Opioids and the veterinary team
Rachael Zimlich, BSN, RN
Freelance writer Rachael Zimlich worked as a reporter for dvm360 magazine before returning to school to become a registered nurse. She now works at The Cleveland Clinic.
Do veterinary practices have a role in alleviating the national crisis? The feds say yes.
Since 1999, more than 630,000 American have died from opioid overdoses, according to the CDC. The problem is widespread and complex, and now regulators are turning to veterinarians to join the fight.
The use of opioids and other controlled substances isn't limited to human medicine, and there is a new push to expand regulations that require usage reporting similar to that used in human medicine to the veterinary community.
FDA Commissioner Scott Gottlieb, MD, released a statement in August urging veterinarians to join in the fight against human opioid abuse.
“While opioids are just one part of the veterinarian's medical arsenal for treating pain in animals, it's important to understand the role veterinarians, who stock and administer these drugs, play in combatting the abuse and misuse of pain medications,” Gottlieb says in the statement.
The FDA created new guidance specific to veterinarians to help increase understanding of state and federal regulations, including how to tell if a prescription is being abused by a pet owner, and more. According to a recent study in the American Journal of Public Health, 13 percent of veterinarians polled were aware of cases where pets were made to appear ill or injured so that a staff member or pet owner could obtain an opioid prescription, and 12 percent had uncovered opioid use or diversion by veterinary staff-yet only 62 percent of veterinarian believed they play a role in preventing opioid abuse.
While the FDA doesn't have specific figures that quantify the extent of the problem veterinary medications play in opioid abuse, FDA spokesperson Juli Putnam says there are many anecdotal reports of abuse by veterinary staff and pet owners.
“Veterinarians have an important role in addressing the opioid epidemic by ensuring the responsible opioid prescribing for pain management in animals,” Putnam says. “It's critical that all healthcare professionals understand their role and responsibility in prescribing these products, and the FDA is committed to lending its support in appropriately managing them.”
Putnam again detailed the resources the FDA has created for veterinarians and offered additional guidance.
“Among the recommendations the FDA has provided for veterinarians is a reminder about the importance of following all state and federal regulations on prescribing opioids to animals for pain management and how to properly safeguard and store these medications to ensure they remain tightly controlled and in the legal supply chain,” Putnam says. “While each state has their own regulations for the practice of veterinary medicine within its borders, including regulations about secure storage of controlled substances like opioids, veterinarians should also follow professional standards set by the AVMA in prescribing these products to ensure those who are working with these medications understand the risks and their role in combatting this epidemic.”
Putnam also notes that the FDA is recommending veterinarians use alternatives to opioids for pain management when appropriate.
“We're educating pet owners on the safe storage and disposal of opioids; we're advising veterinarians to develop a safety plan in the event they encounter a situation involving opioid diversion or clients seeking opioids under the guise of treating their pets; and we're taking steps to help veterinarians spot the signs of opioid abuse,” Putnam says. “We've also provided a list of additional resources on opioid abuse and proper disposal of unused medications, advice on how to keep opioids and other medications safe in a veterinary clinic or other veterinary facility, and access to federal opioid training, among other resources.”
The AVMA did not respond to requests for comment for this story, but in a statement on the veterinarian's role in addressing the opioid epidemic, the association acknowledges a role-albeit a limited one-in mitigating abuse.
“As healthcare providers who administer and prescribe controlled substances, we recognize our responsibility in contributing to solutions for this crisis,” the AVMA declares in its statement, while also recognizing some key differences between human and animal medicine. “Many unique aspects of the practice of veterinary medicine must be considered in the development of laws and regulations that govern the use of opioids and controlled substances in animal patients.”
While the AVMA supports continuing education and ongoing work to develop extended regulations to mitigate opioid abuse, the association stops short of supporting a blanket extension to the veterinarian's role in electronic prescribing and prescription drug reporting. The association suggests in its statement that veterinarians should be exempt from accessing pet owner prescription data when prescribing animal medications due to a lack of training and knowledge about why the pet owner's medication was prescribed.
