidence in this case offered regarding the applicable standard of medical
       practice was not offered to establish malpractice, but rather to support the
       State’s claim that there was an absence of any legitimate medical purpose. It
       is up to you as jurors to decide if the State has proven beyond a reasonable
       doubt the absence of any legitimate medical purpose.

       While a practitioner may not be convicted of criminal distribution of
       dangerous drugs based on mere negligence, practitioners who act outside the
       regular course of professional practice by purposely or knowingly
       prescribing dangerous drugs for no legitimate medical purpose are not
       entitled to this exemption, and may be prosecuted for and convicted of
       criminal distribution of dangerous drugs in accord with all the instructions
       given to you.

¶76    Jury Instruction No. 28, “Evidence of Other Acts,” was also offered to instruct the

jury as to the proper use of Christensen’s past conduct in Idaho introduced at trial. This

instruction stated:

       The State has offered evidence that the Defendant at another time engaged in
       wrongs or acts. That evidence was not admitted to prove the character of the
       Defendant or to show he acted in conformity therewith. The only purpose of
       admitting that evidence was to show knowledge, mental state, and/or absence
       of mistake or accident. You may not use that evidence for any other purpose.

¶77    The jury returned a verdict finding Christensen guilty of all eleven counts of

Criminal Distribution of Dangerous Drugs.

                                             39
Discussion

Constitutional Claims

¶78    We first address the host of constitutional issues Christensen raises on appeal.

Christensen argues that by admitting evidence of the underlying conduct of treatment of

Idaho patients at trial, the court violated his constitutional protections against double

jeopardy and confrontation clause rights. Absent plain error, allegations that constitutional

rights have been violated cannot be raised for the first time on appeal. State v. Minez, 2004

MT 115, ¶ 30, 321 Mont. 148, 89 P.3d 966. Moreover, acquiescence in the alleged error

negates the right of objecting to it. State v. Brown, 1999 MT 339, ¶ 19, 297 Mont. 427,

993 P.2d 672. Christensen did not object before trial or at trial to Uranga’s or Leonard’s

testimony on constitutional grounds regarding the “thumbnail” sketches of allegations

against Christensen in the Idaho Board cases, but only sought to exclude such testimony as

irrelevant or as inadmissible hearsay. Having abandoned his constitutional objections at

trial, Christensen is precluded from raising these issues on appeal.

¶79    Christensen further raises a prosecutorial misconduct claim for the first time on

appeal, arguing that the State misled the jury by suggesting in closing argument that

Christensen was the definitive cause of drug overdose deaths in Idaho.             Criminal

defendants are entitled to a constitutional right to a fair trial by jury. State v. Lawrence,

2016 MT 346, ¶ 13, 386 Mont. 86, 385 P.3d 968 (internal quotations and citations omitted);

U.S. Const. amend. VI; Mont. Const. art. II, § 24. We do not presume prejudice from the

alleged misconduct; rather, the defendant must demonstrate that the alleged misconduct

violated his substantial rights. Lawrence, ¶ 13. Moreover, this Court does not isolate the

                                             40
challenged comments upon review but considers the challenged comments in the context

of the trial and the closing argument as a whole. Lawrence, ¶ 13.

¶80    Christensen refers to the State’s comments in closing argument in isolation, ignoring

the greater context in which these comments were presented. Evidence of Christensen’s

past conduct in Idaho was specifically used to demonstrate that Christensen was on

“notice,” i.e., that because he was stripped of his medical and DEA licenses in Idaho

following overdose deaths of patients, he was thus aware that his prescribing practices were

outside the course of a professional practice and that prescribing opioids in large quantities

without adequate tests, referrals, and follow-ups could risk bodily harm or death.

¶81    The State appropriately referenced the purpose of this evidence in opening

statements—explaining that Christensen did not admit liability, and in closing argument—

stating that when “the Defendant moved his practice to Florence Montana . . . he knew the

dangerous risks to his patients’ lives and health to overprescribing opiates[,]” and “He was

put on notice that if you do this, your patients die.” (Emphasis added.) The court, upon

Christensen’s request, further instructed the jury as to the limited purpose of this evidence,

providing Instruction No. 28, which explained that “The Defendant is not being tried for

those other wrongs or acts[,]” and “The only purpose of admitting that evidence was to

show knowledge, mental state, and/or absence of mistake or accident.” Considering the

trial as a whole, we find the State did not commit prosecutorial misconduct such that it

deprived Christensen of a fair trial.

¶82    Christensen also argues that the District Court denied him of his constitutional right

to present a complete defense because (1) it excluded the testimony of 28 of his former

                                             41
patient witnesses when it granted the State’s motion in limine, (2) barred testimony at trial

from Gayle Christensen and Francie Paddock who would have testified as to Christensen’s

general day-to-day practice, and (3) restricted Christensen’s cross-examination of Erica

Cummings.

¶83    A defendant in a criminal trial has a constitutional right to a meaningful opportunity

to present a complete defense. State v. Glick, 2009 MT 44, ¶ 29, 349 Mont. 277, 203 P.3d

796. However, this right is not absolute; state rules excluding evidence from criminal trials

do not abridge a defendant’s right to present a defense so long as the rule is not arbitrary

or disproportionate to the purpose it is designed to serve. State v. Hauer, 2012 MT 120,

¶ 24, 365 Mont. 184, 279 P.3d 149; United States v. Scheffer, 523 U.S. 303, 308, 118 S. Ct.

1261, 1264 (1998). A district court has broad discretion when determining the relevance

and admissibility of evidence. State v. Daniels, 2011 MT 278, ¶ 11, 362 Mont. 426, 265

P.3d 623. Evidence which is not relevant is not admissible. M. R. Evid. 402.

¶84    Christensen argues that the testimony of his 28 former patients was relevant to his

affirmative defense that he was prescribing drugs in the course of a professional practice,

and that this evidence was admissible pursuant to M. R. Evid. 406, Habit or Routine

Practice. Christensen asserts these patients would have provided a corrective impression

of his professional practice as a whole, including an absence of a criminal scheme to

distribute controlled substances without a legitimate medical purpose.

¶85    M. R. Evid. 406(b) provides, “Evidence of habit or of routine practice . . . is relevant

to prove that conduct on a particular occasion was in conformity with the habit or routine

practice.” This case is not a civil medical malpractice case, however, but a criminal trial,

                                              42
the charges which allege that Christensen was not acting in the course of his professional

practice when he was treating the eleven patients in question. Whether the proposed

testimony of former patients is admissible therefore rests on whether this testimony was

relevant to his treatment of the eleven identified patients.

¶86    Christensen conceded that none of these former patients were present when he

treated or prescribed dangerous drugs to the eleven charged patients. Thus, Christensen

was not seeking to use former patient testimony to prove that his conduct when treating

and prescribing to the eleven patients in this case conformed with his routine practice, but

only that his treatment of these patients was an error and therefore he did not possess the

criminal intent necessary to be prosecuted. Accordingly, their testimony was irrelevant as

to whether Christensen acted in the course of a professional practice when treating the

patients here. The District Court did not err in granting the State’s motion in limine to

exclude this former patient testimony.

¶87    Likewise, the District Court did not err in excluding testimony from Gayle

Christensen and Francie Paddock as to Christensen’s general day-to-day practice. Whether

Christensen “generally” operated in the course of a professional practice is not relevant to

the determination as to whether Christensen operated in the course of a professional

practice as to the eleven charged patients. Because Gayle and Paddock were not testifying

as to Christensen’s treatments with regards to these patients, their offered testimony was

irrelevant, and therefore, inadmissible. M. R. Evid. 401, 402.

¶88    Christensen further asserts that his Confrontation Clause rights were violated

because he was not allowed to question Cummings on cross-examination as to the benefits

                                              43
she received under the plea bargain in her own criminal trial, in which the State agreed to

drop her negligent homicide charges in exchange for her testifying against Christensen in

the present case.

¶89    The Sixth Amendment’s Confrontation Clause, applicable to state prosecution via

the Fourteenth Amendment to the United States Constitution, guarantees a criminal

defendant the right “to be confronted with the witness against him.” U.S. Const. Amends.

VI, XIV; Crawford v. Washington, 541 U.S. 36, 42, 124 S. Ct. 1254, 1259 (2004). The

main purpose of confrontation is to secure for the opponent the opportunity to

cross-examine and expose a witness’s motivation in testifying. State v. Nelson, 2002 MT

122, ¶ 14, 310 Mont. 71, 48 P.3d 739. However, a trial court retains broad discretion to

limit the scope of cross-examination to those issues it determines are relevant to the trial.

State v. Beavers, 1999 MT 260, ¶ 36, 296 Mont. 340, 987 P.2d 371. Limiting the scope of

cross-examination does not necessarily violate a defendant’s right to confront an adverse

witness; the Confrontation Clause guarantees an “opportunity” for effective

cross-examination, not cross-examination that is effective in whatever way or to whatever

extent the defendant desires. Nelson, ¶ 19.

¶90    At trial, Christensen did not object to violations of his due process and confrontation

rights, but only objected as to state law evidentiary issue. And Christensen agreed to a

stipulation pretrial that inferences of potential sentences Christensen faced for charges in

the present case could not be presented to the jury. Christensen acquiesced to any error by

the trial court in limiting the cross-examination of Cummings. Christensen’s constitutional

                                              44
due process and confrontation rights are thus unpreserved and may not be challenged on

appeal. See State v. Reim, 2014 MT 108, ¶¶ 28-29, 374 Mont. 487, 323 P.3d 880.

¶91    Moreover, Christensen was provided an ample opportunity to cross-examine

Cummings and explore the benefit she received under the plea agreement. Cummings

already pleaded guilty to her crimes and had already been sentenced at the time she

testified. Whatever sentence she could have received for other charges was irrelevant. The

District Court did not err in restricting Christensen’s cross-examination of Cummings.

¶92    Lastly, Christensen argues that the plain language of Montana’s criminal

distribution statute, § 45-9-101, MCA, prohibits Christensen from being prosecuted under

Montana law, and broadening its meaning violates his constitutional due process rights.

Christensen argues that he cannot be prosecuted for criminal distribution of dangerous

drugs under Montana law because (1) § 45-9-101, MCA, does not prohibit “prescribing”

of dangerous drugs because “prescribing” does not fit within the plain meaning of “selling,

bartering, exchanging, or giving away,” and (2), the professional practice exemption in

subsection (6) of the statute prevents Christensen from being prosecuted under Montana

law.

¶93    Section 45-9-101(1), MCA, provides in part, “a person commits the offense of

criminal distribution of dangerous drugs if the person sells, barters, exchanges, gives away,

or offers to sell, barter, exchange, or give away any dangerous drug, as defined in

50-32-101.” Dangerous drugs include “a drug, substance, or immediate precursor in

Schedules I through V . . . .” Section 50-32-101(6), MCA. Section 45-9-101(6), MCA,

provides that “Practitioners, as defined in 50-32-101, and agents under their supervision

                                             45
acting in the course of a professional practice are exempt from this section.” A practitioner

includes a “physician . . . or other person licensed, registered, or otherwise permitted to

distribute, dispense . . . or to administer a dangerous drug in the course of professional

practice or research in this state[.]” Section 50-32-101(24)(a), MCA.

¶94    It is undisputed that Christensen was prescribing dangerous drugs, including

Schedule II opioids and Schedule IV benzodiazepines, to patients. It is further undisputed

that at the time the alleged offenses occurred, Christensen wrote all prescriptions at his

office, employed professional staff, and maintained a Montana medical license and DEA

license. Whether Christensen may be prosecuted and convicted under the statute therefore

rests on whether (1) “prescribing” dangerous drugs constitutes “selling, bartering,

exchanging, or giving away,” and (2) he was operating outside the course of a professional

practice at the time he prescribed these controlled substances.

¶95    “In the construction of a statute, the office of the judge is simply to ascertain and

declare what is in terms or in substance contained therein, not to insert what has been

omitted or to omit what has been inserted.” City of Missoula v. Fox, 2019 MT 250, ¶ 18,

397 Mont. 388, 450 P.3d 898. When interpreting a statute, this Court’s objective is to

implement the objectives the Legislature sought to achieve. Bullock v. Fox, 2019 MT 50,

¶ 52, 395 Mont. 35, 435 P.3d 1187. The starting point for interpreting a statute is the

language of the statute itself. Bullock, ¶ 52. If the intent of the Legislature can be

determined from the plain meaning of the words used in the statute, the plain meaning

controls. Mont. Vending, Inc. v. Coca-Cola Bottling Co., 2003 MT 282, ¶ 21, 318 Mont. 1,

78 P.3d 499. Where the Legislature has not defined a statutory term, we consider the term

                                             46
to have its plain and ordinary meaning, and may consider dictionary definitions, prior case

law, and the larger statutory scheme in which the term appears. State v. Alpine Aviation,

Inc., 2016 MT 283, ¶ 11, 385 Mont. 282, 384 P.3d 1035; Giacomelli v. Scottsdale Ins. Co.,

2009 MT 418, ¶ 18, 354 Mont. 15, 221 P.3d 666. This Court will give effect to all

provisions of the statute if possible. Bullock, ¶ 53.

