In July, California Watch examined the medical board's administrative court case against Manougian, who was one of the state’s most prolific prescribers of opioid painkillers to low-income Medi-Cal patients.
Records show that he prescribed doses that were 12 times higher than what pain specialists consider high. One consensus group of pain specialists concluded that prescribing more than 200 milligrams of morphine-equivalent medications per day calls for a thorough reassessment of patient care.
Manougian said he routinely prescribed far more, saying he had a unique understanding of how to help the 240 patients who paid cash at his solo practice in Hercules and Pinole.
In his legal defense, Manougian's attorney, Marvin Firestone, argued that state law says doctors cannot be punished solely for prescribing to patients who are in intractable pain. In an interview, Manougian also said he had a special rapport with patients, who he said were like an extended family.
Anderson acknowledged that doctors can't be disciplined for prescribing alone, but she noted that they are still accountable for unprofessional conduct, negligence or practicing incompetently.
Opioid painkiller prescribing has drawn increasing attention as addiction and overdose deaths have reached what the U.S. Centers for Disease Control and Prevention call “epidemic” levels.
In July, the FBI said it had subpoenaed records from Manougian's office, working with the Health and Human Services Office of the Inspector General and the Drug Enforcement Administration. FBI spokesman Pete Lee said an investigation into his practices is ongoing.
Manougian’s practice drew complaints from pharmacists who balked at some orders that called for 1,000 or more addictive and sedating pills per month.
Anderson, the administrative judge, concluded that his patient care was grossly negligent.
Anderson said he erred in the care of Irma Jean Gray, 62, who was found dead on her kitchen floor in January 2010. Anderson said Manougian failed to substantiate the diagnoses he reached to justify giving Gray “excessive amounts of dangerous drugs.”
He also failed to conduct meaningful reviews of her progress or assess her psychological state after she told him that she felt like checking into a mental hospital in the weeks before her death, records show.
Anderson also concluded that Manougian was grossly negligent in his care of Jeanette Dodds, 35, who died of fentanyl toxicity, and Konya Mattie, 41, who died with toxic doses of Xanax and methadone in his system.
Testimony in the case covered the care of nine other patients who were also treated with high doses of opioids for chronic pain.
An exhibit in the case showed that a pharmacist complained that one Manougian patient sold a bottle of opiate-laced cough syrup before leaving a Walgreens parking lot. An expert testifying on behalf of the state medical board said Manougian’s drugs were likely sold on the street by some patients.
Anderson cited Manougian for failing to take widely accepted steps to monitor patients who are taking addictive drugs, such as ordering urine tests to be sure the drugs were taken and not sold. He also failed to review reports available to doctors that show “doctor shopping” behavior by patients who go to multiple physicians for narcotic drugs.
Anderson’s proposed decision acknowledges that “there can be no doubt” that Manougian “cares about his patients in his own way.”
“But that care is provided through a narrow lens that sees only what he chooses to see, whether about possible effects of the medications he prescribes or the behavior of his patients,” she wrote. “He evidenced a naivete that strained credulity; trusting, as a matter of policy, almost everything told him by his patients, no matter their background or obvious pattern of behavior.”