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The 4-year-old case of a Salinas pain doctor accused of overprescribing powerful painkillers, allegedly contributing to one patient’s overdose death, is moving forward.
Dr. S. Mangar pleaded not guilty Tuesday to 15 felony counts of overprescribing opioids, pain medications related to heroin, and one count of receiving unlawful rebates after he was ordered to stand trial last month.
In early 2015, authorities, including federal officers, raided Mangar’s office and home in Salinas.
Mangar was later arrested and eventually faced 58 felony counts, including fraud and grand theft, as well as special allegations in a criminal case filed originally in May 2016.
But the Monterey County District Attorney’s Office decided to focus on the overprescribing, said Berkley Brannon, assistant DA, and the case was refiled earlier this year.
At July’s two-day preliminary hearing, in which a judge weighs whether there’s enough evidence against a defendant for the case to move forward, Monterey County Deputy District Attorney Steve Somers and law enforcement reviewed the witness statements, undercover surveillance footage and other evidence they’d gathered.
There, local, state and federal investigators said Mangar didn’t keep a close eye on his patients receiving powerful opioids, such as oxycodone, got kickbacks from a pharmaceutical company, and didn’t properly document his patients’ treatments at his Pacific Pain Care office on East Romie Lane.
Mangar’s attorney, Eric Dumars, took issue with the investigation, such as a medical expert applying certain 2018 and 2016 standards to prescriptions from 2013 to 2015 in the “evolving” practice of pain management. He also said many of the medical records law enforcement provided to that expert were incomplete.
Both Dumars and Somers declined to comment on the case Tuesday.
The overdose
One of the overprescribing charges stems from Mangar’s patient, Denasi R.
None of his patients were identified in court beyond their first name and last initial for medical privacy reasons.
She was Mangar’s patient from 2012 until Oct. 24, 2014, when she overdosed on a mixture of “narcotics,” DA Investigator John Coletti testified at the preliminary hearing.
Denasi’s best friend, only identified as Gina L. in court, was also a patient of Mangar. She told Coletti she believed Denasi had become addicted to pain medication that they’d both been prescribed by Mangar.
When they’d been living together, Gina believed Denasi had been stealing her pain pills, Coletti said. She brought up the thefts to Mangar, worrying Denasi had become addicted, Coletti said.
“Mangar told Gina something to the effect of, ‘Well if she doesn’t get it from me, she’ll just get it from somebody else,'” Coletti said.
But Coletti also said Denasi was getting prescriptions from at least one doctor besides Mangar at the time of her overdose.
Dr. Standiford Helm II, a medical expert Coletti consulted on the patients’ histories, determined in both Denasi and Gina’s cases there was no documentation as to any conclusive diagnosis or legitimate reason to prescribe opioids, Coletti said. Helm found similar violations in other patients files he examined.
But Coletti also acknowledged to Dumars that some of the files provided to Helm were incomplete, though some numbered in the hundreds or thousands of pages. Nor did investigators provide the files from patients’ previous doctors, he said.
Dumars also raised concerns because, as Coletti acknowledged, Helm was using 2016 opioid prescription guidelines from the Centers for Disease Control and a 2018 opioid conversion form.
Pain management is a relatively new discipline with guidelines that can change from year to year, according to Dumars. Coletti acknowledged that standards have “gotten much stricter.”
Ranked on a scale of 1 to 10? Zero.
State investigators determined that for “one (Mangar) patient, it was costing over $100,000 per year for her narcotic prescriptions,” said Investigator Douglas Becker with the Health Quality Investigation Unit of the Dept. of Consumer Affairs.
Another patient, Yvonne C., told Coletti that Mangar kept prescribing oxycodone and norcos without referring her to alternative pain treatments, such as physical therapy. She became addicted, eventually ruining her marriage, Coletti said.
She described herself as “walking around like a zombie,” he said.
When Yvonne’s husband accompanied her to appointments, Mangar would mostly chat with him about the Oakland Raiders, said Coletti, the DA investigator. Mangar then would ask her a few basic questions and hand her a prescription for the pain killers.
In the two months after each appointment, she’d go and pick up her prescription refills at the office, usually after a urine and blood pressure test but not any chat with Mangar. That was common among many of Mangar’s patients, Coletti said.
That’s not acceptable, Helm determined. Patients on highly addictive opioid medications should meet with a pain management doctor once-a-month to evaluate medications, Coletti said.
