Hamilton hospitals have lost track of thousands of doses of highly addictive opioids in recent years.<\/p>\n
Exclusive data obtained by The Spectator shows more than 1,900 tablets, pills, vials and ampoules of controlled drugs went missing from Hamilton Health Sciences and St. Joseph\u2019s Healthcare Hamilton sites between January 2020 and April 2025.<\/p>\n
It\u2019s part of a growing countrywide problem known as drug diversion, which experts say puts patient safety at risk, undermines trust in\u00a0health-care systems and fuels addiction.<\/p>\n
The disappearances in Hamilton also come as the city grapples with an opioid epidemic that has left hundreds of people dead this decade.<\/p>\n
Of the roughly 7,800 milligrams in drugs that went unaccounted for at HHS and St. Joe\u2019s between 2020 and 2025, more than 95 per cent cent belonged to a class of opioids used to treat chronic and severe pain, including hydromorphone, oxycodone and morphine.<\/p>\n
A growing problem inside hospitals<\/p>\n
According to The Spectator\u2019s analysis of the\u00a0five-year data set, which was obtained via multiple freedom-of-information requests, half of the vanished drug haul at local hospitals was reportedly stolen.<\/p>\n
<\/p>\n
The Spectator\u2019s analysis found most drug-loss reports at Hamilton hospitals were classified as \u201cmissing\u201d rather than confirmed thefts.<\/p>\n
The Associated Press file photo<\/p>\n
That includes two significant thefts at HHS facilities in 2024, when hundreds of milligrams of\u00a0opioids disappeared over several months in an emergency room and a specialty unit.<\/p>\n
Data shows the complex care unit at St. Peter\u2019s Hospital lost 280 Percocet pills and 138 hydromorphone tablets of varying strengths\u00a0between December 2024 and March 2025.<\/p>\n
HHS described the losses in a data sheet as \u201cdiversion noticed over four months involving (a) nurse on unit.\u201d\u00a0<\/p>\n
The same description was given for the roughly 400 mg of liquid hydromorphone, stored in 200 sealed glass capsules, that was stolen from the emergency room at Hamilton General Hospital between April and October 2024.<\/p>\n
What happened to the missing drugs or the involved nurses\u00a0is unclear.<\/p>\n
HHS cited employee privacy and refused to comment on the cases when asked if staff were disciplined or police were contacted.<\/p>\n
Reports of missing drugs in Canadian hospitals or pharmacies must be filed to Health Canada within 10 days and include a reason, like spillage or theft. Health Canada defines drug diversion as health-care workers redirecting medication from its intended destination for personal use, sale or distribution to others.<\/p>\n
HHS and St. Joe\u2019s operate more than a dozen facilities across the city and employ thousands of people. Cases of diversion are rare relative to the millions of doses of drugs they dispense each year.\u00a0<\/p>\n
Between 2020 and 2025, the health-care networks filed only 131 individual drug loss reports to Health Canada.<\/p>\n
Twenty-seven of those were attributed to theft \u2014 including 21 at HHS.<\/p>\n
In August 2020, HHS reported three incidents of theft at Hamilton General Hospital involving three vials of liquid fentanyl, hydromorphone and morphine.<\/p>\n
A few months later, in November of that year, Hamilton General Hospital experienced another 10 cases of thefts, with HHS reporting multiple forms of hydromorphone \u2014 20 tablets and more than a dozen vials of varying strengths \u2014 seven oxycodone pills and two morphine injections as stolen.<\/p>\n
More losses in recent years<\/p>\n
While HHS has filed fewer missing drug reports to Health Canada than St. Joe\u2019s in the past five years \u2014 58 to 73 \u2014 the former outpaces the latter when it comes to quantity of lost drugs, with 1,162 tablets, pills, ampoules and vials (about 5,300 mg in total) reported missing or stolen compared to 755 (about 2,500 mg total) at St. Joe\u2019s.<\/p>\n
Much of the losses at HHS have come in the past two years. The network reported 486 units of missing or unaccounted for drugs in 2020 before a lull in 2021, 2022 and 2023 saw just 31 units disappear over three years. Since 2024, they\u2019ve reported 648.\u00a0<\/p>\n
\u201cDrug diversion, while rare, is a known risk within the health-care sector,\u201d HHS said in an emailed statement,\u00a0adding it couldn\u2019t comment on specific cases \u2014 such as the thefts \u2014 due to employee privacy and confidentiality.\u00a0\u201cWe take this issue seriously and have robust safeguards in place to prevent and detect it.<\/p>\n
\u201cThis includes the use of automated technology to track and measure controlled substances and flag unusual patterns. We also follow strict policies and procedures that align with regulatory standards to guide our response to any suspected diversion.\u201d<\/p>\n
