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          IN THE UNITED STATES COURT OF APPEALS
                  FOR THE FIFTH CIRCUIT
                                                                         United States Court of Appeals
                                                                                  Fifth Circuit

                                                                                FILED
                                     No. 16-10386                         October 3, 2017
                                                                           Lyle W. Cayce
                                                                                Clerk
UNITED STATES OF AMERICA,

              Plaintiff – Appellee,

v.

ELECHI N. OTI; THEODORE E. OKECHUKU; KELVIN L. RUTLEDGE;
EMMANUEL C. IWUOHA,

              Defendants – Appellants.




                  Appeals from the United States District Court
                       for the Northern District of Texas


Before JOLLY, ELROD, Circuit Judges, and STARRETT, District Judge. *
JENNIFER WALKER ELROD, Circuit Judge:
      After a two-week jury trial, Defendant-Appellants Theodore Okechuku,
Elechi Oti, Emmanuel Iwuoha, and Kevin Rutledge were convicted of
conspiring to unlawfully distribute hydrocodone outside the scope of
professional practice and without a legitimate medical purpose as part of an
alleged pill mill. Okechuku was also convicted of two additional firearm
counts—using, carrying, and brandishing a firearm during and in relation to a
drug-trafficking crime and conspiring to do the same. Appellants challenge the


      *  The Honorable Keith Starrett, of the United States District Court for the Southern
District of Mississippi, sitting by designation.
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                                     No. 16-10386
sufficiency of the evidence of their convictions as well as allege that the district
court committed various errors at trial and at sentencing. Because the evidence
was sufficient to support Appellants’ convictions and because we conclude that
the errors Appellants allege either were not errors or they were harmless, we
AFFIRM.
                                    I. Background
       Defendant-Appellant Theodore Okechuku is a medical doctor who owned
and operated a pain-management clinic called the Medical Rehabilitation
Center in Dallas, Texas. 1 Okechuku worked at the clinic one to two days a
week, also working full-time as a pediatric anesthesiologist at the University
of Mississippi. Okechuku operated the clinic with the assistance of Ignatius
Ezenagu, who worked as office manager at the clinic. The clinic was a cash-
only business, and it did not accept insurance, Medicaid, or Medicare, nor did
it take appointments. When the clinic opened in the mornings, it usually had
thirty to forty patients waiting to enter. On average, the clinic had $5,000 in
revenue a day and as much as $11,000 per day.
       In addition to Okechuku, two of the other defendant-appellants worked
at the clinic. Elechi Oti was a licensed physician’s assistant who saw patients
and wrote prescriptions at the clinic three days a week. Emmanuel Iwuoha,
who did not have a medical license in the United States, saw patients and
wrote prescriptions that were pre-signed by Okechuku. Okechuku paid Oti and
Iwuoha per patient, and the patient visits typically lasted only four to eight
minutes and involved little-to-no physical examination. Their medical notes




       1We present the facts in the light most favorable to the conviction, as we must. See
United States v. Thomas, 690 F.3d 358, 366 (5th Cir. 2012).
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                                      No. 16-10386
were consistently sparse, and they wrote almost every patient a prescription
for hydrocodone. 2
       A man named Jerry Reed frequently brought people to the clinic. David
Reed, Jerry’s brother, and Defendant-Appellant Kevin Rutledge also brought
people to the clinic. Jerry Reed, David Reed, Rutledge, and their cohorts
recruited “patients”—often from homeless shelters—and drove them to the
clinic and paid for their patient examination. After the patients received their
prescriptions from the clinic, these men would pay to fill the prescriptions and
keep the medication to be resold later. The men payed the patients as much as
$50 each for their services.
       Okechuku implemented various security measures at the clinic. A large
amount of cash was generated at the clinic every day. Okechuku put up bars
around the room where clinic employees collected cash, hired armed security
guards, and installed surveillance cameras that allowed him to observe
remotely what was happening at the clinic from his cell phone. He also
required clinic employees to fax him the clinic’s cash earnings each day.
       In April 2013, Okechuku fired Ezenagu. Several days after Okechuku
fired Ezenagu, the FBI executed a search warrant at the clinic, suspecting that
the clinic was being used as a “pill mill”—a drug business exchanging
controlled substances for cash under the guise of a doctor’s office. Agents seized



