April 17, 2018

Pets, Vets, and Opioids

Remaining knowledgeable and observing relevant legal requirements will enable veterinarians to be strong advocates for the responsible use of opioids.
By Carolyn C. Shadle, PhD, and John L. Meyer, PhD
Pushback Among Veterinarians
The Maine Veterinary Medical Association (MVMA) put out a position statement against the state’s PMP law, writing that while the “opioid epidemic is a serious public health crisis that requires all prescribers and dispensers of opioids and benzodiazepines to assist in preventing the misuse or diversion of these drugs, [veterinarians] are ineffective participants in reducing drug abuse by the public [because they] do not have the human medical exposure or back- ground to review medical prescription information for animal owners.” In an interview with American Veterinarian®, Katherine Soverel, executive director of the MVMA, said that including veteri- narians could dilute the data and make the PMPs less effective.

Having advocated for veterinarians to have a seat at the table when such laws are drafted, Soverel is now working to change the law as it pertains to veterinarians. A bill under consideration in Maine would exempt veterinarians from the PMP and expand the types of continuing education (CE) that would meet the current requirements. The MVMA strongly supports this bill, according to Soverel. New Hampshire veterinarians who share that view worked successfully to get their state legislature to pass a revised bill exempting veterinarians from PMP requirements.3

“I’m a veterinarian, not a physician. I shouldn't have access to a human's medical history,” said Kevin Lazarcheff, DVM, president of the California Veterinary Medical Association. He objects to checking a client’s use of controlled substances and points out that there is no protocol directing veterinarians if they suspect that a client is abusing drugs.6

Amanda Bisol, VMD, director and legislative chair for MVMA, knows well that many consider the new legislation unfair to their profession, but she says veterinarians should take the problem seriously and consider how they can help. She urges veterinarians to look for a balance of drugs for in-hospital use, including drug classes such as nonopioid analgesics and steroidal and nonsteroidal anti-inflammatory drugs. When prescribing opioids for external use, she said, veterinarians should make sure they understand and comply with the strictest state and federal standards. Even if they seem too strict, she said, veterinarians must comply. “It’s better to be part of the solution than to risk being a part of the problem,” she said.

Training Response
Veterinarians in all states need to be aware of new legislation—including laws under consideration—regarding the use and prescription of opioids, which might entail training. Maine’s new law requires that veterinarians, along with other prescribers and dispensers of opioids, receive 3 hours of opioid CE every 2 years. As a result, MVMA has partnered with VetBloom, an educational platform owned by Ethos Veterinary Health, a network of hospitals providing specialty and emergency pet care. Directed by Patrick Welch, DVM, MBA, DACVO, VetBloom developed a variety of curricula to meet the needs of veterinarians in New England. Completing an online webinar, created for and with MVMA, enables MVMA members to maintain their state license.

The course consists of 2 sections. The first, created by Dr. Bisol, outlines what state-licensed veterinarians must do comply with the law. The second section is divided into 2 parts; the first deals with the safety and use of opioids. Created by Andrea Looney, DVM, DACVAA, DACVSMR, CCRP, an anesthesiologist with Ethos Veterinary Health, it addresses definitions related to opioid use in veterinary patients, including:
  • What drugs constitute agonists and antagonists
  • Opioid indications and contraindications
  • How receptors and receptor subtypes translate into physiologic and pharmacologic effects
  • How opioids are used in premedication, local blocks, postoperative and intensive care continuous-rate infusions, and in-home chronic care

The second part, developed by Jennifer Kelleher, PharmD, BCPS, FSVHP, formerly with Ethos and now a compounding pharmacist and educator, describes the legal nuances and recommendations for administering opioids in a veterinary clinic. It explains the requirements and considerations for dispensing opioids to clients, covers the steps for prescribing Schedule II–IV opioids using the Maine PMP, and discusses the requirements for electronic, hard-copy, telephone, and faxed opioid prescriptions in the state.

Other Learning
Beyond being aware of the legalities, veterinarians must understand the everyday practicalities of when and why opioids are recommended and how to avoid problems.

