States track dispensing to counter drug fraud

Rules on veterinarians inconsistent among states
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Forty-nine states—all but Missouri—and the District of Columbia track controlled substance dispensing to thwart doctor shopping, the seeking of addictive or dangerous drugs from multiple doctors or pharmacists.

About a third require veterinarians to report to state databases when they dispense controlled substances, whereas about 40 require reports from dispensing physicians.

The opioid problem nationwide only serves to reinforce our role in ensuring that opioids don’t enter inappropriately into the community.

Dr. John Kuehn, a Nebraska state senator and large animal veterinarian

Alabama and Arizona have removed reporting requirements for veterinarians since the start of 2016, while Nebraska has formed a task force on implementing requirements starting in 2018, reflecting debate over whether the risk justifies the reporting burden. By one study’s tally, national annual counts of doctor shoppers at veterinary clinics are in the single digits.

Dr. John Kuehn, a Nebraska state senator and large animal veterinarian, said veterinarians have professional obligations to the public to ensure appropriate drug use and help address a public health crisis.

“The opioid problem nationwide only serves to reinforce our role in ensuring that opioids don’t enter inappropriately into the community,” he said.

He added that veterinarians should be aware that their clinics can be a source of abused drugs.

“Those of us in the large animal world have dealt with this issue with ketamine for quite some time,” he said.

Rise in overdoses

Drug overdose deaths have tripled since 1999, and prescription opioid deaths have quadrupled, according to data from the Centers for Disease Control and Prevention. About 500,000 people died from overdoses of prescription and illegal drugs from 2000-2014. In 2014, about 1.5 times as many people died from overdoses as from car collisions.

States have responded, in part, by implementing prescription drug monitoring programs, or PDMPs, which CDC information indicates have had promising results.

New York and Tennessee, for example, began requiring in 2012 that prescribers check their states’ monitoring programs before prescribing opioids, and in 2013, the numbers of people who saw multiple prescribers for the same drugs declined by 75 percent and 36 percent, respectively.

But one national survey of drug monitoring programs, regulators, and veterinary associations found that, in a typical year, fewer than 10 people were doctor shopping at U.S. veterinary clinics, and “veterinarians are a de minimus source of controlled substances.” The article was written by Dr. Robert J. Simpson, then president-elect of the American Veterinary Medical Law Association.

“When the known cases were adjusted based on state populations, there was an estimated one case per 30 million people, or 6.5 cases per year, in the United States,” he wrote.

Examples include an Ohio woman who visited five veterinarians to receive diazepam for a small dog said to have anxiety problems and a North Carolina woman who visited 24 veterinarians 180 times in one year to obtain butorphanol for a dog that she claimed had a prior prescription.

Dr. Simpson’s article also described several scams used to gain various drugs from veterinarians: requests for controlled substances to calm a high-spirited horse during transportation, increase alertness and aggression in a guard or show dog, or aid weight loss in an overweight pet.

But he also wrote that the incidence of veterinary prescription drug diversion is “infinitesimal,” and requiring reports from veterinarians to PDMPs is “superfluous.”

However, Barbara L. Carreno, a spokeswoman for the Drug Enforce­ment Administration, said doctor shopping is a substantial problem for veterinary clinics, and the DEA is tracking reports. Veterinarians also have to deal with theft and misuse by employees, burglary, and possibly robbery.

“All the things that apply to a human doctor apply to a pet doctor,” she said.

She noted that addicts seek tramadol from veterinarians because it works in humans and has low cost, as well as narcotics such as benzodiazepines and hydrocodone. The DEA recommends vigilance, good record keeping, and secure storage.

Quoting a DEA colleague, Carreno said, “Addicts are very good at getting drugs.”

Against reporting

Dr. Larry Stutts, an Alabama state senator who worked in mixed animal practice before becoming a physician, proposed the legislation that removed reporting requirements for the state’s dispensing veterinarians, effective Aug. 1, 2016.

“I felt it was an unnecessary interference with the private practitioners in the state,” he said.

He said the nation has an opioid abuse epidemic and isn’t so naive to think no veterinarians were involved.

“But as a whole, veterinarians play a very minor, insignificant role in diversion of narcotics,” he said.

