Court Opinion

ID: 9966452
Source: CourtListenerOpinion
Date Created: 2024-05-07 00:00:46.340718+00
Date Added: 2024-06-11T08:25:28.434939
License: Public Domain

Case: 23-30191      Document: 126-1         Page: 1   Date Filed: 05/06/2024

        United States Court of Appeals
             for the Fifth Circuit                           United States Court of Appeals
                                                                      Fifth Circuit
                             ____________                           FILED
                                                                 May 6, 2024
                               No. 23-30191
                             ____________                      Lyle W. Cayce
                                                                    Clerk
United States of America,

                                                          Plaintiff—Appellee,

                                   versus

Randy J. Lamartiniere,

                                        Defendant—Appellant.
               ______________________________

               Appeal from the United States District Court
                   for the Middle District of Louisiana
                         USDC No. 3:18-CR-87-1
               ______________________________

Before Davis, Smith, and Haynes, Circuit Judges.
W. Eugene Davis, Circuit Judge:
       A jury convicted Dr. Randy Lamartiniere, an internal medicine
doctor, of twenty counts of unlawful distribution of controlled substances.
On appeal, Lamartiniere challenges the district court’s jury instructions and
the sufficiency of the evidence supporting his convictions. Finding no
reversible error, we AFFIRM.
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                                 No. 23-30191

                                      I.
                                      A.
       At the time of his trial, Lamartiniere had been practicing as a licensed
physician specializing in internal medicine for approximately thirty years. In
2012, he was hired as a staff physician at a clinic in Baton Rouge, Louisiana,
operated by Ochsner Health. At first, Lamartiniere mainly saw general
internal medicine patients, but that started to change in 2013 as he saw a
growing number of chronic pain patients. By 2014, Ochsner began to develop
concerns about Lamartiniere’s management of opioid and narcotic
prescriptions and his inability to timely maintain his patient records. After
several warnings, Ochsner terminated Lamartiniere at the end of 2014.
       Following his termination from Ochsner, Lamartiniere opened his
own “direct primary care” practice in early 2015. At his new practice,
patients paid a $300 membership fee in exchange for three months of medical
care for any issue that arose during that time period. The practice accepted
neither insurance nor Medicaid. Although Lamartiniere testified that he
initially hoped to see mostly internal medicine patients, within a year of
opening the practice, he had between 200-250 patients, eighty percent of
whom were pain management patients.
       In early 2015, shortly after Lamartiniere opened his practice, the Drug
Enforcement Administration (“DEA”) launched an investigation into his
prescription practices after receiving a tip from a confidential informant. As
part of the DEA’s investigation, it recruited two undercover agents to pose
as chronic pain patients seeking controlled substances from Lamartiniere.
Over the course of almost six months, the undercover agents, outfitted with
recording devices, visited Lamartiniere’s practice a total of nine times, each
time leaving with a prescription for a controlled substance. In November

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2015, the DEA executed a search warrant for fifty patient files from
Lamartiniere’s practice.
        In 2021, a superseding indictment charged Lamartiniere with twenty-
eight counts1 of unlawful distribution of Schedule II controlled substances in
violation of 21 U.S.C. § 841(a)(1). Counts 1 through 7 of the superseding
indictment charged him with prescribing controlled substances to seven
patients on January 5, 2016, after the Louisiana State Board of Medical
Examiners (the “Medical Board”) suspended his state license to prescribe
controlled substances. The remaining counts charged Lamartiniere with
unlawfully prescribing controlled substances to the two undercover agents,
Matthew Dixon and Craig Crawford, and four former patients, Charles
Henson, Brian Boudreaux, Jeremy Doiron, and Fredrick Aughey.
                                           B.
        At trial,2 the Government called nine witnesses, including
Lamartiniere’s former patients, the undercover agents, and expert witnesses.
Additionally, the Government played for the jury recordings of the
undercover agents’ appointments with Lamartiniere. Lamartiniere testified
in his own defense and presented testimony from his former legal counsel.
Below is a sampling of that testimony.
        Both undercover agents testified about their visits with Lamartiniere
between April and September 2015. Detective Dixon testified that at his first
appointment, he told Lamartiniere that he had pain in his right leg from an
old sports injury. After Lamartiniere conducted “some sort of examination

        _____________________
        1
           The superseding indictment charged Lamartiniere with thirty counts, but the
district court granted the Government’s motion to dismiss two counts.
        2
          This case was initially tried without a jury on December 6-7, 2021, and ended in
a mistrial.

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                                       No. 23-30191

or manipulation” of Dixon’s back, he diagnosed Dixon with a “disorder of
[the] lower extremity.”
        In a recording of the visit, the jury heard Dixon tell Lamartiniere that
a friend of his would “hook” him up with a “Lortab3 or something like that”
if his leg bothered him. Lamartiniere responded that getting medication
without a prescription was illegal. However, he said he could prescribe some
pain medication for Dixon, despite acknowledging that “Aleve, Tylenol of
course will work fairly well too” and are “[a] little bit more legal.” After
Dixon said Aleve and Tylenol were ineffective, Lamartiniere wrote him a
prescription for thirty 7.5-milligram Norco4 pills, which he estimated would
last Dixon “a couple of months, at least.”
        At Dixon’s second appointment, he told Lamartiniere that his left leg
(instead of his right leg as initially reported) was the source of his pain.
Although it was only ten days after his initial appointment, Lamartiniere
wrote Dixon a prescription for ninety 7.5-milligram Norco pills. Dixon then
requested a prescription for Adderall, telling Lamartiniere that he took some
of his co-worker’s “addies”5 and it helped him stay awake. Lamartiniere
explained to Dixon that taking Adderall for that purpose was illegal and that
using Adderall to stay awake was a non-indication for adult attention deficit
disorder (“ADD”). However, after Dixon said a prior doctor had prescribed
him ADD medication and that he had trouble focusing on various tasks,
Lamartiniere eventually agreed to prescribe Dixon 20-milligrams of Adderall.

        _____________________
        3
           Lortab is a brand name for hydrocodone, a Schedule II opiate typically prescribed
to treat pain.
        4
            Norco is another brand name for hydrocodone.
        5
          Dixon testified that “addies” is common street terminology for Adderall.
Adderall, another Schedule II substance, is a stimulant.

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        During his next appointment, Dixon identified his right leg as the
source of his pain and asked Lamartiniere for “something better” than
Norcos to “make [him] feel better.” Lamartiniere agreed to switch him to
Percocet6 and wrote him a prescription for ninety tablets of 10-milligram
Percocet. During this appointment, Lamartiniere did not conduct a physical
exam or order any medical tests before switching Dixon to a stronger
medication.
        During Dixon’s final appointment, Lamartiniere raised concerns that
there was no indication in Louisiana’s prescription monitoring program
(“PMP”)7 that Dixon had picked up his prior prescriptions. Dixon had
previously said that he filled his prescriptions in Texas. Lamartiniere
requested that going forward Dixon fill his prescriptions in Louisiana so he
could track them on the PMP. He explained that in order to prescribe
controlled substances, he was required to have documentation that Dixon
was filling his prescriptions. Without such documentation, Lamartiniere
acknowledged that he was “kind of losing track of things” and needed “to do
a better job of recording” Dixon’s prescriptions.
        When Lamartiniere informed Dixon that he was going to drug test
him, Dixon responded that he had not taken his prescribed medications in
several weeks because he ran out early. Lamartiniere told Dixon this created
a problem because in order to ensure prescriptions were not diverted, he
needed to either drug test him or monitor his prescription refills and that he

        _____________________
        6
          Percocet is a brand name for oxycodone (combined with Tylenol) and is a
Schedule II opiate typically prescribed to treat pain. Oxycodone is one and a half times
stronger than hydrocodone.
        7
          Louisiana’s PMP is a database that provides registered physicians in the state
access to reports on what controlled substances were prescribed to patients and how many
of those prescriptions have been filled within Louisiana.

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was “doing neither of those” in Dixon’s case. He further told Dixon that
“[u]nfortunately they treat doctors like they’re supposed to be detectives
these days. They can take licenses [away] for not doing that kind of stuff.”
Although Lamartiniere emphasized that he needed Dixon’s pharmacy
records going forward, he still agreed to provide Dixon with his prescriptions
for Adderall and Percocet.
       The jury also heard testimony from Crawford, the second undercover
officer, who saw Lamartiniere four times between July and September 2015.
At his first visit, Crawford informed Lamartiniere that he had a weightlifting
injury from ten to fifteen years ago that made his leg feel “funny.” Crawford
said he did not have a prescription for pain medication, but he had gotten “a
couple of roxies”8 from his friend that made him “feel good.” Lamartiniere
asked Crawford whether he had any history of drug abuse, and Crawford said,
“No. Like I said [I] take a couple of . . . .” Lamartiniere interrupted
Crawford, finishing his sentence, “[b]ut nothing on a really regular basis, not
large amounts or nothing . . . ,” to which Crawford responded, “No.”
       After Lamartiniere examined Crawford for a few minutes, he
diagnosed Crawford with a nerve issue and a bulging disc. For Crawford’s
pain, Lamartiniere suggested a Schedule IV narcotic, but Crawford insisted
he wanted “roxies.” Lamartiniere informed Crawford that his symptoms
“are really not something . . . [that] any doctor should prescribe a . . . major
narcotic [for,] at least up front.” Nevertheless, Crawford left his first
appointment with a prescription from Lamartiniere for forty-five 5-milligram
Norco tablets.
       At his next appointment, Crawford asked for a stronger prescription.
Lamartiniere again suggested less addictive medications as an alternative, but
       _____________________
       8
           “Roxies” is slang for Roxicodone, a brand name for oxycodone.

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ultimately agreed to write Crawford a prescription for seventy-five tablets of
7.5-milligrams of Percocet.        Lamartiniere warned Crawford that the
“problem is all these pain medicines are addictive” and that people “develop
a tolerance to them,” which is especially concerning “for someone that’s not
really in a lot of pain as you said.”
       Crawford testified that at some point during his second appointment,
Lamartiniere’s demeanor changed when he informed Crawford that
Louisiana’s PMP showed no record of Crawford’s filling his last prescription.
Crawford told Lamartiniere he filled his prescription in Mississippi, to which
Lamartiniere said he would only give Crawford one more prescription unless
he came back with records confirming he had filled his prescription.
Lamartiniere told Crawford it was important to fill his prescriptions in
Louisiana because “they’re using people like you around to catch doctors like
this, so . . . that’s why I have to be careful.” Lamartiniere also asked
Crawford about getting an MRI of his back, again emphasizing that he had to
be “careful” about “treating things without an MRI or records” because it
“doesn’t look right.”
       At his third appointment, Crawford again asked Lamartiniere for
stronger medication that would last longer. Lamartiniere said he could
increase Crawford’s dose of Percocet to 10-milligrams and give him ninety
pills, but beyond that he would “really have to start thinking about . . . [having
an] MRI[] done.”        Lamartiniere also asked Crawford to sign a pain
management agreement and said that, if Crawford was unwilling to do so, he
would not continue prescribing him pain medication. Yet, when Crawford
refused to sign the agreement, Lamartiniere still gave him a prescription for
ninety 10-milligram Percocet tablets.
       At his final appointment, Crawford testified that based on his
experience investigating narcotics cases, he noticed an individual in

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                                     No. 23-30191

Lamartiniere’s waiting room who appeared to be under the influence of a
Schedule II narcotic. Once he was taken back to see Lamartiniere, Crawford
asked for another Percocet prescription because “a guy” had stolen his prior
prescription. Lamartiniere told Crawford that the only way to get another
prescription would be to have a police report, but that it was “hard to get
police to write reports on stolen drugs because they know that some people
will use that to get more medicine.” Lamartiniere agreed to write Crawford
another prescription for Percocet without a police report.
       Charles Henson and Brian Boudreaux9—two of Lamartiniere’s
former patients—also testified. Henson testified that he suffered from a
slipped disc and chemical exposure that impacted his lungs and nerves. He
began seeing Lamartiniere in 2015, after his prior doctor no longer prescribed
him pain medication.         Henson testified that at his first appointment,
Lamartiniere performed a physical examination and required Henson to
provide copies of his prior MRI and CAT scans, as well as proof of his prior
prescriptions.
       Between March and November of 2015, Lamartiniere prescribed
Henson Adderall and two pain medications: oxycodone and Opana, 10 and he
increased the dosage of the pain medications over time. During this time
period, Henson testified that Lamartiniere would conduct random drug
screens, but that he did not recall Lamartiniere’s ever discussing the results
of his tests with him. However, Lamartiniere’s patient files show that
Henson’s July 7, 2015, drug test was positive for methadone, morphine, and
marijuana.       Despite the positive test, Lamartiniere wrote Henson a
       _____________________
       9
         Boudreaux did not appear at trial, and instead the jury was read his testimony
from the prior bench trial in this case.
       10
         Opana is a “formation” of oxymorphone, and oxymorphone in turn is a
“breakdown product” of oxycodone. Oxymorphone is twice as strong as oxycodone.

