United States v. Stanton

103 F.4th 1204

UNITED STATES of America, Plaintiff-Appellee, v. John L. STANTON, M.D., Defendant-Appellant.

No. 23-5394

United States Court of Appeals, Sixth Circuit

Argued: May 28, 2024

Decided and Filed: June 5, 2024

Appeal from the United States District Court for the Eastern District of Kentucky at London. No. 6:21-cr-00019-4—Robert E. Wier, District Judge.

ARGUED: Ronald W. Chapman, II, CHAPMAN LAW GROUP, Troy, Michigan, for Appellant. Allaya Lloyd, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., for Appellee. ON BRIEF: Ronald W. Chapman, II, CHAPMAN LAW GROUP, Troy, Michigan, for Appellant. Allaya Lloyd, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., Charles P. Wisdom, Jr., Andrew E. Smith, UNITED STATES ATTORNEY'S OFFICE, Lexington, Kentucky, for Appellee.

Before: SUTTON, Chief Judge; CLAY and BUSH, Circuit Judges.

OPINION

SUTTON, Chief Judge.

Dr. John Stanton served as the medical director for a pain clinic in northern Tennessee. The federal government alleged that the clinic operated as a pill mill and charged Dr. Stanton with conspiring to violate federal drug laws. After a seven-day trial, a jury convicted him. On appeal, Dr. Stanton challenges the sufficiency of the evidence to support the jury's verdict and several rulings by the trial court. We affirm.

I.

In 2000, Dr. James Maccarone opened Gateway Medical Associates as a primary care medical practice in Clarksville, Tennessee. After a dozen years in operation, Gateway began to serve more patients seeking treatment for pain management. Over time, Dr. Maccarone came to realize that his clinic had gained a "reputation" as a "pill mill" where patients could "walk in, . . . pay whatever it is that it costs, and . . . walk out with narcotics." R.307 at 190. Patients drove as long as five hours each way to reach the clinic, drove by several other pain management clinics along the way, then waited in the parking lot past midnight to be seen, all while claiming (in many cases) to suffer from back pain. Drug dealers "sponsored" many of these patients so they could obtain prescription narcotics. R.306 at 270.

"[D]rowning in debt" and recognizing that he could charge more than twice as much for a pain visit as he did for primary care, Dr. Maccarone leaned into the clinic's growing reputation as a "pill mill." R.307 at 218. Disregarding medical standards, Dr. Maccarone prescribed opioids even after patients failed drug tests, and on the rare occasions when he discharged patients for testing positive, he would allow them back into the practice if they paid an extra fee.

In July 2016, Tennessee began requiring pain management clinics to employ medical directors. See Tenn. Code § 63-1-306(a). Dr. Maccarone lacked the credentials to qualify for this position. But he knew Dr. Stanton. Stanton practiced orthopedic surgery at the facility next door and had received certification in pain management. Dr. Stanton already served as the medical director for another clinic, and he agreed to serve this role at Gateway as well in return for a salary of $1,500 per week.

As Gateway's medical director, Dr. Stanton oversaw its pain management services and safeguards, including state mandated policies for urine screening and pill counts. Dr. Stanton eventually warned Dr. Maccarone that Gateway's unusual hours, long-distance patient population, and high levels of medication raised "red flags." R.307 at 226, 228. But Dr. Maccarone ignored Dr. Stanton's recommendations to taper off high narcotics doses, and Dr. Stanton continued to sign off on state compliance reports despite his concerns.

When Dr. Maccarone took an emergency medical leave of absence in November 2018, Dr. Stanton assumed responsibility for his patients. Dr. Stanton would see as many as three dozen patients in a single afternoon. He maintained Dr. Maccarone's practice of prescribing narcotics to patients who failed drug screens. But he did reduce these prescriptions by a standard amount of five or ten pills when patients refused his advice to try injections or physical therapy as alternatives. After Dr. Maccarone returned to the practice, Dr. Stanton continued to see his patients. Between November 2018 and October 2020, Dr. Stanton wrote roughly 5,800 narcotics prescriptions, and Dr. Maccarone wrote about 9,000 prescriptions.

Gateway's prescription practices, together with large numbers of patients "tailgating" in the parking lot for hours, led state and federal investigators to scrutinize the clinic. R.305 at 103. After conducting a warrant-authorized search of Gateway, the government indicted Dr. Stanton, Dr. Maccarone, and two patient sponsors, Jeffrey Ghent and Terry Prince, for conspiring to distribute controlled substances without a legitimate medical purpose. Dr. Maccarone and the sponsors pleaded guilty. Dr. Stanton went to trial.

