Opioid painkillers are supposed to be closely guarded on their journey from manufacturer to patient.
They are highly addictive, can cause deadly drug poisonings and have a high street value. So how could almost a quarter million of them disappear?
The loss of more than 245,000 hydromorphone tablets, all eight milligrams and sold under the brand-name Dilaudid, was reported to Health Canada in May 2023 by a pharmacy somewhere in Ontario. Whether they disappeared from the pharmacy itself, or even whether they made it there at all, is not known.
They would be worth about $4 million if sold on the street.
There was no armed robbery and no break and enter. The loss did not occur all at once, but over an unspecified period of time, said a Health Canada spokesperson.
The manufacturer of Dilaudid, Purdue Pharma (Canada), told CBC News there were no concerns flagged to them, and the product moved through their supply chain “as appropriate.”
CBC News has learned Health Canada referred a pharmacist to the professional regulatory college.
The Ontario College of Pharmacists confirmed it’s launched an investigation into the matter, but said it couldn’t give further details.
Officially, the reason for the loss cited in Health Canada data is “Loss unexplained.” There’s no requirement to report such losses to police.
That could be one reason the OPP’s top pharmaceutical opioid expert — and several big-city police forces in Ontario polled about the loss by CBC News — either hadn’t heard about it or wouldn’t answer.
Since the pandemic, unexplained losses from Canadian pharmacies appear to be on the rise, according to a CBC News analysis. It’s not clear whether some represent simple accounting mistakes or large-scale diversions to the street, where they fuel addiction and generate huge profits for organized crime.
“It is troublesome that we’re seeing such a high rate of unexplained losses,” said Patricia Trbovich, patient safety research chair at North York General Hospital and associate professor of health policy at the University of Toronto.
“There’s these controlled substances that are going missing and we don’t know why.”
From thefts to losses
CBC analyzed six years (2018-2023) of loss and theft data reported to Health Canada by pharmacies, drug wholesalers, hospitals and other places that handle controlled drugs. CBC obtained the data in an access-to-information request.
Many of the largest losses of drugs were highly addictive opioid painkillers and benzodiazepines.
CBC found unexplained losses — such as the Dilaudid in Ontario — now account for the majority of the potentially addictive and dangerous drugs reported missing to Health Canada.
That’s a change from the previous six-year period, when most of the reported losses were due to theft.
The amount of controlled drugs reported both lost and stolen has been increasing since the pandemic. But while the amount reported stolen dropped in 2023, losses continued to increase.
While thefts are relatively easy to understand — a pharmacy was robbed, or an employee was caught stealing drugs — losses are more ambiguous, and may or may not be indicative of controlled drugs leaking into the illegal market.
There are a number of things that could be contributing to the increase in losses, Health Canada said in a statement.
Reporting them has become easier with the introduction of an online portal, replacing what were in some cases fax communications. Knowledge of and compliance with the reporting requirements has improved, the statement said.
There were also about 1,000 more pharmacies in Canada in 2023 compared to 2018, a 10 per cent increase, according to the National Association of Pharmacy Regulatory Authorities.
However, CBC’s analysis uncovered dozens of individual incidents across the country in which tens of thousands of units of potentially dangerous and addictive drugs were reported missing.
Large losses more frequent
Single incidents, such as robberies or unexplained losses, in which more than 10,000 units of a drug went missing, account for just 102 out of more than 110,000 unique incidents in the data — a fraction of a percent.
And yet, they account for nearly a fifth (17 per cent) of the total amount of drugs gone missing.�
Put another way, this post-pandemic increase comes down to a small number of very large losses.
These large-scale losses are becoming more common. There were 16 of them in 2018; in 2023 there were 23.
A large loss in the data may result from a trickle of missing items all reported at once, if, for example, a pharmacy checks their inventory against what’s been ordered and dispensed for the first time in months and discovers things missing, Trbovich explained.
“It might also signal that we have these gaping holes in our system that are allowing for these large volumes of controlled substances to be stolen or lost at one time.”
