After hearing emotional testimony families of Dr. John Patrick Couch’s deceased patients, U.S. District Court Judge Ginny Granade sentenced the former pain doctor to 20 years in federal prison for his role in one of the most significant “pill mill” operations seen in years.

For Couch, the ruling was the end of a two-year saga that began when his former practice, Physicians Pain Specialist of Alabama (PPSA), was raided by federal agents in 2015. His former business partner and codefendant Dr. Xiulu Ruan will be sentenced tomorrow.

Though thousands of prescriptions for myriad drugs were discussed in the doctors’ seven-week trial, prosecutors focused on the powerful and addictive opiates fentanyl, oxymorphone, oxycodone, hydromorphone and morphine when calculating a sentence for Couch.

Based on the records kept by Alabama’s Prescription Drug Monitoring Program (PDMP), Couch prescribed 548,711 kilograms of those drugs, and that amount was used to calculate his sentence based on formulas used in cases involving an equal quantity of marijuana.

U.S. Attorneys Debra Griffin and Christopher Bodnar also brought in Suzannah Herkert, a diversion investigator with the Drug Enforcement Administration, to compare the numbers and potential sentences in Ruan and Couch’s case to others she’s seen.

Herkert said the cases she’s been involved with during her 12-year a career in Dallas, Los Angeles and Miami were “not even close” to scale of drug diversion that was occurring through Ruan and Couch — the only two doctors in U.S. history to be convicted by a jury on organized crime charges.

However, for the families of some of Couch’s former patients, Thursday was about justice, and several who’d lost a family member under Couch’s care addressed the court.

One was Mary Richardson, whose brother Tim Richardson died after years of taking opiate painkillers prescribed by Couch and his staff at PPSA. Richardson and two of her sisters were wearing buttons with pictures of Tim, saying Couch “pumped poison” into him for years.

“They may not have pulled the trigger, but they put the gun in his hand,” Richardson said, holding back tears. “They took an oath to help people, but they haven’t done that. They’ve only helped themselves. They were the nails of greed that built the house of pain my family lives in.”

Carey Sanford and Ida Foreman were former patients who died under Couch’s care as well, and their families also spoke before Granade — each encouraging her to hand down the maximum sentence to a doctor who put “his own wealth over his patient’s well being.”

However, others patients testified on Couch’s behalf including Andrea Autrey and Carol Cleveland, both of whom were under Couch’s care for years. Cleveland said she suffers from severe migraines, but also said Couch never prescribed her any pain medication. Instead, he performed routine neuroblock procedures on her that helped her live with her migranes.

Things got tense in the courtroom when another former patient spoke about the care she received from Couch. Elizabeth Kinney told Granade that she’d been prescribed opioids by Couch since 1998 and had “always taken them as needed and as prescribed.”

However, not far from the families of patients who’d died under Couch’s care, Kinney said that it’s ultimately “a patient’s responsibility to know what their bodies can and cannot take.”

“[Dr. Couch] was a good man. A loving man and a good physician that cared about his patients,” she added. “I’m sorry that, apparently, some people couldn’t take care of themselves.”

Some of Couch’s own family addressed the court as well, including his ex-wife Joie Donald, who despite a “contentious divorce” with the former doctor, called him “a friend” and “a loving father” to their two children — teenagers who Donald called “innocent victims in all of this.”

One of the last people to speak with Couch himself, telling Granade that despite the evidence that came out at trial, he’d never flippantly used powerful opiates like fentanyl on any patient and was alway did what he thought was best for his patients.

“I did the best I could. I’m sorry everyone didn’t have the same experience,” he added. “Every physician that loses a patient, loses a part of themselves, too. At least that’s true for me.”

Based on the sentencing guidelines Granade approved, one of the lowest possible sentences Couch faced could have landed him in prison for 30 years.

Given that it was based solely on the charges related to drug distribution and didn’t include the convictions related to organized crime, conspiracy, mail fraud and healthcare fraud, the United States requested a prison sentence of 35 years.

Arguing the case, Griffin said Couch had been “no more than a drug dealer with a pen,” calling him “a fraudster” who’d show “no remorse in connection with any of [his criminal convictions].”

However, Couch’s attorney, Brandon Keith Essig, disagreed. He said the facts of the case that grew out of the activities at PPSA were different from any other that has been seen the 11th Circuit.

He said others resulting in sentences or 30 years or more had all been indisputable examples of pill mills, that included “hand to hand” exchanges of cash for pills and convictions that at trial that were directly related to the death of patients.

Essig also said that the practices in those cases didn’t have the numerous patients whose lives benefited that PPSA did. He said the indictment focused on a five-year period of time, but Couch had been treating patients in Mobile for decades.

“In that time his practice wasn’t marked by deaths or over prescribing, it was marked by success stories like those of women who spoke her today,” he added.

Ultimately, Granade sided closer with the defense’s recommendation of a 15 to 20 year prison sentence, agreeing with Essig that the federal sentencing guidelines “were not appropriate in this case” given its unusual nature and unique circumstances.

“We can all see that this was a very unusual case, and this was not a typical pill mill,” Granade said. “I do think Dr. Couch got into a position where his practice had gotten away from him. I don’t think he intended it to go there, but it certainly did, and it was certainly illegal.”

Grande said a 20-year sentence was appropriate, and ordered Couch serve that sentence in a facility as close to Mobile as possible that offers programs for drug and alcohol treatment as well as mental health services.

Upon release, Couch will be required to serve three years of supervised release and will be permanently barred from possessing a firearm. However, the most striking component of Couch’s sentence may be it’s financial aspects.

Though Couch will only be required to pay $1,300 in fines and fees, Granade ordered he and Ruan to collectively pay out more than $16 million in restitution to a number of insurance agencies that paid for services that were fraudulently submitted by PPSA.

Those amounts included $3,649,091 to Blue Cross and Blue Shield of Alabama, $3,371,443 to the U.S. Department of Defense health care system Tricare and $8,131,101 to the federally subsidized Medicare system.

Ruan, who was in the courtroom for part of Thursday’s proceedings, will face his own sentencing hearing before Granade at 9 a.m. on Friday.

While Granade will have the final say, prosecutors have already suggested they’ll seek higher sentence for Ruan because he was more directly involvement with the criminal activity occurring at PPSA.

“But for Dr. Ruan, this criminal enterprise would not have operated the way it did,” Griffin said Thursday. “Dr. Couch is responsible for his own action, but in some regard, he is less culpable.”