¶96     The Montana Legislature has not provided a definition as to “selling, bartering,

exchanging, or giving away.” Accordingly, we consider these terms to have their plain and

ordinary meaning. Black’s Law Dictionary defines “exchange” as “The act of transferring

interests, each in consideration for the other.” Exchange, Black’s Law Dictionary (11th

ed. 2019). We find that “prescribing” of dangerous drugs fits squarely within the definition

of exchange. In exchange for payment, Christensen routinely prescribed dangerous drugs

to the eleven named patients in this case.24 Accordingly, § 45-9-101(1), MCA, does not

prohibit Christensen from being prosecuted for prescribing dangerous drugs so long as he

is acting outside the course of his professional practice.

¶97     Further, § 45-9-101(6), MCA, does not offer a blanket exemption for physicians

from prosecution under the statute, but only does so in the instance in which a physician is

“acting in the course of a professional practice.” Logically, a physician not acting within

the course of a professional practice may be prosecuted under Montana’s statute.

Naturally, if the Montana Legislature had intended physicians to be exempt from the

   24
       While Christensen also relies on other state court interpretations of similar statutes in support
of his argument, none of these statutes possess identical language to Montana’s criminal
distribution statute. Nor do out-of-state decisions possess any binding authority on this Court or
provide insight as to the intent of Montana’s Legislature when crafting statutory language.
                                                  47
statute, it would have provided a wholesale exception rather than create subsection (6). If

this Court were to adopt Christensen’s narrow reading of the statute, it would render

subsection (6) meaningless. See State v. Heath, 2004 MT 126, ¶ 31, 321 Mont. 280, 90

P.3d 426 (“We are required to avoid any statutory interpretation that renders any sections

of the statute superfluous and does not give effect to all the words used.” (citation omitted)).

¶98    Here, the State did not attempt to argue that Christensen could be prosecuted despite

acting in the course of a professional practice or challenge Christensen’s assertion that he

maintained an office or employed professional staff when issuing prescriptions. Rather,

the State alleged that Christensen was acting outside the course of a professional practice

with regard to the eleven named patients because he eschewed the use of appropriate

documentation, assessments, tests, follow-ups, referrals, and provided dangerous drugs in

obscene quantities such that Christensen was not acting like a physician at all but instead

was acting as a “drug pusher.” Accordingly, under the plain meaning of § 45-9-101, MCA,

Christensen may be prosecuted for criminal distribution of dangerous drugs.

¶99    Relatedly, Christensen argues that the State inappropriately relied on a federal

distribution statute, 21 U.S.C. § 841(a), and federal case law in support of its interpretation

of § 45-9-101, MCA, when charging Christensen, arguing that the federal statute and case

law is substantially different than Montana’s criminal distribution statute. We disagree.

¶100 The Federal Uniform Controlled Substances Act (“CSA”) provides, “it shall be

unlawful for any person knowingly or intentionally—(1) to manufacture, distribute, or

dispense, or possess with intent to manufacture, distribute, or dispense, a controlled

substance.” 21 U.S.C. § 841(a). Federal courts have routinely held that physicians and

                                              48
practitioners remain subject to criminal prosecution under § 841 when their activities fall

“outside the usual course of a professional practice.” United States v. Moore, 423 U.S. 122,

124, 96 S. Ct. 335, 337 (1975); United States v. Larson, 507 F.2d 385, 388 (9th Cir. 1974);

United States v. Mackay, 715 F.3d 807, 824-25 (10th Cir. 2013).

¶101 Indeed, in enacting Montana’s drug legislation, the Montana Legislature has long

relied on the CSA for guidance. See State ex rel. Lance v. Dist. Court, 168 Mont. 297,

299-300, 542 P.2d 1211, 1212-13 (1975); State v. Pirello, 2012 MT 155, ¶¶ 14-18, 365

Mont. 399, 282 P.3d 662. Like the CSA and federal case law, § 45-9-101(6), MCA, does

not generally exempt physicians merely because they have maintained a license to

prescribe prescription drugs or conduct their practice in a legitimate office environment

but only exempts those who are acting “in the course of a professional practice.”

See Moore, 423 U.S. at 138, 143, 96 S. Ct. at 343, 345. Thus, the principal inquiry as to

whether a physician is liable for criminal distribution of dangerous drugs is not whether he

or she maintains an office or professional staff, but whether the physician ceases to

distribute or dispense controlled substances as a medical professional and instead acts as a

“pusher.” Feingold, 454 F.3d at 1008.

¶102 Because this case is novel in Montana and federal law defining whether a physician

is acting within the course of a professional practice is congruent with Montana’s criminal

distribution statute, it was appropriate for the State and the District Court to consult the

CSA and Moore and its progeny in interpreting § 45-9-101, MCA.

                                            49
Procedural Claims

¶103 Christensen argues that the District Court improperly instructed the jury as to the

offense of criminal distribution because unlike the primary federal case,25 Feingold, on

which the District Court relied in crafting its jury instructions, the instructions (1) did not

instruct the jury on the heightened mens rea requirement of “intent” necessary for a

physician to be criminally liable for drug distribution, but only required the State to prove

Christensen acted “purposely or knowingly,” and (2) did not include a “good faith” defense

component.26

¶104 In Feingold, the defendant, Dr. Jeffrey Feingold, a naturopathic physician licensed

in Arizona, was indicted for 185 counts of illegal distribution of controlled substances in

violation of 21 U.S.C. § 841(a) for disregarding proper prescribing practices, failure to

   25
       Alternatively, Christensen argues that the District Court erred as a matter of law by using
jury instructions based on federal case law to instruct the jury on Montana law. Although
Christensen now challenges the use of Feingold, the State’s first pretrial motion before the District
Court sought an order clarifying Montana’s drug distribution statute and adoption of jury
instructions, relying on Feingold in support of its motion. Christensen did not file a brief in
opposition, and the District Court determined that Christensen’s failure to file a brief operated as
an admission that the State’s motion was well taken. Accordingly, Christensen effectively waived
his right to raise this issue on appeal. State v. Hanna, 2014 MT 346, ¶ 22, 377 Mont. 418, 341
P.3d 629; § 46-16-410(3), MCA. Further, Montana supports adopting principles of federal jury
instruction law to clarify important safeguards in the absence of applicable Montana case law.
State v. Grimes, 1999 MT 145, ¶¶ 43, 45, 295 Mont. 22, 982 P.2d 1037; Nelson, ¶ 23. As explained
above, because this case is novel in Montana, and Feingold and other federal case law as to whether
a physician may be prosecuted for criminal distribution is not incongruent with Montana’s
Criminal Distribution statute, the District Court did not err in relying on Feingold in crafting its
jury instructions as to Criminal Distribution.
   26
       Christensen further asserts that the final jury instructions did not instruct the jury on the
difference between civil and criminal liability. However, the good-faith instruction provided
clarifies “a practitioner may not be convicted of criminal distribution of dangerous drugs based on
mere negligence,” but only may be for “purposely or knowingly prescribing dangerous drugs for
no legitimate medical purpose.” This instruction clearly indicates that standard negligence, the
standard required for a medical malpractice civil lawsuit, does not apply.
                                                 50
provide physical examinations, improper recordkeeping for prescriptions, and writing

prescriptions to recovering drug addicts. Feingold, 454 F.3d at 1004-06. The District

Court instructed the jury that it had to find three elements to convict Feingold under

§ 841(a) as a licensed practitioner: (1) the defendant distributed a controlled substance;

(2) the defendant distributed the controlled substance knowingly and intentionally; and

(3) the defendant prescribed or distributed the substance other than for a legitimate medical

purpose and not in the usual course of professional practice.” Feingold, 454 F.3d at 1006.

The District Court also provided a supplemental instruction regarding the good faith

defense:

       A practitioner may not be convicted of unlawful distribution of controlled
       substances when he distributes controlled substances in good faith to patients
       in the regular course of professional practice. Only the lawful acts of a
       practitioner, however, are exempted from prosecution under the law. A
       controlled substance is distributed by a practitioner in the usual course of his
       professional practice if the substance is distributed by him in good faith in
       medically treating a patient. Good faith is not merely a practitioner’s sincere
       intention towards the people who come to see him, but, rather, it involves his
       sincerity in attempting to conduct himself in accordance with a standard of
       medical practice generally recognized and accepted in the country. Thus,
       good faith in this context means an honest effort to prescribe for a patient’s
       condition in accordance with the standard of medical practice generally
       recognized and accepted in the country. However, practitioners who act
       outside the usual course of professional practice and prescribe or distribute
       controlled substances for no legitimate medical purpose may be guilty of
       unlawful distribution of controlled substances.

Feingold, 454 F.3d at 1006 (emphasis added).

¶105 The jury found Feingold guilty on all 185 counts. Feingold, 454 F.3d. at 1006.

Feingold appealed, arguing that the district court misrepresented the elements of the crime

because the jury instructions permitted the jury to convict him without an adequate

                                             51
determination of his mens rea, and that to convict a licensed practitioner under the federal

statute, a jury must look into his subjective state of mind and determine that he intended to

act outside the course of his professional practice. Feingold, 454 F.3d. at 1007. The court

agreed, explaining that “a practitioner who acts outside the usual course of professional

practice may be convicted under § 841(a) only if he does so intentionally.” Feingold, 454

F.3d. at 1007. The Ninth Circuit emphasized that to convict a practitioner under § 841(a),

the jury must make a finding of intent both with respect to distribution and with respect to

the doctor’s intent to act as a pusher rather than a medical professional. Feingold, 454 F.3d

at 1008.

¶106 The court, however, was satisfied that the jury instructions required the jury to find

that Feingold intentionally acted outside the usual course of professional practice despite

the instructions not explicitly using the word “intent,” because the supplemental

instructions made at least four references to Feingold’s state of mind, all in connection with

instructions regarding the professional competence of a licensed practitioner. Feingold,

454 F.3d at 1008. Viewed in their entirety, the court held that the instructions “compelled

the jury to consider whether Dr. Feingold intended to distribute the controlled substances

for a legitimate medical purpose and whether he intended to act within the usual course of

professional practice.” Feingold, 454 F.3d at 1009.

¶107 Christensen’s argument conflates the federal heightened mens rea requirement—

“intent”—with Montana’s “purposely” or “knowingly” requirement. Beginning in 1973,

the Montana Legislature modified the mens rea culpability requirements, adopting

“purposely” and “knowingly” to embody “intent.” See State v. Sharbono, 175 Mont. 373,

                                             52
393, 563 P.2d 61, 72 (1977). Section 45-2-103(1), MCA, provides, “Except for deliberate

homicide . . . or an offense that involves absolute liability, a person is not guilty of an

offense unless, with respect to each element described by the statute defining the offense,

a person acts while having one of the mental states of knowingly, negligently, or

purposely.” In Montana, in order to be found guilty of criminal distribution of dangerous

drugs, direct or circumstantial evidence must establish that the defendant acted “purposely”

or “knowingly” with regards to each element of the crime. See § 45-9-101, MCA; State v.

Otto, 2014 MT 20, ¶ 5, 373 Mont. 385, 317 P.3d 810.

¶108 Here, the State and the District Court relied on Feingold not for its federal mens rea

requirement but to ensure that important safeguards were followed in the unique instance

where a physician is being prosecuted for criminal distribution. By consulting Feingold,

the court ensured that the State’s burden was not only to prove criminal intent with respect

to Christensen’s distribution of dangerous drugs, but also Christensen’s intent to do so

outside the course of a professional practice.       The jury instructions here meet the

requirement for Montana law, repeating that the professional practice exemption does not

apply if the defendant “purposely or knowingly prescribes a dangerous drug for no

legitimate medical purpose.” It is clear, based on this instruction, that the jury must infer

that to convict Christensen for criminal distribution he must have known that he was

distributing a dangerous drug and was doing so for no legitimate medical purpose.

¶109 Further, the “good faith” instruction was also provided.            The supplemental

instruction provides:

                                             53
       The legitimacy of the “medical purpose” [exemption] is not determined
       merely by a practitioner’s sincere intent towards his patient. Instead, you are
       to determine from the evidence whether the Defendant made an honest effort
       to prescribe for a patient’s condition in accordance with the standard of
       medical practice, if any, that was generally recognized and accepted in the
       State of Montana during the time period in which the prescription occurred.

(Emphasis added.) This instruction fundamentally mirrors the additional instruction in

Feingold, which provided, “Good faith is not merely a practitioner’s sincere intention

towards the people who come to see him, but, rather, it involves his sincerity in attempting

to conduct himself in accordance with a standard of medical practice generally recognized

and accepted in the country.” Feingold, 451 F.3d at 1006. Here, the State had to prove

that Christensen acted purposely or knowingly when distributing dangerous drugs and

without a legitimate medical purpose. The District Court did not err in its instruction to

the jury for criminal distribution of dangerous drugs.

