Defying “Do No Harm”: Doctors Are Fueling the Opioid Crisis with Limited Criminal Repercussions
Updated: May 11, 2021
“They knew it was being abused, but nothing is ever spoken. I weighed about 90 pounds. I was so sick, and my blood pressure was so low it was bottoming out. I was having seizures. My physical health just deteriorated. I mean, it’s obvious if you walk in, you can tell if someone is an active crackhead or actively abusing pills.”
“They’re making money. Do you know how much money these doctors are making? They’re seeing like – say they see like 45 patients in a day, which I know they see more than that. They’re getting $150 just for the visit, plus if they have a pharmacy there, then they can pull money off the pills. They’re making $20,000 or $30,000 in a day. They don’t want to stop that, and if they stopped all the junkies, then they’re not going to have any customers.”
Between 2006 and 2014, physicians dispensed of 2.17 billion prescriptions across the United States. Each prescription can include up to ninety pills. In West Virginia alone, over 1.1 billion prescription pain pills were imported during this time frame. That amounts to over seventy-six pills a year for each West Virginian. With pills entering this state, and others, at such staggering rates, it is all but certain that massive overprescribing plays a critical role in this crisis. In fact, some suggest that doctors are nothing more than “illegal drug dealers…in a fancy office.”
Consider Dwight Bailey, a former doctor who operated Ridgewood Health Care Clinic in Lebanon, Virginia.Bailey “continually wrote prescriptions for opiates, benzodiazepines, and sleeping pills to patients who were misusing, abusing, and diverting those controlled substances.” As a result of his disregard for the health and safety of his patients, he netted for $750,000 in a single year of business. Bailey was ultimately sentenced to almost thirteen years in federal prison. According to Assistant United States Attorney Daniel P. Bubar, the United States Attorney’s Office for the Western District of Virginia intended for “this lengthy sentence [to] send a strong message that the [federal government] will work tirelessly to prosecute those in healthcare who perpetuate the opioid epidemic by illegally diverting medication to harm their patients and damage the community.”
With billions of prescription pain pills lingering in vulnerable communities at the hands of doctors such as Bailey each year, one would expect federal prosecutors to aggressively prosecute these “illicit drug dealers in fancy offices”. This logic, however, has not carried the day. Many blame and direct subsequent legal efforts towards pharmaceutical and drug manufacturing companies. However, this paper suggests that there is more than enough blame to go around.
This paper tracks the judicial and prosecutorial response to doctors who illegally prescribe opioids in geographic areas most significantly affected by the opioid crisis. The paper will be divided into three parts. Part II will discuss the historical context of the opioid crisis, including its origins in the national spotlights, a snapshot of the crisis today, and an overview of the legal response to the crisis as a whole. It will also identify the paper’s focus areas, which were determined by identifying the states with the highest rate of opioid-related deaths, highest rates of opioid prescribing, and other related factors. One would expect higher numbers o doctors-related prosecutions in states where the opioid crisis has been felt most severely. Notably, that is not always the case. Part II will compare these affected areas based on their current judicial and prosecutorial response and identify the federal districts where more significant response to localized challenges would be expected. Lastly, Part IV will discuss potential reasons for inadequate prosecutorial responses, including perspectives by current federal prosecutors who have extensively worked on this crisis.
II. Background: What is the Opioid Crisis?
Discussing the public health crises in the United States in 2020 without addressing the opioid crisis is inconceivable. Our nation has grappled with drug, and more specifically opioid, use and addiction for much longer than national media sources and public health organizations would indicate. In fact, many pundits deduce that the nation’s current attention and concern with this crisis are predominantly due to its effect on white families in addition to families of color.
a. Historical Origins
Our nation’s current crisis can be directly traced to drug manufacturing companies’ actions and the greater medical field in the 1990’s. In the name of higher sales and increased profits, pharmaceutical companies began encouraging doctors to increase their prescription of painkillers, assuring medical communities, that there was little risk that patients would become addicted to them. According to the Center for Disease Control and Prevention (CDC), the “amount of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled from 1999 to 2012”.Notably, there is no evidence to suggest a legitimate medical purpose for this increase, as there was no overall change in patients’ level of pain reported during this period.
As doctors began to prescribe prescription opioids in larger quantities, the medical community quickly determined that these drugs were, in fact, highly addictive, as widespread diversion and misuse of the medications became rampant. This trend steadily continued through the next decade; in 12010, the number of opioids prescribed was enough to provide every American adult with five milligrams of an opioid drug every four hours for a month. Consequently, some studies reported that eighty percent of heroin users first misused prescription painkillers, a recognized gateway drug to illicit opioids.
According to the CDC, nearly half of all opioid-related deaths involve a prescription, and in 2013, providers wrote nearly 250 million opioid prescriptions. Although leaders of governmental, medical, and other pertinent communities have taken action, the toll on American families persists. In 2017, nearly 50,000 Americans died from an opioid overdose. In that same year, the National Institutes of Health (NIH) estimated that “1.7 million people in the United States suffered from substances abuse disorders related to prescription opioid pain relievers”. Moreover, opioid overdoses increased by seventy percent between July 2016 and September 2017 in the Midwestern region of the United States, signaling that previously implemented measures have been futile. If the current trend continues, 650,000 lives could be lost over the next decade.
b. Overview of Historical and Current Legal Responses
As the opioid crisis has taken its full form, many actors have taken center stage, including federal and state governments, scientists, medical treatment experts and advocates, and members of the legal profession. Legislatures have passed laws both at the state and federal levels. The criminal justice system’s role in addressing the crisis is a more complex issue. As is the case with addressing any societal problem, the first question is what role the criminal justice system plays in the solution. Responses will vary from punitive to rehabilitative, to a combination. For many, a crucial goal of the criminal justice system is to punish those who encouraged and exacerbated the spread with their actions, which consequently serves as a deterrent for similar actors still engaging in harmful behavior. However, its complexity makes it difficult to discern who is legally or morally culpable. In a system with finite resources, which groups should prosecutors target, and in what order?
For some, any using opioid drugs without proper medicinal purpose should be disciplined. Although this was common perspective during the “War of Drugs” era, it has often been refuted for using finite resources to punish addicts for their behavior rather than focusing on the actors fueling those addictions.
Additionally, some experts view doctors as a crucial piece of the puzzle. As the only relevant party with an affirmative duty to provide care, doctors who continue to illegitimately prescribe opioid drugs for financial gain are fundamentally betraying their Hippocratic Oath. Others focus on the pharmacists’ role in this crisis; why not pursue those who turn a blind eye and repeatedly fill the prescriptions of addicts?
Finally, others place most of the blame on pharmaceutical distribution and manufacturing companies, which have primarily been responsible for giving access to, and encouraging doctors to push the influx of drugs into our communities. The American criminal justice system has struggled to find an appropriate way to balance the culpability among the relevant actors, and subsequently, has failed to make meaningful progress in holding each of them responsible.
c. Harmful Effects on Rural Communities
The impact of the opioid crisis, though vast, has not been evenly felt throughout the country. Researchers, by some estimates, have found that almost fifty percent of rural adults and seventy-four percent of farmers have been directly affected by the opioid crisis. Addiction and drug-related deaths have viciously swept through countless rural communities, as the death rate for working-class white Americans without a college degree has risen by twenty-two percent since 1999. Although drug-related deaths have been increasing at alarming rates in cities for numerous decades without much news media attention, a 2017 C.D.C report stated that the rate of spread in rural areas is now far outpacing the rest of the nation.
The region of the country most affected by the opioid crisis is often called the “opioid belt”. It has “more than 90 counties stretching southwest from Webster County, W. Va., through southern Virginia and ending in Monroe County, Ky.” These counties are primarily rural communities that have experienced the highest per capita death rates from opioid in the entire country. From 2006 through 2012, death rates in the opioid belt were 4.5 times the national average.
Rural communities are more susceptible to substance, and more specifically opioid, abuse for several reasons.First, they have an older population on average than urban areas, which correlates with higher numbers of individuals with medical conditions. Second, a more significant proportion of the workforce in rural communities hold jobs that involve physical labor. As a result, individuals are more likely to take painkiller than those in white-collar settings. Finally, once overcome with addiction, rural areas will often lack adequate medical and treatment facilities in comparison to their urban counterparts.
To compare those areas most harshly affected by the opioid crisis to their respective prosecutorial responses (through the number of doctors being prosecuted for illegal drug distribution), I used a regularly updated Washington Post article covering annual Drug Enforcement Administration (DEA) reports, which details the influx rates of pills into each state. The article includes an interactive map that displays the number of pills distributed per person, per year in each county. Although these reports only document prescription pill influxes between the years of 2006 and 2014, prosecutions based on prescribing behavior during time would logically follow in subsequent years. This would allow prosecutors to collect evidence and build their cases before bringing charges.
From this map, I compiled a list of counties by state that contained over seventy-five pills distributed per person, per year. This list identified the respective federal districts that cover these areas, to consider each prosecutorial response. The federal districts with the most significant influx of drugs largely track along the opioid belt. Specifically, the districts of interest include: the Eastern and Western Districts of Oklahoma, the Eastern and Western Districts of Kentucky, the Eastern and Western Districts of Virginia, the Northern District of Georgia, and the Northern District of Alabama. A discussion on the current prosecutorial responses from these states, in terms of the number of prosecutions of doctors for illegal opioid distribution per district, follows below.
III. Current Trends in the Prosecutions of Doctors in Relation to the Opioid Crisis
Between 2006 and 2012, there was a steady increase in the national opioid prescription rate from 72.4 prescription per 100 person to 81.3 prescriptions, respectively. The overall number of opioid prescription written during these years jumped from 215,917,663 in 2006 to 255,207954, totaling an increase in almost 40 million. These facts, as stated above, must be contrasted with the sobering reality that there was no overall change in the level of pain reported by American patients during this period. Thus, as the opioid-related deaths resulting from doctor overprescribing continued to surge, the criminal prosecution of doctors would seemingly follow suit. Unfortunately, that was not the case.
Although the national opioid prescription rate has declined, with over ten percent of counties in the United States containing enough opioid prescription for each person to have one per year, it is quite clear that the prosecutorial response is not only lacking, but serves as little deterrence for doctors choosing to engage in this unlawful prescribing behavior. Part II addresses how doctors are being prosecuted concerning the opioid crisis and how the current judicial and prosecutorial responses vary across the country. More specifically, I will discuss the hardest-hit areas (see above) by the opioid crisis, as well as those areas that in comparison to their opioid influx and drug-related death rates, have prosecuted a relatively high number of doctors.
For this paper, I measured the prosecutorial responses of various federal districts by searching their respective “News” database for each conviction press release and tallied the number of doctors convicted in each district.
b. The CSA’s Physician Exception
This section discusses the process by which the criminal justice system can disincentivize doctors from illegal prescribing opioids. The difficulties associated with this process will be discussed in Part IV. The Controlled Substances Act (CSA) 21 U.S.C. § 801 et. seq., provides that controlled substances may only be distributed lawfully be registered handlers. Practitioners, however, are exempted under the CSA and are permitted to “distribute, dispense, conduct research with respect to [and] administer… a controlled substance” so long as it is done “in the course of professional practice.” The term practitioner includes physicians. The CSA only requires individuals who “prescribe or dispense” controlled substances in Schedules II through V to register with the DEA.
The criminal justice system’s “check” on physician behavior is achieved by 21 U.S.C. § 841. To be clear, as is the case with most criminal offenses, in order to prosecute a doctor for violating the CSA, the government will have to prove that the doctor: (1) knowingly; (2) without legitimate medical purpose; (3) prescribed controlled substances outside the course of professional practice. However, what constitutes both “a legitimate medical purpose” and “the usual course of professional practice” based on existing caselaw hardly gives its readers a sufficient understanding of these standards’ meanings. Some examples of improper professional practice include writing excessive prescriptions and issuing prescriptions without first examining the patient. Additionally, “intent” is difficult to prove when numerous actors play a role in a medical office’s improper business dealings.
c. Focus Areas with Little Prosecutorial Response
i. West Virginia
West Virginia, frequently dubbed the “epicenter” of the opioid crisis, consistently ranks high on the list of states with the highest rates of overdoses. In 2015, there were 41.5 deaths per 100,000 people living in the states. A large aspect of the problem in West Virginia, similar to other states in the opioid belt, is the sheer number of pills brought into the states and subsequently prescribed by doctors each year. In 2017, West Virginia doctors wrote 81.3 opioid prescription for every 100 persons, significantly more that than national average rate of 58.7 prescriptions. Moreover, according to the DEA report of pill distribution, there are thirteen counties spanning across the entire state that average over seventy-five pills per person, per year. With these sobering statistics, one would anticipate aggressive action from the United States Attorney of both the Northern and Southern Districts of West Virginia. That, however, has not been the case.
