Mangino Verdict I: Is Treating Pain a Crime?

Dr. William Mangino on Trial - Is Treating Pain a Crime?; Alex DeLuca; War on Doctors/Pain Crisis blog, Pain Relief Network; 2007-07-05.

On Tuesday, July 3, 2007, Dr. Forest Tennant testified as defense medical expert in the trial of Dr. William Mangino for writing “prescriptions providing narcotics for patients who had no medical need for them,” in the words of ADA Schaffer.

The journalistic record of the case is contained in three articles by Debbie Morris for the New Castle News which are more informative and fair than average for this genre and cannot be called Trash Journalism. Readers interested in a discussion of the Mangino case, in a series of posts to follow here on the blog of the Pain Relief Network, can get an overview of the case by reviewing Ms. Morris’s articles: Jury Selection Begins, Opening Statements in ‘Script Mill’ Trial, and, Pain Expert Testifies published between June 20 and July 3, 2007.

The prosecution asked only one question on cross examination of defense expert Dr. Tennant. The prosecution brought forth no further expert testimony. The defense felt Tennant’s testimony was sufficiently strong and his credibility and professional stature so huge relative to the prosecution expert, and that the prosecution had failed to make it’s case. And so on 2007-07-03, the defense choose not to call it’s second defense expert (myself) and choose not to put Dr. Mangino on the stand, and rested. The case has gone to jury who deliberated Tuesday afternoon and evening of. The jury rested on the 4th of July holiday, and deliberations continue today.

I do not have a sense of what the judge’s instructions to the jury were, or what arguments the prosecution and defense regarding same. My current understanding, from very fragmented reports from people directly involved, is that this part of the proceedings was contentious, and that the prosecution may have made a rather absurd suggestion to the jury on closing, that they disregard both prosecution and defense expert testimony(?!). If true, I would take this as a desperate attempt to mitigate Dr.Tennant’s very strong testimony, which if understood correctly by the jury, should result in swift acquittal on the precedential basis of the 1998 Reversal on appeal of Kansas v. Naramore (full text). See also my recent essay regarding Dr. Naramore’s current problems with the state of Ohio.

A major question I have is what Dr. David Evanko, medical expert for the prosecution who was on the witness stand for ‘most of a week’, testified to, exactly. All we have about this testimony is the following from reporter Debbie Morris:

[Dr. Tennant's] testimony contradicted that of prosecution witness Dr. David Evanko, who spent most of last week on the witness stand. Evanko, a Butler physician, testified about addictive pain medicine, saying Mangino’s work was not in accordance with the acceptable standards of the pain medicine profession, according to deputy state attorney general Jeff Baxter.

That’s all she wrote, so to speak, about Dr. Evanko’s testimony. I eagerly await more detailed information that will be forthcoming after the verdict is rendered.

Dr. Forest Tennant for the defense was on the stand for about half a day, I think, but his testimony is covered in some some detail in the Pain Expert Testifies article:

1. “Tennant, a founder of the American Society of Addiction Medicine, said the [standard of care is] that a doctor has to believe the patient and provide enough relief for the pain without [causing sedation or impairment, and that] opioids including oxycodone are the backbone of chronic pain management for people ‘on the athletic field, on the battlefield and in the clinic…

2. “’Pain itself is a deadly disease,’ Tennant said, noting it can cause detrimental hormone changes in the brain, spinal cord and adrenal glands…

3. “Tennant viewed files of 11 of Mangino’s patients and commented that the guidelines for pain management ‘were quite well followed. I felt the records were well up to the standards and met the regulations… Dr. Mangino did not start any of these people on opioids,’ he continued. ‘I think he was following what he was taught in all of the (pain management) courses’ [aka the "textbook" or "medical" or "reasonable physician" standard of care].

I can directly speak to and confirm Dr. Tennant’s third point, above. In preparing my own testimony, that I ultimately was not called on to give, I have thoroughly reviewed the same (I think) eleven patient medical records that Dr. Tennant testified about.

Dr. Mangino’s medical records were complete, well organized, all containing evaluations of the pain condition and assessed for symptoms of abuse. His medical histories included quite detailed and thoughtful assessments of the patients’ pain complaints. His physical exams were appropriately targeted and expert, reflecting his advanced credentials, and consultant role. In all cases Dr. Mangino practiced to the medical standard of care for pain management. He more than met all state requirements. Nor were the dosages of any of his prescriptions particularly high, and his adjustments of medication regimens were rational and documented. A few of the patients did receive facet injections as part of their pain management, and when this was done it was for rational and appropriately documented medical reasons. In these cases, complete records including informed consent, detailed procedure note, and follow-up progress notes, were kept. In all cases Dr. Mangino was clearly a professional in a legitimate doctor-patient relationship acting in the best interests of his patient.

Please excuse the partial exploration of this issue - we will discuss this further on this blog, soon, in “Mangino Verdict - Part II”.

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