Background
Bernard Shelton, a Michigan internist, was convicted on 21 counts of unlawfully distributing controlled substances. Over several years, Shelton prescribed medications to seven patients—including oxycodone, Xanax, and benzodiazepines—despite multiple indicators of drug-seeking behavior and diversion. His prescriptions generated over 90% of his Medicare income and nearly 100% of his Medicaid income. In January 2016, one patient prescribed oxycodone by Shelton overdosed and died. After a third trial (two prior trials ended in mistrial), Shelton was convicted on all counts and received a mandatory minimum 20-year sentence on the count involving the death.
On appeal, Shelton challenged the sufficiency of evidence, arguing the government failed to prove he knew his prescriptions were unauthorized. He also raised constitutional objections: that Congress unconstitutionally delegated authority to the Attorney General to define “authorization” of prescriptions, and that the district court’s mask mandate on testifying witnesses violated the Confrontation Clause.
The three-judge panel heard arguments in February 2026 and decided the case in July 2026.
The Court’s Holding
The Sixth Circuit affirmed all 21 convictions. The court held that a physician illegally distributes controlled substances when prescribing “without a legitimate medical purpose and outside the usual course of medical practice”—and that the government must prove the doctor *knew* his conduct was unauthorized. Here, abundant circumstantial evidence supported conviction: expert testimony that Shelton’s practices violated medical norms; red flags including patients with signs of “doctor shopping,” failed drug tests, substance abuse histories, and lack of physical exams; Shelton’s falsified medical records; his own statements suggesting awareness of impropriety; and the dramatic reduction in his prescriptions after a DEA visit.
The court rejected Shelton’s nondelegation and major questions arguments. The regulation defining “authorization” (21 C.F.R. § 1306.04(a)) does not conflict with the statutory language in 21 U.S.C. § 841(a)(1)—it merely paraphrases it. Congress itself included the terms “legitimate medical purpose” and “usual course of professional practice” throughout the Controlled Substances Act. The regulation leaves proof to traditional means: expert testimony on accepted medical standards. The mask mandate was not reversible error.
Key Takeaways
- A prescribing physician commits unlawful drug distribution when issuing prescriptions without legitimate medical purpose or outside the usual course of professional practice, *and* knowing the prescriptions lack authorization—subjective intent matters.
- Circumstantial evidence of unauthorized prescribing includes: patients with signs of “doctor shopping” across multiple providers; failure to conduct physical examinations; ignoring failed drug screens; prescribing dangerous combinations without medical justification; falsifying medical records; and other violations of accepted medical standards.
- The Attorney General’s regulation defining “authorized” prescriptions is consistent with the statutory delegation in the Controlled Substances Act and does not trigger nondelegation or major questions doctrine concerns; it refers to objective criteria drawn from the statute itself.
- Expert testimony on whether prescribing practices conform to accepted standards of medical care is the appropriate vehicle for proving unauthorized distribution; courts need not delve into defining substantive medical practice itself.
Why It Matters
This decision establishes a clear framework for prosecuting physicians who use their DEA licensing authority to enable drug diversion. The court emphasized that a doctor’s subjective knowledge of unauthorized conduct—inferred from circumstantial evidence of reckless disregard for red flags—is essential; mere objective violations of medical standards do not suffice. Attorneys defending physicians in CSA cases should note that direct evidence of intent is not required when circumstantial evidence of knowing violations accumulates (e.g., ignoring drug-seeking indicators, falsifying records, prescribing dangerous combinations repeatedly).
The opinion also affirms that the regulatory framework governing prescriber authorization does not raise constitutional problems and reflects Congress’s own statutory language. This forecloses challenges based on improper delegation or major questions doctrine in cases involving established medical practices and professional standards. For prosecutors, the decision validates use of expert testimony on medical norms as the lens for proving a defendant-doctor’s knowledge of unauthorized conduct.