Court Opinion

ID: 4300379
Source: CourtListenerOpinion
Date Created: 2018-08-02 15:02:02.300436+00
Date Added: 2024-06-11T14:42:08.188401
License: Public Domain

United States Court of Appeals
                For the Eighth Circuit

          ___________________________

                  No. 17-1140
          ___________________________

               United States of America

                  Plaintiff - Appellee

                           v.

               Anthony Markeith King

              Defendant - Appellant
         ____________________________

                  No. 17-1976
          ___________________________

               United States of America

                  Plaintiff - Appellee

                           v.

Kristen L. Raines, (originally named Kristin L. Raines)

                Defendant - Appellant

      Appeals from United States District Court
   for the Eastern District of Arkansas - Little Rock
                    ____________
                             Submitted: March 13, 2018
                               Filed: August 2, 2018
                                   ____________

Before WOLLMAN, SHEPHERD, and ERICKSON, Circuit Judges.
                        ____________

ERICKSON, Circuit Judge.

       This consolidated appeal arises out of the operation of a “pill mill” conducted
under the guise of a legitimate clinic. Anthony Markeith King and Kristen L. Raines
were charged in a conspiracy to distribute scheduled controlled substances without
an effective prescription in violation of 21 U.S.C. §§ 841(a)(1), (b)(1)(C), (b)(1)(E),
and 846. Raines was also charged with two counts of distribution of a scheduled
controlled substance without an effective prescription, in violation of 21 U.S.C. §§
841(a)(1), (b)(1)(C), and (b)(1)(E).

       King pled guilty to the conspiracy charge. The district court1 put King at a base
offense level of 26, then added a four-point enhancement for acting as an organizer
or leader and subtracted two points for acceptance of responsibility. King then had
an offense level of 28, criminal history category I, with a Guidelines range of 78-97
months. The court sentenced King to 120 months’ imprisonment, varying upward
due to the nature of King’s role in the conspiracy.

       Raines proceeded to trial and was convicted on the conspiracy charge and
acquitted on the distribution charges. The district court found Raines to be at offense
level 26 (after applying a two-point enhancement for abuse of position of trust),

      1
       The Honorable James M. Moody, United States District Judge for the Eastern
District of Arkansas.

                                          -2-
criminal history category I, with a Guidelines range of 63-78 months. The court
sentenced Raines to 70 months’ imprisonment.

       Raines appeals her conviction and sentence, claiming: 1) the court improperly
admitted evidence at trial, 2) the court erred in instructing the jury, 3) the evidence
was insufficient to sustain a conviction, and 4) her sentence is substantively
unreasonable. King challenges the reasonability of his sentence. We affirm the
district court in all respects.

      I.     Background

      Artex Medical Clinic opened in Little Rock, Arkansas, in June of 2014.
Patients at Artex frequently received prescriptions for hydrocodone and/or Xanax.
Artex operated on a cash-fee basis, where patients would pay $200 in cash prior to
being evaluated. Anthony King worked as a “recruiter” for the clinic. King recruited
patients from across Arkansas to the clinic. Patients were required to sign a “pain
contract” in which they agreed to opioid treatment before they were seen or diagnosed
by medical staff.

      Kristen Raines began working as an Advanced Practice Registered Nurse for
Artex in July of 2014. From nearly the time she was hired until the clinic closed in
September of 2014, Raines was the only employee of Artex present on a daily basis
who was licensed to write prescriptions for hydrocodone and Xanax.

       The Drug Enforcement Administration announced that drugs containing
hydrocodone would become Schedule II drugs on October 6, 2014, which led to
Artex closing its doors at the end of September. Shortly after Artex closed, its
operators (including King) opened KJ Medical Clinic. Because of hydrocodone’s
new scheduling, Artex employed two doctors as prescribing physicians. The new
clinic operated similarly to the old clinic—patients would walk-in and pay either

                                         -3-
$200 for a pain evaluation or $150 for treatment for a “cough.” In early November of
2014, Raines began working at KJ.

