Register Friday | December 9 | 2016

First Do No Harm

Are doctors and drug companies to blame for the opioid-abuse crisis? After two shocking deaths in small-town Ontario, Ann Silversides reports from one of the largest coroner’s inquests in Canadian history.

I.

On Thursday, November 20, 2008, shortly before midnight, Dustin King arrived at an apartment hangout in downtown Brockville, Ontario. He was visibly upset. He’d had an explosive argument with his father, Gerry, and he’d already downed a few beers. King’s parents split up when he was a toddler, and he’d lived mostly with his dad. Their relationship had always been rocky; when he was in his mid-teens, their fights turned physical, prompting the involvement of the police and the Children’s Aid Society.   

The apartment, a three-storey limestone building located at 89 King Street West, was full of people addicted to OxyContin. Curly-haired King, nineteen years old and still in high school, was the youngest of the group; most were in their twenties. King—no stranger to drugs—started using marijuana as a young teenager and graduated to popping prescription stimulants like Ritalin and street drugs like ecstasy. He had even landed in Brockville General Hospital a couple of times with seizures that doctors told him were caused by recreational drugs. But he wasn’t used to Oxy.

Just swallowing Oxys gave the revellers a good high; about one-third of the drug’s active ingredient, oxycodone, is released immediately upon ingestion. But the friends wanted a bigger bang that night, so they snorted and injected the drug, the better to rush the oxycodone into their systems for a more powerful euphoria. Because King didn’t do injection drugs, he agreed to snort half an 80-milligram pill. A friend wiped the coating off the pill with a damp cloth, crushed it with an ashtray and a lighter, and, using a bank card, split the resulting powder into two lines. King lowered his nose to a rolled-up bill and snorted the crushed grains.

A few hours later, around three in the morning, King climbed the stairs to apartment C1, the home of his friend Donna Bertrand. He wanted help figuring out his problems with his father. Bertrand was forty-one and had grown up in Oxford Mills, forty-five minutes north of Brockville. After high school, she attended community college, and later worked in nearby hospitals and nursing homes as a registered practical nurse. She liked to help people and played mother hen to several of the addicts who hung out in the building. She always had Oxys, prescribed for her back pain, and she shared her drugs, sometimes selling them and sometimes giving them away. Bertrand and King were a family of sorts. He called her “mum” and she called him “son.” King’s real mother lived in the United States with her second husband. Bertrand’s biological twelve-year-old son had been living full-time with her parents since he was about five years old.

“This is your lucky day,” Bertrand told King when he arrived at her apartment; she was determined to help him. They talked in her living room. Her window overlooked the city’s main drag and it was quiet in the early-morning hours. Around 4:30 am, King snorted another 80-milligram OxyContin on Bertrand’s coffee table. Two hours after that, they smoked a joint. King eventually fell asleep in the living room on a couch upholstered with nubby grey-brown fabric.

Later that morning, at about 10 am, Bertrand got a lift to Zellers, on the outskirts of town, to pick up an OxyContin prescription. While she was away, there was an unusual amount of activity at her apartment. The building had a new owner, and Kasey Bronkhorst, the twenty-five-year-old janitor, was in and out, helping service people arrange for new windows and carpeting. King slept through all the commotion, although, on Bronkhurst’s forays through Bertrand’s living room, the janitor noticed that the young man on the couch was breathing as if he had nightmares.

Sometime around 11:30 that morning, Vincent Shaver arrived at the apartment, hoping to buy Oxys from Bertrand. Shaver noticed that someone he didn’t recognize was sleeping on the couch. The stranger’s breathing was uneven. He pointed this out to two women who were hanging around Bertrand’s apartment, but they ignored him.

Bertrand returned home shortly afterward. She was ready for a nap, and decided to let King continue to sleep. “I don’t think I heard him cough or anything,” she later remembered. “I wasn’t really paying attention at that point. He is nineteen, and he is going to wake up.” Bertrand dozed off, but was woken by her telephone at 4:30 pm. She rose and went to wake King. She wanted to take him shopping and buy him some clothes. Bertrand kissed him on the forehead and said, “Good morning, son.”

King’s forehead was cold. Saliva and white froth oozed from his mouth and nose. He was dead.

When the call came, Detective Tom Fournier had made it as far as the outskirts of Brockville on the ninety-minute drive home to his wife and daughters in Ottawa. He returned to the police station, called the coroner and headed to 89 King Street West. The scene at apartment C1 shocked him, and became the basis for one of the most extensive coroner’s inquests ever held in Canada—the first in Ontario to highlight the rising death rates from prescription painkillers and, in particular, OxyContin.

King was lying on his back, turned to his left side as if cuddling into the couch. He was shirtless and wearing a pair of black jogging pants. His eyes were closed and he was blue, with mottling all over his body caused by a decrease of oxygen to his skin. A large amount of lividity—pooled blood—was evident on his back. Rigor mortis had set in; his jaw, arms and legs were stiff. His right arm lay across his chest. Bertrand had placed it there after she discovered his body—an old nursing habit.