Between 2015 and 2020, both the Northern District and Southern District of West Virginia convicted only twelve doctors in total for prescribing opioid in violation of the CSA. Of these twelve prosecutions, seven of them occurred in the past year and a half. Although this is a positive sign moving forward, it still raises questions regarding the lack of prosecutorial responses during the early years of clear and rampant over prescription.
In addition to those doctors prosecuted specifically for distribution under the statute, the two districts prosecuted six doctors for various crimes, ranging from using communication devices to commit a felony to instates travel in aid of a racketeering enterprise. The underlying facts of these cases indicate that the primary purpose for pursuing these doctors was their involvement in improperly distributing opioids. This further exemplifies the difficulty of prosecuting doctors pursuant to the CSA when convicting these doctors of lesser, yet related crimes, are seemingly the second-best option.
In a state with staggering pill influx and distribution statistics, coupled with recent studies indicating that twenty-five percent of rural Americans said drug addiction was their biggest concern for their community, it is quite puzzling that the number of prosecutions for doctors has remained fairly low. Though the state is taking promising steps in the civil sector, these steps will not have their intended effects unless its federal districts also hold overprescribing doctors accountable.
Based on the DEA’s report, seven counties in Oklahoma consistently have over seventy-five pills per person per year. In 2017, Oklahoma healthcare providers wrote an average of 88.1 prescriptions for every 100 persons.Given the higher rate of prescribing than that of West Virginia, Oklahoma federal districts should be scrutinizing the actions of doctors who are responsible for most of these prescriptions. Once again, that has not happened.
The Northern and Western Districts of Oklahoma have convicted only one and two doctors, respectively. The Eastern Districts of Oklahoma have yet to prosecute a doctor in this capacity. Similar to West Virginia, Oklahoma’s legal efforts are primarily directed at the drug manufacturers and pharmaceutical industries. As previously noted, although these industries play a formative role in the shape and scope of the crisis, a holistic and effective approach must include an equally aggressive criminal justice response for these doctors.
In 2012, there were more opioid prescriptions written in Tennessee than there were people living in the state.In 2017, healthcare providers in Tennessee wrote 94.4 opioid prescriptions for every 100 persons. The DEA’s report on painkillers indicated that over thirty counties in the state that averaged more than seventy-five pills per person per year. Given these statistics, it should not come as a surprise that in 2018, doctors wrote over six million prescriptions.Unfortunately, the changing statistics indicate that although Tennessee has managed to decrease its opioid-related death rate, millions of opioids continue to enter the state each year. The prosecutorial response towards the medical community has, similar to other states, been lackluster at best. Between 2015 and 2020, only eight doctors were convicted among the state’s three federal districts. The state received federal funding to help finance addiction prevention strategies and has engaged in a multi-district lawsuit against various opioid manufacturers. Although these actions are a crucial piece of any comprehensive solution, Tennessee must similarly intensify its prosecutorial efforts to deter doctors from continuing to engage in this unethical behavior.
d. Focus Areas Showing Concerted Prosecutorial Effort
Although the criminal justice responses from the previously states are quite minimal, some states have employed more comprehensive, and consequently, more successful and effective approaches.
Communities within Virginia, particularly in the western part of the state, have greatly suffered throughout this crisis. Though health providers wrote opioid prescriptions at a rate below the national average in 2017, the state had twenty-one counties with over seventy-five pills per person, per year.
Collectively, the Eastern and Western Districts of Virginia have convicted fifteen doctors between 2015 and 2020. In an effort to ramp up their opioid-related efforts, the Western District also joined the ARPO Strike Force in April of 2019. The state’s success stems, in part, from its multifaceted criminal justice approach. According Thomas Cullen,
“[T]he prosecutors in my office [are] focus[ed] on meaningful enforcement initiatives to staunch the flow of these deadly drugs and deter misuse. From targeting and dismantling major drug trafficking organizations that bring heroin and Fentanyl into our district, to prosecuting dope-peddling physicians and dealers who directly cause overdose deaths, we are committed to holding those most responsible accountable under federal law.”
In addition to focusing on the criminal justice aspect of the opioid crisis, Cullen says his office is also dedicated to “supporting meaningful prevention and recovery programs.” The district also houses one of the only federal drug treatment courts in the nation. With its multidimensional approach at the forefront of criminal justice efforts, the state’s response towards doctors has the potential for a true deterrent effect.
Kentucky is employing a multi-faceted approach in curbing this epidemic as well. In 2017, Kentucky health care providers prescribed approximately 87 opioids for every 100 people statewide. The state is consistently among the top ten states with the highest prescribing rates and subsequent opioid-related death rates. In addition, it is home to thirty-seven counties that average more than seventy-five pills per person per year. However, through a concerted effort of lawmakers, public health organizations and the criminal justice system, Kentucky is on a path to (albeit slow) recover.
The most impressive aspect of Kentucky’s approach has been its aggressive efforts to combat the illegal prescription of opioids throughout its federal districts. For example, Kentucky has convicted fourteen doctors between 2015 and 2020. Kentucky’s districts have also recently joined the ARPO Strike Force.
As stated before, Kentucky’s physician-focused efforts have also come from the state legislature and the medical community. By approaching this crisis through civil, regulatory, and criminal lenses, Kentucky is concurrently procuring funding for essential treatment programs, effectively reducing addictive behavior and holding malicious actors accountable.
Though not commonly considered part of the opioid belt, the opioid crisis has caused considerable damage to communities in Northern Alabama. Alabama has eight counties that contain more than seventy-five pills per person, per year. In 2017, Alabama health care providers wrote 107.2 opioid prescriptions for every 100 persons, totaling the highest prescription rate in the country.
In combatting this crisis, the state has taken aggressive civil, criminal, and regulatory steps to address the issue. Through the work of Alabama’s civil prosecutors and administrative agencies, Alabama’s federal criminal justice system has shown remarkable leadership in dealing with the opioid crisis.
Alabama’s federal districts have convicted nineteen doctors between 2015 and 2020, affirmatively demonstrating the state’s low tolerance for prescribing impropriety. In the Northern District of Alabama, combatting the opioid crisis is one of its Project Safe Neighborhood goals. More specifically, the U.S. Attorney’s office state that, “The U.S. Attorney’s Office Anti-Opioid Initiative combats the opioid epidemic in Alabama by aggressively pursuing enforcement against drug dealers and developing community-based programs that support drug prevention and treatment opportunities for those affected by the opioid epidemic.”
Community outreach and treatment efforts, although helpful, will not prevent these dangerous drugs from getting into vulnerable communities in the first place. However, underperforming states should look to proactive states, such as Alabama, to implement similarly aggressive governmental measures to curb their medical communities’ prescribing rates.
Georgia is home to ten counties holding more than seventy-five pills per person per year. In 2017, Georgia health care providers wrote 70.9 opioid prescriptions for every 100 persons. Also, the state’s health care costs associated with prescription opioid misuse were estimated in 2007 alone, at $447 million.
Georgia, similar to Alabama, is another example of an aggressive governmental response to overprescribing in addition to community outreach and treatment efforts. The federal districts in Georgia have convicted seventeen doctors from 2015 through early 2020. Georgia’s progress in combatting this crisis is undeniably linked to its strong stance regarding prescribing practices.
IV. Theories regarding Perceived Prosecutorial Deficiencies
In part IV, I will discuss the underlying theories for what I call “perceived prosecutorial deficiencies”. Why are large numbers of doctors not prosecuted in states and federal districts where rampant improper prescribing is all but certain? To answer this question, I interviewed several federal prosecutors working in offices falling within the opioid belt. In addition, I looked to the expertise of legal scholars who have researched the greater criminal justice response to the opioid crisis as a whole. Placed these explanations into three main groups: resource constraints, difficulties in proving elements of the crime, and differing priorities.
a. Resource Constraints
The most common explanation plagues countless public health and criminal justice issues in America today: prosecutors do not have the required resources to pursue each and every doctor engaging in this behavior. Many of the interviewed prosecutors directly compared the resources available to prosecute doctors illegally prescribing opioids to prosecuting street dealers distributing heroin. Some of the differences between them include: (1) overall time spent on each case, the number and type of experts needed to prove the case, (2) expertise by and the number of lawyers and investigators needed to review relevant documents, and (3) additional efforts necessary to convincingly present this case to a judge or jury.
This type of crime has been called a “hybrid of white-collar crime and drug dealing”; each of these crimes brings forward distinct challenges and burdens that the prosecution must satisfy in proving its case. To further explain the efforts expended to prosecute a doctor in this capacity, I will walk through some of the steps that prosecutors must take in each of these cases.
First, in building a case, prosecutors must spend countless hours interviewing often reluctant patients and reviewing medical files and a pharmacy’s distribution records. Because these doctors have the legal authority to prescribe opioids in this capacity, prosecutors will have to overcome this presumption by showing that the doctor (1) knowingly, (2) without a legitimate medical purpose; (3) prescribed controlled substances outside the course of professional practice. In reviewing these medical records and interviewing patients, each prosecutor’s office will need investigators who are well-versed in medical terminology, and are familiar with medical practices related to pain management.Interviewing patients in the course of an improper drug distribution case brings its own challenges, as many of them require time-intensive assistance throughout the process. Often times, witnesses in these cases are former patients of the doctors. Moreover, these individuals are frequently still suffering from addiction; as is the case with any prosecution involving witnesses who have been involved in the illegal activity themselves, they are incredibly wary of law enforcement personnel. Other witnesses on the road to recovery may nevertheless be unwilling to cooperate. In the context of a case in West Virginia, an ideal witness refused to testify, as he did not want to relive his experiences with that particular doctor in court.
This category of cases also requires additional expert witness testimony. In a traditional drug distribution case, typical expert witnesses include investigators familiar with common drug trafficking practices and lab analysts who can testify that the substances trafficked are indeed drugs. In addition, these cases require medical experts to testify how the doctor’s behavior compares to standard medical practices.
Specifically, prosecutors must find and compensate doctors for testifying that an indicted doctor prescribed the opioids both without a legitimate medical purpose and outside the course of professional practice.
As a doctor’s course of medical treatment can and should be different for each patient, incorporating their particular symptoms and circumstances, these medical experts will need to overcome the informal presumption that their opinions are not just post hoc differences in medical opinions. Unless a doctor was running a full-fledged pill mill and the facts overwhelmingly suggested illegality, medical experts are unwilling to question another’s professional opinion without being privy to the underlying facts and the patient-doctor medical history at the time the accused doctor wrote each prescription.
Lastly, an additional resource-intensive piece of the process involves the amount of time and effort necessary to ensure both the judge and jury can grasp the information presented at trial. As discussed above, these crimes can be more complicated than a typical drug distribution case. As such, prosecutors must spend more time walking the factfinder through the intricacies of the crime. On average, these investigations, and subsequent trials can take between two to three years, from start to finish.
b. Difficulties Associated with Proving Elements of the Crime
In addition to the complexity of presenting important facts to the factfinder, doctors' prosecution is equally arduous due to the particular elements of the crime that the government must prove. For example, prosecutors must show that the doctor prescribed opioids “outside the course of professional practice”. This particular standard was first recognized in United States v. Moore. In Moore, the court considered a doctor who had prescribed large quantities of prescription medications to patients, regardless of their medical need, for a set price per prescription. Even though this case presents a doctor working extensively outside the course of professional practice, it has given prosecutors little guidance in cases with nuanced factual circumstances. Consider the following questions. Under Moore, how thorough must a medical examination be before prescribing these medications? How high must the number of pills or the number of refills be to raise impropriety question? How should a doctor approach prescribing pills if they suspect a patient may be lying about the extent of their pain?
