How Vets Can Help With Opioid Crisis
From owners abusing pets to get access to vet-prescribed drugs to animals ingesting substances, veterinarians have to take many precautions to help with the drug and opioid crisis.
In 2015, 33,000 people in the United States died from opioid overdoses, according to the Centers for Disease Control and Prevention (CDC)—quadruple the number since 1999, noted Courtney Leonard, a health communication specialist with the CDC’s National Center for Injury Prevention and Control.
While many abuse prescriptions acquired through a doctor, some are looking to local veterinary clinics for their fix, such as Heather Pereira, a Kentucky woman who in a 2014 case slashed her dog with razor blades so she could use its pain medication for herself.
Others include Michael Bannon, who last July pulled a gun on employees at Northeast Veterinary Referral Hospital in Plains, Pa., and left with a bottle of ketamine, according to the Times Leader of Wilkes-Barre.
The U.S. Drug Enforcement Administration reports that ketamine theft from U.S. veterinary clinics is common due to its hallucinogenic properties.
“Veterinarians across the country have reported cases of owners using their pets to get their hands on tramadol, an oral medication that has opiate-like effects,” wrote a CBS online reporter in a recent February piece.
In fact, one 2014 Oregon raid netted 100,000 tramadol pills.
The problem is serious enough that it has caught the attention of the American Veterinary Medical Association.
“Veterinary prescription drugs should be dispensed only in quantities required for the treatment of the animal(s) for which the drugs are dispensed. Avoid unlimited refills of prescriptions or any other activity that might result in misuse of drugs,” the organization wrote in its Guidelines for Veterinary Prescription Drugs.
Of the 50 states, West Virginia had the highest opioid death rate of 41.5 per 100,000 residents in 2015, followed by New Hampshire (34.3), Kentucky (29.9), Ohio (29.9) and Rhode Island (28.2), according to the CDC.
Leonard admitted the agency doesn’t know exactly why West Virginia leads in the rate of overdose deaths, but a 2015 CDC Morbidity and Mortality Weekly Report suggests prescribing patterns might be a factor.
According to the report, West Virginia has higher rates of overlapping prescriptions, with a new opioid prescription given while a patient is already taking benzodiazepine, as an example. Buprenorphine, a drug used for outpatient substance abuse treatment rather than for pain, was prescribed nine times more often in West Virginia than in California, for example. And in West Virginia, a significant fraction of extended-release and long-lasting prescriptions were given to opioid-naïve persons—those who had not had an opioid prescription within the previous two months.
Scott Moore, DVM, who, with his father, Dennis Moore, DVM, and Joseph Romano, DVM, owns and operates the Fairmont Veterinary Hospital in Fairmont, W.V., said he believes in part that the crisis in his state “arises from depressed, unemployed or underemployed individuals.”
Dr. Moore also said that West Virginia by and large has a much older population, with its accompanying health challenges, than other states.
“We encompass the two largest demographics in the crisis—the poor and elderly—and oftentimes they are both,” he said.
Moore’s hospital sees 10,000 animal patient visits annually, but he has never had to confront a pet owner personally who he suspected of pilfering his or her pet’s prescription meds.
Ounce of Prevention
Still, Moore, his partners, associate veterinarians and staff take precautions.
“We see the opioid crisis, but, fortunately, it has not affected us to this point,” Moore said. “On rare occasions, we see people who are struggling and cannot afford care due to addiction.”
Moore said that tramadol and phenobarbital are the most commonly used drugs in veterinary medicine that people abuse.
“We carefully track scripts for controlled drugs and carefully monitor and actively audit onsite medications,” he said.
In addition, all controlled medications at Fairmont are “under lock and key at all hours with video surveillance.”
Furthermore, Moore said the hospital performs regular audits and pill counts.
The veterinarians at Fairmont have had to change phenobarbital on two occasions of “likely abuse,” Moore said. “In both cases, the owner was reporting the med was not working and asked for more or an increase.”
In each case, the animal was moved to “nonabusive drugs like KBr [potassium bromide] for refractory seizures,” according to Moore.
What’s a Vet to Do?
In West Virginia, state-licensed veterinarians like Moore also are mandated reporters who are required to report suspected or obvious animal abuse.
