Consider two pill mill doctors who flooded the streets with oxycodone and other dangerous opioids. The evidence against both doctors was overwhelming. They each sold millions of opioid pills. Both doctors charged addicted patients hundreds of dollars in cash for office visits that involved no physical examinations and no diagnostic tests. Instead, the doctors simply handed the patients opioids in exchange for cash. To maximize their income, both doctors conspired with street dealers to import fake patients — many of them homeless — so that the doctors could write even more prescriptions. Both doctors made millions of dollars profiting off the misery of people addicted to opioids. Even though juries convicted both doctors of similar criminal charges, they received drastically different sentences. The first doctor was sentenced to five years, while the second doctor received a thirty-five-year sentence.

This Article reviews twenty-five of the worst opioid pill mill doctors to be sentenced in the last five years, and it details drastic sentencing disparities in the federal system. In more than half the cases, judges departed well below the Federal Sentencing Guidelines to impose sentences that were decades less than would be expected.

The sentencing variations in pill mill cases are not driven by traditional explanations such as the trial penalty or the defendant’s criminal history. Instead, the sentencing variations are explained primarily by the age of the doctors. Many pill mill doctors are in their sixties and seventies, and judges appear to be tailoring their sentencing decisions to ensure that older doctors will not spend the rest of their lives in prison. Additionally, prosecutors face an uphill battle in proving the drug quantity against white-collar doctors (rather than street dealers) who can claim that some of their prescriptions were legitimate. This Article documents the difficulty of equitably punishing pill mill doctors, as well as the significance of age in sentencing older, white-collar offenders.