¶110 Christensen also raises several arguments that the District Court erred in allowing

impermissible 404(b) evidence to be admitted at trial. First, Christensen argues that the

District Court’s admission of testimony from Idaho Board witnesses Uranga and Leonard,

who provided “thumbnail sketches” of overdose victims Christensen treated in Idaho,

violated the court’s order on motions in limine, was barred as irrelevant under M. R. Evid.

404(b), and was prejudicial under M. R. Evid. 403 and State v. Buckles, 2018 MT 150, 391

Mont. 511, 420 P.3d 511. Christensen further argues that the State did not provide him

with sufficient notice as to the use of this evidence before trial and that the District Court

failed to conduct a hearing prior to admitting this evidence.

                                             54
¶111 M. R. Evid. 404(b) prohibits evidence of “other crimes, wrongs, or acts . . . to prove

the character of a person in order to show action in conformity therewith.” State v.

Spottedbear, 2016 MT 243, ¶ 44, 385 Mont. 68, 380 P.3d 810. However, prior act evidence

may “be admissible for other purposes, such as proof of motive, opportunity, intent,

preparation, plan, knowledge, identity, or absence of mistake or accident.” M. R. Evid.

404(b). The distinction between admissible and inadmissible Rule 404(b) evidence turns

on the intended purpose of the evidence, not its substance. State v. Blaz, 2017 MT 164,

¶ 12, 388 Mont. 105, 398 P.3d 247. Moreover, Rule 404(b) must be viewed in concert with

M. R. Evid. 403, which allows the exclusion of relevant evidence if its probative value is

substantially outweighed by the danger of unfair prejudice. State v. Franks, 2014 MT 273,

¶ 15, 376 Mont. 431, 335 P.3d 725. This occurs “when the evidence will prompt the jury

to decide the case on an improper basis.” State v. Stewart, 2012 MT 317, ¶ 67, 367 Mont.

503, 291 P.3d 1187.

¶112 Prior to admitting 404(b) evidence, the prosecution must disclose evidence it intends

to use regarding “other crimes, wrongs, or acts”; it is the defendant’s burden to identify

any of the State’s evidence he or she believes should be excluded as irrelevant or unfairly

prejudicial and provide argument and authority as to why such evidence should be

excluded. State v. Dist. Court of the Eighteenth Jud. Dist., 2010 MT 263, ¶ 49, 358 Mont.

325, 246 P.3d 415. The court also “should conduct a hearing and issue a written decision

with appropriate findings of fact and conclusions of law.” Eighteenth Jud. Dist., ¶ 49

(emphasis added).

                                            55
¶113 Evidence of Christensen’s prior Idaho conduct was highly relevant and admissible

for non-propensity purposes for all three of Christensen’s charges—to demonstrate that

Christensen’s prescribing practices were done purposely or knowingly and not the product

of a mistake or accident, that he knew of the harm of death or bodily injury by prescribing

opioids without carefully following important safeguards, and that he should have been

aware of the risk of death by prescribing opioids and benzodiazepines to patients who

exhibited histories of drug abuse.       And precisely because this evidence was highly

probative it was therefore not unduly prejudicial.27 See Blaz, ¶ 20 (probative evidence rises

to the level of being unfairly prejudicial only “if it arouses the jury’s hostility or sympathy

for one side without regard to its probative value . . . .”) (emphasis added). Probative

evidence is frequently prejudicial to the defendant; this does not make such evidence

unfairly prejudicial, requiring exclusion. State v. Buslayev, 2013 MT 88, ¶ 11, 369 Mont.

428, 299 P.3d 324.

   27
      Christensen also argues that the court allowed unfairly prejudicial transaction evidence in
admitting testimony from Detective Basnaw regarding his assertion that Christensen was
responsible for a large number of overdose deaths, the State’s questioning of Christensen that
“85 percent” of pharmacies refused to fill his prescriptions, as well as testimony from Cummings,
Golden, Jessop, and Gore, all who testified that they heard about Christensen because he was an
easy source of prescription pills. For the same reasons as Christensen’s past Idaho conduct, this
evidence was highly probative and admissible for non-propensity purposes—to show knowledge
and absence of mistake—for all Christensen’s charges. Moreover, the State did not elicit the
challenged testimony of Basnaw; rather, Basnaw made this statement on cross-examination when
he was asked “when did you decide to target my client.” Similarly, the State questioned
Christensen as to the truthfulness of his own prior admission when he purportedly told the Task
Force that “85 percent of pharmacies” refused to fill his prescriptions. Further, Christensen did
not object to testimony from Cummings, Golden, Jessop, and Gore and therefore waived his right
to challenge the admissibility of this testimony on appeal. Longfellow, ¶ 19.
                                               56
¶114 Christensen was provided with sufficient notice about the proposed use of the Idaho

evidence. The State’s Information, filed over two years prior to trial, clarified that it would

seek to rely on evidence from Idaho to show Christensen was operating outside the course

of a professional practice. Through his pretrial discovery demands, Christensen received

notes from law enforcement officials to be used at trial, was supplied with thousands of

pages of discovery materials, and was notified by the State’s motion in limine about law

enforcement’s contextual evidence it planned to introduce at trial. And at trial, prior to

Uranga’s testimony, Christensen’s counsel acknowledged that “I’m not suggesting in any

way that the information [of the Idaho allegations] itself is a surprise or that the state failed

to provide it to us or anything like that.” Accordingly, Christensen waived any objection

on appeal and cannot now claim unfair surprise to the State’s proposed testimony stemming

from his Idaho Board cases.

¶115 The District Court also did not evade its gatekeeping duties in permitting at trial the

evidence of Christensen’s prior conduct in Idaho. Christensen’s motion in limine did not

request a hearing on the proposed admissibility of the evidence, nor did he file a reply brief

asking for a hearing. Nonetheless, the District Court clearly grasped the significance of

this proposed evidence, issuing an order explaining that evidence of Christensen’s Idaho

conduct was permissible for non-propensity purposes. Moreover, the court consulted with

both parties prior to Uranga’s testimony, to which Christensen’s counsel acknowledged

that “they’ve got to get into the allegations some, so I’m not necessarily suggesting that the

testimony should be restricted . . . .” The court limited the State’s questioning of Uranga

to the type of drugs involved in Idaho, the number of complaints, and general Idaho Board

                                               57
allegations, and the State did not reference Christensen’s federal charges, trial, or acquittal

stemming from his Idaho conduct. And at Christensen’s behest, the court included

Instruction No. 28, which specified the proper purpose for which this evidence could be

used, further mitigating any risk of unfair prejudice. The District Court did not err in

admitting testimony as to Christensen’s prior Idaho conduct.

Sufficient Evidence Claim

¶116 Finally, Christensen argues that there was insufficient evidence for the jury to

conclude that Christensen committed criminal distribution of dangerous drugs.

Christensen argues that the State failed to demonstrate that he was acting outside the course

of a professional practice because every patient had a legitimate medical condition that

caused him or her pain, no State expert testified that Christensen’s treatment was without

a legitimate medical purpose or that he prescribed dangerous drugs outside the course of a

professional practice, and most of the patients testified that they lied to Christensen about

their addictions.

¶117 Here, the jury was tasked with determining whether Christensen committed criminal

distribution beyond a reasonable doubt for each of the eleven named patients. Therefore,

the jury had to decide, based on the presence of direct and circumstantial evidence, whether

Christensen prescribed dangerous drugs to each of these patients purposely or knowingly,

and did so without any legitimate medical purpose while acting outside the course of a

professional practice. Section 45-9-101(6), MCA; Feingold, 454 F.3d at 1008. A person

acts knowingly if he “is aware of [his] own conduct or that the circumstance exists.”

Section 45-2-101(35), MCA. A person acts purposely “if it is the person’s conscious object

                                              58
to engage in that conduct or to cause that result.” Section 45-2-101(65), MCA. In other

words, whether Christensen may be convicted of criminal distribution is contingent on

whether he knew what he was doing and/or he did it on purpose.

¶118 A fundamental principle of the criminal justice system is that the State must prove

each element of a crime beyond a reasonable doubt. State v. Laird, 2019 MT 198, ¶ 59,

397 Mont. 29, 447 P.3d 416. A jury may consider all direct and circumstantial evidence,

as well as any legitimate inferences that may be legally drawn therefrom, to determine a

defendant’s culpability. Laird, ¶ 60. The existence of alternative interpretations of

circumstantial evidence does not mean that both interpretations are equally persuasive.

State v. Sanchez, 2017 MT 192, ¶ 17, 388 Mont. 262, 399 P.3d 886. The jury, exclusively,

draws inferences from circumstantial evidence and should determine its conclusions on

elements of the crime if “warranted by the evidence as a whole.” State v. Kelly, 2005 MT

200, ¶ 21, 328 Mont. 187, 119 P.3d 67. There is sufficient evidence to support a conviction

if, “after reviewing the evidence in the light most favorable to the prosecution, any rational

trier of fact could have found the essential elements of the crime beyond a reasonable

doubt.” State v. Daniels, 2019 MT 214, ¶ 27, 397 Mont. 204, 448 P.3d 511.

¶119 At trial, the State presented testimony from Idaho Board witnesses regarding the

investigation of Christensen in Idaho in an effort to demonstrate that here, Christensen

purposely or knowingly prescribed dangerous drugs outside the course of a professional

practice. Testimony from Uranga revealed that Christensen was previously investigated

for prescribing excessive and inordinate amounts of controlled substances, that he

prescribed these drugs to addicted persons, and that he was operating outside the accepted

                                             59
standards of medical practice established by the Idaho medical community. Furthermore,

Uranga testified that Christensen’s second investigation stemmed from violations of his

first stipulation with the State of Idaho following overprescribing to 28 former patients, 23

of whom were prescribed opioids in conjunction with benzodiazepines, five of whom died

from drug overdoses, and another six who were hospitalized from overdoses. This

testimony supported the jury’s inference that Christensen acted purposely or knowingly

when he engaged in similar conduct in Montana.

¶120 The State also presented extensive expert and patient testimony demonstrating that

Christensen failed to adhere to authorized prescribing practices when treating these

patients. For all eleven patients, Christensen either failed to conduct adequate initial

examinations and assessments or completely disregarded initial assessments. Patients and

experts testified that Christensen never contacted past medical providers before offering

prescriptions; did not conduct sufficient diagnostic tests; met with patients for only five to

25 minutes on the very first visit; did not use imaging studies to pinpoint the source of

patients’ pain or understand potential risks with prescribing opioids; never utilized blood

or urine tests on the first visit to identify red flags; rarely conducted follow-up

appointments other than to refill prescriptions; never used referrals to other medical

professionals; never discussed the goals of treatment; and never used an opioid agreement

to hold patients accountable.     Christensen also ubiquitously refused to utilize other

treatment modalities, only using prolotherapy on two occasions for one patient and physical

therapy for another.

                                             60
¶121 Patient and expert testimony reflected that Christensen prescribed opioids on the

very first visit to all eleven patients, regardless if requested, and often in conjunction with

benzodiazepines. In some instances, Christensen even asked patients directly which

opioids they would prefer or provided them with a drug menu, a fact Christensen confirmed

on cross-examination. Christensen never discussed warnings for taking these medications

together or when to cease taking medications. Furthermore, Christensen prescribed huge

quantities of opioids, far above the 40 or 50 mg per day that experts testified was the highest

effective dose. In the case of Sutherland, Christensen was prescribing up to 1,000 pills at

a time, with instructions to take up to 600 mg of Methadone per day, an amount that

Dr. Wasan testified would never be prescribed to “someone dying of cancer in their final

days.” Dr. Wasan testified that Christensen’s prescriptions for two of these patients was

akin to giving these patients “a loaded gun” to harm or kill themselves. Meridee Lieberg,

Daniel Lieberg’s mother, a nurse for 47 years, testified she had never seen the quantity of

prescriptions Christensen provided to Lieberg.

¶122 Patients further testified that Christensen sometimes told them where to fill

prescriptions, that they often had a hard time filling prescriptions because of the quantities

of drugs prescribed, and that on multiple occasions, Christensen used street slang to refer

to drugs and disclosed their street value. In one case, Christensen often traded prescriptions

in exchange for manual labor from a patient. Christensen provided another patient with

Adderall directly on at least two separate occasions. In a third case, Christensen wrote a

prescription for Adderall to a patient after she failed a urinalysis test for Adderall for which

                                              61
she did not have a prescription, and otherwise did not modify her other prescriptions in any

way. And one patient testified that Christensen asked her if she owed anyone Methadone.

¶123 Additionally, most patients testified that they had a history of addiction to opioids

or other drugs prior to seeing Christensen. In the cases of Sutherland, Lieberg, and Griffin,

Christensen knew or should have been aware that these patients were on Suboxone therapy

for prior opioid addictions because they either told Christensen of their past addictions or

disclosed that information to his risk assessment counselor. In the case of Philbrick, Price

testified that she disclosed to Christensen her struggles with alcohol. In Jessop’s case, she

testified that she had track marks on her arm from past intravenous drug use. And in the

case of Cummings, she testified that she told Christensen directly that she was addicted to

Methadone. Nonetheless, all these patients received opioids from Christensen on the first

appointment. While Christensen argues that many of these patients were dishonest with

him regarding past drug abuse histories, this fact does not relieve Christensen of his duties

to act in good faith within the course of a professional practice. See Feingold, 454 F.3d at

1010. It remains incumbent on the treating physician to utilize careful assessments and

tests to determine risk factors beyond cursory conversations with patients to effectively

treat patients and mitigate the risk of harm.