Besides the fuzziness found in the text of 21 U.S.C. §841, some federal prosecutors indicate that the difficulty in prosecuting doctors in this capacity can be attributed to a jury’s reluctance to prosecute doctors entirely. According to Sarah Wagner, an Assistant United States Attorney for the Northern District of West Virginia, doctors are not viewed as the “bad guys” juries are accustomed to placing in jail. Instead, the medical profession is generally seen as one of the most trusted occupations in society. When placing a doctor on trial, prosecutors are asking jurors to question the legitimacy of those they are expected to trust. In their everyday lives, Americans are implored to follow medical professionals' advice and guidance. With this in mind, one can see how a prosecutor’s duty in these types of cases may extend beyond proving each element beyond a reasonable doubt. In fact, it may depend on their ability to pierce a doctor’s veil of trustworthiness and legitimacy.
c. Differing Priorities
Another reason for fewer prosecutions of doctors in this capacity stem from a difference in office priorities. Some United States Attorney’s Offices dedicate entire teams, or particular lawyers, to the prosecution of these types of cases. For example, Roger West, an Assistant United States Attorney for the Eastern District of Kentucky, has been one of a few lawyers in his office assigned to these types of cases for the last fifteen years.
Other offices spend their time and resources on other aspects of the opioid crisis, as discussed in Part II. For example, the Eastern District of Kentucky has focused its efforts on curbing heroin and fentanyl distribution. This theory rests on the premise that there may not be as many doctors engaging in this practice anymore, as prescription drug users have switched to street opiates to feed their addictions at lower price tags. Though there is merit to this theory, the national prescribing rate data suggests that doctors across the United States are still overprescribing at alarming rates.
Some offices have placed the blame and prioritized their subsequent legal efforts towards pharmaceutical and drug manufacturing companies. A possible reason for this is the DEA’s focus on prescribers, wholesale distributors, pharmacies, and pharmacists. This agency frequently works with United States Attorney’s Offices to prepare drug cases; thus, and consequently, many offices only prosecute cases in which they can rely on the DEA’s guidance and assistance.
Other offices have seemingly made the policy choice to prioritize doctor prosecutions, irrespective of their District’s relatively low opioid prescription rates. For example, the Eastern District of Michigan and the Western District of Pennsylvania, have aggressively prosecuted these offenses, sentencing thirteen, and fifteen doctors,respectively, in a five-year period. One possible explanation for this mismatch is that offices in high profile districts are more likely to prosecute politically popular cases than those in lesser-known districts. Under this theory, these offices are more inclined to open cases relating to “hot button” issues, such as the opioid crisis. This claim has merit, as many of the most well-known districts in the country have adamantly been prosecuting doctors in this capacity, regardless of whether those districts are considered hot spots for purposes of the opioid crisis. For example, although zero counties within the Southern District of New York or the Southern District of Florida have prescription rates of more than seventy-five pills per person, per year, the districts have prosecuted a combined total of sixteen cases between 2015 and 2020.
V. General Considerations
Though the criminal justice system’s proper role in combatting the opioid crisis is quite complex, one aspect of the job is simple: decreasing the number of opioids prescribed and holding those responsible for improper distribution accountable. Medical professionals are one of society’s most trusted members; ensuring that they are disincentivized from profiting off of and proliferating the disease of addiction is vital to combat this epidemic. All data considered, our federal districts are failing to remove improper distribution of prescription opioids from their communities. After taking into account the multitude of difficulties associated with prosecuting doctors in this capacity, it is clear that our federal district do not have the resources in place to handle these cases, or at the very least, their leadership has not made these cases a priority among the various offices. As noted above, some offices have approached the opioid crisis as the serious public health and criminal justice emergency that it is by designating full teams and divisions to stomp out doctors engaging in this type of behavior. Offices not yet following suit, especially those located within the opioid belt, must consider the impact their inaction continues to play in allowing millions of prescriptions to fall into the hands of their most vulnerable. By bringing attention to this national prosecutorial deficiency, while acknowledging possible reasons for its occurrence, I hope that federal districts reevaluate their current priorities and resource allocations to create comprehensive plans that are as aggressive and multifaceted as the opioid crisis itself.
 J.D. Candidate, 2021, William & Mary Law School; B.A., Environmental Studies and Public Policy, 2018, Franklin & Marshall College. Thank you to Professor Adam Gershowitz for his editorial contributions and feedback through the many drafts of this Article, as well as Assistant U.S. Attorney Jennifer Kolman (E.D. Tenn.), Assistant U.S. Attorney Sarah Wagner (N.D.W.V.), Assistant U.S. Attorney Roger West (E.D. Ky.), and Assistant U.S. Attorney Randy Ramseyer (W.D. Va.) for their guidance during phone interviews.  Khary K. Rigg, et al., Prescription Drug Abuse & Diversion: Role of the Pain Clinic, 40(3) J. DRUG ISSUES 681, 685 (2010).  U.S. Prescribing Rate Maps, CDC, https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html (last visited Apr. 12, 2020).  Drilling into the DEA’s pain pill database, Wash. Post: The Opioid Files, https://www.washingtonpost.com/graphics/2019/investigations/dea-pain-pill-database/?itid=lk_inline_manual_9 (last updated Jan. 17, 2020).  It is important to note that most doctors are not illegally prescribing opioids to their patients. In fact, the vast majority of them follow proper prescribing practices religiously. This paper advocates the position that high prescriptions rates are undoubtedly connected to doctors who are illegally prescribing opioids and contributing to this crisis. This minority, however slim, are causing serious societal harms to vulnerable communities that they serve.  Press Release, U.S. Att’y’s Off., S.D. Ga., Georgia Physician Sentenced To 100 Months in Prison, Fined For Role in Fueling Opioid Crisis (Sept. 18, 2018) https://www.justice.gov/usao-sdga/pr/georgia-physician-sentenced-100-months-prison-fined-role-fueling-opioid-crisis.  Press Release, U.S. Att’y’s Off., W.D. Va., Lebanon Doctor Sentenced on Federal Drug Distribution Charges (Feb. 7, 2019) https://www.justice.gov/usao-wdva/pr/lebanon-doctor-sentenced-federal-drug-distribution-charges.  Id.  Id.  Id.  Id.  Courtney Hessler, Hearing in Opioid Cases Set in Charleston, CHARLESTON GAZETTE-MAIL (Jan. 19, 2020), https://www.wvgazettemail.com/news/legal_affairs/hearing-in-opioid-cases-set-in-charleston/article_744235a3-370b-5196-8fba-24d85ef447a3.html#.XiYbvKBVny1.twitter.  The vast majority of these cases were brought by United State Attorney’s Offices, as opposed to their state counterparts. Telephone Interview with Jennifer Kolman, Assistant United States Attorney, U.S. Att’y’s Off., E.D. Tenn. (Feb. 3, 2020). The reasons for this include the sheer amount of time and resources necessary to prosecute each case.  See Abdullah Shihipar, The Opioid Crisis Isn’t White, N.Y. TIMES (Feb. 26, 2019),https://www.nytimes.com/2019/02/26/opinion/opioid-crisis-drug-users.html.  Helena Hansen & Julie Netherland, Is the Prescription Opioid Epidemic a White Problem?, 106 AM. J. PUB. HEALTH 2127, 2128 (2016); Martha Bebinger, Opioid Addiction Drug Going Mostly To Whites, Even As Black Death Rate Rises, NPR (May 8, 2019), https://www.npr.org/sections/health-shots/2019/05/08/721447601/addiction-medicine-mostly-prescribed-to-whites-even-as-opioid-deaths-rose-in-bla.  Opioid Overdose Crisis, NAT’L INST. ON DRUG ABUSE, NIH, https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis (last revised Feb. 2020). 15  Id.; What is the U.S. Opioid Epidemic?, U.S. DEP’T HEALTH & HUMAN SERV., https://www.hhs.gov/opioids/about-the-epidemic/index.html (last accessed Apr. 12, 2020).  Julie A. Warren, Defining the Opioid Crisis and the Limited Role of the Criminal Justice System Resolving It, 48 U. MEM. L. REV. 1205 (2014); see also Understanding the Epidemic, CDC, https://www.cdc.gov/drugoverdose/epidemic/index.html(last accessed Apr. 12, 2020).  Alyssa M. McClure, Illegitimate Overprescription: How Burrage v. United States is Hindering Punishment of Physicians and Bolstering the Opioid Epidemic, 93 NOTRE DAME L. REV. 1747, 1751 (2018).  Id.  Carson Schneider, Redefining What it Means to “Furnish Items in Excess of a Patient’s Needs”: A Federal Tool to Guide Physician Prescribing Behavior and Combat the Opioid Crisis, 90 U. COLO. L. REV. 1157, 1960 (2019).  Anne C. Hazlett, Rural America and the Opioid Crisis: Dimension, Impact, and Response, 23 DRAKE J. AGRIC. L. 45, 46 (2018)  Alyssa M. McClure at 1750–51, supra note 19.  Opioid Overdose Crisis, supra note 16.  Id.  Id.  Alyssa M. McClure at 1750–51, supra note 19.  Mike C. Materni, Criminal Punishment and the Pursuit of Justice, 2 BR. J. AM. LEG. STUDIES 263, 266, 289 (2013).  See, e.g., Ed Gogek, To Treat Addiction, We’ll Still Need Jail Time, Newsweek (Nov. 10, 2015), https://www.newsweek.com/treat-drug-addiction-well-still-need-jail-time-392635.  See Svante Myrick & Alan Webber, ‘War on Drugs’ Doesn’t Tackle the Drug Problem, The Hill (Jan. 22, 2019) https://thehill.com/opinion/healthcare/426458-war-on-drugs-doesnt-tackle-the-drug-problem.  Schneider, supra note 21.  See, e.g., Press Release, U.S. Att’y’s Off., S.D. Ga., Pooler pharmacy, pharmacist to pay up to $2.2 million for dispensing illegitimate prescriptions (Apr. 7, 2020), https://www.justice.gov/usao-sdga/pr/pooler-pharmacy-pharmacist-pay-22-million-dispensing-illegitimate-prescriptions.  Nathan Yerby, DEA Database Shows Generic Drug Manufacturers Contributed Most to the Opioid Epidemic, Addiction Center (Aug. 14, 2019), https://www.addictioncenter.com/news/2019/08/generic-drug-manufacturers-opioid-epidemic/.  