       2 Hydrocodone is an opioid painkiller. Mayo Clinic, Mayo Clinic Q and A: Opioids for
treatment of pain—benefits and risks, https://newsnetwork.mayoclinic.org/discussion/mayo-
clinic-q-and-a-opioids-for-treatment-of-pain-benefits-and-risks/ (last visited September 1,
2017). Opioids account for more fatal overdoses each year than cocaine and heroin
combined. Id. In 2015 alone, there were over 22,000 fatal overdoses on prescription opioid
painkillers—more than twice the number in 2005 and more than five times the number in
2000. NIH, National Overdose Deaths from Select Prescription and Illicit Drugs,
https://www.drugabuse.gov/sites/default/files/overdose_data_1999-2015.xls (last      visited
September 1, 2017).
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                                 No. 16-10386
patient files, business records, pre-written prescriptions, and seventy-seven
days of surveillance camera footage.
      In 2014, Okechuku, Oti, Iwuoha, Rutledge, David Reed, Jerry Reed, and
Ezenagu were all charged in a superseding indictment with conspiring to
unlawfully distribute a controlled substance, in violation of 21 U.S.C. §§ 846,
841(a)(1) & (b)(1)(E)(i) (Count One); using, carrying, and brandishing a firearm
during and in relation to, and possessing and brandishing a firearm in
furtherance of, a drug-trafficking crime, in violation of 18 U.S.C.
§ 924(c)(1)(A)(ii) (Count Two), and conspiring to do the same in violation of 18
U.S.C. § 924(o) (Count Three). The government later filed a motion to dismiss
Count Three as to everyone except for Ezenagu and Okechuku. In October
2015, Okechuku, Iwuoha, Oti, and Rutledge proceeded to trial together.
      At trial, the defense’s theory was that Ezenagu used the clinic without
Okechuku’s knowledge and made an unlawful agreement with Jerry Reed to
bring illegitimate patients into the clinic. Defense counsel contended that these
fake patients duped Okechuku, Oti, and Iwuoha into prescribing them
controlled substances that were not medically necessary. Defense counsel also
asserted that Okechuku and his employees ran a legitimate medical clinic and
conscientiously tried to screen for illegitimate patients. Okechuku testified at
trial in his own defense.
      The government’s theory of the case was that the defendants operated
the clinic as a “pill mill”. In support of this theory, the government presented
five full days of evidence, including eighteen witnesses as well as video and
photographic evidence of the events that transpired at the clinic. After a two-
week trial, the jury found Okechuku, Oti, Iwuoha, and Rutledge guilty of Count
One—conspiring to unlawfully distribute hydrocodone outside the scope of
professional practice and without a legitimate medical purpose. The jury also
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                                 No. 16-10386
found Okechuku guilty of Counts Two and Three—using, carrying, and
brandishing a firearm during and in relation to a drug-trafficking crime and
conspiring to do the same.
      The district court sentenced Okechuku to 300 months in prison, Oti to
97 months, Iwuoha to 97 months, and Rutledge to 120 months. All four of these
defendants now appeal their convictions on various grounds.
                      II. Sufficiency of the Evidence
      Okechuku, Iwuoha, and Oti challenge the sufficiency of the evidence for
their convictions. Because Okechuku and Iwuoha preserved the issue by
moving for acquittal under Federal Rule of Criminal Procedure 29 at the close
of the government’s case-in-chief and again post-verdict, we will review their
challenges de novo. See United States v. Girod, 646 F.3d 304, 313 (5th Cir.
2011). Our de novo review of a challenge to the sufficiency of the evidence is
“highly deferential to the verdict.” United States v. Cannon, 750 F.3d 492, 506
(5th Cir. 2014). We consider the evidence in the light most favorable to the
government, with all reasonable inferences and credibility determinations
made in the government’s favor. United States v. Santillana, 604 F.3d 192, 195
(5th Cir. 2010). “[T]he relevant question is whether, after viewing the evidence
in the light most favorable to the prosecution, any rational trier of fact could
have found the essential elements of the crime beyond a reasonable doubt.”
Jackson v. Virginia, 443 U.S. 307, 319 (1979). Our inquiry is limited to whether
the jury’s verdict was reasonable, not whether we believe it to be correct. See
United States v. Moreno-Gonzalez, 662 F.3d 369, 372 (5th Cir. 2011).
      Because Oti failed to renew her motion for judgment of acquittal after
the jury’s verdict, we review her sufficiency challenge for plain error. See
United States v. McIntosh, 280 F.3d 479, 483 (5th Cir. 2002). In the sufficiency
of the evidence context, this court has stated that it will reverse under plain
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                                      No. 16-10386
error review only if there is a “manifest miscarriage of justice,” which occurs
only where “the record is devoid of evidence pointing to guilt” or the evidence
is so tenuous that a conviction is “shocking.” United States v. Delgado, 672 F.3d
320, 331 (5th Cir. 2012).
                                     A. Count One
       Okechuku, Iwuoha, and Oti each challenge the sufficiency of the
evidence supporting their conviction of conspiring to unlawfully distribute
hydrocodone outside the scope of a professional practice. The elements of
conspiracy to distribute and dispense a controlled substances outside the scope
of professional practice are: (1) an agreement by two or more persons to
unlawfully distribute or dispense a controlled substance outside the scope of
professional practice and without a legitimate medical purpose; 3 (2) the
defendant’s knowledge of the unlawful purpose of the agreement; and (3) the
defendant’s willful participation in the agreement. See United States v.
Simpson, 741 F.3d 539, 547 (5th Cir. 2014) (citing 18 U.S.C. § 1349); see also
21 U.S.C. §§ 846, 841(a)(1). An agreement may be inferred from concert of
action, knowledge may be inferred from surrounding circumstances, and
voluntary participation may be inferred from a collection of circumstances. See
United States v. Grant, 683 F.3d 639, 643 (5th Cir. 2012). We conclude that the
evidence presented at trial is sufficient to support each element of this offense
as to Okechuku, Iwuoha, and Oti. 4




       3 Because Okechuku, Iwuoha, and Oti are all medical professionals and generally
authorized to prescribe controlled substances, the government also had to prove beyond a
reasonable doubt that the distribution was other than in the course of professional practice
and for a legitimate medical purpose. See United States v. Brown, 553 F.3d 768, 781 (5th Cir.
2008).
       4 Okechuku, Iwuoha, and Oti do not challenge the existence of an agreement between

Ezenagu and Jerry Reed to violate narcotics laws. They only challenge the sufficiency of the
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                                        No. 16-10386
       As to Okechuku, the evidence presented by the government at trial
demonstrated that he was the owner of the clinic, and that he kept close tabs
on the clinic. 5 Okechuku was physically present at the clinic two to three days
a week, and he himself testified that he would have known what was occurring
at the clinic. The government offered testimony that Okechuku met several
times alone with Jerry Reed and Ezenagu in his office, as well as Ezenagu’s
testimony that “Okechuku knew from day one” that Jerry Reed was bringing
illegitimate patients to the clinic. The government offered video evidence
showing Jerry Reed freely roaming the halls of the clinic and talking to
Ezenagu just outside Okechuku’s office while Okechuku was present. One
clinic receptionist testified that drug dealers were at the clinic when Okechuku
was present at the clinic, and another receptionist testified that she saw
Okechuku meet with Jerry Reed and Ezenagu a couple of times in his office.
Other video evidence showed Jerry Reed, Ezenagu, and Okechuku meeting at
the clinic while the clinic was closed. Within an eight-hour work day, the clinic
would see forty to fifty patients, a number of patients that the government’s
expert, Dr. Graves Owen, testified would have been “impossible” for a provider
practicing within the normal scope of professional practice. Okechuku was
well-aware that his clinic was seeing this many patients in such a short


evidence showing that they had knowledge of the agreement and that they willfully
participated in the conspiracy.
        5 The evidence showed that when Okechuku was away from the clinic, he kept

remarkably close tabs on its operations. Specifically, Okechuku installed several cameras at
the clinic that allowed him to monitor a live video feed of the clinic’s operations from his cell
phone. Clinic employees testified that they knew Okechuku monitored the cameras because
he often called the clinic when he was away to complain that there were too many people
congregating in the hallway or that patients needed to be controlled outside. Okechuku
himself testified that he “spot check[ed] the cameras each day. The government provided
evidence that those same cameras showed Jerry Reed and others coming to the clinic, signing
in patients, handling patient files, giving cash to patients, and moving freely around the
clinic.
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                                       No. 16-10386
amount of time, as the evidence demonstrated that he required his staff to fax
him the clinic’s earnings and the number of patients the clinic saw each day.
This evidence, when viewed in the light most favorable to the conviction, is
enough to support Okechuku’s conviction under Count One. 6 See Santillana,
604 F.3d at 195.
       The evidence at trial was also sufficient to support Iwuoha’s conviction
that he knew of and willfully participated in a pill mill scheme. The
government presented testimony that even though Iwuoha was not licensed to
write prescriptions, he wrote prescriptions at the clinic that were pre-signed
by Okechuku. The government also presented testimony that Iwuoha held
himself out to be a doctor even though he was not licensed to practice medicine
in Texas. Despite the fact that he was not licensed to practice medicine, the
clinic paid Iwuoha more than eight times the amount he was paid at his other
job as an anesthesiologist technician. Several witnesses testified that many of
the clinic’s patients were obviously homeless and could not afford a $150 or
$190 doctor visit or the prescriptions Iwuoha and the other providers wrote.
Video footage and witness testimony presented at trial established that
Iwuoha’s patient visits usually lasted less than eight minutes, often lasting
less than four minutes. Moreover, Iwuoha’s patient notes were consistently
sparse. Of the 87 patients that Iwuoha saw in a two-day sample period, all 87
of them were prescribed hydrocodone. Ezenagu testified that he saw Jerry
Reed go into Iwuoha’s office, and that based on Ezenagu’s experience at the
clinic, he believed Iwuoha knew what Jerry Reed and the other drug dealers


