Submitted: March 13, 2018
Appeals from United States District Court for the Eastern
District of Arkansas - Little Rock
WOLLMAN, SHEPHERD, and ERICKSON, Circuit Judges.
ERICKSON, CIRCUIT JUDGE.
consolidated appeal arises out of the operation of a
"pill mill" conducted under the guise of a
legitimate clinic. Anthony Markeith King and Kristen L.
Raines were charged in a conspiracy to distribute scheduled
controlled substances without an effective prescription in
violation of 21 U.S.C. §§ 841(a)(1), (b)(1)(C),
(b)(1)(E), and 846. Raines was also charged with two counts
of distribution of a scheduled controlled substance without
an effective prescription, in violation of 21 U.S.C.
§§ 841(a)(1), (b)(1)(C), and (b)(1)(E).
pled guilty to the conspiracy charge. The district
court put King at a base offense level of 26,
then added a four-point enhancement for acting as an
organizer or leader and subtracted two points for acceptance
of responsibility. King then had an offense level of 28,
criminal history category I, with a Guidelines range of 78-97
months. The court sentenced King to 120 months'
imprisonment, varying upward due to the nature of King's
role in the conspiracy.
proceeded to trial and was convicted on the conspiracy charge
and acquitted on the distribution charges. The district court
found Raines to be at offense level 26 (after applying a
two-point enhancement for abuse of position of trust),
criminal history category I, with a Guidelines range of 63-78
months. The court sentenced Raines to 70 months'
appeals her conviction and sentence, claiming: 1) the court
improperly admitted evidence at trial, 2) the court erred in
instructing the jury, 3) the evidence was insufficient to
sustain a conviction, and 4) her sentence is substantively
unreasonable. King challenges the reasonability of his
sentence. We affirm the district court in all respects.
Medical Clinic opened in Little Rock, Arkansas, in June of
2014. Patients at Artex frequently received prescriptions for
hydrocodone and/or Xanax. Artex operated on a cash-fee basis,
where patients would pay $200 in cash prior to being
evaluated. Anthony King worked as a "recruiter" for
the clinic. King recruited patients from across Arkansas to
the clinic. Patients were required to sign a "pain
contract" in which they agreed to opioid treatment
before they were seen or diagnosed by medical staff.
Raines began working as an Advanced Practice Registered Nurse
for Artex in July of 2014. From nearly the time she was hired
until the clinic closed in September of 2014, Raines was the
only employee of Artex present on a daily basis who was
licensed to write prescriptions for hydrocodone and Xanax.
Drug Enforcement Administration announced that drugs
containing hydrocodone would become Schedule II drugs on
October 6, 2014, which led to Artex closing its doors at the
end of September. Shortly after Artex closed, its operators
(including King) opened KJ Medical Clinic. Because of
hydrocodone's new scheduling, Artex employed two doctors
as prescribing physicians. The new clinic operated similarly
to the old clinic-patients would walk-in and pay either $200
for a pain evaluation or $150 for treatment for a
"cough." In early November of 2014, Raines began
working at KJ.
signs that KJ was not operating as a legitimate medical
establishment were apparent. Receptionists at the clinic
guided patients' answers on questionnaires to make them
appropriate candidates for controlled substance
prescriptions. Patients were instructed to fill their
prescriptions only at particular pharmacies. Patients were
required to sign forms attesting that they were not involved
in any government investigation into the clinic. Patients
were given an "entrance number" in the parking lot
near the building and were only allowed inside in limited
numbers. Upon entry plaintiffs were checked for weapons by an
armed security guard.
clinic's unorthodox methods extended to patient
evaluations and the prescription of medications. Doctors at
the clinic would pre-fill prescriptions for hydrocodone and
Xanax. Nurses would then conduct in-person evaluations of the
patients and complete the pre-filled prescriptions over the
left KJ in early January of 2015. King continued recruiting
patients until May of 2015, when the clinic was raided by the
DEA. Following the raid, Raines and King were charged in a
conspiracy to distribute controlled substances. Raines was
also charged with two counts of distribution of a controlled
substance without an effective prescription.
trial the government presented evidence from cooperating
co-conspirators, confidential informants, and an expert
medical witness. Stella Green, a coworker nurse, testified
that using pre-signed prescriptions was standard procedure
for the clinic. Several other witnesses also testified that
the clinic relied on pre-signed prescriptions.
government introduced evidence from a confidential informant
who visited the clinic in November of 2014, January of 2015,
and March of 2015. Raines was working at the clinic during
the time period of the first two visits, but not the third.
The informant testified that on each visit prospective
patients were told to take a number, get in line, and wait to
receive a prescription. She described the atmosphere as
chaotic, with patients arguing about who would get inside to
fill their prescription. She testified that on her first
visit when she handed her paperwork in and marked only a
"5" on the pain scale, a desk clerk asked her to
change her answer to a "10" or else she would be
unable to see a doctor. The government introduced a video
taken during the informant's third visit to the clinic.
The informant testified that the contents of the video were
similar in many ways to her experience during her first two
trips to the clinic. A coworker testified that Raines would
have walked through or seen the same areas that the video was
taken in as an ordinary part of her workday.
medical expert, Dr. Carlos Roman, testified regarding
standards of practice in the field of pain management,
guidelines for prescribing medications, and "red
flags" that indicated potential painkiller abuse. Dr.
Roman had twenty years of experience in the medical
profession and had served on the Arkansas State Medical Board
Review Committee since 2005, including as chairman. Dr. Roman
also served as the Chief of Pain Management at St. Vincent
Infirmary in Little Rock, Arkansas. Dr. Roman noted that the
Artex "pain contract" and KJ's signed form
prohibiting patients from participating in law enforcement
activity were not typical for a legitimate medical
establishment. He also testified regarding the Prescription
Monitoring Program ("PMP") data offered by the
United States as evidence of irregular prescription activity.
The data was submitted to the trial court in a summary chart
form showing hydrocodone and Xanax prescriptions allegedly
written by Raines while working at Artex. The original
versions of the prescriptions referenced in the chart were
also submitted to the court. Of approximately 112 patient
files from KJ, 21 contained paperwork signed by Raines, along
with prescriptions bearing Raines's handwriting and a
Roman testified that he believed the records indicated a
failure to pursue a legitimate medical purpose. He based his
review on all of the files available from Artex, ten files
chosen at random from KJ, and eleven files identified as
relating to patients Raines treated at KJ. He noted that
patients had consistently marked either a "9" or
"10" on the pain scale. He further remarked that
the patients' answers to anxiety and depression
questionnaires were outside the normal boundary for treatment
by a pain specialist and indicated suicidal tendencies. In
particular, he noted that several of the files raised
concerns that medical treatment had been limited to the
prescription of opioids when the alleged circumstances would
have required more detailed and thorough care. He also
commented on an audio recording from an informant patient in
which Raines referred to Xanax by the street term
"bars." He noted that using street terms is not
normal in medical practice.
the jury instruction conference, Raines requested a
"good faith" instruction, proposing ...