(Photos by R. Scott Nolen)
AVMA House of Delegates members want the Association to develop policies and further guidance on emerging issues affecting the profession, such as prescription drug monitoring programs and marijuana treatments for animals. Delegates say they've already fought battles in their state legislatures or had clients bring up these issues in their clinics.
These two topics were part of the third Veterinary Information Forum on July 20, an open discussion during which HOD members address high-profile issues brought by the delegates and their constituents, prior to the House's regular annual session. Other topics discussed were the application and definition of the veterinarian-client-patient relationship along with service and assistance animals.
On the topic of the use of marijuana in veterinary medicine, Dr. Michael Ames, Arizona delegate, pointed out that even though 29 states and the District of Columbia have legalized marijuana for medical use—and nine of them have also legalized it for recreational use—it's still illegal at the federal level.
Dr. Rebecca Ruch-Gallie, Colorado alternate delegate, notes during the AVMA House of Delegate's Veterinary Information Forum on July 20 that Colorado State University is conducting clinical trials involving cannabidiol and dogs with arthritis and epilepsy.
"So while it may be legal for you to use yourself, it's not legal to prescribe it to animals," he said.
Dr. Dick Sullivan, California delegate, said, "We are definitely seeing an increase in toxicity cases. For that reason alone, we need research and our national association to write a letter or petition the FDA to allow us to do research and get good information to our clients because they are asking us, and our obligation, morally and ethically, is to address these cases."
Because marijuana is a schedule I drug, it is difficult to procure for research applications. That said, Colorado State University College of Veterinary Medicine & Biomedical Sciences is conducting two clinical trials examining the efficacy of cannabidiol, a nonpsychoactive cannabinoid, one involving treatment of osteoarthritis and the other involving treatment of epilepsy in dogs. CSU is still recruiting animals for the studies. There is no estimated release date for the findings.
The Colorado VMA has put out a position statement on the use of marijuana in veterinary medicine. And the AVMA Council on Biologic and Therapeutic Agents and the Clinical Practitioners Advisory Committee are looking at this issue.
Prescription drug monitoring programs
On the topic of PDMPs, Dr. Melanie Marsden, Colorado delegate, said the AVMA is aware of only one state, Missouri, that does not have a PDMP. Thirty-four states exempt veterinarians from reporting requirements in some manner, and six states along with the District of Columbia have laws requiring veterinarians to report dispensing of controlled substances, whether within 24 hours or as long as six months after dispensing. HOD members at the forum said they are concerned not only about burdens associated with reporting but also administrative and continuing education requirements as well as concerns of violating the Health Insurance Portability and Accountability Act.
Dr. Anne Del Borgo, Maine delegate, said that in her state, veterinarians have to red-flag patients, but they aren't told what constitutes a red flag. They also have no way of knowing whether clients are drug shopping, because there is no central database for reporting. Another problem: the state requires continuing education on opioid-related issues, but no such education exists right now. "If the AVMA could have webinar material, that would be great," she said.
Because Maine has seen a number of regulations in this area, the Maine VMA developed a draft position statement in June.
Some delegates suggested that practitioners should consider not prescribing opioids or controlled substances, or at least look at how often they are doing so.
While veterinarians may not be prescribing a substantial amount of these drugs, Dr. Marsden said, "It's important to keep in mind that one prescription can have an impact if it falls into the wrong hands."
She continued, "I encourage every state to develop and maintain a relationship with state boards of pharmacy so that we have a voice, so that when this kind of legislation comes into our arena, it doesn't have unintended negative consequences."
Dr. Mark Cox, Texas delegate, went further, saying, "We ask that the AVMA establish a policy on how we see ourselves (on this issue), hopefully excluded from prescription drug monitoring programs. Every state in the union has been faced with this at some point. If we don't have a directive or policy from our mother institution, we'll all fight this fight individually. Our request is development of a policy to give direction on how to work with PDMPs," he said.
