On June 10, 2004, Michael, my only child, 29 years old, died suddenly and unexpectedly. He went to bed at night and never woke up. My life turned upside down and I began searching for answers to “Why and How” this could have happened to a healthy young man. The answers flowing from my personal tragedy would trigger the realization of an ongoing broader tragedy – an epidemic of prescription opioid addiction and death.
For the past eight plus years I have been learning everything I can about prescription drugs, especially the opioids, and I have been trying to make others aware of the dangers. Something that I learned very quickly was that “legal” does not mean “safe”.
In June and again in August 2002, my son was diagnosed with kidney stones at a Toronto Hospital emergency department, treated (morphine, gravol, catheter, ct scans…) and discharged with a prescription for Percocet for pain (30, 60) which I filled immediately. Neither the doctor nor pharmacist disclosed any concerns to us about Percocet. Of course we trusted that they knew and would do what was best for Michael. I realize now that these prescriptions may have started Michael on a treacherous road. Michael was gone within two years of his first Percocet prescription.
After his death we learned that he was prescribed more than13,000 pills, by one doctor, in a period of 14 ½ months. These pills were from virtually every addictive drug category -- opioids, anti-anxiety, stimulants, antidepressants, and antipsychotics -- one drug to counter the side effects of the other. Michael was prescribed Percocet followed by Diazepam to help him sleep. According to the doctor’s notes “the patient is falling asleep at the wheel, we’ll try some Ritalin”; then Paxil, (Ritalin has a rebound effect and causes feelings of depression) he also prescribed Risperdal. The CPSO expert reviewer wondered why he was prescribed Risperdal and questioned why the doctor would prescribe Ritalin when he should have reduced the Diazepam.
On the day Michael died, the Coroner and Police found prescription receipts in his room for large quantities of opioids and wondered whether they had actually been prescribed. The Coroner issued a warrant to obtain copies of Michael’s prescriptions and upon confirmation that the doctor had indeed written all the prescriptions, the Coroner reported the doctor to the CPSO. The Detective informed us that he needed to wait for the CPSO’s decision before pursuing a criminal investigation.
Michael’s death was ruled “accidental” and his toxicology report indicated “hydromorphone intoxication” a prescription drug. There were no street drugs or alcohol in his system. The day before Michael died his doctor prescribed him a new drug -- Dilaudid (hydromorphone)– 8 mg., 150 tablets, to take up to 64 mg. per day. On a milligram to milligram basis Dilaudid is between five to seven times more potent than morphine. That same day, June 9th, the doctor increased his Percocet dosage (275 tablets), did not discontinue any of Michael’s existing prescription drugs and gave him two postdated prescriptions which I found in my son’s wallet after his death – one for 100 Dilaudid tablets, 8 mg. dated June 19th, and the other for 275 Percocet dated June 23rd. These postdated prescriptions were dated only 10 and 14 days after the June 9th prescriptions.
As a result of the Coroner’s concerns and my letter of complaint, the College of Physicians and Surgeons conducted an investigation and the Complaints Committee referred the matter to Discipline (less than 1% are sent to discipline).
Notice of Hearing: “Allegations of Dr. K.’s professional misconduct have been referred to the Discipline Committee of the College. It is alleged that Dr. K. failed to meet the standard of the profession and is incompetent in his psychiatric practice in his care and treatment of 23 (sic) patients and engaged in conduct that would be regarded by members as disgraceful, dishonourable or unprofessional.”
Although the term ‘allegations’ is used, it is important to understand that these are based on the CPSO’s investigation and review of the doctor’s practice.
At a prehearing meeting, from which we were excluded, Dr. K., his lawyer and CPSO prosecutor, negotiated a plea agreement. The doctor would plead ‘no contest’ and the discipline panel would accept the joint submission resulting in a lesser charge. Two of the three allegations were dropped leaving “committed acts of professional misconduct in that he failed to maintain the standard of practice of the profession”.
The CPSO reviewed 26 patient files and found the doctor fell below the professional standard of care in 22 of them. We were told the doctor’s licence would not be revoked because he had no prior ‘Discipline History’. The 22 patient files were not considered separate individual discipline events but instead formed part of our individual case. These patients were never identified and were not present at the hearing.
The doctor’s penalty was a six-month suspension, reduced to three-months (took a prescribing course); his privilege of prescribing narcotics was removed; he required a co-signer for other controlled substances; & was assigned an assessor for one year.