       6 Okechuku lists various pieces of evidence that he claims “the jury could have relied
to counter the government’s evidence.” However, “[t]he evidence need not exclude every
reasonable hypothesis of innocence or be wholly inconsistent with every conclusion except
that of guilty, and the jury is free to choose among reasonable constructions of the evidence.”
United States v. Salazar, 66 F.3d 363, 370 (5th Cir. 1995).
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                                      No. 16-10386
were doing. 7 This evidence of short visits, sparse patient notes, lack of
individualized treatment, and higher pay, combined with all of the other
evidence presented at trial was sufficient to support the jury’s verdict that
Iwuoha was aware of and voluntarily joined in the pill mill activities occurring
at the clinic. See Santillana, 604 F.3d at 195.
       We likewise conclude that the evidence at trial was sufficient to support
Oti’s conviction. The government presented evidence at trial that Oti kept
pages of prescriptions already filled out by her for the highest strength of
hydrocodone. She also frequently issued non-refillable prescriptions. The
government also presented testimony from an undercover agent who was
treated by Oti and testified that Oti watched television during the entire
examination and never touched her. Video evidence presented at trial also
showed the consistently short duration of Oti’s patient visits, and documentary
evidence showed the sparseness of her medical notes. There was also evidence
that Oti was familiar with Jerry Reed and knew what he was doing, including
video evidence of her meeting with Jerry Reed in her office and phone records
showing at least three contacts between them. Further, Ezenagu testified that,
based on his time and experience at the clinic, he believed Oti knew what Jerry
Reed, Rutledge, and David Reed were doing at the clinic. Finally, the
government presented evidence indicating that Oti had worked for a pill mill
in the past and was therefore familiar with how they operated. Far from being




       7 Iwuoha argues that the government’s evidence against him consisted mainly of
Ezenagu’s unsupported testimony that he “believe[d] that Emmanuel Iwuoha and Elechi Oti
were aware of what Jerry Reed [and his cohorts] were doing.” However, Ezenagu’s belief was
based on his experience working at the clinic six days per week and seeing Jerry Reed go into
Iwuoha’s and Oti’s office on multiple occasions. Further, we accept all credibility
determinations made by the jury which tend to support the verdict. See United States v.
Asibor, 109 F.3d 1023, 1030 (5th Cir. 1997).
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                                     No. 16-10386
devoid of evidence, the trial record has ample evidence showing that Oti
knowingly and voluntarily joined in a conspiracy to operate the clinic as a pill
mill. See Delgado, 672 F.3d at 331.
                            B. Counts Two and Three
      Okechuku also challenges the sufficiency of the evidence supporting his
conviction under the firearm counts. Okechuku was convicted of using,
carrying, and brandishing a firearm during and in relation to a drug-
trafficking offense in violation of 18 U.S.C. § 924(c)(1)(A)(ii). Section 924(c)(1)
“requires the prosecution to make two showings. First, the prosecution must
demonstrate that the defendant ‘use[d] or carrie[d] a firearm.’ Second, it must
prove that the use or carrying was ‘during and in relation to’ a ‘crime of violence
or drug trafficking crime.’” 8 Smith v. United States, 508 U.S. 223, 227–28
(1993). The jury also found that the firearm was “brandished,” subjecting
Okechuku to enhanced penalties under 18 U.S.C. § 924(c)(1)(A)(ii). Okechuku
was also convicted of conspiring to violate section 924(c), in violation of 18
U.S.C. § 924(o).
      Okechuku challenges both of his firearm convictions on the same basis,
arguing that there was insufficient evidence to support the “in relation to”
nexus requirement between carrying or using the firearm and the drug-
trafficking crime. “In relation to” means that the firearm must have some
“purpose or effect with respect to the drug trafficking crime; [thus,] its presence
or involvement cannot be the result of accident or coincidence.” Smith, 508 U.S.
at 237–38. Okechuku argues that the evidence fails to show that he intended


      8 Okechuku argues that because the evidence was insufficient with respect to the
drug-trafficking conspiracy, the firearm convictions should be vacated. However, because we
conclude that the evidence at trial was sufficient to support Okechuku’s drug-trafficking
conspiracy conviction, we reject this argument.

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                                      No. 16-10386
to hire armed guards; he argues that it was just “happenstance” that the
security guards were armed and that the presence of firearms was “unrelated”
to and had no “purpose or effect” with respect to the drug-trafficking crime.
       We conclude that the evidence presented at trial is sufficient to support
the “in relation to” nexus requirement of Okechuku’s firearm convictions. This
evidence includes the testimony of Sam Donnell, one of the armed security
guards, who testified that Ezenagu approached him and said that he “might
need the services of an armed security guard” and that he would have to
discuss the quoted price with his “partner,” i.e., Okechuku. Ezenagu testified
that Okechuku ultimately made the decision to hire armed guards. Given the
large amounts of cash held at the clinic and the fact that there were drug
dealers that frequented the clinic, a reasonable jury could have inferred that
Okechuku hired the armed guards in order to protect the proceeds and
personnel of the clinic’s pill mill operation. Indeed, Ezenagu testified that they
“needed to hire a security guard [because] there was too much money going on
in [sic] the place.” Okechuku argues that “it can be inferred” from the evidence
that the fact that the security guards were armed was just a coincidence.
However, all “inferences that can be drawn from the evidence should be
resolved in favor of the jury verdict.” Moreno-Gonzalez, 662 F.3d at 372. Given
this evidence, a reasonable jury could have inferred that Okechuku hired the
armed guards in order to protect the proceeds and personnel of the clinic’s pill
mill business. 9 See Santillana, 604 F.3d at 195.
       Okechuku also argues that the evidence was insufficient to support the
jury’s determination that the firearms were “brandished” because there was


