"These are the days that I hate," Chief Wyoming U.S. District Court Judge Scott Skavdahl said near the end of a two-hour sentencing hearing on Monday for a former Rawlins doctor guilty of dispensing medically unnecessary controlled substances.

Skavdahl sentenced Dr. David Ray Cesko to 20 five-year prison terms to be served concurrently, or at the same time, to be followed by six years of supervised release, and to pay a special assessment of $2,000 and $400 in restitution.

"There is a defendant in front of me who has great ability and talent, and great stupidity and arrogance," Skavdahl said.

Part of the difficulty Skavdahl faced was the seriousness of the crimes,. countered by the support for 67-year-old Cesko.

Assistant U.S. Attorney Stephanie Sprecher referred to the pre-sentence report and recounted the evidence against Cesko, and proposed an approximately eight- to 10-year prison sentence.

While his deteriorating health would warrant a reduced sentence, that didn't let him off the hook, Sprecher said.

"He was a drug dealer in a white coat armed with a pen and a prescription pad," she said.

In February, he pleaded guilty to 20 counts of a 30-count indictment of dispensing oxycodone, alprazolam, hydrocodone, tramadol and other drugs. Some of those drugs were distributed to persons under 21 including a pregnant woman, according to the indictment. (The other 10 counts were dismissed at the sentencing.)

Sprecher said some of the patients were addicts or became addicted, and some sold the drugs to others. Cesko sometimes traded drugs for sexual favors, she added.

Four of his patients died from overdoses, Sprecher added.

During the investigation, Cesko tried to blame the patients even though he knew his conduct was reprehensible, she said.

However, his public defender Melanie Gavisk showed a video with two men and two women who testified Cesko's compassion and hard work, and what he did for them and  Rawlins.

One man, a medical professional, said Cesko would take patients no one else would take, that the loss of his medical license triggered a decline in his health, and that he has accepted responsibility for what he did.

The other man said Cesko had 7,000 patients, that he delivered most of the babies in the county, and that he was the last of the "old-time country doctors" who would make house calls.

He also said that incarceration would be a death sentence because of his declining health, that he can't go anywhere and he's bankrupt.

One woman, a former patient, said Cesko helped her get sober and that she would be dead without his care. He also wrote off patients' bills and sometimes paid their funeral expenses.

The other woman, a former employee of Cesko's, said that Rawlins has had a tough time recruiting and retaining doctors.

After the video, Gavisk said Cesko had a problem knowing the proper boundary of being a physician and caring for his patients that led to inappropriate relationships, that he was a "terrible pain management doctor," and that he was naive.

Cesko's case is far different from that of former Casper Dr. Shakeel Kahn, who was sentenced to 25 years imprisonment for his role in orchestrating a multi-state prescription drug conspiracy that cost a woman her life, she said.

Cesko, on the other hand, wanted to care for his patients and was not a predator like Kahn, she said.

Cesko himself apologized to the court, his family, his patients and all those he hurt.

After the Wyoming Board of Medicine suspended his license in 2017, because he "posed an imminent threat to the health, welfare and safety of the people of Wyoming," he could no longer see patients, had no source of income, and was jailed for a week, he said.

He's had a lot of support from Rawlins residents, but that's not enough to overcome what he lost, he said. "I cry myself to sleep every night."

Skavdahl, before he handed down the sentence, recounted some of the evidence including a comment from Cesko describing himself as "'overworked, underpaid and undersexed.'"

Cesko encouraged one young female patient to send lewd pictures to him, and in return he prescribed here 430 oxycodone pills, he said.

The sentence wasn't just about him, Skavdahl added.

Cesko's reputation for overprescribing was well-known, but nothing was done.

"HIs own peers at the hospital didn't step in to interdict," Skavdahl said.

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