U.S. Supreme Court hears Alabama pain doctor’s appeal to overturn ‘pill mill’ conviction

[Agast]

U.S. Supreme Court hears Alabama pain doctor’s appeal to overturn ‘pill mill’ conviction

Dr. Xiulu Ruan, who was convicted of illegally prescribing opioids to patients, is arguing that a jury should have been able to hear if he had a "good faith" reason to believe the drugs were medically valid.

www.al.com

“The Controlled Substances Act also says doctors violate the law when prescriptions are “not for a legitimate medical purpose.” Although guidelines for opioid prescriptions have been adopted by the Centers for Disease Control and Prevention, there are no legal limits on what doctors can prescribe. Approaches to treating pain have shifted several times in the last 30 years.

“Legitimate medical purpose is a very vague thing on which reasonable people can disagree,” said Justice Brett Kavanaugh.

Ruan appealed his case to the U.S. Supreme Court because his attorneys said the jury should have considered whether the doctor believed high levels of opioids would benefit pain patients.”

I don’t see Ruan having his sentencing reversed. However it does raise the question of when opioid prescribing crosses the line into pill mill based on practitioner judgement. Sort of a “I know it when I see it” situation.

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[myrandom2003]

Should be interesting to see how they rule.
Can’t wait for the independent np pill mill to refer all the opioid seekers to.

 

[Ducttape]

looking at Ruans prescription patterns, the 13 or so luxury cars he had - there was never any legitimate medical reason for his prescribing...

that doesnt even include his "involvement" with Abstral.

 

[RoloTomassi]

“Legitimate medical purpose is a very vague thing on which reasonable people can disagree,” said Justice Brett Kavanaugh.

This is interesting philosophically, especially since pain is subjective. There's heated debate over whether it's best to cut someone open and put screws in them vs do absolutely nothing vs inject some random person's Wharton's jelly in there. Prescribing a pain med for someone in pain is arguably within the range of options.

 

[lobelsteve]

This is interesting philosophically, especially since pain is subjective. There's heated debate over whether it's best to cut someone open and put screws in them vs do absolutely nothing vs inject some random person's Wharton's jelly in there. Prescribing a pain med for someone in pain is arguably within the range of options.

Subsys for non-cancer pain routinely? Arguments can be made for when this is appropriate, but over 99% of us will say never.
Rx for oxy 30 and oxy 15 at same time both tid?
Vicosomaxanax Rx at same time?

We have lots of things that are clearly drug dealing. Rot in jail Ruan.

 

[mid|ine]

Chief Justice John Roberts argued it would not have mattered if the jury was able to hear a “good faith” reason, likening that argument to a driver pulled over by police on a highway for going over a 50 m.p.h. speed limit who then argued that the speed limit should be higher.

What does this have to do with anything? There is no legal limit on the amount of opioids that can be prescribed.

I guess I really don't know what the legal limits are for prescribing opioids. "Medical Necessity" is vague and I can see an extension of a "good faith" argument coming out of this. Seems pretty cut and dry in this case though.

 

[mid|ine]

Subsys for non-cancer pain routinely? Arguments can be made for when this is appropriate, but over 99% of us will say never.
Rx for oxy 30 and oxy 15 at same time both tid?
Vicosomaxanax Rx at same time?

We have lots of things that are clearly drug dealing. Rot in jail Ruan.

Yes, but the question before the SC isn't if he is guilty. They question is what defense he should be able to raise, and by extension, what defense any doctor should be able to raise.

 

[RoloTomassi]

Yes, but the question before the SC isn't if he is guilty. They question is what defense he should be able to raise, and by extension, what defense any doctor should be able to raise.

Exactly. He sounds like a POS, not defending him. But SC is going to make a broad judgement that will be used as precedence.