Remnants of crushed pills lay on the living-room coffee table, as did a blue spoon with white residue on it, and a small amount of marijuana. In Bertrand’s bedroom, there were two orange pill containers that, the labels stated, were for 80-milligram pills of OxyContin. One, dated the previous day, was for 180 tablets. It was empty. The other, also for 180 pills, had been dispensed ten days earlier. It, too, was empty. Each of those prescriptions was worth about $800 at the pharmacy’s list price, and each could fetch about $4,500 on the street.

A bare mattress, stained with spatters of blood, lay on the floor of the spare bedroom. Two yellow biohazard pails containing used needles were nearby, and a collection of clean needles sat in a black cup on top of a table, alongside three knives and a spoon. A baseball bat was partly hidden behind the table; because of the constant threat of theft, many addicts keep a bat handy as a weapon.

A Brockville native, Detective Fournier had graduated from Brock University in St. Catharines, Ontario in 1990, with a double major in physical education and geography. He had intended to return and qualify as a teacher, but that plan was derailed when, after graduation, he took what he thought would be a temporary job with Brockville Police Services. His idea had been to stay for just a few years, to pay off debts and save money, but he realized that he enjoyed police work.

Fournier is lean—he keeps fit by running. His uniform is a sports jacket, slacks, and a shirt and tie. The detective usually radiates calm and patience, but that morning, in Bertrand’s apartment, he was unsettled. Although he didn’t yet know the cause of King’s death, the recently emptied pill bottles troubled him. Police were aware that there was a lot of Oxy on the street in Brockville, but addressing the problem was tricky. When it comes to illegal narcotics, police have a clear mandate. But tackling the proliferation of legal prescription drugs is a whole different challenge—one that often left police feeling helpless.

Fournier called the regional coroner’s office, explained the situation in the apartment and thought, simply, “This is crazy.” Later that evening, he spoke to Gerry King about his son’s death. “He took it very hard,” Fournier recalled. “No matter what kind of parent you are, this is your child.”

Purdue Pharma, based in Connecticut, developed OxyContin as a time-release narcotic for people who need pain relief around the clock. Because the pills provide relief over many hours, they contain a much higher concentration of oxycodone than other opioid painkillers like Percocet. (Oxycodone, a semi-synthetic opioid, is derived from thebaine, a constituent of the opium poppy.) As well, an 80-milligram tablet of OxyContin is as potent a painkiller as 120 to 160 milligrams of morphine, depending on the patient.

Dr. David Juurlink is a pharmacologist, internist and researcher at Sunnybrook Hospital in Toronto. He explained to me that opioids decrease a person’s level of consciousness and impulse to breathe, and that, at high doses, all opioids can be fatal. This is more likely to happen if the user has not taken opioids before—or has not developed a tolerance—and when the drugs are taken with another central nervous system depressant, such as alcohol. Juurlink was frustrated that, at the time of King’s death, OxyContin was available in Canada in a single tablet containing 80 milligrams of oxycodone. “If a teenager recreationally, just out of curiosity, takes a tablet, it could easily kill them—a single dose,” he said.

In the early nineties, in Kemptville, Ontario, about six years into her career as a nurse’s assistant, Donna Bertrand injured her back while lifting a patient. She was off work for six weeks, and when she returned she mostly took on lighter jobs. But for the four years leading up to November 2008, she had lived on government assistance. A combination of Canada Pension Plan disability payments and the Ontario Disability Support Program provided her with about $1,300 a month.

A benefit of the ODSP was that Ontario’s drug plan covered her prescriptions. She’d been on anti-depressants since her late teens, and, in addition to OxyContin, she was now taking anti-anxiety drugs, as well as medications to help her sleep and to counter the side effects, such as nausea and constipation, of the pharmacopoeia she ingested every day.

A year earlier, in October 2007, Bertrand had begged a doctor named Alan Redekopp to take her on as a patient. Her previous family doctor had died a couple of years before, and, in the interim period, her psychiatrist, Dr. Neil McFeely, agreed to double as her family physician. (Brockville was short of doctors.) Bertrand approached Redekopp because he had one thing that McFeely did not: a reputation for generously prescribing narcotics.

Redekopp accepted Bertrand as a patient, and, at her very first appointment, he wrote her first-ever prescription for OxyContin, starting at 120 milligrams daily. Over the next year, he would steadily increase that dose. By late November 2008, he was prescribing her more than ten times that amount: 1,440 milligrams every day. Whenever she said the drugs weren’t keeping her pain in check, he obligingly upped her dose.

