By April Mach, PharmD
It’s unlikely that you haven’t heard the term “opioid epidemic.” And if you haven’t already been personally or indirectly affected by it, you’ve at least seen the shocking and devastating stories in the news. Every day in Massachusetts, 5 people die from opioid overdose.1 Across the United States, that number is drastically higher, at an average of 115 opioid overdose deaths per day.2 The message is clear – we must do something to stop what is an entirely preventable tragedy. But what? And how do we help as veterinary professionals?
It helps to understand what the opioid epidemic is and how it began. The term “opioid crisis” is an umbrella term that encompasses an array of concepts − misuse/abuse of prescription and non-prescription opioids, addiction to these substances, treatment for and recovery from the addiction and most significantly, deaths from opioid overdose. It is called an “epidemic” because this national crisis has serious implications for public health, social welfare and our national economy − and it is killing people in our country at an alarming rate. Much of the current crisis is said to stem from false assurances provided from pharmaceutical manufacturers in the early 1990s, when they claimed that their powerful pain relievers would not cause addiction, leading human physicians to prescribe opioids more liberally.2 Clearly, they were wrong. Statistics today tell us that about 80% of heroin users misused prescription opioids before moving on to heroin.2 And further upstream, about 70% of people using opioid pain relievers for non-medical reasons admit to obtaining them from family and friends3 − this includes the household medicine cabinet where our clients often store their pet’s medications right alongside their own. We can acknowledge that while the veterinary community plays a comparatively small role in the overall scope of the opioid epidemic, this national crisis has grown so large and become so grave, that we are not immune to its effects. Don’t underestimate the impact you can have − even locally − on curbing and preventing the growth of this widespread epidemic.
A direct means of curbing the crisis might be to select a treatment protocol that doesn’t leverage opioids whenever possible. This is not to suggest that you simply “stop prescribing opioids,” but rather, take a stepwise approach to treatment that always considers non-opiate options first. Many disease processes and patient cases will warrant treatment with opioids regardless, but when it comes to certain types of pain, non-opioid pain relievers may not only be safer to have around the household, but also more effective in treating the patient. A 2018 study published in JAVMA showed that Tramadol − one of the most commonly prescribed opioids for acute and chronic pain relief in dogs and other species − was not effective at treating osteoarthritis pain of the elbow or stifle joint in dogs. Clinically significant improvement in three different pain scores was seen with Carprofen treatment, but not with Tramadol or placebo.4 These results echo those of two previous studies which measured the effectiveness of Tramadol, with and against NSAIDs, in post-operative pain for dogs that had undergone either enucleation5 or orthopedic6 surgery; NSAIDs appear to be more effective at treating pain in dogs than Tramadol. While attempting to define any kind of clinical practice guidelines is well outside the scope of this article, it is important to recognize that effective, non-opiate alternatives for pain treatment exist, and have been proven in the literature to be superior to Tramadol.
When opioids are necessary, then heed the advice of FDA Commissioner Scott Gottlieb and just about any pharmacist you’ll talk to − follow all state and federal regulations related to the prescribing and dispensing of opioids7 and all other controlled substances. The opioid drugs going home from clinics or being prescribed most often may include Buprenorphine, Codeine, Hydrocodone/homatropine and Tramadol. It is necessary to be familiar with the limits and requirements for both prescribing and dispensing these drugs. The Drug Enforcement Agency (DEA) assigns all controlled substances to a “schedule,” which is arranged in order of the risk of abuse and dependence.8 Schedule I (1) drugs, often recognized as “street drugs,” are controlled substances which have no currently accepted medical use in the United States. This class includes drugs like heroin, LSD and marijuana. Schedule II contains drugs which have an acceptable medical use and are considered to have a high potential for abuse which may lead to severe psychological or physical dependence. The risk of abuse and dependence decreases with each subsequent schedule (III, IV and V). To complicate matters, Massachusetts categorizes all non-controlled prescription drugs (such as Amoxicillin, Furosemide and Prednisone) into a sixth schedule, called “Schedule VI” drugs − these are not controlled substances, and any state and federal requirements pertaining specifically to controlled substances do not apply to this schedule of drugs (see Figure 1).
The Angell Pharmacy has chosen to impose its own, stricter limits on the dispensing of all opioids from our hospitals − every order, whether the first or the fiftieth, is restricted to a 7-day supply with no refills. Chronic opioid orders or any beyond the 7-day limit must be prescribed outside, where sophisticated refill tracking and reporting systems can detect and stop drug diversion. We encourage the use of outside pharmacies for opioid and other controlled substance prescriptions whenever possible because the pharmacy software programs used to dispense these orders connects and reports to the state PDMP (Prescription Drug Monitoring Program). Additionally, nearly all of the major retail chains impose strict limits on controlled substance refill schedules and have the ability to track refill history to identify and stop potential misuse.