       The signs that KJ was not operating as a legitimate medical establishment were
apparent. Receptionists at the clinic guided patients’ answers on questionnaires to
make them appropriate candidates for controlled substance prescriptions. Patients
were instructed to fill their prescriptions only at particular pharmacies. Patients were
required to sign forms attesting that they were not involved in any government
investigation into the clinic. Patients were given an “entrance number” in the parking
lot near the building and were only allowed inside in limited numbers. Upon entry
plaintiffs were checked for weapons by an armed security guard.

      The clinic’s unorthodox methods extended to patient evaluations and the
prescription of medications. Doctors at the clinic would pre-fill prescriptions for
hydrocodone and Xanax. Nurses would then conduct in-person evaluations of the
patients and complete the pre-filled prescriptions over the physician’s signature.

      Raines left KJ in early January of 2015. King continued recruiting patients
until May of 2015, when the clinic was raided by the DEA. Following the raid,
Raines and King were charged in a conspiracy to distribute controlled substances.
Raines was also charged with two counts of distribution of a controlled substance
without an effective prescription.

       At trial the government presented evidence from cooperating co-conspirators,
confidential informants, and an expert medical witness. Stella Green, a coworker
nurse, testified that using pre-signed prescriptions was standard procedure for the
clinic. Several other witnesses also testified that the clinic relied on pre-signed
prescriptions.

                                          -4-
       The government introduced evidence from a confidential informant who visited
the clinic in November of 2014, January of 2015, and March of 2015. Raines was
working at the clinic during the time period of the first two visits, but not the third.
The informant testified that on each visit prospective patients were told to take a
number, get in line, and wait to receive a prescription. She described the atmosphere
as chaotic, with patients arguing about who would get inside to fill their prescription.
She testified that on her first visit when she handed her paperwork in and marked
only a “5” on the pain scale, a desk clerk asked her to change her answer to a “10” or
else she would be unable to see a doctor. The government introduced a video taken
during the informant’s third visit to the clinic. The informant testified that the
contents of the video were similar in many ways to her experience during her first two
trips to the clinic. A coworker testified that Raines would have walked through or
seen the same areas that the video was taken in as an ordinary part of her workday.

       A medical expert, Dr. Carlos Roman, testified regarding standards of practice
in the field of pain management, guidelines for prescribing medications, and “red
flags” that indicated potential painkiller abuse. Dr. Roman had twenty years of
experience in the medical profession and had served on the Arkansas State Medical
Board Review Committee since 2005, including as chairman. Dr. Roman also served
as the Chief of Pain Management at St. Vincent Infirmary in Little Rock, Arkansas.
Dr. Roman noted that the Artex “pain contract” and KJ’s signed form prohibiting
patients from participating in law enforcement activity were not typical for a
legitimate medical establishment. He also testified regarding the Prescription
Monitoring Program (“PMP”) data offered by the United States as evidence of
irregular prescription activity. The data was submitted to the trial court in a summary
chart form showing hydrocodone and Xanax prescriptions allegedly written by Raines
while working at Artex. The original versions of the prescriptions referenced in the
chart were also submitted to the court. Of approximately 112 patient files from KJ,
21 contained paperwork signed by Raines, along with prescriptions bearing Raines’s
handwriting and a physician’s signature.

                                          -5-
       Dr. Roman testified that he believed the records indicated a failure to pursue
a legitimate medical purpose. He based his review on all of the files available from
Artex, ten files chosen at random from KJ, and eleven files identified as relating to
patients Raines treated at KJ. He noted that patients had consistently marked either
a “9” or “10” on the pain scale. He further remarked that the patients’ answers to
anxiety and depression questionnaires were outside the normal boundary for
treatment by a pain specialist and indicated suicidal tendencies. In particular, he
noted that several of the files raised concerns that medical treatment had been limited
to the prescription of opioids when the alleged circumstances would have required
more detailed and thorough care. He also commented on an audio recording from an
informant patient in which Raines referred to Xanax by the street term “bars.” He
noted that using street terms is not normal in medical practice.

       During the jury instruction conference, Raines requested a “good faith”
instruction, proposing the following language:

             When you consider the good faith defense, it is the defendant’s
      belief that is important. It is the sincerity of the defendant’s belief that
      determines if he or she acted in good faith. If the defendant’s belief is
      unreasonable, you may consider that in determining his or her sincerity
      of belief, but an unreasonable belief sincerely held is good faith.

