Court Opinion

ID: 2832657
Source: CourtListenerOpinion
Date Created: 2015-09-01 15:01:03.363862+00
Date Added: 2024-06-11T11:31:47.085376
License: Public Domain

Case: 13-10661       Date Filed: 09/01/2015      Page: 1 of 47

                                                                      [DO NOT PUBLISH]

                 IN THE UNITED STATES COURT OF APPEALS

                           FOR THE ELEVENTH CIRCUIT
                             ________________________

                                    No. 13-10661
                              ________________________

                        D.C. Docket No. 3:10-cr-00101-MCR-2

UNITED STATES OF AMERICA,

                                                                         Plaintiff-Appellee,

                                           versus

GERARD M. DILEO,
DENNIS M. CARONI,
JOSEPH GEORGE PASTOREK, II,
                                                                    Defendants-Appellants.

                              ________________________

                     Appeals from the United States District Court
                         for the Northern District of Florida
                            ________________________

                                   (September 1, 2015)

Before MARTIN and ANDERSON, Circuit Judges, and COTE, District Judge.

___________

*      Honorable Denise Cote, United States District Judge for the Southern District of New
York, sitting by designation.
              Case: 13-10661      Date Filed: 09/01/2015       Page: 2 of 47

PER CURIAM:

      In September 2010, a federal grand jury charged Dennis Caroni, Gerard M.

DiLeo, Theodore G. Aufdemorte, Jr., 1 and Joseph George Pastorek, II, with one

count of conspiracy to distribute drugs and one count of conspiracy to commit

money laundering. The indictment charged that DiLeo and Pastorek were

physicians licensed by the state of Louisiana with the authority to prescribe

controlled substances in Schedules II through V. Using Caroni and Aufdemorte’s

company, Global Pain Management, LLC (“Global Pain”), the four codefendants

allegedly conspired to unlawfully prescribe Schedule II and III controlled

substances through prescription practices done outside the usual course of medical

practice and for other than legitimate medical purposes. The indictment further

alleged that the offense involved “a mixture and substance containing” multiple

prescription drugs, and that the drugs had caused at least one death.

      Caroni and Aufdemorte formed Global Pain in January 2004 to operate and

manage pain management clinics under various names in the New Orleans area. In

2005, Caroni opened a Global Pain pain management clinic in Pensacola that

stayed open for approximately two weeks. The DEA began surveilling one of

Global Pain’s clinics in November 2005 and identified five separate incidents in

which individuals who had previously been convicted of controlled substances

1
      The indictment against Aufdemorte was later dismissed.

                                            2
              Case: 13-10661     Date Filed: 09/01/2015    Page: 3 of 47

charges visited the clinic. In January and March 2006, two undercover DEA

agents tried to obtain prescriptions for controlled substances from Global Pain

without a legitimate medical reason but neither agent was successful.

      In February 2008, the Government obtained search warrants for the offices

of two of Global Pain’s clinics and for Caroni’s grandmother’s house. A jury trial

was conducted from October 19, 2011, through November 23, 2011. Dr. Ted

Parran, a government-retained expert in the field of pain management, addiction

medicine, and the prescription of controlled substances, reviewed 96 patient files

that were seized by the government. Dr. Parran opined that the prescription

practices of Global Pain were dangerous, not consistent with the usual course of

medical practice, and not for legitimate medical purposes. Another Government

pain expert witness, Dr. Robin Hamill-Ruth, reviewed files from the Pensacola

clinic and testified that the prescribing done there was unsafe and outside the usual

course of medical practice. Dr. Carol Warfield, Caroni’s expert in pain

management, reviewed the same patient files that Dr. Parran had reviewed. She

concluded that the pain medications were prescribed to patients for legitimate

medical reasons and were done so within the accepted standard of care of the

practice of pain medicine.

      Former office staff testified that follow-up visits at the clinics took an

average of five minutes per patient. At some point during the conspiracy, patients

                                           3
                 Case: 13-10661   Date Filed: 09/01/2015   Page: 4 of 47

were able to pay for two two-week prescriptions, with the second prescription post-

dated, in a single visit; they would pick up the second prescription later, without

having to see a doctor. Global Pain eventually required patients to make two clinic

visits per month where the second visit would entail the patients receiving their

prescriptions after only briefly seeing a doctor. During the week after Hurricane

Katrina occurred, Global Pain allowed its patients to pick up their prescriptions

without having to see a doctor or enter the clinic as long as they paid for their

prescriptions.

      The patient files revealed that Global Pain was aware that several of its

patients suffered from drug addiction, and some of those patients’ families asked

Global Pain to not give them access to pain medication. Patients testified that they

were never examined by a doctor at the clinics even though some of their

respective files indicated that an examination was performed. Clinic staff testified

that the exam rooms either contained no examination tables or that the tables were

not used because they never changed the tables’ paper covering. One of the

doctors testified that the only physical examination he conducted was to check a

patient’s heart and lungs with a stethoscope. Patients often appeared to be under

the influence when they were in the waiting room. Prescriptions were sometimes

provided despite the doctors stating that the medication was not needed.

                                           4
               Case: 13-10661    Date Filed: 09/01/2015    Page: 5 of 47

       Global Pain employees testified that patients were charged between $100 to

$400 per visit based on whether they were receiving Schedule II drugs or Schedule

III, IV, or V drugs. Caroni called the clinics regularly, though later on he was

rarely physically present, and he instructed one of his employees to give him daily

updates of the cash totals. He established a patient referral program where patients

could earn a free visit if they referred five patients to Global Pain. Caroni told at

least two employees that what patients did with the prescriptions was not his

business. One doctor testified that he walked away from Global Pain’s $500,000

annual salary without any future job prospects because he did not want to be a part

of a “pill mill.”

       Global Pain did not accept insurance claims, and patients had to pay in cash

until 2007, at which point it also began accepting some payments by check, money

order, and credit card. At some point in time, Global Pain’s money was kept at

Caroni’s grandmother’s house for approximately one month because the clinic did

not have a bank account. It frequently changed banks because bank managers

closed the company’s accounts as a result of Caroni’s behavior. Caroni and DiLeo

opened approximately 57 bank accounts at 15 different banks during the course of

the conspiracy. Caroni, or other employees on his behalf, deposited large sums of

cash into the bank accounts almost daily, and sometimes into more than two

separate bank accounts. Each deposit was always under $10,000 to avoid the

                                           5
              Case: 13-10661      Date Filed: 09/01/2015   Page: 6 of 47

reporting requirements. In total, Global Pain deposited approximately $8,557,205

from January 2004 through December 2007. After a jury trial, Caroni and DiLeo

were found guilty of both drug and money laundering conspiracies, and Pastorek

was found guilty of the drug conspiracy. The Defendants raise numerous

challenges to the judgment of the district court. We address each in turn.

                                    I. DISCUSSION

A.    Venue

      DiLeo argues that the Government failed to prove venue and that the district

court erred when it refused to allow the defense to argue it was missing or submit a

jury instruction on the issue. 2 The parties stipulated that Pensacola – the location

of the third clinic that Caroni ran for a short time – was located in the Northern

District of Florida for venue purposes. Specifically, the parties agreed that “the

activities within Pensacola, and in Escambia County, that those activities,

Pensacola and Escambia County are situated within the Northern District of

Florida for venue purposes.” During the charge conference, the Government

attorney stated that the Defendants had stipulated to venue while defense counsel

countered that they had just stipulated that Pensacola was in the Northern District.

The court suggested that the Defendants were “long past a venue challenge.” After

reading the stipulation, the court stated that if they were seeking an instruction on

2
      Both Caroni and Pastorek adopt this argument.

                                             6
                Case: 13-10661       Date Filed: 09/01/2015        Page: 7 of 47

venue, they needed to get working on it, because it was not something that had

ever been presented to her before as an issue and it was really a legal question that

needed to be decided first and foremost. After the Government attorney stated that

venue had never been raised before, counsel for one of the Defendants stated that

he did not realize that it was an issue until now. The Government attorney replied

that he did not know how the Defendants did not know because he mentioned why

they were in Florida in his opening statement. The court told defense counsel that

he should research and prepare something for her because it was not something she

had anticipated.