Dr. Arnold Goldman, then Connecticut alternate delegate and now AVMA treasurer, mentioned efforts by state legislatures to require all health practitioners, including veterinarians, to prescribe by electronic means even though veterinarians don't have software that interacts directly with pharmacies. The Connecticut VMA was able to get an exemption for its members.
"This would further tie our hands when treating patients," he said. "I wouldn't be surprised if that's the next thing that's coming" in other states.
Other delegates did, in fact, mention difficulties in their states with legislatures. Twice in Texas, the state legislature has tried to require that its prescription drug monitoring program apply to veterinarians, but it failed both times.
Finally, on the topic of the application and definition of the VCPR, delegates discussed the fact that the AVMA and the Food and Drug Administration have different definitions of the VCPR. The main difference is that the AVMA has added a requirement to include veterinary oversight of treatment and outcome and that records be maintained. Dr. Steven Solomon, director of the FDA Center for Veterinary Medicine, said, "We recognize that the federal VCPR, the definition adopted by states, and the AVMA's are not all harmonized. That has the opportunity to create some confusion. We're open to discussing how to move forward to harmonize to the extent possible and that comes with a close working relationship with the AVMA."
Dr. Kathleen Smiler, Michigan delegate, gives her input during the forum. She says she knows of a neurologist who is already prescribing cannabis for ataxic dogs.
The AVMA Council on Veterinary Service will review the Association's model practice act starting next year, with the potential to include provisions on unlicensed practice, said Dr. Melanie Marsden, Colorado delegate.
Dr. Solomon added, "The veterinary profession continues to evolve, including the use of technologies such as telemedicine. We're committed to working with the AVMA to advance such technology but won't undermine the principles of the VCPR. Our current thinking is a VCPR cannot be established remotely, but once established, telemedicine can be a useful tool in maintaining a VCPR."
The AVMA, too, takes the stance that veterinary telemedicine should be conducted only within an existing VCPR, with the exception for advice given in an emergency until that patient can be seen by a veterinarian.
Jim Penrod, executive director of the American Association of Veterinary State Boards, said his organization feels it is important to establish a model policy to be used as an educational tool for state leaders so that regulations are not dictated to boards by uninformed forces.
"The AAVSB encourages timely exploration of pilot projects testing the using of telehealth technologies to ensure the health of the patient is met and standards of care are maintained," he said.
Following the forum, HOD members attended reference committee meetings, then reconvened July 21 and took the following relevant actions that were approved by the full House:
- Recommended the AVMA Board of Directors consider creating and disseminating informational pieces on the current legal status of cannabis as applied to practitioners; unified definitions of cannabis and its derivatives; current research available; and the signs, symptoms, and treatment of cannabis toxicosis in animals for both practitioners and clients.
- Recommended the Board investigate working with other research organizations and medical stakeholders to reclassify cannabis from schedule I to schedule II to facilitate research opportunities for veterinary and human medical uses.
- Recommended the Board encourage appropriate AVMA entities to develop model language pertaining to veterinarians' involvement in state PDMPs and report back to the HOD during the 2018 regular annual session. Recommend that this includes the following as background: model language for waivers; information on how to positively interact with state boards of pharmacy; recommendations for reporting that are practical, reasonable, and realistic; development of appropriate software; methods for permanent identification for animals; veterinarians' responsibility in monitoring; continuing education for veterinarians, such as best prescribing practices and identifying diversion and abuse; clarifying the differences between patients (in human medicine) and clients (in veterinary medicine) and the impact of HIPAA; and what happens with the information, such as who is tracking it or being notified.
Dr. Cathy Lund, Rhode Island delegate, said, "These topics in the Veterinary Information Forum underscore the essential fact that we need to be ahead of this as a leader. If we want to be relevant to the profession, we have to tackle these topics."
AVMA members who have ideas for discussion topics for the next Veterinary Information Forum, to be held at the AVMA Veterinary Leadership Conference in January, can reach out to their delegates through contact information in the House of Delegates directory.
Related JAVMA content:
States track dispensing to counter drug fraud (Feb. 1, 2017)
Veterinary marijuana? (June 15, 2013)