Trina Saby blames drug addiction for cutting her son's life short and believes the physicians that treated him share some of the blame.
"He wasn't on the street corner buying something. He was at the hospital or doctor's office getting these prescriptions," said Saby.
Her son, Kenneth Lee Pears, was 27 years old when he overdosed on prescription morphine.
Saby filed a complaint to the College of Physicians and Surgeons of B.C. alleging that the physicians treating her son over prescribed narcotics, despite knowledge of his addiction and mental health issues.
- The Fentanyl Fix is a week long CBC series exploring potential solutions to B.C.'s opioid overdose crisis.
CBC News obtained a copy of the letter reviewing Pears' care. It admits mistakes were made by some of the doctors that treated Pears.
Pears had visited at least seven different doctors, a term known as 'doctor shopping' — the practice of visiting multiple doctors to obtain multiple prescriptions.
The committee was highly critical of one of the physicians who prescribed Pears narcotics, noting it couldn't find any notes on the rationale for the prescription.
It also said Pears' frequent requests for two-month supplies of high-dosage narcotics should have raised red flags.
"Mr. Pears was given prescriptions for high-dose narcotics that heavily outweighed his problem. There was no evidence that [the physician] reviewed risks of suicide, addiction or diversion with Mr. Pears," the document stated.
Saby wants her son's case to be a warning to parents, patients and physicians in the province on just how dangerous prescription opioids can be.
"It was just so easy to get these prescriptions and they were free and I think he had a sense of security with them, because they are prescribed by the doctor," she said.
"Had that [prescriptions] not been so readily available, his story might have been a little different," said Saby.
The B.C. College of Physicians and Surgeons admits physicians have contributed to the opioid crisis with over-prescribing, and in 2016, it issued new standards and guidelines for safer prescribing.
According to Alan Cassels, a pharmaceutical policy researcher, B.C. dispenses more than double the amount of opioids compared to the lowest opioid dispensing province, Quebec.
"The fact they are prescribing hundreds of pills to someone with lower back pain or for wisdom tooth extraction, that to me is a sign of a way too liberal an approach to prescribing these drugs," said Cassels.
Cassels along with other experts are calling for more training on pain management for physicians.
Addiction medicine specialist and family physician, Dr. Alexander Caudarella, worries that without proper pain management training, some physicians may cut off opioid dependent patients and that could have deadly and unintended consequences.
"Leads them directly to heroin or fentanyl on the street, increasing their chances of an overdose even further," said Caudarella.
Caudarella also worries some physicians may dismiss opioid-dependant patients from their practice if the physician feels incompetent in safely treating the patient. He worries that will lead addicts not only to street drugs but to 'doctor shopping'.
Cassels said in order to avoid that, all physicians need to religiously use the province's PharmaNet service, the province wide system used to check the drug history of patients, which is currently not mandatory for all physicians.
Only doctors in methadone clinics, walk-in and urgent care settings are required to have access to PharmaNet, though the Ministry of Health and the college say they are working to make it mandatory — although no date has been given.
With files from Natalie Clancy.