Dr. Brad Fields, assistant executive director of the Alabama VMA, also said the data collection on veterinary drugs was an undue burden.

“It wasn’t valid or valuable data to the Department of Public Health and the PDMP program,” he said. “There hasn’t been any doctor shopper identified in the veterinary world through the PDMP.”

Veterinarians were required to report prescriptions issued, starting with the database’s implementation in April 2006. Dr. Fields said veterinary clinics lack the standardized software used by physicians and pharmacists to report dispensing, so veterinarians’ reports were more labor-intensive.

Dr. Simpson’s article notes that veterinary practice management software systems are incompatible with many states’ PDMP reporting protocols, requiring that veterinarians submit reports through alternative means such as online forms or hard copies. The labor required for data entry in clinics and state offices was considered in excluding veterinarians from Kentucky’s PDMP, he wrote.

On doctor shopping at U.S. veterinary clinics:

When the known cases were adjusted based on state populations, there was an estimated one case per 30 million people, or 6.5 cases per year, in the United States.

Dr. Robert J. Simpson, in a 2014 article published in the Journal of Animal and Environmental Law, while he was president-elect of the American Veterinary Medical Law Association

In addition, Alabama’s database lacked unique identifiers for veterinary patients, Dr. Fields said. Prescriptions for humans are tied to Social Security numbers, but information on animal patients is tied only to pet names out of concern that adding information to an owner’s medical records could violate federal privacy laws, he said.

Dr. Fields also contends that seeking drugs from veterinary clinics requires bringing in an animal with clinical signs and the money to cover examination fees.

“I think the potential certainly exists,” he said. “I mean, anybody would be a fool to say it doesn’t happen in the veterinary world, but it’s much more difficult.”

The New York State VMS has issued a statement that the 2013 regulations broke a promise that veterinarians would be exempted from reporting requirements.

“The NYSVMS continues to maintain, in its most vehement and aggressive manner, that this regulatory change exposes pets in New York State to unnecessary suffering, is an unnecessary drain on veterinarian’s (sic) resources, and increases the regulatory burden placed on small businesses in rural areas where access to 24-hour pharmacy services is unavailable,” the statement reads.

Bill Christian, a spokesman for the Tennessee Department of Health, said data on controlled substances dispensed by veterinarians were unavailable, since veterinary prescriptions are not distinguished from other entries in the state’s Controlled Substance Monitoring Database. But, he said, all data in the database are “making an impact in how we address the opioid epidemic.”

In a March 2013 newsletter, then–Kansas VMA president Dr. Tom Jernigan wrote that a five-year state government study found veterinarians should not be included in the state prescription drug monitoring program. A six-member task force, comprising two representatives each from the Kansas Board of Pharmacy, Kansas Board of Veterinary Examiners, and KVMA, conducted the study.

The Minnesota Board of Pharmacy, in a 2011 report to the state legislature, found that the board’s evidence did not support requirements that veterinarians report when they dispense controlled substances for outpatient administration. That report also indicates veterinarians routinely dispense these types of drugs in low quantities for short treatment durations and that 5 percent of veterinarians responding to a survey had seen overt doctor shopping.

In the Fall 2014 newsletter of the Minnesota Board of Veterinary Medicine, Barbara Carter, prescription drug monitoring program manager for the Minnesota Board of Pharmacy, wrote that veterinarians still could look up prescribing histories through the state database to help reduce availability of controlled substances for misuse or diversion, ongoing problems in the state. She noted that includes misuse or diversion of tramadol.

“Veterinarians can be unknowingly targeted by individuals diverting or using controlled substances for nonmedical purposes,” she wrote. Veterinarians in Minnesota are now also legally required to report any employees suspected to be diverting.

Minimizing risk

Sherry Green, president of the National Alliance for Model State Drug Laws, which drafts and analyzes drug and alcohol laws, policies, and regulations, said those misusing or selling drugs for nonmedical purposes tend to take the path of least resistance for acquiring those drugs. As states close routes to obtaining medications, addicts and sellers will choose others, she said. For that reasons, she supports requiring reports from all dispensers.

Green acknowledges she has seen no evidence of substantial diversion through veterinarians’ offices, and she would expect to have seen reports, studies, and discussions with colleagues if it were happening. That tells her veterinary clinics are not the easiest diversion route.

