CLEARFIELD – The trial for a former Clearfield doctor accused of breaking the law got under way on Monday morning.
Dr. Amer Khouri is charged with four counts of obtaining a controlled substance by misrepresentation, fraud, forgery, deception or subterfuge, four counts of prescribing a controlled substance not in good faith and outside the treatment principles accepted by a responsible segment of the medical profession, four counts of possession of a controlled substance, and one count of misbranding a controlled substance. According to the criminal complaint, Khouri habitually prescribed doses of Actiq lozenges in varying strengths to patients fighting cancer and recalled the prescriptions citing dosage error.
Jurors and those in the gallery heard testimony from the family members of four patients Khouri treated during the time period he is alleged to have broken the law. The testimony was similar between all four; Khouri would prescribe the Actiq “lollipops”, then contact them, as soon as the same day in some cases, asking them to return them to his office, after hours and on weekends, and in some instances, on holidays or holiday weekends. Bonnie Greene testified that Khouri once drove to her house during an ice storm to retrieve Actiq. She said that Khouri told her there was a hospice patient in the area who needed them. She said her (late) husband, who Khouri was treating for prostate cancer, was allowed to keep eight lozenges until the next day, when she went in and was given four prescriptions for Actiq. Alexis Brolin testified that during Khouri’s treatment of his late wife, Khouri contacted him on Thanksgiving day of 2004.
Defense attorney Jim Naddeo, during cross-examination, touched on the number of times Khouri would change dosages. He asked Greene if Khouri was constantly managing her husband’s pain, to which she replied, “Yes”. He also asked Greene if her husband’s family doctor ever commented on the medications or amounts prescribed by Khouri. She indicated no.
Greene and others who testified said they were asked by Khouri to bring the medicine to him via the back door of the Medical Arts Building at Clearfield Hospital. There, the patients or their caregivers would give Khouri the medication, and he would write them new prescriptions and give them vouchers for Actiq. A voucher for Actiq was good for a 30-count of medicinal lollipops of varying dosages, as prescribed by the doctor.
Both Greene and Brolin testified that they both trusted Khouri. They also both testified that Khouri told them the Actiq he was taking back was going to hospice patients or other cancer patients.
That feeling was not the same for all of the families or patients involved, at least not the entire time Khouri treated them. Theresa Yeager’s late son Scott Yeager was a patient of Khouri’s. She testified that Khouri prescribed her son Fentanyl patches for her son’s pain. She stated her son had a bad reaction to the patches, so Khouri prescribed him some pills. Almost immediately after that, she stated he prescribed Actiq. She stated Scott never used any of the pills, and that Khouri asked for them to be turned over to him. She said she did not give him the pills, instead locking them away.
She stated on Aug. 18, 2006, Khouri called looking for Scott. She said Khouri wanted to know what she did with with the pills. She said after the call, she counted them and flushed them. She said Khouri called again shortly after, and asked for the pills to be returned. She said she told him she flushed them, and that he was upset, indicating that was not a proper way to dispose of them. She said that in September 2006, she and Scott were on their way home from the hospital when Khouri called and asked Scott to return some Actiq. She said Scott lied to him, telling him they were at his mother’s. She said that Scott put Khouri on speaker phone, and that Khouri made her nervous during the call.
One question Naddeo asked Theresa, which he also asked the other family members who testified, was whether Khouri referred the patients to other physicians. Theresa stated that Khouri referred Scott to one facility, but that it was Scott’s initial decision to go.
Steve Briskar Jr. testified that Khouri treated his late father. His testimony was similar to those above him; he learned that his father was asked by Khouri to return medication, and that his father would then get another prescription for a greater or lesser dosage. He said Khouri convinced the Actiq was going to cancer patients who could not afford it. He said he talked to his father and tried to convince him that the constant dose changing was not right.