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prescription for Opana on July 24, 2015, and increased the quantity of pills
prescribed. Henson admitted that he was addicted to pain medication before
he began seeing Lamartiniere and that only after his final appointment with
Lamartiniere did he enter a rehabilitation program. On cross-examination,
however, Henson agreed that Lamartiniere was “one of the hardest pain
doctors . . . to obtain narcotic medications.”
       Boudreaux, another former patient, testified that he began seeing
Lamartiniere in March of 2015 for pain management after he was in a car
accident.   Boudreaux testified that Lamartiniere would drug test him
occasionally at first. After Boudreaux tested positive for heroin and tested
negative for his prescribed medications, Lamartiniere switched to testing him
at each appointment. Following the positive test, Lamartiniere agreed to
continue prescribing Boudreaux oxycodone and Adderall, but instead of
writing him a thirty-day prescription, as he usually did, Lamartiniere gave
him only a seven-day prescription. Seven days later, however, Lamartiniere
returned to writing Boudreaux thirty-day prescriptions. After Boudreaux
stopped seeing Lamartiniere, he was arrested for distribution of oxycodone.
       Dr. Cecilia Mouton, the former Director of Investigations for the
Medical Board, also testified for the Government. She testified that in early
2015, the Medical Board opened an investigation into Lamartiniere after
receiving complaints about his “manner of prescribing controlled
substances,” including a complaint from a pharmacist who was
uncomfortable filling Lamartiniere’s prescriptions.         Based on the
investigation, on November 24, 2015, the Medical Board issued an
emergency partial suspension of Lamartiniere’s medical license which
prohibited him from prescribing controlled substances.        The Medical
Board’s suspension letter stated that it had information indicating that
Lamartiniere was “prescribing controlled substances without appropriate
medical justification or in a manner without concern for patient safety.” It

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further stated that the Medical Board was “persuaded that Dr.
Lamartiniere’s continued ability to prescribe controlled substances to his
patients could constitute a risk of imminent patient harm.” The partial
suspension of Lamartiniere’s state license did not rescind his DEA
certification to prescribe controlled substances.11
       Dr. Mouton testified that in early December of 2015, she met with
Lamartiniere and his legal counsel. During that meeting, Lamartiniere asked
for a thirty-day delay of the Medical Board’s suspension, which had taken
effect on November 24. Although Dr. Mouton agreed to recommend a delay
to the Medical Board, she told Lamartiniere she did not have the authority to
make that agreement herself. The Medical Board ultimately adopted Dr.
Mouton’s recommendation and sent Lamartiniere a notice with an updated
suspension date of December 30, 2015. According to a delivery receipt,
Lamartiniere signed for a package containing the notice on January 4, 2016.
       The Government additionally called Dr. Gene Kennedy as an expert
in prescribing controlled substances in a family practice and pain
management setting. Before testifying, Dr. Kennedy reviewed eighteen
patient charts and PMP reports, “a few” drug screens, and the videos and
transcripts from the undercover agents’ appointments. Based on his review,
Dr. Kennedy testified in detail about the deficiencies he found in
Lamartiniere’s patient charts, emphasizing Lamartiniere’s lack of
documentation regarding physical examinations and prior medical records.
Dr. Kennedy also expressed concern that Lamartiniere did not repeatedly

       _____________________
       11
           The Government provided testimony from a DEA investigator about the DEA’s
registration process for practitioners. The investigator explained that “[a]nyone who
handles controlled substances must be registered with the DEA,” and that in order to
obtain such a registration, the practitioner must also “have appropriate licensure from
[their] state.”

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drug test his patients. He additionally opined that some of Lamartiniere’s
prescriptions lacked an adequate diagnostic basis. For example, Dr. Kennedy
testified that Lamartiniere’s diagnosis of Dixon with “disorder of the lower
extremity” was “so vague as to be essentially a useless diagnosis.” He also
stated that Lamartiniere prescribed Dixon Adderall for an established
“illegitimate purpose” and without a diagnosis of ADD.
       Throughout         his    testimony,      Dr.   Kennedy       emphasized   that
Lamartiniere’s response to obvious signs of drug abuse in his patients fell
outside the standard of care. For instance, Dr. Kennedy testified that it was
concerning that after Boudreaux tested positive for heroin, Lamartiniere’s
only response was to limit his prescriptions for a week.                 This lack of
monitoring was especially concerning given that Boudreaux’s PMP report
showed that he was receiving controlled substances from seven physicians
and filling those prescriptions at eleven different pharmacies, which Dr.
Kennedy characterized as “alarming . . . doctor shopping as well as pharmacy
shopping.” Additionally, Dr. Kennedy testified that Henson’s positive test
for methadone12 was particularly concerning because methadone’s potential
to interact with controlled substances could be “perilous.” However, shortly
after receiving Henson’s positive test, Lamartiniere increased his quantity of
Opana, a controlled substance.
       Dr. Kennedy also discussed Lamartiniere’s prescriptions to Jeremy
Doiron, a former patient who did not testify at trial. Dr. Kennedy testified
that Lamartiniere prescribed Doiron methadone and oxycodone pills in
“alarming” quantities over a two-week period in August 2015.
Lamartiniere’s chart on Doiron noted that he was in a motor vehicle accident
and that an emergency room physician diagnosed him with drug abuse. Of

       _____________________
       12
            Methadone is another Schedule II controlled substance.

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particular note to Dr. Kennedy was that although Lamartiniere
acknowledged this diagnosis, he proceeded to increase Doiron’s dosage of
methadone following the accident. In fact, eight days after Lamartiniere
wrote Doiron a prescription for methadone and oxycodone, he wrote Doiron
a second prescription for the same medications as a “replacement supply”
because Doiron’s medication was “destroyed when [his] vehicle caught
fire.”
         On cross-examination, Dr. Kennedy agreed with Lamartiniere’s
counsel that it appeared Lamartiniere had a hard time saying “no” to
persistent patients and was overly trusting of his patients. He clarified later
in his testimony that the fact Lamartiniere was struggling to say no to his
patients was an indication that he was running afoul of the pertinent
regulations because “if there is a struggle, then he [Lamartiniere] recognizes
that he’s considering something that is wrong.” Ultimately, Dr. Kennedy
opined that based on patient information he reviewed, each of the charged
prescriptions in Counts 8 through 9 and 12 through 30 were outside the
normal course of professional practice and did not serve a legitimate medical
purpose.
         Dr. Kennedy additionally testified about the prescriptions
Lamartiniere wrote after he received notice on January 4, 2016, of the partial
suspension of his state license. He testified that under 21 C.F.R. § 1306.03,
a physician must have two things before prescribing controlled substances:
(1) a state registration without any restrictions and (2) a valid DEA
registration. In light of the partial suspension of Lamartiniere’s state license,
and based on his review of the patient charts, Dr. Kennedy opined that the
prescriptions Lamartiniere wrote on January 5, 2016, were not within the
usual course of medical practice and were not for a legitimate medical
purpose.

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       After the Government rested its case, Lamartiniere moved for
judgment of acquittal under Federal Rule of Criminal Procedure 29(a), which
the district court denied.
       Lamartiniere then testified in his own defense. The thrust of his
testimony was that each of his chronic pain patients had “legitimate medical
conditions” that he was genuinely trying to treat. Even as to the undercover
agents, Lamartiniere testified that at the time he wrote their prescriptions, he
believed they were in legitimate pain and that the prescriptions were for
legitimate medical purposes. He emphasized that he monitored his patients,
including his former patients who testified at trial, for signs of addiction or
abuse by conducting drug screens, checking the PMP for evidence of doctor
shopping, and following-up if patients were going through their medication
too quickly.
       Lamartiniere also discussed the partial suspension of his state license.
He testified that following his meeting with Dr. Mouton, he was under the
impression that they had an agreement to delay his suspension that the
Medical Board would “almost certainly” agree to.                Lamartiniere’s
understanding of that agreement was that his partial suspension would be
delayed until he could “properly discharge” his patients. Lamartiniere
testified that he received a letter from the Medical Board on January 4, 2016,
stating that his license would be partially suspended as of December 30, 2015.
Despite receiving the letter, Lamartiniere testified that he continued to write
prescriptions to his patients on January 5, 2016, because he believed he could
do so based on his tentative agreement with Dr. Mouton.
                                      C.
       At the close of all the evidence, Lamartiniere renewed his motion for
a judgment of acquittal, which the district court denied. The jury convicted

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                                         No. 23-30191

Lamartiniere of twenty counts of unlawful distribution under § 841(a)(1) and
acquitted him on the remaining eight counts.13
        Lamartiniere filed a post-trial brief requesting a new trial under Rule
33 and renewing his motion for acquittal pursuant to Rule 29(c). In a written
decision, the district court denied both motions.                    The court rejected
Lamartiniere’s challenges to the jury instructions, concluding that the
instructions had properly defined § 841(a)(1)’s authorization element and
that the court’s deliberate ignorance instruction was supported by the
evidence. The court additionally held that “[a]pplying the correct view of
‘authorization,’ Defendant’s challenge to the sufficiency of the evidence falls
flat.” Lamartiniere filed a motion for reconsideration based on new Tenth
Circuit authority, United States v. Kahn (Kahn II),14 which the district court
denied. The district court sentenced Lamartiniere to 180 months, per count,
to run concurrently. Lamartiniere timely appealed.
                                               II.
        We start with Lamartiniere’s various challenges to the district court’s
jury instructions. “We review jury instructions for abuse of discretion if the
alleged error is preserved below.”15 However, when “a jury instruction
hinges on a question of statutory construction, this court’s review is de
novo.”16 In reviewing jury instructions, “[w]e consider whether the jury
        _____________________
        13
          Specifically, the jury convicted Lamartiniere on all counts pertaining to his post-
license suspension prescriptions and his prescriptions for Doiron, and it acquitted him on
all counts pertaining to Aughey. As to Lamartiniere’s prescriptions for Henson, Dixon,
Boudreaux, and Crawford, the jury convicted him on all but four counts, which
corresponded to prescriptions written during each person’s initial visit with Lamartiniere.
        14
             58 F.4th 1308 (10th Cir. 2023).
        15
             United States v. Fuchs, 467 F.3d 889, 900 (5th Cir. 2006).
        16
          United States v. Garcia-Gonzalez, 714 F.3d 306, 312 (5th Cir. 2013) (internal
quotation marks and citation omitted); see also United States v. Ferris, 52 F.4th 235, 239 (5th

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                                         No. 23-30191

instruction, taken as a whole, ‘is a correct statement of the law and whether
it clearly instructs jurors as to the principles of the law applicable to the
factual issues confronting them.’”17 Any error in a jury instruction is subject
to harmless-error review.18
        Jury instructions that were not timely objected to are reviewed for
plain error.19 “[W]e have discretion to reverse a forfeited error only if ‘there
is (1) error, (2) that is plain, and (3) that affects substantial rights.’”20 If these
three elements are met, “we may only exercise this discretion if ‘(4) the error
seriously affects the fairness, integrity, or public reputation of judicial
proceedings.’”21
        On appeal, Lamartiniere argues the district court erred in instructing
the jury on § 841(a)(1)’s authorization and mens rea elements. He further
challenges the court’s instruction regarding the state-licensing requirement
to prescribe controlled substances. Finally, Lamartiniere asserts that the
district court erred in instructing the jury on deliberate ignorance. We first
set forth the district court’s jury instructions and then review each of
Lamartiniere’s challenges in turn.