“Veterinarians are not trained to evaluate the appropriateness of a human prescription and are not trained in the privacy practices surrounding human medical information,” the AVMA states.
The association also supports the “exemption of veterinarians from mandatory electronic prescribing for controlled substances due to the lack of veterinary electronic medical record compatibility with electronic prescription programs. Remediation of this problem would require funding, resulting in an increased financial burden to taxpayers and clients.” Additionally, the AVMA suggests that when prescription drug monitoring and reporting are required, that software be developed equivalent to that of human healthcare software, and that more research be completed on how veterinary prescriptions intersect with human medicine and the opioid epidemic.
Mark Cushing, JD, CEO and founder of the Animal Policy Group, says there are just 17 states that now require veterinarians to report to prescription drug monitoring programs, but the number is growing-and for good reason.
“You cannot make the case that veterinarians don't have any involvement with opioids or controlled substance,” Cushing says. “There's no question that opioids are part of veterinary practices. But does that obligate veterinarians to have a broader social responsibility in their practices to try and slow the use of controlled substances more broadly by society? This is where viewpoints split. Some veterinarians think they are not a big enough part of the problem, and others think everyone needs to take steps to minimize use and access.”
The number of states requiring veterinarians to join in efforts to mitigate the opioid crisis is growing, partly due to the scope of the problem and partly due to awareness, Cushing says. He thinks the FDA's call to continue to increase the veterinarian's role and Commissioner Gottlieb's assertion that veterinarians are obligated to be part of the solution simply because they handle opioids makes sense.
“It's a very simple premise,” Cushing says of Gottlieb's position. “I think a progressive veterinarian today will understand that. I think it's foolish given the scope of the problem to try and carve veterinarians out and say we are special, trust us, we care-but don't ask us to do anything when it comes to the opioid problem.”
Some state veterinary medical associations are seeing the trend toward increasing regulation on veterinarians and working to be part of the solution, Cushing says. One of these is the Indiana Veterinary Medical Association.
“They saw legislation begin to be introduced and got engaged,” Cushing says. “They created an internal task force to educate themselves and members. They went to the state capitol and met with committees, they met with the state health department. They began to talk through concerns and possible regulations, and how to implement them. They worked through pretty much all of the issues quietly.”
Lisa Perius, executive director of the Indiana Veterinary Medical Association, credits the board of directors of the association with leading the charge for collaboration when it became clear that Indiana's governor was making the opioid crisis an area of focus.
“We can't put our heads in the sand. It's not just the human side,” Perius says. “We want veterinarians to have a seat at the table when discussing what laws are going to be changed and how it's going to impact veterinary medicine, and how to educate members on what is going on at the state level.”
A prescription drug monitoring program (PDMP) was already in place in Indiana for human medicine, and by 2021, veterinarians will have to query pet owners prior to writing prescriptions, Perius says. Veterinarians will also have to complete two hours of continuing education training on opioid prescribing before renewing controlled substance registrations. IVMA is now working on legislation to clarify certain requirements of the new regulation, including what pet owner queries will look like in the PDMP, supply limitations for opioid prescriptions, and other veterinary-specific issues. The IVMA's early involvement brought forth questions that can now be asked well before regulatory deadlines, and provides amply time for education, she says.
“We look at this as another proactive way to close any potential impact points where someone could figure out how to get a medicine,” Perius says. “It's a way to be able to tighten up any point where they could make any kind of inroad to access.”
Cushing says some practices are concerned about the cost of implementing new regulations. While there is little specific cost data, Cushing says many practices already have electronic health records, so software costs and the labor costs associated with queries on PDMPs should be not be exorbitant. Fighting against a call to become involved in opioid abuse reduction measures, however, could be costly in terms of public relations and the good reputation of veterinarians.
“Every state in the country has a huge opioid problem, period. Regulators don't have the goal of punishing veterinarians. They don't start out with a bias, but they don't know what they don't know about how veterinary practices work,” Cushing says. “Get in front of it and work it out.”
Rachael Zimlich is a former reporter for dvm360. In addition to freelance writing, she works as a registered nurse at the Cleveland Clinic in Cleveland, Ohio.