“You may not have a lot of diversion going on now, but, as you eliminate other opportunities and as you strengthen the monitoring, that suddenly may become a route that looks viable to someone who’s trying to get their hands on the drugs,” she said.

While Green acknowledged the difficulties described by Dr. Fields in gaining veterinary prescription drugs, she said addicts and drug sellers consider risks and opportunities, including using animals toward their ends and stealing money to cover clinic fees. Severity of addiction or profit motive determines how hard someone looks for opportunities to feed those needs, she said, citing increases in drug seeking across state lines as some states implemented monitoring programs and recent concerns that legal exemptions for nursing homes were enabling diversion through home-based care.

She wants further consideration of how states could prevent veterinary clinics from becoming targets without undue burden. She said reporting by dispensers benefits all prescribers.

Rhode Island has had about 1,200 overdose deaths since 2011, exceeding the combined deaths from car crashes, shootings, and fires, according to information published by the governor’s office in July 2016. The state requires dispensing reports from veterinarians.

Peter Karczmar, MD, the 2014-15 president of the Rhode Island Medical Society and husband of Dr. Cathy Lund, alternate representative from Rhode Island in the AVMA House of Delegates, was among those who helped incorporate the reporting and checking mechanism into the state’s medical system. He also has confronted patients after seeing their prescription history in the database.

Dr. Karczmar said veterinarians need to be involved in efforts to reduce the risks of controlled substance abuse.

“I think it’s important for veterinarians to understand there is a significant potential for diversion of controlled substances,” he said.

You may not have a lot of diversion going on now, but, as you eliminate other opportunities and as you strengthen the monitoring, that suddenly may become a route that looks viable to someone who’s trying to get their hands on the drugs.

Sherry Green, president, National Alliance for Model State Drug Laws

Dr. Lund, who described Rhode Island’s requirements during an open discussion at the AVMA HOD regular annual session in August 2016, said in a later interview that the monitoring program has been important in dealing with the drug overdose crisis in Rhode Island, and physicians worked with veterinarians as colleagues in developing the solution.

Patrick Knue, director of the Prescription Drug Monitoring Program Training and Technical Assistance Center at Brandeis University, noted that, in the minority of states that require veterinarians report controlled substances dispensed, some are unable to identify fraud at veterinary clinics—especially when it is performed under multiple pet names. With programs that track prescriptions by the owners’ addresses, he said, veterinarians can at least use that information to see how many prescriptions are going to one residence.

“It’s actually not evidence of anything,” he said. “It’s just an indicator.”

He and colleagues at the center were unable to find any studies or research related to veterinarians’ use of prescription drug monitoring programs or potential diversion or abuse. From his previous experience working on Texas’ prescription drug monitoring program, he remembers only a few reports of inventory theft and improper ordering by clinic staff.

Burden and responsibility

The Nebraska state government’s 10-member Veterinary Prescription Monitoring Program Task Force began studying in 2016 the types of drug dispensing that veterinarians should be required to report when their participation in the state’s drug monitoring program becomes mandatory in January 2018.

Dr. Kuehn, the state senator, is chair of the task force, which he said is deliberating on how to make reporting work well for veterinarians and accomplish the PDMP goals. In mid-December 2016, he said that conflicts within the task force had delayed the report past its Dec. 1 deadline, but the group was making progress.

“What we’re trying to figure out is how do we have a system that protects veterinarians, protects the public, and ensures the integrity of our ability to utilize controlled substances,” he said.

Because Nebraska has lagged in developing a monitoring program, Dr. Kuehn said, it has become a haven for drug-seeking activity and needs to act to close improper access to opioids.

If physicians, pharmacists, and dentists are expected to keep records of the controlled substances they send into the community, Dr. Kuehn questions why veterinarians would lack such an obligation. Spending less than one minute to fill in a form is, to him, a tiny obligation, especially in light of the risk that a misused prescription could kill someone.

“When is something a burden, and when does something become a professional obligation?” he asked.

If veterinarians want roles in combined medicine and public health, he questioned why they would not have the same responsibilities and obligations as other medical professionals.

“The idea that this is only a regulatory burden, without recognizing our responsibility to ensure the integrity of the controlled substances that we send into the community, is a discussion that, frankly, baffles me,” he said.