Requirements for veterinarians who handle opioids and other controlled substances have generated a flurry of activity in legislatures and a bevy of articles in trade media. While state VMAs regularly update practitioners about what’s expected and about state pharmacy board deadlines, I can help by laying out where things stand, or are heading, and look at solutions that could make the entire process more effective.
1. What’s the Fuss?
It’s pretty simple. States and the federal government are under extreme pressure to fix or slow the epidemic of abuse and to treat abuse victims. A consensus is forming that every practitioner who handles opioids and controlled substances in human or veterinary medicine must be engaged and take some responsibility. The U.S. Food and Drug Administration commissioner said as much in an August 2018 announcement.
Veterinarians will find it harder each year to argue that their prescribing of controlled substances is so minimal, and their impact so insignificant in the national scheme of things, that no extra precautions or duties should be imposed.
2. What New Duties Are Being Considered or Implemented?
While 32 states exempt veterinarians from any compliance, many states impose some version of the following measures:
- Require some form of reporting (electronic or otherwise) to pharmacy boards or health departments regarding opioid or controlled substance prescriptions. Reporting requirements range from same day to once a quarter. (Where: Alaska, Arkansas, California, Connecticut, District of Columbia, Illinois, Indiana, Maine, Michigan, Nebraska, New Hampshire, New York, North Dakota, Oklahoma, South Carolina, Tennessee, Virginia, Washington, West Virginia.)
- A small number of states are adopting the most controversial requirement: mandating that practitioners consult a state database regarding individual prescription histories with opioids or controlled substances before a prescription is issued to a pet owner. At this time, no state requiring pre-investigation has obligated veterinarians to withhold a prescription if the pet owner appears to have a history of abuse. (Where: Connecticut, Colorado and Oklahoma.)
- Electronic prescriptions have been proposed in several states, like Arizona, but as of today I am unaware of any software that would allow veterinarians access to send e-scripts to human pharmacies. The infrastructure is simply not available. Thus, states like Arizona are providing veterinarians with a waiver of up to one year to figure out how best to comply.
- Dosage restrictions on controlled substances or opioid prescriptions pose a challenge in veterinary medicine. Some states imposing dose restrictions require a prescription be for no more than five, seven or 10 days. These truncated lengths are of concern with at-home compliance, the fear being an animal owner will not want to bring a pet back to the clinic for a recheck to get the balance of a longer course of treatment. This is clearly problematic for cases where the proper course of treatment requires a prescription longer than is allowed.
- Mandatory continuing education regarding opioids. Many states have implemented specific requirements for safe handling, recordkeeping, abuse prevention and awareness continuing education as a result of the opioid crisis and following the human medical lead.
While one might hope for all the states to agree, or for Congress or the FDA to impose a national regulatory scheme, we should expect that these issues, like most veterinary matters, will remain the prerogative of individual states. But you can be sure the number of states imposing some type of obligation on veterinarians is likely to grow each year.
3. What Can or Should the Veterinary Profession Do to Be Proactive?
From discussions at conferences and articles in the trade press, clearly there is no national consensus on how the profession should deal with these issues. On the one hand, a majority of practitioners apparently believe that the evidence of opioid abuse by veterinarians or their clients is so small as to not warrant any new mandates on practitioners. On the other hand, a majority of practitioners and veterinary associations do not recommend that veterinarians stand up in the middle of a nationwide opioid crisis and proclaim that veterinarians have no role in solving the problems.
4. Where Does All This Leave Us?
First, the topic needs more discussion at veterinary conferences so that a clear consensus can be formed. Not a top-down approach, perhaps, but through individual veterinarians sharing and debating views on the solutions under consideration. The Indiana Veterinary Medical Association led such a stakeholder process over the past two years and made sure veterinarians are aware of the choices and have a seat at the table in the state capital, where alternatives are being considered. This model could work in any state, and Indiana VMA leaders are willing to share information and how-to tips.
Second, state regulatory bodies such as pharmacy boards and health departments are open to discussing with veterinarians the feasibility of different means of reporting opioid or controlled substance prescriptions. Most, if not all, veterinary practices lack the software to report to a state agency, as this has not been a professional requirement and software providers have not developed veterinary applications. Human health care has such offerings, of course, given the daily reporting required at state and federal levels.
If practitioners nationwide can reach a consensus as to what is feasible, then we could take solutions to the regulatory agencies and push for uniform requirements. The greatest challenges involve reporting and pre-investigation duties before a prescription is issued or filled.
Anyone who picks up a newspaper or reads online media will understand that the U.S. opioids crisis is massive and devastating to individuals, families and communities. It’s not going away. Veterinarians must take careful steps, and act thoughtfully, but time is running out on any hope that these clouds will pass.
If part of your job involves handling opioids or controlled substances, you should expect that the government considers you part of the solution to the crisis.