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Wyoming DEA Defense Attorney
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Last Updated on: 14th December 2025, 10:53 pm
Dr. David Cesko faced 32 federal counts for prescribing opioids and other controlled substances for no medical reason. Not insufficient medical reason. Not questionable medical judgment. No medical reason at all. Thirty-two separate instances where a licensed physician wrote prescriptions that had zero legitimate medical purpose. The Wyoming Board of Medicine suspended his license in 2017, making a determination that echoes in enforcement documents: Cesko “posed an imminent threat to the health, welfare and safety of the people of Wyoming.”
The board’s findings went beyond typical overprescribing concerns. Cesko was prescribing controlled substances to known abusers – patients he knew would misuse the medications he prescribed. He wasn’t failing to detect drug-seeking behavior. He was knowingly supplying people whose abuse patterns were already established. Each prescription to a known abuser represented deliberate distribution to someone certain to misuse it.
But the most disturbing detail: offering drugs in exchange for sex. According to board findings, Cesko used controlled substance prescriptions as currency for sexual exploitation. Patients who needed medications – patients whose desperation made them vulnerable – could obtain prescriptions by providing sexual favors. The medical license that exists to help people became a tool for predatory exploitation. He voluntarily surrendered his license in August 2018 and faced federal prosecution in Cheyenne on 32 counts.
Drugs for Sex
Heres what offering drugs for sex means in the context of controlled substance distribution. A patient comes to a doctor needing medications. That patient may be in pain. That patient may be dependent on opioids. That patient is in a position of vulnerability – needing something the doctor controls. The doctor exploits that vulnerability, offering the needed medications in exchange for sexual acts.
The power dynamic is absolute. The doctor decides who gets prescriptions. The patient needs the prescription. The doctor sets the terms. When those terms include sexual favors, the prescription becomes coercion. The patient’s medical need becomes leverage for sexual exploitation.
Think about what kind of practice this creates. Patients who comply with sexual demands get prescriptions. Patients who refuse dont. The controlled substance access – which should be determined by medical necessity – becomes determined by willingness to submit to exploitation. Medical practice transforms into sexual predation with a prescription pad.
The drugs-for-sex conduct elevates the case beyond overprescribing into exploitation of vulnerable patients. Prosecutors presenting this evidence to juries aren’t just showing improper prescribing – they’re showing a physician who used his medical authority to sexually exploit desperate people. The jury instruction may focus on controlled substance distribution, but the moral weight includes predatory behavior.
Prescribing to Known Abusers
The board findings specified that Cesko prescribed to “known abusers.” Not patients who displayed warning signs he failed to notice. Known abusers – patients whose abuse patterns were already established and documented. Each prescription to a known abuser demonstrates knowledge that the medication would be misused.
Heres why prescribing to known abusers creates maximum legal exposure. The federal controlled substances standard requires prescriptions be issued for legitimate medical purpose in the usual course of professional practice. When the prescriber knows the patient will abuse the medication, there’s no legitimate medical purpose. The prescription becomes distribution to a known drug abuser – exactly what controlled substance laws prohibit.
The “known” element eliminates defenses based on clinical uncertainty:
- A prescriber might argue they missed warning signs.
- They might argue patients deceived them.
- When the prescribing is to patients whose abuse is already known, those defenses disappear.
The knowledge that the patient would misuse the medication is established. Each prescription becomes deliberate distribution.
This prescribing pattern also demonstrates business model rather then medical practice. A legitimate practice would stop prescribing to patients known to abuse medications. Continuing to prescribe suggests the practice exists to distribute controlled substances, not to provide medical care. The pattern evidence transforms individual prescriptions into documented drug distribution.
Imminent Threat Determination
The Wyoming Board of Medicine made a specific determination: Cesko “posed an imminent threat to the health, welfare and safety of the people of Wyoming.” This isnt routine license suspension language. This is emergency action language. The board concluded that allowing him to continue practicing endangered the public immediately.
Heres what “imminent threat” means procedurally. Normal licensing actions involve investigation, notice, hearings, and opportunity to respond. Imminent threat determinations allow emergency suspension without the normal process because waiting would endanger the public. The board determined that the situation was too dangerous to follow standard procedures.
The imminent threat finding also creates evidence for federal prosecution. When the state medical board – the entity responsible for physician oversight – determines a physician poses immediate danger to public safety, that determination carries weight. Federal prosecutors can point to the state board’s own conclusion that this prescriber was dangerous.
Cesko surrendered his license voluntarily in August 2018, after the 2017 suspension. The voluntary surrender might have been an attempt to avoid formal revocation proceedings. But the federal charges followed anyway. The license was gone, but the criminal prosecution for the prescribing conduct continued in federal court.
Fentanyl Deaths Quadrupled
Between 2018 and 2021, synthetic opioid-involved fatal overdoses among Wyoming residents more then quadrupled. Four times as many people dying from fentanyl and related synthetics in just three years. The escalation was dramatic and deadly.
The 2023 numbers show the ongoing crisis:
- Opioids were connected to 81 of Wyoming’s reported overdose deaths
- Fentanyl specifically was linked to 52 deaths
- Methamphetamine contributed to 48 deaths
The substances overlap – many deaths involve multiple drugs. But fentanyl’s involvement in 52 of 81 opioid deaths shows its dominance.
