Committee: Discipline
Decision Date: 22 Jul 2019
Summary:
On July 22, 2019, on the basis of an Agreed Statement of Facts and Admission (Liability), the Discipline Committee found that Dr. Tetyana Yaremivna Hurmatov committed an act of professional misconduct, in that she has failed to maintain the standard of practice of the profession, and has engaged in an act or omission relevant to the practice of medicine that, having regard to all circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional.
Agreed Statement of Facts and Admission (Liability)
Dr. Hurmatov is 41 years old, and practices family medicine in St. Catharines, Ontario. She received her certificate of registration authorizing independent practice from the College in 2010. Information from the Narcotics Monitoring System
In October 2016, the College received information from the Ministry of Health and Long-Term Care’s Narcotics Monitoring System regarding Dr. Hurmatov’s prescribing of controlled drugs, including narcotics, from January 1, 2015 to December 31, 2015 (the “NMS data”). The NMS data indicated that Dr. Hurmatov had been identified as a physician who, in 2015, had eight or more patients receiving at least 650 oral morphine equivalents (“OMEs”) per day, and who had issued at least one prescription exceeding 20,000 OMEs.
Investigation of Dr. Hurmatov’s Practice
The College retained Dr. Andrew Grant to opine on Dr. Hurmatov’s prescribing of controlled substances, with a specific focus on the use of opioids for non-cancer pain. Dr. Grant identified a number of issues with Dr. Hurmatov’s opioid prescribing:
a) Dr. Hurmatov prescribed a high-dose opioid to a patient attempting to get pregnant;
b) Dr. Hurmatov provided a patient with dosing instructions for use of high-dose long-
acting opioids on an as-needed (“PRN”) basis, leading to large dose fluctuations with no
gradual titration upwards;
c) Patients self-escalated their opioid doses, contrary to signed opioid contracts which stated that patients were only to take opioids at the doses prescribed by Dr. Hurmatov. Although Dr. Hurmatov did warn some patients not to self-escalate their dose, in some other cases Dr. Hurmatov’s responded by increasing the dose of prescribed opioid to the amount that the patient had achieved by self-escalation;
d) Dr. Hurmatov’s poor interpretation of urine drug screen results. In six cases, Dr. Hurmatov continued prescribing high dose opiates in the setting of urine drug screen results that were significantly abnormal and that potentially indicated drug addiction and/or diversion;
e) Dr. Hurmatov concurrently prescribed large dose immediate release opioids in addition to large dose controlled release opioids, indicating a lack of knowledge about the appropriate use and dosing of short acting opioids;
f) In three cases, Dr. Hurmatov rotated patients’ opioids at high doses, without reducing the morphine equivalent dose of the new opioid to account for lack of tolerance;
g) There was poor tracking of patients’ opioid renewal dates, inappropriate early refills, and lack of oversight with respect to patients’ accumulation of surplus high dose opioids;
h) Dr. Hurmatov frequently used controlled release opioids at a shorter dosing interval than recommended (i.e. with TID or QID dosing);
i) Dr. Hurmatov co-prescribed benzodiazepines with high dose opioids; and
j) Dr. Hurmatov rapidly escalated patients’ doses of controlled release opioids. The College also retained Dr. Linda Klapwyk to provide an opinion as to Dr. Hurmatov’s prescribing practices, other than with respect to her opioid prescribing. Dr. Klapwyk expressed a number of concerns with respect to Dr. Hurmatov’s prescribing:
a) Concomitant prescribing of benzodiazepines with high-dose opioids, which may result in profound sedation, respiratory depression, coma, and death, and which should very rarely be prescribed together;
b) Prescribing of benzodiazepines in high doses and for long periods of time;
c) Combining central nervous system depressants such as anticonvulsants, antipsychotics, hypnotics, and skeletal muscle relaxants with opioids;
d) Inappropriate prescribing of stimulants to address complaints of fatigue and sedation in patients to whom central nervous system depressants had also been prescribed;
e) Prescribing Olanzapine, an atypical antipsychotic indicated for schizophrenia or bipolar disorder, for sleep in a patient who was overmedicated, at risk for respiratory depression, and did not have an indication for an olanzapine prescription other than sedation as there was no documentation of schizophrenia or bipolar disorder;
f) Failure to reduce patients’ prescriptions for sedatives despite documentation of side- effects or harm such as sedation, fatigue, and impaired cognition.