The most common reason cited by veterinarians for avoiding the use of opioids is the fear of adverse effects, according to Mark E. Epstein, DVM, DABVP, CVPP, director at Carolinas Animal Pain Management and TotalBond Veterinary Hospital in Gastonia, North Carolina.12 He advises veterinarians to understand how these drugs work within the peripheral and central nervous system and how to recognize and treat potential adverse effects. Veterinarians should be knowledgeable about 3 general drug categories, he said:
  • Pure mu agonists (strong opioids), such as morphine and fentanyl
  • Partial mu agonists and agonist-antagonists (weak opioids), such as buprenorphine and butorphanol
  • Mu antagonists (reversal agents), such as naloxone, which are used in cases of overdose or severe adverse effects

With new drugs being introduced constantly, veterinarians must stay current, Dr. Epstein said. Tapentadol, for example, a new class of analgesic for humans, has shown some utility in animal models. A sustained-released injectable buprenorphine may be available soon, as well.

Conclusion 
Even veterinarians who feel removed from the opioid crisis would be well served to become knowledgeable about and comfortable with the use of these drugs. By staying current with local, state, and national laws, veterinarians can be strong advocates for the responsible use of opioids and an important part of the conversation around the epidemic.

 
Dr. Shadle earned her PhD in interpersonal and organizational communication from the State University of New York at Buffalo. Dr. Meyer earned his PhD in communication studies and speech arts from the University of Minnesota. They write and train through Interpersonal Communication Services, Inc. (veterinariancommunication.com). They have trained veterinary professionals at numerous national and international conferences.
References:
  1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 20l6;65(5051):1445-1452. doi: 10.15585/mmwr.mm655051e1.
  2. Mercola J. Is PetMed selling opiates for people, not pets? Mercola website. articles.mercola.com/sites/articles/archive/2017/09/12/petmed-selling-opiates.aspx. Published September 12, 2017. Accessed February 15, 2018.
  3. Edelman A. Pet connection: opioid addicts score drugs from the local vet. NBC News website. nbcnews.com/news/us-news/pet-connection-opioid-addicts-score-drugs-local-vet-n798211. Published September 3, 2017. Accessed February 15, 2018.
  4. Kelly M. Opioid addicts turn to pet medications to get high. WPBF News website. wpbf.com/article/opioid-addicts-turn-to-pet-medications-to-get-high/10274777. Published July 9, 2017. Accessed February 15, 2018.
  5. Morgan R. People are now maiming their pets to score drugs. New York Post website. nypost.com/2017/01/16/people-are-now-maiming-their-pets-to-score-drugs/. Published January 16, 2017. Accessed February 15, 2018.
  6. Mercer M. When addicts steal their pet’s painkillers, what’s a vet to do? The Washington Post website. washingtonpost.com/national/health-science/when-addicts-steal-their-pets-painkillers-whats-a-vet-to-do/2017/09/15/009c5956-8cd4-11e7-91d5-ab4e4bb76a3a_story.html?utm_term=.f189f824afc9. Published September 16, 2017. Accessed February 15, 2018.
  7. Bode K. Puppy overdoses after ingesting opioid on morning walk. Eagle-Tribune website. eagletribune.com/news/merrimack_valley/puppy-overdoses-after-ingesting-opioid-on-morning-walk/article_83b24095-9294-54b1-a62d-81971efc54dd.html. Published October 24, 2017. Accessed February 15, 2018.
  8. Gregory J. New Jersey law limits initial opioid prescriptions to five days. HealthExec website. healthexec.com/topics/care-delivery/nj-law-limits-initial-opioid-prescriptions-five-days. Published February 16, 2017. Accessed February 15, 2018.
  9. King K. New Jersey seeks to expand opioid prescription monitoring to veterinarians. Wall Street Journal website. cetusnews.com/news/New-Jersey-Seeks-to-Expand-Opioid-Prescription-Monitoring-to-Veterinarians-.ryl-3cVhhW.html. Published October 11, 2017. Accessed February 15, 2018.
  10. O’Shea T. New Jersey enacts strict opioid prescribing law. Pharmacy Times website. pharmacytimes.com/contributor/timothy-o-shea/2017/02/new-jersey-enacts-strict-opioid-prescribing-law. Published February 20, 2017. Accessed February 15, 2018.
  11. Prevention of prescription drug overdose and abuse. National Conference of State Legislatures website. ncsl.org/research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx. Published May 23, 2016. Accessed February 15, 2018.
  12. Epstein M. CVC highlight: opioids: the good, the bad, and the future. DVM360 website. veterinarymedicine.dvm360.com/cvc-highlight-opioids-good-bad-and-future. Published December 1, 2011. Accessed February 15, 2018.


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