Redekopp believed in OxyContin. In his opinion, it was the best-in-class of controlled-release narcotics. Redekopp later said that, over the years, Purdue sales representatives visited him every two months or so. At first, they told him OxyContin had low abuse potential. A few years later, in the face of mounting evidence, they began to acknowledge the possibility of abuse. But, Redekopp said, they never mentioned anything about maximum or watchful doses. Instead, they told him that, at specialized pain clinics, daily doses in the range of 900 to 1,000 milligrams were not uncommon. Still, 1,440 milligrams a day was a hefty dose. In 2010, when Canadian clinical guidelines for opioid treatment of chronic non-cancer pain were finally published, 200 milligrams of morphine equivalent—an amount equal to about 133 milligrams of oxycodone—was set as a daily “watchful” dose that should be exceeded only with great care. 

While Bertrand’s $80-a-day prescription for OxyContin was ostensibly to treat her back pain, Redekopp had never gathered any clinical evidence of her condition. Bertrand did not have any obvious functional limitations, such as difficulty walking or climbing stairs, as a result of her injury. She had told Redekopp about her back pain at her first appointment, and he had diagnosed her with spinal stenosis, a degenerative condition that causes compression of the spinal nerve cord. But it was almost another year before he would refer her for a CT scan to confirm his diagnosis. She didn’t keep the appointment.

Bertrand had become seriously addicted to OxyContin. She made at least half a dozen reports to police alleging that her drugs had been stolen—reports that police concluded were mostly false. But some were likely true; many local addicts knew about Bertrand’s prescriptions. For four years, she had patronized a Pharmasave near her apartment, but, in September 2008, Rock Coulombe, the store’s pharmacist and co-owner, had terminated Bertrand as a client. She had a history of reporting her painkillers lost, misplaced or stolen, and once told him that she left her pills at the funeral of her sister—who was, in fact, very much alive. The pharmacist had telephoned Redekopp to express his concern about Bertrand’s behaviour, and the doctor, Coulombe said, listened “politely and professionally.” But Redekopp kept prescribing pills for Bertrand.

Finally, on September 2, 2008, when Bertrand once again told Coulombe that her pills had been stolen, he said he would not dispense her drugs anymore; he was uncomfortable with her narcotic use. He phoned Redekopp to inform him of his decision and his reasons. The doctor listened “respectfully,” Coulombe later said.

Early Friday evening, after visiting the scene of King’s death, Fournier interviewed Bertrand at the police station. At forty-two, he was just a year her senior, and they were on a first-name basis; the detective had had a few minor dealings with her over the years. When she was sober, she was pleasant and sensible. When she was stoned, she couldn’t remember what she’d said five minutes earlier. It wasn’t that she lied. She just forgot.

The formal police questioning of Bertrand began at 5:36 pm on the evening of November 21. She consented to audio and video recording, and to make a sworn statement. “It’s like I am getting married or something,” she joked. “This is so weird.” Her immediate concern, she said, was that she was supposed to be at her parents’ house looking after her son.

Bertrand recalled the events leading up to King’s death. But when a police officer asked to examine a container of OxyContin that she had in her pocket, she became stubborn and angry. “No, you don’t have a warrant,” she said. “I am carrying these with me. I have cooperated with you guys enough.”

Bertrand then announced that she wanted “the people who sell drugs” out of her building. “It’s a crack shack, that apartment,” she said, referring to the residence below hers, where King had snorted his first Oxy the night before. Bertrand volunteered that she was waiting for her boyfriend, Travis, to get out of jail, and then would start a new life. “I want to have my prescription pills and have a nice apartment and save our money for two years and have enough for a down payment for a house in the country,” she said. At the house, she would live with her boyfriend. She added, “I thought I would have Dustin with me, and I would have two sons.”

At about 10 pm, she was driven to her to her parents’ home in North Augusta, half an hour from Brockville; she wouldn’t be able to return to her apartment until Monday, as police had sealed it pending King’s autopsy results. She arrived hungry and asked for a sandwich. Her mother, Hilda Bertrand, wanted her to talk about what had happened. “Mom, honest to God, we only smoked a joint,” Bertrand said. She was nodding her head sleepily and went to bed.

The next afternoon, she was still asleep when Hilda grabbed her feet to wake her up. Bertrand drank half a cup of coffee and told her mother that she felt very bad about what had happened, that King was a good friend, that she didn’t know he was dead, that she didn’t know what was going on. “She wasn’t making a lot of sense,” her mother recalled. Bertrand slept for most of the weekend.

On Monday, November 24, Hilda drove Bertrand back to Brockville. They fought the whole time. That was the way their relationship had always been. “I can’t remember a day when there wasn’t turmoil,” Hilda said. “Everything for Donna was turmoil, a catastrophe.” When they arrived at her apartment, Bertrand asked her mother for $20.

