RICHMOND – One had been to jail and nursed a gunshot wound. Another had run away from home as a teenager and lost her children to foster care. A third was struggling with the death of her daughter and had a history of alcohol abuse.
Before they died, they’d paid $100 for a visit with Dr. Edward Manougian in his East Bay offices and left with prescriptions for hundreds of opioid pain pills, highly addictive and, on the street, worth thousands of dollars. Records show that one Manougian patient sold his drugs before leaving the pharmacy parking lot.
In his career, Manougian has ordered so many OxyContin pills for low-income patients that he ranked a few years ago as one of the state’s most prolific prescribers.
He prescribed patients a cocktail of sedative, antianxiety and narcotic pain pills, including Vicodin, Norco, methadone, Soma and Valium. Until the California medical board stopped his prescribing last year, Manougian ordered patients to take doses of opiate pain pills that are three to 12 times higher than what doctors consider high.
Now, Manougian's practice has drawn the attention of federal investigators. The FBI, the Health and Human Services Office of the Inspector General and the Drug Enforcement Administration have subpoenaed Manougian's medical records, said FBI spokeswoman Julianne H. Sohn. She described their work as an ongoing investigation but declined to elaborate.
In an interview at his spare Richmond office, the 83-year-old doctor said he is fighting the medical board’s effort to take his license to practice medicine. Manougian denies playing a role in his patients’ deaths and likens himself to a fish swimming against the school: a doctor who offers hope to the 240 struggling men and women under his care, a bold prescriber who understands the doses required to effectively treat chronic pain.
“It’s like a big family,” Manougian said of his patients. “I'm part of their extended family.”
The doctor’s case offers a window into a thorny question that physicians increasingly face. Given the widespread problems of overdose and addiction related to opioid painkillers, when does prescribing actually exacerbate the suffering it’s meant to ease?
Health professionals are re-examining the risks and benefits of prescribing opioid pain pills – and whether their use should be limited.
Controversial limits have been mandated in Washington state, compelling doctors to refer noncancer patients to specialists when daily morphine-equivalent doses reach a certain level. In California, the medical and pharmacy boards have agreed to meet to take a closer look at policies on prescribing for pain.
There is little controversy over short-course opiate use for pain after surgery or even long-term use for patients who are dying. But many pain doctors agree that patients taking more than about 200 milligrams of morphine-equivalent medication per day are on a high dose and deserve a careful reassessment.
“The sands are shifting,” said Christine Miaskowski, a UC San Francisco nursing professor who has specialized in studying pain and its treatment.
She was part of a group of pain specialists who defined the 200-milligram red-flag zone for daily opioid prescriptions – less than two top-strength OxyContin pills in a day.
With some patients, Manougian surpassed that by 1,000 milligrams or more. He said he has ordered daily doses of 14 to 24 maximum-strength OxyContin pills for a single patient.
Manougian has built his legal defense around a state law that says no doctor can be disciplined for prescribing to a patient with intractable pain.
“Whatever it takes,” Manougian said, “that's what the Intractable Pain (Treatment) Act says.”
Manougian has operated a solo practice in Pinole and Hercules since 2003, seeing many patients whose pills are paid for by the state Medi-Cal program. Records show that since 2005, the state paid than $1.5 million for oxycodone prescriptions ordered by Manougian.
He has faced accusations from outraged pharmacists and a relative of a patient who died under his care that his methods are dangerous.