 

[drusso]

U.S. Supreme Court hears Alabama pain doctor’s appeal to overturn ‘pill mill’ conviction

Dr. Xiulu Ruan, who was convicted of illegally prescribing opioids to patients, is arguing that a jury should have been able to hear if he had a "good faith" reason to believe the drugs were medically valid.

www.al.com

“The Controlled Substances Act also says doctors violate the law when prescriptions are “not for a legitimate medical purpose.” Although guidelines for opioid prescriptions have been adopted by the Centers for Disease Control and Prevention, there are no legal limits on what doctors can prescribe. Approaches to treating pain have shifted several times in the last 30 years.

“Legitimate medical purpose is a very vague thing on which reasonable people can disagree,” said Justice Brett Kavanaugh.

Ruan appealed his case to the U.S. Supreme Court because his attorneys said the jury should have considered whether the doctor believed high levels of opioids would benefit pain patients.”

I don’t see Ruan having his sentencing reversed. However it does raise the question of when opioid prescribing crosses the line into pill mill based on practitioner judgement. Sort of a “I know it when I see it” situation.

Some of the Taper KOL's have been speculating/worried that the SCOTUS will overturn the CDC guidelines and tell them to pound sand.

 

[mid|ine]

Some of the Taper KOL's have been speculating/worried that the SCOTUS will overturn the CDC guidelines and tell them to pound sand.

The CDC guidelines are not in question, and only that guidelines. There is NO limit in the guidelines (unlike a speed limit).

 

[Ferrismonk]

There is no official "limit" to opioids, but there is accepted medical practice. This is easy to figure out by asking medical societies, medical experts, guidelines, etc. If he's deviated significantly from standard medical practice (which it sounds like he has), then there must be an alternative motivation for such behavior.

Either way, this wasn't a "too many pills" issue by itself. He's guilty of illegal kickbacks, prescribing meds without examining patients, etc.

 

[drusso]

The CDC guidelines are not in question, and only that guidelines. There is NO limit in the guidelines (unlike a speed limit).

I think Justice Kavanaugh might have concerns about what kind of "force" regulatory agencies have over the practice of medicine. Do you know anyone who has ever felt like their hands were tied due to a poorly conceived agency or regulatory rule that was based on incomplete evidence or defective analysis? IF the DEA relies on a defective analysis to prosecute a crime, then there could be a problem.

Docket for 20-1410

 

[Ducttape]

seems like the justices did not clearly spell out what they were going to decide:

In opioids “pill mill” case, justices grapple with physician intent - SCOTUSblog

For nearly 90 minutes on Tuesday, the court grappled with the question of whether good faith is a defense for doctors criminally prosecuted for unlawful distribution of controlled substances. The court probed both sides intensely, struggling with the grammar of the Controlled Substances Act, the cla

www.scotusblog.com

In the end, it was not clear what direction the court is likely to take. The tension between allowing a physician to effectively define the scope of what is illegal, no matter how irrational her subjective belief about legitimate medical practice, seemed as unacceptable to many of the justices as a standard in which a difference of opinion about medical norms, with intent to violate the law, could result in criminal liability.

 

[mid|ine]

The rule at issue in this case allows doctors to dispense a controlled substance that is “issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.

The government argues the intent standard is an objective one — an “honest effort” to comply with professional norms. The doctors argue that the standard must be subjective — did the doctor subjectively believe she was not prescribing for a legitimate medical purpose — in order to differentiate a criminal offense from a mere regulatory violation.

The government’s burden of proof also was the subject of much back and forth, even though it was not a major component of the briefing. Several justices asked first, whether, for every element of a crime, the government had to prove mens rea; and second, what precise burden remains on the government once a doctor puts forward lack of criminal intent as a defense. Several justices seemed unsatisfied with both sides’ answers to these questions, pressing again and again for a more specific position as to the burden. They also seemed quite interested in a provision of the CSA that provides that the government need not “negative any exemption or exception … in any complaint, information, indictment, or other pleading or in any trial.” Yet despite the justices’ prodding, both sides agreed that the government bore the ultimate burden of proof — once the defendant put forward evidence of his good faith. But that burden, Feigin said for the government, is “to prove beyond a reasonable doubt that the defendant was not even attempting to recognizably practice medicine,” not something subjective.

