Dr. Nelson Onaro conceded last summer that he\u2019d written illegal prescriptions, although he said he was thinking only of his patients. From a tiny, brick clinic in Oklahoma, he doled out hundreds of opioid pills and dozens of fentanyl patches with no legitimate medical purpose<\/a>.<\/p>\n

\u201cThose medications were prescribed to help my patients, from my own point of view,\u201d Onaro said in court, as he reluctantly pleaded guilty to six counts of drug dealing. Because he confessed, the doctor was likely to get a reduced sentence of three years or less in prison.<\/p>\n

But Onaro changed his mind in July. In the days before his sentencing, he asked a federal judge to throw out his plea deal, sending his case toward a trial. For a chance at exoneration, he\u2019d face four times the charges and the possibility of a harsher sentence.<\/p>\n

Why take the risk? A Supreme Court ruling has raised the bar to convict in a case like Onaro\u2019s. In a June decision, the court said prosecutors must not only prove a prescription was not medically justified \u2015 possibly because it was too large or dangerous, or simply unnecessary \u2015 but also that the prescriber knew as much.<\/p>\n

Suddenly, Onaro\u2019s state of mind carries more weight in court. Prosecutors have not opposed the doctor withdrawing his plea to most of his charges, conceding in a court filing that he faces \u201ca different legal calculus\u201d after the Supreme Court decision.<\/p>\n

The court\u2019s unanimous ruling complicates the Department of Justice\u2019s ongoing efforts to hold irresponsible prescribers criminally liable for fueling the opioid crisis. Previously, lower courts had not considered a prescriber\u2019s intention. Until now, doctors on trial largely could not defend themselves by arguing they were acting in good faith when they wrote bad prescriptions. Now they can, attorneys say, although it is not necessarily a get-out-of-jail-free card.<\/p>\n

\u201cEssentially, the doctors were handcuffed,\u201d said Zach Enlow, Onaro\u2019s attorney. \u201cNow they can take off their handcuffs. But it doesn\u2019t mean they are going to win the fight.\u201d<\/p>\n

The Supreme Court\u2019s decision in Ruan v. United States<\/em><\/a>, issued June 27, was overshadowed by the nation-shaking controversy ignited three days earlier, when the court erased federal abortion rights. But the lesser-known ruling is now quietly percolating through federal courthouses, where it has emboldened defendants in overprescribing cases and may have a chilling effect on future prosecutions of doctors under the Controlled Substances Act.<\/p>\n

In the three months since it was issued, the Ruan<\/em> decision has been invoked in at least 15 ongoing prosecutions across 10 states, according to a KHN review of federal court records. Doctors cited the decision in post-conviction appeals, motions for acquittals, new trials, plea reversals, and a failed attempt to exclude the testimony of a prescribing expert, arguing their opinion was now irrelevant. Other defendants have successfully petitioned to delay their cases so the Ruan<\/em> decision could be folded into their arguments at upcoming trials or sentencing hearings.<\/p>\n

David Rivera, a former Obama-era U.S. attorney who once led overprescribing prosecutions in Middle Tennessee, said he believes doctors have a \u201cgreat chance\u201d of overturning convictions if they were prohibited from arguing a good faith defense or a jury was instructed to ignore one.<\/p>\n

Rivera said defendants who ran true pill mills would still be convicted, even if a second trial was ultimately required. But the Supreme Court has extended a \u201clifeline\u201d to a narrow group of defendants who \u201cdispensed with their heart, not their mind,\u201d he said.<\/p>\n

\u201cWhat the Supreme Court is trying to do is divide between a bad doctor and a person who might have a license to practice medicine but is not acting as a doctor at all and is a drug dealer,\u201d Rivera said. \u201cA doctor who is acting under a sincerely held belief that he is doing the right thing, even if he may be horrible at his job and should not be trusted with human lives \u2015 that\u2019s still not criminal.\u201d<\/p>\n

The Ruan<\/em> decision resulted from the appeals of two doctors, Xiulu Ruan and Shakeel Kahn, who were separately convicted of running pill mills in Alabama and Wyoming, respectively, then sentenced to 21 and 25 years in prison. In both cases, prosecutors relied on a common tactic to show the prescriptions were a crime: Expert witnesses reviewed the defendants\u2019 prescriptions and testified that they were far out of line with what a reasonable doctor would do.<\/p>\n