We met with the college registrar who told us there is a shortage of doctors and that the CPSO’s primary role is to remediate. The college prosecutor repeatedly told me that the college could not address criminal matters and that Michael’s death and the narcotic/controlled drug deaths of his other patients would not be addressed by the Discipline Committee.
The CPSO’s administration of justice is very different from the public’s idea of justice. We had no real say, the process lacked transparency and decisions were predetermined prior to the public hearing. The CPSO will include/exclude information based on its intended discipline outcomes. For example: Michael’s medical records from his family doctor confirming his good health prior to seeing Dr. K. were deemed irrelevant and were not presented at the hearing. The official toxicology reports from Ontario’s Centre of Forensic Sciences in Toronto, one of the most extensive forensic science facilities in North America, were dismissed as preliminary & incomplete. Other patient deaths were ignored. None of the investigative information was shared with us so we had no way of knowing if anything was overlooked. The lack of transparency did not ensure correctness, completeness, fairness nor instill confidence in the CPSO’s discipline proceedings.
We acknowledge human error resulting in honest mistakes. But our difficulty is with a physician who repeatedly acts in a reckless and negligent manner, never conducts examinations or contacts the family doctor, continues to put patients at risk and then is defended by deflecting the issues to his patients. In addition to our disappointment with the entire discipline process, we were concerned with the growing prescription opioid epidemic and CPSO’s failure to get this under control.
In contrast to the regulatory college, the medical experts retained in our civil action stated: “From a Standard of Practice perspective: The doctor was the source of the narcotics that were prescribed in doses that were potentially lethal -- If the patient followed the prescribing instructions, he would ingest five times more opioid analgesics in morphine equivalents, than what he was previously prescribed. This is far above the usual and safe opioid dosing change, putting the patient at risk of an overdose.” Also, “The pharmacist very clearly failed to keep the patient safe in dispensing the medication as prescribed.”
I have learned that addiction and deaths caused by prescription drugs are very common. Michael’s death is not an isolated case. The misuse of prescription drugs is a multifaceted problem that impacts all of society. Regulations and legislation need to be changed to resolve this epidemic. The Controlled Drugs and Substances Act was put in place to protect the public and physicians were given this responsibility via prescription, however, this mechanism has failed. Only a qualified healthcare provider can change a piece of paper into a prescription.
Upon conclusion of the CPSO proceedings, the Detective issued a warrant to the regulatory college to obtain Michael’s file, had an expert review the file, and felt there were probable grounds to pursue a charge of ‘criminal negligence causing death’ and took the file to the Crown. The crown also had an expert review the file and their initial decision was to proceed, however upon further discussions with personnel downtown, the crown made a decision not to pursue criminal charges against the doctor. We met with the Detective and the Crown and felt their explanations not to pursue charges made no sense to us. We were told that to proceed they would need to have 85% certainty of successfully convicting the doctor; the focus could only be on Michael, not the other two deaths; only address the period of time just before Michael died and not the full 14 ½ months while Michael was under the care of Dr. K.. This all sounded very illogical to us and we wondered whether the esteemed doctor’s position, well-known identity and the fact that he sat on the criminal review board had anything to do with the decision not to lay a charge.
When there has been abusive use of a doctor’s prescribing power leading to addiction and especially in cases leading to death a thorough police investigation must follow. We entrust the police and our courts with this responsibility not the medical regulatory boards whose focus is to remediate a doctor. Although doctors are subject to disciplinary action they still freely prescribe these drugs with very little regulation & accountability.
Laying a criminal charge is contingent upon a complete and thorough police investigation. The crown exercises their discretionary purview and can only make a sound determination in bringing a case before the courts when the police have conducted a detailed investigation and lay a charge. But in addition to a thorough Police investigation there must be a willingness to deal with delicate and sensitive issues involving complex professional crime for which Police have very little training and experience. Support by way of evidentiary competence and best practices must be available to Police and the justice system in areas of unchartered waters. A thorough investigation should continue if warranted, based on merit and not wait and see what the CPSO does or does not do.
Doctors should not be above the law. But somehow Dr. K. managed to escape any real penalties. The medical community’s lack of leadership and refusal/inability of regulatory bodies to do what is right – protect the public - clearly demonstrates the urgent need for legislative changes.
In 2012, the doctor made application to the CPSO by way of a “Motion to Vary” his discipline order, specifically, to have the co-signer requirement removed and his bimonthly supervision changed to monthly. Although I made application to participate in the Hearing, provided a sworn affidavit and made an oral submission, the discipline panel granted the doctor’s request -- giving him permission to prescribe controlled drugs without a co-signer and again putting his interests above his patients.