       9 Okechuku also argues that the government relied on improper expert testimony to
prove that the firearm was related to the drug-trafficking conspiracy. We address this issue
in Part III.A.1, infra.
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no evidence that the guards intended to intimidate anyone by carrying the
firearms. “[B]randish means, with respect to a firearm, to display all or part of
the firearm, or otherwise make the presence of the firearm known to another
person, in order to intimidate that person, regardless of whether the firearm is
directly visible to that person.” 18 U.S.C. 924(c)(4). Donnell testified that his
job was to control the unruly crowds of patients and to prevent robberies. He
also testified that if there was a fight, robbery, or any type of chaos, he was
there to quell it with his firearm. Donnell also testified that the firearm was
displayed every day he came to work at the clinic. On these facts, a reasonable
jury could have found that the security guards visibly wore firearms with the
intent to intimidate others at the clinic. See Moreno-Gonzalez, 662 F.3d at 372.
                        III. Evidentiary Challenges
      Okechuku, Iwuoha, and Rutledge each raise challenges regarding the
evidence admitted at trial. “When a district court’s determination as to the
admissibility of evidence is questioned on appeal, our applicable standard of
review is abuse of discretion.” United States v. O’Keefe, 426 F.3d 274, 280 (5th
Cir. 2005); see also United States v. Wise, 221 F.3d 140, 148 (5th Cir. 2000)
(“[T]he proper standard of reviewing a district court’s admission or exclusion
of expert testimony is abuse of discretion.”). The government argues as to each
of Appellees’ evidentiary challenges that even if the district court erred, the
error was harmless. See Wise, 221 F.3d at 157. Under this harmless error
analysis, we will not reverse “[u]nless there is a reasonable possibility that the
improperly admitted evidence contributed to the conviction.” United States v.
Mendoza-Medina, 346 F.3d 121, 127 (5th Cir. 2003). The government bears the
burden of demonstrating that the error was harmless. United States v. Akpan,
407 F.3d 360, 377 (5th Cir. 2005).


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       “We review for plain error objections to evidence that were not made
before the district court.” United States v. McGee, 821 F.3d 644, 646 (5th Cir.
2016). Under our plain error review, the appellant must show that: (1) there
was an error; (2) the error was clear or obvious; (3) the error affected his or her
substantial rights; and (4) the error seriously affects the fairness, integrity, or
public reputation of judicial proceedings such that we should exercise our
discretion to reverse. See Delgado, 672 F.3d at 329–31.
       We address each of the appellants’ evidentiary challenges in turn. 10
                     A. Okechuku’s Evidentiary Challenges
                                               1.
       Okechuku argues that the district court erred under Federal Rule of
Evidence 704 by allowing the government’s expert witness, ATF Special Agent
Gordon, to testify as to a legal conclusion regarding the firearm offenses for
which Okechuku was found guilty. At trial, Gordon was permitted by the
district court to testify as an expert with regard to the use of firearms in the
drug trade. 11 Gordon has investigated hundreds of drug-trafficking offenses in
his 18-year career, including several pill mills. During his testimony, the
government asked Gordon the following:
       Based upon the evidence that you saw and the photographs, the
       videotape, and the information that was made available to you, do
       you have an opinion as to whether or not those security guards


       10 Both Okechuku and Iwuoha argue that their convictions require reversal under the
cumulative error doctrine. The cumulative error doctrine “provides that an aggregation of
non-reversible errors (i.e., plain errors failing to necessitate reversal and harmless errors)
can yield a denial of the constitutional right to a fair trial, which calls for reversal.” United
States v. Munoz, 150 F.3d 401, 418 (5th Cir. 1998). Cumulative error justifies reversal only
when errors “so fatally infect the trial that they violated the trial’s fundamental fairness.”
Delgado, 672 F.3d at 344. “[T]he possibility of cumulative error is often acknowledged but
practically never found persuasive.” Id. Here, the alleged errors do not rise to the level of
cumulative error.
       11 Okechuku does not challenge Agent Gordon’s designation as an expert witness.