The fact that more than a third of reported drug-loss incidents at HHS were attributed to theft, rather than just missing or lost, is unusual.\u00a0<\/p>\n
Research on drug diversion in Canada\u00a0suggests most drug losses are reported as missing without explanation.<\/p>\n
Between 2015 and 2019, for example, hospital pharmacies in Canada reported more than 3,000 incidents involving lost or stolen substances, according to a study<\/a> in the Canadian Medical Association Journal. Among those, 84 per cent were classified as \u201cunexplained.\u201d<\/p>\n \u201cIt\u2019s quite difficult to track diversion,\u201d said Mark Fan, a researcher at North York General Hospital who studies drug diversion.<\/p>\n In hospital settings, Fan explained, the ordering, dispensing and charting of medication often occurs across multiple different computer systems \u2014 and sometimes on paper \u2014 that don\u2019t always connect. Linking those transactions can be so tedious that drug losses slip through the cracks, he said.<\/p>\n \u201cBecause it\u2019s so time consuming to link these transactions between all these systems, we think there\u2019s a likelihood there could be under-detection happening.\u201d<\/p>\n A 2019 analysis in the Journal of Hospital Medicine,<\/a> co-authored by Fan, noted controlled opioid losses are increasing in Canada \u2014 partly because of the many potential routes for diversion. Doctors might over-prescribe medications or falsify prescriptions, while nurses and other staff might swipe drugs from storage, divert medication meant for the waste bin or substitute doses with something like a saline solution to conceal thefts.<\/p>\n Speaking generally, Fan said diversion can happen in two ways: There\u2019s the physical stream, where someone just takes the drug from storage, and the \u201cmore sophisticated\u201d avenue, which involves the manipulation of records and documents.<\/p>\n \u201cLet\u2019s say two boxes of medication arrive at a hospital but (staff) report only one arrived,\u201d Fan explained. \u201cYou have more difficulty realizing that something has happened because the documentation almost makes it look like it never showed up.\u201d<\/p>\n Those gaps in tracking align with research<\/a> Fan co-authored at the University of Toronto, released in 2020, which analyzed Health Canada data from 2012 to 2017 and identified nearly 65,000 reported opioid losses at Canadian health facilities. A large share of those were marked as \u201cunexplained,\u201d a pattern the authors said points to under detection, misclassification of diversion and the difficulty of tracking.<\/p>\n \u201cThe prominence of \u2018unexplained losses\u2019 in all facilities suggests that further research is needed to understand why Canadian facilities are unable to track the reasons for loss,\u201d the study stated.<\/p>\n \u201cUnexplained losses were something that jumped out at us,\u201d Fan added in an interview. \u201cThere\u2019s a lot more we can do to look at our processes in the health-care system in terms of tracking, monitoring and just improving our detection and prevention of these incidents.\u201d<\/p>\n St. Joe\u2019s cases and safeguards<\/p>\n At St. Joseph\u2019s Healthcare Hamilton, more than 90 per cent of reported drug-loss incidents between 2020 and 2025 were classified as \u201cmissing,\u201d according to The Spec\u2019s data analysis.<\/p>\n Brooke Cowell, the network\u2019s executive vice-president of clinical operations and chief nursing executive, said cases of missing medication can often be attributed to human error like the incorrect counting of a received supply, miscounting of pills, accidental spilling or wasting, and patients declining medication.<\/p>\n \u201cAny controlled substances loss or theft is thoroughly investigated internally,\u201d she said in a statement. \u201cImprovements to our processes are implemented based on the findings of these reviews as per our continuous quality improvement approach.\u201d<\/p>\n Cowell noted that losses or thefts at St. Joe\u2019s are \u201cvery rare\u201d: the network securely dispenses more than four million doses of medication per year.<\/p>\n Still, the safe handling and distribution of drugs at its sites is \u201can extremely important element of (our) operations,\u201d she said.<\/p>\n Every hospital in Canada must take a standardized approach to medication management, but Cowell contended St. Joe\u2019s goes further, with additional safeguards including weekly audits of pharmacy orders and inventory, automated dispensing cabinets that track access, random checks of patient areas to ensure doses match prescriptions and staff training on controlled substance safety.<\/p>\n While St. Joe\u2019s has reported a half-dozen cases of theft since 2020 \u2014 three times less than HHS \u2014 the volume of drugs stolen in each theft is more than twice as much.<\/p>\n Data shows almost 224 mg of substances were stolen on average at St. Joe\u2019s, while the amount taken per theft at HHS was closer to 78 mg.