The trial judge declined to provide the instruction. The trial judge provided an
instruction on willful blindness over Raines’s objection.

       Raines was convicted on the conspiracy charge and acquitted on the
substantive distribution charges. At sentencing the district court found Raines
responsible for 125,940 pills of hydrocodone and 151,076 pills of Xanax. The court
also applied an enhancement for abuse of position of trust. Raines was sentenced to
a term of 70 months’ imprisonment to be followed by three years of supervised
release.

                                          -6-
      The district court applied a sentence enhancement to King for being an
organizer or leader and also applied a reduction for acceptance of responsibility.
King was sentenced to a term of 120 months’ imprisonment to be followed by three
years of supervised release.

      II.    Discussion

             A.     Evidentiary Rulings

       “Federal Rule of Evidence 403 allows a district court to exclude evidence ‘if
its probative value is substantially outweighed by a danger of . . . unfair prejudice,
confusing the issues, misleading the jury, undue delay, wasting time, or needlessly
presenting cumulative evidence.’” Davis v. White, 858 F.3d 1155, 1159 (8th Cir.
2017). We give great deference to the district court’s Rule 403 determinations and
will reverse its evidentiary rulings only for a “clear and prejudicial abuse of
discretion.” Quigley v. Winter, 598 F.3d 938, 946 (8th Cir. 2010). “[A] district
court’s discretion in determining the admissibility of evidence is ‘particularly broad
in a conspiracy trial.’” United States v. Darden, 70 F.3d 1507, 1539 (8th Cir. 1995)
(quoting United States v. Willis, 997 F.2d 407, 414 (8th Cir. 1993)). Raines raises
a series of objections to evidentiary decisions made by the district court.

                    1. The Prescription Monitoring Program Data Summaries

       Raines claims the PMP data is inadmissable because it is of questionable
reliability and is unfairly prejudicial. The PMP data was corroborated by several other
pieces of evidence, including cross-references to particular days on which Raines
worked, patient sign-in logs for those days, and hard copies of the actual prescriptions
offered to those patients. Those corroborating elements provided sufficient reliability

                                          -7-
for the PMP summaries.2 Contrary to Raines’s assertion, it was not unfairly
prejudicial for the PMP summaries to include only those prescriptions for the
particular substances alleged in the conspiracy. The district court did not abuse its
discretion by admitting the PMP evidence.3

                     2. Expert Physician Testimony

       Raines objects to the admission of Dr. Roman’s expert physician testimony on
the grounds that it was based on both a lack of personal knowledge and an inadequate
review of the prescription records. Rule 702 of the Federal Rules of Evidence
governs the admission of expert testimony. “We review a district court’s decision to
admit expert testimony for an abuse of discretion.” Robinson v. GEICO Gen. Ins.
Co., 447 F.3d 1096, 1100 (8th Cir. 2006) (citing United States v. Cawthorn, 429 F.3d
793, 799 (8th Cir. 2005)). Rule 702 requires only that an expert “possess
‘knowledge, skill, experience, training, or education’ sufficient to ‘assist’ the trier of
fact, which is ‘satisfied where expert testimony advances the trier of fact’s

       2
       Raines’s reliance on United States v. Jones, 570 F.2d 765, 769 (8th Cir. 1978),
is misplaced. In that case we held that specific prescriptions introduced into evidence
but not addressed in the relevant indictment should have been barred on Rule 404(b)
and 403 grounds. Here there is no Rule 404(b) problem, as the PMP summaries only
contain prescriptions relating to the charged conspiracy. See United States v. Ali, 799
F.3d 1008, 1026 (8th Cir. 2015) (evidence is intrinsic in a conspiracy if it “completes the
story or provides a total picture of the charged crime”). The summaries also do not pose
the Rule 403 problems we identified in Jones, as they are accompanied by other
evidence beyond mere quantity and do not include prescriptions relating to “other
claims of wrongdoing.” See 570 F.2d 765, 768-69.
       3
        Raines’s remaining objections to the PMP data were amply addressed via her
ability to cross-examine witnesses regarding the construction of the PMP charts. See
Watkins v. Sowders, 449 U.S. 341, 349 (1981) (“[U]nder our adversary system of
justice, cross-examination has always been considered a most effective way to
ascertain truth.”).
                                           -8-
understanding to any degree.’” Id. (quoting 29 CHARLES ALAN WRIGHT & VICTOR
JAMES GOLD, FEDERAL PRACTICE AND PROCEDURE: EVIDENCE § 6265 (1997)); see
also Polski v. Quigley Corp., 538 F.3d 836, 839 (8th Cir. 2008) (quoting Lauzon v.
Senco Prods., Inc., 270 F.3d 681, 686 (8th Cir. 2001)) (explaining that district courts
should apply three-part test to expert testimony by addressing relevancy, reliability,
and the qualifications of the witness).