The justices did not ask questions about one of the main issues raised in the briefs, which was a concern about chilling the practice of medicine (and particular concerns about growing evidence that the heightened enforcement environment has chilled the legitimate practice of pain medicine). But Feigin did emphatically insist the statutory scheme is meant to target doctors who are effectively “drug dealing,” not doctors making medical calls that some might dispute. Nevertheless, at least several justices appeared hung up on the scenario in which, in a “close call” case, involving a battle of the experts about norms of professional practices, a jury might pick one side of the line and send a doctor who believed he was legitimately practicing medicine to prison for 20 years. Kavanaugh compared the facts at issue to an older case, Morrissette v. United States, in which the court held that criminal intent was necessary for the conviction of someone who took abandoned property mistakenly thinking he was authorized to do so.

 

[drusso]

seems like the justices did not clearly spell out what they were going to decide:

In opioids “pill mill” case, justices grapple with physician intent - SCOTUSblog

For nearly 90 minutes on Tuesday, the court grappled with the question of whether good faith is a defense for doctors criminally prosecuted for unlawful distribution of controlled substances. The court probed both sides intensely, struggling with the grammar of the Controlled Substances Act, the cla

www.scotusblog.com

I'm most impressed with the brief Cato filed with the court.

https://www.supremecourt.gov/DocketPDF/20/20-1410/206518/20211227144729883_Ruan%20merits.pdf

I think some of the Taper KOLs and their interest groups will be weighing in on the matter through the court of public opinion.

 

[Yo GabbaPentin]

Subsys for non-cancer pain routinely? Arguments can be made for when this is appropriate, but over 99% of us will say never.
Rx for oxy 30 and oxy 15 at same time both tid?
Vicosomaxanax Rx at same time?

We have lots of things that are clearly drug dealing. Rot in jail Ruan.

I work within driving range of their old clinic. The things that I used to see in charts were unreal. IT pumps in 18 year olds with no imaging. Ungodly amounts of meds. I was absolutely shocked that the DEA didn’t find a large number of ODs and start slinging manslaughter charges. We reviewed hundreds of referrals of their previous patients. Declined every single one.

I couldn’t agree more with “rot in jail ruan.”

 

[NJPAIN]

I work within driving range of their old clinic. The things that I used to see in charts were unreal. IT pumps in 18 year olds with no imaging. Ungodly amounts of meds. I was absolutely shocked that the DEA didn’t find a large number of ODs and start slinging manslaughter charges. We reviewed hundreds of referrals of their previous patients. Declined every single one.

I couldn’t agree more with “rot in jail ruan.”

In the early 90s Medtronic flew me down to meet his partner Pat Couch and his “model” pump practice. He was compounding his own intrathecal refills in a tiny room in the office. He had safe full of powdered morphine. He sterilized the drug by passing it through a filter between two 30ml syringes. The materials cost him next to nothing and he made thousands on every refill.

 

[Ducttape]

I'm most impressed with the brief Cato filed with the court.

https://www.supremecourt.gov/DocketPDF/20/20-1410/206518/20211227144729883_Ruan%20merits.pdf

I think some of the Taper KOLs and their interest groups will be weighing in on the matter through the court of public opinion.

problem is, people like Ruan, Webster, Fine, Tennant, will then argue that any dose is within good faith.

subsys and abstral could be within "good faith", if a doctor "believes" what he is doing is right for the patient, even if the patient ODs. after all, that would put an end to suffering from chronic pain, and the doctor did it in "good faith" but unfortunately the patient expired...

where does it end? there would be no ceiling.

 

[Agast]

I think Tennant is a true believer, though.

 

[drusso]

problem is, people like Ruan, Webster, Fine, Tennant, will then argue that any dose is within good faith.

subsys and abstral could be within "good faith", if a doctor "believes" what he is doing is right for the patient, even if the patient ODs. after all, that would put an end to suffering from chronic pain, and the doctor did it in "good faith" but unfortunately the patient expired...

where does it end? there would be no ceiling.

