Toronto Police drug-squad constable Dave Stinson, a specialist in crimes associated with prescription-drug trafficking and abuse, is an expert in catching doctors who break the law — he helped put away Toronto physician and Oxycontin trafficker John Kitakufe for eight years — and in helping doctors deal with patients trying to fraudulently get their hands on narcotics. It’s a major problem and it’s getting worse, he says. For physicians, the issue raises legal concerns, ethical concerns, concerns about protecting patients’ privacy, and concerns about misidentifying patients who suffer from “pseudo-addiction,” in which inadequate pain management can lead to behaviour that could be mistaken for drug-seeking. Mr. Stinson says doctors also need to be concerned that the drugs they prescribe could be reaching the black market.

PE What do you do?
DAVE STINSON It’s my 22nd year and I’ve been involved with three projects -- one with a corrupt pharmacist, and two with corrupt doctors. The one doctor of note you’d probably remember was Dr [John] Kitakufe, who received an eight-year sentence. The Toronto Star three years ago did quite a story on him.

PE What's your position in the police force?
DS I work in a narcotics section, with a subspecialty of prescription drugs and the criminality that goes with them.

PE And one of the things you do is you help doctors recognize narcotics scams?
DS I have given guest lectures at Dr [Alan] Russell’s invitation to doctors and pharmacists, speaking about the signs and some of the concern the police have with prescription painkillers especially, or narcotics in general. And so in those settings we talk about how the methodology of criminal individuals, conspiracies involving groups, and in some cases organized crime, traditional organized crime, or other crime groups. And there are lots of reasons why it’s an increasing market for legal narcotics used illegally...

PE It’s not easy for doctors to handle the situation if they suspect someone is trying to scam them.
I think doctors are in a tough spot. They have confidentiality issues at the highest level. That’s the way our country, our province approaches that, and that’s a good thing -- nobody wants their health records shared with law enforcement. By the same token, as a just society, to quote Trudeau, it shouldn’t and we can’t allow it to be used as a veil to hide criminality. What I'm seeing is an increase in criminality that not only involves the public getting involved -- there is a greater demand than ever before for prescription drugs -- but also healthcare professionals unfortunately acting in a criminal way themselves. I think it’s unprecedented, actually, but I have no solid data to back it up. I just have anecdote and my personal experiences over the last eight years of dealing in these cases specifically. There are a few factors: one is the availability of prescription narcotics in the province of Ontario. As you know, we are a Western nation with very good access to generic drugs, and prescription narcotics are part of that. And we’re also, as a second point, a province that has universal healthcare, and through universal healthcare we get drug benefits. So even if you’re destitute, you, describing the proper symptoms to a legitimate doctor or a corrupt doctor, can probably get prescribed narcotics -- legal narcotics -- that you will then subsequently abuse. Especially oxycodone, and Oxycontin as a brand. Prior to that, from the 60s on, there’s been abuse of Percocet and all the other sort of antidepressants that were on the market and painkillers now. But oxycodone has certainly seen a spike in abuse by the public and also by physicians or pharmacists that are, I believe, looking to make extra money.

PE I recall I had surgery seven or eight years ago and had Percocet prescribed.
DS And did it work?

PE It worked too well. I couldn’t understand why anybody would use it recreationally.
DS [Laughs]

PE I lost a couple of days. I have no idea what happened.
DS I guess what some people do is cut it up and then they also build up a tolerance. I know people that if you ingest or I ingest the same amount of cocaine they do in a day, we’d OD by medical standards, but they’ve been on cocaine for 18 years so it’s no problem. They’ve built up a tolerance, obviously.

PE You mentioned that a lot of people learn what to say to doctors. They figure out what buttons to push to make doctors believe they need these drugs when they don't, or when they may need something less strong. What have you seen?
DS You will have -- let’s call this person a gatekeeper. You will have a gatekeeper who, let’s say, lives at a men’s homeless shelter. He will, through self-education on the internet, talking to doctors over years, maybe because he did have legitimate pain issues or maybe because he talks to former patients and current patients that are legitimately entitled to pain medications or narcotics, he educates himself on what the language is, what the symptoms are, and what the frequency of requests should be for such narcotics to then gather in customers that he will make business propositions to. So, for example, he’ll say to six men he has huddled in a park at a picnic table, “Everybody at this table can make $300 cash today. This is what you have to do.” And he explains to other homeless men that he’s brought from the shelter just down the street to the park at the picnic table how each one will get a lesson in their symptoms and what prescription if the doctor asks would previously work for them and try to therefore dupe the doctor into prescribing that narcotic.