       Later that same day, the court told the defense that it could not argue venue

to the jury and then refused to instruct the jury on venue. At first, she stated that

they could bring a proposed instruction later but then she scolded the defense for

not raising it sooner and stated that they could not bring the issue in a proposed

instruction at all.

       DiLeo argues that the district court committed structural error when it

prohibited defense counsel from arguing the Government failed to prove venue,

and reversible error when it refused to give the requested jury instructions on

venue.3

3
       The Defendants did not waive this argument by raising it when they did: “when an
indictment contains a proper allegation of venue so that a defendant has no notice of a defect of

                                                7
               Case: 13-10661        Date Filed: 09/01/2015      Page: 8 of 47

       We have stated that venue is an essential element in a criminal case and

should not be treated as a mere technicality. United States v. Snipes, 611 F.3d 855,

865 (11th Cir. 2010). It is guaranteed by the Constitution and a question of fact for

the jury. Id. at 866. We have also stated:

       A conspiracy may be prosecuted in the district where it was formed or
       in any district where an overt act was committed in furtherance of its
       objects. An overt act may be that of only a single one of the
       conspirators and need not be itself a crime. An individual conspirator
       need not participate in the overt act in furtherance of the conspiracy.
       Once a conspiracy is established, and an individual is linked to that
       conspiracy, an overt act committed by any conspirator is sufficient.

United States v. Schlei, 122 F.3d 944, 975 (11th Cir. 1997) (internal citations and

punctuation omitted). Our precedent states that it is reversible error to fail to

instruct when the defendant requests it and the testimony puts venue at issue.

United States v. Green, 309 F.2d 852, 856-57 (5th Cir. 1962).4 We have stated that

although venue is an essential element, it is not a substantive element, requiring per

se reversal when instructions are sought but not given. United States v. White, 611
F.2d 531, 536 (5th Cir. 1980) (holding that no plain error was committed when the

venue until the Government rests its case, the objection is timely if made at the close of
evidence.” United States v. Daniels, 5 F.3d 495, 496 (11th Cir. 1993). Here, the indictment
alleged venue and thus, Defendants’ objection to venue was timely. Defendants did not waive
the objection by failing to raise it before trial.
4
        In Bonner v. City of Prichard, 661 F.2d 1206, 1209 (11th Cir. 1981)(en banc), this Court
adopted as binding precedent all of the decisions of the former Fifth Circuit handed down prior
to the close of business on September 30, 1981.

                                                8
              Case: 13-10661     Date Filed: 09/01/2015   Page: 9 of 47

district court failed to instruct on venue). The Supreme Court has held that

harmless error applies when the trial court fails to instruct on an essential element

of a crime, Neder v. United States, 527 U.S. 1, 9, 119 S. Ct. 1827, 1834 (1999),

and other courts have held that this specific error should be reviewed for harmless

error, United States v. Casch, 448 F.3d 1115, 1117 (9th Cir. 2006). In Casch, the

court employed a standard that if the evidence that the defendant committed the

conspiracy in the district where convicted was substantial and uncontroverted, the

district court’s error was harmless. Id.

      While the district court erred, the evidence of venue was uncontroverted,

making that error harmless. After the Defendants entered into their conspiracy,

Caroni, DiLeo, and two others made plans to open the clinic in Pensacola. Caroni

and DiLeo hired and trained Dr. Klug to be the prescribing physician. The same

unlawful practices used in New Orleans were carried over to the Pensacola Global

clinic. When Dr. Klug asked Dr. DiLeo for guidance because of his inexperience

with respect to pain management, Dr. DiLeo instructed him to just prescribe what

the patients had previously been receiving. And with respect to physical exams,

Dr. Klug testified that he merely listened with a stethoscope to the patients’ hearts

and lungs. Expert Hamill-Ruth testified that Klug’s prescribing was outside of the

standard of care and inconsistent with the operation of a legal clinic. Caroni

                                           9
              Case: 13-10661      Date Filed: 09/01/2015    Page: 10 of 47

opened two bank accounts in Pensacola in the name of the clinic in which money

from the clinic was deposited.

      Defendants also procured facilities to house the Pensacola clinic and

operated it for eight days. Defendants sent several employees to either run the

office or help train those working there. They procured an apartment for one of

those employees, whom they sent from the office in Covington to work at the new

clinic. Even though the three Defendants never traveled to the Northern District of

Florida, it was abundantly clear that it was part of their plan and conspiracy.

Although there was strong evidence that the activities in Pensacola were in fact

criminal, venue exists under our case law “in any district where an overt act was

committed in furtherance of its objects . . . [and the] overt act . . . need not be itself

a crime.” Schlei, 122 F.3d at 975 (internal citations and punctuation omitted). The

foregoing evidence is uncontroverted. There is overwhelming evidence that overt

acts in furtherance of the conspiracy occurred in Pensacola. In sum, there was

overwhelming evidence that venue existed there. Thus, any error was harmless.

      B.     Deliberate ignorance

      Pastorek argues that the district court erred when it instructed the jury on

deliberate ignorance. 5 He asserts that this court has stated that the instruction

should be given only in rare cases where the facts point in the direction of

5
      Caroni and DiLeo adopt this argument.

                                              10
             Case: 13-10661      Date Filed: 09/01/2015    Page: 11 of 47

deliberate ignorance, but that in this case, the Government argued that the

Defendants knew what they were doing and took steps to cover their tracks. The

two battling theories of the case were that the Defendants knew the controlled

substances were being issued outside their usual course of medical practice or that

the substances were being prescribed pursuant to a legitimate medical purpose.

Neither, he argues, supports the deliberate ignorance factual predicate of

defendants being subjectively aware of a high probability that controlled

substances were being issued outside the usual course of medical practice and that

they deliberately contrived to avoid discovering or confirming this. He further

argues that the error was not harmless: giving the instruction, without the proper

factual predicate, runs the risk that the jury will convict based on a belief that the

Defendants were negligent or reckless in failing to learn of the alleged illegal

activity, rather than that they had actual knowledge of it.

      This court gives wide discretion to the style and wording of instructions on

deliberate ignorance. Such an instruction is justified when the facts “support the

inference that the defendant was aware of a high probability of the existence of the

fact in question and purposely contrived to avoid learning all of the facts in order

to have a defense in the event of a subsequent prosecution.” United States v.

Rivera, 944 F.2d 1563, 1571 (11th Cir. 1991). We have stated that when the

deliberate ignorance instruction is correctly given, and because by its own words

                                           11
              Case: 13-10661      Date Filed: 09/01/2015   Page: 12 of 47

the instruction did not apply because there was insufficient evidence to prove

deliberate ignorance, there was no reason to believe that the jury convicted the

defendant on it and such an instruction is harmless per se. United States v. Stone,

9 F.3d 934, 939, 941-42 (11th Cir. 1993). In Stone, we determined that the

instruction was clear in setting as a precondition of finding the defendant guilty of

deliberate ignorance that there was proof beyond a reasonable doubt that he

deliberately kept himself ignorant. Id. at 937-38. Rejecting the defendant’s

argument that the jury had not followed the instruction, we reasoned that as long as

one theory of conviction was supported by evidence, the error is harmless. Id. at

939. Further, where one theory was supported, the jury will be presumed to have

made the proper choice. Id. Finally, we rejected the ideas that a jury instructed on

deliberate ignorance in the absence of evidence would employ a reckless or

negligence standard or that by finding this error harmless, the appellate court

substituted itself for the jury. Id. at 941.