Who better than a doctor to believe in the best interests of patients? We shouldn't abdicate that to DEA agents. That's in our control. I didn't go to medical school so I could be bossed around by a bunch of non-doctors on how to practice medicine. Does anyone want to see the Federal government regulate medicine?

 

[ateria radicularis magna]

In the early 90s Medtronic flew me down to meet his partner Pat Couch and his “model” pump practice. He was compounding his own intrathecal refills in a tiny room in the office. He had safe full of powdered morphine. He sterilized the drug by passing it through a filter between two 30ml syringes. The materials cost him next to nothing and he made thousands on every refill.

Whoooaaahhhhhhhhh!!!

 

[hyperalgesia]

In the early 90s Medtronic flew me down to meet his partner Pat Couch and his “model” pump practice. He was compounding his own intrathecal refills in a tiny room in the office. He had safe full of powdered morphine. He sterilized the drug by passing it through a filter between two 30ml syringes. The materials cost him next to nothing and he made thousands on every refill.

That says a lot about our corporate friends if that is their "model".

 

[callmeanesthesia]

Who better than a doctor to believe in the best interests of patients? We shouldn't abdicate that to DEA agents. That's in our control. I didn't go to medical school so I could be bossed around by a bunch of non-doctors on how to practice medicine. Does anyone want to see the Federal government regulate medicine?

View attachment 351307

Who better than a doctor? A group of doctors, who collectively decide standard of care. And this guy was so far outside the standard of care it’s crazy. If taken literally, what you say would mean a medical degree is carte blanche to sell whatever “treatments” you want to whomever you want.

 

[lobelsteve]

Who better than a doctor? A group of doctors, who collectively decide standard of care. And this guy was so far outside the standard of care it’s crazy. If taken literally, what you say would mean a medical degree is carte blanche to sell whatever “treatments” you want to whomever you want.

It's called Regenexx.

 

[drusso]

It's called Regenexx.

Orthobiologic Ethics

orthobioethics.com

 

[Ducttape]

Who better than a doctor to believe in the best interests of patients? We shouldn't abdicate that to DEA agents. That's in our control. I didn't go to medical school so I could be bossed around by a bunch of non-doctors on how to practice medicine. Does anyone want to see the Federal government regulate medicine?

View attachment 351307

you didnt go to medical school to focus on making $$$$. im thinking Ruan did.

but here we are.

 

[Ducttape]

Orthobiologic Ethics

orthobioethics.com

1. Informed consent for orthobiologic procedures should include discussion of published human outcomes relevant to the specific procedure to be performed. Clinicians may also discuss outcomes solely based on their personal experience. For example, placing a claim on a web-site that “80%” of patients get improvement is unethical unless it’s substantiated by at least case series data. However, discussing a clinician's personal experience with the patient that about 80% of patients get improvement is consistent with appropriate ethical behavior.

ya that works.

you know, i have 100% success rate with Intracept, SI fusion and Minuteman. based on my personal experience. (N=0)

 

[drusso]

ya that works.

you know, i have 100% success rate with Intracept, SI fusion and Minuteman. based on my personal experience. (N=0)

Guidelines

 

[mid|ine]

I think the group is conflating the innocence or guilt of this one individual (sounds very guilty) with physicians' right to assert a "good faith" defense for their practice of medicine.

