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 each of these three patients died from prescription drug overdoses, medical experts said, they'd paid $100 for a visit with Dr. Edward Manougian in his East Bay offices. They had left with prescriptions for hundreds of opioid pain pills -- highly addictive and, on the street, worth thousands of dollars. Records show that one unidentified 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.
Records show Manougian prescribed patients a cocktail of sedative, anti-anxiety and narcotic pain pills, including Vicodin, Norco, methadone, Soma and Valium. Until the Medical Board of California barred him from writing prescriptions last year, Manougian ordered patients to take doses of opioid pain pills that are three to 12 times greater than what other doctors consider high.
Now, Manougian's practice has drawn the attention of federal investigators. The FBI, the 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 state 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 said he played no part in the deaths of patients who had been under his care. He 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 more than $1.5 million for oxycodone prescriptions ordered by Manougian.
The Medical Board of California has linked his prescriptions to the death of Irma Jean Gray and two other patients who overdosed on pills the doctor had ordered. Gray was found dead at 62 in her San Pablo apartment in January 2010.
"To me, the guy is a drug dealer," said Charles Agnew, Gray's son. "I would have never thought she was getting that much drugs from a doctor." At the time of Gray's death, Manougian's daily prescription for opiates was nearly three times the dose that the American Pain Society deems high. And his order blended hypnotic drugs that can heighten the risk of death: four top-strength OxyContin pills, eight Norco pills and nine more sedative and anti-anxiety pills.
During the medical board hearing over Manougian's license, patients testified on his behalf, saying he is a thorough and caring doctor. Manougian said many of his patients know each other and found him through word-of-mouth. Others come from as far as Sonora -- more than 100 miles from his practice -- and recognize him as the only doctor willing to dispense the quantities they seek.
Attorney Marvin Firestone, of San Mateo, argued in a closing brief that Manougian "simply believes in the ultimate goodness of people and always had his patients' best interests in mind." He called the board's allegations "hollow and without merit."
California's medical board has relied on the state's current laws to curb Manougian, winning an order in April 2011 to stop him from writing prescriptions.
For years, health authorities who crossed paths with Manougian have sounded alarms over his prescriptions.
David Ash had practiced as a pharmacist for 44 years when he balked at two prescriptions Manougian's patients brought to the White Cross Professional Pharmacy in Pinole.
The patients were prescribed a cocktail of 1,100 pills to be taken in a month. They included opioid painkillers Norco and methadone; Valium, an anti-anxiety pill; and Soma, a muscle relaxer.
Ash faxed a complaint to the Medical Board of California in November 2007, decrying excessive quantities and combinations of drugs. He attached the prescriptions and asked the board "to see for yourself how he is overdosing his patients."
"This is not pain management," Ash said in an interview. "This is absurd."
The first to die under Manougian's care was Jeanette Dodds, 35, who saw the doctor in October 2008. Manougian determined that her complaint of bodywide pain was related to a kidney condition. Two experts, including one testifying on behalf of Manougian, said the condition should not have caused chronic pain.
Manougian prescribed her massive daily doses of medications: four methadone and 10 Norco opioid pain pills and 14 more anti-anxiety, muscle-relaxing and allergy pills.
Manougian also prescribed 10 full-strength fentanyl patches, creating a "potentially toxic combination," according to Kurt Miller, a Fresno pain doctor who served as a second medical board expert in the case.
About four months after her visit with Manougian, Dodds was found dead in her mother's Oakley home. The cause was determined to be an overdose of fentanyl, one of the drugs Manougian prescribed. Miller testified that Dodds' treatment was "likely detrimental to the patient, leading to her death." Manougian said in a deposition that he prescribed the medications to Dodds in hopes that relieving her pain would ease her general sorrow. He said neither her death nor the two others were related to his care.
"The medical board is trying to make something out of nothing," he said.
Another patient to die under Manougian's care, Konya Mattie, 41, was given the highest doses of potent opioid drugs.
In the weeks before Mattie died in Antioch, Manougian prescribed him a daily regimen of 36 pills: 12 full-strength OxyContin; 10 methadone; four Xanax, an addictive anti-anxiety drug; and 10 Norco, another opioid pain pill. He was ordered to drink nearly a gallon of opiate-laced cough syrup in a month.
Miller concluded that Mattie "died as a result of excessive prescribing by Dr. Manougian." Manougian denied the claim, saying Mattie likely died for the opposite reason: that he did not get enough medication during a hospital stay for a stroke he suffered days before he died.
Manougian said he is a target because the cost to the state to cover his prescriptions is high and the value of his patients to society is low. He said he is nothing like a drug dealer and has not profited from ordering high doses of pills.
As for Manougian's own battle with pain in his knees and shoulder, he said he relies on isometric exercises for relief. "I never take drugs," he said.
Staff writer Michael Montgomery contributed to this report. This story was edited by Robert Salladay and copy edited by Nikki Frick and Christine Lee. California Watch is part of the independent, nonprofit Center for Investigative Reporting. For more, visit www.californiawatch.org. Jewett can be reached at firstname.lastname@example.org.