The same morning, coroner Dr. Jonathan Wyatt telephoned Redekopp to inform him that a young man had died from an overdose in Bertrand’s apartment. He mentioned that the dead man was lying near an empty prescription bottle, made out to Bertrand, with Redekopp’s name on it. Wyatt suggested that Redekopp contact the police, but Redekopp didn’t feel that was necessary. Instead, he sat down and wrote Bertrand a letter of dismissal: “Dear Donna, Effective immediately I will no longer be seeing you as your family doctor. This is due to the misuse of your prescription medications. We have informed the local pharmacies of this and any prescriptions on hold have been cancelled. When you have obtained a new physician and I have received a signed release for your file from that office, I will transfer your medical information to them. Please do not contact the office to discuss the matter.”

King’s autopsy took place the same day. When pathologist Dr. Samuel Ludwin examined the teenager’s corpse, he found pulmonary edema—an accumulation of fluid in the lungs, common in drug-overdose deaths—and a lot of frothy material in the lungs, trachea and mouth. King’s body showed .46 milligrams of oxycodone per litre of blood—a level consistent with a fatal overdose. A person who had developed tolerance to the drug through continued use could survive with the level found in King’s body, Ludwin explained, but it was “within the fatal range.”

In the week following King’s death, Donna Bertrand called her mother every night. Mother and daughter were supposed to go Christmas shopping on Friday, but Bertrand bowed out. She phoned her mother that evening to apologize for skipping their date; later that night, she spoke to her son after he returned from a school dance.

Hilda had to make a trip to Brockville two days later, on Sunday, November 30. She dropped by her daughter’s apartment building, rang the buzzer and got no answer. She walked down King Street to Tim Hortons, one of her daughter’s favourite hangouts. Bertrand wasn’t there and no one had seen her. Hilda returned to 89 King Street West and rang the buzzer several more times. The next day, she told her husband that she would call the police if she didn’t hear from Bertrand soon. It wasn’t like Bertrand to be out of touch with both her mother and her son.

The following Tuesday, just before noon, Tommy Douglas, a childhood friend of King’s, decided to climb through Bertrand’s back window via the fire escape. He had been knocking on her door for a couple of days. Bertrand was the only person from whom the twenty-two-year-old would buy OxyContin, since she never overcharged. Douglas clambered through the kitchen window, which looked out onto the St. Lawrence River, and walked toward the living room. There was an odd smell. He saw Bertrand’s legs, and pills scattered on the floor.

Douglas panicked, fumbled with the double locks on the front door and sprinted down the stairs to find Bronkhurst, the janitor. They returned to the apartment. Bertrand was lying facedown in the living room. She was wearing a blue velour top, blue jeans and brown boots. Her right arm was underneath her body and her left arm was curled into her. On the coffee table lay a copy of In Touch magazine, with the blaring headline “Betrayal.”

Tom Fournier arrived on the scene around 1 pm. Just eleven days earlier, he had found Dustin King dead in the same room. The corner of the couch where King’s head had lain was still stained with the white froth from his mouth and nose. Yellow sticky notes, put there by police to identify each room in the apartment by number, remained on the doorframes.

It wasn’t oxycodone toxicity that killed Bertrand. Instead, the pathologist who performed the autopsy found elevated levels of Paroxetine (an anti-depressant), Venlafaxine (another anti-depressant) and Prochlorperazine (a psychiatric medication) in her body. Those drugs were responsible for her overdose. Her death appeared to be a suicide. “This is not a situation where an individual was forgetful and took an extra tablet,” toxicologist Dr. Daryl Mayers later said.

Bertrand had been dead for a day or two when her body was found. In North Augusta, Hilda Bertrand had just put on a pot of coffee, and was preparing to call the police about her daughter, when she saw a squad car park outside her house. She knew right away that something terrible had happened.

II.

Drug abuse isn’t the sort of thing that most people would associate with small, stately Brockville, population twenty-two thousand. But pills were an integral part of the city’s past. Brockville, one of the oldest settlements in Ontario, was built along the St. Lawrence Seaway shipping route, and is now located just off the Trans-Canada highway, between Toronto and Montreal. The legacy of the city’s old money is evident in the grand mansions along the river. One of the most impressive is the former home of George Fulford, an entrepreneur who made a fortune pushing his Pink Pills for Pale People. They were advertised as a “miracle cure” for conditions ranging from digestive to emotional problems, although they contained little more than iron oxide and Epsom salts. The Fulford estate is now a Brockville tourist attraction and museum of patent medicines.

In June 2011, more than two and half years after Dustin King and Donna Bertrand died, the inquest into their deaths began. It was held in the imposing Brockville Court House, a neoclassical stone building completed in 1844 that sits uphill from the city core. Justice, holding her scales, stands at the apex of the Court House roof; she gazes over the heritage buildings of downtown, the twentieth-century condominiums that perch on the waterfront, the riverfront marinas and the ships passing by on the St. Lawrence. The inquest lasted seventeen days, more than three times as long as the average Ontario inquest over the previous five years. About forty witnesses appeared.