From the CATO brief

“Conventionally understood” drug dealing and trafficking means “[selling] drugs, ‘primarily for the profits to be derived therefrom’ and . . . acting so far outside the usual course of professional practice that their behavior is akin to that of a ‘large-scale [drug] pusher, not as a physician.’” United States v. Moore, 423 U.S. 122, 135 (1975) (citations omitted). Federal courts have consistently held that a deviation from the standard of care is not sufficient to meet the mens rea requirement under the Controlled Substances Act. See, e.g., United States v. Feingold, 454 F.3d 1001, 1007 (9th Cir. 2006). Instead, providers must depart further from being even a “bad doctor” to “a ‘pusher’ whose conduct is without a legitimate medical justification.” Id. The key question for whether a physician may be prosecuted under the CSA, then, is whether she acted as a doctor or intentionally abandoned that role in favor of becoming a drug trafficker

 

[Agast]

US Supreme Court sides with doctors challenging opioid convictions

“The justices ruled 9-0 in favor of Xiulu Ruan and Shakeel Kahn, who had argued in appealing their convictions that their trials were unfair because jurors were not required to consider whether the two physicians had "good faith" reasons to believe their numerous opioid prescriptions were medically valid.”

Wow, all 9 of them agreed on this, of all things O_O

“Liberal Justice Stephen Breyer, writing for the court, said that once defendants produce evidence that they were authorized to dispense controlled substances like opioids, prosecutors must prove they knew they were acting in an unauthorized manner.”

 

[Ducttape]

sent back to lower courts - basically ruled that the jury was supposed to be given instructions to consider whether the doctors knew they were being bad.

im sure Ruan and Kahns lawyers will quote Tennant, Fine, Webster, Portenoy and Passik and tell them that the millions of scripts were all medically valid.

 

[mid|ine]

This is a win for all doctors! Even if these particular doctors were dirty, this ruling helps protect all doctors.

 

[drusso]

sent back to lower courts - basically ruled that the jury was supposed to be given instructions to consider whether the doctors knew they were being bad.

im sure Ruan and Kahns lawyers will quote Tennant, Fine, Webster, Portenoy and Passik and tell them that the millions of scripts were all medically valid.

There was a lot of behind-the-scenes activity between taper KOLs and medical practice defense attorneys. I think SCOTUS made the right call here.

 

[Centurion38]

An open question to the Ayn Rand fanboys and CATO lovers on this forum:

Would your views change if Ruan and his minions had flooded your community with opioids? Would your views change if one of your family members accidentally OD'd at a party with one of his stolen/shared/sold pills?

This guy (I refuse to grant him the title of Physician) was a public health menace. This decision by SCOTUS is nothing to celebrate.

 

[Drd105]

I think people don’t care about what they think doesn’t personally impact them. “My family/friends do not OD at parties” therefore care factor=0.

 

[lobelsteve]

This is same as decision on abortion. Kicked back down to state level.
Hopefully he is retried and gets life in prison for being a drug dealer.
People gotta stop being so sensitive/woke and take care of their society.

 

[Drd105]

This is same as decision on abortion. Kicked back down to state level.
Hopefully he is retried and gets life in prison for being a drug dealer.
People gotta stop being so sensitive/woke and take care of their society.

🤞

 

[SSdoc33]

This is same as decision on abortion. Kicked back down to state level.
Hopefully he is retried and gets life in prison for being a drug dealer.
People gotta stop being so sensitive/woke and take care of their society.

? what does that even mean?

people use the term "woke" as some sort of boogeyman. as if everything in society can be blamed on the "woke" mob. nothing to do with this case at all.

 

[lobelsteve]

? what does that even mean?

people use the term "woke" as some sort of boogeyman. as if everything in society can be blamed on the "woke" mob. nothing to do with this case at all.

Peoples comments on how this may be helpful for doctors. No it won't . It will make the job harder. People will try and get in and instead of saying CDC was wrong and retracted, they will say Subsys, fent 100 with oxy30 qid, Soma/Xanax. It is my right.

 

[Pain Applicant1]

? what does that even mean?

people use the term "woke" as some sort of boogeyman. as if everything in society can be blamed on the "woke" mob. nothing to do with this case at all.

Doesn't matter if there's an association or not. Everything is now seen through a polarized lens.

Repubs: Can you believe the people who say the gov't has a right to force you to wear your mask are the same ones who say the gov't has no say in abortion?

Dems: Can you believe the people who say the gov't has no right to force you to wear your mask are the same ones who say the gov't has a say in abortion?

