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Canada Only Ontario doctor disciplined for over-prescribing opioids agrees to give up his licence

The only Ontario doctor to face formal discipline as a result of a province-wide investigation sparked by the opioid crisis has agreed to give up his licence and never practice medicine again.

Robert Stewart Cameron admitted he engaged in professional misconduct when he doled out extraordinarily high doses of painkillers to patients whose cases should have raised red flags, including some who provided “questionable explanations for lost, stolen or damaged narcotics” and others who “may have sustained accidents or injuries due to these prescriptions.”

Dr. Robert Cameron at the disciplinary hearing at the College of Physicians and Surgeons of Ontario

Chris Donovan/The Globe and Mail

A disciplinary hearing held Monday for Dr. Cameron was the culmination of a series of investigations that began in 2016, when a provincial government coming to grips with the opioid crisis sent the names of 84 high-prescribing doctors to the College of Physicians and Surgeons of Ontario (CPSO) for review.

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The CPSO has now completed 81 investigations, and in every case but Dr. Cameron’s the doctors were either cleared or asked to undertake “remedial” work, such as a safe opioid prescribing course.

The college also adopted new opioid-prescribing guidelines last year that say the potentially addictive painkillers should be used sparingly and in the lowest doses possible.

Before Dr. Cameron accepted his punishment at a hearing in Toronto, he made an impassioned plea on behalf of his opioid-dependent patients in a downtrodden section of Windsor, saying some had died after the CPSO forced him to stop prescribing narcotics..

“Those people depended on their medication to stay alive,” the 65-year-old doctor said, his voice cracking as he addressed a five-member disciplinary panel.

“When the college lowered the boom on me, people that very day were coming in for their regular [prescription] repeats. They were in panic … patients have died since then because the college did this.”

The CPSO “strongly disputes,” that assertion, a spokeswoman said by e-mail after the hearing.

The self-regulating body that oversees doctors in Ontario has tried to walk a fine line in response to an opioid epidemic that killed 1,053 people in the province in the first six months of last year, up 52 per cent from 694 deaths in the same period in 2016.

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CPSO officials have said they want to ensure doctors follow more conservative guidelines on opioid prescribing.

But they fear an aggressive crackdown could lead to physicians abandoning their addicted patients, which is why the college took a “remedial” approach to most of the 84 high-dose opioid prescribers flagged for investigation in 2016.

The probe that led to Dr. Cameron’s disciplinary hearing began when the Ontario Ministry of Health and Long-Term Care scoured its narcotics monitoring system to find physicians who were prescribing more than the equivalent of 650 milligrams of morphine per day to eight or more patients and who had issued at least one, usually long-term, prescription exceeding 20,000 milligrams of morphine equivalent.

Canada’s new guidelines on prescribing opioids for patients with chronic, non-cancer pain, which the CPSO adopted last year, recommend strongly against prescribing more than the equivalent of 90 milligrams of morphine per day.

However, even the old version of the guidelines – adopted in 2010 and in place when the ministry reviewed the prescribing data for 2015 – warned doctors to be careful about prescribing more than the equivalent of 200 milligrams of morphine daily.

The CPSO has completed investigations into 81 of the 84 doctors.

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In every case but Dr. Cameron’s, the CPSO either cleared the physician or ordered some kind of “remediation” such as taking an opioid prescribing course, practicing under the guidance of a clinical supervisor or relinquishing certain prescribing privileges.

In Dr. Cameron’s case, a physician investigator reviewed the charts of 24 of his patients and found that in 18 cases, Dr. Cameron’s care fell below the standard of practice for his profession.

In 16 cases, Dr. Cameron’s care “placed his patients at risk of harm,” according to an agreed statement of fact read at Monday’s hearing.

The statement said Dr. Cameron had a tendency to prescribe narcotics at high doses with few physical exams or other evaluations; that he failed to react to information from third parties about potential opioid abuse; and that he failed to refer patients to specialists, including pain and addiction specialists, when he should have.

Despite agreeing to plead guilty to professional misconduct and to resign from the college effective April 30, Dr. Cameron defended himself vigorously.

Sporting a long grey ponytail and a red tie with blue jeans, he described the challenges of working in the “slum” of Windsor, where many of his patients were social-assistance recipients and some risked being robbed of their medications when they left his walk-in clinic.

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“As a family doctor you develop relationships with these people. You care about these people,” he said. “You’re not just sitting there in an ivory tower somewhere saying, ‘Oh, these are the new rules. You gotta do it.’ Life isn’t that simple. People deserve respect and even people who have dependency problems deserve respect.”

Dr. Cameron said the college’s decision to dramatically curtail his prescribing privileges in June of 2017, pending a disciplinary hearing, led to the deaths of patients who lost access to their opioids, but he did not provide specifics.

Jessica Amey, legal counsel for the CPSO, told the panel that Dr. Cameron’s approach hurt his patients rather than helped them.

“Being an ally and advocate for your patients does not mean you throw applicable guidelines to the wind,” she said. “Being compassionate does not mean you give your patients what they want, always.”

Dr. Cameron’s track record was an aggravating factor in the case, Ms. Amey added. He has twice been disciplined for unrelated wrongdoing.

Because of the plea arrangement, the only issue to be decided on Monday was whether Dr. Cameron would have to pay costs.

The panel ordered Dr. Cameron to pay $10,180, the cost of a one-day hearing.

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