The motto of the Office of the Chief Coroner of Ontario is “We speak for the dead to protect the living.” By calling the inquest, Chief Coroner Dr. Andrew McCallum was sending a signal: his office was giving top priority to the alarming increase in prescription drug–related deaths in Ontario. During 2008, the year King and Bertrand died, almost three people a week had died from overdoses of oxycodone in the province. The “narratives” around those 148 deaths indicated that the majority had taken OxyContin, McCallum told the inquest. Three other widely used prescription narcotics—morphine, hydromorphone and Fentanyl—accounted for another 202 deaths. All told, a prescription narcotic–related death occurred almost every day in Ontario in 2008.

Some of those who died, like King, were using OxyContin that had not been prescribed for them. “But some—and this is an important consideration—were using it within the context of therapy,” McCallum noted. “They may have just been taking more than was intended, or they may have been prescribed a dose that was above the safe level.”

Given the mortality rate from prescription painkillers that year, there were many other deaths that could have been the subject of an inquest. The Brockville deaths were selected in part because the events were “exemplary of the problem,” and it was believed a jury could, on the basis of the evidence, “make practical and reasonable recommendations to prevent future deaths,” McCallum later told me. As well, Fournier had pushed hard for an inquest into the deaths that had shaken his hometown.

One question facing the inquest was why so much OxyContin was being prescribed so widely. McCallum attributed the increase to a change in opioid-prescribing philosophy over the previous twenty years, from an “as-needed” basis for sick and dying patients toward constant, slow-release dosing. Post-operatively, patients heal better if their pain is better controlled, and slow-release painkillers, such as OxyContin and hydromorphone, are ideal for end-of-life care, and for treating cancer-related pain. There had also been a long pendulum swing away from so-called “opiophobia,” which once prevailed due to concerns that opioids can lead to addiction.

But problems developed when family doctors began to prescribe slow-release opioids for chronic non-cancer pain—and especially when such drugs were prescribed at high doses. Dr. Irfan Dhalla, a clinician and researcher who appeared at the inquest as an expert witness, co-authored a report that studied patients on the Ontario Drug Benefit Program who received opioids over a nine-year period. Its findings: those who were prescribed more than 200 milligrams of oxycodone a day were three times as likely to die of opioid toxicity as those on lower doses.

The manufacturer of OxyContin had, in fact, carefully choreographed this shift in prescribing patterns. When OxyContin was approved—1995 in the United States, the following year in Canada—Purdue Pharma began to aggressively market the drug for chronic-pain patients. In the US, alarm bells went off within a few years. In 2003, the US General Accounting Office, at the request of Congress, published a report on OxyContin abuse and diversion that noted the company’s marketing campaign. Four years later, the US Food and Drug Administration’s Office of Criminal Investigations announced that Purdue had agreed to pay more than $600 million “to resolve criminal charges and civil liabilities in connection with a long-term illegal scheme to promote, market and sell OxyContin, a powerful prescription pain reliever that the company produces.” The company, the OCI concluded, had set out to expand its market share by making false claims about the drug. Sales forces were trained to tell doctors that it did not cause euphoria, that it was less addictive than morphine and that, at low doses, the drug could be discontinued without the patient suffering withdrawal symptoms.

When the drug was made available on Ontario’s public plan in 2000, the number of prescriptions began to soar. Purdue promoted OxyContin in Canada so successfully that, between 1998 and 2010, sales rose from $3 million to $243 million. Sales levels were nudged upward by “thought leaders” in medicine who told their colleagues that there was no dose limit for OxyContin, Dhalla said at the inquest. Such thought leaders, who were mainly pain specialists, often shared these opinions at pharmaceutical company–sponsored dinner meetings, workshops and continuing medical education sessions.

In 2004, faced with alarming rates of addiction and death, Newfoundland and Labrador established an OxyContin Task Force. But in Ontario the problem mostly went unchecked, even though the province took the lead in Oxy prescriptions. By 2008, the College of Physicians and Surgeons of Ontario, the regulatory body for doctors, was getting urgent phone calls from communities around the province seeking help with issues surrounding prescription painkillers—addiction, diversion and misuse. “They were having problems and they knew that doctors were part of the problem,” Rhoda Reardon, CPSO’s research and evaluation manager, told the inquest. “Generally speaking, the one you heard about was OxyContin.”

In response, the college convened a wide group of stakeholders, and in September 2010 it published Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis. The report, which contained thirty-one recommendations, was released quietly and received little media attention, despite the fact that the normally staid CPSO had declared Ontario “in the midst of a public health crisis stemming from the inappropriate prescribing, dispensing and illicit use of opioids.” Worse, the CPSO acknowledged that the crisis was iatrogenic—that is, fostered by the health-care system itself.

What makes OxyContin so attractive, so addictive? Tommy Douglas, who was addicted to Oxy for two years, put it this way: “It makes you nod like your eyes are closed, you are so relaxed. You hear everything but you are in your own little world.” Others talk about the euphoria, the elimination of worry and stress that accompanies a hit.