Opioids still top loss reports but benzos rising
The opioid painkiller oxycodone remains the drug reported missing — most often stolen, rather than lost — in the highest quantities, CBC’s analysis found. This was especially true in Ontario, Alberta and Newfoundland.
However, there were fewer oxycodone tablets reported missing in 2018-23 compared with 2012-17. Other opioid painkillers, such as codeine and especially hydromorphone, saw an increase.
Some people who have been using oxycodone for a long time seek out hydromorphone because it is stronger, according to Detective-Constable Chris Auger of the OPP’s Drug Enforcement Unit.�
“They’ll either switch to fentanyl … or they go to something stronger as well with hydromorphone, which would be six to eight times more powerful than morphine, whereas oxycodone would be 2.5,” he said.
“So there’s going to be a gradual progression with people … who use drugs that may seek out something [stronger] to get that first high that they got again.”
The amount of benzodiazepines reported lost increased significantly between 2012-17 and 2018-23, particularly in Quebec and B.C. Benzodiazepines are depressants commonly prescribed to treat anxiety.
Auger says he, too, is seeing more of them on the streets.
“When we do get samples back from Health Canada, we are seeing benzodiazepines sort of mixed in with fentanyl to cause a more depressant type effect.”
On their own, benzos will not result in drug poisonings, Auger says.
“I was told by my pharmacology prof, the only way you got killed by benzos, you got hit by the Xanax truck delivering it,” he quipped.
But they do become dangerous when mixed with opioids or alcohol, Auger explains.
“They’ll take it together and it’ll make them feel almost super drunk. But really what’s happening is they’re poisoning their system. Same with the opioids. They might take the opioids and … they might feel a new type of high or a more sustained high.”
When benzos are mixed with opioids, there’s no quick first aid that first responders can give in the event of a drug poisoning, Auger said. Patients will not be revived with naloxone, which is used to treat opioid poisonings, and have to be taken to the emergency department, he added.
Technology could help
The widespread introduction of time-delay safes in Ontario pharmacies in 2023, following some other provinces, is likely why the amount of controlled drugs stolen in armed robberies and B&Es dropped significantly, Auger says.
These safes are used to store certain high-value drugs, such as opioids and testosterone, and don’t open for a set amount of time after a pharmacist enters a code. Prominent signage on pharmacy doors and windows tells prospective thieves the safes are in use.
This keeps pharmacists safer, which is good news, Auger says. But he’s also seeing more clandestine methods of theft, such as frauds and forgeries, creeping up.
There are a number of things that can be done to cut down on such losses, says Mark Fan, a research manager who works with Trbovich at North York General Hospital.
Some are as simple as ensuring it’s not the same person doing the ordering, the receiving and the dispensing. In one case study, a hospital pharmacy technician had all of these roles, Fan said. It was only when that person got into a car accident and someone else had to take over that it was discovered they’d been stealing drugs.
While it can be tempting to focus on identifying and punishing the person responsible, that alone will not solve the problem, Trbovich says.
“The idea behind that thinking is that if you remove the bad apple from the system, then your systems are going to be safe. The reality, however, is that this blame-and-shame approach doesn’t really make your system safer because you still have these lingering safety threats.”
Key to making things more secure is taking humans out of some of these processes, Trbovich says.
Automation of things like drug counts in different locations, or reconciling what’s been ordered against what’s been received and dispensed are all things that could cut down on losses, she says.
Another vulnerability Trbovich identified are handoff points where drugs are transferred from one place to another. Cameras set up in these places could be a powerful deterrent, she said.
“Unless we have the proper checks and balances in place and the proper signals to detect when a loss or theft has occurred, then we’re going to continue to see an increase in these losses,” she said.
“Essentially we need to put the control back into controlled substances.”
With files from Jocelyn Shepel and Aloysius Wong
Methodology
CBC News filed an access to information request with Health Canada for controlled drug loss and theft reports for 2018-2023.
The drugs lost were measured in 18 different units. CBC took all loss reports measured in tablets, capsules, or similar forms – which comprised 95 per cent of the missing drug reports in the data – and used this as the basis for our analysis. Losses measured in millilitres, milligrams, grams and kilograms, as well as patches and vials, were analyzed separately.