        _____________________
Cir. 2022) (“[W]hen the instruction is claimed to misstate an element of the offense,
review is de novo, subject to harmless-error review.” (internal quotation marks and citation
omitted)), cert. denied, 143 S. Ct. 846 (2023).
        17
           United States v. Guidry, 406 F.3d 314, 321 (5th Cir. 2005) (quoting United States
v. Daniels, 281 F.3d 168, 183 (5th Cir. 2002)).
        18
             Ferris, 52 F.4th at 239.
        19
             Fuchs, 467 F.3d at 900.
        20
          United States v. Ricard, 922 F.3d 639, 655 (5th Cir. 2019) (quoting United States
v. Martinez-Rodriguez, 821 F.3d 659, 662 (5th Cir. 2016)).
        21
             Id. (quoting Martinez-Rodriguez, 821 F.3d at 663).

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                                      A.
       The district court instructed the jury that to find Lamartiniere guilty
of distributing controlled substances under § 841(a)(1), the Government had
to prove beyond a reasonable doubt the following four elements: (1) “that the
Defendant dispensed a controlled substance;” (2) “that the Defendant
dispensed the controlled substance knowingly or intentionally;” (3) “that the
Defendant’s dispensation of the charged controlled substance was not
authorized;” and (4) “that the Defendant knew he was acting in an
unauthorized manner when he dispensed the controlled substance or
intended to act in an unauthorized manner.”
       The district court then provided additional instructions defining the
above elements:
       A prescription is authorized if it is issued for a legitimate
       medical purpose by an individual practitioner acting in the
       usual course of his professional practice.
              Both prongs are necessary for a prescription to be
       authorized. One is not sufficient. That is, the prescription
       must be issued for a legitimate purpose and within the usual
       course of a practitioner’s professional practice.
               By contrast, a prescription is unauthorized if the
       prescription either lacks a legitimate medical purpose or is
       outside the usual course of professional practice. In other
       words, knowingly issuing a prescription outside the course of
       professional practice is a sufficient condition to convict a
       medical practitioner of unlawful dispensation of a controlled
       substance. Likewise, knowingly issuing a prescription without
       a legitimate medical purpose is a sufficient condition to convict
       a medical practitioner of unlawful dispensation of a controlled
       substance.
             The term “legitimate medical purpose” in the usual
       course of his medical practice is defined by reference to the

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                                 No. 23-30191

       standard of medical practice generally recognized and accepted
       by the medical profession in the United States.
The district court further instructed jurors that when “considering whether
the Defendant issued a prescription for a legitimate medical purpose in the
usual course of professional practice, you may consider all of the Defendant’s
actions and the circumstances surrounding them.” The court went on to
instruct that:
                Knowingly keeping insufficient medical records alone
       does not establish the Defendant’s guilt of the charges alleged.
       Likewise, acting outside the standard of care generally required
       of physicians throughout the United States alone does not
       establish the Defendant’s guilt. However, you may consider
       . . . evidence of such facts when determining whether the
       Defendant was acting in an unauthorized manner when he
       dispensed a controlled substance or intended to act in an
       unauthorized manner.
       The district court also provided the following good-faith instruction:
“[a] controlled substance is prescribed by a physician for a legitimate medical
purpose in the usual course of medical practice and, therefore, authorized if
the controlled substance is prescribed by him in good faith.” It defined good
faith “in this context” as “an honest effort to prescribe for a patient’s
condition in accordance with the standards of medical practice generally
recognized or accepted in the United States.”
       The court additionally instructed jurors that a prescription for a
controlled substance “may be issued only by an individual medical
practitioner who is, one, authorized to prescribe controlled substances by the
jurisdiction in which he is licensed to practice his profession; and, two, in
possession of a valid registration from the U.S. Drug Enforcement
Administration, unless otherwise exempted from that registration
requirement.” Earlier in the instructions, the court cautioned jurors that

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                                        No. 23-30191

even if they found “that the Defendant violated applicable civil or
administrative rules, regulations, or contract terms, that alone would not be
a criminal violation. However, civil or administrative rules, regulations, and
contract terms may be relevant to determine whether a Defendant acted with
criminal intent; that is, knowingly, intentionally, and without authorization.”
                                             B.
       Lamartiniere first challenges the district court’s instructions defining
the third element—authorization—of the § 841(a)(1) charge. The statute
underlying Lamartiniere’s convictions, 21 U.S.C. § 841(a)(1), makes it
unlawful, “[e]xcept as authorized[,] . . . for any person knowingly or
intentionally . . . to manufacture, distribute, or dispense . . . a controlled
substance.”22        In turn, § 822(b) provides that medical practitioners
registered with the Attorney General “are authorized to possess,
manufacture, distribute, or dispense” controlled substances “to the extent
authorized by their registration and in conformity with the other provisions”
of the Controlled Substances Act (“CSA”).23 In other words, “[s]ection
822(b) defines the scope of authorization under the Act in circular terms.”24
However, an accompanying regulation promulgated by the Attorney
General, 21 C.F.R. § 1306.04(a), provides that a prescription is authorized,
and therefore outside § 841(a)(1)’s prohibition, if it is “issued for a legitimate
medical purpose by an individual practitioner acting in the usual course of his

       _____________________
       22
            21 U.S.C. § 841(a)(1) (emphasis added).
       23
            21 U.S.C. § 822(b).
       24
            United States v. Moore, 423 U.S. 122, 140 (1975).

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                                       No. 23-30191

professional practice.”25           In Gonzales v. Oregon,26 the Supreme Court
characterized § 1306.04(a) as “a parroting regulation” because it “just
repeats two statutory phrases [from the CSA] and attempts to summarize the
others.”27
        Consistent with the relevant regulation, the district court here
instructed the jury that “a prescription is unauthorized if the prescription
either lacks a legitimate medical purpose or is outside the usual course of
professional practice.” Lamartiniere contends that the court’s instruction
erred by defining authorization based on a federal regulation. He argues that
authorization is correctly defined based solely on whether a prescription
serves a legitimate medical purpose, regardless of whether it is outside the
course of professional practice.               Consistent with his definition of
authorization, Lamartiniere proposed the following limited jury instruction:
“[a]s to the third element, [a] defendant acts in an unauthorized manner
when he distributes a controlled substance other than for a legitimate medical
purpose.” The district court rejected the limited instruction as contrary to
established Fifth Circuit precedent and reasoned that the Supreme Court’s
recent decision in “Ruan [v. United States] did not address—much less

        _____________________
        25
           21 C.F.R. § 1306.04(a); see also Ruan v. United States, 597 U.S. 450, 454 (2022)
(“[A]s provided by regulation, a prescription is only authorized when a doctor issues it ‘for
a legitimate medical purpose . . . acting in the usual course of his professional practice.’”
(alteration in original) (quoting 21 C.F.R. § 1306.04(a))).
        26
             546 U.S. 243 (2006).
        27
           See id. at 257 (“The CSA allows prescription of drugs only if they have a
‘currently accepted medical use,’ 21 U.S.C. § 812(b); requires a ‘medical purpose’ for
dispensing the least controlled substances of those on the schedules, § 829(c); and, in its
reporting provision, defines a ‘valid prescription’ as one ‘issued for a legitimate medical
purpose,’ § 830(b)(3)(A)(ii) . . . [and] physicians are considered to be acting as
practitioners under the statute if they dispense controlled substances ‘in the course of
professional practice[,]’ § 802(21).”).

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                                         No. 23-30191

disturb—the Fifth Circuit’s two-prong [authorization] test.”                    Because
Lamartiniere has preserved his challenge to § 841(a)(1)’s definition of
authorization, our review is de novo.
       As recognized by the district court, Lamartiniere’s challenge to the
regulatory definition of authorization is foreclosed by this Court’s precedent.
In United States v. Armstrong,28 this Court affirmed jury instructions that
required the Government to prove that a medical practitioner: (1)
“prescribed or dispensed the controlled substance alleged in the
indictment;” (2) “did so knowingly and intentionally;” and (3) “prescribed
or dispensed the controlled substance either without a legitimate medical
purpose or outside the course of his or her professional practice.”29 As to the
third element, we acknowledged that it was “not expressly required by the
text of § 841, but relevant regulations [21 C.F.R. § 1306.04(a)] provide that a
controlled substance can be dispensed by a prescription ‘issued for a
legitimate medical purpose by an individual practitioner acting in the usual
course of his professional practice.’”30 We further noted that in Gonzales,
“the Supreme Court determined that § 1306.04 ‘does little more than restate
the terms of the [CSA] itself.’”31
       Armstrong additionally held that “a logical reading of 21 C.F.R.
§ 1306.04” shows that “[b]oth prongs are necessary for a prescription to be
legitimate;” and the “logical converse is that a practitioner is unauthorized
to dispense a controlled substance if the prescription either lacks a legitimate

       _____________________
       28
            550 F.3d 382 (5th Cir. 2008).
       29
            Id. at 398.
       30
            Id. at 397 (quoting 21 C.F.R. § 1306.04(a)).
       31
            Id. at 397 n.26 (quoting Gonzales, 546 U.S. at 257).