But he acknowledged Helm had testified there are instances when a doctor can give more than one prescription for a medication at once, as long as they’re dated a month apart. Usually, that’s when a doctor determines a patient is stable enough or going on an extended vacation, Coletti said.
Dumars, Mangar’s attorney, noted that in his closing arguments.
“There is a legitimate reason to write two to three scripts and not require the patient to meet with the doctor, as said by Helm,” Dumars said.
With the blood pressure and urine tests, “Mangar’s course of conduct was actually more inquisitive (and) provided more information to medical professionals than the process described as acceptable,” Dumars said.
Deputy DA Somers, however, said that approach should be the exception, not the rule.
Still, Helm also told Coletti that “he was going to give the benefit of the doubt” to Mangar, who documented Yvonne had scoliosis.
“The records lacked. But there was enough for (Helm) to say, ‘I will give him the benefit of the doubt that, yes, it would be within the usual course of practice,'” Coletti said.
She has since switched to another doctor and was weaned off opioids. But she still suffers from psychological issues from Mangar’s treatment, which she was “very unhappy with,” he said.
“On a scale of 1 to 10, she said he was a zero,” Coletti said.
Undercover
In addition, Coletti spoke with a Department of Insurance investigator who went undercover. At three meetings with Mangar, he received three prescriptions for three different opioid pain medications: Vicoprofen, oxycodone and Percocet.
The oxycodone was prescribed on the third trip even though the investigator never filled the previous Percocet. That should have raised a red-flag when the unfilled prescription showed up in a statewide database that tracks filled scripts in order to prevent people from selling their prescriptions, Coletti said.
Mangar also allegedly joked about selling drugs on the street with the investigator, Coletti said.
When Dr. Helm reviewed that case, he had very strong opinions about it, Coletti told the court.
“He said, ‘This is the exact example of what a pill mill is,'” Coletti said.
On average, however, he’d see 25 to 35 patients a day, mostly in the morning, Coletti said.
Dumars pointed out that’s about three patients per hour, however.
Kickbacks
Mangar also faces a single count of receiving illegal rebates, or bribes, from opioid manufacturer Insys Therapeutics, Coletti said. Essentially, Mangar earned $105,000 in food, beverages, travel and stipends from the company between 2013 and 2015 in exchange for speaking about Subsys, a sublingual opioid spray, to other medical professionals and prescribing more of it.
During that time, he went from 197 Subsys prescriptions in 2013 to 313 in 2015, said Jonathan Madore, an investigator with the U.S. Department of Health and Human Services’ Office of the Inspector General, at the preliminary hearing.
Subsys is approved only for sudden bursts of pain in cancer patients, which is called breakout cancer pain.
“You could be sitting on the couch and all of the sudden you might have undergone chemotherapy or other treatments that cause this onset of pain, and you need something that’s fast-acting,” Madore said.
Subsys can run $4,000 to $30,000 per month depending on the amount prescribed.
Mangar would prescribe it off-label, for non-approved pain management uses, and Insys would take over negotiations with Medicare, Coletti said.
Madore acknowledged that off-label prescribing isn’t illegal, it just usually isn’t covered by insurance.
Insys then, in cases beyond Mangar’s, defrauded Medicare by pretending the prescriptions were for an approved use.
Insys is currently entering bankruptcy in June, according to USA Today. In addition, several Insys executives were found guilty of “orchestrating a scheme involving bribes and kickbacks to physicians who prescribed large amounts of the drug (Subsys) to patients who didn’t need it” in May.
Medicare shelled out more than $1,033,000 for Subsys prescriptions from Mangar between 2012 and Sept. 2016, Madore said.
But Dumars noted that other doctors have received millions from drug companies.
Mangar received $2,200 for each of his 21 presentations in 2014, and most doctors speak about products they believe in, Madore acknowledged.
He also admitted that Insys’ fraud “had nothing to do with Dr. Mangar” in response to Dumars’ question.
Mangar’s next hearing on the overprescribing allegations will be at 10 a.m. Sept. 26, where Dumars will ask the court to reduce the charges because they don’t meet the legal threshold.
In addition, Mangar has a separate misdemeanor impaired driving case moving in another court, related to allegedly using methamphetamine in 2015. His attorney in that case, Evan George, referred questions to Dumars.
Mangar’s office manager, Maria “Aloha” Eclavea, previously pleaded no contest to three misdemeanor insurance fraud counts.