¶124 The State’s multiple expert witnesses testified about the standard of care with which

medical professionals must comply.        Dr. Wasan reviewed all the medical files for

Christensen as to his treatment of the eleven patients and testified that Christensen’s

conduct fell far below the applicable professional practice standards. Christensen failed to

conduct appropriate assessments, tests and interviews, failed to conduct follow-ups, failed

                                                62
to utilize treatment modalities beyond opioids, failed to utilize opioid agreements or

treatment plans, and prescribed dangerous quantities of opioids and benzodiazepines

without any documented reason. Even Dr. Tennant, Christensen’s expert, testified that,

although he believed Christensen was acting within the course of a professional practice,

Christensen’s care was “atrocious” and “laughable.” Dr. Wasan, Dr. Ravitz, Dr. Furrow,

and Dr. Bender also all testified that Christensen’s medical charts were woefully

inadequate, described by one expert as insufficient to pass as a second-year medical

student.

¶125 Christensen argues that all eleven patients had a legitimate medical issue such that

he was nonetheless acting within the course of a professional practice. However, the

presence of a legitimate medical issue does not grant a physician a free pass to prescribe

scheduled narcotics in any way that he or she pleases; the appropriate inquiry rests on

whether the distribution of controlled substances was for a legitimate medical purpose.

Feingold, 454 F.3d at 1010. Here, expert testimony established that Christensen’s lack of

appropriate assessments or follow-ups fundamentally undermined his ability to make

accurate diagnoses of underlying causes of pain. Accordingly, it was reasonable for the

jury to conclude that there was in fact no legitimate medical purpose for prescribing

massive quantities of opioids and benzodiazepines to these patients.

¶126 Christensen further asserts that he cannot be convicted because none of the State’s

medical experts explicitly testified that he was acting outside the course of a professional

practice and for no legitimate medical purpose, and the only expert testimony offered on

the issue was his own, Dr. Tennant, who testified Christensen was acting within the course

                                            63
of a professional practice.    However, the existence of alternative interpretations of

circumstantial evidence does not mean that both interpretations are equally persuasive.

Sanchez, ¶ 17. Moreover, the jury may infer the requisite mental state from what a

defendant says and does, and from all the facts and circumstances involved. Section

45-2-103(3), MCA.

¶127 Reviewing the facts in the light most favorable to the prosecution, we conclude there

was overwhelming evidence for a reasonable jury to find that Christensen used his

prescription writing authority as a pretext to act as a drug dealer, supporting drug tolerance

or feeding addictions for all eleven patients, and that he purposely or knowingly acted

outside the course of a professional practice and for no legitimate medical purpose when

prescribing dangerous drugs to these patients. Accordingly, we affirm Christensen’s

convictions for eleven counts of Criminal Distribution of Dangerous Drugs.

¶128 Issue Two: Whether the State proved beyond a reasonable doubt that Christensen
     committed Criminal Endangerment as to his treatment of nine patients.

¶129 On January 18, 2017, Christensen filed a motion to dismiss his criminal

endangerment charges, arguing that Montana’s criminal endangerment statute, § 45-5-207,

MCA, is unconstitutionally vague as applied because the statute does not prohibit a specific

type of medical practice or specify a quantifiable amount of risk such that physicians are

not provided fair notice that prescribing controlled substances could constitute conduct

creating a substantial risk of death or serious bodily injury. On April 5, 2017, the District

Court issued an Opinion and Order denying Christensen’s motion. The court held that the

statute provided sufficient notice to Christensen because the allegations assert that

                                             64
Christensen prescribed controlled substances outside the course of a professional practice,

and minimal standards are provided to those enforcing the statute.

Discussion

¶130 Christensen first argues that the District Court improperly denied his motion to

dismiss because Montana’s criminal endangerment statute is unconstitutionally vague as

applied to physicians. Christensen contends that the statute uses broad, undefined terms,

provides no guidelines about its application in a medical context, and fails to distinguish

legal from illegal prescribing of controlled substances.

¶131 Statutes are presumed constitutional, and a party challenging a statute’s

constitutionality must establish beyond a reasonable doubt that the statute is

unconstitutional; any doubt must be resolved in favor of the statute. State v. Knudson, 2007

MT 324, ¶ 12, 340 Mont. 167, 174 P.3d 469. A void for vagueness challenge to a statute

may be raised on two different bases: (1) “facial,” where the statute is so vague that it is

rendered void on its face, or (2) “as-applied,” where the statute is vague as applied to the

facts of a particular situation. Knudson ¶ 16. A vagueness as-applied analysis has two

elements: (1) whether the statute provides actual notice to citizens, and (2) and whether the

statute provides minimal guidelines to govern law enforcement. State v. Dixon, 2000 MT

82, ¶ 28, 299 Mont. 165, 998 P.2d 544.

¶132 In determining whether a statute provides actual notice to citizens, this Court must

determine whether the statute provides a person of ordinary intelligence fair notice that

their contemplated conduct is forbidden. Dixon, ¶ 28. A statute challenged for vagueness

as-applied to a particular defendant must be examined in light of the conduct with which

                                             65
the defendant is charged in order to determine whether the defendant could have reasonably

understood that his conduct was proscribed. Knudson, ¶ 21.

¶133 A person commits the offense of criminal endangerment when he “knowingly

engages in conduct that creates a substantial risk of death or serious bodily injury to

another.” Section 45-5-207, MCA; State v. Fleming, 2019 MT 237, ¶ 13, 397 Mont. 345,

449 P.3d 1234. The criminal endangerment statute does not require the victim suffer actual

physical injury, but only that the defendant engage in conduct creating a substantial risk of

death or serious bodily injury. Fleming, ¶ 13. A person acts knowingly for the purposes

of criminal endangerment when the person is aware of the high probability that the conduct

in which he is engaged will cause a substantial risk of death or serious bodily injury to

another. Sections 45-2-101(35), 45-5-207(1), MCA. “Conduct” is defined as “an act or

series of acts and the accompanying mental state.” Section 45-2-101(15), MCA.

¶134 Christensen’s argument insinuates that physicians generally are not provided with

fair notice because of limited definitions of terms in the statute such as “substantial risk.”

However, the Legislature need not define every term it employs when constructing a statute

so long as the meaning of the statute is clear and provides a defendant with adequate notice

of what conduct is proscribed. State v. Nye, 283 Mont. 505, 513, 943 P.2d 96, 101-02

(1997). And the issue is not, as Christensen contends, whether the statute fails to put any

reasonable person on notice that the act of prescribing scheduled drugs in any medical

practice constitutes a felony under the statute. Rather, the issue is whether Christensen

could have reasonably understood that the statute prohibited his conduct—overprescribing

and disregarding essential tests, follow-ups, and safeguards along with prescribing massive

                                             66
amounts of dangerous prescription drugs to patients with histories of drug abuse and

addiction. See Dixon, ¶ 29.

¶135 The statute clearly applies to Christensen such that he had actual notice that his

conduct was prohibited.       First, Christensen’s past conduct in Idaho, in which he

overprescribed opioid and benzodiazepine medications and failed to provide appropriate

tests, diagnoses, or monitoring, alerted Christensen to the fact that he should have been

reasonably aware of the impropriety of his behavior, given that five of these patients died

from drug overdoses, six additional patients were hospitalized, and Christensen was subject

to two separate investigations and sanctions by the Idaho Board of Medicine. Similarly,

Montana’s medical guidelines further exemplify the need for licensed physicians to create

pain management plans, identify risks of abuse, consult past medical histories, and follow

appropriate follow-up plans to effectively treat chronic pain patients with opioids.

¶136 Common sense dictates that a licensed medical doctor who has practiced for 30

years and possesses a DEA license to administer scheduled narcotics would have known

the inherent risks of prescribing opioids, benzodiazepines, and numerous other Schedule II

and Schedule IV controlled substances in shocking quantities and often at the same time.

He demonstrated that he knew he was way out of the realm of professional medical practice

by telling patients to use a Corvallis pharmacy, as other pharmacists refused to fill his

prescriptions. Despite these warnings, Christensen’s conduct in Montana reflected a

similar pattern of behavior as he previously exhibited in Idaho, using his practice as a cover

to administer dangerous drugs, disregarding or ignoring past medical records, ignoring

appropriate tests or efforts to appropriately diagnose patients’ underlying cause of pain,

                                             67
and failing to utilize important safeguards when prescribing dangerous drugs. Christensen

could have reasonably understood that his conduct was proscribed such that the statute

provided Christensen with actual notice.

¶137 In analyzing the second element under the void-for-vagueness doctrine—whether

the statute provides minimal guidance—we consider whether the challenged statute

provides an explicit standard for those who apply them, or whether the law impermissibly

delegates basic policy matters to police, judges, and juries for resolution on an ad hoc and

subjective basis, risking arbitrary and discriminatory application. State v. Stanko, 1998

MT 321, ¶ 23, 292 Mont. 192, 974 P.2d 1132. Christensen contends that there were no

minimal guidelines to enforce the statute because the statute fails to distinguish legal from

illegal prescribing of controlled substances and does not specify a quantifiable or

understandable amount of risk. Again, we find Christensen’s argument unavailing.

¶138 The inquiry is not whether the standard is imprecise, but whether there is no standard

of conduct specified at all. Monroe v. State, 265 Mont. 1, 4, 873 P.2d 230, 231 (1994)

(citing Village of Hoffman Estates v. Flipside, Hoffman Estates, Inc., 455 U.S. 489, 495,

n. 7, 102 S. Ct. 1186, 1191 (1982)). The statute clarifies that it only applies to conduct

creating a “high probability” of a “substantial risk” of death or serious bodily injury, and

must be accompanied by a requisite mental state, “knowingly,” creating such a risk, thus

mandating conformance to a basic, even if imprecise, standard. It is undisputed that the

drugs Christensen administered to the nine patients were inherently dangerous and subject

to abuse. And, in enforcing the statute, police, prosecutors, and juries must adhere to the

legal requirement that a physician may only be prosecuted if he or she knowingly

                                             68
disregards risks of abuse and nonetheless prescribes such drugs in such a manner and

quantity that the risk of death or bodily injury to patients is “substantial.” The Dissent

essentially contends that a practicing physician can never constitutionally be prosecuted

under this statute. We conclude that § 45-5-207, MCA, is not unconstitutionally vague as

applied to Christensen’s incredibly dangerous and unconscionable conduct. The District

Court did not err in denying Christensen’s motion to dismiss the criminal endangerment

charges.28

¶139 Christensen also argues that the State presented insufficient evidence demonstrating

that his conduct amounted to criminal endangerment because the State failed to prove that

Christensen was aware of the high probability of the risk of death or serious bodily injury

that could result from his conduct.

¶140 As already stated, Christensen cannot in good faith argue that he was not aware of

the high risk of death or serious bodily injury from prescribing dangerous drugs. For a

physician to prescribe dangerous drugs, such as Schedule II and Schedule IV narcotics, he

or she must undergo extensive medical training and is subject to tight prescribing

restrictions by both federal and state law. And Christensen himself testified that he was

“more than willing” to ignore red flags like patient requests for certain drugs, that he rarely

used the prescription drug registry, that he was concerned about the amount of opioids he

   28
       The Court is mindful that physicians routinely prescribe narcotics to patients who need
them—often in large quantities. We are also aware that narcotics are often liberally prescribed as
palliative care. The facts here show none of these eleven patients had legitimate medical reasons
for the type or quantity of narcotics they received from Christensen, and none were palliative care
patients.
                                                69
was prescribing to some patients but continued to prescribe the same quantities and in the

same manner regardless, and that following his Idaho Board stipulations and death of

Griffin in Montana, he had ample time to reevaluate his prescription writing practices. The

evidence indicates that despite knowledge of the risk of death or serious bodily injury to

patients, Christensen purposely chose not to modify his behavior when treating patients.

¶141 Further, extensive medical literature, including Montana’s own guidelines,

highlights the need for physicians to carefully follow certain assessment, follow-up, and

documentation procedures to ensure that prescriptions are serving their intended purpose

of treating chronic pain patients and not feeding addiction or tolerance. This literature also

indicates, as referenced by numerous medical experts in the case, that opioids can cause a

negative effect on the heart’s electrical conduction signals, can cause a build-up over time

in the patient’s system, can suppress breathing, and further, that combining opioids with

benzodiazepines may create toxic and deadly outcomes for patients. Without careful

review of patients’ medical files, psychological assessments to determine the risk for abuse,

and diligent monitoring, it is evident that such prescriptions can cause harm and death.

