Case Analysis of Dr. Ball

You may gather from some of my writings that I have a dim view of federal interference in the practice of medicine.  That is probably because I do.  But there are a few doctors who, for whatever reason, clearly do act more like drug dealers.

The problem is knowing the difference without access to the truth, and from my evaluations, the public statements of the DEA rarely involve much truth.  On the other hand: There are some things that a doctor can do that no reasonable physician would think is okay.  Since the government’s statements are always in a light most unfavorable to the accused, mainly to convince the public that the prosecution was a good thing, let’s look at a recent conviction in a light most favorable to the accused physician.

Our case today is a doctor from Arlington, Virginia, who has been sentenced to a decade in prison for what the government calls, “a drug distribution scheme.” Let’s look at the available information from a DEA press release with an adversarial perspective:

• Kirsten Van Steenberg Ball was found guilty by a federal jury in December of the illicit distribution of more than a million oxycodone pills. She was sentenced today (Wednesday) in Alexandria federal court.

Question: a million pills over what time frame and to how many patients? Without context, this statement is inflammatory but meaningless… Let’s move to the next one.

• Prosecutors say three of Ball’s former patients died of drug overdoses, including at least two who had just received large oxycodone prescriptions.

Question: Did the doctor believe that the patient had pain?  If so, did the doctor prescribe more than the maximum FDA-approved dose? If these two criteria are met, then this is not a crime.  It is a tragedy.  Though the family may want someone to pay for their loss, in which case the DOJ will jump at the opportunity.  But that is unjust. If a patient chooses to end their life after suffering severe chronic pain, is it the doctor’s fault if a patient takes a medication other than as prescribed?  

• Ball, 69, operated her primary care practice out of her house, according to prosecutors.

Question: While his is not conventional these days it used to be quite common and. in any event, it is not a crime. 

• It goes on to say “Ball directed her office manager, Candie Marie Calix, 42, of Front Royal, to recruit other individuals – including several of Calix’s immediate family members – to become pain patients of Dr. Ball’s so that she could prescribe large quantities of oxycodone to them. Question: Directed her office manager to recruit patients. Real patients or not? It is not uncommon for those working in medicine to want their family treated by a doctor they know and trust. 

• Calix, in turn, then sold the tens of thousands of oxycodone pills that Ball prescribed to them. Calix was herself a patient of Ball.

Question: Did the doctor know what Calix was doing? Or did Calix lie to Ball and then throw her under the bus when caught?  This is much more common than you might think.  Facing a long sentence, some patients and even some employees will “offer” read “be encouraged/coerced,” to help prosecute the doctor.  Under this stress, statements made by these people cannot be taken at face value.  Many people will say anything when they are scared.

• Ball prescribed Calix approximately 50,000 oxycodone pills over 10 years.

Response: According to my limited data skills, that’s 120 months, which means ~416.7 pills per month and ~13.9 per day. Question? 5mg or 30 or what? If they were 5mg each, that would be a total of just ~70mg per day. Not unreasonable but taking that many pills would be strange.  If it were four 20mg pills per day, we get 80mg, which is not an unusual dose.  If these are 30mg pills, we get over 400 milligrams a day, which would be a heck of a lot unless the patient has terminal cancer, in which case, ten years?  Perhaps they have a great oncologist, but who knows?  But this IS starting to look bad.

• It was common for Ball to prescribe her patients as many as 360 oxycodone 30-mg pills per month, although she would split the prescriptions into two 180-pill prescriptions to try to disguise the amount.

My response: Or perhaps to ensure the pharmacy would have enough and could restock?  Also, what do these people have?  A hang nail or metastatic carcinoma?

• Ball continued to prescribe oxycodone to patients showing blatant signs of drug dependence

Response: “blatant signs of dependence”? That is an expected consequence of continued opiate treatment and NOT a sign of addiction.

 …to patients who had been arrested and convicted for selling illegal drugs;

How the heck would the doctor know what someone had been arrested for? We have no access to accurate arrest records and do not base medical treatment on someone’s legal status.

• …and to patients who asked for early refills of oxycodone based on unsubstantiated claims of lost or stolen pills.

Response: Unsubstantiated claims of lost or stolen pills?  What would be a substantiated claim unless they caught the thief?  How many times have they made this claim? Was there a police report or vehicle damage?

 …abuse, diversion, and addiction;

Response: the doctor can treat someone for pain even if they display signs of abuse or addiction, even if they have a diagnosis of addiction, unless the docto is prescribing the opiate to treat the addiction and not the pain.  In the case of addiction treatment can be with methadone from an approved facility or buprenorphine after some training. No other opiate agonists can be used for this purpose at this time as far as I know. Now for diversion; did the doctor know the medication was being diverted?  Not should have known or was ‘willfully blind’ to some nonexistent metric, but actually knew.  Authorities will often use a single negative drug screen as “proof” of “willful blindness,” ignoring the existence of false negatives, PRN dosing with a good day, drug holidays, and fast metabolizers.  Without true mens rea, a truly guilty or “evil mind,” there can be no crime.  We are not cops or drug agents, we are not on the street.

• The government’s investigation identified three of Ball’s former patients who died of drug overdoses. Ball consistently overprescribed oxycodone to these patients and ignored signs of drug abuse, fueling their addictions.

Response: Again, who is diagnosing these patients with addiction?  Is it being done retrospectively? Based solely on the outcome?  The only way to make sure no one ever dies of an overdose is to never prescribe a medication… Any medication just about.  More people kill themselves on purpose with Tylenol than opiates.

• For example, Ball concurrently prescribed a patient from Fauquier County large doses of both oxycodone and benzodiazepines, which when prescribed in combination with opioids significantly increases the risk of overdose.