But animal abuse investigators need more than just a professional opinion to move forward, said Sgt. Paul Rodriguez, with the Los Angeles Police Department’s(LAPD) Southeast Division.
“We have to have a little more than just a hunch,” he said.
Rodriguez said a veterinarian reporting someone coming in for the same prescription three times in one month is a tip police “can use to investigate further and actually send a detective to go and do some follow-up questioning.”
The LAPD, which consists of 22 divisions, fields animal cruelty calls “frequently.”
“Any type of animal cruelty we will investigate,” Rodriguez said. “If it is crime, we’ll arrest the [pet] owner.”
But investigators must tread lightly, especially in cases where conjecture is involved, he added.
“You can’t violate someone’s rights by asking them questions that are going to incriminate them when they are admitting to drug use and defrauding the veterinarian,” Rodriguez said.
If the LAPD receives a tip from a veterinarian, according to Rodriguez, investigators would visit the veterinarian first (veterinarians in California also are mandated reporters) and then the pet owner under suspicion to ask follow-up questions.
“You can show up and do a consensual encounter and say, ‘I’m here just to ask some questions. You’re not under arrest.’ It all depends how you speak to them,” Rodriguez said.
The Other Opioid Crisis
Madeline Bernstein, president of the Society for the Prevention of Cruelty to Animals Los Angeles (SPCALA) and a former prosecutor, said that in her many years with SPCALA that she has never seen anyone bring in an animal that they deliberately injured so they could access the pet’s prescription away from prying eyes.
For Bernstein, the problem isn’t so much addicts using their pets for drugs but rather addict pet owners bringing their pets in to the five nonprofit L.A. animal shelters the SPCALA runs and availing themselves of veterinary services because their pets are overdosing.
“We do see a lot of cases where the dogs are overdosing because either they’re getting ahold of the stuff or edibles, or idiots think it’s funny to get their dog high or to share their heroin with their dog,” Bernstein said.
Recently, Bernstein was at her own veterinarian with her dog and saw some hysterical heroin addicts bring their dog in because it had overdosed on heroin they had fed it.
The dog died.
Bernstein calls it a clear case of abuse.
“The police were there, and they were going to press charges,” she said.
But Bernstein admitted it’s harder to prosecute deliberate pet OD cases where the dog “sleeps it off” or accidental drug poisonings, but investigators can still resort to warnings, scaring perpetrators or counseling them if it is accidental.
“To prove a crime is a higher bar,” Bernstein said.
The humane officers under Bernstein’s watch have all the power of peace officers when performing their duties under California State Law. But unlike local police, humane officers in California hold statewide jurisdiction.
“They’re armed, they can make arrests, they can investigate and then they would bring their findings to a prosecutor and the prosecutor would file a case,” Bernstein said.
Bernstein said that sharing your pet’s medicine doesn’t necessarily constitute abuse.
“If a dog is in the throes of cancer and is suffering and in intense pain, and the person is taking the meds and the dog is suffering—you call me,” she said.
At least in Los Angeles, veterinarians who suspect animal abuse can call the LAPD or SPCALA.
“We’ve done stuff together,” Bernstein said. “Sometimes it is reported to both agencies, and they’ll talk and share reports or decide ‘you do it.’”
Animal abuse cases are often multi-agency (SPCALA, LAPD, FBI, ICE, DEA) according to Bernstein.
“We all work together, but it is a different focus; we are looking at different things at the same crime scene,” she said.
“None of these crimes happens in a vacuum,” she added. “There is usually more than one crime at every scene.”
A sign that an owner might be using their pets to gain access to prescription drugs? If they are making refill requests for odd reasons or before the prescription is due for a refill.
Reading the Red Flags
Moore and five other veterinarians at the hospital mentally check off answers to the following questions to determine if a pet owner might have an addiction issue.
- Is an owner bringing in multiple animals for a very specific—yet uncommon—problem?
- When prescribed a controlled drug, are there odd requests for filling and prescribing?
- Does the animal have the problem the owner is describing?
“The Internet provides so much information that people can create a false history, but the animal often tells a different story,” Moore said.
