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Doctors rush to use Supreme Court ruling to escape opioid charges

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dr. Nelson Onaro admitted to writing illegal prescriptions last summer, though he said he only thought of his patients. From a small brick clinic in Oklahoma, he handed out hundreds of opioid pills and dozens of fentanyl patches with no legitimate medical purpose.

“Those drugs were prescribed to help my patients, from my own point of view,” Onaro said in court, as he reluctantly pleaded guilty to six counts of drug trafficking. Because he confessed, the doctor likely got a reduced sentence of three years or less in prison.

But Onaro changed his mind in July. In the days before his sentencing, he asked a federal judge to dismiss his plea deal and send his case to trial. For a chance of acquittal, he would face charges four times and the possibility of a harsher sentence.

Why take the risk? A Supreme Court ruling has raised the bar for conviction in a case like Onaro’s. In a June decision, the court said prosecutors had to prove not only that a prescription was medically unjustified — possibly because it was too large or dangerous, or simply not necessary — but also that the prescriber knew.

Suddenly, Onaro’s state of mind weighs more heavily in the courtroom. Prosecutors have not opposed the doctor’s withdrawal of his plea for most of his charges, admitting in a lawsuit that he faces “another legal calculation” following the Supreme Court decision.

The court’s unanimous decision complicates the Department of Justice’s ongoing efforts to hold irresponsible prescribers criminally liable for fueling the opioid crisis. Previously, lower courts had not taken into account the intent of a prescriber. Until now, doctors on trial have largely been unable to defend themselves by claiming that they acted in good faith when writing bad prescriptions. Now they can, lawyers say, although it’s not necessarily a card to get out of jail.

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“Essentially, the doctors were enthralled,” said Zach Enlow, Onaro’s attorney. “Now they can take off their handcuffs. But that doesn’t mean they’re going to win the fight.’

The Supreme Court Ruan v. United States decisionissued on June 27, was overshadowed by the nation-shaking controversy that had ignited three days earlier, when the court dismissed the federal abortion rights. But the lesser-known ruling is now quietly seeping through federal courthouses, where it has encouraged defendants to over-prescribe and could have a chilling effect on future prosecutions of doctors under the Controlled Substances Act.

Outline of the Supreme Court's Arguments
Attorney Lawrence Robbins pleads before the Supreme Court on behalf of two doctors who are challenging their drug trafficking convictions. In a unanimous decision in June 2022, the court raised the bar in such cases, saying that prosecutors must prove that prescribers knew their prescriptions were medically unjustified.

Art Lien


In the three months since it was issued, Ruan According to a KHN investigation of federal court files, the decision has been appealed in at least 15 pending prosecutions in 10 states. Doctors cited the decision in post-conviction appeals, acquittal requests, retrials, reversals of pleas and a failed attempt to exclude a prescribing expert’s testimony, arguing that their opinion was now irrelevant. Other defendants have successfully filed for adjournment of their cases so that the Ruan decision could be incorporated into their arguments at upcoming trials or hearings.

David Rivera, a former Obama-era U.S. attorney who once led prosecutions for overprescribing in Middle Tennessee, said he believes doctors have a “high chance” of overturning convictions if they were not allowed a defense in good faith. or if a jury was ordered to ignore one.

Rivera said defendants who ran real pill factories would still be convicted, even if a second trial were ultimately required. But the Supreme Court has extended a “lifeline” to a small group of defendants who “renounced their hearts, not their minds,” he said.

“What the Supreme Court is trying to do is separate a bad doctor from a person who may be licensed to practice medicine but who is not acting as a doctor at all and is a drug dealer,” Rivera said. “A doctor who acts on the genuine belief that he is doing the right thing, even though he may be terrible at his job and not allowed to entrust human lives – that is still not criminal.”

The Ruan The decision stemmed from the appeals of two doctors, Xiulu Ruan and Shakeel Kahn, who were separately convicted of running pill factories in Alabama and Wyoming, respectively, and subsequently sentenced to 21 and 25 years in prison. In both cases, prosecutors relied on a common tactic to show that the prescriptions were a crime: expert witnesses reviewed the defendants’ prescriptions and testified that they were far removed from what a reasonable doctor would do.

But in writing the Supreme Court opinion, then-Judge Stephen Breyer insisted that the burden of proof shouldn’t be so easy to overcome, and sent both convictions back to the lower courts for reconsideration.

Because doctors can and expect to distribute drugs, Breyer wrote, prosecutors must prove not only that they wrote prescriptions for no medical purpose, but also that they did so “knowingly or intentionally.” Otherwise, the courts risk punishing “conduct that is close to, but on the admissible side of, the criminal line,” Breyer wrote.

The unanimous verdict sent an unequivocal message to defense lawyers.

“This is a hyperpolarized time in America, and especially on the field,” Enlow said. “And yet this was a 9-0 ruling stating that the… gentlemen real “or the doctor’s mental state – it matters.”

Maybe nowhere was the Ruan decision that was more urgent than in the case of Dr. David Jankowski, a Michigan physician who was on trial when the burden of proof shifted beneath his feet.

Jankowski was convicted of federal drug and fraud offenses and faces 20 years in prison. in a announcement of the verdictthe DOJ said the doctor and his clinic gave people “no need for the drugs,” which were “sold on the street to feed the addictions of opioid addicts.”

Defense attorney Anjali Prasad said: Ruan verdict fell to jury deliberations in the case, but after prosecutors for weeks presented the argument that Jankowski’s behavior was not that of a reasonable prescriber — a legal standard that is no longer sufficient on its own to convict.

Prasad quoted the Ruan decision in a motion for a retrial, which was denied, saying she plans to use the decision as a basis for an upcoming appeals process. The attorney also said she is in talks with two other clients about challenging their convictions with… Ruan.

“My hope is that criminal defense attorneys like me will be more encouraged to take their cases to court and their clients will be 100% ready to fight the FBI, which is not an easy task,” Prasad said. “We’ll just fight it out in court. That way we can prevail.’

Some suspects try. So far, a few have had small victories. And at least one suffered a crushing defeat.

In Tennessee, nurse specialist Jeffrey Young is accused of trading opioids for sex and fame for a reality show pilotsuccessfully postponed his trial from May to November to take into account the Ruan concludes, arguing that it would “drasically change the landscape of the government’s war against prescribers”.

Also in Tennessee, Samson Orusa, a doctor and pastor who was convicted last year of handing out opioid prescriptions without examining patientsfiled a motion for a new trial based on the Ruan decision, then persuaded a reluctant judge to postpone his sentencing for six months to consider it.

And in Ohio, Dr. Martin Escobar de: Ruan verdict in an 11-hour effort to avoid jail.

Escobar pleaded guilty in January to 54 counts of distributing a controlled substance, including prescriptions that caused the deaths of two patients. After the Ruan decision, Escobar tried to withdraw his plea, saying he would have been sued had he known prosecutors had to prove his intent.

A week later, on the day Escobar was due to be sentenced, a federal judge denied the request.

His admission of guilt remained.

Escobar got 25 years.


KHN (Kaiser Health News) is a national editorial that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three most important operational programs on KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information on health issues to the nation.

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