United States v. Pierre, 88 F.4th 574

James Pierre, a physician, was convicted for unlawfully dispensing controlled substances as the sole doctor at an illegal Houston "pill mill," West Parker Medical Clinic.
The clinic, operating as a pain management clinic, functioned by issuing prescriptions—typically for opioids and muscle relaxers—without legitimate medical purpose, largely for cash payments and without meaningful medical examinations.
Multiple co-conspirators, including the clinic's owner, cooperated with the government and provided detailed testimony about the illegal operations.
Pierre was charged with several counts of unlawfully distributing controlled substances and conspiracy under 21 U.S.C. §§ 841 and 846.
On appeal, Pierre challenged both the admission of certain trial testimony as improper "profiling" evidence and the adequacy of jury instructions in light of the Supreme Court's decision in Ruan v. United States.

Issue	Pierre's Argument	Government's Argument	Held
Improper Profiling Evidence	Testimony about clinic operations was inadmissible "profiling" evidence suggesting guilt by similarity to pill mills.	Testimony explained pill mill operations to help the jury understand context, not to prove guilt by profile.	No error; testimony provided permissible context/background, not improper profiling.
Jury Instructions Post-Ruan	Jury instructions failed to require a finding that Pierre subjectively knew he was acting without authorization.	Even if instructions were imperfect, any error was harmless due to overwhelming evidence of Pierre’s knowledge.	Any error did not affect substantial rights; overwhelming evidence of guilty knowledge.
Preservation of Errors	Arguments preserved at trial for review.	Arguments were not preserved; plain error review applies.	Plain error review applies; no reversible error found.
Use of "or" vs. "and" in Conspiracy Instruction	Conspiracy instruction should require both lack of legitimate purpose "and" departure from usual practice.	Regulation allows for either basis of invalidity; instruction correct as worded.	Instruction properly reflected the law using "or."

United States v. Evans, 892 F.3d 692 (5th Cir. 2018) (defines "pill mill" and characterizes operations with no legitimate medical purpose)
United States v. Ajayi, 64 F.4th 243 (5th Cir. 2023) (clarifies post-Ruan mental state requirement for § 841 prosecutions)
United States v. Staggers, 961 F.3d 745 (5th Cir. 2020) (admissibility of testimony explaining drug trafficking operations)
United States v. Gonzalez-Rodriguez, 621 F.3d 354 (5th Cir. 2010) (profiling testimony restrictions in drug cases)
United States v. Speer, 30 F.3d 605 (5th Cir. 1994) (allowing expert testimony on drug trafficking practices)
United States v. Garcia, 86 F.3d 394 (5th Cir. 1996) (expert testimony on significance of certain behaviors in narcotics trade)
United States v. Dixon, 273 F.3d 636 (5th Cir. 2001) (harmless error review for instructional mistakes)