Hazlett, supra at 45.  Id. at 47.  Julie Netherland & Helena B. Hansen, The War on Drugs That Wasn’t: Wasted Whiteness, “Dirty Doctors,” and Race in Media Coverage of Prescription Opioid Misuse, Cult Med Psychiatry (December 1, 2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5121004/.  Hazlett, supra at 47; see also Sari Horwitz et al., Opioid Death Rates Sourced in Communities Where Pain Pills Flowed, WASH. POST (July 17, 2019), https://www.washingtonpost.com/investigations/opioid-death-rates-soared-in-communities-where-pain-pills-flowed/2019/07/17/f3595da4-a8a4-11e9-a3a6-ab670962db05_story.html.  See Sari Horwitz et al., Opioid Death Rates Sourced in Communities Where Pain Pills Flowed, WASH. POST (July 17, 2019).  Id.  Hazlett, supra at 48  Id.  Id.  Id.  Hazlett, supra at 48-49  Id.  Drilling into the DEA’s pain pill database, supra note 4.  Id.  See Press Release, U.S. Att’y’s Off., N.D. Ala., Huntsville Pill Mill Doctor Pleads Guilty to Illegal Prescribing and Health Care Fraud (Oct. 27, 2016) (reporting that Dr. Shelinder Aggarwal was sentenced to 15 years in prison for illegally prescribing opioids. He ultimately pleaded guilty in 2016 to facts taking place between 2011 and 2013). https://www.justice.gov/usao-ndal/pr/huntsville-pill-mill-doctor-pleads-guilty-illegal-prescribing-and-health-care-fraud.  List on File with the Author. There were 199 counties that met this threshold in total. Seventy-five was the median rate on Drilling into the DEA’s pain pill database’s interactive map legend. See Drilling into the DEA’s pain pill database, supra note 4.  U.S. Prescribing Rate Maps, supra note 3.  Id.  McClure, supra at 1751.  U.S. Prescribing Rate Maps, supra note 2  In fairness, the DEA has reported a “steady rise in successful criminal prosecutions of physicians, from just fifteen convictions in 2003 to forty-three in 2008”. See McClure, supra at 1748.  This paper includes all doctors convicted in each district between 2015 and 2020. This was conducted by tracking each doctor’s case through various press releases and including them in my data only if they were convicted in 2015. For example, if a doctor were charged or indicted in 2014, but not convicted in 2015, that doctor would be included. Also, if a doctor were arrested, charged, or indicted, but the database did not contain a subsequent press release indicating a conviction, that doctor would not be included. Although this list likely includes most doctors prosecuted during these years, there may be doctors that the searching process failed to capture. For an example of a News database, see generally News, U.S. ATT’Y’S OFF., S.D. W.VA., https://www.justice.gov/usao-ndwv/pr?keys=doctor+&items_per_page=50 (last accessed Apr. 10, 2020).  21 U.S.C. § 801 et. seq. (1970).  Id.  Id.  Id.  Id. § 841.  See United States v. Moore, 423 U.S. 122 (1975).  McClure supra note 16.  R. Merino et al., The Opioid Epidemic in West Virginia, 32 HEALTH CARE MANAG. 187 (2019).  Id.  West Virginia Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/opioid-summaries-by-state/west-virginia-opioid-summary.  See Drilling into the DEA’s pain pill database, supra note 4.  See Press Release, U.S. Att’y’s Off., N.D. W.Va., Former Marion County physician admits to drug charge (Mar. 6, 2020) https://www.justice.gov/usao-ndwv/pr/former-marion-county-physician-admits-drug-charge; Press Release, U.S. Att’y’s Off., S.D. W.Va., HOPE Clinic Physician Pleads Guilty to Drug Crime (Feb. 3, 2020) https://www.justice.gov/usao-sdwv/pr/hope-clinic-physician-pleads-guilty-drug-crime; Press Release, U.S. Att’y’s Off., N.D. W.Va., Pennsylvania physician sentenced for drug charge (Jan. 31, 2020) https://www.justice.gov/usao-ndwv/pr/pennsylvania-physician-sentenced-drug-charge; Press Release, U.S. Att’ys Off., S.D. W.Va., Doctor of Osteopathic Medicine Sentenced for Drug Distribution (Oct. 23, 2019) https://www.justice.gov/usao-sdwv/pr/doctor-osteopathic-medicine-sentenced-drug-distribution; Press Release, U.S. Att’ys Off., S.D. W.Va., Former Parkersburg Physician Pleads Guilty for His Role in Hope Clinic Conspiracy (Oct. 3, 2019) https://www.justice.gov/usao-sdwv/pr/former-parkersburg-physician-pleads-guilty-his-role-hope-clinic-conspiracy; Press Release, U.S. Att’y’s Off., N.D. W.Va., West Virginia physician sentenced for illegal opioid distribution to patients (Sept. 3, 2019) https://www.justice.gov/usao-ndwv/pr/west-virginia-physician-sentenced-illegal-opioid-distribution-patients; Press Release, U.S. Att’ys Off., S.D. W.Va., Charleston Doctor Pleads Guilty to Illegal Distribution of Methadone (Aug. 24, 2019) https://www.justice.gov/usao-sdwv/pr/charleston-doctor-pleads-guilty-illegal-distribution-methadone-0; Press Release, U.S. Att’y’s Off., N.D. W.Va., Ohio physician sentenced to nearly five years for fraudulently distributing controlled substances (Sept. 17, 2018) https://www.justice.gov/usao-ndwv/pr/ohio-physician-sentenced-nearly-five-years-fraudulently-distributing-controlled; Press Release, U.S. Att’ys Off., S.D. W.Va., Beckley area physician sentenced to 20 years in federal prison for oxycodone crime (Aug, 23, 2017) https://www.justice.gov/usao-sdwv/pr/beckley-area-physician-sentenced-20-years-federal-prison-oxycodone-crime; Press Release, U.S. Att’y’s Off., N.D. W.Va., Martinsburg doctor pleads guilty to illegal distribution of alprazolam and lorazepam (Feb. 27, 2017) https://www.justice.gov/usao-ndwv/pr/martinsburg-doctor-pleads-guilty-illegal-distribution-alprazolam-and-lorazepam; Press Release, U.S. Att’ys Off., S.D. W.Va., Beckley doctor sentenced to eight years in prison for Federal drug crime and health care fraud (Apr. 27, 2016) https://www.justice.gov/usao-sdwv/pr/beckley-doctor-sentenced-eight-years-prison-federal-drug-crime-and-health-care-fraud; Press Release, U.S. Att’y’s Off., N.D. W.Va., Bridgeport, WV doctor sentenced to 5 years for unlawful prescribing practices (May 12, 2015) https://www.justice.gov/usao-ndwv/pr/bridgeport-wv-doctor-sentenced-5-years-unlawful- prescribing-practices; see also Phone Interview with Sarah Wagner, Assistant United States Attorney, U.S. Att’y’s Off., N.D.W.V. (Feb. 6, 2020).  See Press Release, U.S. Att’y’s Off., N.D. W.Va., Former Marion County physician admits to drug charge (Mar. 6, 2020) https://www.justice.gov/usao-ndwv/pr/former-marion-county-physician-admits-drug-charge; Press Release, U.S. Att’ys Off., S.D. W.Va., HOPE Clinic Physician Pleads Guilty to Drug Crime (Feb. 3, 2020) https://www.justice.gov/usao-sdwv/pr/hope-clinic-physician-pleads-guilty-drug-crime; Press Release, U.S. Att’y’s Off., N.D. W.Va., Pennsylvania physician sentenced for drug charge (Jan. 31, 2020) https://www.justice.gov/usao-ndwv/pr/pennsylvania-physician-sentenced-drug-charge; Press Release, U.S. Att’ys Off., S.D. W.Va., Doctor of Osteopathic Medicine Sentenced for Drug Distribution (Oct. 23, 2019) https://www.justice.gov/usao-sdwv/pr/doctor-osteopathic-medicine-sentenced-drug-distribution; Press Release, U.S. Att’ys Off., S.D. W.Va., Former Parkersburg Physician Pleads Guilty for His Role in Hope Clinic Conspiracy (Oct. 3, 2019) https://www.justice.gov/usao-sdwv/pr/former-parkersburg-physician-pleads-guilty-his-role-hope-clinic-conspiracy; Press Release, U.S. Att’y’s Off., N.D. W.Va., West Virginia physician sentenced for illegal opioid distribution to patients (Sept. 3, 2019) https://www.justice.gov/usao-ndwv/pr/west-virginia-physician-sentenced-illegal-opioid-distribution-patients; Press Release, U.S. Att’ys Off., S.D. W.Va., Charleston Doctor Pleads Guilty to Illegal Distribution of Methadone (Aug. 24, 2019) https://www.justice.gov/usao-sdwv/pr/charleston-doctor-pleads-guilty-illegal-distribution-methadone-0.  See Press Release, U.S. Att’y’s Off., N.D. W.Va., West Virginia physician sentenced for illegally distributing drugs (Jan 31, 2020) https://www.justice.gov/usao-ndwv/pr/west-virginia-physician-sentenced-illegally-distributing-drugs; Press Release, U.S. Att’ys Off., S.D. W.Va., HOPE Clinic Physician Pleads Guilty (Jan. 27, 2020) https://www.justice.gov/usao-sdwv/pr/hope-clinic-physician-pleads-guilty;Press Release, U.S. Att’ys Off., S.D. W.Va., HOPE Clinic Physician Sentenced for Money Laundering Conspiracy (Jan. 10, 2019) https://www.justice.gov/usao-sdwv/pr/hope-clinic-physician-sentenced-money-laundering-conspiracy; Press Release, U.S. Att’y’s Off., N.D. W.Va., Martinsburg, WV doctor sentenced for unlawful distribution of prescription painkillers (June 28, 2016) https://www.justice.gov/usao-ndwv/pr/martinsburg-wv-doctor-sentenced-unlawful-distribution-prescription-painkillers; Press Release, U.S. Att’ys Off., S.D. W.Va., Charleston doctor pleads guilty to Federal crime involving dispensing fentanyl (Apr. 21, 2016) https://www.justice.gov/usao-sdwv/pr/charleston-doctor-pleads-guilty-federal-crime-involving-dispensing-fentanyl; Press Release, U.S. Att’ys Off., S.D. W.Va., Ohio Doctor Sentenced for two drug-related felonies (Jan. 12, 2015) https://www.justice.gov/usao-sdwv/pr/ohio-doctor-sentenced-two-drug-related-felonies.  Id.  Sydney Boles, Rural Americans Increasingly Concerned About Opioid Addiction, Study Finds, W.V. PUB. BROADCASTING (Jan. 10, 2020), https://www.wvpublic.org/post/rural-americans-increasingly-concerned-about-opioid-addiction-study-finds#stream/0.  Press Release, DOJ, Off. Pub. Aff., Department of Justice Awards Nearly $38 Million to Reduce Crime, Improve Public Safety in West Virginia (Dec. 13, 2019) https://www.justice.gov/opa/pr/department-justice-awards-nearly-38-million-reduce-crime-improve-public-safety-west-virginia (The state has secured financial support to increase the accessibility of drug treatment in a variety of ways. The state was recently awarded a $8 million grant from the Department of Justice (DOJ) to “fight the opioid crisis”) The general purpose of the funding is to “reduce crime and improve public safety,” with substantial funding allocated to the West Virginia Law Enforcement Assisted Diversion (LEAD), which “steer[s] low-level drug offenders away from prosecution and into treatment”, See Justice Department Awards nearly $38m . Additionally, the state has sought funding to promote widespread and effective treatment by gaining financial retribution from pharmaceutical companies. Recently, lawyers representing the state reached a $1.25 billion settlement with major actors in the pharmaceutical industry. Courtney Hessler, Talks to settle all WV opioid cases underway, Charleston Gazette-Mail (Mar. 1, 2020), https://www.wvgazettemail.com/news/talks-to-settle-all-wv-opioid-cases-underway/article_09de3ccd-97e5-5b84-a143-e13412b2f203.html. Though the actual breakdown of the settlement is still in consideration, the settlement award is projected to be divided “among the state and local governments, hospitals and other entities” to potentially reverse some of the harm these particular industries caused. See Hessler.  