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FDA cautions vets to be aware of risks in using, stocking opioids

 

By Emma Hopkins-O’Brien

Indiana Correspondent

WASHINGTON, D.C. — According to the U.S. Food and Drug Administration (FDA), the national opioid crisis, which affects health care professionals and pharmacists across the country, can also extend to veterinarians and their practices.

Drug overdoses killed 64,000 Americans in 2016, and 66 percent of those involved a prescription or illicit opioid. The crisis continues to have devastating effects across the country, according to statistics from the Centers for Disease Control and Prevention (CDC). Though doctors for people come to mind as the first line of defense against opioid addiction, the FDA notes that veterinarians also have access to and prescribe opioid medications to animal owners. This applies almost exclusively to companion animals, as livestock are not typically treated with opioids.

“While opioids are a small part of the veterinarian’s medical arsenal for treating pain in animals, stocking and administering these drugs also makes it important for veterinarians to understand how they can help combat the abuse and misuse of pain medications,” declared an FDA on its website in August 2018.

Vets do prescribe oral opioids to some patients to take home, but Ashley Mitek, an assistant professor and companion animal extension veterinarian at the University of Illinois, said there are laws in place to deter clients from “drug shopping.”

“In the state of Illinois and a lot of other states, a PMP, or prescription monitoring program, is in place,” Mitek said. “As of January 1, 2018, in Illinois, they have amended that legislation to include vet medicine. Any time a vet chooses to prescribe an outpatient opioid or other controlled substance to a patient, they have to look up the client in a database and make sure that client isn’t ‘drug shopping.’”

Drug or veterinarian shopping is a method an addict might use to obtain drugs from a vet, by seeking opioids under the guise of treating their pets. Under a PMP, vets must look up clients’ names to confirm they have not been to another vet to get drugs and there is not a “frequent flyer” tag in the database.

The FDA emphasizes that vets follow all state and federal regulations as they apply to controlled substances. Brian Korus, a veterinary pharmacist also at the U of I, said vets can find information about federal regulations on the Drug Enforcement Administration (DEA) website.

“A Web search can help providers with state regulations and phone numbers,” he added. “They have access to the statutes themselves online, which are tedious to read, or they can try their own professional group, which may have resources.

“The prescribers also talk to each other. I have fielded several calls here from outside doctors as to what best practices may be for dealing with their controlled substances.”

Mitek said the typical cat-and-dog veterinarian will most commonly prescribe the opioids tramadol and buprenorphine. The latter, most often used on cats, is a drug also prescribed to human addicts.

“Interestingly, if you are a human opioid addict, that’s one of the things they prescribe to help,” she said. “How it works in the body actually helps to get you off that really hard high of heroin, or morphine or methadone.”

Tramadol is still used a lot in the veterinary profession, Mitek said, because it has a good safety profile and is inexpensive – but it is not extremely effective in dogs because they cannot metabolize it.

One other drug at risk of being abused by pet owners is a fentanyl patch. This is applied to skin and provides a constant infusion of fentanyl across the skin barrier. Mitek said there have been reports of people taking the fentanyl patches for an animal to instead lick or put on their own skin.

Dissimilar dosages

Animals process opioids differently than humans, which is one of the reasons there are few “take home” opioids a veterinarian would prescribe, Mitek said. Additionally, dosing of such medications are unique between humans and pets; while humans and primates are quite sensitive to the respiratory depressant effects of opioids, cats and dogs are not. This can make it especially dangerous for addicts attempting to use veterinarian-issued drugs.

“A dose that would make a human stop breathing is really small compared to what a dose is for a dog,” Mitek explained. “So to appropriately dose, say, a dog, with morphine, it is definitely more than you would give a human. You could definitely potentially kill a human with a canine dose.”

But drugs such as morphine are usually only administered to animals by vets themselves.

“There’s actually a big black hole where we don’t have really great at-home, strong pain medication in the opioid category for dogs and cats,” she said. “Buprenorphine is definitely one that works for cats, but that’s not something you would really see being used by a human.”

Injectable drugs such as methadone, morphine, hydrocodone and sensedol are all used in vets’ offices as well as in human hospitals. The difference is, a veterinarian would not send those home with a client – they are always administered by a professional. Of course, if a break-in were to occur in a vet’s office, those drugs would be available.

Mitek said such a break-in could most likely only be accomplished by sophisticated criminals.

“All of those are controlled substances according to the DEA, and the regulations of keeping those at a facility are strict,” she said. “Ours are under multiple locks and keys, and it would be like trying to break into an ATM – it can be done, but you’re going to have to be a very sophisticated criminal to pull that off.”

The FDA also notes when controlled substances are stolen from a clinic, veterinarians must report the theft to the DEA and to their local police department as soon as possible.

There have been cases where pet owners have intentionally hurt their pets to obtain medication, Mitek said, and the medication they are usually after is tramadol. Because humans have been known to abuse that drug, she said vets are becoming vigilant in prescribing.

Even so, some vets may feel uncomfortable having to look up a client’s personal information in a medication monitoring program. “My first concern is the patient,” Mitek said. “I get it; the epidemic is probably going to get worse before it gets better, and I think we need to do the best we can to try to keep opioids out of the hands of the wrong people.”

Combating opioid addiction and addressing misuse of pain medication continues to be one of the FDA’s highest priorities. More information about opioids such as how to spot a drug shopper or employee addict, how to handle situations involving drug abuse and how to help an animal that has been overdosed on an opioid can be found online at www.fda.gov/animalveterinary/resourcesforyou/ucm616944.htm

Alternatives available

Mitek said there are many pain-relief alternatives for treating animals, though opioids will always be the “gold standard.” In the case of post-operative pain or injury, vets can use local anesthetics (painkillers injected near a nerve to numb small areas) in a variety of ways – putting it directly on the incision, for example, or around the wrist for declawing cats.

Anti-inflammatory drugs such as cuprofen or rimadyl are effective but should only be used on otherwise healthy and stable animals. More creative solutions – such as running a soaker catheter under an incision which constantly pumps in lidocaine – are often inexpensive.

For animals with chronic pain, drugs like ketamine, amantadine and gabapentin are all inexpensive and can help modulate pain signals from reaching the brain. Mitek said she would be hesitant to perform a procedure such as an amputation without opioids, but she expects biotechnology could have a better alternative in the future.

“Even if you look at pain management in animals just 20 years ago to now, the progress has been insane,” she said. “A lot of these drugs have gone off patent and are inexpensive and easier to give, and need to be given less often.”

1/16/2019