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                                  No. 16-10386
      were using, carrying, and brandishing a firearm in furtherance of
      a drug trafficking activity?
Gordon responded “Absolutely.” Defense counsel objected, and the district
court judge called counsel to the bench. After the bench conference, the
government was allowed to continue its line of questioning. Gordon was asked
whether, “assuming that the jury in this case were to find that . . . a pill mill
was being operated out of the [the clinic] . . . [do you] have an opinion as to
whether or not you believe that firearms were being used to protect this . . .
drug enterprise?” Gordon responded “Yes, sir.” When asked what his opinion
was, Gordon added:
      My opinion is that the firearms used in this particular operation
      are very similar to cases that I’ve investigated in the past where
      people would hire security guards or even law enforcement officers
      to protect the drug trafficking activity and those individuals
      carrying those firearms were using those firearms in furtherance
      of the drug trafficking activity and those individuals who hired
      those security guards or law enforcement officers were also using
      those firearms in furtherance of the drug trafficking activity.
Okechuku argues that the district court erred by admitting this portion of
Gordon’s testimony because it states a legal conclusion and circumvented the
jury’s decision-making function by telling it how to decide the case.
      We have repeatedly addressed the proper bounds of expert testimony.
See, e.g., United States v. Haines, 803 F.3d 713, 728–34 (5th Cir. 2015); United
States v. Thomas, 847 F.3d 193, 206 (5th Cir. 2017). We have especially urged
the government to use caution when case agents also function as experts
because the expert label “confers upon [the agent] the aura of special reliability
and trustworthiness surrounding expert testimony.” Haines, 803 F.3d at 730
(quoting United States v. Dukagjini, 326 F.3d 43, 53 (2d Cir. 2003)). An expert
witness is permitted to give his opinion on an “ultimate issue” of fact, assuming
he is qualified to do so. Goodman v. Harris Cnty., 571 F.3d 388, 399 (5th Cir.
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2009). However, an expert witness is not permitted to offer conclusions of law.
Fed. R. Evid. 704; see also Goodman, 571 F.3d at 399 (“[A]n expert may never
render conclusions of law[.]”). This rule and the other Federal Rules of
Evidence “afford ample assurances against the admission of opinions which
would merely tell the jury what result to reach.” Salas v. Carpenter, 980 F.2d
299, 305 n.4 (5th Cir. 1992); Fed. R. Evid. 704 advisory committee’s notes
(1972).
      We recognize that there is often a fine line between admissible expert
testimony pertaining to inferences that can be drawn from the facts of a case
and inadmissible legal conclusions. However, the government must resist the
temptation to test the boundaries of that line. Here, the government solicited
testimony from Gordon that the security guards at the clinic were “similar to”
other cases that he had investigated in which the security guards “were using
those firearms in furtherance of the drug trafficking activity and those
individuals who hired those security guards . . . were also using those firearms
in furtherance of the drug trafficking activity.” Gordon’s use of the phrase “in
furtherance of the drug trafficking activity” stated a legal conclusion that
should have been left to the jury to decide. The fact that Gordon was actually
discussing past cases he had investigated—and not technically discussing
Okechuku’s actions in this case—is of no matter. See United States v. Alvarez,
837 F.2d 1024, 1030 (11th Cir. 1988) (“When the expert is a government law
enforcement agent testifying on behalf of the prosecution about participation
in prior and similar cases, the possibility that the jury will give undue weight
to the expert’s testimony is greatly increased.”).
      Even though Gordon’s testimony ventured into forbidden territory and
its admission constituted error, we conclude that the error was harmless. As
discussed above, even excluding Gordon’s testimony, there was ample evidence
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                                 No. 16-10386
to support Okechuku’s conviction under the firearm counts. The testimony of
Ezenagu and Donnell show that Ezenagu acted as Okechuku’s agent in seeking
the services of armed guards at the clinic. Ezenagu also testified that the
purpose of having the armed guards was to protect the high amount of cash
coming into the clinic. Finally, Donnell testified that he and the other security
guards visibly wore their firearms every day at the clinic and that he was there
to quell any disturbances with his firearm. Because of this evidence supporting
the firearm conviction, allowing Gordon’s testimony was harmless error. See
Haines, 803 F.3d at 732 (holding that the error of admitting an agent’s
impermissible testimony was harmless because the record, even excluding the
impermissible testimony, was “replete with evidence” that defendants had
participated in the conspiracy); see also United States v. Williams, 343 F.3d
423, 435 n.11 (5th Cir. 2003) (affirming convictions based on the strength of
the evidence, despite testimony admitted in violation of Rule 704).
                                       2.
      Okechuku argues that the district court erred when it allowed FBI
Special Agent Pekala to testify on cross-examination that Jerry Reed, a non-
testifying co-defendant, told him that a Post-It note was an agreement between
Okechuku and Reed. Okechuku contends that in admitting this evidence, the
district court violated his Sixth Amendment right to confrontation under
Bruton v. United States, 391 U.S. 123, 137 (1968). Okechuku concedes that he
did not lodge an objection to Pekala’s testimony, therefore we apply plain error
review. See McGee, 821 F.3d at 646.
      At trial, FBI Special Agent Pekala testified that Jerry Reed, a non-
testifying co-defendant, had told him that a hand-written Post-It note was
evidence of the conspiratorial agreement between Reed and Okechuku. The
Post-It note read: “Jerry 170 1 Free Every 10[.]” During Pekala’s testimony, he
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                                  No. 16-10386
testified that he found the note in the trash during his search of the clinic. He
also testified that the note “appears to be an agreement between Jerry Reed
and the clinic” and that he thought “the 170 is referring to the cost of an office
visit. For every ten patients, [Jerry Reed] gets one—I am assuming—
prescription for free.” During cross-examination, Pekala was asked how he
knew it was an agreement. Pekala responded that Ezenagu and Jerry Reed
told him it was an agreement. He was asked, “And that is the basis of you
saying what you said in this courtroom?” Pekala responded, “Well, I thought it
was that before that.”’ Okechuku argues that this testimony violated his Sixth
Amendment rights because it deprived him of the opportunity to confront Jerry
Reed, the real source of the testimony that was being presented to the jury
through Pekala.
      Even assuming arguendo that the district court erred and that the error
was plain, Okechuku has not demonstrated that the error affected his
substantial rights. A defendant demonstrates that an error had an effect on
his substantial rights when he shows a reasonable probability that the jury,
absent the error, would have acquitted him. See United States v. Powell, 732
F.3d 361, 379 (5th Cir. 2013). Pekala’s testimony pertaining to the Post-It note
did not affect Okechuku’s substantial rights because, as discussed above in
Part II, supra, there is ample evidence supporting Okechuku’s drug trafficking
conspiracy conviction. We conclude that Okechuku’s Bruton argument fails on
the third prong of plain error review. See Powell, 732 F.3d at 379.
                                        3.
      Okechuku argues that the district court erred when it permitted the
government to impeach him during his testimony regarding the FBI
investigating him for possible insurance fraud. During its cross-examination
of Okechuku, the government asked Okechuku whether he “was aware of the
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                                       No. 16-10386
FBI’s actions” regarding an insurance fraud investigation into a business that
Okechuku owned. Okechuku denied any knowledge of the government’s
assertion, and the government did not inquire further. Okechuku contends
that the district court erred in allowing the government to ask him this
question on cross-examination because the government failed to provide a
good-faith basis for the question and the probative value of the question was
substantially outweighed by the danger of unfair prejudice. We review this
challenge for plain error. 12
       Questions about past specific instances of misconduct pertaining to fraud
are admissible under Federal Rule of Evidence 608(b) because they are “clearly
probative of truthfulness or untruthfulness.” United States v. Tomblin, 46 F.3d
1369, 1389 (5th Cir. 1995). However, when admitting such testimony, the
danger of unfair prejudice should not substantially outweigh the testimony’s
probative value. Fed. R. Evid. 403. The district court has substantial discretion
in determining whether the probative value of the testimony substantially
outweighs the danger of unfair prejudice. See United States v. Farias-Farias,
925 F.2d 805, 809 & 811 n.11 (5th Cir. 1991).
       We are unpersuaded by Okechuku’s contention that the government
failed to provide a good-faith basis for its question about the FBI investigation.


       12 The parties agree that we should apply the plain error standard of review to
Okechuku’s argument regarding the good-faith basis for the government’s question about the
FBI investigation. However, the parties disagree about whether Okechuku preserved his
argument that he was unfairly prejudiced by the question about the FBI investigation.
Because we conclude that Okechuku raised this specific objection for the first time on appeal,
we review the district court’s actions for plain error. United States v. Hernandez-Martinez,
485 F.3d 270, 273 (5th Cir. 2007) (reviewing for plain error where the district court “was not
on notice of the arguments” the defendant presented on appeal). Moreover, even if we were
to review the district court’s allowance of this question for abuse of discretion, Okechuku has
not demonstrated that the district court abused its discretion in allowing questions
pertaining to the FBI investigation.

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                                   No. 16-10386
Whether a good-faith basis exists for the government’s question is an issue of
fact. If Okechuku had timely raised the issue of whether there was a good-faith
basis for the questioning, the district court could have held a hearing during
which the government could have presented evidence. Because Okechuku did
not raise this issue before the district court, the district court did not plainly
err by allowing the testimony. See United States v. Illies, 805 F.3d 607, 609
(5th Cir. 2015) (“In this circuit . . . questions of fact capable of resolution by the
district court can never constitute plain error.”).
      Okechuku also argues that the government’s question was unfairly
prejudicial because there was no preliminary showing that he actually
committed the acts alleged. But this argument is similarly unpersuasive.
Okechuku asks for what Rule 608(b) prohibits—extrinsic evidence showing
that he committed the prior acts. See Fed. R. Evid. 608(b). We have specifically
held that the basis for questions under Rule 608(b) does not have to “be proved
as a fact before a good faith inquiry can be made.” United States v. Nixon, 777
F.2d 958, 970 (5th Cir. 1985); see also Tomblin, 46 F.3d at 1389. Accordingly,
we conclude that the district court did not commit plain error by allowing the
government to inquire about the FBI investigation.
                     B. Iwuoha’s Evidentiary Challenges
                                         1.
      Iwuoha argues that the district court erred when it made a comment
before the jury that had the effect of lessening the government’s standard of
proof. During the defense’s direct examination of defense expert Dr. Warfield,
the district court made the following comment:
      Counsel, I still don’t—that’s just a variation of that last question.
      I don’t see how that is going to help this jury answer the issues
      before them, whether the prescriptions were properly issued in