Education of the client is an important step that should be taken every time an opioid is prescribed to a patient for the first time. Many clients do not realize just how dangerous the opioid drug being prescribed to their pet is, or that it is even a controlled substance. Taking the time to discuss the proper ways to handle, store and dispose of controlled substances may be the best way to stop these powerful drugs from getting into the hands of a curious teenager or a drug-seeking friend or family member. Tell clients to keep the drugs out of sight, out of the reach of children and inaccessible to visitors. The best way to accomplish this may be with a hidden lock-box (sold specifically for this purpose at pharmacies throughout Massachusetts). Clients must also be educated on proper disposal − either through a medication disposal envelope system, at a local facility that accepts controlled drugs or via one of the Drug Enforcement Administration (DEA)’s semi-annual National Prescription Drug Take Back Days.9
Finally − know how to recognize drug-seeking behavior. Clients may present with a new patient that has suspicious injuries, become aggressive, ask for drugs by name, repeatedly request refills earlier than they should be needed or provide a new reason each time they request an early refill. Employees abusing or diverting opioids may exhibit mood swings, changes in behavior or performance or may frequently volunteer for tasks involving opioids or controlled substances. You should develop a protocol to handle drug-seeking clients and if you suspect or confirm an employee to be abusing or diverting opioids or other controlled substances, you should take the proper steps to address it, including notification of local authorities.
The bottom line is this: while at first glance it may seem that veterinarians don’t play a role in stopping the opioid crisis, you may be able to do far more than you think. Stay informed of available non-opioid treatment options and evidence-based medicine, always practice within state and federally mandated controlled substance guidelines and lastly, educate your clients − providing them tools whenever possible − about opioid handling and disposal. The actions of few become the impact of many, and if we all do our part, we can win the fight against opioids.
- gov. https://www.mass.gov/files/documents/2018/11/16/Opioid-related-Overdose-Deaths-among-MA-Residents-November-2018.pdf. Published 2018. Accessed November 16, 2018.
- Opioid Overdose Crisis. Drugabuse.gov. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis. Published 2018. Accessed November 16, 2018.
- org. https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/safe-storage.pdf. Published 2018. Accessed November 16, 2018.
- Budsberg S, Torres B, Kleine S, Sandberg G, Berjeski A. Lack of effectiveness of tramadol hydrochloride for the treatment of pain and joint dysfunction in dogs with chronic osteoarthritis. J Am Vet Med Assoc. 2018;252(4):427-432. doi:10.2460/javma.252.4.427
- Delgado C, Bentley E, Hetzel S, Smith L. Comparison of carprofen and tramadol for postoperative analgesia in dogs undergoing enucleation. J Am Vet Med Assoc. 2014;245(12):1375-1381. doi:10.2460/javma.245.12.1375
- Davila D, Keeshen TP, Evans RB, Conzemius MG. Comparison of the analgesic efficacy of perioperative firocoxib and tramadol administration in dogs undergoing tibial plateau leveling osteotomy. J Am Vet Med Assoc. 2013;243(2):225-31. doi: 10.2460/javma.243.2.225.
- The Opioid Epidemic: What Veterinarians Need to Know. Fda.gov. https://www.fda.gov/animalveterinary/resourcesforyou/ucm616944.htm. Published 2018. Accessed November 17, 2018.
- Controlled Substance Schedules. Deadiversion.usdoj.gov. https://www.deadiversion.usdoj.gov/schedules/. Published 2018. Accessed November 16, 2018.
- National Prescription Drug Take Back Day. Deadiversion.usdoj.gov. https://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html. Published 2018. Accessed November 17, 2018.
Figure 1: Controlled Substance Prescribing and Dispensing Requirements in Massachusetts
||NO / 0
||Hydrocodone, Codeine, Fentanyl
||5 within 6 months
||5 within 6 months
||Tramadol, Diazepam, Phenobarbital
|C-VI (MA only)
||Amoxicillin, Enalapril, Prednisone
|All first-time opioid prescriptions in MA are limited by state law to a 7-day supply, regardless of schedule.
Every prescription issued for Schedule II opioid drugs must contain the statement: “Partial fill upon patient request”
All controlled substance prescriptions must contain the prescriber’s name, signature and DEA number (in addition to all other required prescription elements)