The Rx Headache

Lynne White-Shim, MS, DVM, and Kimberly May, DVM, MS

Drs. White-Shim and May share how to handle any questions related to prescriptions and online pharmacies.

It has been a long, busy day at the clinic. With one patient in particular, you dedicated extensive time and effort to determine a diagnosis and appropriate treatment plan. After explaining to the owner what medications you will be dispensing, she asks, “Can I get a prescription instead? It’s so much cheaper to buy medications online.”

This is the moment you have begun to dread: the prescription discussion. And you wonder, what happened to the “good old days,” when the veterinarian dispensed medications and we all lived happily ever after?

However, the reality is—online pharmacies are here to stay. By purchasing in high volume, these pharmacies can often offer medications at prices well below those paid by veterinarians just to obtain them.

PET OWNER PERCEPTIONS & REALITIES

Online pharmacies bombard pet owners with online, television, and radio commercials focused on convincing them that veterinarians are overcharging for medications. This message is reinforced when clients only pay a few dollars for many of their own prescriptions.

In addition, not only have necessary costs for maintaining family life, such as groceries and gas, risen and continue to rise, but so have the costs of pet food, supplies, and veterinary care. Pet owners are increasingly seeking cost savings when it comes their pets’ care, including shopping by price for medications.

There’s a storm brewing that threatens to undermine our reputation as compassionate providers who are not driven by monetary gain. Owners want the freedom to choose where they fill prescriptions for their pets and how much they pay. This is not a fad—it is becoming the status quo.

ANSWERS TO KEY QUESTIONS

How do I compete with online pharmacies?

• Consider establishing your own online pharmacy. Several options are available to practicing veterinarians. Be sure to follow all state rules because rules on disclosure may apply.
• Some veterinary practices will match prices offered by online pharmacies. This decision is up to you, based on your preferences and financial feasibility.
• Educate clients about the benefits of purchasing medications through their veterinary clinic rather than online pharmacies (see The Prescription Discussion), and train the practice team about how to have this conversation with clients.

How can I help clients make informed prescription purchases?
1. Provide clients with a:

• Good pharmaceutical source for their pets’ medications and/or the information they need to make an educated decision.
• Copy of, or link to, the FDA’s Be Online Pet Pharmacy A.W.A.R.E brochure,¹ which provides guidance on selecting online pharmacies.
• Link to the National Association of Boards of Pharmacy² website, which contains links to the respective state board of pharmacy where pharmacy licenses can generally be verified.

2. Instruct clients to:

• Buy medications from a reputable source that has properly handled, stored, and shipped the medications.
• Ensure the medication received is the same as the one prescribed, in the correct dose and form, and not from an international source selling non-FDA approved medications.
• Never purchase a prescription drug from a pharmacy that says no prescription is needed.
• Refuse to accept any deviations from the prescription provided (medication, dose, form, etc) without approval from the prescribing veterinarian.
• Contact you or tell the pharmacist to contact you if there are any questions or concerns about the prescription.

3. Explain that some manufacturers will only guarantee their products if purchased from a veterinary clinic, and identify medications in this category. Check with manufacturers to ensure your information is accurate prior to informing the client.

4. Make sure the prescribing veterinarian’s contact information is readily visible on a written prescription in case the pharmacist has questions.

Should I provide a prescription if a client requests one?

Certainly. Once you decide that a pet needs a prescription drug, the AVMA Principles of Veterinary Medical Ethics³ state that, when requested by the client, a prescription should be provided in lieu of a dispensed drug.
In addition, many states require that, upon request, written prescriptions be provided to clients whose pets need prescription drugs⁴ and, should any federal prescription-writing legislation ultimately pass, federal law could also require it.

Many veterinarians readily provide written prescriptions, whether or not required by law. Remember, by providing a prescription upon request, you are building goodwill with your client.

Can and should I charge for that prescription?

It takes time to write the prescription, confirm the information, and sign the prescription form. However, clients may not perceive the value of this service, considering the process simple and quick.