And even assuming Christensen was willfully ignorant to these standards, he was already

subject to multiple investigations in Idaho for the same behaviors he exhibited in Montana.

¶142 Christensen further argues that the State did not prove that his prescribing of opioids

posed a “high probability” of death or serious bodily injury to the nine surviving patients

because Dr. Wasan did not offer any testimony that prescribing high doses of opioids or

opioids combined with benzodiazepines posed a “high probability” of a risk of death or

                                             70
serious bodily injury, and most of the patients who testified admitted they lied extensively

to Christensen about prior addiction histories, pain needs, and addictive behaviors.

¶143 Christensen misstates the standard. In essence, Christensen’s argument mirrors the

erroneous proposition offered by the defendant in Fleming, arguing that providing opioids

and benzodiazepines to patients merely creates only the “possibility” of a substantial risk

of death or serious bodily injury. See Fleming, ¶ 20. But as we held in Fleming, the plain

language of the criminal endangerment statute “does not require a high probability of death

or serious bodily injury from the defendant’s conduct, but a substantial risk to life or limb.”

Fleming, ¶ 16. The correct mental state thus requires that the defendant only “be aware of

a high probability that his conduct may cause a substantial risk of death or serious bodily

injury to another.” Fleming, ¶ 16 (emphasis added).

¶144 Again, testimony from all nine surviving patients and numerous experts indicated

that Christensen did not conduct appropriate assessments, disregarded or failed to even

obtain past medical files for all nine patients, performed limited if any diagnostic tests to

determine patients’ sources of pain, and abjured extensive psychological assessments to

accurately determine the risks of prescribing these drugs to patients. With at least two

patients, he provided a list of drugs from which they could choose at their own discretion.

Despite the lack of appropriate tests, Christensen prescribed opioids in obscene quantities

to all nine patients on the very first visit, most of whom had extensive histories of opioid

abuse. He did not provide careful monitoring or follow-ups to determine how patients

would respond to drugs, but often simply refilled prescriptions. Further, expert testimony

from Dr. Wasan, Dr. Farrow, Dr. Ravitz, and Dr. Bender indicated that Christensen’s

                                              71
treatment fell far below the standard of practice accepted in the medical community. It is

not dispositive that the State’s experts did not attempt to quantify the risk; as already stated,

the existence of a mental state may be inferred from the acts of the accused and the facts

and circumstances connected with the offense. Section 45-2-103(3), MCA.

¶145 While at least six of these patients testified that they were dishonest with

Christensen about their pain and addiction histories, as Dr. Wasan noted, it is for the

prescriber to adhere to the standards of practice in order to determine the accuracy of such

statements. The mental state required to prove criminal endangerment therefore rests on

Christensen’s efforts to conform to standards of practice given the inherent risk of

administering prescriptions for highly dangerous drugs such that a “substantial” risk of

injury or death is not imparted to the patient.           Given ample testimony regarding

Christensen’s prescribing practices, viewing the evidence in the light most favorable to the

prosecution, we conclude there was sufficient evidence from which a rational jury could

find that Christensen was aware of a high probability that providing opioids,

benzodiazepines, and other drugs to the nine named patients created a substantial risk of

death or serious bodily injury.

¶146 Issue Three: Whether the State proved beyond a reasonable doubt that Christensen
     negligently caused the deaths of Kara Philbrick and Gregg Griffin.

¶147 On January 18, 2017, Christensen filed a motion to dismiss the negligent homicide

charges. Christensen argued that nothing in the charging documents alleged any facts to

indicate he was the cause-in-fact of the deaths of Philbrick and Griffin. The court denied

Christensen’s motion, finding that there was sufficient evidence and legal authority, relying

                                               72
on State v. Bier, 181 Mont. 27, 591 P.2d 1115 (1979), such that it remained in the province

of a jury to determine whether the State could prove beyond a reasonable doubt that

Christensen’s conduct caused the deaths of Philbrick and Griffin.

¶148 Jerry Price, Philbrick’s husband, testified that Philbrick was a patient of Dr. Ravitz

for three years prior to seeing Christensen. Price testified that throughout her time with

Dr. Ravitz, she was drinking 2/3 of a gallon of vodka per day. Because of her alcohol

abuse, Dr. Ravitz discontinued her Methadone prescription and changed her to a Fentanyl

patch. Eventually, Philbrick asked Dr. Ravitz to switch her back to Methadone and

increase her dosage to 80 mg per day. Dr. Ravitz declined. On March 13, 2013, two days

after her last visit with Dr. Ravitz, Philbrick visited Christensen who prescribed her

Methadone and Dilaudid and gave her a four-day taper off Fentanyl. Price testified that

Philbrick did not provide Christensen her medical records and that Christensen only

conducted a physical exam of her hand. Christensen did not utilize any blood tests or

perform an EKG. On March 15, 2013, Philbrick died.

¶149 At trial, Scott Schlueter, a forensic toxicologist with the Montana crime lab testified

that he examined Philbrick’s blood and urine. He detected the presence of Methadone,

Dilaudid, Fentanyl, Valium, Zoloft, Tramadol, and alcohol in her blood. Philbrick’s

prescriptions from Christensen were only for Methadone and Dilaudid. Detective Steve

Deibert, a coroner with the Missoula County Sheriff’s Office, testified that Philbrick’s

cause of death was “mixed drug toxicity,” and he indicated that it was an overdose accident.

He recovered 12 unaccounted-for Methadone pills and two unaccounted-for Dilaudid pills,

both prescribed by Christensen, and one Fentanyl patch prescribed by Dr. Ravitz.

                                            73
¶150 Dr. Furrow, Gregg Griffin’s previous treating physician, testified that she treated

Griffin with Suboxone therapy from January 2009 until February 2012, and prescribed him

Zoloft for anxiety. In 2011, Dr. Furrow testified that she referred Griffin to a psychiatric

specialist to overtake Griffin’s care for anxiety; the specialist prescribed Zoloft and Xanax

to Griffin. She also testified that Griffin had previously seen Christensen to obtain medical

marijuana cards, issued in 2008, 2009, and 2010. She testified that in 2008, Griffin filled

out a questionnaire in Christensen’s office, notifying Christensen that he was taking

Suboxone.

¶151 Dr. Furrow testified that on February 22, 2012, Christensen prescribed Griffin

Methadone on his first visit, and that Christensen did not contact her about Griffin. On

March 2, 2012, Christensen increased Griffin’s Methadone prescription to 70 mg per day.

On March 21, 2012, Marchand evaluated Griffin, noting that Griffin posed a “high risk”

for history of abuse and dependency, a “high risk” for developing problems on long-term

opioid therapy, and recommended “high monitoring.” Marchand also noted that Griffin

told him that “suboxone has been very helpful and he would like to discuss the use of this

medication further with [Christensen].” Griffin’s mother, Sharon, also testified that Griffin

was on Suboxone therapy to keep him off opioids. She testified that on March 10, 2012,

she took Griffin to the emergency room because of adverse effects from his Methadone

prescription.

¶152 On March 30, 2012, Christensen issued a prescription of 200 pills of Methadone to

Griffin as well as a prescription for Xanax. Christensen did not provide an office visit but

simply refilled Griffin’s prescription. Dr. Furrow testified that there were no warnings or

                                             74
discussions with Griffin documented regarding the risks of taking his medications or a

specified reason as to why he was prescribed Xanax when he was already receiving that

medication from an additional provider. Dr. Furrow testified that Griffin’s death could not

be attributed to an “overdose” because there was no monitoring and it was irresponsible to

give him this quantity of medications, particularly given his history of addiction. Sharon

Griffin testified that on April 2, 2012, she found Griffin dead.

¶153 Jace Dicken, the lieutenant of patrol and chief deputy coroner for the Missoula

County Sherriff’s Office, testified that on April 2, 2012, he responded to a coroner call for

Griffin.   Dicken testified that Griffin’s cause of death was listed as an “accidental

overdose” from “mixed drug toxicity.” Dicken also testified that 60 Methadone pills, nine

Xanax pills, and ten to 20 Doxepin pills were missing from Griffin’s prescription bottles.

Schlueter, the toxicologist, testified that he tested Griffin’s blood and urine samples which

tested positive for Methadone, Xanax, Doxepin, THC, and Propranolol. Schlueter also

testified that Griffin’s urine test showed that he had also taken additional morphine and

benzodiazepine substances not prescribed by Christensen. At the close of the State’s

case-in-chief and again after the close of all evidence, Christensen renewed his motions to

dismiss the negligent homicide charges. The District Court denied Christensen’s motions,

finding that sufficient evidence was presented such that a jury could reasonably find that

Christensen negligently caused the deaths of Philbrick and Griffin.

Discussion

¶154 Christensen argues that there was not sufficient evidence for a reasonable jury to

find Christensen negligently caused the deaths of Philbrick and Griffin. A person commits

                                             75
the offense of negligent homicide “if the person negligently causes the death of another

human being.” Section 45-5-104(1), MCA. “Negligence” is defined as follows:

       [W]hen the person consciously disregards a risk that the result will occur or
       that the circumstances exists or when the person disregards a risk of which
       the person should be aware that the result will occur or that the circumstance
       exists. The risk must be of a nature and degree that to disregard it involves
       a gross deviation from the standard of conduct that a reasonable person
       would observe in the actor’s situation.

Section 45-2-101(43), MCA (emphasis added).

¶155 “Gross deviation” is “a deviation that is considerably greater than lack of ordinary

care.” Section 45-2-101(43), MCA. A gross deviation under the statutory definition is

analogous to gross negligence in the law of torts. Bier, 181 Mont. at 32, 591 P.2d at 1118.

Although somewhat nebulous in concept, gross negligence is generally considered to fall

short of a reckless disregard for consequences and is said to differ from ordinary negligence

only in degree, not in kind. Bier, 181 Mont. at 32, 591 P.2d at 118 (citing Prosser, Law of

Torts, 183-84 (4th Ed. 1971)).

¶156 In addition, where a crime is based on some form of negligence, the State must also

demonstrate that the defendant’s conduct was both the “cause-in-fact” of the victim’s death

and that the victim was “foreseeably endangered” in a manner and to a degree of harm

which was foreseeable. Bier, 181 Mont. at 32-33, 591 P.2d at 1118. Conduct is a cause-

in-fact of an event if the event would not have occurred but for that conduct; conversely,

the defendant’s conduct is not a cause-in-fact of the event if the event would have occurred

without it. State ex rel. Kuntz v. Mont. Thirteenth Jud. Dist. Court, 2000 MT 22, ¶ 37, 298

Mont. 146, 995 P.2d 951. Clearly, the risk created by Christensen’s conduct under the

                                             76
circumstances—providing large quantities of prescription drugs with no proper review of

Philbrick’s and Griffin’s medical files, with specific knowledge that Philbrick and Griffin

had a history of addiction—was foreseeable. Therefore, whether Christensen is liable for

negligent homicide rests on whether he was the cause-in-fact of Philbrick’s and Griffin’s

deaths.

¶157 We conclude that the State failed to meet its burden to prove beyond a reasonable

doubt that Christensen’s prescribing of dangerous drugs was the cause-in-fact of the deaths

of Philbrick and Griffin. The toxicologist determined that both deaths were “accidental

overdose deaths,” caused from “mixed drug toxicity.” Further, both Griffin and Philbrick

had a mixture of legal and illegal drugs in their system, not all of which were prescribed

by Christensen. And no expert testimony provided that the actual cause of death was from

Methadone and benzodiazepine prescriptions written by Christensen or opined as to how

each victim’s combination of drugs caused their deaths.

¶158 To be sure, expert testimony is not required to prove causation in homicide cases.

See Laird, ¶ 70. But under these facts, without more, whether Christensen’s prescriptions,

standing alone, caused the deaths of Philbrick and Griffin remains speculation. The State

argues that Christensen’s grossly negligent conduct, in which he provided Griffin and

Philbrick with dangerous prescriptions, contributed directly to their deaths “as if he handed

each a loaded gun.” However, the evidence presented at trial does not indicate that

Christensen’s prescribing practices caused Philbrick and Griffin to die or that Christensen’s

prescriptions were the sole cause of Philbrick’s and Griffin’s deaths. Because there was

no evidence that Christensen’s negligent prescribing of dangerous drugs was the cause of

                                             77
Philbrick’s and Griffin’s deaths, there was insufficient evidence to support Christensen’s

convictions for negligent homicide.

                                        CONCLUSION

¶159 For the reasons stated, Christensen’s convictions for eleven counts of Criminal

Distribution of Dangerous Drugs, § 45-9-101, MCA, and nine counts of Criminal

Endangerment, § 45-5-207, MCA, are affirmed. We reverse and vacate Christensen’s

conviction for two counts of Negligent Homicide, § 45-5-104(1), MCA, because the State

did not meet its burden to demonstrate that Christensen was the cause-in-fact of the deaths

of Kara Philbrick and Gregg Griffin.

                                                     /S/ MIKE McGRATH

We Concur:

/S/ JAMES JEREMIAH SHEA

Justice Ingrid Gustafson dissenting in part and concurring in part.