Response: It does indeed, but a physician has the right to make a risk benefit analysis and decide to prescribe both.  Even DHHS agrees with this, and the CDC for what that’s worth. 

• Ball repeatedly documented in the patient’s chart that the patient was overusing or abusing her medication and had even been admitted to the local emergency room for a likely drug overdose, yet Ball continued to prescribe oxycodone to her. On July 22, 2016, Ball prescribed 240 oxycodone 30-mg pills. A few weeks later, the patient was found dead in her home of an oxycodone overdose.

Response: that would be 8 pills a day, a total of 240mg; that’s a lot, but how long had they been on that?  If it was the first dose, of course. Or even a recent increase from, say, 120mg.  If they had been on this dose for years, then this was not an overdose.  What did the coroner’s report say?  I have seen cases where the coroner says heart failure, but Dr. DEA decided it was it was an overdose.  This is a conclusion in search of support.

• In 2015, at the same time Ball was under investigation by state regulatory authorities, Ball discharged a patient whom she knew was overusing his medication. Rather than referring the patient to a substance abuse clinic or another medical provider, Ball prescribed a total of 500 oxycodone 30-mg tablets, along with 90 diazepam 10-mg tablets, and 60 methadone 10-mg tablets, for the month of June 2015, even though she knew this was a dangerous combination of drugs. On July 14, 2015, Ball issued a final prescription to the patient for another 160 oxycodone 30-mg pills

Response: This is a bit unusual. She “fired” a patient but did not refer them to drug treatment, or at least it was not documented. If a patient refuses something, you think they need to DOCUMENT IT! Do not trust that anyone will take your word later. Next, 500 tablets for 30 days? Again, what dose? That’s a lot of pills, though. About 17 a day again. Opiates are extremely variable between patients, and it can take a lot in some people, but still.  A pain pump is a better option if they need this much medication, I would think.

• In August 2015, the patient died of a drug overdose in his home. The Medical Examiner’s report noted a “toxic level of oxycodone.”

Response: the doctor was tapering the patient’s medication because he was overusing his medication.  How is she then responsible for an overdose?  You can’t just cut someone off of that much medication without putting them at risk of death.  But no one gets prosecuted for someone dying after they were abandoned.

If this patient had died after being “fired” without a taper would the doctor have been blamed?  Not criminally that I have seen in the hundreds I’ve evaluated.

• While under investigation by the Virginia Department of Health Professions (DHP) in 2014 and 2015, and again in 2021, Ball falsified records that she submitted to DHP to cover up the fact that she was prescribing oxycodone to patients for no legitimate medical purpose and outside the usual course of professional practice.

Response: The government claims those phrases have no set meaning, which would imply they have no objective application, so… There’s no way to know what they mean by that other than she practiced in a manner they didn’t like.  Also, how did she “falsify” records? I’ve seen doctors prosecuted and convicted for “fraud” when using steroid injections, a common practice, after a government-paid “expert” said they were “no different than opiates” and “not commonly used anymore.” Statements that are false on their face. Context matters. What did she falsify or was it a matter of opinion?

• Following the first DHP investigation, Ball directed Calix to use a false name in her capacity as office manager to hide the fact that Calix was receiving oxycodone from Ball.

Response: Now, this is a REAL legal problem and, if true, a clearly wrongful act with mens rea. Unless you are prescribing drugs from the Whitehouse, where this is apparently standard operating procedure.  DO NOT EVER PRESCRIBE A CONTROLLED OR ANY OTHER MEDICATION IN A FALSE NAME.  I’m looking at you, Rush.

 The FBI introduced an undercover law enforcement officer, purporting to be the nephew of an existing patient. In recorded conversations, the undercover told Ball that he was sharing pills with his family members. In response, Ball told the undercover that was “a felony” that she would simply not write it down in his patient file and not to tell anybody else. She continued to prescribe escalating quantities of oxycodone to the undercover.

Response: This does not look good at all.  Perhaps she believed he would not do it again, but at this point, she needed to refer this patient to a specialist, in my opinion. This is tough because maybe you believe they made a mistake and won’t do it again or that there is no one who can see them before they go into terrible withdrawals. What do you do? Finding inpatient treatment is very difficult. But this clearly provides not just mens rea but knowledge that the act is a felony. 

So, what can we take from this? First, we cannot trust what is said in the papers. We also can’t trust DOJ releases, as they routinely contain false or inflammatory information. On the other hand, if this doctor KNEW that medications were being sold for money and continued prescribing them, that would satisfy the Supreme Court’s ruling in Ruan.

Again, not “should have known” or “willfully blind to”-that could be said of anyone… except prosecutors when they falsely convict someone. For some reason, that argument is never applied to them. Second, family members often share medications, not realizing it is a crime.  Informing someone that it can be important, but in today’s environment, I don’t think a second chance with the same physician is safe.  Get backup and a WRITTEN opinion from a professional that treatment should be continued before doing so.  A psychiatrist would be good.

Don’t use your own in-house counselors or psych ANPs for these evaluations, as they can be threatened with prosecution if they support your defense. Go outside. Telemedicine can be great for this.  On Dec. 12, 2023, a federal jury convicted Ball on one count of conspiracy to distribute oxycodone, and 19 counts of distribution of oxycodone. On Sept. 28, 2022, Calix was sentenced to seven years in prison for conspiring to distribute oxycodone.

In addition to the 10-year prison sentence, the Court ordered Ball to forfeit $750,000 and pay an additional $50,000 in community restitution. The community restitution payment, which is the first of its kind in the Eastern District of Virginia, will go to two separate Virginia state entities, including the department tasked with receiving federal funds for substance abuse programs in the state.