A public notification from the College of Pharmacists of BC has ignited heated discussions across Vancouver. At the center of the uproar is a pharmacist who, between January and August 2021, dispensed over 28,400 doses of naloxone nasal spray. What makes this staggering number even more troubling is that all doses were reportedly given to a single “patient representative” using the medical records of 301 unsuspecting individuals.
In a province grappling with an unrelenting opioid crisis and documented shortages of naloxone in areas like Downtown Eastside, the revelation raises critical questions. Was this an elaborate scheme for financial gain? Where did the doses actually go? And how did regulatory systems fail to catch the issue sooner?
This isn’t just a story about one pharmacist—it’s a window into systemic weaknesses in oversight, accountability, and resource allocation during one of the most urgent public health crises in British Columbia’s history.
Misconduct by the Numbers
Between January and August 2021, Geoffrey Kyle Soo Chan processed 1,646 transactions involving the nasal form of naloxone, a life-saving drug for opioid overdoses. These transactions used the personal health records of 301 individuals, many unaware their information was being accessed. Alarmingly, every dose was dispensed to a single individual acting as a “patient representative.”
The College of Pharmacists flagged multiple violations, including breaches of patient consent protocols and record-keeping laws. Beyond ethical lapses, this incident underscores an alarming lack of safeguards to prevent such large-scale misuse.
The volume involved is hard to grasp: 28,404 doses over eight months translate to roughly 118 daily doses. Even with the DTES’s high demand, this quantity defies typical community needs. The College labeled Chan’s actions as significant professional misconduct, resulting in a six-month suspension, fines, and a prohibition from managing or owning pharmacies for three years.
Profiting from Public Health Supplies
One of the most glaring aspects of this case is the potential financial incentive behind the excessive dispensing. Naloxone nasal spray, priced at $156.60 per two-pack in 2021, isn’t covered by Pharmacare but is funded by organizations like the First Nations Health Authority (FNHA). With 28,404 doses distributed, the total cost to FNHA could exceed $2.2 million. Add the allowable 6.5% markup and dispensing fees, and the potential profit margin climbs even higher—somewhere between $147,000 and $286,000 over six months.
What makes this even more troubling is the resale potential of naloxone in secondary markets. Nasal naloxone, due to its ease of use, often resells informally for up to $50 per dose. Given the high demand and limited supply, particularly in the DTES, a large portion of these doses could easily have been redirected to unofficial distribution networks or even outside the province.
The financial structure surrounding naloxone reveals a troubling contradiction. While intended to save lives, the system also provides opportunities for exploitation—opportunities that appear to have been seized in this case.
Where Did the Naloxone Go?
Amid widespread naloxone shortages in the DTES, this case begs an urgent question: where did all those doses go?
One possibility is informal redistribution. During the opioid crisis, naloxone kits often found their way into community networks through individuals who stockpiled supplies to distribute to friends, first responders, or vulnerable populations unable to access official programs. However, the sheer scale here raises doubts. Moving 28,000 doses would require storage facilities, distribution networks, or even online sales platforms.
A darker theory suggests that the doses might never have existed at all. Could this have been a case of “paper fraud,” where claims were processed to extract financial gain without actual goods being delivered? The lack of physical evidence—coupled with whistleblower speculation about how many kits could realistically be moved in such a short time—fuels this possibility.
What’s clear is that this case reflects a catastrophic breakdown in oversight. The government agencies funding naloxone must urgently address how such discrepancies went unnoticed for months.
A Perfect Storm for Exploitation
At the heart of this controversy lies a system struggling to balance accessibility with accountability.
First, regulatory loopholes allow pharmacists significant discretion when dispensing medications. While this autonomy supports patient access, it also creates gaps where exploitation can flourish. In Chan’s case, the lack of stringent identity checks or verification protocols made large-scale misconduct possible.
Second, supply imbalances exacerbate vulnerabilities. Nasal naloxone is highly sought after, especially by non-drug users or youth who prefer its user-friendly format. However, its higher price tag and limited availability make it a prime target for black-market resale. In the DTES, where overdose rates are among the highest in Canada, shortages of this life-saving drug are a matter of life and death.