Drilling into the DEA’s pain pill database, supra note 4.  Oklahoma Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/oklahoma-opioid-involved-deaths-related-harms.  Compare West Virginia Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/opioid-summaries-by-state/west-virginia-opioid-summary with Oklahoma Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/oklahoma-opioid-involved-deaths-related-harms.  Press Release, U.S. Att’ys Off., E.D. Okla., Warr Acres Doctor Pleads Guilty to Drug and Identity-Theft Charges (Jan. 10, 2020) https://www.justice.gov/usao-wdok/pr/warr-acres-doctor-pleads-guilty-drug-and-identity-theft-charges; Press Release, U.S. Att’ys Off., N.D. Okla., Orthopedic Surgeon Sentenced for Opioid Prescription Conspiracies (Apr. 10, 2019) https://www.justice.gov/usao-ndok/pr/orthopedic-surgeon-sentenced-opioid-prescription-conspiracies; Press Release, U.S. Att’ys Off., E.D. Okla., Guymon Doctor Sentenced to Prison for Dispensing Opiates Without a Medical Purpose (Apr. 3, 2018) https://www.justice.gov/usao-wdok/pr/guymon-doctor-sentenced-prison-dispensing-opiates-without-medical-purpose.  When searching the Eastern District of Oklahoma’s News database, zero Press Releases regarding doctors prosecuted in this capacity appear. https://www.oked.uscourts.gov/.  See Jan Hoffman, Johnson & Johnson Ordered to Pay $572 Million in Landmark Opioid Trial, N.Y. TIMES (Aug. 30, 2019), https://www.nytimes.com/2019/08/26/health/oklahoma-opioids-johnson-and-johnson.html (stating In 2019, a state district judge ordered Johnson & Johnson to pay the state $572 million after it “intentionally played down the dangers and oversold the benefits of opioids”) As of January 2020, the state has won more than $829 million from settlements or court orders with drug companies. However, much of the court ordered funds have not yet made their way to the state, as they are frozen in the appellate process. Id. In addition, in 2019, the DOJ awarded the state $4.5 million to be usewd towards “state-wide and western Oklahoma governmental bodies to address public safety issues relating to opioids.” See Press Release, U.S. Att’y’s Off., W.D. Okla., Justice Department Awards Millions to Fight Opioid Crisis in Western Oklahoma (Dec. 13, 2019), https://www.justice.gov/usao-wdok/pr/justice-department-awards-millions-fight-opioid-crisis-western-oklahoma. Although these funds will be crucial in mitigation and treatment efforts across the state, once again, a discussion of alterations to doctor behavior are nowhere to be found. Id.  Carson Schneider, supra note 19.  See Tennessee Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/tennessee-opioid-involved-deaths-related-harms.  Drilling into the DEA’s pain pill database, supra note 4.  See Tennessee Faces of Opioids, TENN. DEP’T OF HEALTH, https://www.tn.gov/tnfacesofopioids.html (last visited Apr. 12, 2020)  See Tennessee Opioid Summary, supra note 79.  See Press Release, U.S. Att’y’s Off., W.D. Tenn., West Tennessee Psychiatrist Found Guilty of Unlawfully Distributing Opioids (Feb. 21, 2020) https://www.justice.gov/opa/pr/west-tennessee-psychiatrist-found-guilty-unlawfully-distributing-opioids; Press Release, U.S. Att’ys Off., M.D. Tenn., Former Tennessee Medical Doctor Pleads Guilty to Unlawfully Distributing Controlled Substances (Dec. 2, 2019) https://www.justice.gov/opa/pr/former-tennessee-medical-doctor- pleads-guilty-unlawfully-distributing-controlled-substances; Press Release, U.S. Att’ys Off., M.D. Tenn., Tennessee Emergency Medical Doctor Pleads Guilty to Unlawfully Distributing Controlled Substances (Nov. 25, 2019) https://www.justice.gov/opa/pr/tennessee-emergency-medical-doctor-pleads-guilty-unlawfully-distributing-controlled; Press Release, U.S. Att’ys Off., W.D. Tenn., Second Appalachian Region Prescription Opioid Strikeforce Takedown Results in Charges Against 13 Individuals, Including 11 Physicians (Sept. 24, 2019) https://www.justice.gov/opa/pr/second-appalachian-region-prescription-opioid-strikeforce-takedown-results-charges-against-13; Press Release, U.S. Att’ys Off., E.D. Tenn., Chattanooga Pill Mill Operator Sentenced To 280 Years In Prison (Aug. 28, 2015) https://www.justice.gov/usao -edtn/pr/chattanooga-pill-mill-operator-sentenced-280-years-prison; Press Release, U.S. Att’ys Off., E.D. Tenn., Ihsaan Al-Amin Sentenced To 100 Month In Prison For Illegally Dispensing Controlled Substances (June 1, 2015) https://www.justice.gov/usao-edtn/pr/ihsaan-al-amin-sentenced-100-month-prison-illegally-dispensing-controlled-substances; Press Release, U.S. Att’y’s Off., E.D. Tenn., Nine Medical Practitioners Indicted In Conspiracy To Distribute Controlled Pain Medication As Employees Of Breakthrough Pain Therapy Center In Maryville (Oct 16, 2014) https://www.justice.gov/usao-edtn/pr/nine-medical-practitioners-indicted-conspiracy-distribute-controlled-pain-medication.  In 2019, Tennessee received $46.7 million from the federal government to “help fight the opioid crisis”. See Allison Collins, Tennessee to receive $46.7 million in federal funding tocombat opioid crisis, CHATTANOOGA TIMES FREE PRESS (Sept. 4, 2019), https://www.timesfreepress.com/news/breakingnews/story/2019/sep/04/tennessee-receive-467-million-federal-funding-combat-opioid-crisis/502783/. This funding will help finance opioid addiction prevention, treatment and recovery programs, as well as to help the state health department collect overdose data in real time. Id. Additionally, the state is still in the middle of a 2017 lawsuit filed by fourteen state prosecutors representing counties in Middle and Eastern Tennessee against a variety of opioid manufacturers. See Mike Christen, Tennessee DAs take state’s opioid battle to courtroom, COLUMBIA DAILY HERALD (Dec. 29, 2019), https://www.columbiadailyherald.com/news/20191229/tennessee-das-take-state8217s--opioid-battle-to-courtroom.  Virginia Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/opioid-summaries-by-state/virginia-opioid-summary.  Drilling into the DEA’s pain pill database, supra note 4.  See Press Release, U.S. Att’ys Off., E.D. Va., Pain Doctor Sentenced to Prison for Illegally Prescribing Opiates (Feb. 24, 2020) https://www.justice.gov/usao-edva/pr/pain-doctor-sentenced-prison-illegally-prescribing-opiates; Press Release, U.S. Att’ys Off., W.D. Va., Norton Doctor Pleads Guilty to Illegally Prescribing Prescription Drugs (Dec. 20, 2019) https://www.justice.gov/usao-wdva/pr/norton-doctor-pleads-guilty-illegally-prescribing-prescription-drugs; Press Release, U.S. Att’ys Off., E.D. Va., Dentist Pleads Guilty to Running Oxycodone Conspiracy (May 9, 2019) https://www.justice.gov/usao-edva/pr/dentist-pleads-guilty-running-oxycodone-conspiracy; Press Release, U.S. Att’ys Off., W.D. Va., Virginia Doctor Convicted on 861 Federal Counts of Drug Distribution, Including Distribution Resulting in Death: Faces Mandatory Minimum of 20 Years in Federal Prison (May 9, 2019) https://www.justice.gov/usao-wdva/pr/virginia-doctor-convicted-861-federal-counts-drug-distribution-including-distribution; Press Release, U.S. Att’ys Off., E.D. Va., Former Doctor Sentenced to Prison for Illegal Sale of Opioids (Apr. 26, 2019) https://www.justice.gov/usao-edva/pr/former-doctor-sentenced-prison-illegal-sale-opioids; Press Release, U.S. Att’ys Off., W.D. Va., Former Blacksburg Doctor Sentenced on Federal Drug Charges (Feb. 13, 2019) https://www.justice.gov/usao-wdva/pr/former-blacksburg-doctor-sentenced-federal-drug-charges; Press Release, U.S. Att’ys Off., W.D. Va., Lebanon Doctor Sentenced on Federal Drug Distribution Charges (Feb. 7, 2019) https://www.justice.gov/usao-wdva/pr/lebanon-doctor-sentenced-federal-drug-distribution-charges; Press Release, U.S. Att’ys Off., W.D. Va., Coeburn Doctor Sentenced on Healthcare Fraud, Drug Charges (Mar. 19, 2018) https://www.justice.gov/usao-wdva/pr/coeburn-doctor-sentenced-healthcare-fraud-drug-charges; Press Release, U.S. Att’ys Off., E.D. Va., Doctor Sentenced to 30 Years for Oxycodone Distribution Conspiracy (Dec. 18, 2017) https://www.justice.gov/usao-edva/pr/doctor-sentenced-30-years-oxycodone-distribution-conspiracy; Press Release, U.S. Att’ys Off., W.D. Va., Norton Doctor Sentenced on Federal Drug Charge (Dec. 15, 2017) https://www.justice.gov/usao-wdva/pr/norton-doctor-sentenced-federal-drug-charge; Press Release, U.S. Att’ys Off., W.D. Va., Staunton Doctor Sentencing for Illegal Prescribing of Narcotics (Feb. 1, 2017) https://www.justice.gov/usao-wdva/pr/staunton-doctor-sentencing-illegal-prescribing-narcotics; Press Release, U.S. Att’y's Off., E.D. Va., Stafford Doctor Sentenced to Four Years in Prison for Distribution of Oxycodone and Health Care Fraud (June 26, 2015) https://www.justice.gov/usao-edva/pr/stafford-doctor-sentenced-four-years-prison-distribution-oxycodone-and-health-care; Press Release, U.S. Att’y's Off., E.D. Va., Arlington Doctor Sentenced to 15 Years in Prison in Oxycodone Conspiracy (Mar. 6, 2015) https://www.justice.gov/usao-edva/pr/press-release-6; Press Release, U.S. Att’y's Off., W.D. Va., Local Doctor Pleads Guilty to Child Porn, Prescription Drug Charges (Feb. 19, 2015) https://www.justice.gov/usao-wdva/pr/local-doctor-pleads-guilty-child-porn-prescription-drug-charges.  “The mission of the ARPO Strike Force is to identify and investigate health care fraud schemes in the Appalachian region and surrounding areas, and to effectively and efficiently prosecute medical professionals and others involved in the illegal prescription and distribution of opioids.” SeePress Release, U.S. Dep’t Justice, Off. Pub. Aff., Appalachian Regional Prescription Opioid (ARPO) Strike Force Takedown Results in Charges Against 60 Individuals, Including 53 Medical Professionals (Apr. 17, 2019), https://www.justice.gov/opa/pr/appalachian-regional-prescription-opioid-arpo-strike-force-takedown-results-charges-against; Robert Sorrell, Federal strike force combatting opioids expanding to Virginia, Bristol Herald Courier (Apr. 17, 2019), https://www.heraldcourier.com/news/federal-strike-force-combating-opioids-expanding-to-virginia/article_16151b62-4710-58a9-a505-7999a0a83d9f.html.  In 2019, the Western district was awarded 2.5 million in grants to fight the crisis. Press Release, U.S. Att’y’s Off., W.D. Va., Justice Department Awards More than $333 Million to Fight Opioid Epidemic Across the U.S. (Dec. 16, 2019) https://www.justice.gov/usao-wdva/pr/justice-department-awards-more-333-million-fight-opioid-epidemic-across-us.  