An opioid-dependent anaesthetist repeatedly and secretly bored small holes into glass vials of fentanyl, extracted the drug and replaced it with saline.
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Daniel Carayannis conducted his intricate operation more than 35 times in 2019, leaning on glasswork skills his father had taught him.
While since acknowledging he placed patients at risk, the doctor's conduct was only revealed months later when a crew for medical retrieval service CareFlight began preparing the next day's drugs and noticed a leaky vial.
Further investigation showed 38 fentanyl vials and seven morphine vials had been altered across CareFlight's Westmead and Mascot sites.
Dr Carayannis then admitted using an engraving to break into the vials and a needle and syringe to substitute the drugs with saline.
The tiny holes were then patched with off-the-shelf super glue.
He also admitted taking home and using the leftover portions of drugs used to anaesthetise patients in operations at Royal Prince Alfred Hospital over nine days in August 2019.
The anaesthetist explained the opioid use stemmed from back pain and stress in mid-2019.
Before his father died of terminal cancer in June, the doctor spent many nights sleeping in a chair at his father's bedside.
He initially self-treated with oxycodone left over from his earlier back surgery before taking used vials out of the sharps bin in his father's hospital room.
Rapidly developing an opioid addiction and a tolerance to hydromorphone, he switched to CareFlight's code-protected drug safes.
The removal of the drugs from the vials at the charity's bases led to several potential risks to patients, the NSW Civil and Administrative Tribunal said on Tuesday.
A clinician could unknowingly use a tampered vial, see their patient's pain hasn't subsided and then potentially over-sedate the patient with an untampered vial, the tribunal said.
Patients with underlying heart problems requiring sedation were also at potential risk of death if given an altered vial.
"Dr Carayannis acknowledges that he put patients at risk for which he is deeply sorry," the tribunal said.
A review of the treatment of 72 patients seen by the two CareFlight bases in the relevant time period revealed no evidence of adverse events, the tribunal said.
Dr Carayannis has since undergone specialist treatment for depression, substance abuse issues and back pain; and passed thrice-weekly urine testing and quarterly hair testing for opioids over 18 months.
A mentor told the tribunal the offending was significantly out of character for the respectful, diligent and kind practitioner.
NCAT reprimanded Dr Carayannis on Tuesday for three counts of unsatisfactory professional conduct and placed 22 conditions on his registration.
He cannot take on locum or retrieval medicine work, must continue drug screening and must remain under the mentorship of an experienced anaesthetist.
His mental health and addiction treatment must also continue.
Australian Associated Press