He testified that on Oct. 10, 2005, his father made it clear to him that his father felt he was being used by Khouri. He said that his father had returned from chemo therapy, placed his medicine on the table and the phone rang, with Khouri on the other end. He said that Khouri wanted the Actiq returned. He said his father made it clear he was not returning the medicine, and the phone conversation soon ended. Briskar said his father’s phone and cell phone then began ringing and that it was Khouri trying to contact his father. He said he eventually answered it, a brief conversation ensued, and Khouri hung up.
Stefanie Briskar Sattesahn, sister of Steve Briskar Jr. and daughter of Steve Briskar Sr., testified that on Oct. 10, 2005 her father received a phone call from Khouri asking him to bring his medicine back because he wanted to change his dose. She, like her brother, questioned him about this practice. She said her father told her that Khouri called and asked him to return the medication during lunch or after-hours, and that her father was told the returned medicine would go to cancer patients who could not afford it.
Steve Briskar jr. said he contacted the state police, who put him through to the Clearfield Borough Police Department, who put him in contact with the Office of the Attorney General. He said he also contacted Clearfield Hospital.
At some point after each family member tesitfied, Agent Sherri Kramer testified. Kramer, a narcotic’s agent with the AG’s office, testified that she began investigating the case in October 2005 after being contacted by the CBPD. She said she looked at prescriptions written by Khouri then compared them with the ones filled at pharmacies. Kramer also testified that they investigated where Khouri may have shipped and how he may have shipped the Actiq, but that they came up empty. She also stated that she talked with local police departments and the Clearfield County Drug Task Force to see if it was an active street drug, and that it was not.
Kramer also referenced a recommended dosage of four Actiq lozenges, as recommended by the drug’s manufacturer. This recommended dosage was a matter of contention, as the commonwealth based a lot of their argument on over prescribing on that number, while the defense countered that it was only a recommended dosage.
The commonwealth provided exhibits which displayed how many doses/prescriptions of Actiq each of the four late patients had filled, and if it was paid for by insurance or through the vouchers.
Other witnesses included:
-Randy Spokane, a regional director for Cephalon, the manufacturer of Actiq. He indicated that the voucher program had a threefold purpose: 1.) to initiate therapy; 2.) scaling up (or down) the dosage; 3.) pain management while insurance issues are resolved. He stated that the company receives reports on a monthly basis on voucher activity, and, as a judgment call, if they feel the volume of vouchers being prescribed by a doctor is high, they call the doctor and remind them what the vouchers are for. He stated that Khouri was contacted by the company regarding the vouchers and their purpose. Under cross-examination, he testified that the four units/day was a recommended amount, and that doctors used their own discretion in prescribing the dosage.
-Michelle Freeman, pharmacist at CVS, testified that she had discussions with two patients/family members regarding Khouri’s taking the medication. She indicated that what he was doing was not normal. She said she also talked to him twice to find out what he did with the medication. She said he told her they were given to the hospital pharmacy to be destroyed.
– Jackie Starr, director of the Clearfield Hospital pharmacy, testified that the policy has a policy in which they do not return medication to the pharmacy. She also testified that Khouri never returned medication to be destroyed, and that Khouri had requested the pharmacy carry Actiq. She said it was not approved by the the formulary.
-Kelly Hoffmaster-Reese, director of Medical Oncology at Clearfield Hospital, testified that they did not accept medication returns. She also testified that the Actiq vouchers were to be logged in, then logged out so they knew who received them. She stated that she did not know when they were taken, but that Khouri took them. She indicated he had contact with the drug company representative, and that they had no idea how many he was getting.
-Jon Steen, vice-president of human resources at the hospital, testified that the hospital had received complaints about Khouri taking medicine back from patients. He said Khouri denied this allegation when confronted with it. He testified that Khouri was terminated due to breaking the hospital’s policy for taking back medicine. He also indicated that Khouri had approached him about allowing him to direct unused medication to the hospital pharmacy. Steen stated they might be able to, but then stated a letter was sent to Khouri telling him they could not.
-Rose Lloyd, office coordinator in Khouri’s office, testified that patients returned medication, sometimes quite often, depending on the patient. She stated that she was directed to call area pharmacies about once a week to see how many drugs they had in supply.