       Stone thus stands for the principle that a jury, when presented with two

alternate theories, will take the instructions to heart and apply them. Here, there

was evidence that the Defendants ignored evidence that their patients were abusing

the prescribed substances: they did not order routine and inexpensive drug screens

to ensure that the patients were complying with the prescriptions, they refilled

prescriptions early without questioning, they did not administer physical exams to

                                               12
             Case: 13-10661      Date Filed: 09/01/2015   Page: 13 of 47

ensure an underlying pathology, and they wrote blanket prescriptions based upon

previous doctors’ scripts. Additionally, as discussed below, there was sufficient

evidence to support the alternative theory. Thus, it was not error to instruct on

deliberate ignorance.

      C. Prejudicial Evidence

      Caroni argues that his motion for mistrial should have been granted after the

jury was improperly exposed to evidence about two patients’ death (i.e., the deaths

of J.P. and E.A.A.). 6 He also supported his mistrial motion with the fact that the

jury was exposed to three letters from parents of two patients – complaining to the

clinics or to the Louisiana State Board of Medical Examiners (“LSBME”) that the

clinics’ prescriptions caused overdoses, and urging the clinics to stop prescribing

to their son. There were four such letters, all admitted for the purpose of showing

that Defendants had notice that their prescriptions were being misused and were

creating dangerous health conditions. After it became apparent that the clinics had

not received three of the four letters, the jury was instructed that Defendants had

had no knowledge of those letters, which therefore could not serve as notice to

them that their prescriptions were being misused.

      The prosecution stated, during opening argument, that Defendants were

responsible for the deaths and had ignored letters from the patients’ parents asking

6
      Both Pastorek and DiLeo adopt this argument.

                                           13
             Case: 13-10661     Date Filed: 09/01/2015    Page: 14 of 47

them to cease giving the patients drugs. The jury heard from one patient’s (J.P.’s)

girlfriend who was with him when he had a seizure and crashed his car into a tree,

killing him. The Government put the state trooper who responded to the accident

on the stand as well as the coroner who issued the death certificate but did not do

the autopsy. The director of the lab testified and introduced into evidence the

toxicology report, and opined that J.P.’s level of methadone was sufficient to cause

death. After receiving that toxicology report, J.P.’s autopsy report was modified to

reflect that the cause of death was an overdose. However, the director of the

toxicology lab later testified that he had not conducted the tests himself or done the

analyses underlying the report, causing the defense to move to strike his testimony.

Similarly, the other victim’s (E.A.A.’s) daughter testified about her mother’s drug

addiction and death. After a friend also testified, the prosecution admitted that it

did not have the person who performed the toxicology report available to testify,

and therefore the prosecution admitted that it could not prove the cause of death.

      At that point, the Justice Department advised the prosecution that it should

concede the inadmissibility of the autopsy evidence. The court then instructed the

jury that it would not be asked to consider whether the deaths resulted from the

conspiracy charge, and that it must not consider that part of the indictment. The

court instructed the jury to disregard all of the evidence introduced about the

deaths. In particular, the jury was instructed as follows:

                                          14
             Case: 13-10661     Date Filed: 09/01/2015    Page: 15 of 47

             [Y]ou will not be asked in this case to consider whether
             death resulted to [J.P.] and/or [E.A.A.] from the
             conspiracy charged in the indictment. And you must not
             consider this part of the indictment in any way for any
             purpose during your deliberations. As a result, you are
             instructed that you must disregard all of the evidence
             introduced in the trial regarding the circumstances
             surrounding and the cause of the deaths of [J.P.] and
             [E.A.A.]. This would include all of the testimony of the
             following witnesses: the toxicologist, Robert Middleberg;
             the coroner, Tom Wilson; the Alabama Trooper, James
             Ray; and the medical examiner, Dr. Emily Ward.

                    You must also disregard portions of the testimony
             of the following witnesses: Lisa Riddle, who was
             [E.A.A.’s] daughter; Joyce Bohannon, who we heard
             from yesterday afternoon, who was [E.A.A.’s] friend;
             and then, Hollie Thompson, who was [J.P.’s] fiancé.
             You must disregard the portions of their testimony that
             specifically referred to the circumstances surrounding
             and the cause of their deaths.

Docket 656:25:3-27:13 (format changed). This contemporaneous instruction was

repeated almost verbatim in the court’s final instructions to the jury.

      Caroni also identifies as prejudicial letters from a patient’s parent to the

clinic that expert Dr. Parran read into evidence. The letters asked the clinic to stop

prescribing to her son because he almost died of an overdose. The government

argued that the letters were relevant to show that the defendants knew what their

actions were causing. This parent wrote three letters, but only the first was

received before the patient was discharged by the clinic. Although the government

conceded that the defendants had not received the last two letters before the
                                          15
             Case: 13-10661      Date Filed: 09/01/2015    Page: 16 of 47

patient’s final office visit, the court allowed the mother to testify why she had

written the letters and to identify the letters. The court gave a limiting instruction

with respect to the two letters which were not received before the patient’s final

office visit. Expert Dr. Parran also discussed another patient whose mother had

written a letter of complaint to LSBME, but the intended copy of that letter was

never received by the defendants. The court struck that letter, but stated that the

jury could consider the patient’s mother’s testimony about writing the letter and

the fact that she had made a complaint.

      Caroni had moved for a mistrial after the government rested, which the court

denied. Caroni argued that the evidence was so prejudicial that, even though

curative instructions were given, they could not cure the damage done.

      We review a district court’s refusal to grant a mistrial for an abuse of

discretion. United States v. Trujillo, 146 F.3d 838, 845 (11th Cir. 1998). “The

decision of whether to grant a mistrial lies within the sound discretion of a trial

judge as he or she is in the best position to evaluate the prejudicial effect of

improper testimony.” United States v. Perez, 30 F.3d 1407, 1410 (11th Cir. 1994).

“When a curative instruction has been given to address some improper and

prejudicial evidence, we will reverse only if the evidence ‘is so highly prejudicial

as to be incurable by the trial court’s admonition.’” Id. (quoting United States v.

Funt, 896 F.2d 1288, 1295 (11th Cir. 1990)).

                                           16
              Case: 13-10661     Date Filed: 09/01/2015   Page: 17 of 47

        In United States v. Ignasiak, 667 F.3d 1217 (11th Cir. 2012), we held that

the admission of autopsy reports and testimony about them by a physician who was

not their author was a violation of the Confrontation Clause. We determined that

the admission of the reports and the testimony was not harmless. Because it was a

constitutional error, we reviewed under a more stringent standard: “whether it

appears beyond a reasonable doubt that the error complained of did not contribute

to the verdict obtained.” Id. at 1235. We stated that we could not ignore the

powerful impact the reports must have had, and we also noted that the jury was

allowed to consider the testimony concerning seven deaths. Id. Furthermore,

knowledge of the deaths undermined the defendant’s good faith defense. Id. at

1236.

        Unlike in Ignasiak, the prejudicial evidence about the deaths in this case was

excluded, and the jury was instructed not to consider it. Additionally, the jury was

instructed that the clinic did not receive the three challenged letters and the jury

was instructed that it could consider those letters only for the limited purpose of

revealing what the two patients’ families thought of the clinic but not as notice to

the clinic or the defendants about the effect of the prescriptions.

        Because the evidence about the deaths was excluded, there was no

Confrontation Clause violation and thus we need not employ the more stringent

standard of review that the court used in Ignasiak. Because the court gave clear

                                          17
               Case: 13-10661    Date Filed: 09/01/2015    Page: 18 of 47

instructions to the jury to disregard the evidence, we instead review for whether the

evidence was so highly prejudicial as to be incurable. Perez, 30 F.3d at 1410.

      Our careful review of the entire record persuades us that the jury’s exposure

to the evidence relating to the two deaths and to the challenged letters was not so

highly prejudicial as to be incurable. As noted, the jury was clearly instructed –

both shortly after the exposure to the inadmissible evidence of the deaths and in the

final instructions – to “disregard all of the evidence introduced . . . regarding the

circumstances surrounding and the cause of the deaths.” Similarly, strong and

proper curative instructions were given at both times with respect to the challenged

letters. With respect to the latter, there was ample other evidence that the

defendants were aware that the prescriptions were causing or contributing to

addiction or overdoses. With respect to the exposure to the evidence of the deaths,

the jury is presumed to have followed the clear instructions to disregard same. Our

careful review of the totality of the evidence persuades us that the jury could and

did do that.