Thomas Cullen, Cullen: Federal court hopes to be model for opioid cases, ROANOKE TIMES (Dec. 5, 2018) , https://www.roanoke.com/opinion/commentary/cullen-federal-court-hopes-to-be-model-for-opioid-cases/article_81c199c3-d35d-5446-89eb-916c96a87f78.html.  Id.  Id.  Kentucky Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/opioid-summaries-by-state/kentucky-opioid-summary  Drilling into the DEA’s pain pill database, supra note 4.  See Press Release, U.S. Att’y’s Off., W.D. Ky., Louisville Psychiatrist Pleads Guilty To Distributing Controlled Substances Without A Medical Purpose (Mar. 11, 2020) https://www.justice.gov/usao-wdky/pr/louisville-psychiatrist-pleads-guilty-distributing-controlled-substances-without; Press Release, U.S. Att’y’s Off., E.D. Ky., Kentucky Physician Pleads Guilty to Unlawfully Distributing Opioids (Oct. 17, 2019) https://www.justice.gov/opa/pr/kentucky-physician-pleads-guilty-unlawfully-distributing-opioids; Press Release, U.S. Att’y’s Off., E.D. Ky., Oak Ridge, Tennessee Doctor and Boca Raton, Florida Pain Clinic Owner Sentenced for Oxycodone Trafficking Conspiracy (Aug. 9, 2019) https://www.justice.gov/usao-edky/pr/oak-ridge-tennessee-doctor-and-boca-raton-florida-pain-clinic-owner-sentenced-oxycodone; Press Release, U.S. Att’y’s Off., W.D. Ky., Clinton County Doctor Sentenced To 30 Months In Prison For Illegally Prescribing Opioids (July 29, 2019) https://www.justice.gov/usao-wdky/pr/clinton-county-doctor-sentenced-30-months-prison-illegally-prescribing-opioids; Press Release, U.S. Att’y’s Off., W.D. Ky., Physician Sentenced To Federal Prison For Drug Trafficking (Aug. 10, 2018) https://www.justice.gov/usao-wdky/pr/physician-sentenced-federal-prison-drug-trafficking; Press Release, U.S. Att’y’s Off., E.D. Ky., Grant County Doctor Sentenced To 151 Months For Drug Trafficking (July 26, 2018) https://www.justice.gov/usao-edky/pr/grant-county-doctor-sentenced-151-months-drug-trafficking; Press Release, U.S. Att’y’s Off., E.D. Ky., Cincinnati Physician Sentenced to 60 Months for Illegal Distribution of Oxycodone Pills (Apr. 26, 2018) https://www.justice.gov/usao-edky/pr/cincinnati-physician-sentenced-60-months-illegal-distribution-oxycodone-pills; Press Release, U.S. Att’y’s Off., W.D. Ky., Bowling Green Physician Guilty Of Conspiring To Unlawfully Distribute And Dispense Controlled Substances And Health Care Fraud (Feb. 5, 2018) https://www.justice.gov/usao-wdky/pr/bowling-green-physician-guilty-conspiring-unlawfully-distribute-and-dispense-controlled; Press Release, U.S. Att’y’s Off., E.D. Ky., Hazard Physician And Wife Sentenced For Unlawful Distribution Of Prescription Opioids And Health Care Fraud (Sept. 29, 2017) https://www.justice.gov/usao-edky/pr/hazard-physician-and-wife-sentenced-unlawful-distribution-prescription-opioids-and; Press Release, U.S. Att’y’s Off., W.D. Ky., Louisville Physician Sentenced To 48 Months In Prison For Unlawful Distribution Of Controlled Substances And Health Care Fraud (June 5, 2017) https://www.justice.gov/usao-wdky/pr/louisville-physician-sentenced-48-months-prison-unlawful-distribution-controlled; Press Release, U.S. Att’y’s Off., W.D. Ky., Monroe County Physician Sentenced To One Year In Prison For Illegally Prescribing Pain Medications (Apr. 21, 2017) https://www.justice.gov/usao-wdky/pr/monroe-county-physician-sentenced-one-year-prison-illegally-prescribing-pain; Press Release, U.S. Att’y’s Off., W.D. Ky., Cave City, Kentucky, Physician Sentenced To 18 Months In Prison For Illegally Dispensing Controlled Substances Outside Of His Professional Medical Practice And Health Care Fraud (Mar. 20, 2017) https://www.justice.gov/usao-wdky/pr/cave-city-kentucky-physician-sentenced-18-months-prison-illegally-dispensing-controlled; Press Release, U.S. Att’y’s Off., W.D. Ky., Kentucky Anesthesiologist Sentenced to 100 Months for Unlawful Distribution of Controlled Substances, Health Care Fraud, Conspiracy and Money Laundering (May 12, 2016) https://www.justice.gov/opa/pr/kentucky-anesthesiologist-sentenced-100-months-unlawful- distribution-controlled-substances; Press Release, U.S. Att’y’s Off., E.D. Ky., Former Georgia Doctor Admits to Unlawfully Prescribing Pain Medication to Thousands of Kentuckians (Oct. 9, 2015) https://www.justice.gov/usao-edky/pr/former-georgia-doctor-admits-unlawfully-prescribing-pain-medication-thousands.  See Press Release, U.S. Att’y’s Off., E.D. Ky., Justice Department's Criminal Division Creates Appalachian Regional Prescription Opioid Strike Force to Focus on Illegal Opioid Prescriptions (Oct 25, 2018) https://www.justice.gov/usao-edky/pr/justice-departments-criminal-divison-creates-appalachian-regional-prescription-opioid.  For example, Leadership at Kentucky hospitals are seeking to “slash high-risk prescription opioid rates” by at least half. See Alex Acquisto, ‘We’re creating addicts.’ How Kentucky doctors plan to slash opioid use at hospitals., ST. CLAIRE HEALTHCARE (Nov. 8, 2019) https://www.st-claire.org/news/releases/we-re-creating-addicts-how-kentucky-doctors-plan-to-slash-opioid-use-at-hospitals/. In addition, Kentucky hospitals, such as St. Claire Hospital, have stringent policies in place to severely limit the prescription of opioids to only the most urgent cases. Id. For example, St. Claire requires that if opioids are necessary, each patient must first be searched in the statewide controlled prescription monitoring database. Id. In addition, refills on opioids are not allowed. Id. The Kentucky General Assembly has also prioritized limiting prescriptions by passing House Bill 333, which places a three-day limit on opioid prescriptions for acute pain. See KY Gen Assemb. H.B. 333 (2017).  Drilling into the DEA’s pain pill database, supra note 4.  Alabama Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019) https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/alabama-opioid-summary.  For example, in 2019, the state was awarded $6.3 million from the federal government “to help fund community health centers in rural” areas. See Alex Torres-Perez, $6.3 Million Grant to Fight Opioid Crisis in Alabama, WAAY 31, ABC (Aug. 11, 2019),https://www.waaytv.com/content/news/63-million-grant-to-fight-opioid-crisis-in-Alabama-536218131.html. The funding will be allocated to schools to expand and improve access to mental health services and substance abuse treatment. Id. Alabama has also taken serious administrative efforts to address the particularly severe overprescribing issue. For example, in 2018, the Alabama Medicaid Agency (AMA) implemented a policy limiting opioid prescription lengths to seven days and a maximum of fifty morphine milligram equivalent per day on a claim. See FACTSHEET: Alabama’s Oversight of Opioid Prescribing and Monitoring of Opioid Use, U.S. OFF. INSPECTOR GEN. 2 (Nov. 2019),https://oig.hhs.gov/oas/reports/region4/41900125_Factsheet.pdf. In addition, the Alabama State Board of Medical Examiners (ABME) requires doctors to “document the use of risk and abuse mitigation strategies in the patient’s medical record” for each patient to which they have prescribed opioids. Id. at 3.  See Press Release, U.S. Att’y’s Off., S.D. Ala., Mobile Doctor Sentenced to Five Years Probation and Ordered to Pay Quarter Million Dollar Fine for Prescription Drug Offense (Mar. 11, 2020) https://www.justice.gov/usao-sdal/pr/mobile-doctor-sentenced-five-years-probation-and-ordered-pay-quarter-million-dollar; Press Release, U.S. Att’y’s Off., N.D. Ala., Alabama Physician Pleads Guilty to Drug Distribution Charges for Prescription of Opioids (Jan. 31, 2020) https://www.justice.gov/opa/pr/alabama-physician-pleads-guilty-drug-distribution-charges-prescription-opioids; Press Release, U.S. Att’y’s Off., M.D. Ala., Montgomery Doctor Convicted on Drug Distribution, Health Care Fraud, and Money Laundering Charges (Dec. 20, 2019) https://www.justice.gov/usao-mdal/pr/montgomery-doctor-convicted-drug-distribution-health-care-fraud-and-money-laundering; Press Release, U.S. Att’y’s Off., N.D. Ala., Federal Jury Convicts Birmingham Doctor and Nurse for $7.8 Million Health Care Fraud, Unlawful Drug Distribution and Money Laundering (July 16, 2019) https://www.justice.gov/usao-ndal/pr/federal-jury-convicts-birmingham-doctor-and-nurse-78-million-health-care-fraud-unlawful; Press Release, U.S. Att’y’s Off., N.D. Ala., Madison County Pill Mill Doctor Pleads Guilty to Illegally Dispensing Prescription Drugs (June 21, 2019) https://www.justice.gov/usao-ndal/pr/madison-county-pill-mill-doctor-pleads-guilty-illegally-dispensing-prescription-drugs; Press Release, U.S. Att’y’s Off., N.D. Ala., Vestavia Hills Cardiologist Sentenced to 87 Months in Prison for Illegally Prescribing Opioids (May 7. 2019) https://www.justice.gov/usao-ndal/pr/vestavia-hills-cardiologist-sentenced-87-months-prison-illegally-prescribing-opioids; Press Release, U.S. Att’y’s Off., M.D. Ala., Montgomery “Pill Mill” Doctor Receives a 145- Month Sentence for Drug Distribution, Health Care Fraud, and Money Laundering Offenses; “Pill Mill” Mental Health Counselor Pleads Guilty in Related Case (Aug. 24, 2018) https://www.justice.gov/usao-mdal/pr/montgomery-pill-mill-doctor-receives-145-month-sentence-drug-distribution-health-care; Press Release, U.S. Att’y’s Off., M.D. Ala., Another Physician Pleads Guilty in the Montgomery “Pill Mill” Prosecution (June 12, 2018) https://www.justice.gov/usao-mdal/pr/another-physician-pleads-guilty-montgomery-pill-mill-prosecution; Press Release, U.S. Att’y’s Off., S.D. Ala., Former Pain Management Doctor Receives 5 Years in Health Care Fraud Case, Ordered to Pay More Than 15 Million Dollars in Restitution (June 8, 2018)https://www.justice.gov/usao-sdal/pr/former-pain-management-doctor-receives-5-years-health-care-fraud-case-ordered-pay-more; Press Release, U.S. Att’y’s Off., M.D. Ala., Physician, Nurse Practitioner, and Nurse Plead Guilty in Montgomery “Pill Mill” Case (May 15, 2018) https://www.justice.gov/usao-mdal/pr/physician-nurse-practitioner-and-nurse-plead-guilty-montgomery-pill-mill-case; Press Release, U.S. Att’y’s Off., M.D. Ala., Another Montgomery “Pill Mill” Doctor Pleads Guilty to Drug Distribution and Money Laundering Charges (Dec. 11, 2017) https://www.justice.gov/usao-mdal/pr/another-montgomery-pill-mill-doctor-pleads-guilty-drug-distribution-and-money; Press Release, U.S. Att’y’s Off., S.D. Ala., Dr. Couch and Dr. Ruan Sentenced to 240 and 252 Months In Federal Prison For Running Massive Pill Mill (May 26, 2017) https://www.justice.gov/usao-sdal/pr/dr-couch-and-dr-ruan-sentenced-240-and-252-months-federal-prison-running-massive-pill; Press Release, U.S. Att’y’s Off., S.D. Ala., Dr. John Patrick Couch Sentenced to 240 