        Here Dr. Roman’s testimony regarding standards of medical care and the PMP
data satisfied Rule 702’s requirements. Dr. Roman was well qualified to testify
concerning standards of practice in the field of pain management, including warning
signs regarding abuse of pain medication or diversion of medication. And given Dr.
Roman’s “personal knowledge [and] experience,” he was a reliable source of
testimony on standards of medical care and the import of the PMP charts. See United
States v. Holmes, 751 F.3d 846, 850 (8th Cir. 2014) (quoting Kumho Tire Co. v.
Carmichael, 526 U.S. 137, 147 (1999)) (explaining that the “relevant reliability
concerns may focus upon personal knowledge or experience”). While Dr. Roman
acknowledged that he could not definitively state that any particular prescription was
illegitimate absent more information, his opinion on the general operation of the
clinic based on the accumulated evidence was still relevant. On the whole, Dr.
Roman’s opinion on the PMP charts “advance[d] the trier of fact’s understanding”
of the clinical practices at KJ and Artex and how they differed from ordinary medical
facilities. The trial court did not abuse its discretion by admitting Dr. Roman’s
testimony.

                    3. Testimony from Clinic Coworker

       Stella Green testified regarding her personal knowledge of the general practice
of the clinic. As a fellow nurse, Green had direct knowledge of the clinic’s general
operating practices. While Green testified about her own observations and
knowledge, it was circumstantial evidence of Raines’s knowledge of or willful

                                         -9-
blindness to the nature of the clinic. Defense counsel was given the opportunity to
cross-examine Green regarding her personal knowledge (or lack thereof) of Raines’s
specific actions. That opportunity sufficiently ensured the reliability of the testimony.
See United States v. Wilder, 597 F.3d 936, 944 (8th Cir. 2010) (explaining that the
fact-finder is the final arbiter of witness credibility). Additionally, “[w]here evidence
does not have a substantial influence on the verdict because it is cumulative, there is
no prejudice.” Davis, 858 F.3d at 1159. Green’s testimony was corroborated by other
evidence offered through the course of the trial, particularly that the clinic relied on
pre-signed prescriptions. Admitting the testimony was not an abuse of discretion.

                    4. Videotape by an Informant

       Raines claims that the district court abused its discretion by admitting a
videotape of a visit by a confidential informant that took place while she was not
employed by the clinic. The video was offered as circumstantial evidence of Raines’s
knowledge of or willful blindness to the nature of the clinic. While Raines did not
work at the clinic at the time the video was taken, the informant who captured the
video testified that the contents were similar to her prior visits to the clinic—which
did occur while Raines was employed by the clinic. Other testimony corroborated
that Raines would have viewed the same areas of the clinic shown on the video as
part of her ordinary workday.

       We need not decide whether admission of the video was error, as “improper
admission of evidence which is cumulative of matters shown by admissible evidence
is harmless error.” Id. (quoting Wilson v. City of Des Moines, 442 F.3d 637, 644 (8th
Cir. 2006)). The scene depicted in the video was cumulative of and consistent with
extensive testimony put before the jury regarding the day-to-day atmosphere at the
clinic. If there is any error, it is harmless.