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                                        No. 23-30191

medical purpose or is outside the usual course of professional practice.”32 In
the years following Armstrong, this Court has continually affirmed the use
§ 1306.04(a)’s definition of authorization to define the term under
§ 841(a)(1).33
        Most notably, Armstrong rejected the definition of authorization that
Lamartiniere now seeks to revive, namely that a prescription is unauthorized
only if it lacks a legitimate medical purpose. In rejecting that argument,
Armstrong held that such a limited interpretation of authorization was
inconsistent with “the relevant statutory language, regulation, [United States
v.] Moore, and Fifth Circuit precedent.”34 In particular, we highlighted that
the jury instructions in Moore “did not include the requirement that the

        _____________________
        32
             Id. at 397.
        33
           See, e.g., United States v. Bennett, 874 F.3d 236, 245 (5th Cir. 2017) (recognizing
that “relevant regulations provide that a controlled substance can be dispensed by a
prescription issued for a legitimate medical purpose by an individual practitioner acting in
the usual course of his professional practice” (internal quotation marks and citation
omitted)); United States v. Evans, 892 F.3d 692, 703 (5th Cir. 2018) (requiring the
Government to prove that the “charged prescriptions had no legitimate medical purpose
or were written outside the course of [defendant’s] professional practice” to satisfy
§ 841(a)(1)’s authorization element); United States v. Pierre, 88 F.4th 574, 580 n.7, 582 n.8
(5th Cir. 2023) (identifying § 1306.04(a) as the “relevant regulation” defining authorized
prescriptions); United States v. Little, Nos. 21-11225 & 21-11228, 2023 WL 7294199, at *9
(5th Cir. Nov. 3, 2023) (per curiam) (unpublished) (“[A] practitioner is unauthorized to
dispense a controlled substance if the prescription either lacks a legitimate purpose or is
outside the usual course of professional practice.” (alteration in original) (internal
quotation marks and citation omitted)).
        34
          Armstrong, 550 F.3d at 396 & n.25; see also United States v. Brown, 553 F.3d 768,
791 n.71 (5th Cir. 2008) (adopting the reasoning of a prior unpublished opinion in which
this Court rejected the argument that the Government was “attempt[ing] to impermissibly
bootstrap a violation of 21 C.F.R. § 1306.04(a) . . . into a criminal offense [under § 841(a)]”
on the grounds “that the regulation was an interpretive regulation, not a civil regulation;
the indictment only charged a violation of § 841(a), and physicians can be prosecuted for
prescribing drugs outside of professional practice” (quoting United States v. Ogle, 201 F.
App’x 979, 980 (5th Cir. 2006) (per curiam) (unpublished))).

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                                           No. 23-30191

Government prove beyond a reasonable doubt that the physician prescribed
the controlled substance other than for a legitimate medical purpose.”35
Indeed, contrary to Lamartiniere’s treatment of the phrase usual course of
professional practice as surplusage, the Supreme Court in Moore held that the
“scheme of the statute [§ 841], viewed against the background of the
legislative history, reveals an intent to limit a registered physician’s
dispensing authority to the course of his ‘professional practice.’” 36
Accordingly, both Moore and Armstrong are directly at odds with
Lamartiniere’s proposed definition of authorization.37
        Under this Court’s rule of orderliness, “one panel of our court may
not overturn another panel’s decision, absent an intervening change in the
law, such as by a statutory amendment, or the Supreme Court, or our en banc
court.”38 “[F]or a Supreme Court decision to change our Circuit’s law, it
must be more than merely illuminating with respect to the case before [the
court] and must unequivocally overrule prior precedent.”39 Similarly, an “en
banc decision cannot overturn a binding published panel decision unless it
does so clearly.”40

        _____________________
        35
             Armstrong, 550 F.3d at 399.
        36
             Moore, 423 U.S. at 140.
        37
           See id. at 124 (holding “that registered physicians can be prosecuted under § 841
when their activities fall outside the usual course of professional practice”); Armstrong, 550
F.3d at 397 (“In other words, knowingly distributing prescriptions outside the course of
professional practice is a sufficient condition to convict a defendant under the criminal
statutes relating to controlled substances.”).
        38
             Jacobs v. Nat’l Drug Intel. Ctr., 548 F.3d 375, 378 (5th Cir. 2008).
        39
          Tech. Automation Servs. Corp. v. Liberty Surplus Ins. Corp., 673 F.3d 399, 405 (5th
Cir. 2012) (second alteration in original) (internal quotation marks and citation omitted).
        40
             United States v. Vega, 960 F.3d 669, 675 (5th Cir. 2020).

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                                          No. 23-30191

       Seeking to avoid the conclusion that Armstrong controls under the rule
of orderliness, Lamartiniere initially attempts to distinguish the jury
instructions given in this case from Armstrong. He alternatively argues that a
combination of the Supreme Court’s decision in Ruan, the major questions
doctrine, and this Court’s en banc decision in Cargill v. Garland41 constitute
an intervening change in the law that requires us to depart from Armstrong.
Neither argument is persuasive.
       First, the relevant jury instructions in this case are indistinguishable
from Armstrong. Lamartiniere seeks to distinguish them on the grounds that
in Armstrong, we acknowledged that “the district court essentially defined
conduct ‘in the usual course of professional practice’ as conduct that is
intended ‘for a legitimate medical purpose.’”42 The basis for this statement
in Armstrong was the district court’s instruction regarding good faith, which
stated that prescriptions were lawful if they were prescribed by a physician in
good faith, and that “[g]ood faith in this context means an honest effort to
prescribe for a patient’s condition in accordance with the standards of medical
practice generally recognized or accepted in this country.” 43 According to
Lamartiniere, the phrases “legitimate medical purpose” and “usual course
of professional practice” mean the same thing; consequently, Armstrong’s
instructions were a correct statement of law. He submits that the instructions
given in this case are distinguishable because they emphasize that the phrases
mean different things and erroneously provide that either prong is sufficient
for a conviction.

       _____________________
       41
            57 F.4th 447 (5th Cir. 2023) (en banc), cert. granted, 144 S. Ct. 374 (2023).
       42
            Armstrong, 550 F.3d at 398.
       43
            Id.

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                                         No. 23-30191

        The problem with Lamartiniere’s argument is that the district court’s
good-faith instruction in this case is almost identical to the good-faith
instruction in Armstrong.44 Thus, to the extent the good-faith instruction in
Armstrong treated the two phrases as interchangeable, so too did the good-
faith instruction here. Moreover, like the instructions here, the instructions
in Armstrong elsewhere made clear that the Government satisfies the
authorization element if it proves “either that the physician prescribed or
dispensed the drug other than for a legitimate medical purpose or that the
physician dispensed the drug not in the usual course of medical practice.” 45
Thus, Lamartiniere’s effort to distinguish Armstrong is unavailing.
        In the alternative, Lamartiniere asserts that Armstrong has been
overruled by an intervening change in the law. But despite Lamartiniere’s
arguments to the contrary, neither Ruan, Cargill, nor the major questions
doctrine overruled Armstrong or the Supreme Court cases upon which
Armstrong relied.
        In Ruan, the Supreme Court reviewed two cases from the Tenth and
Eleventh Circuits consolidated on appeal. The Supreme Court addressed
“the state of mind that the Government must prove to convict . . . doctors of
violating [§ 841(a)(1)].”46 In resolving this issue, the Court held “that the
statute’s ‘knowingly or intentionally’ mens rea applies to authorization.”47
        _____________________
        44
           In Armstrong, the district court instructed the jury that “Good faith in this context
means an honest effort to prescribe for a patient’s condition in accordance with the standards of
medical practice generally recognized or accepted in this country.” Id. Here, the district
court instructed the jury that “‘Good faith’ in this context means an honest effort to
prescribe for a patient’s condition in accordance with the standards of medical practice
generally recognized or accepted in the United States.”
        45
             Id.
        46
             Ruan, 597 U.S. at 454.
        47
             Id.

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                                        No. 23-30191

The Court further explained that “[a]fter a defendant produces evidence that
he or she was authorized to dispense controlled substances, the Government
must prove beyond a reasonable doubt that the defendant knew that he or she
was acting in an unauthorized manner, or intended to do so.”48 After setting
forth the required mens rea, the Court remanded the cases to their respective
circuits for determinations in the first instance of whether the jury
instructions at issue were consistent with the Court’s decision. 49
        As an initial matter, Ruan addressed the mens rea requirement for a
conviction under § 841(a)(1), not the separate authorization element. To the
extent Ruan mentioned the definition of an authorized prescription, it did so
with reference to the regulatory definition Lamartiniere challenges here. 50 It
is therefore unsurprising that on remand, neither the Tenth nor Eleventh
Circuit questioned that the regulatory definition of authorization governed

        _____________________
        48
             Id.
        49
             Id. at 467.
        50
            See id. at 454 (noting that “as provided by regulation, a prescription is only
authorized when a doctor issues it ‘for a legitimate medical purpose . . . acting in the usual
course of his professional practice’” (alteration in original) (quoting 21 C.F.R.
§ 1306.04(a))); see also id. at 467 (citing 21 C.F.R. § 1306.04(a) as “the regulation defining
the scope of a doctor’s prescribing authority”); id. at 455 (“We assume, as did the courts
below and the parties here, that a prescription is ‘authorized’ and therefore lawful if it
satisfies [§ 1306.04(a)].”).

                                             25
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                                        No. 23-30191

the third element of the offense.51 And since Ruan, both this Court52 and our
sister circuits53 have rejected similar challenges to § 1306.04(a)’s definition
of authorization.        Simply put, Ruan did not even question, let alone

        _____________________
        51
          See Kahn II, 58 F.4th at 1319 (“Here, the government is correct that the Supreme
Court has acknowledged that ‘the scope of a doctor’s prescribing authority’ remains
tethered ‘to objective criteria such as legitimate medical purpose and usual course of
professional practice’” (quoting Ruan, 597 U.S. at 467)); United States v. Ruan, 56 F.4th
1291, 1296 (11th Cir. 2023) (Ruan II) (per curiam) (“The relevant drugs in this case are
only ‘authorized’ to be dispensed pursuant to a prescription, and an effective prescription
must be made for a ‘legitimate medical purpose by an individual practitioner acting in the
usual course of his professional practice.’” (quoting 21 C.F.R. § 1306.04(a))), cert. denied,
144 S. Ct. 377 (2023).
        52
             See Pierre, 88 F.4th at 582 n.8 (rejecting the defendant’s argument that “it was
error to ask the jury whether he agreed to unlawfully dispense drugs ‘outside the scope of
professional practice or without a legitimate medical purpose,’” because the instruction
“correctly conveyed what the regulation provides”); United States v. Capistrano, 74 F.4th
756, 771 n.51 (5th Cir. 2023) (same), cert. denied, 144 S. Ct. 516 (2023); see also Little, 2023
WL 7294199, at *9–10 (rejecting the defendant’s preserved challenge to the sufficiency of
the evidence about whether the charged prescriptions were outside the usual course of
professional practice or lacked a legitimate medical purpose). Lamartiniere argues that
Pierre and Capistrano are “not binding on this Court” because the Court’s authorization
discussion was dicta and both cases only reviewed the jury instructions under our plain-
error standard of review. Although both Pierre and Capistrano were decided under a
standard of review different from the one in this case, the relevant statements were not
dicta because they were essential to the holdings given that defendants in both cases were
challenging the definition of authorization as articulated in the jury instructions. See Int’l
Truck & Engine Corp. v. Bray, 372 F.3d 717, 721 (5th Cir. 2004) (“A statement is not dictum
if it is necessary to the result or constitutes an explication of the governing rules of law.”).
        53
           See, e.g., United States v. Heaton, 59 F.4th 1226, 1238–40 & 1241 n.17 (11th Cir.
2023) (rejecting a defendant’s challenge to jury charges reflecting the regulatory language
that a prescription is unauthorized if it is issued “outside the usual course of professional
practice” or “for no legitimate medical purpose”); United States v. Bauer, 82 F.4th 522,
528 (6th Cir. 2023) (“Registered doctors are among those ‘authorized’ to prescribe
controlled substances but only when the doctor ‘issued [the prescription] for a legitimate
medical purpose . . . acting in the usual course of his professional practice.’” (alterations in
original) (quoting 21 C.F.R. § 1306.04(a))).

