In a case of first impression, a state appeals court has upheld the manslaughter convictions of a doctor who overprescribed painkillers to two patients while running a prescription pain medication “pill mill” out of an office in Queens.

The unanimous decision from an Appellate Division, First Department, panel legally affirms that a doctor who recklessly prescribes a controlled substance, such as opioids, in New York state can be held criminally liable for homicide despite the lack of a statute expressly saying so.

The office of Manhattan District Attorney Cyrus Vance Jr. has said that the charges brought against Dr. Stan Xuhui Li made it a case of first impression in the state.

The case was lodged by New York City’s Special Narcotics Prosecutor Bridget Brennan, and typically her office will charge physicians accused of giving painkillers to addicts with the criminal sale of a prescription for a controlled substance. But within a few days of Li prescribing pills to Joseph Haeg, 37, and Nicholas Rappold, 21, each died, and Brennan chose to level manslaughter charges. It’s a strategy that has been used in some other states but is rare in New York, according to news reports.

In a detailed opinion knocking down Li’s argument that his manslaughter convictions must be reversed, the First Department panel made clear that in New York state a doctor may be guilty of homicide if he or she is criminally reckless in prescribing opioids.

“Defendant argues that the manslaughter convictions should be reversed because, as a matter of law, the sale of a controlled substance can never support a homicide charge in the absence of express legislative authorization,” the panel wrote in an unsigned opinion.

But “nothing in [People v. Pinckney, 38 AD2d 217 (2d Dept 1972) affd 32 NY2d 749 (1973), the case cited by Li] suggests that one who provides a controlled substance, whether it be heroin by a street dealer, or opioids by a medical doctor, can never be indicted on a manslaughter charge,” the panel said.

The justices added, “At bottom, all that was needed for the manslaughter charge to be sustained was for the people to satisfy its elements. … The question then becomes whether the people presented sufficient evidence to establish that defendant consciously disregarded the risk that Haeg and Rappold would die as a result of his prescribing practices.”

The panel, consisting of Justices Sallie Manzanet-Daniels, Angela Mazzarelli, Troy Webber and Jeffrey Oing, said that sufficient evidence clearly had been presented.

Li, a pain management physician from Hamilton, New Jersey, ran a one-day-a-week pain clinic in Flushing, Queens, treating as many as 80 patients in a day, according to the panel and news reports. Prosecutors painted the clinic as simply a “pill mill” serving people who were hopelessly addicted to pain medicine, mostly opioids, the panel wrote.

The government’s evidence, presented during a four-month jury trial in Manhattan Supreme Court in 2014, showed that Li “engaged in only the most cursory attempts to confirm patients’ complaints,” the panel wrote, and he often prescribed opioids as a first resort, not a last resort.

Appointments weren’t needed at the basement clinic, and all payments had to be made in cash, with Li usually stuffing the money into his pocket, the panel and news reports said.

At times, Li would even dish out prescriptions without seeing a patient at all, the panel said.

From 2008 through October 2011, he wrote more than 21,000 prescriptions for controlled substances, at an increasing pace, with more than half for drugs containing the opioid oxycodone, and more than a quarter for alprazolam (Xanax), the panel wrote. Citing a prosecution-side expert, NYU Director of Pain Medicine Christopher Gharibo, the justices pointed out that Xanax, when taken with opioids, can depress respiration and thereby make the combination especially dangerous.

In analyzing Li’s legal arguments urging a reversal of his two second-degree manslaughter convictions, the panel addressed the Pinckney case in detail, first noting that the defendant in Pinckney sold heroin and then gave the buyer a means to inject it, before the person died.

The justices in People v. Li, 5170/11, then pointed out that Li “contends that there is no legal distinction between himself and the drug dealer in Pinckney, since, he claims, opioids are not even as dangerous as heroin and, in any event, he merely provided the pills, and was not present when Haeg and Rappold ingested them.”

In addition, the panel noted in the Nov. 30 opinion that Li “argues that, since the [state] Penal Law, in the sections criminalizing sales of controlled substances, is silent on the consequences if a sale results in the buyer’s death, his prosecution for manslaughter is without any legal basis.”

But the justices then wrote, “we disagree,” and pointed to People v. Cruciani, 36 NY2d 304 (1975), in which the Court of Appeals affirmed the second-degree manslaughter conviction of a man who injected a woman with heroin because he knew she was already in a highly intoxicated state. The Cruciani court distinguished Pinckney, the panel noted, when it explained that in Pinckney there was no proof, as in Cruciani, “of awareness of the ongoing effect of drugs in the victim’s body at the time.”

The justices subsequently showed that in Li’s case, ample evidence established that he “consciously disregarded” the life risk to Haeg and Rappold. And thereby the panel suggested that his case was closer in circumstances to Cruciani than to Pinckney.

Li gave Haeg 15 prescriptions in the three months before his 2009 death, and more than 500 pills of controlled substances in his final month, according to a news report that cited court records. Rappold was given Xanax and oxycodone prescriptions from Li when last seeing him and soon after died in 2010 from the combined effects of Xanax and oxycodone, said the same report, again citing court records.

In July 2014, a jury convicted Li of 200 of the 211 charges against him, including counts for reckless endangerment and criminal sale of a prescription for a controlled substance. Manhattan Supreme Court Justice Michael Sonberg presided. He later sentenced Li to more than a decade in prison.

Brennan, the special narcotics prosecutor, noted in an email on Thursday that “the investigation and trial presented significant challenges.”

“Without previous case law to guide us,” she said, “our office developed an approach that included an extensive review of practices and procedures  in Dr. Li’s office.” In addition, “expert testimony regarding accepted standards of care, and the over-prescribing and toxic mixes of prescribed drugs that led to the individual deaths in this case was critical,” she said.

Of the panel’s appeals ruling, she said that it “clarifies that drug dealers are drug dealers and whether they wear a white coat or are out on the street they can be held accountable for causing a death.”

“The opioid crisis requires us to look broadly at the problem and explore untraveled but appropriate paths to address it,” Brennan said. “The genesis of this epidemic lies with the pharmaceutical industry and overprescribing of addictive medications. Prosecutions are an essential component of a multi-faceted approach.”

Raymond Belair of Belair & Evans in Manhattan represented Li. He did return a call seeking comment for this story.

Appeals of Brennan’s office’s cases are handled by Manhattan District Attorney Vance’s office. Assistant District Attorney and Senior Appellate Counsel Vincent Rivellese appeared for Vance’s office.

Brennan’s prosecution trial team included Peter Kougasian, counsel to the Special Narcotics Prosecutor, and Special Narcotics Prosecutor Assistant District Attorney Charlotte Fishman.