Tellingly, addicts are much more eloquent about the excruciating pain of withdrawal, an experience that comes after taking the drug for only a few weeks or months. “You would be sick, have hot flashes, you’d sweat, your whole body is in pain,” Douglas told the inquest. Vincent Shaver, who went through cold-turkey withdrawal while in jail, explained that, with a lot of drugs, withdrawal is in your head, but with OxyContin it’s physical: “It’s like the flu three times over. You are puking, you have diarrhea, you want to curl up in a ball and dig a hole and bury yourself.” But, according to Douglas, all the pain “would melt away just like that”—he snapped his fingers—“when you got more.”

Could withdrawal have played a role in Bertrand’s suicide? At the inquest, Crown Attorney Curt Flanagan asked Redekopp about the letter he had written to Bertrand on the first weekday after King’s death—the letter that terminated her as a patient, advised her that he was informing all Brockville pharmacists about his decision and warned her not to contact his office. “We have heard evidence of withdrawal symptoms, that it can be very serious—body aches, vomiting, nausea, depression,” Flanagan said. “So by cutting her off, was there no concern about withdrawal?”

“It never occurred to me,” Redekopp answered. “My mind was flying.” When questioned about this lapse later, by Bertrand’s older sister, the doctor replied, “I felt a deep sense of betrayal that Donna had lied to me. I was angry at Donna.”

Throughout her life, Bertrand had struggled hard with various addictions. The youngest of three, she’d been a rebellious teenager. At age fifteen, she ran away from her parents’ home, which was in the countryside near Oxford Mills. Her sister Joanna tracked her down at a boarding house in Ottawa, and, about a month later, “home she came,” her mother said. Bertrand later told her psychiatrist that she had been raped and confined for three days at age sixteen.

Still, she graduated from high school in the mid-1980s, enrolled in a two-year course to qualify as a registered practical nurse and began working. A photo of her from that time depicts a tall, slim woman in a light-blue dress, with long dark hair and big-frame eyeglasses. She’s smiling saucily at the camera, a cigarette dangling between the fingers of her right hand.

But after she injured her back, her life began to roll downhill. She lost her full-time job and ended up cobbling together part-time work. In 1996, Bertrand gave birth to her son. Three years later, Bertrand attempted suicide by overdose and had her stomach pumped. A short while later, she tried to slit her wrists. After that incident, Hilda begged Bertrand’s doctor to put her in a short-stay psychiatric unit. The doctor told Hilda that Bertrand was simply looking for attention.

By the early 2000s, Bertrand’s life was spinning out of control. Generous to a fault, she would “give you the shirt off her back,” her mother said, “but she couldn’t seem to help herself.” Her son was mostly living with his maternal grandparents, and Bertrand was sometimes working, sometimes on welfare. In November 2003, she began to see Cliff Redman, a Brockville-based counsellor with the Tri-County Addiction Services. In her self-assessment intake report, Bertrand, then thirty-six, admitted that she was addicted to crack cocaine and that she had lost both her job and her son as a result. She also said that she was not confident she could resist the drug.

Redman managed to fast-track her into a twenty-one-day residential-treatment program in Ottawa. She attended, but discharged herself early; shortly afterward, in early 2004, she enrolled in a day-treatment program at the Ottawa Hospital. Over the next three years, Redman continued to meet with Bertrand about twice a month, and he arranged for her enrolment in two other residential-treatment programs, in Windsor and Sudbury, both of which she completed. “There was a side to Donna that cared a great deal about her son, and there was a side that felt caught in a lifestyle that had its own attraction,” Redman said.

Since at least 2001, Bertrand’s family doctor, Dr. John Findlay, had been prescribing Percocet for her ongoing back pain. In January 2005, she was charged with forgery because she had altered a prescription for Percocets to read eighteen instead of eight.

When Findlay died, in April 2005, McFeely agreed to act as her family doctor as well as her psychiatrist. Bertrand was still addicted to drugs. According to McFeely’s testimony, her first urine test under his care came back positive for cannabis and cocaine. “I see a lot of people get into street drugs because of their past. You try to get them to realize that this was a past incident and not let this run your life,” he told the inquest. Donna, he continued, was “more a sad person than a bad person.” He diagnosed her with depression and ongoing anxiety.

By September of the following year, new urine tests would show that Bertrand had put cocaine behind her. But all was not right in her life. She was having serious emotional difficulties, in part because her son, now ten, didn’t want to live with her. She was also facing legal problems connected to her abuse of the medical system. In July 2006, she had been charged with twenty-two counts of double doctoring; she had obtained prescriptions for Percocet from at least two doctors other than McFeely, and the province’s drug-benefit plan had flagged her activity. In exchange for the charges being dropped, Bertrand agreed to enrol in one of the residential-rehabilitation programs Redman arranged for her, and McFeely kept her as a patient. Then, in October 2007, Alan Redekopp became her family doctor.