                                              26
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                                         No. 23-30191

“unequivocally overrule” Armstrong’s use of the regulatory definition of
authorization.
        Lamartiniere next contends that because Congress did not authorize
the Attorney General to define the scope of authorization, Armstrong’s
reliance on a regulation (as opposed to the underlying statute) runs afoul of
the major questions doctrine and conflicts with Cargill’s holding that agency
interpretations of criminal statutes are not entitled to deference. But, as
recognized by Armstrong, the Supreme Court in Gonzales made clear that
§ 1306.04(a)’s definition of authorization “does little more than restate the
terms of the [CSA] itself.”54 Lamartiniere does not suggest that Gonzales has
been overruled, and to the contrary, relies on the case throughout his briefing.
Lamartiniere’s arguments are therefore foreclosed by the Supreme Court’s
holding in Gonzales.
        Under the rule of orderliness, we remain bound to follow established
precedent that a prescription is unauthorized under § 841(a)(1) if it lacks a
legitimate medical purpose or was issued outside the usual course of
professional practice. Because the district court’s instructions defining
authorization are consistent with this precedent, Lamartiniere’s challenge to
these instructions lacks merit.
                                              C.
        Lamartiniere next renews his preserved challenge to the district
court’s state-licensing instruction. The challenged instruction, which is
based on 21 C.F.R. § 1306.03(a),55 informed the jury that in order to prescribe

        _____________________
        54
             Armstrong, 550 F.3d at 397 n.26 (quoting Gonzales, 546 U.S. at 257).
        55
          “A prescription for a controlled substance may be issued only by an individual
practitioner who is: (1) Authorized to prescribe controlled substances by the jurisdiction in

                                              27
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                                       No. 23-30191

controlled substances, a medical practitioner must be “[1] authorized . . . by
the jurisdiction in which he is licensed to practice his profession” and “[2]
in possession of a valid registration from the U.S. Drug Enforcement
Administration.”
        Lamartiniere asserts that the challenged instruction permitted the jury
to find him strictly liable for prescriptions he wrote after his license to
prescribe controlled substances was suspended by the Medical Board based
solely on a violation of § 1306.03(a). Specifically, Lamartiniere maintains
that the instruction allowed the jury to find that he lacked authorization to
issue the charged prescriptions without deciding whether they served a
legitimate medical purpose and despite the fact that he had a valid DEA
license to distribute controlled substances.
        Taken together, the district court’s jury instructions cannot be read as
giving jurors license to conclude that the prescriptions charged in Counts 1
through 7 were unauthorized solely because they were written after
Lamartiniere’s state medical license was partially suspended.56 In addition
to the state-licensing instruction, the court instructed the jury that a
“prescription is authorized if it is issued for a legitimate medical purpose by
an individual practitioner acting in the usual course of his professional
practice.” It further instructed jurors that in deciding whether Lamartiniere
issued prescriptions for a legitimate medical purpose in the usual course of
professional practice, they “may consider all of the Defendant’s actions and

        _____________________
which he is licensed to practice his profession and (2) Either registered or exempted from
registration pursuant to §§ 1301.22(c) and 1301.23 of this chapter.” 21 C.F.R. § 1306.03(a).
        56
           See United States v. Phea, 755 F.3d 255, 266 (5th Cir. 2014) (“[S]pecific jury
instructions are to be judged not in isolation, but must be considered in the context of the
instructions as a whole and the trial record.” (internal quotation marks and citation
omitted)).

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                                       No. 23-30191

the circumstances surrounding them.” Finally, the court cautioned jurors
that even if they found that Lamartiniere “violated applicable civil or
administrative rules, regulations, or contract terms, that alone would not be
a criminal violation,” but that such violations “may be relevant to determine
whether [Lamartiniere] acted . . . knowingly, intentionally, and without
authorization.”
        These instructions, read as a whole, did not impermissibly require the
jury to convict Lamartiniere simply for prescribing controlled substances
with a suspended state license. Instead, the instructions permitted jurors to
consider the fact that Lamartiniere issued prescriptions with a suspended
state license in violation of § 1306.03(a) as evidence that those prescriptions
were not issued for a legitimate medical purpose or in the usual course of
professional practice. This Court has upheld the use of regulations for this
purpose in both United States v. Bennett57 and United States v. Brown.58
Indeed, as in Bennett, the fact that Lamartiniere wrote these prescriptions
after his state license was suspended was relevant evidence for the jury to
consider in determining whether the prescriptions were outside the scope of
his professional practice.59          Furthermore, the fact that Lamartiniere

        _____________________
        57
           In Bennett, we rejected the argument that a § 841(a)(1) conviction was based on
the defendant’s “failure to adhere to medical regulations, rather than the elements of the
crimes charged.” 874 F.3d at 243. In particular, we held that the Government’s reference
to relevant regulations was appropriate given that the regulations “helped clarify the scope
and contour of ‘outside the course of professional practice’—the very purpose for which
the trial was being conducted—and thus did not work a due process violation against [the
defendant].” Id. at 245.
        58
          In Brown, we similarly rejected the argument that the “prosecution secured a
criminal conviction by proving that the [defendant] pharmacists violated the [Texas
Pharmacy Laws and Regulations]” by acknowledging the “commonplace use of duly issued
regulations in clarifying the scope and contour of criminal laws.” 553 F.3d at 791.
        59
         See Bennett, 874 F.3d at 245 (holding that reference to the relevant regulations
was appropriate because the regulations “helped clarify the scope and contour of ‘outside

                                            29
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                                        No. 23-30191

maintained his DEA registration at the time is of no moment. The Supreme
Court has made clear that a physician is not exempt from prosecution under
§ 841(a)(1) simply by having a DEA registration. 60 Accordingly, the district
court did not err by giving the state-licensing instruction.
                                             D.
        Turning to Lamartiniere’s challenges to the district court’s mens rea
instructions, Lamartiniere asserts that both the court’s articulation of the
mens rea element and its instructions defining that element run afoul of the
Supreme Court’s decision in Ruan.
                                             1.
        In stating the fourth element of a § 841(a)(1) offense—the mens rea
requirement—the district court instructed the jury that the Government was
required to prove “that the Defendant knew he was acting in an unauthorized
manner when he dispensed the controlled substance or intended to act in an
unauthorized manner.”             The court issued this instruction instead of
Lamartiniere’s proposed instruction that the Government was required to
prove “the defendant knew or intended that his conduct was unauthorized.”
        On appeal, Lamartiniere argues that there is an important distinction
between knowingly acting in an unauthorized manner and knowing that a
prescription is unauthorized. Because Lamartiniere did not challenge the

        _____________________
the course of professional practice’”); cf. Moore, 423 U.S. at 140–41 (“In the case of a
physician . . . [the CSA] contemplates that he is authorized by the State to practice medicine
and to dispense drugs in connection with his professional practice.”).
        60
          See Moore, 423 U.S. at 131–32 (“We think the statutory language cannot fairly be
read to support the view that all activities of registered physicians are exempted from the
reach of § 841 simply because of their status.”).

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                                        No. 23-30191

district court’s articulation of the mens rea element below,61 and instead
agreed that the instruction’s language was “directly from Ruan,” we review
his challenge for plain error.
        As Lamartiniere recognized below, the district court’s statement of
the mens rea element comes from Ruan. Specifically, Ruan held that “the
Government must prove beyond a reasonable doubt that the defendant
knowingly or intentionally acted in an unauthorized manner.” 62 Because
there is no meaningful difference between this language in Ruan and the
district court’s articulation of the mens rea element, the instruction was not
erroneous, plain or otherwise.
                                             2.
        Lamartiniere further contends that even if the district court’s
instruction was correct, the way the court went on to define the mens rea
element was inconsistent with Ruan. In particular, he challenges the district
court’s instruction that “knowingly issuing a prescription outside the course
of professional practice is a sufficient condition to convict a medical
practitioner of unlawful dispensation of a controlled substance” 63 and
“[l]ikewise, knowingly issuing a prescription without a legitimate medical

        _____________________
        61
           See United States v. Rosenthal, 805 F.3d 523, 530 (5th Cir. 2015) (recognizing that
the defendant did not preserve his challenges to the jury instructions simply by “proffering
jury instructions that were refused”).
        62
             Ruan, 597 U.S. at 457.
        63
          To the extent Lamartiniere argues that the mens rea element can only be satisfied
if the Government shows he knowingly issued prescriptions without a legitimate medical
purpose, that argument is foreclosed by Ruan which makes clear the Government can
compare a defendant’s subjective beliefs against objective criteria, including the usual
course of professional practice. Id. at 467.

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                                       No. 23-30191

purpose is a sufficient condition to convict a medical practitioner of unlawful
dispensation of a controlled substance.”
        According to Lamartiniere, in order to establish the mens rea element,
a “knowing violation of the standard articulated in CFR § 1306.04(a) is
circumstantial evidence that a defendant knew his conduct was outside the
scope of his CSA authorization,” but pursuant to Ruan, it is “not
dispositive.” Because Lamartiniere preserved his challenge to the definition
of the mens rea requirement, our review is de novo.
        In Ruan, the Court overruled decisions from the Tenth and Eleventh
Circuits that required the Government to prove that a physician “either:
(1) subjectively knew a prescription was issued not for a legitimate medical
purpose; or (2) issued a prescription that was objectively not in the usual
course of professional practice.”64 Specifically, the Court rejected the
assertion that the Government could establish a defendant’s mens rea by
proving the defendant did not make an “objectively reasonable attempt to
ascertain and act within the bounds of professional medicine.” 65 In so
holding, the Court provided the following guidance on establishing mens rea:
        The Government, of course, can prove knowledge of a lack of
        authorization through circumstantial evidence. And the regu-
        lation defining the scope of a doctor’s prescribing authority
        does so by reference to objective criteria such as “legitimate
        medical purpose” and “usual course” of “professional prac-
        tice.” As we have said before, “the more unreasonable” a de-
        fendant’s “asserted beliefs or misunderstandings are,” espe-
        cially as measured against objective criteria, “the more likely
        _____________________
        64
           Id. at 456–57 (quoting United States v. Kahn, 989 F.3d 806, 825 (10th Cir. 2021),
vacated and remanded sub nom. Ruan, 597 U.S. 450); id. at 456 (stating the Eleventh Circuit
jury instructions).
        65
             Id. at 465.

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                                           No. 23-30191

        the jury . . . will find that the Government has carried its burden
        of proving knowledge.” But the Government must still carry
        this burden. And for purposes of a criminal conviction under
        § 841, this requires proving that a defendant knew or intended
        that his or her conduct was unauthorized.66
        On remand, the Eleventh Circuit vacated the defendants’ convictions
under § 841(a)(1) after concluding that “the district court did not adequately
instruct the jury that the defendants must have ‘knowingly or intentionally’
prescribed outside the usual course of their professional practices.” 67 In
subsequent cases, the Eleventh Circuit has concluded there is “no Ruan
error” in mens rea instructions that require the Government to prove the
defendant subjectively knew a controlled substance prescription lacked a
legitimate medical purpose or was outside the usual course of professional
practice.68
        In the consolidated case remanded to the Tenth Circuit—Kahn II—
the court there concluded that the district court’s mens rea instruction was
erroneous under Ruan for two reasons.69 “First, Ruan expressly disallows
conviction under § 841(a)(1) for behavior that is only objectively

        _____________________
        66
             Id. at 467 (alteration in original) (internal citations omitted).
        67
             Ruan II, 56 F.4th at 1298.
        68
           See Heaton, 59 F.4th at 1241–42 & n.16 (rejecting the defendant’s challenge to
the jury instruction as to the mens rea element because the “jury was properly instructed
that whether [defendant] prescribed controlled substances for a legitimate medical purpose
‘depend[ed] on his subjective belief,’” and although the jury was instructed that the usual
course of professional practice inquiry was objective, the error was harmless because “the
government presented overwhelming evidence that [defendant] subjectively knew his
conduct fell outside the usual course of his professional practice”); see also United States v.
Duldulao, 87 F.4th 1239, 1258 (11th Cir. 2023) (summarizing circuit precedent on
§ 841(a)(1)’s mens rea jury instructions).
        69
             Kahn II, 58 F.4th at 1315–18.