PE How then, because obviously there’s a lot of thought and forethought that goes into this on what you call the gatekeeper’s part, are doctors supposed to distinguish between these people and other people who are not trying to pull a scam or some ruse?
DS Well, it’s a great question -- it’s the million-dollar question. On a case-by-case basis. If you have a patient that comes in every 30, 60 or 90 days saying they’re losing their prescription, as an example, that should become a red flag to the healthcare practitioner.

PE Are there any other red flags?
DS Oh, sure, because there are so many ways to do this... [Static and radio chatter] Sometimes a doctor would -- Oh, you know what? I’m gonna have to call you back, Sam. We’re following somebody.

[Several hours later]

PE So, did you catch ’em?
DS Well, we were just following him. We’ve been involved in a wiretap project for a couple of months so now we’ve watched him do deals. We did buy half a key [kilogram] of heroin today!

PE That’s a lot.
DS Yeah, heroin, for a key right now, it’s $80,000 a key.

PE No kidding?
DS No.

PE Jeez.
DS And that’s why, as an example of what we’re talking about, why a synthetic form of heroin -- Oxycontin -- is so prized on the street, and that’s one of the reasons that kind of crime is increasing, because instead of relying on some unknown in Afghanistan cutting it with rat poison, you have a reputable pharmaceutical firm manufacturing it so your quality is assured and the supply has a lot less risk because it doesn’t have to be brought through many hands and over seas. It can be obtained fraudulently through feigning some symptoms or a corrupt medical practitioner slash pharmacist who says, “You know what, I just want to make money so I’ll sell the scrips.”

PE And there’s not the same stigma.
DS Exactly! And, see, that’s the whole cultural shift. My generation, it was all organic drugs -- hash, weed, cocaine. They’re all derivatives, of course, of organic matter. But if you look now at the 80s on, you’ve got the rave scene and designer drugs, and designer drugs on their own like ecstasy and Special K are part and parcel of that, and people are saying, “Well, you know, if I’m going to do an opiate, why would I want some farmer in Afghanistan I can’t trust? I’ll go with a pharmacy.” It’s almost a class distinction and a quality assurance. Which is appropriate in the bigger picture when we all want organic food, drinking water, healthier lifestyle -- we want healthier recreational drugs. Or at least we believe them to be.

PE What are some other red flags?
DS Another red flag is a patient who never seems to recover. Now, there are some with chronic pain, but even Dr. Russell will agree that those with chronic pain for the rest of their life are not the majority of people. And so as a physician I think it’s incumbent upon them to weigh up through their experience, their knowledge, the questions they ask the patient, the physical evidence they see, maybe the patient’s posture, the X-rays, the blood tests, and come to some sort of corroboration that leads them to believe the patient is still in pain versus they’re just feigning pain ’cause they’re addicted and they want more or they’re selling them and making a profit. Of course another red flag is obvious: greed. Where a patient comes in and proposes to doctor or a pharmacist, like a gatekeeper will, “I’ll give you so much money for each patient I bring in to you.” And I guess in a more subtler way, a patient who over a period of time seems to bring the doctor an inordinate amount of new clientele. That may say to a doctor, “Okay. Why is this patient able to bring me in the last six months 30 new Oxy patients?” A doctor cannot be complacent and perhaps become subject to willful blindness if they’re on the up and up. They have to say, “This is not normal, to have 30 patients brought to me by the original patient for this narcotic in particular.” You see a pattern forming.

PE All right, so we’ve got these red flags, but what’s the next step? What should doctors do when they suspect a patient might be trying to pull something?
DS If I am a doctor prescribing a narcotic, I don’t think the College [of Physicians and Surgeons] or the oath of office or any of the regulations under the Ministry of Health prevent the doctor from saying “I am concerned and here’s why” to a patient. Having said that, I know some doctors say, “Look, I work in Cabbagetown or Parkdale -- a lot of homeless people -- and I don’t want to confront them. I’d rather just give them the drug.” To me, that’s a real cop-out, pardon the pun. You can’t just give them the drugs because you’re afraid. Because if you’re really afraid, there are ways to remedy that, such as contacting the College and then contacting law enforcement, and in a professional and subtle way diverting that patient to a new doctor, or directly facing that patient with the police present and have the police say to them, “You will no longer be coming to this office, because under the Trespass of Property Act, you’re prohibited.” Hold on one second, Sammy -- [Static and radio chatter: “We’re on the move, guys, he is now going...”]