At the inquest, on June 14, 2011, Flanagan asked Redekopp, “Were you aware of her drug abuse?”

“No,” Redekopp answered.

“So you had no information from outside sources, except Donna Bertrand. You had no records from Dr. McFeely, Dr. McGillis”—an anaesthetist who ran a part-time pain clinic—“and Dr. Findlay? So you relied exclusively on what she told you?”

“At regular office visits,” Redekopp replied, “I took her blood pressure, checked her heart, examined her back and did other quick tests.” Through two days of questioning at the inquest, Redekopp remained calm, often sitting with his legs crossed. He never became defensive or angry, even when Flanagan questioned him aggressively.

On the opening day of the inquest, the presiding coroner, Dr. Roger Skinner, had explained that inquests are held in part to “satisfy the community that the death of no one is overlooked, concealed or ignored.” But would this just be seen as the death of a couple of addicts? Shawn White, a detective with Cornwall Community Police Services, told the courtroom that prescription narcotics are “not a drug isolated by economic class; there are health-care professionals I am aware of who have developed a severe addiction to prescription opioids.” But he added that police generally deal with street-level drug enforcement, which tends to involve people of lower socio-economic classes. According to Dr. Meldon Kahan, the head of addictions at St. Joseph’s Hospital in Toronto, the prescription-opioid crisis is particularly hard on the most vulnerable and marginalized, who may have fewer options to deal with pain, and may also have psychiatric and physical disabilities.

In Canada, there is little communication between physicians who treat pain and those who treat addiction. Some pain doctors have dismissed the attention that opioid misuse has received, labelling it scare-mongering, a resurgence of opiophobia, and insisting that only a tiny minority of people—like Donna Bertrand—run into trouble with addiction. McCallum acknowledged this divide. “There is a diversity of opinion out there,” he told me in an interview, choosing his words carefully. “There are people who would view themselves in the chronic pain treatment lobby who want, quite justifiably, to see people with chronic pain adequately treated. And there are those who say the treatment can’t be worse than the disease.” It’s difficult to treat pain, he continued, because there is no objective test. “But the treatment of pain has to be done in a sophisticated and multidisciplinary manner. Simply prescribing narcotics on request can’t be an appropriate and sufficient treatment for people with chronic non-cancer pain.”  

Bertrand did not become addicted to Oxy after buying it on the street—she was “exposed therapeutically,” as Beth Sproule, an advanced practice pharmacist at the Centre for Addiction and Mental Health, put it. Sproule, an expert witness at the inquest, did some of the early research on prescription-opioid addiction in Ontario. Her findings revealed that most people who sought treatment at her institution were in their forties and had been prescribed OxyContin by their physicians. “Even if opioids are used as prescribed,” she said, “patients can become addicted.”

Redekopp missed many red flags about Bertrand’s addiction. There were obvious signs of trouble: just two months after he accepted her as a patient, he received a report from a colleague that Bertrand had shown up in the emergency room of the Brockville General Hospital. The physician said that Bertrand “appeared to be drug seeking.” Over the fourteen months Redekopp saw her as a patient, he acknowledged, he had been contacted at least four times by police, who were concerned that Bertrand was diverting her drugs.

People like Bertrand, who face mental-health problems, have heightened feelings of pain and blunted responses to opioids, Kahan told the inquest. “It’s futile to keep increasing the dose if there is no response,” he said. Bertrand was in pain, “but let me emphasize—the pain was almost a red herring for her. She was addicted.” OxyContin, if prescribed in moderate doses to selected patients, can help relieve pain. “It’s like alcohol. Most people can enjoy a drink, and drink moderately,” he said. “But a minority have their lives destroyed. Only in this case, the cause is a substance prescribed by doctors who, if they don’t know what they are doing, can cause terrible harm to patients.”

At any coroner’s inquest, parties with an interest in the proceedings are given “standing”—they sit near the front of the courtroom and can ask questions of the witnesses. Given Purdue’s role in producing and marketing OxyContin, it was understandable that the company hired two senior lawyers from a leading Bay Street law firm, Borden Ladner Gervais, to represent its interests at the inquest. The lawyers kept a low profile, intervening rarely but significantly.

When a drug is approved, Health Canada and the company agree on the text of a product monograph, which provides information about the drug’s active ingredients, dosage form, risk information, side effects and other matters. At the inquest, one of Purdue’s lawyers pointedly asked Redekopp if he understood that the information in the OxyContin product monograph was “more important than what sales representatives tell you.” Yes, Redekopp replied, he knew that. The lawyer’s question avoided the issue of why sales representatives—who, after all, worked for Purdue and had received bonuses for increasing OxyContin prescriptions in their sales territory—provided misleading information in the first place.