¶160 This is a classic case where bad facts make bad law.1 Today, the majority has

basically granted prosecutors discretion to criminalize medical malpractice. I dissent.

1
  It is clear Christensen is not a skilled physician who has kept abreast of evidence-based medical
treatment for patients suffering from both substance use disorders and physical conditions resulting
in chronic pain. From the evidence presented at trial, he clearly committed multiple instances of
malpractice related to treatment of at least eleven of his patients. It is also clear that, prior to
becoming licensed in Montana, he committed various instances of malpractice in Idaho and failed
to meet standards imposed by the Idaho medical licensing board which resulted in revocation of
his license to practice medicine in Idaho. From the record before us, we do not know why, with
this history, he was able to obtain a license to practice medicine in Montana or why his Montana
license was not revoked or suspended sooner. This Dissent in no way suggests Christensen
provided appropriate medical treatment to the eleven patients associated with the criminal
charges—it is this egregious malpractice which has unfortunately driven the Court to advance bad
                                                78
¶161 As is abundantly clear from the Opinion’s factual discussions, this is a medical

malpractice case presented under the guise of criminal law. In Montana, the threshold

obligation of a plaintiff in a medical malpractice case is twofold: first, evidence must be

presented to establish the standard of professional care in the type of case involved; second,

it must be shown the physician departed from this recognized standard in treatment of the

plaintiff resulting in damage to the plaintiff. This is typically established through expert

testimony because the conduct complained of is usually not readily ascertainable by a

layman. Gilkey v. Schweitzer, 1999 MT 188, ¶ 17, 295 Mont. 345, 983 P.2d 869. The

Opinion discusses the expert medical evidence provided by the State’s experts to establish

the standard of care for medical physicians treating pain patients including the standard for

assessment, treatment plans, monitoring, and documentation and discusses how

Christensen’s assessment, treatment, monitoring, and documentation with regard to the

representative2 patients “fell below or far below the accepted standards of practice

law in this case. I take issue only with the complete inappropriateness of opening the door to
criminal prosecution of licensed physicians for malpractice or criminal endangerment occurring in
the course of treating patients who have presented themselves to the physician’s professional
practice.
2
  The Opinion conveniently ignores that the State presented these claims and patients as
representative patients. The State portrayed these patients as “representative” of all of
Christensen’s patients and representative of his malpractice in the overall operation of his medical
practice. Throughout trial, the State presented “representative” patients to present its overarching
theory of the case that Christensen’s medical practice was a criminal scheme to distribute
dangerous drugs—his practice was to distribute “opiates on the first visit, every time” to all his
patients, the only patients that went to see Christensen were addicts seeking drugs, and his practice
consisted of him being nothing more than a drug pusher. Ignoring the State’s theme and
evidentiary presentation to justify the result is not only intellectually dishonest but erodes the
credibility of this Court.

                                                 79
recognized in the medical community[.]” Opinion, ¶ 61. The Opinion, in essence,

concludes that, despite all of Christensen’s drug prescribing occurring while he was

operating as a licensed physician with prescribing authority from a business office with

employed professional staff, he was not conducting himself as part of a “professional

practice” as his conduct did not meet accepted standards of practice—the ultimate

conclusion being that when a licensed physician commits malpractice, he or she is

potentially subject to criminal prosecution for that malpractice.3 I do not believe that is

what the Legislature intended when it adopted § 45-9-101(1) and (6), MCA. Further, the

Opinion opens the door to physician prosecution for criminal endangerment under

§ 45-5-207, MCA, not necessarily limited to malpractice.             I believe as-applied to

physicians § 45-5-207, MCA, is unconstitutional.

Criminal Distribution of Dangerous Drugs

¶162 “[A] person commits the offense of criminal distribution of dangerous drugs if the

person sells, barters, exchanges, gives away, or offers to sell, barter, exchange, or give

away any dangerous drug[.]” Section 45-9-101(1), MCA. “Practitioners, as defined in

50-32-101, and agents under their supervision acting in the course of a professional practice

are exempt from” prosecution under § 45-9-101(1), MCA. Section 45-9-101(6), MCA.

Section 50-32-101(24)(a), MCA, defines “practitioner” to include “a physician . . .

3
  As noted in Opinion, ¶ 138 n.28, Christensen’s convictions result from malpractice—failure to
have legitimate medical reasons for the type and quantity of drugs prescribed. Establishing such
a standard imprudently invites the State to second guess assessment and treatment provided by
licensed physicians to criminalize malpractice.

                                              80
licensed, registered, or otherwise permitted to distribute[ or] dispense . . . a dangerous drug

in the course of professional practice . . . in this state[.]”

¶163 First, the Opinion strains logic to conclude that under § 45-9-101(1), MCA,

“prescribing” fits squarely within the term “exchanges.” Section 50-32-101(25) provides

“‘[p]rescription’ means an order given individually for the person for whom prescribed

directly from the prescriber to the furnisher or indirectly to the furnisher by means of an

order signed by the prescriber and bearing the name and address of the prescriber, the

prescriber’s license classification, the name of the patient, the name and quantity of the

drug or drugs prescribed, the directions for use, and the date of its issue.” “Prescribing”

would merely be the action of issuing a prescription. Issuing an order for a particular drug

for a person to a furnisher of the drug is clearly not “[t]he act of transferring interests, each

in consideration for the other”—the definition of “exchanges” provided in the Opinion.

Opinion, ¶ 96.

¶164 Section 50-32-101, MCA, provides other instructive definitions and insight into

legislative intent.4 Section 50-32-101(1)(a), MCA, defines “administer” to mean “the

direct application of a dangerous drug . . . by a practitioner[.]” Section 50-32-101(10),

MCA, defines “dispense” as meaning “to deliver a dangerous drug to an ultimate user or

research subject by or pursuant to the lawful order of a practitioner, including the

prescribing . . . [of] the drug[.]” (Emphasis added.) Section 50-32-101(11), MCA, defines

4
  “Whenever the meaning of a word or phrase is defined in any part of this code, such definition
is applicable to the same word or phrase wherever it occurs, except where a contrary intention
plainly applies.” Section 1-2-107, MCA.

                                                81
“dispenser” to mean “a practitioner who dispenses.” Section 50-32-101(12), MCA, defines

“distribute” to mean “to deliver other than by administering or dispensing a dangerous

drug.”   It is clear from these definitions the Legislature did not intend to include

prescribing, administering, or dispensing dangerous drugs by practitioners to be illegal

conduct under § 45-9-101(1), MCA, and to the extent a prosecutor could contort the

language of § 45-9-101(1), MCA, to assert otherwise, as occurred in this case, the

Legislature enacted § 45-9-101(6), MCA, to prevent this.         The Opinion asserts the

exclusion set forth in § 45-9-101(6), MCA, has no meaning if “prescribing” is not

encompassed in selling, bartering, exchanging, or giving away. Such is simply not true.

In the course of a professional practice, physicians at times directly provide patients with

medications. The cost of the medication and the medical treatment in administering it are

generally charged to the patient. Section 45-9-101(6), MCA, exempts this type of “sale”

from prosecution. Additionally, in the course of a professional practice, physicians

regularly dispense medication samples to patients. Section 45-9-101(6), MCA, excludes

this type of giving away from prosecution. In enacting the definitions found in § 50-32-

101, MCA, the Legislature specifically labeled and defined a practitioner’s actions or

conduct in providing dangerous drugs to patients in the course of a professional practice,

making them distinctly different than those precluded by § 45-9-101(1), MCA—“selling,”

“bartering,” “exchanging,” or “giving away.”

¶165 Next, the Opinion strains logic to conclude that the exclusion from prosecution

provided for in § 45-9-101(6), MCA,—specifically, the language “in the course of a

professional practice”—does not apply to a physician operating as a licensed physician,

                                            82
with State and DEA prescribing authority, from a business office with employed

professional staff, but instead is a requirement the physician is to conform to the standard

of care in the medical community. The Opinion concludes if the physician fails in the use

of appropriate documentation, assessments, tests, follow-ups, and referrals and provides

prescriptions for controlled substances in amounts exceeding the standard of care—in

essence, commits malpractice—the physician is not acting in the course of a professional

practice. Had the Legislature intended the exclusion to apply in situations of malpractice,

the Legislature could have clearly delineated such by stating a practitioner is not exempt

from prosecution if the practitioner fails to meet accepted standards of practice recognized

in the medical community. It is clear from the plain language of § 45-9-101(6), MCA, the

Legislature did not want the criminal justice system to second-guess a physician’s

decision-making made in real time while operating as a licensed physician with prescribing

authority from a business office with employed professional staff, but instead left the

policing of such to the physician’s licensing board and/or the civil tort of medical

malpractice. I would conclude § 45-9-101(6), MCA, bars prosecution of Christensen for

criminal distribution of dangerous drugs based on his prescribing controlled substances to

the eleven representative patients and remand for dismissal of these charges.

Criminal Endangerment

¶166 More egregious and alarming than upholding the criminal distribution of dangerous

drug convictions, the Court dangerously upholds Christensen’s criminal endangerment

convictions. “A person who knowingly engages in conduct that creates a substantial risk

of death or serious bodily injury to another commits the offense of criminal endangerment.”

                                            83
Section 45-5-207, MCA. Christensen challenges his nine convictions under this statute by

asserting an as-applied constitutional challenge. Christensen basically asserts there is no

set of circumstances when applied to physicians under which the statute would be valid—

providing sufficient notice of what conduct is violative of the statute or providing

guidelines to govern law enforcement. In this circumstance, analysis under our as-applied

criteria is appropriate. As the Opinion notes, an as-applied analysis involves two elements:

(1) whether the statute provides actual notice of violative conduct, and (2) whether the

statute provides minimal guidelines to govern law enforcement. Opinion, ¶ 131 (citing

Dixon, ¶ 28). The Opinion concludes that since Christensen, in essence, committed

malpractice—failed to conform to the standard of care for the medical profession in

assessing, treating, monitoring, documenting, and prescribing prescription drugs to the

representative patients—and had previously had his medical license revoked in Idaho, “he

had actual notice his conduct was prohibited.” Opinion, ¶ 135. The Opinion goes on to

conclude that common sense dictates a physician, such as Christensen, should have known

of the inherent risks of prescribing opiates and benzodiazepines together.5 Opinion, ¶ 136.

This conclusion appears absurd to me. Section 45-5-207, MCA, provides no notice to

Christensen or any other physician that commission of malpractice or any other acts taken

by a physician in the course of providing medical care to another will result in criminal

5
 While prescribing opiates and benzodiazepines together has inherent risks, similar to prescribing
any other controlled medications, physicians do at times prescribe such medications together in
providing care for a patient and nothing in § 45-5-207, MCA, provides notice that doing so is
considered criminal conduct subject to prosecution.

                                               84
liability, nor does it provide any notice that professional sanction such as license

suspension or revocation, will subject him or any other physician to criminal liability. By

his malpractice, Christensen was on reasonable notice he could be sued civilly by patients

for medical malpractice. By his prior license and DEA prescription revocations, he was on

reasonable notice that if he did not meet the requirements of the medical licensing board

or DEA, his medical license and/or DEA prescription authority could be suspended or

revoked. He was not reasonably on notice he was subject to criminal liability.

¶167 Section 45-5-207, MCA, as-applied to physicians, fails to provide any physician

with notice as to what conduct taken in the course of the physician providing medical care

to another would subject him or her to criminal prosecution. Prescribing controlled

substances or performing any type of surgical procedure by their very nature create a

substantial risk of death or serious bodily injury to another. This is the very reason the

barriers to entry into the profession are substantial—requiring at a minimum four years of

medical school, a multi-year residency, and licensing. Despite physicians giving their best

efforts, some are not as skilled as others, have less experience, make mistakes, or have poor

results which result in death or serious bodily injury to another. How many prescriptions

constitute criminal endangerment? In what dosages? If a surgery results in an outcome

which can occur but is not usually expected, is that criminal endangerment? What if a

surgeon mistakenly operates on the wrong limb or removes the wrong organ, or

accidentally cuts the carotid artery while performing a tonsillectomy? What if a surgery

has considerable risk of death but not doing the surgery has a slightly higher risk of death?

What if a surgery has considerable risk of death but could restore the patient considerable

                                             85
function but not doing the surgery had almost no risk of death or further serious bodily

injury but would result in significant ongoing functional limitation? If a physician gives a

patient medication to preserve cardiac function in the setting of a heart attack but in doing

so increases the patient’s risk of stroke, is it criminal endangerment if the patient suffers a

major stroke? And the list goes on and on. Section 45-5-207, MCA, provides no

reasonable notice of what conduct, malpractice or otherwise, taken by a physician in

providing medical care to another is violative of the statute.

¶168 Further, as-applied to physicians, § 45-5-207, MCA, provides no meaningful

guidelines to govern law enforcement of a physician’s actions in providing medical care to

others. Accordingly, I would conclude § 45-5-207, MCA, as-applied to physicians, does

not rationally further the intended legitimate government interest in criminalizing reckless

conduct creating a risk to others and is void-for-vagueness or lack of notice and, thus,

unconstitutional. I would reverse and vacate Christensen’s nine criminal endangerment

convictions.