      In its closing arguments, the government did not comment at all on the death

evidence that was ruled inadmissible. Moreover, with respect to both deaths, the

jury was also exposed to significant evidence that indicated either that the death

was not in fact caused by the defendants’ prescriptions or that eroded the

prejudicial effect of the inadmissible evidence. With respect to J.P., the jury was

                                           18
             Case: 13-10661     Date Filed: 09/01/2015    Page: 19 of 47

exposed to evidence that he had obtained 120 methadone tablets from a Tennessee

clinic a week before his fatal automobile accident, thus eroding any causal link

between J.P.’s death and these defendants’ prescriptions. The jury could very

readily, and most probably actually did, follow the judge’s instruction to disregard

all of the evidence tending to link the drugs prescribed by these defendants as a

cause of J.P.’s death. With respect to E.E.A., the jury was also exposed to

evidence that she had cervical cancer, thus eroding the prejudicial impact of the

jury’s exposure to the inadmissible evidence with respect to her death, and making

it easier for the jury to follow the judge’s instruction. Moreover, there was ample

other evidence that the strength and combination of the drugs being prescribed by

these defendants, and their modus operandi, had the potential to cause serious

harm, and ample other evidence that defendants’ prescriptions had actually caused

overdoses. In light of the totality of the evidence in this case, we do not believe

that the inadmissible evidence that the jury was clearly instructed to disregard was

so highly prejudicial as to be incurable.

      With respect to the totality of the evidence in this case, unlike the Ignasiak

case, the evidence of these defendants’ guilt was strong. Numerous patients and

former employees testified that the drugs were prescribed notwithstanding the

complete absence of, or only cursory, physical examinations. They also testified

that patients were able to obtain prescriptions despite obvious indications of

                                            19
             Case: 13-10661    Date Filed: 09/01/2015   Page: 20 of 47

addiction, abuse of the drugs, and doctor-shopping. There was evidence that the

number of patients the doctors saw each day was very large; that patients were

offered bonuses for referrals; and that patients’ dosages were increased upon

request (i.e., not based upon demonstrable need) and in spite of drug screening

indicating that the patients were not taking the drugs and, in some cases, were

taking street drugs. There was significant evidence from employees, including Dr.

Klug, that defendants Caroni and DiLeo actually said that what the patients did

with the drugs after they left the office was none of their business or concern. And

there was evidence that patients were selling some of the drugs prescribed, and at

least some evidence that co-conspirator Caroni was aware of that. Dr. Klug also

testified that, when he sought guidance because of his own inexperience with pain

management, Dr. DiLeo advised him to just prescribe the same controlled

substances that the patient had been receiving. The evidence showed that

defendants charged fees depending upon the type and strength of the controlled

substance, much more like drug dealers than like professionals who base their fees

on the time expended and/or the complexity or value of the service. Significant

testimony also came from Dr. Lonseth, who brought his family to New Orleans

from California to accept a position with Global Pain at a salary of $500,000.

After observing the operation for a less than a month, he walked away from the

$500,000 salary (notwithstanding he had no other current offer) because he thought

                                         20
             Case: 13-10661      Date Filed: 09/01/2015   Page: 21 of 47

the operation was a “pill mill.” Two former staff members also estimated that

about three-fourths of the patients were there to support their addictions. Although

there was some conflict in the expert testimony, the foregoing evidence provides

strong support for the opinions of the two government experts – Dr. Parran and Dr.

Hamill-Ruth – that the operation of Global Pain was inconsistent with the legal

requirement that prescriptions for controlled substances must be issued for

legitimate medical purposes in the usual course of a professional practice.

      In sum, we cannot conclude that the district court abused its discretion in

denying defendant’s motion for a mistrial.

D.    Sufficiency of evidence – conspiracy

      Caroni argues that the evidence was legally insufficient to support his

conviction for conspiring with his co-defendants to run an illegitimate practice. 7

Under 21 CFR § 1306.04(a), “a prescription for a controlled substance to be

effective must be issued for a legitimate medical purpose by an individual

practitioner acting in the usual course of his professional practice.” The indictment

alleges that DiLeo, Pastorek, and Caroni conspired to unlawfully distribute

Schedule II, III, and IV controlled substances through prescription practices done

outside the usual course of medical practice and for other than legitimate medical

7
      Both Pastorek and DiLeo adopt this argument.

                                           21
               Case: 13-10661        Date Filed: 09/01/2015        Page: 22 of 47

purpose. Caroni asserts that the Government’s theory was that the clinics were pill

mills but yet the clinics had employed nine doctors and only two were indicted.

Caroni asserts that the Government alleged, and had to prove, an entirely corrupt

practice. He also argues that the files reviewed by the experts were not statistically

representative of the whole practice.

       We review questions about the sufficiency of the evidence de novo,

“viewing the evidence in the light most favorable to the government, with all

reasonable inferences and credibility choices made in the government’s favor.”

United States v. Sosa, 777 F.3d 1279, 1289 (11th Cir. 2015) (internal quotations

omitted and alterations adopted). Further, “we will affirm a conviction where ‘a

reasonable jury could find the defendant’s guilt beyond a reasonable doubt.’” Id.

(quoting United States v. Utter, 97 F.3d 509, 512 (11th Cir. 1996)).

       Caroni cites no cases that require the Government to show that the entire

practice was illegitimate. This would be an unreasonable burden and allow a

completely illegal clinic to evade prosecution by having a few legitimate patients.

Rather, the Government needed to prove that there was very substantial illegal

activity occurring at the clinic, thus removing any reasonable doubt that unlawful

prescriptions were being issued by mistake or through negligence. 8 Thus, the

8
        The district court expressly instructed the jury that “negligence, mistake or carelessness is
not a sufficient finding of knowledge.”

                                                 22
             Case: 13-10661      Date Filed: 09/01/2015    Page: 23 of 47

selection of the files for the experts to review did not need to precisely reflect the

composition of the clinic’s patient population; rather, it had to demonstrate that the

illegal behavior was substantial and it did just that.

      In United States v. Joseph, 709 F.3d 1082 (11th Cir. 2013), we upheld a

jury’s finding of an illegitimate practice. There, we pointed to the defendant’s

prescription of large quantities of controlled substances, the large number of those

prescriptions, failure to do physical examinations, prescriptions to patients

knowing they were giving them to others, and no relationship between the drug

prescribed and the treatment of the condition alleged.

      The evidence in this case was similar to that in Joseph. As set forth in the

immediately preceding Part C. of this opinion, there was ample evidence to support

the jury’s verdict. And while there was some evidence that the Defendants became

more careful about doctor shopping and misuse of prescriptions in the last year of

the clinic, a reasonable jury could have concluded this was a response to the

shutting down of other pain management clinics by the DEA and an effort to evade

detection.

                                           23
             Case: 13-10661        Date Filed: 09/01/2015   Page: 24 of 47

      E.     Sufficiency of evidence – money laundering

      Caroni argues that the Government produced insufficient evidence to prove

promotion money laundering. 9 To prove promotion money laundering, the

Government must show not only that the money was the result of illegal activity

but also that it was spent on promoting the illegal activity. Caroni argues that the

evidence only showed that cash was deposited into bank accounts, using simple

graphs prepared by the agent.

      Caroni is correct that our precedent requires the Government to show that

the deposited money was intended promote the conspiracy. In United States v.

Calderon, we reversed a conviction because the Government only showed that the

Appellant knew that the money was ill-gained but never put on any evidence that

the Appellant intended to do more than conceal the money. 169 F.3d 718, 721

(11th Cir. 1999). There was no evidence of how the money was to be spent once it

was deposited or any evidence of how her actions furthered the underlying drug

trafficking. Id.