Months (May 25, 2017) https://www.justice.gov/usao-sdal/pr/dr-john-patrick-couch-sentenced-240-months; Press Release, U.S. Att’y’s Off., M.D. Ala., Phenix City “Pill Mill” Doctor Receives a Ten-Year Sentence for Participating in a Drug Distribution Conspiracy (May 10, 2017) https://www.justice.gov/usao-mdal/pr/phenix-city-pill-mill-doctor-receives-ten-year-sentence-participating-drug-distribution; Press Release, U.S. Att’y’s Off., N.D. Ala., Huntsville Pill Mill Doctor Sentenced to 15 Years in Prison for Illegal Prescribing and Health Care Fraud (Feb. 7, 2017) https://www.justice.gov/usao-ndal/pr/huntsville-pill-mill-doctor-sentenced-15-years-prison-illegal-prescribing-and-health; Press Release, U.S. Att’y’s Off., N.D. Ala., Jasper Pain Clinic Physician Sentenced to Nearly Three Years in Prison for Illegally Dispensing Narcotics (Apr. 8, 2016) https://www.justice.gov/usao-ndal/pr/jasper-pain-clinic-physician-sentenced-nearly-three-years-prison-illegally-dispensing; Press Release, U.S. Att’y’s Off., M.D. Ala., “Pill Mill” Operators Plead Guilty to Drug Distribution and Money Laundering Charges (Mar. 4, 2016) https://www.justice.gov/usao-mdal/pr/pill-mill-operators-plead-guilty-drug-distribution-and-money-laundering-charges; Press Release, U.S. Att’y’s Off., N.D. Ala., Jasper Pharmacist and a Pharmacy Technician Indicted for Conspiracy to Illegally Distribute Prescription Drugs (Dec. 29, 2015) https://www.justice.gov/usao-ndal/pr/jasper-pharmacist-and-pharmacy-technician-indicted-conspiracy-illegally-distribute; Press Release, U.S. Att’y’s Off., N.D. Ala., Birmingham Physician Sentenced for Illegally Supplying Opioid Painkillers (Oct. 28, 2015) https://www.justice.gov/usao-ndal/pr/birmingham-physician-sentenced-illegally-supplying-opioid-painkillers.  Project Safe Neighborhoods, U.S. Att’y’s Off., N.D. Ala., https://www.justice.gov/usao-ndal/project-safe-neighborhoods (last accessed Apr. 12, 2020).  Id.  Drilling into the DEA’s pain pill database, supra note 4.  Georgia Opioid Summary, NAT’L INST. ON DRUG ABUSE, NIH (last revised Mar. 2019), https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/georgia-opioid-summary.  Prescription Opioids and Heroin Epidemic in Georgia, GA. PREVENTION PROJECT, SUBSTANCE ABUSE RESEARCH ALLIANCE (2017), https://www.senate.ga.gov/sro/Documents/StudyCommRpts/OpioidsAppendix.pdf.  The state has also focused its efforts towards procuring funding for addiction prevention and treatment. In 2019, Georgia was given $10.3 million to “expand access to medication-assisted treatment for opioid addiction and overdose”. See Ellen Eldridge, Georgia Gets $10.3 Million ToCombat Opioid Crisis, GPB RADIO NEWS, NPR (Apr. 24, 2019), https://www.gpbnews.org/post/georgia-gets-103-million-combat-opioid-crisis.  See Press Release, U.S. Att’y’s Off., N.D. Ga., Former Union General Hospital CEO and Blairsville doctor convicted of illegally prescribing and obtaining more than 15,000 pain pills from pharmacies in three states (Oct. 30, 2019) https://www.justice.gov/usao-ndga/pr/former-union-general-hospital-ceo-and-blairsville-doctor-convicted-illegally; Press Release, U.S. Att’y’s Off., S.D. Ga., Pill-mill doctor convicted on 16 counts of healthcare fraud, illegally dispensing drugs (Oct. 11, 2019) https://www.justice.gov/usao-sdga/pr/pill-mill-doctor-convicted-16-counts-healthcare-fraud-illegally-dispensing-drugs; Press Release, U.S. Att’y’s Off., S.D. Ga., Doctor sentenced to prison for prescribing narcotics to non-patients (June 13, 2019) https://www.justice.gov/usao-sdga/pr/doctor-sentenced-prison-prescribing-narcotics-non-patients; Press Release, U.S. Att’y’s Off., N.D. Ga., Jury finds podiatrist guilty of operating pill mill (May 9, 2019) https://www.justice.gov/usao-ndga/pr/jury-finds-podiatrist-guilty-operating-pill-mill; Press Release, U.S. Att’y’s Off., M.D. Ga., Physician Sentenced For His Role In Prolific Georgia Pill Mills (Apr. 4, 2019) https://www.justice.gov/usao-mdga/pr/physician-sentenced-his-role-prolific-georgia-pill-mills; Press Release, U.S. Att’y’s Off., N.D. Ga., Major Illegal Distributor of Prescription Painkillers Changes Plea to Guilty After Government Begins Presenting Evidence at Trial (Sept. 7, 2018) https://www.justice.gov/usao-wdpa/pr/major-illegal-distributor-prescription-painkillers-changes-plea-guilty-after-government; Press Release, U.S. Att’y’s Off., N.D. Ga., Former Georgia medical examiner sentenced for opioid conspiracy (Aug. 30, 2018) https://www.justice.gov/usao-ndga/pr/former-georgia-medical-examiner-sentenced-opioid-conspiracy; Press Release, U.S. Att’y’s Off., M.D. Ga., Doctors Found Guilty For Role In Valdosta And Columbus Pill Mills (June 14, 2018) https://www.justice.gov/usao-mdga/pr/doctors-found-guilty-role-valdosta-and-columbus-pill-mills; Press Release, U.S. Att’y’s Off., S.D. Ga., Physician Pleads Guilty To Drug Distribution and Money Laundering Conspiracies (Mar. 26, 2018) https://www.justice.gov/usao-sdga/pr/physician-pleads-guilty-drug-distribution-and-money-laundering-conspiracies; Press Release, U.S. Att’y’s Off., N.D. Ga., Two Doctors and Clinic Owners sentenced for operating Pill Mills in Metro Atlanta (June 26, 2017) https://www.justice.gov/usao-ndga/pr/two-doctors-and-clinic-owners-sentenced-operating-pill-mills-metro-atlanta; Press Release, U.S. Att’y’s Off., S.D. Ga., Georgia Doctor Sentenced To Federal Prison in Pill Mill Case (Apr. 4, 2017) https://www.justice.gov/usao-sdga/pr/georgia-doctor-sentenced-federal-prison-pill-mill-case; Press Release, U.S. Att’y’s Off., N.D. Ga., Physician and Owner of Atlanta Pain Clinic Sentenced for Illegally Prescribing Painkillers (Mar. 29, 2017) https://www.justice.gov/usao-ndga/pr/physician-and-owner-atlanta-pain-clinic-sentenced-illegally-prescribing-painkillers; Press Release, U.S. Att’y’s Off., N.D. Ga., Anesthesiologist Sentenced for Illegally Prescribing Oxycodone and Other Prescription Painkillers (Feb. 23, 2017) https://www.justice.gov/usao-ndga/pr/anesthesiologist-sentenced-illegally-prescribing-oxycodone-and-other-prescription; Press Release, U.S. Att’y’s Off., M.D. Ga., Fitzgerald Physician Pleads Guilty To Drug Charges (Nov. 1, 2016) https://www.justice.gov/usao-mdga/pr/fitzgerald-physician-pleads-guilty-drug-charges; Press Release, U.S. Att’y’s Off., N.D. Ga., Six Defendants Sentenced to Prison for Operating a “Pill Mill” in Lilburn, Georgia (Jan. 22, 2016) https://www.justice.gov/usao-ndga/pr/six-defendants-sentenced-prison-operating-pill-mill-lilburn-georgia; Press Release, U.S. Att’y’s Off., N.D. Ga., Former Heart Surgeon Convicted of Unlawfully Prescribing and Dispensing Oxycodone (Sept. 28, 2015) https://www.justice.gov/usao-ndga/pr/former-heart-surgeon-convicted-unlawfully-prescribing-and-dispensing-oxycodone.  Though these interviewees remain largely confidential given their present posts as Assistant United States Attorneys at Districts within the opioid belt, notes from each interview are on file with the author. Interviewees include Jennifer Kolman (E.D. Tenn.), Sarah Wagner (N.D.W.V.), Roger West (E.D. Ky.), and Randy Ramseyer (W.D. Va.).  See, e.g., Adam Gershowitz, Punishing Pill Mill Doctors: Sentencing Disparities in the Opioid Epidemic, SSRN (Dec. 13, 2019)https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3503662.  Telephone Interviews with Assistant U.S. Att’y’s (2020).  Telephone Interview with Jennifer Kolman, supra note 110.  Id.  United States v. Moore, 423 U.S. 122, 124-25,142-43 (1975).  Telephone Interviews with Assistant U.S.Att’y’s, supra note 110.  Telephone Interview with Sarah Wagner, Assistant United States Attorney, U.S. Att’y’s Off., N.D.W.V. (Feb. 6, 2020).  Telephone Interviews with Assistant United States Attorneys, supra note 110.  Telephone Interview with Sarah Wagner, supra note 117.  Id.  Id.  Telephone Interviews with Assistant United States Attorneys, supra note 110.  Id.  Id.  Id.  Telephone Interviews with Assistant United States Attorneys, supra note 110.  Id.  Id.  Telephone Interview with Jennifer Kolman, supra note 110.  21 U.S.C. § 801 et. seq. (1970).  United States v. Moore, 423 U.S. 122 (1975).  Id.  Telephone Interview with Sarah Wagner, supra note 117.  Niall McCarthy, America’s Most & Least Trusted Professions, FORBES (Jan. 11, 2019), https://www.forbes.com/sites/niallmccarthy/2019/01/11/americas-most-least-trusted-professions-infographic/#666078bb7e94  Telephone Interview with Sarah Wagner, supra note 117.  Telephone Interview with Roger West, Assistant United States Attorney, U.S. Att’y’s Off., (Feb. 2, 2020).  Id.  U.S. Prescribing Rate Maps, supra note 2.  Courtney Hessler, Hearing in Opioid Cases Set in Charleston, CHARLESTON GAZETTE-MAIL (Jan. 19, 2020), https://www.wvgazettemail.com/news/legal_affairs/hearing-in-opioid-cases-set-in-charleston/article_744235a3-370b-5196-8fba-24d85ef447a3.html#.XiYbvKBVny1.twitter.  Francis B. Palumbo & Lindsay P. Holmes, Culpability in the Opioid Crisis All Parties Must Remain Vigilant and Establish Best Practices to Address the Epidemic, 21 J. HEALTH CARE COMPLIANCE 5, 8 (2019).  The prosecution of Dr. Jeanne Germeil highlights an example of United States Attorney’s Office and DEA collaboration. See, e.g., Press Release, U.S. Att’y’s Off., S.D. Fl., South Florida Pain Management Doctor Sentenced to 17 ½ Years in Prison for Illegally Dispensing Opioid Drugs and Jumping Bond (Nov. 26, 2019) https://www.justice.gov/usao-sdfl/pr/south-florida-pain-management-doctor-sentenced-17-years-prison-illegally-dispensing.  