Negligent Homicide

¶169 I concur with the Opinion’s reversal and vacation of Christensen’s conviction for

two counts of negligent homicide.

Other Matters

¶170 As I would conclude § 45-9-101(6), MCA, precludes prosecution of Christensen for

distribution of dangerous drugs as discussed above and that § 45-5-207, MCA, as-applied

to physicians, is unconstitutional, the various evidentiary issues raised would be moot. As

the Opinion inappropriately concludes otherwise, I am compelled to address at least some

                                              86
of the inconsistency of the District Court and the Opinion in marshalling evidence and

determining proper jury instruction.

       Application of Feingold

¶171 As noted in the Opinion, the State relied on a federal distribution statute—21 U.S.C.

§ 841(a)—and federal case law in support of its interpretation of § 45-9-101, MCA. As

discussed in the Opinion, Christensen asserts the District Court improperly instructed the

jury pursuant to Feingold, without including instruction as to the good faith defense.6

Given the plain language of § 45-9-101(1) and (6), MCA, it is not necessary to consult

Moore and its progeny in interpreting § 45-9-101, MCA. However, as the Opinion imposes

an obligation to consult Moore and its progeny in interpreting § 45-9-101, MCA, and more

specifically employ jury instructions consistent with Feingold, I address this issue. To

begin, the exemption provided physicians under § 45-9-101(6), MCA, does not exist in the

federal law, as such the comparison is already one of apples to oranges. To convict under

§ 841(a) of the CSA, the federal criminal drug distribution statute, the government must

prove: “(1) that the practitioner distributed controlled substances, (2) that the distribution

of those controlled substances was outside the usual course of professional practice and

without a legitimate medical purpose, and (3) that the practitioner acted with intent to

6
  Christensen contests the use of federal law and Feingold in prosecution of Montana’s criminal
distribution statute. The Opinion concludes Christensen waived this argument as he did not file a
brief in opposition to the State’s first pretrial motion seeking an order clarifying Montana’s drug
distribution statute and adoption of jury instructions. At the time of the State’s motion, Christensen
had not yet secured legal counsel. While he did not file a brief in opposition, he requested stay of
the issue until he secured legal counsel. After securing legal counsel, he filed a motion to dismiss
which by its nature opposed the use of federal law in addressing Montana’s criminal distribution
statute. Accordingly, I would conclude he did not waive this argument for appeal.

                                                 87
distribute the drugs and with intent to distribute them outside the course of professional

practice. In other words, the jury must make a finding of intent not merely with respect to

distribution, but also with respect to the doctor’s intent to act as a pusher rather than a

medical professional.” Feingold, 454 F.3d at 1008 (first emphasis in original, second

emphasis added). Feingold further explained, “an instruction is improper if it allows a jury

to convict a licensed practitioner under § 841(a) solely on a finding that he has committed

malpractice, intentional or otherwise.” Feingold, 454 F.3d at 1010. “If a practitioner’s

distribution of controlled substances becomes illegal only by virtue of the fact that his

actions are outside the usual course of professional practice, it follows that the practitioner

must have deliberately acted in this fashion in order for him to be convicted of a crime. . . .

[T]he jury must look into a practitioner’s mind to determine whether he prescribed the pills

for what he thought was a medical purpose or whether he was passing out the pills to

anyone who asked for them.” Feingold, 454 F.3d 1007-08 (emphasis added) (internal

citations and quotations omitted).

¶172 As discussed in the Opinion, Feingold then provided a supplemental instruction

regarding the good faith defense—a practitioner may not be convicted of unlawful

distribution of controlled substances when he distributes controlled substances in good

faith to patients in the regular course of professional practice. The good faith instruction

endorsed in Feingold defined “in the usual course of his professional practice” as

prescribed in good faith in medically treating the patient. It defined good faith in terms of

sincerity of the physician in attempting to conduct himself in accordance with a standard

of medical practice and honest effort to prescribe for a patient’s condition. The good faith

                                              88
instruction from Feingold further advised “practitioners who act outside the usual course

of professional practice and prescribe or distribute controlled substances for no legitimate

medical purpose may be guilty of unlawful distribution of controlled substances.”

Feingold, 454 F.3d at 1006 (emphasis added). The Opinion concludes the supplemental

instruction provided here mirrored the good faith instruction of Feingold. I do not agree.

Here, contrary to the Feingold good faith instruction, the good faith instruction instructed

the legitimacy of the medical purpose is not determined by a practitioner’s sincerity, when

in part it is. Pursuant to Feingold, “practitioners who act outside the usual course of

professional practice and prescribe or distribute controlled substances for no legitimate

medical purpose may be guilty of unlawful distribution of controlled substances” when

they have “acted not as a doctor, or even as a bad doctor, but as a ‘pusher[.]’” Feingold,

454 F.3d at 1006-07 (emphasis added). The Opinion concludes, “[t]he jury instructions

here meet the requirement for Montana law, repeating that the professional practice

exemption does not apply if the defendant ‘purposely or knowingly prescribes a dangerous

drug for no legitimate medical purpose.’” Opinion, ¶ 108. The jury instructions here, as

a whole, permitted a conviction for malpractice7 and, unlike Feingold, did not instruct that

the practitioner had to act not only with intent to prescribe the drugs—purposely or

7
  And indeed the District Court at sentencing repeatedly referred to Christensen’s “careless”
prescribing practices and noted Christensen’s training and education was “to treat pain
aggressively, and there was apparently a clear tendency in the literature to recommend that at that
time” but that he “got stuck in that mindset and rejected more recent efforts over a long period of
years to rein in opiate use and to advocate a stepped up approach to pain management” indicating
not an intent to act as a pusher but rather malpractice in failing to stay current as to treatment
modalities.

                                                89
knowingly—without a legitimate medical purpose but also with intent to act as a pusher

rather than a medical professional. As such, even if Feingold were applicable, the District

Court erred in applying it.

       Testimony of 28 Other Patients

¶173 Prior to trial, the State sought, via a motion in limine, which was granted by the

District Court, to preclude Christensen from presenting testimony of former patients to

establish his habit and routine in treating patients. As the Opinion notes, Christensen

asserted this testimony was relevant to his affirmative defense that he was prescribing drugs

in the course of a professional practice and this evidence was admissible pursuant to M. R.

Evid. 406, Habit and Routine Practice. The District Court and now the Opinion conclude

their testimony was irrelevant as to how Christensen acted in treating “the eleven

representative patients.”     Although the State brought eleven charges of criminal

distribution of dangerous drugs in connection with eleven specific patients, the State

portrayed these patients as “representative” of all of Christensen’s patients and

representative of his malpractice in the overall operation of his medical practice. As

“representative” patients, the implication was that Christensen was operating as a “drug

pusher” in the entirety of his professional practice rather than as a physician. Throughout

trial, the State presented “representative” patients to present its overarching theory of the

case that Christensen’s medical practice was a criminal scheme to distribute dangerous

drugs—his practice was to distribute “opiates on the first visit, every time” to all his

patients, the only patients that went to see Christensen were addicts seeking drugs, and his

practice consisted of him being nothing more than a drug pusher. Christensen sought to

                                             90
present testimony from 28 former patients to combat the State’s overarching theory of the

case. Christensen asserts these patients would testify some received alternative medical

treatments for pain, other than prescription opiates; some were denied prescription opiates

by Christensen; some had no issues with pain and Christensen did not push pain medication

on them; and some received prescription opiates, followed the prescriptions, and benefitted

from the treatment without side-effects. By granting the State’s motion in limine, the

District Court unfairly precluded Christensen from contesting, rebutting, or correcting the

State’s portrayal that the medical services rendered to these eleven patients represented the

malpractice Christensen’s inflicted on all his patients in the overall conduct of operating

his medical practice. Indeed, at sentencing when Christensen was able to present some of

this evidence, the District Court noted a stark contrast to the physician the State presented

at trial and the caring professional described by satisfied patients.8

¶174 I am concerned the Court has adopted a dangerous course of opening physicians to

criminal prosecution in the setting of malpractice. Further, when claims relating to

particular patients are asserted to be representative of all patients, fundamental fairness

dictates such a physician should then not be hamstrung from showing a habit and practice

in assessing, treating, and following-up with patients inconsistent with the claimed

8
  “And in this case, as much or more as any other I’ve had, I’ve been presented with two competing
pictures of the Defendant that are at odds with one another. That’s not uncommon in these cases,
but it’s probably more stark here than most. I have literally dozens of letters here from satisfied
patients talking about a -- describing a doctor who is knowledgeable, caring, compassionate,
unselfish, unconcerned with financial compensation to some extent; and then we have, at the same
time, the doctor described at trial, who was careless in the extreme with, at least certain patients
. . . .”

                                                91
“representative” practices. In this context the District Court erred in concluding the

evidence of other patients was not relevant and not M. R. Evid. 406 habit and routine

practice evidence.

                                                   /S/ INGRID GUSTAFSON

Justice Dirk Sandefur joins in the dissenting and concurring Opinion of Justice
Gustafson.

                                                   /S/ DIRK M. SANDEFUR

Justice Dirk Sandefur, concurring in part and dissenting in part.

¶175 I concur in the Court’s holding that the State failed to prove beyond a reasonable

doubt that Dr. Christensen is guilty of negligent homicide, as more stringently defined than

a mere failure to use reasonable care. However, I join Justice Gustafson’s well-reasoned

dissent exposing many of the manifest technical deficiencies in the balance of the Court’s

reasoning. I add the following to accentuate it.

¶176 Just as we license, pay, expect, and need them to do, Montana physicians often

purposely and knowingly make medical care decisions, including the prescription of

potentially dangerous drugs, that involve a substantial risk of death or serious bodily injury

to patients. They do so with the consent of their patients and in the exercise of their

professional judgment, however sound, and licensed authority under state and federal law.

Until today, whether physicians acted in accordance with generally accepted medical

standards, and the appropriate sanction if they did not, were questions of professional

                                             92
licensing regulation, and well-settled civil medical malpractice law, guided by professional

standards and expert medical opinion. Without prior notice to physicians, the Court’s

unprecedented decision now places those matters in the ill-suited hands of police,

prosecutors, and sentencing judges in criminal cases, where, as here, expert medical

opinion regarding the alleged breach of standard of care or resulting patient-specific

medical causation of risk and harm are, at most, only secondary considerations.

¶177 Regardless of the degree of egregious or dangerous conduct at issue in a particular

case, and the resulting prosecutorial and public fervor for the offending physician to be

criminally punished, the irrefutable fact is that the Legislature neither designed, nor

intended, Montana’s current criminal endangerment and criminal distribution of dangerous

drugs statutes for the prosecution of duly licensed physicians for writing ill-advised

medical prescriptions to patients. Like it or not, in the current void of any applicable

Montana law enacted for the purpose of criminally punishing such conduct, the problem is

plainly one of public policy for the Legislature to prospectively address in the exercise of

its exclusive constitutional authority and duty.

¶178 In the interim, this Court has no business, as it does today, leaving its constitutional

lane to arbitrarily contort our existing criminal law beyond its designed and intended

bounds to reach a desirable result in an undeniably troublesome case. The limited duty and

authority of this Court regarding the criminal law is to correctly interpret and apply existing

constitutional and statutory law as written and intended—not to make it up or reshape it as

we go to address the uncontemplated urgency of the day, however serious or tragic.

Medical prescriptions simply do not involve any barter, sale, or exchange of drugs between

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physician and patient. They are no more than an authorization from a physician for a

patient to legally obtain a physician-recommended drug from a pharmacy for medicinal

purposes. The Court’s unsupported, illogical, and ominous contortion of our limited

criminal law can and will now be used, as here, by well-meaning but over-zealous police

and prosecutors to equate a duly licensed physician’s issuance of a medical prescription

with an illegal drug deal on the street.

¶179 As manifest by the degree of contortion used to justify it, the Court’s legally

unsound, result-oriented decision is unsupported by existing Montana law and proper

evidence. It will surely have untold and boundless chilling and menacing effects on the

legitimate provision of essential medical care by the responsible and dedicated physicians

upon whom we all so crucially depend. Hopefully, the next Legislature will, for the first

time, squarely consider the problem of abusive prescription practices and revise our

currently inadequate law to particularly and fairly address the problem in the public interest

as deemed appropriate to protect both patients and physicians.

                                                  /S/ DIRK M. SANDEFUR

Justice Laurie McKinnon, concurring and dissenting.

¶180 I join the Court’s opinion on Issues One and Two. I respectfully dissent on

Issue Three.

