Dozens of doctors and pharmacists failed to catch an impostor who duped them into handing over 23,000 painkillers during a five-year drug shopping spree using two women's stolen care cards, B.C. regulators say.
The B.C. College of Physicians and Surgeons and the College of Pharmacists began investigating after a CBC Go Public investigation exposed how easily Audrey Gettings was able to use two other women's personal health numbers to get oxycodone using a convincing story about back pain.
"She went in screaming about a sore back and she was able to get 400 or 600 oxys," Sandra Adamson said of the impostor, who used her care card number to fool physicians and pharmacists.
'Nobody caught it'
"She walked into a doctor's office gave them my name, gave them my date of birth and said, 'I don't have my care card' … and nobody caught it," said Sandra, who is furious pharmacists and doctors failed to check Gettings's ID.
Oxycodone is a highly addictive narcotic known as "hillbilly heroin" on the street, where one pill can fetch $20.
Sandra and her sister Lisa Adamson had no idea their care cards were being used in an elaborate drug-shopping spree until they were both nearly arrested.
Police advised them to request their medical records after a prescription in Sandra's name was stolen from a pharmacy by a woman she recognized as Gettings, her former sister-in-law, on the pharmacy's surveillance video.
In B.C., a secure online database called Pharmanet tracks all prescriptions.
Records show 51 doctors wrote Gettings more than 250 prescriptions that were filled at 104 pharmacies between January 2007 and January 2013.
"Most of these doctors issued these prescriptions out of compassion for a compelling story for a patient in pain," said Dr. Galt Wilson, senior deputy registrar of B.C.'s College of Physicians and Surgeons.
He said the college chose to re-educate rather than punish the physicians who failed to detect the scam and that there was no evidence physicians intentionally over-prescribed.
Doctors 'required education'
"They didn't intend to do harm, they required education," said Wilson.
Forty-six doctors were found to be deficient in their prescribing practices and sent for three days of retraining.
The sessions involved paid actors posing as patients seeking narcotics.
"The medical profession needed to step up and do better, and these physicians have," said Wilson.
Most of the physicians failed to check Pharmanet, B.C.'s database that would have shown their patient was getting narcotics from dozens of doctors, because both health cards she was using were repeatedly prescribed oxycodone.
"A person dying of cancer doesn't even get that much medication," said Sandra Adamson, who questions how doctors were so easily fooled by Gettings's claims of back pain.
Sixteen physicians who repeatedly wrote prescriptions had their entire medical practices reviewed.
"A few wanted to blame the pharmacist, and that's unacceptable," said Wilson.
49 pharmacists disciplined
"This is something that shouldn't have happened," said Bob Nakagawa, registrar of the College of Pharmacists of B.C.
Forty-nine pharmacists had to sign promises to uphold their professional standards, and in particular, to check ID, to check what other drugs the patient is on, question the prescribing physician and flag a suspicious drug-seeker.
Eleven of the pharmacists who repeatedly filled Gettings's prescriptions were formally reprimanded, which means they could lose their licence if there is a repeat offence.
"Pharmacists take that very seriously, nobody wants to have a black mark on their record," said Nakagawa.
Records show some pharmacists did check Pharmanet records and dispensed the pills anyway, but Nakagawa said investigators found no evidence of intentional errors.
He said the pharmacists thought they "were doing the right thing and inadvertently allowed those drugs to be given to the wrong people."
Red flags were missed
He said pharmacists missed "a pattern of frequent narcotic use that's over a therapeutic need."
Lisa Adamson, whose medical records have since been corrected after she was wrongly accused of stealing a physician's medical bag and prescription pad, said she thinks there should have been suspensions.
"It's upsetting to be me, because I could have been arrested," she said, believing the medical professionals got off easy.
Gettings was convicted of impersonating Sandra Adamson, theft of a bottle of pills and obstruction.
The college of pharmacists says stopping prescription fraud is a priority, but Nakagawa said that while it's "less likely to happen, it's hard to say it won't happen at all."
Sandra Adamson said she's worried it could happen again. "What's to stop someone from going into another walk-in clinic and saying, 'I don't have my care card?'"
She believes Gettings would still be obtaining phoney prescriptions if she hadn't contacted CBC.
"Twenty-three thousand pills those doctors prescribed and the pharmacists filled. … and had we not called you guys, had she not stolen the bottle of pills, it would still be going on," she said.
The unnecessary doctor visits and prescriptions in this case cost taxpayers an estimated $30,000.