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                                        No. 23-30191

unauthorized.”70 Thus, the court’s instruction treating the usual course of
professional practice inquiry as wholly objective was inconsistent with
Ruan.71 And second, “Ruan treats the two criteria in § 1306.04(a) not as
distinct bases to support a conviction, but as . . . circumstantial evidence of a
defendant’s subjective intent to act in an unauthorized manner.” 72
Accordingly, the Tenth Circuit held that “because [the instructions] allowed
the jury to convict [defendant] after concluding either that [defendant]
subjectively knew a prescription was issued not for a legitimate medical
purpose, or that he issued a prescription that was objectively not in the usual
course of professional practice, . . . [b]oth approaches run counter to Ruan.”73
The court underscored that “the government’s showing of objective criteria,
without proving that a defendant actually intended or knew he or she was
acting in an unauthorized way, is not enough to convict.”74
        Lamartiniere emphasizes that Kahn II supports his challenge to the
mens rea jury instructions here because it casts doubt on whether a jury could
convict a defendant solely for knowingly violating the criteria in § 1306.04(a).
But as Lamartiniere acknowledges, we are not bound by Kahn II, and both
the Eleventh and Sixth Circuits75 have affirmed—consistent with the

        _____________________
        70
             Id. at 1316.
        71
             Id.
        72
          Id.; see also id. at 1319 (“A physician’s serial disregard of accepted medical norms
constitutes relevant evidence of his mental state . . . .”).
        73
             Id. at 1316.
        74
             Id. at 1315.
        75
           See United States v. Anderson, 67 F.4th 755, 766, 769–70 (6th Cir. 2023) (per
curiam) (upholding defendant’s § 841(a)(1) convictions after finding that a jury could
conclude that the defendant “knowingly prescribed controlled substances without a
legitimate medical purpose and outside the usual course of professional practice”), cert.
denied, 144 S. Ct. 552 (2024).

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                                          No. 23-30191

instructions given in this case—that a defendant knowingly acts in an
unauthorized manner when he or she prescribes controlled substances
knowing they are without a legitimate medical purpose or knowing they are
outside the usual course of professional practice. Moreover, this Court, in a
plain-error review case post-Ruan, held that “a defendant can be convicted
either for knowing prescriptions were issued for an illegitimate purpose or
knowing they were dispensed outside the usual course of professional
practice.”76
        We find no error in the district court’s instructions on the mens rea
element. Consistent with Ruan, the court’s instructions made clear from the
outset that in order to convict Lamartiniere the jury had to find the
Government proved beyond a reasonable doubt that he knew he was acting in
an unauthorized manner when he dispensed the controlled substances. 77
Maintaining the focus on Lamartiniere’s subjective intent, the district court
further instructed jurors that “knowingly issuing a prescription outside the
course of professional practice is a sufficient condition to convict a medical
practitioner” and that “knowingly issuing a prescription without a legitimate
medical purpose” is also “a sufficient condition to convict a medical
practitioner.” Such an instruction is consistent with Ruan’s statement that
jurors are free to consider the reasonableness of a defendant’s beliefs “as
measured against objective criteria,” such as “legitimate medical purpose”
and “usual course” of “professional practice.”78                     And because the
instructions required jurors to focus on Lamartiniere’s subjective intent

        _____________________
        76
             Capistrano, 74 F.4th at 771 n.51.
        77
           See Ruan, 597 U.S. at 467 (“And for purposes of a criminal conviction under
§ 841, this requires proving that a defendant knew or intended that his or her conduct was
unauthorized.”).
        78
             Id.

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                                        No. 23-30191

under both prongs of § 1306.04(a), they are readily distinguishable from the
instructions reviewed in Ruan and rejected by our sister circuits on remand.79
        Moreover, the instructions as a whole conveyed to jurors that to the
extent they found Lamartiniere knowingly prescribed controlled substances
without a legitimate medical purpose or outside the usual course of
professional conduct, they should treat such findings as probative
circumstantial evidence that he knew his actions were unauthorized. For
example, jurors were instructed that in determining whether Lamartiniere
issued prescriptions “for a legitimate medical purpose in the usual course of
professional practice,” they “may consider all of [his] actions and the
circumstances surrounding them.”                  And critically, jurors were also
instructed that “[k]nowingly keeping insufficient medical records alone does
not establish the Defendant’s guilt” and nor do any actions he took “outside
the standard of care generally required of physicians.” But that they “may
consider . . . evidence of such facts when determining whether the Defendant
. . . . intended to act in an unauthorized manner.”
        The above instructions properly focused on Lamartiniere’s subjective
intent, while also recognizing that under Ruan, the jury may consider the
reasonableness of Lamartiniere’s beliefs as measured against objective

        _____________________
        79
           Id. at 456–57; see also Kahn II, 58 F.4th at 1316 (noting that the district court’s
instructions treated the second prong of § 1306.04(a) “as wholly objective, considering
whether a defendant-practitioner objectively acted within that scope [of professional
practice], regardless of whether he believed he was doing so” (internal quotation marks and
citation omitted)); Duldulao, 87 F.4th at 1251 (“Before Ruan[], our precedent required the
government to show that a defendant subjectively knew he was acting not for a legitimate
medical purpose under § 841” but “when it came to whether a physician acted outside the
usual course of professional practice, the appropriate focus [was] not on the subjective
intent of the doctor but rather on whether, from an objective standpoint, the controlled
substances were dispensed in the usual course of professional practice.” (internal quotation
marks and citation omitted)).

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                                        No. 23-30191

criteria. Accordingly, viewing the instructions as a whole, we find no error
under Ruan.
                                             3.
        Third, and finally, Lamartiniere argues that even if the Government
could satisfy § 841(a)(1)’s mens rea element by showing he wrote
prescriptions knowing they were outside the usual course of professional
practice, the district court’s good-faith instruction did not require the
Government to prove as much. The district court instructed jurors that a
controlled substance is authorized if it is “prescribed by [a physician] in good
faith,” which means a physician’s “honest effort to prescribe for a patient’s
condition in accordance with standards of medical practice generally
recognized or accepted in the United States.”
        Lamartiniere objects to the instruction on the grounds that it allowed
the jury to convict him based on an objective standard, regardless of whether
the jury found that he believed his prescriptions were in accordance with
standards of medical practice. He also asserts that the court’s good-faith
definition was “nearly identical” to the good-faith standard rejected in Ruan.
Because Lamartiniere raised the objections to the good-faith instruction he
presses on appeal for the first time in his motion for a new trial, our review is
limited to plain error.80
        In requiring the Government to prove that a defendant subjectively
knew that his prescriptions were unauthorized, the Court in Ruan rejected
the “substitute mens rea standard” offered by the Government, which would

        _____________________
        80
           See United States v. Green, 47 F.4th 279, 289 (5th Cir. 2022) (reviewing a
defendant’s challenge to jury instructions under plain error because the defendant “did not
object to the jury instructions in the district court until his Rule 33 motion for a new trial
and thus did not preserve the issue for appeal”), cert. denied, 143 S. Ct. 747 (2023).

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                                         No. 23-30191

have read § 841(a)(1) “as implicitly containing an ‘objectively reasonable
good-faith effort’ or ‘objective honest-effort standard.’”81           The Court
refused to adopt the Government’s standard for two reasons: (1) § 841 does
not include words such as “good faith,” “objectively,” “reasonable,” or
“honest effort” and (2) the proposed standard “would turn a defendant’s
criminal liability on the mental state of a hypothetical ‘reasonable’ doctor,
not on the mental state of the defendant himself or herself.” 82
       In both jury instructions reviewed in Ruan, the district courts included
good-faith instructions. In the appeal from the Eleventh Circuit, the district
court instructed “the jury that a doctor acts lawfully when he prescribes ‘in
good faith as part of his medical treatment of a patient in accordance with the
standard of medical practice generally recognized and accepted in the United
States.’”83 And in the appeal from the Tenth Circuit, the district court
“instructed the jury that it should not convict if it found that [the defendant]
acted in ‘good faith,’ defined as ‘an attempt to act in accordance with what a
reasonable physician should believe to be proper medical practice.’” 84
       On remand, the Eleventh Circuit explained that the phrase “good
faith,” absent qualification, “encompasses both subjective and objective
good faith,” and that in Ruan, the Supreme Court “explicitly held [that] only
the subjective version is appropriate.”85 The Eleventh Circuit ultimately
remanded the case to the district court after concluding that “the remaining
jury instructions did not help convey that a subjective analysis was

       _____________________
       81
            Ruan, 597 U.S. at 465.
       82
            Id.
       83
            Id. at 455.
       84
            Id. at 456.
       85
            Ruan II, 56 F.4th at 1297.

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                                          No. 23-30191

required.”86 On remand in the Tenth Circuit, the court held that the district
court’s good-faith instruction was “problematic” under Ruan by relying “on
terms like ‘reasonable physician’ and ‘should believe,’” which “impose an
objective standard and are exactly the type of language that the Supreme
Court stated is impermissible.”87
        Here, the district court’s good-faith instruction is distinguishable in
three important ways from the instructions at issue in Ruan. First, unlike the
Government’s proposed mens rea standard rejected by the Court, the district
court’s good-faith instruction did not include phrases such as “objectively
reasonable good-faith effort,” or “objective honest-effort standard.”88
Second, unlike the instruction from the Tenth Circuit appeal, the instruction
here did not use the phrase, “what a reasonable physician should believe,”
which denotes an objective nature to the good-faith inquiry.
        Finally, unlike the instruction from the Eleventh Circuit appeal, the
instruction here defined good faith in terms of the defendant’s subjective
belief by using the phrase “honest effort,” and any objective aspect of the
instruction was properly qualified in the context of the instructions as a
whole.89 Specifically, the district court’s charge that “acting outside the
standard of care generally required of physicians throughout the United
States alone does not establish the Defendant’s guilt,” makes clear that any
objective aspect of the good-faith instruction is not a basis, by itself, to convict
a defendant. Furthermore, the court’s instruction that the Government must

        _____________________
        86
             Id.
        87
             Kahn II, 58 F.4th at 1317.
        88
             Ruan, 597 U.S. at 465.
        89
         Cf. Ruan II, 56 F.4th at 1298 (“[T]he summary of the charge also did not help to
convey the required mens rea.”).