Same argument on both sides. I wonder if people will soon move to new states based on politics which will further exacerbate the divide.

 

[SSdoc33]

Peoples comments on how this may be helpful for doctors. No it won't . It will make the job harder. People will try and get in and instead of saying CDC was wrong and retracted, they will say Subsys, fent 100 with oxy30 qid, Soma/Xanax. It is my right.

and that makes these people "woke"?

quite a stretch

also, most of my patients dont go around citing SCOTUS rulings.....

 

[lobelsteve]

and that makes these people "woke"?

quite a stretch

also, most of my patients dont go around citing SCOTUS rulings.....

I just like the term to get you going. Care for dinner with the future Gov of AZ Kari Lake?

 

[SSdoc33]

I just like the term to get you going. Care for dinner with the future Gov of AZ Kari Lake?

sure. i can wear my best "outfit"......

from wiki:

Lake was friends for years with drag queen Barbra Seville, also known as Rick Stevens. When Lake publicly criticized drag queens in 2022, calling them a danger to children, Stevens published photos and screenshots documenting the friendship. These included Lake embracing Stevens while he was dressed in drag, and Stevens performing at Lake's home and around Lake's children at Lake's invitation. Stevens called her "a complete hypocrite" for her public hostility to drag queens.[43]

 

[Pain Applicant1]

Doesn't matter if there's an association or not. Everything is now seen through a polarized lens.

Repubs: Can you believe the people who say the gov't has a right to force you to wear your mask are the same ones who say the gov't has no say in abortion?

Dems: Can you believe the people who say the gov't has no right to force you to wear your mask are the same ones who say the gov't has a say in abortion?

Same argument on both sides. I wonder if people will soon move to new states based on politics which will further exacerbate the divide.

PS. What does this post have to do with anything? Absolutely nothing. I just wanted to sneak it in there since I thought it sounded cool, lol!

 

[lobelsteve]

 

[Ducttape]

her whole twitter thread is a testament of lack of insight into the side effects of opioids while wholesale advocacy for opioid use.

its advocacy suggests that US as a society will probably never truly be able to view opioids in an appropriate and safe manner.

 

[Drd105]

Omg. Not the “there were 31 days in that month” lolllllll makes me feel like I am taking crazy pills.

 

[Yo GabbaPentin]

An open question to the Ayn Rand fanboys and CATO lovers on this forum:

Would your views change if Ruan and his minions had flooded your community with opioids? Would your views change if one of your family members accidentally OD'd at a party with one of his stolen/shared/sold pills?

This guy (I refuse to grant him the title of Physician) was a public health menace. This decision by SCOTUS is nothing to celebrate.

He did this to my community. And it was not a debatable argument that he was doing this for the good of even a single patient. I’m sure his warehouse of over 20 super exotic cars speaks volumes to his care for the good of patients. Straight up corrupt drug dealer. I’ve reviewed hundreds of records from that clinic with not a single legit patient that I saw. Countless 18 year olds on fentanyl plus a pump without imaging. NPs and the other doc sprawled out over the clinic all high on opioids.

I hope that MF’er bounces back to the state court at which point they dig a little deeper to find one of the many inevitable ODs and instead nail him on that too. After it’s all said and done, I’m hoping his sentence is actually doubled.

But yeah, at least hopefully helps a doc who the feds go after for a minor debatable offense. However I’ve yet to actually see any like that. Most are pretty egregious.

 

[emd123]

If this is sent back to lower courts or a new trial is ordered, I doubt the outcome will be any different. The only thing certain, is that the lawyers will get richer.

 

[Yo GabbaPentin]

If this is sent back to lower courts or a new trial is ordered, I doubt the outcome will be any different. The only thing certain, is that the lawyers will get richer.

How many drug dealing docs have been convicted now over the years? Yet this POS somehow gets his case elevated to the Supreme Court? At this point, I just expect him to be opening a practice right next door to me in like 6 months time.