Beyond the need to follow state rules as you consider whether or how to charge for a prescription, consider the potential impact on the veterinarian–client relationship:

• Charging a fee that your client may find unreasonable can make them pause and question other fees you charge.
• Clients are looking to provide affordable care for their pets; charging a fee reinforces the message disseminated by some pharmacies—that veterinarians are strictly focused on making money.
• While you understand the economic needs of your clients, they likely do not recognize your own economic limitations and the impact of changes in drug inventory.

What should I consider before prescribing drugs for extra-label use?

Extra-label use means use of a drug in any way that differs from what the label says, no matter how slight. When it comes to prescribing a nonveterinary drug from a pharmacy versus the clinic, recognize that federal rules apply to extra-label drug use (ELDU), such as:

• ELDU is permitted only by or under the supervision of a veterinarian.
• ELDU is allowed only for FDA-approved animal and human drugs.
• A veterinarian/client/patient relationship is a prerequisite for all ELDU.
  In addition, consider:
• When you administer or prescribe a drug in an extra-label manner, doing so within the confines of the law will help you minimize your risk of liability in case of an adverse event. Failure to follow the FDA’s ELDU regulations could potentially make you liable if an adverse event occurs. Contact your liability insurance carrier with any questions about specifics of coverage.
• Gaining informed consent from the client before dispensing or writing a prescription for extra-label use of a drug, which may include having the client sign a consent form that is retained in the pet’s medical record. Although the Animal Medicinal Drug Use Clarification Act (AMDUCA) is generally sufficient to protect patients and the public from inappropriate ELDU, your state veterinary practice act may include regulations regarding client consent in ELDU.
• Establishing a rapport with your local pharmacists, to help to ensure that pharmacists understand their roles and responsibilities for counseling and educating clients when filling a veterinary prescription. These include verification with the prescribing veterinarian should the pharmacist have any question about the medication or dosage.
  The AVMA has created an interactive algorithm to help clarify appropriate extra-label use of medications.⁵

If I encounter problems with a pharmacy or medication, what should I do?

Report any:

• Unlawful pharmacy activities to the board of pharmacy² in the animal’s state and, if applicable, the board in the pharmacy’s state.
• Perceived threats or intimidations by online pharmacies to the FDA and state board of pharmacy.²
• Adverse events associated with drugs used in patients to the manufacturer, who is required to file a report with the FDA.

IN SUMMARY

Although pharmacies are here to stay, so are veterinarians and the valuable services we provide for clients and patients. By communicating helpful information on pharmacies and prescriptions to your clients, these discussions become a routine, but important, part of your patient’s visit.

AVMA = American Veterinary Medical Association; FDA = U.S. Food & Drug Administration; ELDU = extra-label drug use

References

1. Protect Yourself and Your Pet: Be Online Pet Pharmacy A.W.A.R.E (Pet Owner Handout): fda.gov/downloads/AnimalVeterinary/ResourcesforYou /AnimalHealthLiteracy/UCM332442.pdf
2. National Association of Boards of Pharmacy: nabp.net/boards-of-pharmacy
3. Principles of Veterinary Medical Ethics of the AVMA: avma.org/KB/Policies/Pages/Principles-of-Veterinary-Medical-Ethics-of-the-AVMA.aspx
4. State Policies Regarding Client Requests for Prescriptions (AVMA): avma.org/Advocacy/StateAndLocal/Pages/veterinary-prescription-orders.aspx
5. AVMA Extralabel Drug Use Algorithm: avma.org/KB/Resources/Reference/Pages/AMDUCA2.aspx

Lynne White-Shim, MS, DVM, is an assistant director in the AVMA’s Scientific Activities Division. She works with the Council on Biologic and Therapeutic Agents and the Clinical Practitioners Advisory Committee to advocate for the availability of biologics and therapeutic products in veterinary medicine. Before coming to AVMA in 2007, Dr. White-Shim worked in a small animal practice. She received her DVM from the University of Illinois and her MS from the University of Kentucky.

Kimberly May, DVM, MS, is an assistant director in the AVMA’s Communications Division and the director of professional and public affairs at the AVMA. She is board certified in large animal surgery and worked in private equine practices and referral practices before coming to the AVMA in 2005. She received both her DVM and MS from Virginia-Maryland Regional College of Veterinary Medicine.