¶181 However, before turning to Issue Three, I feel compelled to address the notion that

a physician who traffics in drugs is nonetheless immune from criminal liability by virtue

of the “practitioner” exemption provided in § 45-9-101(6), MCA, and the existence of

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additional civil and administrative remedies.      Section 45-9-101, MCA, provides for

criminal liability when “a person commits the offense of criminal distribution of dangerous

drugs . . . .” (Emphasis added.) By its terms, § 45-9-101, MCA, reaches any “person” who

knowingly and intentionally distributes dangerous drugs. The plain language of the statute

sets forth a blanket prohibition on the distribution of dangerous drugs. However, the statute

carves out a limited and qualified exemption to criminal liability for physicians who,

“in the   course    of   a    professional    practice,”   prescribe    dangerous     drugs.

Section 45-9-101(6), MCA (emphasis added).         The legislature could have exempted

all physicians from criminal liability, thereby allowing for the modest penalties of state

administrative and regulatory proceedings and for civil medical malpractice proceedings

alone to remediate the injuries caused by drug-trafficking physicians, but it did not.

Instead, the legislature chose to qualify the exemption for only legitimate physician

activities. The legislature did not establish two separate and distinct penalty systems which

are mutually exclusive—one for physicians and one for everyone else. There is nothing in

the statutory scheme of § 45-9-101, MCA, that justifies a conclusion that a physician who

acts as a drug pusher is exempt from criminal liability for distribution or the deaths of

addicts simply because of his status as a physician. The qualified authorization of certain

physician activities does not create a “status” of defendants who are immune from criminal

prosecution. See United States v. Moore, 423 U.S. 122, 134, 96 S. Ct. 335, 46 L. Ed. 2d 333

(1975).   Montana’s legislature could hardly have deemed a medical malpractice or

administrative proceeding as an appropriate resolution for the drug trafficking and deaths

that have occurred here. Physicians who cease to distribute dangerous drugs as a medical

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professional and who, instead, act as a drug pusher can be, and ought to be, prosecuted

under the Statute just like any other drug pusher or person. Moore, 423 U.S. at 124,

96 S. Ct. at 337 (holding that registered physicians can be prosecuted under § 841 of the

Controlled Substances Act when their activities fall outside the usual course of professional

practice).

¶182 The focus of the physician exemption necessarily must be on the legitimacy of the

transaction, rather than the status of the defendant.          Moore, 423 U.S. at 134,

96 S. Ct. at 342. When a physician distributes drugs other than for a legitimate and

good-faith purpose guided by the standards of the physician’s medical profession, the

physician is no longer entitled to the limited statutory exemption and cannot escape

criminal liability. Moore, 423 U.S. at 135, 96 S. Ct. at 343. Physicians, who have the

greatest access to controlled substances, and therefore the greatest opportunity for

diversion, are not exempt from criminal liability when they traffic drugs for illegitimate

purposes. Here, Christensen’s distribution of drugs had no legitimate purpose and the jury

concluded his distribution of drugs was outside the boundaries of any legitimate

professional practice. We commit to juries the authority to make the most important

decisions in our lives. Our country’s judicial process is founded upon our faith that, when

properly instructed and evidence properly admitted, juries will arrive at a verdict that we

can adhere by. There is little doubt in my mind that juries can assess and consider whether

a physician has ceased to act as a medical professional and, instead, distributed drugs as a

drug pusher. I cannot subscribe to the notion that physicians are somehow above the law;

are not criminally accountable for their actions conducted outside the scope of their medical

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profession; or that a criminal jury trial is an inappropriate forum to evaluate their

misconduct. Physicians who depart from the usual course of medical practice are subject

to the same penalties as street pushers with no claim to legitimacy.

¶183 I turn now to Issue Three and whether Christensen negligently caused Gregg’s and

Kara’s deaths. There was, in my opinion, ample forensic evidence establishing the

“but for” causation requirement for the offense of negligent homicide. Gregg had been an

addict for years. Ignoring medical records from Gregg’s prior physician, Christensen

changed Gregg’s treatment plan from Suboxone, which was used for addiction

management, to methadone, which was used for pain management. The toxicologist,

physician, and coroners, clearly established that the presence of a “lethal” amount of

methadone in Gregg’s body, distributed by Christensen four days before Gregg died, was

the cause-in-fact of Gregg’s methadone-induced overdose death.            The amount of

methadone in Gregg’s body was nearly “twice the level” found in “methadone-only

overdose deaths.” Additionally, there was overwhelming evidence establishing that when

methadone, an opioid, is mixed with Xanax, a benzodiazepine—both of which were

prescribed by Christensen and were present in Gregg’s blood—the dangerous combination

reduces the body’s ability to sense the need to breathe and increases the likelihood of

accidental overdoses.

¶184 Respecting Kara, the forensic evidence established that the drugs Christensen

prescribed to her were also the cause-in-fact of her death. Following a single consultation

with Christensen, Kara, who also had a severe addiction, left Christensen with a

prescription allowing her to ingest lethal amounts of opioids, both methadone and Dilaudid,

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and to ingest them in combination with a benzodiazepine. These opioid prescriptions from

Christensen were in excess of Kara’s existing prescriptions from Dr. Ravitz of fentanyl, an

opioid, and Valium, a benzodiazepine. Both prescriptions from Dr. Ravitz were indicated

within Kara’s medical history records and were known to Christensen upon acceptance of

Kara as a patient. The evidence was sufficient for the jury to conclude that Christensen

was the cause-in-fact of Kara’s overdose death when she was found dead three-days after

her visit to Christensen.

¶185 For both Gregg’s and Kara’s deaths, the Court concludes that there was “mixed drug

toxicity” and, for this reason, a jury could only speculate that Christensen was the

cause-in-fact of their deaths. Opinion, ¶ 158. The Court’s conclusion is incorrect for two

fundamental reasons.        First, and probably most problematic, the conclusion reached

ultimately creates a status of victims—addicts—for whom physicians acting as

drug pushers may escape criminal liability. An addict compulsively and habitually seeks

out and abuses drugs, often many types of drugs. It can be expected that at any given point

in time there likely will be more than one substance present in an addict’s blood, which

may have been acquired from several sources. By requiring that the drugs Christensen

distributed to Gregg and Kara be the sole cause of their deaths, the Court immunizes the

physician-drug pusher when the victim who has died, as a result of his illegal distribution

of drugs, is an addict. Here, the medical evidence established that Gregg died from a lethal

amount of methadone, which had been distributed by Christensen four days earlier.

Christensen also distributed to Gregg a benzodiazepine, which can be lethal when mixed

with methadone. It was up to a jury to decide whether either, both, or all the drugs detected

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in Gregg’s blood and distributed to him by Christensen caused his death. Similarly,

Christensen distributed to Kara drugs in excess of her current prescriptions, which

produced lethal amounts of opioids and benzodiazepine in her blood at the time of her

death. Gregg’s and Kara’s severe addiction was well-known to Christensen and, in fact, it

was their addictions, and that of others, that Christensen exploited in order to make money.

¶186 A physician cannot escape criminal liability on the basis that his addict-victims did

what any medical professional would expect them to do; that is, taking more than directed

the drug to which they are addicted, resulting in their accidental overdose death.

Christensen distributed medically unsupportable dosages and amounts of drugs repeatedly

to his victims, who were addicts. As a medical professional, Christensen was required to

consider their addictions before prescribing drugs, just as a physician would be required to

consider a patient’s heart condition before prescribing certain medication. Christensen not

only prescribed excessive amounts of drugs to persons whom he knew were addicts, but

whom he knew were ingesting excessive amounts beyond what was directed or medically

appropriate because he continued to supply refills and excessive dosages. In rendering a

verdict that Christensen caused Gregg’s and Kara’s deaths, the jury rejected the argument

that Gregg and Kara were responsible for their own deaths by taking more of the drugs

than directed. The evidence of causation was neither speculative nor insufficient; to the

contrary, the evidence of criminal negligence and causation was overwhelming.

¶187 Second, by requiring that Christensen’s distribution of drugs to Gregg and Kara be

the sole cause of their deaths, the Court incorrectly interprets the element of causation for

the offense of negligent homicide. A “person commits the offense of negligent homicide

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if   the     person   negligently   causes   the    death   of    another    human     being.”

Section 45-5-104, MCA. The jury was instructed, consistent with § 45-2-101(43), MCA,

that “[a] person acts negligently with respect to a result or to a circumstance described by

a statute defining an offense when the person consciously disregards a risk that the result

will occur or that the circumstance exists or when the person disregards a risk of which the

person should be aware that the result will occur or that the circumstance exists.”

Section 45-2-101(43), MCA (emphasis added). “The risk must be of a nature and degree

that to disregard it involves a gross deviation from the standard of conduct that a reasonable

person would observe in the actor’s situation. ‘Gross deviation’ means a deviation that is

considerably greater than lack of ordinary care.” Section 45-2-101(43), MCA. A gross

deviation under the statutory definition is analogous to gross negligence in the law of torts.

State v. Bier, 181 Mont. 27, 32, 591 P.2d 1115, 1118 (1979). Gross negligence is generally

considered to fall short of a reckless disregard for consequences and is said to differ from

ordinary negligence only in degree, not in kind. Bier, 181 Mont. at 32, 591 P.2d at 1118.

¶188       Section 45-2-201(1)(a), MCA, defines the causal relationship between the conduct

and result: “Conduct is the cause of a result if . . . without the conduct the result would not

have occurred . . . .” Where a crime is based on some form of negligence, the State must

show the defendant’s negligent conduct was the cause-in-fact of the victim’s death.

Bowen v. State, 2015 MT 246, ¶ 33, 380 Mont. 433, 356 P.3d 449. A party’s conduct is a

cause-in-fact of an event if the event would not have occurred but for that conduct;

conversely, the defendant’s conduct is not the cause-in-fact of the event if the event would

have occurred without it. Bowen, ¶ 33. Accordingly, for Christensen to have been found

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guilty of negligent homicide, the State had to prove that Gregg’s and Kara’s deaths would

not have occurred “but for” Christensen’s negligent act; that is, Christensen negligently

disregarded that his distribution to addicts of an excessive amount of dangerous drugs

would create a risk of drug overdose in his victims. Stated alternatively, for the jury to find

Christensen not guilty of negligent homicide the jury would have had to conclude that

Gregg and Kara would have died without Christensen’s negligent act of distributing them

drugs. It is hard for me to understand the Court’s conclusion that the jury speculated on

the element of causation because, in my opinion, the evidence does not support that

Gregg and Kara would have died regardless of Christensen’s conduct in distributing to

them lethal amounts of drugs just prior to their deaths.

¶189 This is true particularly since the jury, during deliberations, sent a question to the

court asking: “Please provide the legal definition of ‘caused’ as it applies to the charge of

negligent homicide.” The question evidences the jury’s appreciation of the causation

element as it relates to a negligent homicide charge, and that they understood the

significance of the requirement they were tasked with deciding.             In response, the

District Court instructed on the statutory definition of causation, as set forth in

§ 45-2-201(1)(a) and (3), MCA, in the context of a negligent homicide charge:

       Conduct is the cause of a result if without the conduct the result would not
       have occurred.

       If negligently causing a particular result is an element of an offense and the
       result is not within the risk of which the offender is aware or should be aware,
       either element can nevertheless be established if the actual result involves the
       same kind of injury or harm as the probable result, unless the actual result is
       too remote or accidental to have a bearing on the offender’s liability or on
       the gravity of the offense.

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¶190 The jury considered the evidence and reached a verdict that Christensen had caused

Gregg’s death. In doing so, the jury concluded that Gregg’s death, only four days after

Christensen distributed to him a lethal amount of methadone and benzodiazepine, would

not have occurred absent Christensen’s negligent conduct. Gregg had been on a Suboxone

program for his addiction for years and had not died. After having been properly instructed

on causation, the jury determined that the drugs Christensen distributed to Gregg caused

his death. Similarly, Kara had an active prescription for fentanyl, an opioid, and Valium,

a benzodiazepine, from Dr. Ravitz. Christensen knew this, but nonetheless prescribed

more opioids—both methadone and Dilaudid—causing Kara’s opioid levels to rise to a

lethal amount—especially when ingested in combination with a benzodiazepine like

Valium.

¶191 Whether Gregg’s and Kara’s deaths were caused by Christensen’s conduct was a

question for the jury to decide. The jury was specifically instructed that to convict

Christensen of negligent homicide they had to find that Christensen (1) “caused”

Gregg’s and Kara’s deaths; and (2) that Christensen acted negligently. The jury asked the

District Court for clarification on the legal definition of causation and, in reaching a verdict

that Christensen had caused Gregg’s and Kara’s deaths, rejected the notion that their

deaths were accidental or too remote. The jury was in the best position to consider the

evidence and was the body charged with deciding whether Gregg’s and Kara’s deaths were

accidental, too remote, or would have occurred regardless of Christensen’s

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negligent conduct. I think it is a mistake for this Court to substitute its judgment for that

of the trier of fact; here, the jury.

¶192 I dissent, and I would affirm the jury’s verdict that Christensen is guilty of negligent

homicide for the deaths of Gregg and Kara.

                                                  /S/ LAURIE McKINNON

Justices Beth Baker and Jim Rice join in the Concurrence and Dissent of Justice McKinnon.

                                                  /S/ BETH BAKER
                                                  /S/ JIM RICE

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