Finally, funding structures invite misuse. Some organizations are vital in ensuring medication access but may lack the auditing mechanisms to prevent overbilling or fraud. Without real-time checks, large-scale anomalies can persist unchecked until audits reveal the damage.
These systemic issues aren’t unique to naloxone—they reflect broader challenges in public health supply chains, where urgency often outweighs due diligence.
Learning from the Past
This case isn’t an isolated incident. In 2014, a Richmond pharmacist faced legal repercussions for submitting over 2,400 fraudulent PharmaCare claims. While that case aimed to alleviate financial burdens for low-income patients, it revealed similar gaps in regulatory oversight. The pharmacist’s motivations were different—compassionate, albeit misguided—but the outcomes were strikingly familiar: a breach of trust in a system designed to serve the public good.
Chan’s case, however, appears more profit-driven. With no evidence that the naloxone reached those in need, this situation highlights how opportunists can exploit public health systems, ultimately undermining the trust they rely on to function.
Towards Transparency and Reform
As the dust settles on this case, the focus shifts from penalties to the systemic vulnerabilities it exposes. The volume of naloxone dispensed and the timeline over which it occurred reveals critical lapses in oversight. The staggering number of doses dispensed to a single recipient acting as a ‘patient representative’ should have raised red flags much earlier. This delay points to a failure not only at the pharmacy level but also in the auditing processes of agencies tasked with funding and monitoring high-demand medications. Without rigorous checks, such large-scale discrepancies can go unnoticed for months, if not longer.
The gaps in the naloxone supply chain reflect a broader issue of accountability in public health systems. High-demand medications like nasal naloxone, which are integral to combating the opioid crisis, require stronger safeguards against misuse. Yet, the current system relies heavily on trust between pharmacies and funding agencies—a trust that can be easily exploited. Audits must be more frequent, and large-volume transactions should be flagged and reviewed in real time to prevent abuse. Addressing these weaknesses is about catching misconduct and ensuring that life-saving resources reach those who truly need them.
Most critically, investigations must determine the fate of the missing doses. The unaccounted-for naloxone represents more than just a bureaucratic failure—it’s a potential threat to the lives of those relying on this medication amid a worsening crisis. In a system already strained by shortages, every missing kit could mean a lost life. Uncovering where the doses went is vital for restitution and restoring public confidence in the health system’s ability to manage its resources effectively. This isn’t merely a financial or logistical issue—it’s a moral imperative.
Following the Trail of Accountability
The case of over 28,000 missing doses of naloxone is far from just a regulatory mishap; it underscores the fragility of a system meant to safeguard public health during a critical crisis. At its core lies an urgent need for answers: how did such an enormous quantity of a life-saving drug disappear under the watch of multiple oversight bodies? For British Columbians living amid an unrelenting opioid crisis, these are not abstract questions—they are matters of life and death.
This investigation has exposed vulnerabilities in how naloxone is funded, distributed, and monitored. The sheer scale of the quantities involved suggests either deliberate exploitation or a profound failure in resource management. Both scenarios demand immediate scrutiny, not just from regulatory bodies but also from the public and media. The absence of transparency surrounding the naloxone’s final destination raises alarms. Without clarity, these gaps remain open invitations for future misuse while the public pays financially and through eroded trust.
Moving forward, this case will likely serve as a litmus test for accountability within BC’s public health framework. Answers about where these doses went—and whether they saved lives or vanished into exploitation—are essential. However, the larger story is whether BC’s systems can evolve to handle the scale of the crisis at hand. For now, the unanswered questions leave a glaring reminder: the opioid epidemic demands not just compassion but also unflinching vigilance in how we protect and distribute the resources that can save lives.
Glenn is dedicated to scrutinizing government actions affecting the Downtown Eastside and holding those in power accountable for their commitments. With a focus on transparency and policy analysis, his writing aims to expose gaps between promises and outcomes, pushing for meaningful changes that benefit the community.
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