      Our United States v. Martinelli, 454 F.3d 1300 (11th Cir. 2006), decision

approved a district court’s instruction that the jury had to find that the defendant

engaged in the financial transaction with “the intent to promote the carrying on of

such specified unlawful activity” and that “[t]he term with the intent to promote the

9
      DiLeo adopts this argument

                                            24
              Case: 13-10661    Date Filed: 09/01/2015    Page: 25 of 47

carrying on of the specified unlawful activity means that the defendant must have

conducted or attempted to conduct the financial transaction for the purpose of

facilitating or making easier or helping to bring about the specified unlawful

activity as has been defined.” Id. at 1318. We stated that with such instructions,

“the jury could not have found Martinelli guilty if it believed the financial

transactions were undertaken for legitimate, non-fraudulent business expenses.”

Id.

       Here, the jury was instructed with the same pattern jury instructions as in

Martinelli. The agent who provided evidence about the monetary transactions

testified that the funds at issue were used to pay overhead, rent, and malpractice

insurance. Further, in Caroni’s deposition in a civil case, which was entered into

evidence, he testified that they used the funds from Global Pensacola to pay “bills

and whatnot.” Thus, the proceeds of the unlawful activity were deposited into

numerous bank accounts and then spent to pay overhead, rent, malpractice

insurance, bills, and whatnot – all expenses incurred to promote and continue the

operation of the conspiracy to unlawfully dispense controlled substances.

Accordingly, there was sufficient evidence that the funds were spent to promote

the illegal practice.

                                          25
             Case: 13-10661      Date Filed: 09/01/2015   Page: 26 of 47

      F.     Indictment amendment

      Caroni argues that his Fifth Amendment rights were violated when the jury

was charged in the disjunctive but the indictment read in the conjunctive. 10 Count

One charged the Defendants with engaging in a conspiracy to unlawfully dispense

controlled substances through prescription practices done outside the usual course

of medical practice and for other than legitimate medical purposes. However, the

Government’s proposed jury instructions stated that the jury only had to find one

or the other. Caroni objected and asked for a ruling before opening arguments.

The district court instructed the lawyers to avoid the standard in their openings and

did not rule until 20 days into the trial, after the Government had rested. It

overruled Caroni’s objection and instructed the jury in the disjunctive. Caroni

argues that the charge impermissibly expanded the indictment by broadening the

possible bases for conviction.

      Caroni points to our decision in United States v. Cancelliere, 69 F.3d 1116

(11th Cir. 1995), where we held that the Government had to prove willfulness even

though the statute did not include that language because the Government had put

the word in the indictment. We so held because the entire defense was based on

the defendant’s lack of willfulness and the Government did not seek to have

willfulness removed until after the close of evidence. Here, Caroni contends that

10
      Both Pastorek and DiLeo adopt this argument.

                                           26
             Case: 13-10661     Date Filed: 09/01/2015   Page: 27 of 47

his entire defense was prepared based on the grand jury’s charges and changing the

rules midstream was highly prejudicial.

      We have explained that a constructive amendment “takes place ‘when the

essential elements of the offense contained in the indictment are altered to broaden

the possible bases for conviction beyond what is contained in the indictment.’”

United States v. Mozie, 752 F.3d 1271, 1283 (11th Cir. 2014)) (quoting United

States v. Dortch, 696 F.3d 1104, 1111 (11th Cir. 2012)). We have stated

repeatedly that when an indictment charges several means of violating a statute, a

conviction may be obtained on proof of only one of the means. Id. at 1283-84. In

Mozie, we explained that in Cancelliere, there were some key differences. One

was that willfulness was not an alternative means because it was not in the statute.

Id. at 1284. Second, Cancelliere was different because the defendant based his

entire defense on disproving the mental state that was removed. Id. Finally, we

stated that to the extent Cancelliere supported Mozie’s position, it was inconsistent

with cases that came before it and they would trump Cancelliere. Id. at 1285.

      Caroni’s argument fails for several reasons. This case is more like Mozie

than Cancelliere. The disjunctive instruction was not error. Section 1306.04(a) of

the code of Federal Regulations provides an exception to the prohibitions found in

§ 841 that ban the sale and provision of certain drugs. That regulation permits

prescriptions for controlled substance if they are “issued for a legitimate medical

                                          27
             Case: 13-10661      Date Filed: 09/01/2015   Page: 28 of 47

purpose by an individual practitioner acting in the usual course of his professional

practice.” Thus, under the plain language of the regulation, in order to qualify for

the exception, a defendant must have provided the prescription for both a

legitimate medical purpose and while acting in the usually course of his profession.

Without both, the defendant is subject to prosecution. Accord Joseph, 709 F.3d at

1094 (citing the regulation and holding “[i]f a prescription is issued without a

legitimate medical purpose or outside the usual course of professional practice”, it

is subject to criminal penalties). Hence, the Government needed only to prove one

of the two prongs and the Defendants were on notice because the language of the

section clearly mandated that requirement.

      G.     Caroni’s sentence

      1. General verdict precluded sentencing to an underlying object offense.

      Caroni asserts that in a multi-object conspiracy, a general verdict from the

jury precludes the court from sentencing the defendant to an underlying object

offense unless the court finds beyond a reasonable doubt that the defendant

conspired to commit that particular object offense. He argues that his sentences

should be limited by his three-year statutory maximum sentence for Count 1

because the jury did not specifically find that he was guilty of conspiring to

distribute Schedule II drugs. He also contends that the district court erred by

failing to separately calculate his offense level for Count 2 under U.S.S.G. § 2S1.1

                                          28
               Case: 13-10661    Date Filed: 09/01/2015   Page: 29 of 47

to determine what his highest guideline range was. He argues that the court’s use

of § 2D1.1 to calculate his offense level for Count 2 in conjunction with the

application of the statutory maximum sentence for Count 2 is unconstitutional.

         Pursuant to 18 U.S.C. § 1956, a person convicted for money laundering

faces a maximum sentence of 20 years’ imprisonment. 18 U.S.C. §

1956(a)(1)(B)(ii). The Sentencing Guidelines dictate that closely related counts

shall be grouped together for sentencing purposes. U.S.S.G. § 3D1.2. In a case

where the defendant is convicted of money laundering and convicted of the

underlying offense from which the laundered funds were derived, the counts shall

be grouped pursuant to § 3D1.2(c), and the highest offense level shall be applied.

U.S.S.G. § 2S1.1, comment. (n.6); U.S.S.G. § 3D1.3(a). While typically it is

necessary to determine the offense level for each of the counts, the formal

determination of the offense level is unnecessary where it is clear that one count

cannot have a higher offense level than another. U.S.S.G. § 3D1.3, comment.

(n.2).

         Money laundering offenses are covered by § 2S1.1 of the Guidelines.

U.S.S.G. § 2S1.1. Under § 2S1.1, the offense level of the underlying offense from

which the laundered funds were derived is to be applied as long as it can be

determined. U.S.S.G. § 2S1.1(a)(1). Offenses involving a conspiracy to distribute

controlled substances are covered by § 2D1.1 of the Guidelines. U.S.S.G. § 2D1.1.

                                          29
               Case: 13-10661      Date Filed: 09/01/2015       Page: 30 of 47

In determining the drug quantity for purposes of § 2D1.1, types and quantities of

drugs not specified in the count of convictions may be considered. U.S.S.G. §

2D1.1, comment. (n.12)(2011).11 Additionally, the court may approximate the

drug quantity by considering various factors, including financial and business

records. Id.

      Caroni’s claim fails because the district court properly calculated his

guideline range and neither of his sentences exceed their respective statutory

maximum penalties. Because he was convicted of laundering the money that he

derived from the drug offense, the district court properly grouped his counts.