                                          -10-
              B.     Jury Instructions

       “We review the district court’s jury instructions for abuse of discretion,” and
“will affirm if the instructions, taken as a whole, fairly and adequately submitted the
issues to the jury.” United States v. Katz, 445 F.3d 1023, 1030 (8th Cir. 2006)
(quoting United States v. Garcia-Gonon, 433 F.3d 587, 591 (8th Cir. 2006)). “A
defendant is entitled to a specific jury instruction ‘that conveys the substance of his
request if his request is timely, it is supported by evidence in the case, and is a correct
statement of the law.’” United States v. Cruz-Zuniga, 571 F.3d 721, 725 (8th Cir.
2009) (quoting United States v. Whitehead, 176 F.3d 1030, 1037 (8th Cir. 1999)).
A defendant “is not entitled to a particularly-worded instruction when the instructions
actually given by the trial court adequately and correctly cover the substance of the
requested instruction.” Id. (quoting United States v. Long, 977 F.2d 1262, 1272 (8th
Cir. 1992)). “We review the district court’s denial of a proposed jury instruction for
abuse of discretion, reversing ‘only if the district court’s alleged erroneous failure to
give a particular instruction was prejudicial.’” Id. (quoting Whitehead, 176 F.3d at
1037).

       Raines argues that the district court should not have provided the jury with a
willful blindness instruction. An instruction on willful blindness is especially
appropriate “when the defendant denies any knowledge of a criminal scheme despite
strong evidence to the contrary.” United States v. Sigillito, 759 F.3d 913, 939 (8th
Cir. 2014) (quoting United States v. Lewis, 557 F.3d 601, 613 (8th Cir. 2009)).
Raines took the stand to protest that she lacked actual knowledge of the scheme. The
evidence supports a theory that any lack of understanding of the nature of the clinic
as a pill mill could only have been held by refusing to take note of the obvious.
Including a willful blindness instruction was well within the district court’s
discretion.

                                           -11-
       Raines also claims the district court should have provided her proposed good
faith instruction. The government bore the burden of establishing that Raines’s
actions were not for legitimate medical purposes in the usual course of medical
practice. See United States v. Smith, 573 F.3d 639, 647-49 (8th Cir. 2009) (discussing
meaning of “usual course of professional practice”). A medical professional’s good
faith may be relevant to a jury’s determination of whether the doctor acted outside the
bounds of medical practice or with a legitimate medical purpose when prescribing
narcotics. See id. (discussing a good faith instruction in a case involving § 841).

       Raines’s good faith instruction was unwarranted here because it misstated the
applicable law. Raines’s instruction incorrectly suggested that the standard for
appropriate medical practice was subjective, rather than objective. See id. at 648-49
(quoting United States v. Moore, 423 U.S. 122, 143 (1975)) (internal quotation marks
omitted) (explaining that if “a subjective standard were to prevail, it would allow an
individual [medical professional] to define the parameters of his or her practice and
effectively shield the practitioner from criminal liability despite the fact that the
practitioner may be acting as nothing more than a ‘large-scale pusher’”).

      More importantly, the instructions as a whole described the specific intent
necessary to commit the crime and cover the same ground the good faith instruction
would cover. Under these circumstances there is no error. United States v. Brown,
478 F.3d 926, 928 (8th Cir. 2007). Here the jury instructions on conspiracy
adequately set out the required elements of knowledge and intent. The district court
did not abuse its discretion by refusing to provide a good faith instruction.

             C.     Sufficiency of the Evidence

       Raines challenges the sufficiency of the evidence presented at trial. We review
“the sufficiency of the evidence de novo, viewing evidence in the light most favorable
to the jury’s verdict, resolving conflicts in the government’s favor, and accepting all

                                         -12-
reasonable inferences that support the verdict.” United States v. Tillman, 765 F.3d
831, 833 (8th Cir. 2014) (quoting United States v. Harris-Thompson, 751 F.3d 590,
598 (8th Cir. 2014)). “A defendant challenging the sufficiency of the evidence in a
conspiracy case has a heavy burden.” United States v. Mann, 701 F.3d 274, 296 (8th
Cir. 2012) (quoting United States v. Mickelson, 378 F.3d 810, 821 (8th Cir. 2004)).
“[I]n evaluating the sufficiency of evidence to sustain a verdict, circumstantial
evidence must be treated no differently than direct evidence.” United States v.
Young, 753 F.3d 757, 783 (8th Cir. 2014) (citing United States v. Lam, 338 F.3d 868,
871 (8th Cir. 2003)). We will overturn the verdict only if no reasonable jury could
have found the defendant guilty beyond a reasonable doubt. United States v. Colton,
742 F.3d 345, 348 (8th Cir. 2014) (quoting United States v. Bell, 477 F.3d 607, 613
(8th Cir. 2007)).