Dr. John Gicking, a veterinarian at Blue Pearl in Tampa, Fla., described the red flags he looks for in owners whenever he prescribes tramadol.
“Prescriptions are being used up faster or they have been reported to being spilled multiple times,” Gicking said.
Recently, Dr. Polly Fleckenstein of the Veterinary Medical Center (VCM) of Central New York encountered clients who requested opiate refills prescribed to their pets on a timeline that raised suspicion.
The clinic uses video cameras to monitor drug boxes; one person per shift has keys for two different locks. Whenever patients receive a controlled substance, staff records the date, time, name and how many pills were taken.
VCM veterinarians might send owner and pet home with about half a dozen different meds, but they are limited to a 30-day supply. If more are needed, pet owners must return to the clinic and talk to staff in person.
“If I’m suspicious someone might be abusing tramadol, I might say, ‘You know, it doesn’t seem to be working as well, maybe we should try gabapentin … or acupuncture,’” Fleckenstein said.
Veterinarians in New York report to the state’s prescription monitoring program every day, Fleckenstein said.
AVMA Guidelines for Veterinary Prescription Drugs
Veterinary prescription drugs are those drugs restricted by federal law to use by or on the order of a licensed veterinarian [Section 503(f) Food, Drug, and Cosmetic Act]. The law requires that the drug sponsor label such drugs with the statement: “Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian.”
- Veterinary prescription drugs are labeled for use only by or on the order of a licensed veterinarian. Incidents involving the sale and use of prescription drugs without a prescription should be reported to the proper state authority and the U.S. Food and Drug Administration.
- Veterinarians making treatment decisions must use sound clinical judgment and current medical information and must be in compliance with federal, state, and local laws and regulations.
- Veterinary prescription drugs must be properly labeled before being dispensed.
- Appropriate dispensing and treatment records must be maintained.
- Veterinary prescription drugs should be dispensed only in quantities required for the treatment of the animal(s) for which the drugs are dispensed. Avoid unlimited refills of prescriptions or any other activity that might result in misuse of drugs.
- Any drug used in a manner not in accordance with its labeling should be subjected to the same supervisory precautions that apply to veterinary prescription drugs.
Finding Answers to Troubling Questions
Each state has controlled substance guidelines for veterinarians. Below are the New York State Veterinary Medical Society’s answers to some frequently asked prescription drug questions.
My car was broken into and my prescription pad stolen. It has my DEA number on it. I reported the theft to the police. What else should I do?
Call the Pharmacists Society of New York [contact your state pharmacy association] and tell them where the theft occurred. They will notify area pharmacists to be aware. A DEA number is not required on all prescriptions, only on triplicate prescription forms. In the future, print only your license number on your prescription pads.
Should I store needles and syringes under lock and key?
Veterinarians are not required to store needles and syringes under lock and key; however, our VFAP [Veterinary Facility Accreditation Program] standards suggest that needles and syringes not in reserve, not in main stock and not in use be kept under suitable locked protection.
I wrote a prescription for a client for 20 pills. She added a zero and faxed the prescription to a catalog company for 200. Fortunately, the company called me to verify. What can I do the next time?
Write “twenty” on the prescription.
I’m missing nearly 1,000 phenobarbital pills. What should I do?
The Public Health Law requires veterinarians to contact the Bureau of Controlled Substances to report missing controlled substances. It is the veterinarian’s responsibility to properly safeguard the supply of controlled substances, and it is the veterinarian who must account for all drugs received and dispensed in the practice.
The Bureau of Controlled Substances will mail you a form to complete and return to them. If the situation dictates it, they will assign an investigator who will visit your practice, interview the doctors and staff, examine drug invoices, review operating procedures and how and where controlled substances are stored.
A veterinarian who suffers a loss of a controlled substance and/or suspects someone has stolen drugs but does not report it puts his/her license in jeopardy for failure to notify the Bureau of Controlled Substances and/or aiding and abetting someone in an illegal activity.
A licensed veterinarian or veterinary technician who steals or diverts controlled substances puts their license to practice in jeopardy; these cases are investigated by the Bureau of Controlled Substances and referred to the Office of Professional Discipline when appropriate.
Originally published in the May 2017 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!