U.S.S.G. § 2S1.3, comment. (n.6). Because Caroni’s base offense level under §

2S1.1 was set to the offense level of his underlying drug offense, and he was

eligible for the role adjustment in connection with either provision, he had the

same total offense level for both counts. See U.S.S.G. § 2S1.1(a)(1). As such, it

was unnecessary to independently determine his offense level for both counts, and

either one could be used as the highest offense level. See U.S.S.G. § 3D1.3(a);

U.S.S.G. § 3D1.3, comment. (n.2). He was subsequently sentenced to concurrent

sentences of 36 months for Count 1 and 240 months for Count 2, both within his

respective statutory maximum penalties.

11
      The district court employed the 2011 Guidelines because the trial took place that year.

                                              30
              Case: 13-10661      Date Filed: 09/01/2015      Page: 31 of 47

       Although Caroni argues that the court should have limited his sentence for

Count 2 with his statutory maximum penalty for Count 1, he offers no authority to

support this position, and the money laundering guidelines specifically require the

use of the drug offense guidelines in cases like this without any directive to alter

the respective statutory penalties. 12 Finally, he offers no authority to support his

position that the court was not entitled to consider the Schedule II drugs involved

in the drug offense under the Guidelines in determining his drug quantity. See

U.S.S.G. § 2D1.1, comment. (n.12). Accordingly, Caroni’s challenge fails.

       2. Calculation of drug quantity

       Caroni challenges the court’s calculation of his drug quantity. He argues

that the district court clearly erred in determining the drug quantity based upon his

assertion that many of the drugs were prescribed legitimately and the court was

required to exclude those drugs.

       This Court reviews the district court’s interpretation of the Sentencing

Guidelines de novo and accepts its factual findings unless clearly erroneous.

United States v. Jordi, 418 F.3d 1212, 1214 (11th Cir. 2005). In order to be clearly

erroneous, the finding of the district court must leave this Court with a “definite

and firm conviction that a mistake has been committed.” United States v.
12
       We also reject Caroni’s arguments based on Apprendi v. New Jersey, 530 U.S. 466, 120
S. Ct. 2348 (2000), and United States v. Allen, 302 F.3d 1260 (11th Cir. 2002), because the
pertinent statutory maximum is the one for money laundering.

                                             31
              Case: 13-10661     Date Filed: 09/01/2015    Page: 32 of 47

Rothenberg, 610 F.3d 621, 624 (11th Cir. 2010). However, a factual finding

cannot be clearly erroneous when the fact finder is choosing between two

permissible views of the evidence. United States v. Saingerard, 621 F.3d 1341,

1343 (11th Cir. 2010). For sentencing purposes, the government bears the burden

of establishing drug quantity by a preponderance of the evidence. United States v.

Rodriguez, 398 F.3d 1291, 1296 (11th Cir. 2005). The court must ensure that the

government carries this burden by presenting reliable and specific evidence.

United States v. Lawrence, 47 F.3d 1559, 1566 (11th Cir. 1995).

      The district court did not rely on a limited subset of the patient files to

conclude that all of the patients received illegitimate prescriptions, but instead

analyzed all of the identified patient files to reach the conclusion that all of the

prescriptions were not for a legitimate medical purpose and were outside of those

usual course of medical practice. Thus, with respect to all of the controlled

substances for which Caroni was held responsible, the district court made a finding

of fact that they were not prescribed for a legitimate medical purpose. The

evidence showed that patients were able to pick up their prescriptions, often

without seeing a doctor, simply by making the required payments. Patients had to

pay in all cash, and prescriptions were often given out to patients with addiction

problems, to patients that appeared to be under the influence, and in situations

where the prescribing doctor believed that medication was not necessary.

                                           32
             Case: 13-10661     Date Filed: 09/01/2015    Page: 33 of 47

Furthermore, the government and the court excluded many of the patient files from

the original 96 patient files that were seized and reviewed. The PSI initially

considered 68 of the patient files, and only 67 were considered at sentencing

following the government’s concession that one of the patients’ prescriptions

should not be counted.

      Although Caroni argued that some of the patient files contained information

suggesting that the patients legitimately needed the medication, he offered no

reliable evidence to establish that the medications were for a legitimate medical

purpose or within the usual course of medical practice. Caroni submitted the

conclusions of his expert witness, Warfield, but the district court correctly noted

that the weight of her opinion had to be tempered by the jury's guilty verdict.

Accordingly, the district court did not clearly err in determining that a

preponderance of the evidence supported the drug quantity specified in the PSI.

      3. Substantively unreasonable sentence

      Finally, Caroni argues that his sentences are substantively unreasonable. He

contends that the court impermissibly concluded that the conspiracy involved

Schedule II drugs. Additionally, he points to the sentencing disparity between his

sentences and those of his codefendants to argue that the district court made a clear

error in judgment. He also argues that the court improperly considered evidence of

                                          33
              Case: 13-10661      Date Filed: 09/01/2015     Page: 34 of 47

the patient deaths and of Mark Artigues’s 13 conduct, evidence that he argues was

not properly in the record. Finally, he asserts that the court prejudicially concluded

that he was responsible for ruining the lives of the doctors involved in the cases

when they were culpable for their own conduct.

       This Court reviews the reasonableness of a sentence under a deferential

abuse of discretion standard. Gall v. United States, 552 U.S. 38, 41, 128 S. Ct.
586, 591 (2007). This Court may “set aside a sentence only if [it] determine[s],

after giving a full measure of deference to the sentencing judge, that the sentence

imposed truly is unreasonable.” United States v. Irey, 612 F.3d 1160, 1191 (11th

Cir. 2010) (en banc).

       The district court must impose a sentence “sufficient, but not greater than

necessary, to comply with the purposes” listed in 18 U.S.C. § 3553(a)(2), including

the need to reflect the seriousness of the offense, promote respect for the law,

provide just punishment for the offense, deter criminal conduct, and protect the

public from the defendant’s future criminal conduct. 18 U.S.C. § 3553(a)(2). In

imposing a particular sentence, the court must also consider the nature and

circumstances of the offense, the history and characteristics of the defendant, the

kinds of sentences available, the applicable guideline range, the pertinent policy

13
       Artigues was the former employee whom Caroni sued when he alleged that Artigues stole
the Pensacola clinic from him.

                                            34
             Case: 13-10661      Date Filed: 09/01/2015   Page: 35 of 47

statements of the Sentencing Commission, the need to avoid unwarranted

sentencing disparities, and the need to provide restitution to victims. 18 U.S.C.

§3553(a)(1), (3) (7).

      In reviewing the reasonableness of a sentence, this Court first ensures that

the sentence was procedurally reasonable, meaning the district court properly

calculated the guideline range, treated the Guidelines as advisory and not

mandatory, considered the § 3553(a) factors, did not select a sentence based on

clearly erroneous facts, and adequately explained the chosen sentence. Gall, 552
U.S. at 51, 128 S. Ct. at 597. The Guidelines dictate that where a sentence

imposed on the count carrying the highest statutory maximum is less than the total

punishment, then the sentence imposed on the other count shall run consecutively

to the extent necessary to produce a combined sentence equal to the total

punishment. U.S.S.G. § 5G1.2(d). Once the Court determines that a sentence is

procedurally sound, it examines whether the sentence was substantively reasonable

in light of the totality of the circumstances. Id.

      “The party challenging the sentence bears the burden to show it is

unreasonable in light of the record and the § 3553(a) factors.” United States v.

Tome, 611 F.3d 1371, 1378 (11th Cir. 2010). Although this Court does not apply a

presumption of reasonableness for sentences falling within the guidelines range,

“ordinarily [this Court] would expect a sentence within the Guidelines range to be

                                           35
             Case: 13-10661      Date Filed: 09/01/2015    Page: 36 of 47

reasonable.” United States v. Talley, 431 F.3d 784, 787-88 (11th Cir. 2005). This

Court reverses only if “left with the definite and firm conviction that the district

court committed a clear error of judgment in weighing the § 3553(a) factors by

arriving at a sentence that lies outside the range of reasonable sentences dictated by

the facts of the case.” Irey, 612 F.3d at 1190. “The fact that the appellate court

might reasonably have concluded that a different sentence was appropriate is

insufficient to justify reversal of the district court.” Gall, 552 U.S. at 51, 128 S. Ct.

at 597.