       To convict Raines of conspiracy, the government needed to show that (i) two
or more persons agreed to distribute controlled substances without an effective
prescription, (ii) the defendant knew the agreement’s purpose, and (iii) the defendant
knowingly and voluntarily joined the agreement. See United States v. Hansen, 791
F.3d 863, 870-72 (8th Cir. 2015) (applying conspiracy elements to mail/wire fraud
case). No explicit agreement is required; “a tacit or implicit understanding” is
sufficient. United States v. Wells, 646 F.3d 1097, 1102 (8th Cir. 2011). Even a
minor participatory role in the conspiracy will sustain a conviction once an
underlying conspiracy has been established. See United States v. Lopez, 443 F.3d
1026, 1030 (8th Cir. 2006) (en banc). A jury verdict may be based “solely on the
testimony of cooperating witnesses.” Tillman, 765 F.3d at 834 (quoting United States
v. Smith, 632 F.3d 1043, 1046 (8th Cir. 2011)). While the “government may not rely
solely on the jury’s disbelief of a defendant’s denials to meet its burden of proof,”
when there is “other corroborative evidence of guilt, the jury can properly draw an
inference of guilt from its disbelief of the defendant’s denials.” United States v.
Reed, 297 F.3d 787, 789 (8th Cir. 2002) (quoting United States v. Davidson, 122 F.3d
531, 536 (8th Cir. 1997)). “[W]illful blindness may serve as the basis for knowledge

                                        -13-
if, ‘in light of certain obvious facts, reasonable inferences support a finding that a
defendant’s failure to investigate is equivalent to burying one’s head in the sand.’”
United States v. Chavez-Alvarez, 594 F.3d 1062, 1067 (8th Cir. 2010) (quoting
United States v. Florez, 368 F.3d 1042, 1044 (8th Cir. 2004)) (internal quotation
marks omitted).

       The evidence in this case was overwhelming that Raines was involved in the
conspiracy. The jury was presented with extensive evidence that Artex and KJ were
not run as legitimate medical enterprises. Raines does not contest the existence of a
conspiracy; rather, she claims the evidence was insufficient to prove she joined the
conspiracy and had knowledge of its purpose. Raines continued to work at the clinic
despite obvious signs that the clinic was a pill mill. Raines’s decision to work at the
clinic despite the clinic’s obviously illegitimate nature is readily seen as a “tacit or
implicit understanding” of her role in the scheme. Given the evidence, a reasonable
jury could easily find Raines guilty beyond a reasonable doubt.

             D.     Sentencing Decisions

       Raines and King raise a number of challenges to the district court’s sentencing
decisions. We “review all sentences—whether inside, just outside, or significantly
outside the Guidelines range—under a deferential abuse-of-discretion standard.”
United States v. Stone, 873 F.3d 648, 649 (8th Cir. 2017) (citing Gall v. United
States, 552 U.S. 38, 41 (2007) . We “first ensure that the district court committed no
significant procedural error, such as failing to calculate (or improperly calculating)
the Guidelines range, treating the Guidelines as mandatory, failing to consider the §
3553(a) factors, selecting a sentence based on clearly erroneous facts, or failing to
adequately explain the chosen sentence—including an explanation for any deviation
from the Guidelines range.” United States v. Smith, 573 F.3d 639, 658-59 (8th Cir.
2009) (quoting Gall, 552 U.S. at 50-51). If there is no procedural error, we review

                                         -14-
the substantive reasonableness of the sentence. Id. (quoting United States v. Alvizo-
Trujillo, 521 F.3d 1015, 1017 (8th Cir. 2008)).