See Press Release, U.S. Att’ys Off., E.D. Mich., Lathrup Village Doctor Pleaded Guilty to Diverting Prescription Pills and Committing Health Care Fraud (Sept. 30, 2019) https://www.justice.gov/usao-edmi/pr/lathrup-village-doctor-pleaded-guilty-diverting-prescription-pills-and-committing; Press Release, U.S. Att’ys Off., E.D. Mich., Livonia Doctor Sentenced to More Than Twelve Years for Conspiring With Others to Illegally Distribute Prescription Drugs (Apr. 17, 2019) https://www.justice.gov/usao-edmi/pr/livonia-doctor-sentenced-more-twelve-years-conspiring-others-illegally-distribute; Press Release, U.S. Att’ys Off., E.D. Mich., Former Doctor Sentenced to 75 Months in Prison for Illegally Prescribing Opiates and Committing Health Care Fraud (Feb. 6, 2018) https://www.justice.gov/usao-edmi/pr/former-doctor-sentenced-75-months-prison-illegally-prescribing-opiates-and-committing; Press Release, U.S. Att’ys Off., E.D. Mich., Oak Park Doctor Pleads Guilty To Unlawful Distribution Of Prescription Pills (Aug. 17, 2017) https://www.justice.gov/usao-edmi/pr/oak-park-doctor-pleads-guilty-unlawful-distribution-prescription-pills; Press Release, U.S. Att’ys Off., E.D. Mich., Former Doctor Sentenced to 23 Years in Prison for Distributing Prescription Drugs, Health Care Fraud and Money Laundering (June 15, 2017) https://www.justice.gov/usao-edmi/pr/former-doctor-sentenced-23-years-prison-distributing-prescription-drugs-health-care; Press Release, U.S. Att’ys Off., E.D. Mich., Farmington Hills Doctor Sentenced to 19 Years in Prison for Distributing Prescription Drugs and Health Care Fraud (May 19, 2017) https://www.justice.gov/usao-edmi/pr/farmington-hills-doctor-sentenced-19-years-prison-distributing-prescription-drugs-and; Press Release, U.S. Att’ys Off., E.D. Mich., Two Physicians Found Guilty For Distributing Oxycodone (Mar. 22, 2017) https://www.justice.gov/usao-edmi/pr/two-physicians-found-guilty-distributing-oxycodone; Press Release, U.S. Att’ys Off., E.D. Mich., Detroit-Area Neurosurgeon Sentenced to 235 Months in Prison for Role in $2.8 Million Health Care Fraud Scheme (Jan. 10, 2017) https://www.justice.gov/usao-edmi/pr/detroit-area-neurosurgeon-sentenced-235-months-prison-role-28-million-health-care-fraud; Press Release, U.S. Att’ys Off., E.D. Mich., Detroit Doctor Sentenced for Unlawful Opioid Prescriptions (Sept. 20, 2016) https://www.justice.gov/usao-edmi/pr/detroit-doctor-sentenced-unlawful-opioid-prescriptions; Press Release, U.S. Att’ys Off., E.D. Mich., Doctor Sentenced to 84 Months In Prison for Distributing Prescription Drugs (Mar. 1, 2016) https://www.justice.gov/usao-edmi/pr/doctor-sentenced-84-months-prison-distributing-prescription-drugs; Press Release, U.S. Att’ys Off., E.D. Mich., Warren Doctor Sentenced For Unlawful Oxycodone Prescriptions and Health Care Fraud (Nov. 16, 2015) https://www.justice.gov/usao-edmi/pr/warren-doctor-sentenced-unlawful-oxycodone-prescriptions-and-health-care-fraud.  See Press Release, U.S. Att’ys Off., W.D. Pa., Judge Sends Former Greensburg Doctor to Prison for Illegally Distributing Opioids (Feb. 7, 2020) https://www.justice.gov/usao-wdpa/pr/judge-sends-former-greensburg-doctor-prison-illegally-distributing-opioids; Press Release, U.S. Att’ys Off., W.D. Pa., Greensburg Doctor Charged with Conspiring to Receive Kickbacks for Prescribing Fentanyl, and Then Causing Insurers to Pay for the Unlawful Prescriptions (Feb. 3, 2020) https://www.justice.gov/usao-wdpa/pr/greensburg-doctor-charged-conspiring-receive-kickbacks-prescribing-fentanyl-and-then; Press Release, U.S. Att’ys Off., W.D. Pa., Ex-Doctor Sentenced to More Than 11 Years’ Imprisonment for His Role in Illegal Oxycodone Prescribing, Health Care Fraud, and Money Laundering Scheme and for Committing Social Security Fraud (Oct. 29, 2019) https://www.justice.gov/usao-wdpa/pr/ex-doctor-sentenced-more-11-years-imprisonment-his-role-illegal-oxycodone-prescribing; Press Release, U.S. Att’ys Off., W.D. Pa., Former Suboxone Clinic Doctor Sentenced for Illegal Prescribing and Health Care Fraud (Oct. 16, 2019) https://www.justice.gov/usao-wdpa/pr/former-suboxone-clinic-doctor-sentenced-illegal-prescribing-and-health-care-fraud; Press Release, U.S. Att’ys Off., W.D. Pa., New Castle Doctor Pleads Guilty to Illegally Prescribing and Distributing Oxycodone, Fentanyl, and Opana ER (Aug. 21, 2019) https://www.justice.gov/usao-wdpa/pr/new-castle-doctor-pleads-guilty-illegally-prescribing-and-distributing-oxycodone; Press Release, U.S. Att’ys Off., W.D. Pa., Contracted Physician, Operations Manager of Redirections Treatment Advocates Sentenced for Suboxone Distribution Scheme (July 17, 2019) https://www.justice.gov/usao-wdpa/pr/contracted-physician-operations-manager-redirections-treatment-advocates-sentenced; Press Release, U.S. Att’ys Off., W.D. Pa., Former Doctor Sentenced to Prison for Unlawfully Dispensing Vicodin and Defrauding the University of Pittsburgh Medical Center Health Plan (May 9, 2019) https://www.justice.gov/usao-wdpa/pr/former-doctor-sentenced-prison-unlawfully-dispensing-vicodin-and-defrauding-university; Press Release, U.S. Att’ys Off., W.D. Pa., 2nd SKS Associates Doctor Pleads Guilty to Unlawfully Dispensing Controlled Substances, Health Care Fraud (Nov. 19, 2018); https://www.justice.gov/usao-wdpa/pr/2nd-sks-associates-doctor-pleads-guilty-unlawfully-dispensing-controlled-substances; Press Release, U.S. Att’ys Off., W.D. Pa., Greensburg Physician Charged with Illegally Distributing Suboxone, Health Care Fraud (Sept. 28, 2018) https://www.justice.gov/usao-wdpa/pr/greensburg-physician-charged-illegally-distributing-suboxone-health -care-fraud; Press Release, U.S. Att’ys Off., W.D. Pa., Suboxone Clinic Doctor Pleads Guilty to Unlawfully Dispensing Controlled Substances, Health Care Fraud (Aug, 31, 2018) https://www.justice.gov/usao-wdpa/pr/suboxone-clinic-doctor-pleads-guilty-unlawfully-dispensing-controlled-substances-health; Press Release, U.S. Att’ys Off., W.D. Pa., Pittsburgh Physician Sentenced to 5 Years in Prison for Illegally Prescribing Drugs and Defrauding Health Care Companies (Mar. 13, 2018) https://www.justice.gov/usao-wdpa/pr/pittsburgh-physician-sentenced-5-years-prison-illegally-prescribing-drugs-and; Press Release, U.S. Att’ys Off., W.D. Pa., Pittsburgh Psychiatrist Pleads Guilty to Health Care Fraud, Illegally Distributing Oxycodone (Jan. 20, 2017) https://www.justice.gov/usao-wdpa/pr/pittsburgh-psychiatrist-pleads-guilty-health-care-fraud-illegally-distributing; Press Release, U.S. Att’ys Off., W.D. Pa., Physician Sentenced for Illegally Distributing Oxycodone (Jan. 12, 2017) https://www.justice.gov/usao-wdpa/pr/physician-sentenced-illegally-distributing -oxycodone; Press Release, U.S. Att’ys Off., W.D. Pa., Medical Doctor Pleads Guilty to Health Care Fraud, Illegally Distributing Drugs (Sept. 1, 2016) https://www.justice.gov/usao-wdpa/pr/medical-doctor-pleads-guilty-health-care-fraud-illegally-distributing-drugs; Press Release, U.S. Att’ys Off., W.D. Pa., Pain Doctor Sentenced to 6 Years in Prison for Overprescribing Controlled Substances (Feb. 23, 2016) https://www.justice.gov/usao-wdpa/pr/pain-doctor-sentenced-6-years-prison-overprescribing-controlled-substances.  Drilling into the DEA’s pain pill database, supra note 4.  The U.S. Attorney’s Office for the Southern District of New York has prosecuted 11 doctors. See Press Release, U.S. Att’ys Off., S.D.N.Y., Manhattan Doctor Pleads Guilty To The Illegal Distribution Of Oxycodone And Fentanyl Resulting In Patient’s Overdose (Dec. 18, 2019) https://www.justice.gov/usao-sdny/pr/manhattan-doctor-pleads-guilty-illegal-distribution-oxycodone-and-fentanyl-resulting; Press Release, U.S. Att’ys Off., S.D.N.Y., Four Individuals Who Operated Queens Medical Clinic Convicted For Illegally Distributing Oxycodone (Oct. 25, 2019) https://www.justice.gov/usao-sdny/pr/four-individuals-who-operated-queens-medical-clinic-convicted-illegally-distributing; Press Release, U.S. Att’ys Off., S.D.N.Y., Staten Island Doctor Pleads Guilty To Illegally Distributing Oxycodone (Oct. 21, 2019) https://www.justice.gov/usao-sdny/pr/staten-island-doctor-pleads-guilty-illegally-distributing-oxycodone-1; Press Release, U.S. Att’ys Off., S.D.N.Y., Staten Island Doctor Pleads Guilty To Illegally Distributing Oxycodone (Oct. 4, 2019) https://www.justice.gov/usao-sdny/pr/staten-island-doctor-pleads-guilty-illegally-distributing-oxycodone; Press Release, U.S. Att’ys Off., S.D.N.Y., Doctor Who Operated Oxycodone And Fentanyl Diversion Scheme Sentenced To 5 Years In Prison (July 2, 2019) https://www.justice.gov/usao-sdny/pr/doctor-who-operated-oxycodone-and-fentanyl-diversion-scheme-sentenced-5-years-prison; Press Release, U.S. Att’ys Off., S.D.N.Y., Manhattan Doctor Pleads Guilty To Illegally Distributing Oxycodone And Other Drugs (May 2, 2019) https://www.justice.gov/usao-sdny/pr/manhattan-doctor-pleads-guilty-illegally-distributing-oxycodone-and-other-drugs; Press Release, U.S. Att’ys Off., S.D.N.Y., Doctor Convicted For Illegal Distribution Of Over 100,000 Oxycodone Pills (Dec. 6, 2018) https://www.justice.gov/usao-sdny/pr/doctor-convicted-illegal-distribution-over-100000-oxycodone-pills; Press Release, U.S. Att’ys Off., S.D.N.Y., Doctor Sentenced To More Than 9 Years In Prison For Selling Fentanyl That Resulted In Manhattan Man’s Overdose Death (Mar. 22, 2018) https://www.justice.gov/usao-sdny/pr/doctor-sentenced-more-9-years-prison-selling-fentanyl-resulted-manhattan-man-s-overdose; Press Release, U.S. Att’ys Off., S.D.N.Y., Doctor Pleads Guilty In Manhattan Federal Court To Scheme To Illegally Distribute Oxycodone (Mar. 1, 2018) https://www.justice.gov/usao-sdny/pr/doctor-pleads-guilty-manhattan-federal-court-scheme-illegally-distribute-oxycodone; Press Release, U.S. Att’ys Off., S.D.N.Y., Former Doctor Sentenced In White Plains Federal Court To 18 Months In Prison For Selling Oxycodone Prescriptions (Nov. 18, 2016) https://www.justice.gov/usao-sdny/pr/former-doctor-sentenced-white-plains-federal-court-18-months-prison-selling-oxycodone; Press Release, U.S. Att’ys Off., S.D.N.Y., Manhattan U.S. Attorney Announces Conviction Of Local Doctor For Unlawfully Dispensing More Than 1.2 Million Oxycodone Pills (Mar. 17, 2016) https://www.justice.gov/usao-sdny/pr/manhattan-us-attorney -announces-conviction-local-doctor-unlawfully-dispensing-more-12. The U.S. Attorney’s Office for the Southern District of Florida has prosecuted 5 doctors. See Press Release, U.S. Att’ys Off., S.D. Fl., South Florida Doctor Sentenced to 8 Years in Prison for Conspiring to Illegally Distribute Oxycodone (Dec. 17, 2019) https://www.justice.gov/usao-sdfl/pr/south-florida-doctor-sentenced-8-years-prison-conspiring-illegally-distribute-oxycodone; Press Release, U.S. Att’ys Off., S.D. Fl., South Florida Pain Management Doctor Sentenced to 17 ½ Years in Prison for Illegally Dispensing Opioid Drugs and Jumping Bond (Nov. 26, 2019) https://www.justice.gov/usao-sdfl/pr/south-florida-pain-management-doctor-sentenced-17-years-prison-illegally-dispensing; Press Release, U.S. Att’ys Off., S.D. Fl., South Florida Doctor Sentenced to 78 Months in Prison for Participating in a Conspiracy to Illegally Dispense Opioids and Other Drugs (Sept. 7, 2019) https://www.justice.gov/usao-sdfl/pr/south-florida-doctor-sentenced-78-months-prison-participating-conspiracy-illegally; Press Release, U.S. Att’ys Off., S.D. Fl., Medical Director of Substance Abuse Treatment Facility Pleads Guilty to Unlawfully Distributing Opioids, Barbiturates, and Benzodiazepines (Oct. 18, 2018) https://www.justice.gov/usao-sdfl/pr/medical-director-substance-abuse-treatment-facility-pleads-guilty-unlawfully; Press Release, U.S. Att’ys Off., S.D. Fl., Miami-Based Physician Pleads Guilty For Role in Pain Pill Diversion and Medicare Fraud Scheme (July 13, 2017) https://www.justice.gov/usao-sdfl/pr/miami-based-physician-pleads-guilty-role-pain-pill-diversion-and-medicare-fraud-scheme.