      Congress has explicitly provided that there is no limitation on the

information concerning “the background, character, and conduct” of the defendant

that a court may consider in determining the appropriate sentences. 18 U.S.C. §

3661. At sentencing, a court’s factual findings may be based on trial evidence,

undisputed statements in the PSI, or evidence presented at the sentencing hearing.

United States v. Wilson, 884 F.2d 1355, 1356 (11th Cir. 1989).

      First, the district court did not err in considering evidence regarding Artigues

or the patient deaths. The Caroni deposition testimony recounted how two Global

Pain employees were hired to work at Artigues’s clinic, and the clinic’s earnings

went to Caroni, who would then pay Artigues. It was also permissible for the court

to consider the evidence of the patient deaths because that evidence was introduced

at sentencing. Wilson, 884 F.2d at 1356. Regardless, any error with respect to the

                                           36
             Case: 13-10661     Date Filed: 09/01/2015    Page: 37 of 47

consideration of the death evidence was harmless because the court stated that it

did not affect Caroni’s sentences.

      As to his argument regarding the consideration of Schedule II drugs in

calculating his drug quantity, such consideration is expressly contemplated by the

Guidelines. See U.S.S.G. § 2D1.1, comment. (n.12). Likewise, the court’s partial

attribution of the consequences the doctors faced to Caroni is consistent with the

determination that he held a leadership role in the offense, and the court stated that

it was not absolving the doctors of their own conduct. While Caroni is correct in

pointing out that his sentences are significantly higher than those of DiLeo and

Pastorek, their sentences are the result of “extraordinary” situations that warranted

significant departures. DiLeo initially had a sentencing range of 188 to 235

months, the same range Caroni would have had without the leadership role

adjustment. He received a 12-level departure because of the medical condition and

special needs of his child, which resulted in a guideline range of 51 to 63 months.

From there, the court imposed concurrent sentences of 24 months for both counts,

representing a 27-month variance from the low end of his guideline range.

Pastorek started with a much lower initial sentencing range because he was only

charged and convicted for Count 1, and his guideline range was limited by his

statutory maximum penalty. He received a 6-level departure for the medical

                                          37
              Case: 13-10661    Date Filed: 09/01/2015    Page: 38 of 47

condition and medical needs of his child, and he was sentenced to 12 months and 1

day of imprisonment, which was within his guideline range.

      By contrast, Caroni’s otherwise applicable guideline range was 292 to 365

months. Under § 5G1.2(d), the court should have imposed his statutory maximum

sentences consecutively to approximate his recommended guideline range, which

would have resulted in a sentence of 276 months. Thus, his total sentence of 240

months represented a downward variance of 36 months, which is actually greater

than the variance that DiLeo received. Accordingly, the disparities in the

sentences are explained by the differences in circumstances between the three

defendants.

      Finally, Caroni’s sentences are reasonable in light of the record as a whole.

The district court thoroughly considered the § 3553(a) factors, the trial evidence,

and the arguments of the parties. The court emphasized that it believed strong

sentences were warranted based on the seriousness of the offenses and Caroni's

role in perpetuating them. The nature and scope of Caroni's conduct resulted in the

distribution of the equivalency of 16,517.99 kilograms of marijuana and resulted in

the laundering of approximately $8,557,205 in funds. Further, his 240-month

sentences represented a downward variance from his applicable guideline range, as

discussed above. Given the seriousness and magnitude of the offenses, Caroni’s

leadership role in the offenses, and the district court’s consideration of the §

                                          38
             Case: 13-10661    Date Filed: 09/01/2015   Page: 39 of 47

3553(a) factors, Caroni’s sentences are substantively reasonable. Accordingly, this

Court affirms Caroni’s sentences.

      AFFIRMED.

                                        39
              Case: 13-10661       Date Filed: 09/01/2015   Page: 40 of 47

MARTIN, Circuit Judge, dissenting:
      It is well-settled that the government bears the burden of proving venue in

every criminal case. United States v. Snipes, 611 F.3d 855, 865 (11th Cir. 2010).

Here, Dennis Caroni, Gerard DiLeo, and Joseph Pastorek were indicted and tried in

the Northern District of Florida even though they never traveled to that district.

Consistent with our long-standing precedent, the government alleged that venue

was proper because the defendants briefly extended their drug and money

laundering conspiracies to the Northern District of Florida by hiring co-

conspirators to open Global Pensacola, a pain management clinic in Pensacola,

Florida. See United States v. Schlei, 122 F.3d 944, 975 (11th Cir. 1997) (a

conspiracy may be prosecuted in any district in which an “overt act was committed

in furtherance of its objects”).

      The precise issue that Messrs. Caroni, DiLeo, and Pastorek raise is not that

this is a legally insufficient allegation, or even that the government failed to offer

evidence in support of it. Instead, they argue that because venue is a question of

fact, they were entitled to have the jury make a specific finding that either they or

one of their co-conspirators committed an overt act in the Northern District of

Florida. I agree with Messrs. Caroni, DiLeo, and Pastorek, as well as the majority,

that the District Court erred by refusing to provide a jury instruction on venue and

                                            40
               Case: 13-10661       Date Filed: 09/01/2015       Page: 41 of 47

prohibiting defense counsel from arguing that the government had failed to prove

venue.

       I part ways with the majority with respect to its holding that the District

Court’s error was harmless. I write separately to explain why the District Court’s

failure to instruct on venue and restriction of defense counsel’s closing arguments

constitute reversible error.

                                              I.

       A defendant in a criminal case has the right to be tried in the district in

which the crime was committed. For conspiracy offenses that span more than one

district, venue is proper in any district in which the conspiracy was formed or in

which a co-conspirator committed an act in furtherance of the conspiracy. Schlei,
122 F.3d at 975.

       Questions of venue are not merely “pedantic, justice-defeating

technicalit[ies],” but issues of constitutional magnitude. Green v. United States,

309 F.2d 852, 856 (5th Cir. 1962). 1 As the Supreme Court explained in United

States v. Johnson, 323 U.S. 273, 65 S. Ct. 249 (1944), venue “touch[es] closely the

fair administration of criminal justice and public confidence in it” by protecting

defendants from prosecution in unfavorable or remote locations. Id. at 276, 278,

       1
          In Bonner v. City of Prichard, 661 F.2d 1206 (11th Cir. 1981) (en banc), this Court
adopted as binding precedent all of the decisions of the former Fifth Circuit handed down prior
to the close of business on September 30, 1981. Id. at 1207.

                                               41
              Case: 13-10661      Date Filed: 09/01/2015     Page: 42 of 47
65 S. Ct. at 250, 252. Indeed, the importance of this right is evident from the fact

that it is guaranteed by two separate constitutional provisions and a federal statute.

See U.S. Const. art. III, § 2, cl. 3 (“The Trial of all Crimes . . . shall be held in the

State where the said Crimes shall have been committed . . . .”); id. amend. VI

(requiring trial “by an impartial jury of the State and district wherein the crime

shall have been committed”); Fed. R. Crim. P. 18 (“Unless a statute or these rules

permit otherwise, the government must prosecute an offense in a district where the

offense was committed.”).

       Because it is grounded in our constitution, we have characterized venue as

an “essential element of the government’s proof at trial,” Snipes, 611 F.3d at 865,

and continuously reaffirmed that the government bears the burden of proving

venue in every criminal prosecution, see, e.g., United States v. Stickle, 454 F.3d
1265, 1272 (11th Cir. 2006); United States v. Breitweiser, 357 F.3d 1249, 1253

(11th Cir. 2004); United States v. White, 611 F.2d 531, 534 (5th Cir. 1980). And

we have also explained that it is especially important for courts to safeguard a

defendant’s venue right in conspiracy prosecutions because a jury need not find

that the government proved every act alleged in the indictment in order to convict.