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                                  No. 16-10386
      this case. That’s the issue the jury is going to have to answer. Stick
      with that.
Iwuoha argues that the question before the jury was not whether the
prescriptions were properly issued but whether they were legally issued.
Iwuoha argues that the district court’s comment led the jury to believe that
mere negligent care in issuing prescriptions warranted a conviction and
therefore impacted his right to a fair trial. Because Iwuoha did not object to
the district court’s statement, we review the district court’s statement for plain
error. See McGee, 821 F.3d at 646.
      We are unpersuaded that the district court’s statement amounts to plain
error because Iwuoha has failed to show that the comment plainly misstated
the law nor has he shown that he was prejudiced by the comment. In the
context of the district court’s statement, the difference between properly issued
and legally issued appears to be merely semantic in nature. The district court
never indicated that there was a distinction between the two terms in the way
it used them and therefore did not lower the standard by using the word
“properly” in the comment to defense counsel. However, even assuming
arguendo that the district court misstated the law, Iwuoha has failed to show
that he was prejudiced by a single comment to defense counsel during a two-
week jury trial. Any harmful effect this comment might have had on the jury
was cured by the jury instructions, which correctly charged that it must find
that the defendants “unlawfully distributed or dispensed hydrocodone . . .
outside the scope of professional practice.”
                                        2.
      Iwuoha also argues that both the prosecutor and the government’s
expert witness misled the jury by indicating that the act of pre-signing a
prescription for hydrocodone is a felony in Texas. Because Iwuoha did not raise

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                                  No. 16-10386
this objection at trial, we apply plain error review. See United States v. Fields,
483 F.3d 313, 360 (5th Cir. 2007).
      Section 481.074 of the Texas Health & Safety Code provides that “a
person may not dispense a controlled substance in Schedule III or IV . . .
without a written . . . prescription of a practitioner . . . . A prescription under
this subsection must comply with other applicable state and federal laws.” Tex.
Health & Safety Code § 481.074(g). Iwuoha acknowledges that the
prescriptions he gave to patients with pre-signed prescriptions were Schedule
III drugs. And federal regulations provide that “[a]ll prescriptions for
controlled substances shall be dated as of, and signed on, the day when
issued[.]” 21 C.F.R. § 1306.05. Because Texas and federal law state that it is
unlawful to dispense the drugs Iwuoha was dispensing without a prescription
signed on the same day they were prescribed, we conclude that there was no
error here, plain or otherwise.
                     C. Rutlege’s Evidentiary Challenge
      In the only issue he raises on appeal, Rutledge argues that his conviction
was based on false testimony in violation of Napue v. Illinois, 360 U.S. 264
(1959). Prior to trial, one of the prosecutors and two agents interviewed Nancy
Gapen, the manager of the property that the clinic leased. The prosecutor
recorded notes from the interview on his laptop, including a note that stated,
“Masses of traffic, knowing it was a pain med center; my bias was the dude’s
[sic] from Nigeria, having gone through what I saw at Estate Lane; more
sensitized to the issues[.]” Later, when the prosecutor reviewed his notes in
preparation for trial, he could not remember Gapen having said anything
regarding a bias. The prosecutor asked the two agents who had accompanied
him during the interview whether they could recall what was said, and neither
of them could remember Gapen saying anything like what was written in the
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                                       No. 16-10386
prosecutor’s notes. The prosecutor also asked Gapen, and she stated that she
did not remember saying anything like what the prosecutor had written. Even
though no one could remember that statement being said, the prosecutor
disclosed the note to defense counsel.
       At trial, on direct examination, the prosecutor tried to clear up any
confusion by explicitly asking Gapen whether she had a bias against Nigerians,
to which she responded, “No.” During cross-examination, counsel for Okechuku
asked her whether she had expressed a bias towards Nigerians during a
meeting with the prosecutor. She responded, “No, I did not.” Later, outside the
presence of the jury, Oti and Okechuku moved to strike Gapen’s testimony on
the ground that she falsely testified that she did not have a bias against
Nigerians. Rutledge joined the motion. The district court denied the motions
to strike, but permitted defense counsel to recall Gapen so they could cross-
examine her about her purported bias.
       Rutledge now argues that the government violated Napue in not striking
Gapen’s testimony. We review Rutledge’s challenge for plain error. 13
       “In order to establish a Napue violation, the defendant must show (1) the
statements in question are actually false; (2) the prosecution knew that the
statements were false; and (3) the statements were material.” United States v.


       13 The parties disagree as to whether the abuse of discretion or plain error standard
of review should apply to this issue. Rutledge argues that the abuse of discretion standard
applies because, at the conclusion of Gapen’s testimony, the defense asked that her testimony
be stricken because she had allegedly falsely testified about her bias. However, at no point
did Rutledge or the other defendants allege that the government knew Gapen testified falsely
in violation of Napue. Further, Rutledge did not object to the district court’s finding that the
prosecutor acted properly and in good faith. Because Rutledge never alleged that the
government knew Gapen testified falsely—an element under Napue—we review Rutledge’s
Napue argument for plain error. See Hernandez-Martinez, 485 F.3d at 273. However, even if
we were to determine that Rutledge preserved his challenge under Napue and were to review
his argument under an abuse of discretion standard of review, we would conclude that he
does not prevail under that standard.
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                                       No. 16-10386
Haese, 162 F.3d 359, 365 (5th Cir. 1998). Rutledge has failed to satisfy any of
these three prongs. First, Rutledge has not shown that Gapen’s testimony that
she harbors no bias against Nigerians is actually false. None of the people
present when the notes were taken remember Gapen actually making the
statement and Gapen testified under oath that she did not have a bias. Second,
even if Gapen’s testimony was actually false, Rutledge has not shown that the
government knew that her testimony was false. The prosecutor told the district
court that he doubted that Gapen actually said the statement and the district
court concluded that the prosecutor was credible and acted in good faith. Third,
Rutledge has not shown that the false statement was material. 14 Even if
Gapen’s statement was excluded, Gapen’s testimony was cumulative of other
evidence at trial and there was sufficient evidence presented at trial of
Rutledge’s guilt.
                      IV. Deliberate Ignorance Instruction
       Okechuku, Oti, and Iwuoha argue that the district court erred by giving
the jury a deliberate ignorance instruction, thus allowing the jury to conclude
that each of them knowingly joined the conspiracy if it found that they
“deliberately closed [their] eyes to what would otherwise have been obvious to
[them].” Okechuku, Oti, and Iwuoha contend that the instruction is
inappropriate in conspiracy cases and also that the instruction was not
supported by the evidence.
       In the district court, Appellants only objected to the deliberate ignorance
instruction on the basis that the instruction was inappropriate in conspiracy
cases. At no time did Appellants argue in the district court that the evidence