Wyoming’s small population – under 600,000 – makes raw numbers seem less alarming then larger states. But per-capita, the crisis is severe. A hundred overdose deaths in a state with half a million people affects communities proportionally as much as thousands of deaths in states with tens of millions. The statistical denominator is smaller, but families and communities feel the losses equally.
The quadrupling of fentanyl deaths between 2018 and 2021 correlates with the period when Cesko was being prosecuted. The crisis was exploding while federal investigators were pursuing physician prescribers. The enforcement environment reflects the escalation. Federal resources flow to states were the crisis is worsening, and Wyoming saw some of the most rapid increase in fentanyl deaths in the mountain west.
WORx Since 2004
Wyoming’s prescription monitoring program – called WORx – has been operational since 2004. Thats two decades of tracking controlled substance prescriptions. The program was among the earlier state PDMPs, established through the Wyoming Controlled Substance Act before many states had functioning monitoring systems.
The Wyoming State Board of Pharmacy administers WORx, which collects Schedule II through V controlled substance prescription information from all pharmacies – both resident and non-resident – that dispense to Wyoming residents. The coverage is comprehensive. Prescriptions dispensed to Wyoming patients are tracked regardless of were the pharmacy is located.
Since 2020, Wyoming law has required mandatory use. Prescribers and pharmacists must check a patient’s controlled substance prescription history through WORx before prescribing or dispensing. The requirement transforms the monitoring system from passive database to active workflow requirement. You cant prescribe controlled substances without checking the system first.
Reporting must occur by the close of business on the business day immediately following dispensing. Next-day reporting means the database stays current. Patterns develop in near real-time. Prescription shopping across multiple providers becomes visible within days rather then weeks.
Active Investigation Access
Law enforcement access to Wyoming’s PDMP requires an active investigation and a written request. Thats lower then states requiring subpoenas or court orders, but higher then states allowing general access. The active investigation requirement means investigators must have basis for looking at a specific patient or prescriber – not fishing through the database generally.
The written request creates documentation of why access was sought. The request becomes part of the investigative file. If prosecution follows, the request documents that proper procedures were followed to access the prescription data.
Data retention is five years. Your prescribing history for half a decade exists in the WORx database. Investigators looking at current conduct can see patterns extending back five years. The comparison data that might show escalation, changes in practice, or outlier patterns relative to peers – all documented.
The Rocky Mountain Field Division of DEA covers Wyoming along with Colorado, Utah, and Montana. Federal resources are shared across these states. The regional approach means Wyoming practitioners face the same federal enforcement apparatus as neighboring states with larger populations.
What Actually Protects Wyoming Practitioners
If your prescribing controlled substances in Wyoming, your operating in a state were a doctor was charged with 32 counts for prescribing for no medical reason, were that doctor offered drugs for sex and prescribed to known abusers, and were fentanyl deaths quadrupled in three years. What actualy protects you?
First: Understanding that prescribing with no medical reason creates maximum exposure. Cesko’s 32 counts reflected prescriptions that had zero legitimate medical purpose. Not weak documentation – no purpose at all. Each prescription you write must have documented medical foundation.
Second: Prescribing to known abusers eliminates defenses. The “known” element removes any argument about failing to detect drug-seeking behavior. If you continue prescribing to patients whose abuse is documented, you’re distributing to known abusers deliberately.
Third: The drugs-for-sex conduct demonstrates how far physician exploitation can go. Using controlled substance access as leverage for personal exploitation transforms overprescribing into predatory conduct. The power differential between prescriber and patient creates exploitation potential that enforcement takes seriously.
Fourth: “Imminent threat” determinations enable emergency suspension. The board can act without normal procedures when the situation is dangerous enough. The Cesko case shows that boards will make these determinations and act quickly when prescriber conduct threatens public safety.
Fifth: WORx has tracked prescriptions since 2004. Twenty years of Wyoming prescription monitoring. Your prescribing patterns exist in one of the longer-running state PDMP systems.
Sixth: Mandatory use since 2020 means you must check before prescribing. The system isnt optional. Failure to check before prescribing controlled substances violates the requirement and creates its own exposure.
Seventh: The Rocky Mountain Field Division provides federal resources. Wyoming shares DEA coverage with Colorado, Utah, and Montana. Federal enforcement capacity extends across the region.
Eighth: Immediate counsel upon any board contact or federal investigation. The Cesko case moved from board suspension (2017) to voluntary surrender (2018) to federal prosecution (2019). The tracks proceed separately. Legal strategy from initial board contact shapes wheather you face the 32-count federal outcome or some other resolution.
Thats the reality of prescribing controlled substances in Wyoming in 2025. A doctor who offered drugs for sex and prescribed to known abusers facing 32 federal counts. An “imminent threat” determination by the state board. Fentanyl deaths that quadrupled in three years. A prescription monitoring system thats been operational for two decades with mandatory use since 2020. And a regional DEA field division that covers the mountain west with coordinated federal resources. What protects you is prescribing with documented medical purpose for every patient, never to anyone whose abuse patterns you know, in a state were exploitation of vulnerable patients led to 32 federal counts.