Did opioid prescribing practices factor into Hamilton boy’s death?

In the month leading up to her four-year-old son's death, Lisa Strickland travelled from her Hamilton Mountain home to the same Toronto clinic, where she saw the same two doctors eight times.

She was given prescriptions for a staggering 800 hydromorphone tablets, a mix of 1 and 2 milligram doses of the powerful opioid. All were filled at the same pharmacy.

During one of those visits to Bay College Medical and Lockwood Diagnostic (BCML) on Sept. 11, 2017 she told Dr. Ilan Shahin that she wanted to go off hydromorphone because it was making her careless," according to medical records summarized in an agreed statement of facts in the case against the 42-year-old mother. She had put her phone in the fridge.

She was given a codeine prescription, but returned for more hydromorphone a week later.

On the morning of Sept. 25, Kane Driscoll was found by his parents, lifeless in his bed. Months later, toxicology results would show the kindergartener who had serious medical issues, including a heart defect, died of hydromorphone poisoning. No one knows how the drug entered his body.

Last week Strickland pleaded guilty to criminal negligence causing death and was handed a two-and-half-year sentence.

The doctors were not on trial, but the Crown named them in the agreed statement of facts. Lawyers on both sides and the judge questioned their role in helping to create the environment that led to such a tragedy.

I think that the doctors share responsibility," defence attorney Beth Bromberg said during submissions.

And Ontario Court Justice Anthony Leitch appeared to agree.

You don't give someone suspected of being an addict 800 pills ... the doctors bear some responsibility in how many," he said during a line of questioning about whether Strickland was following her prescriptions.

Both Dr. Shahin and the other doctor named in court, Dr. Matthew Friszt, have been investigated by the College of Physicians and Surgeons of Ontario (CPSO) and required to undergo training around opioid prescribing, The Spectator has confirmed.

Neither the doctors nor the clinic could be reached for comment.

Shahin and Friszt are among 84 doctors the college looked into during an opioid investigation that began in 2016.

That CPSO investigation was part of the opioid strategy developed by the college that year. The 84 physicians were investigated based on data from Ontario's Narcotics Monitoring System that showed high opioid prescribing.

A spokesperson for college would not comment on doctors Shahin or Friszt.

However, in a statement, the college said all of those investigations are now complete. While some problems were identified, most of the cases led to remediation to support appropriate prescribing."

In some cases, physicians may have entered into undertakings with the college, agreeing to complete specific educational requirements," the college said.

According to information published in a 2018 issue of Dialogue - the CPSO magazine - of the 84 investigations, just one case was referred to discipline. There were 36 who had mandated remediation, eight with mandated remediation and a caution, two had prescribing restrictions and one had prescribing restrictions and a caution. At that time, three investigations were still in progress. The college says all investigations are now complete.

For doctors who had restrictions or mandated remediation, the decisions are posted on the CPSO website under each doctor's profile. However, once the restriction is lifted or remediation is complete, the document is removed and no longer available to the public. All that remains is a list of the date the terms were imposed and then lifted.

The CPSO profiles for Shahin and Friszt state their certificates were restricted and terms and conditions were imposed on Nov. 26, 2019. And both returned to independent practice on Aug. 25, 2020.

According to the undertaking signed by Friszt, obtained by The Spectator, the college investigated whether he had engaged in professional misconduct and/or is incompetent in his practice of family medicine, including prescribing controlled substances."

As a result, he was required to take the safer opioid prescribing series at the University of Toronto. He was also required to submit to a reassessment of his practice after six months that could include a minimum of 15 patient's charts being reviewed, an interview, observation of his care and interviews with colleagues.

The Spectator has not seen Dr. Shahin's undertaking, but a source with knowledge of the investigation said his was similar to that of Friszt.

A review of Strickland's medical files after her son's death concluded she was being prescribed hydromorphone at eight times the regular dose and that her medical condition did not require that level of opioids.

Court heard she'd been taking the prescribed drug for years for a range of painful ailments that ranged from uterine cysts to peptic ulcers. She was on leave from her job, where she worked as a registered practical nurse, at the time of her son's death.

After spending months in jail, contemplating her son's death and what led to it, her lawyer said she's realized she has an addiction. The PTSD she suffered following her son's death only compounded existing mental health problems. Court heard she's on a range of medications including for depression and anxiety.

The extreme case is a sign of much deeper problems around how chronic pain is treated and how opioids are prescribed in Canada, said Dr. Jason Busse, an associate professor at McMaster University.

He was the main editor of the 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain, which is being updated. He does not have direct knowledge of Strickland's case, but said what was revealed in court illustrates a pattern he has seen too often with opioid prescribing and addiction.

Unfortunately it's not a unique story," he said, later adding that what makes this case exceptional is the tragic collateral damage."

I think that there is probably a lot of blame to go around," he said.

When opioids, such as OxyContin, first hit the market, a lot of marketing claimed they were safer than other pain medications. There was also misleading information in medical journals, and doctors had not been trained on opioids. That led to over-prescribing.

Busse said research shows about 5 per cent of patients prescribed opioids become addicted. Typically doses increase over time to the point that the medication may not work for pain, but the patient may be addicted.

Chronic pain is also complex, he noted. It's common that a patient with chronic pain will get multiple diagnoses. There are almost always other issues, including everything from mental illness, housing or job strains to caring for a special-needs child.

But studies show opioids actually aren't very effective for chronic pain, which affects one-in-five Canadians. An assessment of more than 26,000 patients in clinic trials showed that only one in eight patients had a noticeable change in pain, he said.

That's why the opioid guideline recommends opioids should not be the first line of therapy for chronic pain, he said.

Prescribing can be complicated, he said, because you also don't want to drastically cut someone's opioids because they will go into withdrawal. Evidence shows this can lead to patients seeking street drugs and an increased risk of overdose.

Some change is happening, including work by the Canadian Pain Task Force and the Association of Faculties of Medicine of Canada developing curriculum to train new doctors on opioids.

In Strickland's case, he said there were red flags, including her own assessment of feeling careless" and the enormous prescriptions being filled.

An alarm should have gone off somewhere," he said.

If this case and ones like it have any benefit, it is to shine a spotlight" on these issues.

Nicole O'Reilly is a Hamilton-based reporter covering crime and justice for The Spectator. Reach her via email: noreilly@thespec.com