Thus, “[t]he dangers of abuse are manifold if the Government can obtain an

indictment for conspiracy in a district other than the district where the offense was

                                            42
               Case: 13-10661        Date Filed: 09/01/2015       Page: 43 of 47

actually committed merely by alleging that one act, which need never be proved,

was committed in that district.” Green, 309 F.2d at 856.

       However, although venue is a question of fact—did the crime take place in

the district of prosecution?—our precedent makes clear that a district court is not

always required to present this question to the jury. Compare Bellard v. United

States, 356 F.2d 437, 439 (5th Cir. 1966), with Snipes, 611 F.3d at 866; see also

United States v. Perez, 280 F.3d 318, 330 (3d Cir. 2002) (stating that “venue does

not automatically present a question for the jury”). This Court last addressed the

specific question raised by the appellants—in what circumstances a district court

errs by failing to instruct the jury on venue—in White, 611 F.2d 531. In that case,

Charles White was convicted in the Middle District of Florida for a number of

offenses arising from the theft and forgery of a Social Security check. Id. at 533–

34. Mr. White argued that the district court erred by failing to give a jury

instruction on venue because the government had offered no direct evidence that

his crimes had been committed in the Middle District. Id. at 535–36.

       We held that the district court’s failure to provide a venue instruction did not

constitute plain error 2 for the following reasons:

       First, Count Two of the indictment charged that White forged the
       check in the Middle District of Florida. The indictment appears to

2
 Unlike the appellants in this case, Mr. White did not request a jury instruction on venue.
White, 611 F.2d at 536.

                                                43
              Case: 13-10661    Date Filed: 09/01/2015    Page: 44 of 47

      have been read to the jury only once, before the jury was sworn, but
      the trial judge sent a copy of the indictment into the jury room for
      consideration by the jury during its deliberations. Second, in
      instructing the jury on the essential elements of forgery, the trial court
      stated that the government must prove beyond a reasonable doubt “the
      act of forging the payee’s endorsement on the United States Treasury
      check as charged.” Third, White’s counsel argued the territorial
      jurisdiction and venue question in his closing argument. Finally, there
      was sufficient evidence for a jury to conclude that the forgery
      occurred in the Middle District of Florida.

Id. at 537.

      White’s reasoning is instructive: no separate venue instruction was required

because the jury’s guilty verdict necessarily included a finding of proper venue. In

other words, because the indictment alleged offense conduct only in the Middle

District of Florida, the jury could not have found the defendant guilty unless it

specifically found that the defendant committed an act within that jurisdiction. See

id. Several other circuits have articulated similar rules. See, e.g., United States v.

Miller, 111 F.3d 747, 751 (10th Cir. 1997) (“We therefore adopt the rule that

failure to instruct on venue, when requested, is reversible error unless it is beyond

a reasonable doubt that the jury’s guilty verdict on the charged offense necessarily

incorporates a finding of proper venue.”); United States v. Martinez, 901 F.2d 374,

376 (4th Cir. 1990) (“Venue is an issue in this case because the jury was able to

convict the defendant of the offenses charged without an implicit finding that the

acts used to establish venue had been proven.”); United States v. Moeckly, 769

                                          44
               Case: 13-10661        Date Filed: 09/01/2015        Page: 45 of 47
F.2d 453, 461 (8th Cir. 1985) (“The issue here is whether venue was proven where

there was no finding by the jury that at least one overt act or the conspiratorial

agreement occurred in Minnesota . . . . Some finding by the jury on this issue

should have been required.”).

       Applying this standard, the District Court erred. The indictment in this case

alleged a conspiracy in both the Northern District of Florida and the Eastern

District of Louisiana, and the jury’s guilty verdict did not necessarily incorporate a

finding that the defendants committed any act—criminal or otherwise—in the

Northern District of Florida. Thus, the District Court should have provided a jury

instruction on venue and permitted defense counsel to argue that the government

had failed to prove venue. The majority does not dispute this conclusion.

       The majority and I part ways, however, in our application of the harmless

error standard. Under Chapman v. California, 386 U.S. 18, 87 S. Ct. 824 (1967),

Messrs. Caroni, DiLeo, and Pastorek are entitled to reversal unless the government

“prove[s] beyond a reasonable doubt that the error complained of did not

contribute to the verdict obtained.” 3 Id. at 24, 87 S. Ct. at 828. Under these

3
 To the extent that the majority applies some other harmless error standard, it has no basis in our
precedent. And although several of our sister circuits have held that a failure to instruct the jury
on venue is harmless error if evidence of venue is “substantial and uncontroverted,”
uncontroverted in this context takes its literal meaning: not contested at trial. See Martinez, 901
F.2d at 377 (holding that evidence of venue was “substantial and uncontroverted” where it had
not been contested at trial); see also United States v. Neder, 197 F.3d 1122, 1129 n.6 (11th Cir.
1999) (stating that the fact that an omitted element “was not contested supports the conclusion

                                                45
               Case: 13-10661       Date Filed: 09/01/2015       Page: 46 of 47

circumstances, where the jury has made no finding on a required element of an

offense, our inquiry focuses on “whether the record contains evidence that could

rationally lead to a contrary finding with respect to the omitted element.” Neder v.

United States, 527 U.S. 1, 19, 119 S. Ct. 1827, 1839 (1999). Said differently, the

government bears the burden of proving, beyond a reasonable doubt, that a rational

jury could not have concluded that venue was improper. I believe the government

has failed to carry this burden.

       The majority makes much of the “substantial and uncontroverted” evidence

regarding Global Pensacola. However, while it was not disputed that Mr. Caroni

founded Global Pensacola, the relevant question here is whether its establishment

was an overt act in furtherance of the conspiracy between Messrs. Caroni, DiLeo,

and Pastorek such that it could establish venue in the Northern District of Florida.

The evidence on this question was more limited. Global Pensacola operated for

only two weeks during what was otherwise a four-year conspiracy, and Mr. Caroni

was the only one of the three defendants who had a role in founding the clinic.

Indeed, the government presented no evidence whatsoever linking Mr. Pastorek to

that the jury’s verdict would have been the same absent the error.” (emphasis added)). The
defendants here contested whether their conspiracy extended to the Northern District of Florida.

                                               46
               Case: 13-10661       Date Filed: 09/01/2015       Page: 47 of 47

Global Pensacola. 4 Finally, as a result of the short amount of time that Global

Pensacola operated, the government’s evidence about this clinic’s operations was

necessarily quite limited. For instance, although a critical question in this case was

whether patients received prescriptions that were made “outside the usual course of

medical practice and for other than legitimate medical purposes,” the jury only

heard from one Global Pensacola patient who had visited the clinic a single time

and had not been treated by any of the defendants.

       For the reasons described in the majority opinion, it is certainly conceivable

that the jury—if it had been presented with the question—would have found that

venue was proper in the Northern District of Florida. But that is not our inquiry.

Because this question was taken away from the jury in violation of the defendants’

constitutional rights, our task on harmless error review is to determine whether

there exists “evidence that could rationally lead to a contrary finding.” Neder, 527
U.S. at 19, 119 S. Ct. at 1839. Under these facts, my answer is yes. I respectfully

dissent.

4
 I recognize that a co-conspirator may be held responsible for aspects of a conspiracy in which
he had no direct involvement. However, the government’s inability to connect Mr. Pastorek to
Global Pensacola is undoubtedly relevant to the question we face here—whether the
establishment of Global Pensacola was an overt act in furtherance of a conspiracy involving Mr.
Pastorek. See United States v. Chandler, 388 F.3d 796, 811–12 (11th Cir. 2004). As this Court
explained in Green, “[t]here is grave danger of injustice where, as in the present case, one
defendant was not even alleged to have participated in the one act which occurred in the district
where the indictment against him . . . was returned.” 309 F.2d at 856.

                                               47