       14 The Supreme Court has defined “material” in terms of a “reasonable probability” of
a different outcome if the evidence or testimony was excluded. Kyles v. Whitley, 514 U.S. 419,
434 (1995).
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                                  No. 16-10386
did not support the instruction. Accordingly, we review for abuse of discretion
Appellants’   argument     that   the   deliberate   ignorance    instruction   is
inappropriate in conspiracy cases. See United States v. Fuchs, 467 F.3d 889,
901 (5th Cir. 2006). We review for plain error Appellants’ argument that the
evidence presented at trial did not support giving the instruction to the jury.
See United States v. Scott, 159 F.3d 916, 923 (5th Cir. 1998).
      We reject Appellants’ first argument that a deliberate ignorance
instruction cannot be given in conspiracy cases. We have held that the
deliberate ignorance instruction is consistent with the elements of conspiracy.
See United States v. Inv. Enters., 10 F.3d 263, 269 (5th Cir. 1993) (“To the
extent that the instruction is merely a way of allowing the jury to arrive at the
conclusion that the defendant knew the unlawful purpose of the conspiracy, it
is hardly inconsistent with a finding that the defendant intended to further the
unlawful purpose.”). Indeed, we have consistently upheld deliberate ignorance
instructions in the conspiracy context, so long as sufficient evidence supported
the instruction. See Scott, 159 F.3d at 924 & n.6 (citing cases); see also, United
States v. Brown, No 16-3033, slip op. at 4 (5th Cir. Sept. 13, 2017) (collecting
conspiracy cases where deliberate ignorance instruction was properly given).
      Regarding Appellants’ second argument, the proper factual basis for the
deliberate ignorance instruction exists “if the record supports inferences that
(1) the defendant was subjectively aware of a high probability of the existence
of illegal conduct; and (2) the defendant purposely contrived to avoid learning
of the illegal conduct.” Fuchs, 467 F.3d at 902. “In deciding whether the
evidence reasonably supports the jury charge, the court reviews the evidence
and all reasonable inferences that may be drawn therefrom in the light most
favorable to the government.” Id. at 901.


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                                 No. 16-10386
      “We have often cautioned against the use of the deliberate ignorance
instruction.” Mendoza-Medina, 346 F.3d at 127. In United States v. Skilling,
we noted that such an instruction should be given only in “‘rare’ instance[s]”
and observed:
      The concern is that once a jury learns that it can convict a
      defendant despite evidence of a lack of knowledge, it will be misled
      into thinking that it can convict based on negligent or reckless
      ignorance rather than intentional ignorance. In other words, the
      jury may erroneously apply a lesser mens rea requirement: a
      “should have known” standard of knowledge.
Skilling, 554 F.3d at 548–49, rev’d on other grounds, 561 U.S. 358 (2010). “The
instruction is appropriate only in the circumstances where a defendant claims
a lack of guilty knowledge and the proof at trial supports an inference of
deliberate indifference.” United States v. Kuhrt, 788 F.3d 403, 417 (5th Cir.
2015).
      Appellants argue that the instruction was inappropriate because, with
the evidence before it, the jury had the choice of deciding whether Appellants
were actually aware of the pill mill activities or actually not aware of the
activities. We agree. “[T]he district court should not instruct the jury on
deliberate ignorance when the evidence raises only the inferences that the
defendant had actual knowledge or no knowledge at all of the facts in
question.” Mendoza-Medina, 346 F.3d at 133–34. The government has failed to
cite to specific evidence in the record that demonstrates that Okechuku, Oti,
or Iwuoha purposely contrived to avoid learning of the pill mill activities. This
showing is necessary as to each defendant to justify the use of the deliberate
ignorance instruction. A boilerplate deliberate ignorance instruction that
applies to all defendants in a case is inappropriate absent a showing that the
proper factual basis exists as to each defendant. See Fuchs, 467 F.3d at 902.


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                                    No. 16-10386
Where the government relies on evidence of actual knowledge, the deliberate
ignorance instruction is not appropriate. Kuhrt, 788 F.3d at 417.
      Rather than being a case of deliberate ignorance, the government’s case
against Okechuku, Oti, and Iwuoha was that they actually knew of the pill mill
operations taking place at the clinic. 15 As to Okechuku, the evidence
demonstrated that he kept incredibly close tabs on the clinic, watching
surveillance video remotely as well as frequently reviewing the amount of cash
the clinic brought in each day and the high number of patients that his clinic
saw—a number of patients that the government expert testified would have
been “impossible” for a provider practicing within the normal scope of
professional practice to see. The evidence also showed that Okechuku was well
aware of the frequent presence of Jerry Reed and his cohorts at the clinic and
of the clientele Jerry Reed brought in. Okechuku met several times alone with
Jerry Reed and Ezenagu in his office. Critically, Ezenagu testified that
“Okechuku knew from day one” that Jerry Reed was bringing illegitimate
patients to the clinic.
      The government’s case as to Iwuoha was also that he had actual
knowledge of the pill mill scheme. The government presented evidence that
even though Iwuoha was not licensed to practice medicine, the clinic paid him
more than eight times the amount he was paid at his other job as an
anesthesiologist technician. The evidence at trial showed the short, four-to-
eight-minute examinations that Iwuoha had with his patients. Of the 87
patients that Iwuoha saw in a two-day sample period, he prescribed all 87 of
them hydrocodone. Ezenagu testified that he saw Jerry Reed go into Iwuoha’s