                     1. Drug Quantity Calculations

       Raines challenges the district court’s drug quantity calculations. Drug quantity
determinations “are factual findings, which we review for clear error, applying the
preponderance-of-the-evidence standard.” United States v. Walker, 688 F.3d 416,
420 (8th Cir. 2012) (citation omitted) (internal quotation marks omitted). The district
court’s factual determinations will stand “unless the decision is unsupported by
substantial evidence, is based on an erroneous view of the applicable law, or in light
of the entire record, we are left with a firm and definite conviction that a mistake has
been made.” Colton, 742 F.3d at 348 (quoting United States v. Miller, 511 F.3d 821,
823 (8th Cir. 2008)).

       “[F]or purposes of calculating drug quantity in a drug conspiracy case, ‘the
district court may consider amounts from drug transactions in which the defendant
was not directly involved if those dealings were part of the same course of conduct
or scheme.’” Id. at 349 (citing United States v. Bradley, 643 F.3d 1121, 1126 (8th
Cir. 2011)). This includes “all transactions known or reasonably foreseeable to the
defendant that were made in furtherance of the conspiracy.” Id. (citing United States
v. Plancarte-Vazquez, 450 F.3d 848, 852 (8th Cir. 2006)). “The court may make a
specific numeric determination of quantity based on imprecise evidence . . . so long
as the record reflects a basis for the court’s decision.” United States v. Roach, 164
F.3d 403, 413-14 (8th Cir. 1998).

       The district court’s drug quantity calculations included a number of pills
directly attributable to Raines, as well as pills from other transactions by the pill mill.
The record amply provides a basis for the district court’s calculation. The jury found
beyond a reasonable doubt that Raines had knowledge of the conspiracy. Given the

                                           -15-
“pill mill” nature of the conspiracy, the drug quantities involved were reasonably
foreseeable to Raines. The district court did not clearly err in making its drug
quantity calculations.

                     2. The Abuse of Trust Enhancement

       “To warrant an abuse-of-trust enhancement, the government must prove by a
preponderance of the evidence that, ‘(1) defendant occupied a position of . . . trust,
and (2) defendant used this position in a manner that significantly facilitated the
commission or concealment of the offense.’” United States v. Walker, 818 F.3d 416,
423 (8th Cir. 2016) (quoting United States v. Miell, 661 F.3d 995, 998 (8th Cir.
2011)) (emphasis removed from original). “We review the legal component of the
abuse of trust determination de novo and the district court’s factual findings for clear
error.” Id. (quoting United States v. Anderson, 349 F.3d 568, 573 (8th Cir. 2003)).

       The district court properly found that Raines’s role as a medical professional
meant she served in a position of trust. See United States v. Stella, 591 F.3d 23, 29
(1st Cir. 2009) (holding that registered nurse served in a position of public trust).
And Raines’s role as a medical professional “significantly facilitated” her ability to
aid the conspiracy, which revolved around the illegitimate dispensing of drugs. The
district court did not err in its determination.

                     3. Substantive Reasonableness of the Sentences

        A sentencing court “abuses its discretion if it fails to consider a relevant factor
that should have received significant weight, gives significant weight to an improper
or irrelevant factor, or considers only the appropriate factors but commits a clear error
of judgment in weighing those factors.” United States v. Watson, 480 F.3d 1175,
1177 (8th Cir. 2007) (citing United States v. Haack, 403 F.3d 997, 1004 (8th Cir.

                                           -16-
2005)). A sentence within the Guidelines range is presumptively reasonable. Id.
(citing United States v. Lincoln, 413 F.3d 716, 718 (8th Cir. 2005)).

       Raines’s within-Guidelines sentence was substantively reasonable. The district
court adequately explained its sentence, even noting that it was appropriate with or
without the existence of the Guidelines in light of the quantity of drugs that Raines
had helped enter her community. The district court’s decision not to weigh mitigating
factors as heavily as Raines “would have preferred does not justify reversal.” United
States v. Bridges, 569 F.3d 374, 379 (8th Cir. 2009).

       King’s sentence was also substantively reasonable. The district court
articulated its opinion that King’s role as a recruiter who connected users from across
the state of Arkansas with the pill mill deserved a stronger sentence than that
contemplated by the Guidelines. The court noted that the sentence was designed to
address the needs of the particular offender, given King’s daily violation of the law
and the damage caused to the community. Under these circumstances, an upward
variance of 23 months was not an abuse of discretion.

      III.   Conclusion

      We affirm the judgments of the district court.
                      ______________________________

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