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The first doctor to be formally disciplined as a result of an Ontario-wide investigation into high-dose opioid prescribers kept providing painkillers to his patients despite “red flags” that the pills were being abused or diverted, according to a review of his case files released to The Globe and Mail.

Robert Stewart Cameron admitted to professional misconduct at a College of Physicians and Surgeons of Ontario (CPSO) disciplinary hearing in March and agreed never to practice medicine again.

From the archives: Only Ontario doctor disciplined for over-prescribing opioids agrees to give up his licence

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The review of 24 patient charts that led to Dr. Cameron’s punishment provides a rare, on-the-ground glimpse of how the opioid crisis played out inside one walk-in clinic in a rough part of Windsor, a border city that is part of a region where more opioids were dispensed for pain per-capita last year than anywhere else in the province, according to the Ontario Drug Policy Research Network.

The CPSO recently released a copy of the report at The Globe’s request after redacting details that might identify Dr. Cameron’s former patients.

The overall impression left by the case reports is of a doctor reluctant to say no to desperate patients on doses of painkillers that vastly exceeded the guidelines for safe opioid prescribing for chronic pain, which at the time warned doctors to be careful about prescribing more than the equivalent of 200 milligrams of morphine a day.

The CPSO last year adopted new Canadian guidelines that recommend strongly against prescribing more than the equivalent of 90 milligrams of morphine a day for chronic pain.

In 14 of Dr. Cameron’s charts, patients were receiving more than 200 milligrams of morphine equivalent (MME) a day; in three cases, patients were receiving 720 MME daily.

Jeffrey Sloan, the family doctor and Queen’s University professor who reviewed the charts for the CPSO, concluded that Dr. Cameron met the standards for his profession in only six of the 24 cases, and exposed 16 of the patients to risks of harm.

Dr. Cameron, who had practised medicine for 40 years, could not be reached for comment after the report was provided to The Globe.

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But in an interview after his hearing on March 26, he said Dr. Sloan’s review of his charts didn’t capture how he cut off opioid supplies to “dozens of people who [he] had good reason to believe were playing games” or how he helped despondent patients with nowhere else to turn.

“Many of these patients wrote letters saying how they were only able to function with the medicines I gave [them]. How I’ve – well, saved their lives might be a little extreme – but made their lives livable,” Dr. Cameron said.

However, Dr. Sloan took a different view in his report.

“[Dr. Cameron] demonstrated questionable and at times very poor judgment in continuing to prescribe large doses of narcotics to individuals who had repeatedly demonstrated aberrant behaviour and was too accepting of patients often questionable explanations for lost, stolen, or damaged narcotics,” he wrote. “This rather naive acceptance of patients' explanations could also be construed as a lack of skill in dealing with difficult patients.”

In one of the charts Dr. Sloan summarized, a patient who repeatedly asked Dr. Cameron for early refills of his opioid prescriptions claimed his painkillers had been stolen four times in three years.

In another, a patient asked to be switched from a tamper-proof version of oxycodone to an old formulation that is easier to crush and snort or inject for a quick high.

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Another physician who saw the patient at a pain clinic warned Dr. Cameron against the change, yet he kept prescribing the old version to the patient anyway. A urine test at a cannabis clinic revealed the patient had no oxycodone in his system, which is “a red flag for possible diversion” – meaning the patient might have been selling his pills rather than swallowing them.

In another of the cases, Dr. Cameron kept prescribing opioids for a patient who had been flagged for possible double-doctoring, even after he received an anonymous phone call that the patient was abusing his medications and using crystal meth.

Dr. Cameron told the patient he wouldn’t prescribe any more narcotics for him and urged him to attend a methadone clinic, then wrote another prescription for the patient before another abnormal urine test convinced him to dismiss the patient for good.

In two of the cases, Dr. Cameron wrote letters to patients saying he could no longer treat them because they had become his “personal friends.” Dr. Cameron continued to prescribe opioids to the patients anyway because no other doctor would, he later told Dr. Sloan.

“Everybody in town is running scared,” Dr. Cameron told The Globe after the hearing in March. "All the doctors know this is happening, and very few people want to take on additional narcotics patients for fear the same thing is going to happen to them.”

Dr. Cameron was referring to the medical regulator’s investigation of 84 doctors who were flagged by the Ontario Ministry of Health and Long-Term Care for prescribing more than the equivalent of 650 milligrams of morphine a day to eight or more patients and who had issued at least one, usually long-term, prescription exceeding 20,000 MME.

“We understand that there remains some anxiety amongst physicians as a result of the critical attention being paid to prescribing of opioids over the last few years,” Shae Greenfield, a spokesman for the CPSO, said by e-mail. “Our message to physicians is clear – we expect them to be aware of the guidelines, but they need to consider the unique situation of each patient they see and make decisions based on their clinical expertise.”

He added that it is “never appropriate” to abandon patients on long-term opioid therapy.

The CPSO’s investigations, which wrapped up in the spring, resulted in Dr. Cameron and one other physician being referred for formal discipline. A hearing for the second doctor has yet to take place.

The medical regulator took a “remedial” approach in the vast majority of the cases, fearing a tougher crackdown could lead doctors to abandon opioid users at a time when the black-market alternatives could be contaminated with fentanyl.

The arrival in Ontario of illicit fentanyl – a synthetic opioid that can be 100 times stronger than morphine – is the driving force behind the recent spike in opioid-related deaths.

Last year, Public Health Ontario found there were 1,261 confirmed and probable opioid-related deaths across the province, up from 867 in 2016 and 728 in 2015.

Nationally, Health Canada said there were nearly 4,000 apparent opioid-related deaths across Canada last year, up 34 per cent from the year before.

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