      15 Indeed, at oral argument, the government stated that there was “overwhelming
evidence as to actual knowledge” as to appellants.
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                                  No. 16-10386
office to meet with Iwuoha, and that based on Ezenagu’s experience at the
clinic, he believed Iwuoha knew what Jerry Reed and the other drug dealers
were doing with the drugs from the clinic.
      Finally, the government’s case as to Oti was also that she had actual
knowledge of the pill mill scheme. The government presented evidence at trial
that Oti had worked for a pill mill in the past and was therefore familiar with
how they operated. An undercover agent testified that she was treated by Oti
and that Oti watched television during the entire examination and never
touched her. Oti’s patient visits were consistently short and her medical notes
were sparse. There was also evidence that Oti was familiar with Jerry Reed
and knew what he was doing, including video evidence of her meeting with
Jerry Reed in her office and records showing that they had spoken on the phone
at least three times. Further, Ezenagu testified that, based on his time and
experience at the clinic, he believed Oti knew what Jerry Reed and his cohorts
were doing at the clinic. Critically, as to each Okechuku, Iwuoha, and Oti, the
government presented testimony of other clinic staff members who had
considerably less medical training and experience than the appellants who
testified that they knew that the clinic was operating as a pill mill.
      Even though it was error for the district court to give the deliberate
ignorance instruction when the government’s theory was that Okechuku, Oti,
and Iwuoha actually knew of the pill mill operation, we have held “that giving
the instruction is harmless where there is substantial evidence of actual
knowledge.” Kuhrt, 788 F.3d at 417; see also United States v. St. Junius, 739
F.3d 193, 204–05 (5th Cir. 2013) (“Even if the district court errs in its decision
to give the deliberate ignorance instruction, any such error is harmless where
substantial evidence of actual knowledge is presented at trial.”). That is the
situation here. As discussed above, there was ample evidence presented at
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                                 No. 16-10386
trial, including Ezenagu’s testimony, that Okechuku, Oti, and Iwuoha each
knew of the illegal purposes for which Jerry Reed and others used the clinic’s
services. Therefore, we conclude that any error in using the instruction was
harmless and that Okechuku, Oti, and Iwuoha cannot show that the district
court plainly erred in giving the instruction. Kuhrt, 788 F.3d at 418 (“[T]here
was testimony that Appellants were actual participants in the illegal activity.
Therefore, the error was harmless.”).
        We emphasize once again, however, that the deliberate ignorance
instruction should rarely be given. Kuhrt, 788 F.3d at 417; United States v.
Faulkner, 17 F.3d 745, 766 (5th Cir. 1994); United States v. Ojebode, 957 F.2d
1218, 1229 (5th Cir. 1992); see also United States v. Cartwright, 6 F.3d 294,
301 (5th Cir. 1993) (“Because the deliberate ignorance instruction may confuse
the jury, the instruction should rarely be given.”). The instruction is not a
failsafe mechanism that the government can implement to relieve itself of
proving the mens rea requirement of a crime. See Kuhrt, 788 F.3d at 417 (“The
proper role of the deliberate ignorance instruction is not as a backup or
supplement in a case that hinges on a defendant’s actual knowledge.”). We
caution the government that, while this instance of misapplying the deliberate
ignorance instruction amounted to harmless error, that will not always be the
case.
                        V. Challenges to Sentencing
        Okechuku argues that the quantity of drugs attributed to him for
purposes of sentencing was excessive. At sentencing, Okechuku was held
accountable for all of the prescriptions written at the clinic because he was the
clinic’s owner and operator and its only licensed physician. The presentence
report (PSR) calculated that Okechuku was responsible for 1,314,300
hydrocodone pills, 39,289 Xanax pills, and 5,558 units of Promethazine with
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                                      No. 16-10386
Codeine. After calculating a marijuana equivalent, Okechuku was ultimately
held accountable for 999.99 kilograms of marijuana. 16
       Okechuku preserved this challenge by objecting to the PSR’s drug-
quantity determination. Therefore, we review the district court’s calculation of
the quantity of drugs—a factual determination—for clear error. United States
v. Betancourt, 422 F.3d 240, 246 (5th Cir. 2005). We will deem the district
court’s factual findings clearly erroneous only if, based on the entirety of the
evidence, we are left with the definite and firm conviction that a mistake has
been committed. United States v. Akins, 746 F.3d 590, 609 (5th Cir. 2014).
       Okechuku first argues that the quantity of drugs attributed to him is
excessive because the government failed to prove that all of the clinic’s patients
who were given prescriptions were given them without a legitimate medical
purpose. Okechuku cites to evidence that the clinic treated legitimate patients
in addition to the patients Jerry Reed brought in. Id. However, just because a
patient was not brought in by Jerry Reed does not mean that the prescription
issued to that patient was legitimate. The district court found that all of the
clinic’s prescriptions were issued outside the scope of professional practice and
without a legitimate medical purpose. Because there is evidence that all of the
visits with patients lasted 4–8 minutes, that few, if any, notes were taken, and
that clinic employees prescribed hydrocodone to almost every patient, the
district court’s finding is “plausible in light of the record as a whole” and is



       16 When an offense involves several types of controlled substances, the quantities of
differing controlled substances are combined using a marijuana equivalent. See USSG §
2D1.1, comment. (n.8(B)). Using this method, the PSR determined that the three controlled
substances were the equivalent of 1,316.79 kilograms of marijuana—the hydrocodone was
converted to 1,314,000 grams of marijuana, the Xanax to 2455 grams, and the Promethazine
with Codeine to 34.73 grams. Okechuku was ultimately held accountable for only 999.99
kilograms, however, because the combined weight of all Schedule III substances is capped at
999.99 kilograms of marijuana. See USSG § 2D1.1, comment. (n.8(D)).
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                                 No. 16-10386
therefore not clearly erroneous. United States v. Coleman, 609 F.3d 699, 708
(5th Cir. 2010).
      Okechuku also argues that there were many prescriptions issued
without his knowledge or authorization, for which he should not be held
responsible. Okechuku cites Ezenagu’s testimony that Jerry Reed sometimes
paid clinic employees to provide extra prescriptions. However, this argument
is unpersuasive because those prescriptions that were issued without
Okechuku’s knowledge would not have been included in the clinic’s seized
records upon which Okechuku’s total drug quantity was based.
      Finally, Okechuku argues that the PSR should not have relied on Agent
Pekala’s determination of quantities because he is not a medical doctor and
therefore cannot make the determination as to which prescriptions were
medically necessary. However, Pekala did not ultimately determine whether
the prescriptions were medically necessary—the jury made this determination
after considering substantial evidence showing that the clinic operated as a pill
mill. An expert is not required to make this determination. See United States
v. Armstrong, 550 F.3d 382, 388–89 (5th Cir. 2008), overruled on other grounds
by United States v. Balleza, 613 F.3d 432, 433 (5th Cir. 2010) (“[E]xpert
testimony is not always required in order to show that a physician is acting for
other than proper medical purposes.”).
      Even assuming arguendo that there was an error at sentencing in
calculating Okechuku’s drug quantity, any such error was harmless. In order
to have any effect on Okechuku’s base offense level, the 1,316.79 kilograms of
marijuana equivalent for which Okechuku was held accountable would have




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    Case: 16-10386        Document: 00514180895          Page: 31      Date Filed: 10/03/2017



                                        No. 16-10386
to have been reduced to less than 700 kilograms of marijuana equivalent. 17
Therefore, almost half of all of the clinic’s prescriptions would need to be
deemed legitimate in order to reduce Okechuku’s sentence. However, the
evidence does not support this low number. Therefore, we conclude that the
district court did not err in calculating Okechuku’s drug quantity amount. 18
                                      VI. Conclusion
       For the foregoing reasons, the district court’s judgment and sentence are
AFFIRMED.




       17 The district court determined a base offense level of 30 based on the already reduced
999.99 kilograms of marijuana, which was “at least 700 kilograms, but less than 1,000
kilograms of marijuana.” USSG § 2D1.1(c)(5).
        18 Oti and Iwuoha both dispute the district court’s application of the sentencing

enhancement under U.S.S.G. § 2D1.1(b)(1), arguing that it is unconstitutional to base a
defendant’s sentencing guidelines calculation on acquitted conduct. But, as they concede, the
issue is foreclosed. United States v. Watts, 519 U.S. 148, 157 (1997) (holding that “a jury’s
verdict of acquittal does not prevent the sentencing court from considering conduct
underlying the acquitted charge, so long as that conduct has been proved by a preponderance
of the evidence”); see also United States v. Grace, 640 F. App’x 298, 300 (5th Cir. 2016) (“Watts
continues to remain controlling law.”).
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