Self-prescribing and Self-Treatment
Between 2011 and 2017, Dr. Hurmatov wrote numerous prescriptions in her name and the name of her clinic for her own use and/or which she used and treated herself, between approximately 2011 and 2017, including for narcotics and controlled substances:
a) Dr. Hurmatov started herself on Cipralex 10mg in January 2011;
b) In the fall of 2011, Dr. Hurmatov injected herself with Juvederm hydrate. She obtained the filler over the Internet from Ireland. She developed facial edema and neck swelling, which she self-treated with Prednisone, subsequent injections of Kenalog and Hyaluronidase, Lasix, antibiotics, Percocet, and Tylenol #1. Dr. Hurmatov developed adrenal insufficiency with Cushingoid appearance due to self-administering cortisone injections;
c) In December 2011, Dr. Hurmatov was started on Pristiq 50mg per day by another physician. Dr. Hurmatov increased the Pristiq to 100mg on her own, and later lowered it back down to 50 mg;
d) In January 2012, Dr. Hurmatov started herself on Temazepam and Atenolol;
e) In March 2012, Dr. Hurmatov began self-prescribing Dilaudid 2 mg. She sourced the Dilaudid, an opioid, from tablets returned by a patient. She also gave herself Xylocaine occipital nerve blocks;
f) In June 2013 and April 2014, Dr. Hurmatov took Nootropil that she had ordered online, to help relax and as a memory aid;
g) In March 2014, Dr. Hurmatov had some sleep problems which she attempted to self treat by taking extra amounts of Clonazepam;
h) By 2017, Dr. Hurmatov had been prescribed Cymbalta 30 mg and Zopiclone 7.5 mg by another physician. She increased the Cymbalta to 60 mg and the Zopiclone to 15 mg without a physician’s approval;
i) In June 2017, the College received information from the NMS that Dr. Hurmatov prescribed benzodiazepines to herself between March 2013 and April 2017, as follows:
Date Drug Quantity
Days’
Supply
2013/03/14 Ativan Sublingual/1mg/SL Tab 30.0 5
2014/03/24 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2014/07/28 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2014/08/19 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2014/09/08 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2014/09/30 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2014/10/20 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2015/01/05 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2015/03/09 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2015/05/04 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2015/06/12 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2015/07/23 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2015/11/09 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2015/12/09 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/02/11 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2016/03/11 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 30
2016/06/20 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/07/04 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/07/19 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/08/03 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/08/25 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/10/08 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/10/28 Apo-Clonazepam/2mg/Tab 12.0 10
2016/11/08 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2016/11/25 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2017/01/09 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2017/03/15 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2017/03/21 Apo-Lorazepam Sublingual/1mg/SL Tab 30.0 10
2017/04/27 Apo-Lorazepam/2mg/Tab 15.0 5
j) In addition to writing herself prescriptions for benzodiazepines as set out above, Dr. Hurmatov also self-prescribed other medications, as follows:
Date Drug Name
14-Jan-2015 CAP Prometrium 100mg
15-Mar-2016 CAP Prometrium 100mg
15-Apr-2016 TAB Apo-Sumatriptan 100mg
10-Jun-2016 TAB Apo-Eletriptan 20mg
Date Drug Name
29-Jul-2016 TAB Apo-Sumatriptan 100mg
15-Mar-2016 GM Estrogel 0.06%
18-Mar-2016 TAB Cytomel 25mcg
10-Feb-2017 CAP Prometrium 100mg
Dr. Hurmatov’s self-prescribing took place in the context of depression and anxiety. Since February 2018, Dr. Hurmatov has been under the treatment of a physician, and there have been no further issues with self-prescribing.