Over the course of seven days, the jury heard from nineteen government witnesses, including Dr. Maccarone, the sponsors, and several clinic patients, as well as from Dr. Stanton and two other defense witnesses. The government also planned to offer expert testimony that Dr. Stanton's prescription practices lacked a legitimate medical basis. On the second day of trial, it asked the court to substitute a new expert witness, Dr. Timothy King, after it had second thoughts about its existing expert. The trial court held that this late disclosure would prejudice Dr. Stanton. But the court did allow Dr. King to testify as a rebuttal witness solely in response to Dr. Stanton's own testimony.

The jury found Dr. Stanton guilty of the drug conspiracy charge. At sentencing, the court concluded that the files for 21 patients introduced at trial showed Dr. Stanton had prescribed a converted drug weight of at least 21,524 kilograms. On that basis, the Sentencing Guidelines recommended a minimum sentence of 188 months. The trial court varied downward to 120 months.

II.

On appeal, Dr. Stanton challenges his conviction and sentence in five ways: (1) insufficient evidence to convict him for conspiracy; (2) reversible error in allowing Dr. King to testify on rebuttal; (3) abuse of discretion in instructing the jury on deliberate ignorance; (4) reversible error in responding to the jury's questions about the jury instructions; and (5) insufficient evidence to support the drug weight calculation at sentencing.

Sufficiency of the evidence. In reviewing this challenge, we make all reasonable inferences from the testimony and trial record in favor of the jury verdict. United States v. Anderson, 67 F.4th 755, 768 (6th Cir. 2023) (per curiam). We will reverse only if no "trier of fact" could have found that the government proved the elements of this crime beyond a reasonable doubt. Id.

To prove its case, the government had to establish that two or more people agreed to violate federal drug laws and that Dr. Stanton knowingly and voluntarily participated in the agreement. See United States v. Wheat, 988 F.3d 299, 306 (6th Cir. 2021). The government may establish these elements of the crime through circumstantial evidence, including knowledge of unusual prescribing practices or knowledge of unusual patient protocols. United States v. Volkman, 797 F.3d 377, 390 (6th Cir. 2015); see United States v. Fowler, 819 F.3d 298, 309 (6th Cir. 2016).

The evidence sufficed to make this finding. The jury heard considerable evidence from Dr. Maccarone and other witnesses that Gateway operated as a pill mill and violated federal law in doing so. The question before the jury thus was not whether a drug conspiracy existed; it was whether Dr. Stanton agreed to join it. Ample evidence showed that Dr. Stanton agreed to join the conspiracy.

Dr. Stanton agreed to help Dr. Maccarone operate Gateway by serving as its medical director. He saw plenty of red flags that Gateway operated as a pill mill and declined to cure them: the long and unusual clinic hours; patients traveling long distances from out of state; high narcotics dosages without individualization or tapering; and continued prescriptions to patients who failed drug screens. See United States v. Lang, 717 F. App'x 523, 544 (6th Cir. 2017) (affirming a clinic owner's conviction for drug conspiracy when "it was clear to even casual observers that [the clinic] was a pill mill"). Even after seeing these red flags, he continued to sign off on compliance reports, and he continued to see the high-dosage patients whose prescriptions Dr. Maccarone refused to lower.

The jury also could have found that Dr. Stanton's prescriptions furthered the conspiracy. He spent only a few minutes with each of his own patients before signing off on pre-printed prescriptions. His medical assistant testified that neither doctor used the clinic's electronic medical records, and a pharmacy expert testified that Dr. Stanton's prescriptions lacked the dosage individualization of legitimate pain management practices. Even after Dr. Maccarone returned to Gateway, Dr. Stanton continued to see patients and wrote almost 40% of Gateway's prescriptions between November 2018 and October 2020.

The jury also could have found that Dr. Stanton's unconvincing efforts to clear his name with investigators amounted to an effort to cover up his participation in the drug conspiracy. Dr. Stanton, for instance, told an investigator from the Drug Enforcement Agency that Gateway discharged patients who tested positive for heroin and cocaine, even though Gateway's records showed otherwise. Cf. United States v. Gardiner, 463 F.3d 445, 462-63 (6th Cir. 2006) (distinguishing acts of concealment that further an ongoing conspiracy from those that cover up previous crimes).

Dr. Stanton replies that the government failed to prove that he wrote any prescriptions at Gateway without proper medical authorization. But that proof would have mattered only if the government had charged Dr. Stanton with distributing controlled substances under 21 U.S.C. § 841(a). See Ruan v. United States, 597 U.S. 450, 457, 142 S.Ct. 2370, 213...