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                                         No. 23-30191

prove the defendant’s knowledge or intent to act in an unauthorized manner
squarely frames the mens rea inquiry as a subjective one. Because the good-
faith instruction, read in context of the full jury charge, properly
communicated to the jury the appropriate mens rea standard, the instruction
was not plainly erroneous under Ruan.90
                                               E.
        Lamartiniere’s final claim of jury instruction error is that the district
court improperly gave a deliberate ignorance instruction.91                        Because
Lamartiniere preserved this challenge, we review the district court’s
instruction under an abuse of discretion standard.92
        This Court has “often cautioned against the use of the deliberate
ignorance instruction.”93 We have repeatedly emphasized that a deliberate
ignorance instruction should not be given as “a backup or supplement in a
case that hinges on a defendant’s actual knowledge,” and that the
“instruction is appropriate only in the circumstances where a defendant
‘claims a lack of guilty knowledge and the proof at trial supports an inference

        _____________________
        90
           See United States v. Mencia, No. 18-13967, 2022 WL 17336503, at *14 (11th Cir.
Nov. 30, 2022) (per curiam) (“Consistent with the Court’s holding in Ruan, the good faith
instruction in this case required the jury to consider [defendant]’s subjective intent in
determining whether he had a ‘good faith reasonable belief’ that the distribution of
controlled substances was unauthorized.”).
        91
          The district court gave the following instruction on deliberate ignorance: “[y]ou
may find that Defendant had knowledge of a fact if you find that the Defendant deliberately
closed his eyes to what would otherwise have been obvious to him.” The court further
instructed that “[w]hile knowledge on the part of the Defendant cannot be established
merely by demonstrating that the Defendant was negligent, careless, or foolish, knowledge
can be inferred if the Defendant deliberately blinded himself to the existence of a fact.”
        92
             United States v. Lee, 966 F.3d 310, 324 (5th Cir. 2020).
        93
             United States v. Mendoza-Medina, 346 F.3d 121, 132 (5th Cir. 2003).

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                                          No. 23-30191

of deliberate indifference.’”94 To support that inference, the evidence at trial
must show: “(1) the defendant was subjectively aware of a high probability of
the existence of the illegal conduct; and (2) the defendant purposely
contrived to avoid learning of the illegal conduct.”95
        The district court rejected Lamartiniere’s challenge to the inclusion
of the deliberate ignorance instruction after concluding that the “evidence at
trial plainly showed that Defendant ignored multiple obvious signs that his
patients were abusing or illegally diverting the prescriptions he wrote for
them.” The court further explained that “[i]n particular, the undercover
recordings of Defendant’s interactions with law enforcement agents posing
as patients captured numerous statements confirming that Defendant was
acutely aware of the illegality of his conduct.” Although Lamartiniere
disagrees with the district court’s characterization of the evidence, he
nevertheless contends that the court’s reasoning is inconsistent with our
precedent that the deliberate ignorance instruction is inappropriate in cases
premised on actual knowledge. Moreover, he maintains that the evidence at
trial showed he directly confronted facts about illegal activity.
        The thrust of the Government’s case was that Lamartiniere knew he
was prescribing controlled substances in an unauthorized manner to patients
he knew were abusing or diverting the drugs. And although Lamartiniere
disputes that he had the requisite knowledge, the evidence presented at trial
was to the contrary.
        For example, the Government presented evidence that Lamartiniere
wrote prescriptions after he knew the Medical Board partially suspended his

        _____________________
        94
           United States v. Kuhrt, 788 F.3d 403, 417 (5th Cir. 2015) (quoting United States
v. Brooks, 681 F.3d 678, 701 (5th Cir. 2012)).
        95
             Id. (quoting Brooks, 681 F.3d at 701).

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                                      No. 23-30191

license based on its finding that his “continued ability to prescribe controlled
substances to his patients could constitute a risk of imminent patient harm.”
It also presented evidence that Lamartiniere continued to prescribe Schedule
II controlled substances to Dixon, Crawford, Henson, and Boudreaux, even
though each of them testified they told Lamartiniere that they had illegally
obtained drugs from their friends. Lamartiniere’s records also confirm that
he knew Boudreaux and Henson both failed drug tests, and that Doiron was
diagnosed by another physician as suffering from drug abuse.                        And
Lamartiniere himself testified that he saw the needle tracks on Boudreaux’s
arms, which he acknowledged was an indication of heroin use.
        Moreover, the video and audio recordings from the undercover agents
include numerous statements by Lamartiniere confirming that he knew his
prescriptions were unauthorized. For example, Lamartiniere told Dixon that
prescribing Aleve or Tylenol for him would be “[a] little bit more legal.” He
later admitted to Dixon that he was doing “neither” of the things necessary
to ensure Dixon was not diverting his prescriptions, and that he could have
his license taken away for “not doing that kind of stuff.” Lamartiniere also
told Crawford that his symptoms were “not something . . . [that] any doctor
should prescribe a . . . major narcotic [for], and that he had to be “careful”
about prescribing him controlled substances “without an MRI or records,”
because it “doesn’t look right.” As the Government reiterated in closing
arguments, these recorded statements show that Lamartiniere “knew what
he was doing was wrong” and “knew that these prescriptions were not
legitimate.”
        Given this evidence (and more) of actual knowledge, it was arguably
an error for the district court to give the deliberate ignorance instruction. 96
        _____________________
        96
         See id. (“The government constructed its case on the premise that Appellants
were criminally liable based upon their actual knowledge of the fraud and their efforts to

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                                             No. 23-30191

But assuming arguendo that the district court did err, we have held that “any
such error is harmless where substantial evidence of actual knowledge is
presented at trial.”97 As discussed above, there was ample evidence at trial
that Lamartiniere had actual knowledge that his prescriptions were
unauthorized. Accordingly, any error by the district court’s inclusion of the
deliberate ignorance instruction was harmless.
                                                  III.
          Lamartiniere argues there was insufficient evidence to support his
convictions.            The standard of review for sufficiency-of-the-evidence
challenges “depends on whether the claims were preserved.” 98 “We review
claims preserved through a Rule 29 motion de novo, but ‘with substantial
deference to the jury verdict.’”99 Under this standard, we will uphold a
jury’s verdict as long as “a reasonable trier of fact could conclude . . . the
elements of the offense were established beyond a reasonable doubt.”100
Additionally, in light of the deference given to a jury’s factfinding role, we
“view[] the evidence in the light most favorable to the verdict and draw[] all
reasonable inferences from the evidence to support the verdict.” 101 In short,

          _____________________
further the fraud. Thus, it arguably was error for the district court to give the deliberate
ignorance instruction.”).
          97
          United States v. St. Junius, 739 F.3d 193, 204–05 (5th Cir. 2013) (internal
quotation marks and citation omitted).
          98
               United States v. Suarez, 879 F.3d 626, 630 (5th Cir. 2018).
          99
                Id. (quoting United States v. Delgado, 672 F.3d 320, 330–31 (5th Cir. 2012) (en
banc)).
          100
                Id. (alteration in original) (citation omitted).
          101
                United States v. Jimenez-Elvirez, 862 F.3d 527, 533 (5th Cir. 2017) (citation
omitted).

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                                          No. 23-30191

“a defendant seeking reversal on the basis of insufficient evidence swims
upstream.”102
        However, if a sufficiency-of-the-evidence claim was not preserved,
our review is only for plain error.103 Under plain-error review, the defendant
“must show a clear or obvious legal error that affects his substantial rights
and ‘seriously affect[s] the fairness, integrity, or public reputation of the
judicial proceedings.’”104 We have held that relief “under this exacting
standard” is appropriate “only if the Government’s evidence is obviously
insufficient and the defendant shows a manifest miscarriage of justice.” 105
        Because Lamartiniere filed motions for acquittal challenging the
sufficiency of the evidence against him, we review his preserved challenges
de novo. But as to his claim raised for the first time on appeal—that the
Government did not present sufficient evidence that the pre-license
suspension prescriptions were outside the usual course of professional
practice under United States v. Rosen106—our review is limited to plain
error.107

        _____________________
        102
              Capistrano, 74 F.4th at 766 (internal quotation marks and citation omitted).
        103
              Suarez, 879 F.3d at 630.
        104
              Id. (alteration in original) (quoting Puckett v. United States, 556 U.S. 129, 135
(2009)).
        105
              Id. at 631 (internal quotation marks and citations omitted).
        106
              582 F.2d 1032 (5th Cir. 1978).
        107
            Lamartiniere disputes that he “waive[d] or forfeit[ed] any of the sufficiency
arguments presented in his opening brief,” asserting that his motions for acquittal argued
that the evidence was insufficient to establish both that the prescriptions were unauthorized
and that he knew they were unauthorized. But Lamartiniere’s Rule 29 motions focused on
whether the prescriptions lacked a legitimate medical purpose and whether he had the
requisite knowledge. To the extent Lamartiniere challenged that the prescriptions were
outside the usual course of professional practice, he only argued that Dr. Kennedy’s
testimony that his practices fell outside the rules set forth by the Louisiana Medical Board

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                                        No. 23-30191

        As reflected in the jury instructions, to convict Lamartiniere of the
offenses charged under § 841(a)(1), the Government was required to prove
that he: (1) dispensed a controlled substance; (2) dispensed the controlled
substance knowingly or intentionally; (3) his dispensation of the controlled
substance was not authorized; and (4) he knew he was acting in an
unauthorized manner when he dispensed the controlled substance or
intended to act in an unauthorized manner. Lamartiniere does not dispute
that there was sufficient evidence as to the first two elements, thus focusing
our attention on whether there was sufficient evidence that the prescriptions
were unauthorized, and that he knew they were unauthorized.
                                             A.
        Counts 1 through 7 of the superseding indictment charged
Lamartiniere with issuing prescriptions for controlled substances on January
5, 2016, after his state license was partially suspended.                     As to these
convictions, Lamartiniere contends there was insufficient evidence to
establish the charged prescriptions lacked a legitimate medical purpose and
were therefore unauthorized.              Lamartiniere concedes that there was
sufficient evidence for the jury to conclude that he received the Medical
Board’s suspension letter before issuing the prescriptions on January 5, 2016,
and that he knew the suspension prohibited him for issuing those

        _____________________
was insufficient to prove his conduct fell outside the usual course of professional practice
in the United States generally. But his challenge on appeal is centered on whether there is
sufficient evidence that the charged prescriptions were outside the usual course of
professional practice under the factors identified by this Court in United States v. Rosen.
Accordingly, Lamartiniere’s argument on appeal regarding the sufficiency of evidence
about the usual course of professional practice prong is distinct from his sufficiency
challenge in district court on this prong. “Where, as here, a defendant asserts specific
grounds for a specific element of a specific count for a Rule 29 motion, he waives all others
for that specific count,” and our review of those waived objections is limited to plain error.
United States v. Herrera, 313 F.3d 882, 884–85 (5th Cir. 2002) (en banc) (per curiam).