Treatment of Family Members
Between 2011 and 2017, Dr. Hurmatov wrote prescriptions for family members:
a) Family Member A:
Date Drug Name Quantity
17-Oct-2011 TAB Dexedrine 5mg 20
04-Feb-2013 CAP Tamiflu 75mg 10
29-Jul-2015 CAP Apo-Minocycline 30
29-Jul-2015 TAB Apo-Indapamide 2.5mg 20
21-Sep-2016 GM Fiducin Cream 2% 60
b) Family Member B:
Date Drug Name Quantity
02-Oct-2014 ML Apo-Amoxi Oral Susp 125mg/5ml 100
02-Oct-2014 ML Apo-Amoxi Oral Susp 125mg/5ml 100
27-Sep-2016 DOS Omnaris 50mcg/act 120
c) Family Member C:
Date Drug Name Quantity
04-Feb-2013 CAP Tamiflu 45mg
10 d) Family Member D:
Date Drug Name Quantity
30-Jan-2012 POW Pms-Azithromycin 200mg/5ml 15
30-Jan-2012 ML Sandoz-Azithromycin 200mg/5ml 15
07-Apr-2015 ML Apo-Amoxi Oral Susp (Sugar Free) 125mg/5ml 100
10-Nov-2015 ML Apo-Amoxi Oral Susp (Sugar Free) 125mg/5ml 100
03-Dec-2016 ML Apo-Amoxi Oral Susp 125mg/5ml 150
06-Feb-2017 ML Apo-Amoxi Oral Susp 125mg/5ml 150
e) Family Member E
Date Drug Name Quantity
04-Feb-2013 TAB Apo-Cefprozil 500mg 20
04-Feb-2013 CAP Tamiflu 75mg 10
22-Feb-2013 STR Oracle Test Strips 100
22-Mar-2013 TAB Co-Rizatroptan ODT 10mg 10
22-Mar-2013 TAB Pms-Metodopramide 10mg 30
25-Mar-2013 WAF Maxalt RPD 10mg 6
15-Apr-2013 WAF Maxalt RPD 10mg 12
07-Sep-2013 DOS Nitrolingual Pumpspray 0.4mg 200
07-Sep-2013 DOS Ventolin HFA 100mcg 200
02-Nov-2013 TAB Apo-Valacyclovir 500mg 30
21-Nov-2013 TAB Apo-Valacyclovir 500mg 60
28-Aug-2014 CAP Apo-Amoxi 500mg 21
02-Mar-2015 TAB Apo-Escitalopram 20mg 180
09-Jun-2015 TAB Mylan-Ciprofloxacin 500mg 28
02-Oct-2015 CAP Mylan-Minocycline 100mg 20
15-Oct-2015 TAB Mylan-Ciprofloxacin 500mg 20
11-Feb-2016 GM Anusol-HC Ointment
30 01-Mar-2016 CAP Apo-Amoxl 500mg 30
18-Mar-2016 TAB Apo-Atenol 50mg 90
21-May-2016 GM Anusol-HC Ointment 60
16-Jun-2016 ML Apo-Olopantadine 0.1% 5
16-Jun-2016
TAB-Mylan-Baclofen 20mg 60
16-Jun-2016 TAB Apo-Metoprolol (L) 100mg 200
16-Jun-2016 TAB Novo-Rabeprazole EC 20mg 100
18-Mar-2016 CAP Creon 25 100
07-Jul-2016 CAP Creon 25 270
03-Aug-2016 TAB Pms-Ciprofloxacin XL 500mg 20
24-Aug-2016 TAB Novo-Lexin 500mg 40
09-Sep-2016 GM Taro-Mometasone 0.1% 60
09-Sep-2016 GM Ketoderm Cream 2% 60
09-Sep-2016 TAB Novo-Semide 40mg 30
13-Sep-2016 CAP Xenical 120mg 84
19-Sep-2016 TAB Teva-Almotriptan 12.5mg 6
19-Sep-2016 CAP Apo-Amoxi 500mg 40
26-Mar-2016 TAB Glucobay 10mg 120
26-Mar-2016 TAB Apo-Metformin 500mg 300
22-Sep-2016 GM Fucidin Cream 2% 90
09-Sep-2016 TAB Mylan-Baclofen 20mg 60
09-Sep-2016 ML Ratio-Ectosone Scalp Lotion 0.1% 150
12-Oct-2016 TAB Apo-Baclofen 20mg 180
22-Nov-2016 CAP Apo-Amoxi 500mg 30
03-Dec-2016 TAB Apo-Amoxi Clav 875/125 875/125mg 20
Date Drug Name Quantity
15-Dec-2016 TAB Novo-Sucralate 1gm 60
15-Dec-2016 TAB Pantoprazole Magnesium 40 mg 100
20-Dec-2016 TAB Acto-Clarithromycin XL 500 mg 20
09-Sep-2016 DOS Apo-Ciclesonide 50mcg/spray 120
30-Dec-2016 TAB Apo- Baclofen 180
03-Jan-2017 CAP Creon 25 90
06-Feb-2017 TAB Apo-Bisoprolol 5mg 60