<\/p>\n St. Joe\u2019s entire theft tally stems from six instances at its Charlton campus in late 2021, all involving an employee who Hamilton police charged<\/a> with theft under $5,000 and criminal breach of trust in January 2022.<\/p>\n Data shows the stolen lot included 363 doses of hydromorphone, seven vials of morphine, and three tablets of low-strength clonazepam.<\/p>\n According to a decision<\/a> from the College of Nurses of Ontario, released last December, the employee worked as a registered nurse at the Charlton emergency room from 2015 until August 2021 \u2014 just before the thefts \u2014 when she was transferred to a non-nursing position as a porter.<\/p>\n The decision stated the worker wasn\u2019t assigned to care for patients or permitted to handle medications when she accessed the hospital\u2019s automated dispensing machine and withdrew hydromorphone 183 times between August and December 2021. The worker used \u201cher own unique access code to override the (dispensing) system,\u201d according to the decision.<\/p>\n St. Joe\u2019s fired the worker in June 2022. Later that year, after pleading guilty to theft under $5,000, the Ontario Court of Justice handed her a suspended sentence of 12 months\u2019 probation. The woman permanently resigned her position with the College of Nurses of Ontario.\u00a0<\/p>\n The college\u2019s decision noted the former nurse \u201chad a substance abuse condition\u201d at the time of the thefts.<\/p>\n When health-care workers divert drugs<\/p>\n Experts say drug \u201cdiversion\u201d \u2014 when health-care workers steal or misuse medications \u2014 is often linked to substance-use disorder rather than profit.<\/p>\n Sherry Young\/Dreamstime<\/p>\n Studies in Canada and the United States suggest health-care workers aren\u2019t immune to the opioid crisis.<\/p>\n A 2019 report<\/a> from the Canadian Society of Hospital Pharmacists states health professionals who steal drugs from their workplace often do so for personal use and not to sell on the street.<\/p>\n \u201cIn most cases, the diverter is suffering from substance-use disorder.\u201d<\/p>\n That\u2019s not to say losses from health-care facilities don\u2019t have the potential to end up being sold.<\/p>\n In the U.S., the Drug Enforcement\u00a0Administration publishes a report annually on narcotic losses from hospitals and pharmacies. The country saw 6.6 million doses of unaccounted-for controlled opioids end up on the street in 2024, up from five million doses in 2023, according to a recently released National Drug Threat Assessment<\/a> report. It\u2019s an increase the DEA said might be linked to distrust of fentanyl-laced street-level pills, \u201ccreating a renewed demand for licit medications.\u201d<\/p>\n Health Canada, the Canadian authority that captures drug losses from health-care facilities, doesn\u2019t publish an equivalent report.<\/p>\n \u201cWe think there could be more work on it, for sure,\u201d Fan said about the state of drug-diversion research and awareness in Canada.<\/p>\n Cases of drug diversion are often investigated as standalone incidents \u2014 but it\u2019s the whole health-care system that suffers.<\/p>\n On one hand, it leaves patients at serious risk, from inadequate pain relief because of missing or tampered with drugs to unsafe care delivered by impaired health-care workers. \u201cThere\u2019s also potential for infections,\u201d Fan said, pointing to multiple hepatitis C outbreaks in the U.S.<\/a> that were linked to diversion by health workers using contaminated syringes.<\/p>\n Diversion also undermines public trust in the health-care system \u2014 not to mention costs taxpayers. When medications go missing, hospitals have to replace them. There are also a lot of resources that go into diversion investigations.<\/p>\n \u201cYou have to interview people, someone has to go through all the records, and that takes time.\u201d<\/p>\n Meanwhile, there\u2019s obvious risk to the diverter of drugs themselves \u2014 addiction, overdose and loss of work.<\/p>\n One clear theme in drug-loss prevention research is to focus on the gaps in health systems that allow diversion to happen or go unnoticed \u2014 not blame individuals.<\/p>\n After their 2020 study, Fan and his research colleagues at U of T created a free risk assessment tool<\/a>\u00a0online that helps hospitals identify vulnerabilities and suggests actionable safeguards. Rather than waiting for losses or thefts to occur, the tool offers a proactive way to detect weak points in medication management systems.<\/p>\n \u201cIt\u2019s not just about diversion. It\u2019s also about making sure that we have good controls in place for these medications,\u201d Fan said.<\/p>\n The Institute for Safe Medications Practices Canada, a non-profit dedicated to the advancement of medication safety, thinks similarly.<\/p>\n<\/p>\n