Justices on the U.S. Supreme Court have agreed to hear the appeal of an Alabama pain doctor convicted of running a pill mill, a case that could change how federal prosecutors handle opioid cases.
A federal judge in 2017 sentenced Dr. Xiulu Ruan of Mobile to 21 years in prison for several charges including drug distribution and money laundering related to operations at Physicians Pain Specialists of Alabama. Ruan appealed his conviction last year to the 11th U.S. Circuit Court of Appeals but lost. The U.S. Supreme Court agreed earlier this year to hear Ruan’s appeal.
The doctor claims his prescriptions of fentanyl and other opioids were supposed to help patients with severe pain. In a brief, his lawyers said physicians should not risk arrest and prosecution for unconventional treatments when other approaches have failed. In Ruan’s case, he prescribed fentanyl approved for patients with cancer pain to people suffering from back, neck and joint pain, according to the U.S. Department of Justice.
The law does not set a limit for the amount of opioids a patient should receive, although professional groups and government agencies have created guidelines. Doctors use their expertise and judgment to determine how many pills to prescribe. Prosecutions of pain doctors such as Ruan have made it more difficult for patients to get effective treatment, his lawyers said.
“It is no exaggeration to say that [Controlled Substances Act] prosecutions of physicians have already impaired the treatment of chronic pain,” the brief said. “In response to the opioid crisis, fear of prosecution has increasingly prompted pain management doctors to avoid or reduce opioid prescriptions, even when those decisions leave chronic pain patients without recourse.”
Ruan’s appeal has been consolidated with another case, Dr. Shakeel Kahn, who practiced in Arizona and Wyoming. Both men were found guilty of violating the federal Controlled Substances Act and said juries were not allowed to consider a “good faith” defense, which is aimed at protecting doctors trying to help patients. The supreme court could uphold his conviction or send his case back to trial.
Ruan’s criminal trial lasted seven weeks in 2017 and featured testimony from patients who supported the doctor and family members who said loved ones received dangerous doses of addictive painkillers. Prosecutors acknowledged that many patients received good care at the two clinics, but said some prescriptions fell far outside the norm.
Ruan and another practitioner at the clinic, Dr. John Patrick Couch, were among the nation’s top prescribers of fentanyl painkillers. Couch was also convicted and sentenced to 20 years in prison. He has also appealed his case.
In its response, attorneys for the U.S. Department of Justice said Ruan prescribed much higher rates of opioids than other doctors and earned more than $4 million as a result. Ruan and his partner issued almost 300,000 prescriptions for controlled substances, they wrote.
Prosecutors said Ruan had deep ties to drug companies that created fentanyl medications. After his conviction, they seized assets that included exotic cars, residential and commercial property.
Prescriptions for opioids increased sharply in the 1990s and 2000s after the introduction of OxyContin, a blockbuster pain medication created by Purdue Pharma. Guidelines imposed by accreditation organizations at the time encouraged aggressive treatment of pain.
As overdoses linked to prescription opioids rose, attitudes changed and an increasing number of doctors faced prosecution for running pill mills. In many cases, doctors at those clinics only accepted cash-paying patients who did not receive examinations or tests. Purdue Pharma recently pleaded guilty to three felonies in federal court for its role in the opioid crisis.
In his brief, Ruan’s attorney wrote that Physicians Pain Specialists of Alabama did not operate as pill mills. The clinics only accepted patients with insurance, refused cash payment and used diagnostic tools to find the sources of patients’ pain. Only patients with intractable pain received fentanyl, Ruan testified at his trial.
“He also testified that the medication was a ‘lifesaver’ for patients who would otherwise ‘have to go to [the] ER’ during such an episode,” the brief said.
Pain patients have criticized crackdowns on pain clinics and doctors. Compassion & Choices, an organization that advocates for dying patients, submitted a brief in support of Ruan.
“Medical practitioners prescribing opioids to such patients in good faith are not drug pushers under the Act,” according to the Compassion & Choices brief. “Practitioners thus should not have to suffer the specter of criminal liability simply for treating such patients at such a vulnerable, critical, and private time in their lives.”
Ruan’s lawyers argued that doctors fearing prosecution might hesitate to treat legitimate pain if his conviction stands. Two experts on law and health policy wrote a brief saying cases such as Ruan’s could cause physicians to turn away patients most in need of care.
“Patients with pain, addiction, or both desperately need appropriate care and treatment,” wrote law professors Jennifer Oliva and Kelly Dineen in their brief. “Patient abandonment will grow more widespread as practitioners avoid legal scrutiny.”
Arguments in Ruan’s case are scheduled for March 1, 2022.
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