06-Feb-2017 CAP Xenical 120mg 30
06-Feb-2017 GM Anusol-HC Ointment 60
14-Feb-2017 CAP Apo-Hydroxyzine 50mg 30
26-Jun-2017 ML Ciprodex Otic Soln 7.5
Dr. Hurmatov did not maintain patient charts for the family members to whom she prescribed and treated. Dr. Hurmatov did not bill OHIP for prescribing to and treating her family members. Dr. Hurmatov engaged in this treatment of her family members during a period when she was suffering from depression and anxiety, and in the context of a difficult family dynamic. Since November 2017, Dr. Hurmatov’s family members have been exclusively under the care of an unrelated family physician.
ADMISSION
Dr. Hurmatov admits the facts above, and admits that, based on these facts, she engaged in professional misconduct under:
a) paragraph 1(1)2 of Ontario Regulation 856/93 made under the Medicine Act, 1991, in that she failed to maintain the standard of practice of the profession; and
b) paragraph 1(1)33 of O Reg. 856/93, in that she engaged in acts or omissions relevant to the practice of medicine that would be regarded by members as disgraceful, dishonourable or unprofessional.
AGREED STATEMENT OF FACTS (PENALTY)
On July 16, 2019, Dr. Hurmatov entered into an undertaking with the College by which, among other things, she permanently agreed not to issue new prescriptions or renew existing prescriptions for or administer any of the following substances, effective July 22, 2019:
a) Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
b) Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
c) Controlled Drugs (from Part G of the Food and Drug Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);
d) Benzodiazepines and Other Targeted Substances (from the Benzodiazepines and Other Targeted Substances Regulations made under the Controlled Drugs and Substances Act., S.C., 1996, c. 19); and
e) Monitored Drugs (as defined under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22).
DISPOSITION
The Discipline Committee ordered that:
- Dr. Hurmatov attend before the panel to be reprimanded.
- The Registrar suspend Dr. Hurmatov’s certificate of registration for a period of three (3) months, commencing from July 23, 2019, at 12:01 a.m.
- The Registrar place the following terms, conditions and limitations on Dr. Hurmatov’s certificate of registration:
(i) Dr. Hurmatov will participate in the PROBE Ethics & Boundaries Program offered by the Centre for Personalized Education for Professionals, by receiving a passing evaluation or grade, without any condition or qualification. Dr. Hurmatov will complete the PROBE program within 6 months of the date of this Order, and will provide proof to the College of her completion, including proof of registration and attendance and participant assessment reports, within one (1) month of completing it.
- Dr. Hurmatov pay costs to the College in the amount of $6,000.00 within thirty (30) days from the date of this Order.