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                                  No. 23-30191

prescriptions under Louisiana’s medical regulations. But he contends that
because he still maintained his DEA registration, the Government did not
establish that the prescriptions were unauthorized because it provided no
analysis of the relevant patient files, and Dr. Kennedy only provided a
“conclusory” opinion that the prescriptions lacked a legitimate medical
purpose.
       The district court correctly recognized that Lamartiniere’s
sufficiency   arguments   “fall    flat”   under   “the   correct   view   of
‘authorization.’” In other words, Lamartiniere’s argument that there was
insufficient evidence that the prescriptions lacked a legitimate medical
purpose ignores the fact that the Government can also establish a
prescription is unauthorized if it is issued outside the usual course of
professional practice. It is undisputed that the Government presented
sufficient evidence for a reasonable jury to conclude that writing
prescriptions for controlled substances with a suspended state license is
outside the usual course of professional practice for a physician. And as
Lamartiniere acknowledges, there was sufficient evidence based on his own
testimony and Dr. Mouton’s testimony that he wrote the prescriptions on
January 5, 2016, despite knowing that his state license was partially
suspended and that such a suspension prohibited him from prescribing
controlled substances. We therefore reject Lamartiniere’s sufficiency-of-
the-evidence challenge as to his convictions for Counts 1 through 7.
                                      B.
       Lamartiniere also challenges the sufficiency of the evidence
supporting his pre-license suspension convictions (Counts 9, 13 through 16,
18 through 19, and 25 through 30). Lamartiniere first contends that the pre-
suspension prescriptions all served a legitimate medical purpose because

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                                      No. 23-30191

they helped his patients who were in pain and there was no evidence that his
patients abused their medication. We disagree.
        As to the convictions related to the undercover agents, the jury heard
testimony and undercover recordings that Lamartiniere did not establish a
legitimate pain diagnosis or require any objective evidence of a medical
problem before prescribing controlled substances.                      In both cases,
Lamartiniere failed to order diagnostic imaging or require prior medical
records, and instead relied on the agents’ vague descriptions of their pain.
For example, Dixon testified that each time he saw Lamartiniere he switched
which leg was the source of his pain. And Dr. Kennedy testified that
Lamartiniere’s diagnosis of Dixon with “disorder of the lower extremity”
was “so vague as to be essentially a useless diagnosis.” Additionally,
Lamartiniere’s assertion that his patients were in real pain cannot be
reconciled with his statement in an undercover recording that Crawford was
“someone that’s not really in a lot of pain,” and that his symptoms were
“really not something” doctors prescribe “major narcotic[s]” for.
        As for the convictions related to Lamartiniere’s former patients, the
jury heard testimony that each of these patients was abusing drugs, but that
Lamartiniere continued to prescribe them controlled substances and did not
adequately monitor them.108 In Boudreaux’s case, he tested positive for
heroin and negative for the drugs prescribed by Lamartiniere. Henson tested
        _____________________
        108
            See Lee, 966 F.3d at 318 (rejecting the defendants’ sufficiency-of-the-evidence
challenge to their convictions of conspiring to distribute controlled substances where
evidence showed they continued to prescribe controlled substances to their patients after
they “either test[ed] positive for illegal drugs or test[ed] negative for the drugs [the
defendants] had prescribed them”); Anderson, 67 F.4th at 769 (holding that the evidence
at trial was sufficient to support a conviction under § 841(a)(1) where the “jury heard
testimony from two of [defendant’s] former patients who testified that they either showed
signs of or admitted to addiction when they came to [defendant] asking for pain
medications”).

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positive for methadone, which Dr. Kennedy testified was especially
dangerous because of the potential interactions between methadone and high
doses of controlled substances. Finally, Doiron was diagnosed with drug
abuse while under Lamartiniere’s care, but instead of referring him to
substance abuse treatment or tapering his medication, Lamartiniere
continued to prescribe him controlled substances in what Dr. Kennedy
described as “alarming” quantities. Although Lamartiniere testified that he
monitored his patients for signs of addiction or abuse by conducting drug
screens and checking the PMP for evidence of doctor shopping, the
Government presented evidence to the contrary. For example, Dr. Kennedy
testified that there was no record of Lamartiniere’s ever drug testing Doiron,
and Boudreaux’s PMP report obviously showed he was both doctor and
pharmacy shopping.
       Moreover, Dr. Kennedy testified in no uncertain terms that each of
the charged prescriptions did not serve a legitimate medical purpose. Dr.
Kennedy’s conclusion is consistent with Dr. Mouton’s testimony and the
Medical Board’s letter to Lamartiniere informing him that it had information
he was “prescribing controlled substances without appropriate medical
justification or in a manner without concern for patient safety.” Viewing the
evidence in the light most favorable to the verdict, we conclude the
Government presented sufficient evidence that each of Lamartiniere’s pre-
suspension prescriptions did not serve a legitimate medical purpose.
       In the alternative, Lamartiniere, for the first time on appeal, contends
that even if the Government could show a prescription was unauthorized if it
was outside the course of professional practice, the Government failed to
present sufficient evidence to do so.           In support of this argument,

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Lamartiniere cites the factors this Court identified in Rosen109 as associated
with unauthorized prescriptions and contends that “the evidence at trial
negated most, if not all” of the factors. As noted above, we review this
sufficiency-of-the-evidence challenge for plain error.
        First, the Rosen factors are not an exclusive list of circumstances in
which prescriptions are unauthorized, and instead are simply “recurring . . .
examples” of “condemned behavior” that this Court “glean[ed] from
reported cases.”110 Second, the testimony, viewed in the light most favorable
to the verdict, supports a finding that many of the factors identified in Rosen
are present here, such as evidence of limited physical examinations, 111 early
prescription refills,112 the use of street slang by Lamartiniere’s patients,113 and

        _____________________
        109
             Those factors include: (1) an “inordinately large quantity of controlled
substances was prescribed;” (2) “[l]arge numbers of prescriptions were issued;” (3) “[n]o
physical examination was given;” (4) the “physician warned the patient to fill prescriptions
at different drug stores;” (5) the “physician issued prescriptions to a patient known to be
delivering the drugs to others;” (6) the “physician prescribed controlled drugs at intervals
inconsistent with legitimate medical treatment;” (7) the “physician involved used street
slang rather than medical terminology for the drugs prescribed;” (8) “[t]here was no logical
relationship between the drugs prescribed and treatment of the condition allegedly
existing;” and (9) the “physician wrote more than one prescription on occasions in order
to spread them out.” Rosen, 582 F.2d at 1036.
        110
              Id. at 1035–36.
        111
           Although the jury heard conflicting testimony about whether Lamartiniere
conducted physical exams during initial visits, the testimony was undisputed that he either
did not conduct exams on subsequent appointments or conducted only cursory ones.
        112
           There was testimony at trial that Lamartiniere refilled both Crawford’s and
Doiron’s prescriptions early based on unverified claims that their prescriptions had been
stolen or destroyed. And Lamartiniere renewed Dixon’s Norco prescription just ten days
after he wrote his initial prescription which was estimated to last Dixon a couple of months.
        113
          Both Crawford and Dixon used street slang to describe drugs, such as “roxies”
for Roxicodone and “addies” for Adderall.

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testimony that there was no logical connection between the prescriptions
Lamartiniere wrote and the alleged medical conditions he was treating.114
        And third, irrespective of the Rosen factors, the Government’s
evidence that the prescriptions corresponding to Lamartiniere’s convictions
were outside the usual course of professional practice was not “obviously
insufficient.”115 Dr. Kennedy testified that based on his review of the patient
records, Lamartiniere issued the prescriptions outside the usual course of
professional practice in part because he failed to conduct physical
examinations (or at least to document such examinations), review past
medical records, or require frequent drug tests. Additionally, Lamartiniere’s
practice of continuing to write prescriptions for his patients despite clear
signs of addiction and abuse is at odds with what Dr. Mouton testified was
the standard of care, which requires physicians to refer their patients to
substance abuse treatment and to taper their medications.116
        From the above sampling of the evidence alone, a jury could
reasonably infer that Lamartiniere issued the pre-suspension prescriptions
without a legitimate medical purpose or outside the usual course of
professional practice, and thus the prescriptions were unauthorized.

        _____________________
        114
           As an example, in an undercover recording, Lamartiniere tells Dixon that his use
of Adderall to stay awake was a “non-indication” of ADD, but ultimately agrees to write
him a prescription. Dr. Kennedy testified that Lamartiniere’s prescription for Adderall
was for an “illegitimate purpose.”
        115
              Suarez, 879 F.3d at 631 (internal quotation marks and citation omitted).
        116
             See Moore, 423 U.S. at 127, 142–43 (“The evidence presented at trial was
sufficient for the jury to find that respondent’s conduct exceeded the bounds of
‘professional practice,’” given that the respondent failed to keep accurate records, “gave
inadequate physical examinations or none at all[,] . . . ignored the results of the tests he did
make[,] . . . and took no precautions against [drug] misuse and diversion.”).

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        Lamartiniere also argues that that there was insufficient evidence to
satisfy the mens rea element as to the pre-suspension convictions. Without
providing any authority, Lamartiniere lists two “factors” that he deems to be
particularly relevant in determining mens rea: “(1) Did the doctor engage in
medical decision making and (2) did the doctor organize his practice in a
manner designed to exploit or profit from the addiction and dependency of
his patients.”
        The first “factor” Lamartiniere identifies appears to be another way
of asking whether a doctor knowingly prescribed controlled substances
without a legitimate medical purpose.              According to Lamartiniere, the
evidence presented at trial that he was “struggling” to find the medically
correct treatment shows that he was engaged in legitimate medical decision
making. But the jury could instead view Lamartiniere’s struggle to say “no”
to his patients as Dr. Kennedy testified—an indication that Lamartiniere
knew he was “considering something that is wrong.” Additionally, as
recounted in the discussion on the deliberate ignorance instruction, the
Government presented extensive evidence that Lamartiniere knew his
prescriptions were not for a legitimate medical purpose.117
        As to the second “factor” identified by Lamartiniere, he asserts that
his practice and fee structure undercut any finding that he knowingly wrote
unauthorized prescriptions. Lamartiniere highlights that he did not charge
patients on a per-prescription basis and that one patient, Henson, testified at
trial that Lamartiniere was “one of the hardest pain doctors . . . to obtain

        _____________________
        117
            See Lee, 966 F.3d at 318–19 (rejecting the defendants’ sufficiency-of-the-
evidence challenges to their convictions for conspiring to distribute controlled substances
in part because of evidence that for “at least some of the[] prescriptions” defendants “had
direct knowledge that the patients exhibited obvious drug-seeking behavior” but
nonetheless continued to prescribe drugs).

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narcotic medications” from. But Lamartiniere’s focus on these two pieces
of evidence, to the exclusion of extensive contrary evidence presented by the
Government, is inconsistent with the standard of review in this case, which
requires us to view the evidence in the light most favorable to the verdict. 118
        Even as it relates to the two pieces of evidence highlighted by
Lamartiniere, his arguments fall flat. For instance, even though Lamartiniere
did not require payment for each prescription he wrote, that by itself is not
inconsistent with the jury’s finding that he knowingly wrote unauthorized
prescriptions.119 In fact, the Government presented evidence that raised red
flags about the financial structure of Lamartiniere’s practice, such as the fact
he did not accept insurance or Medicaid.120 Similarly, although Henson
testified it was difficult to get controlled substances from Lamartiniere, that
is inconsistent with the fact that two undercover agents with vague
allegations of prior injuries, no medical records, no previous diagnoses, and
admissions of prior illegal drug use, were able to get prescriptions from
Lamartiniere for progressively more potent controlled substances.121
Accordingly, viewed in the light most favorable to the verdict, there was
sufficient evidence that Lamartiniere had the requisite mens rea.

        _____________________
        118
           See United States v. Cabello, 33 F.4th 281, 288 (5th Cir. 2022) (noting that we
place “a heavy thumb on the scale in favor of the verdict” in reviewing preserved
sufficiency-of-the-evidence challenges).
        119
           See Bauer, 82 F.4th at 529 (finding “ample circumstantial evidence from which
a jury could infer that [defendant] did have the required subjective knowledge of
unauthorized distribution” despite the defendant’s argument that “he lacked any financial
incentive to overprescribe opioids”).
        120
           See Lee, 966 F.3d at 317–18 (emphasizing that patients at defendants’ clinic
“could not use insurance for their first visit, and they could never use Medicaid” was a
hallmark of medical practices that serve as a front for dealing prescription drugs).
        121
            See United States v. Moreno-Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011) (“[A]ny
conflict in the evidence must be resolved in favor of the jury’s verdict.”).

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       In sum, the evidence presented at trial was sufficient to support
Lamartiniere’s convictions under § 841(a)(1) as to the pre-suspension
prescriptions.
                                   IV.
       For the foregoing reasons, we AFFIRM Lamartiniere’s convictions
under § 841(a)(1).

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