The families of Dustin King and Donna Bertrand were also granted standing to ask questions at the inquest, but couldn’t afford to hire lawyers. Alongside the attorneys from major law firms—one such firm also represented Redekopp and McFeely—sat King’s mother, Brenda Wiles-Toupin, and Donna’s sister, Joanna Bertrand. Wiles-Toupin, who had been living in Pennsylvania at the time of her son’s death, had kept in touch with King every few days. Joanna lived with her family in Ottawa and had cut ties with Bertrand five years earlier, out of anger at her sister’s behaviour. Articulate and fiery, she now acted as a strong advocate, and asked tough questions of various witnesses. At one point, she asked Redekopp what he was thinking when he wrote the letter terminating her sister as a patient.

“I wasn’t thinking of the consequences of cutting her off abruptly,” he replied.

“Are you not trained to think?” Joanna asked.

Because OxyContin is a legal drug, it’s extremely challenging for police to prevent its illegal diversion. Costly undercover surveillance is required. But Detective Fournier was determined to do something about one source of the drug: Alan Redekopp and his high rates of prescribing. On June 30, 2009—seven months after Bertrand’s death and almost two years before the inquest—Fournier had filed a complaint about Redekopp with the CPSO.

The CPSO commissioned an expert report on Redekopp’s practice. The unnamed expert examined Bertrand’s file and took a sample of charts of twenty-one patients still under Redekopp’s care, focusing on those that included narcotic prescriptions. (Redekopp told the college that, of his approximately 2,500 patients, he was treating about one hundred for chronic pain.)

The report concluded that Redekopp failed to act on warning signs from eight patients to whom he had prescribed narcotics and benzodiazepines, and that he prescribed “bizarre” and dangerous combinations of drugs. In one case, he had prescribed narcotics to a patient after meeting her for the first—and only—time.

Family physicians prescribing opioids for chronic pain must keep meticulous medication logs, use urine drug screening, fax prescriptions directly to pharmacies and confront aberrant patient behaviour, the report stated. The fact that Redekopp “had neither instituted nor even apparently contemplated such changes in his practice following the death of a patient is troubling.”

It would not be until Remembrance Day of 2010 that the CPSO prohibited Redekopp from prescribing narcotics or controlled substances. Just over a year later, on November 21, 2011, the college’s disciplinary committee issued its final decision. Redekopp was reprimanded. The prohibition on his prescribing narcotics was made permanent and noted on his licence to practice medicine.

In his final address to the jury, Dr. Roger Skinner noted that doctors take an oath to do no harm, and yet, he added, “it is clear to me that doctors bear a great responsibility” for the problem of prescription narcotic–related addiction and death. Doctors have acted “not out of malice but because of information and misinformation provided in part by those who produce the drugs. It is also clear to me that immediate action must be taken to address this situation.”

On July 5, 2011, the inquest jury ruled that King’s death was accidental and that Bertrand’s was suicide. The jury made forty-eight recommendations. The first was that Health Canada fund research studies of more than twelve months’ duration to determine the long-term effectiveness of opioids for chronic non-cancer pain; another was that Health Canada withdraw approval for all controlled-release opioid formulations that exceed the equivalent of 100 milligrams of morphine. Although the Coroner’s Office says it has a good track record of having recommendations acted on, Health Canada has not funded long-term research studies and rejected the idea of banning doses above a certain amount. The jury also recommended that the Ontario Ministry of Health and Long-Term Care prioritize development of the province’s long-delayed electronic health-record system; develop a coordinated and comprehensive strategy for the treatment of pain and addiction in Ontario; and fund joint education sessions of the CPSO and Ontario College of Pharmacists. These recommendations, the Ministry says, are under consideration or have been acted on.  

A year after the inquest, in June 2012, I met with Fournier at the Brockville Police Services headquarters, a low-rise brick building located off a busy thoroughfare near the Trans-Canada Highway. I wanted to know how he felt about the inquest and what, if any, changes it had brought about locally. Fournier ushered me into the station and we spoke in the office of a colleague who was on leave. A dark blue bullet-resistant vest was draped on the back of a chair.

Fournier told me that prescription narcotics are now “a little bit tougher” to get on the street in Brockville and, when available, are more expensive. Relations among the police, pharmacists and doctors have improved. But the detective expressed some surprise at what he considered the mild penalty that the CPSO had imposed on Redekopp. The doctor, for his part, has told reporters that his medical practice is now “better off” because he doesn’t have to cope with patients seeking more narcotics, or reporting lost or stolen prescriptions.

Purdue Pharma, which was so expensively represented at the inquest, kept a low profile and survived the process without censure. In March 2012, the company pulled OxyContin from the Canadian market and replaced it with OxyNeo, a formulation the company says is harder to abuse because the pills have been “hardened to reduce the risk of being broken, crushed, or chewed.” But, eight months later, Purdue’s patent on OxyContin expired. Almost immediately, despite the public objections of many doctors, chiefs of police and provincial health ministers, Health Canada gave market authorization for six companies to manufacture generic versions of the original OxyContin.