My humble 2 cents:

These reactionary regulations seem unnecessary in their entirety and just vague enough to cause problems for honest vets. 1) Prescribe the appropriate medication in 2) the appropriate dose 3) for the appropriate amount of time: it seems like this goes without saying and should be under the "practice good medicine act." The human opiate epidemic is catastrophic and severe but is unlikely to be driven by a well intentioned veterinarian dispensing 0.02 Mg/kg buprenorphine to a cat for 8 (more than 7) days. While I understand the intent of the regulation, the fact that such regulations are considered and enacted brings supposed blame on the veterinary community for the opiate problem. The problem is not caused by veterinarians and there should be no burden placed on our profession as a reaction to a human medicine problem. The number of veterinarians prescribing month long doses of oxycontin and other highly human addictive opiates in zero. The opiate problem in VA does not lie with our honest profession and we should be left out of the blame game as our board should not knee jerk more reactionary regulations.

We finally have the tools with which to adequately control pain in our veterinary patients and I am concerned and resentful that because humans abuse said drugs, that our ability to practice good medicine is in jeopardy. I don't believe the opioid problem stems to any measureable extent from legally-prescribed veterinary drugs. I recently underwent knee surgery, for which I was prescribed 60 capsules containing an opioid. I took three. Good lord why prescribe 60? In speaking to other patients, this seems to be common practice. And so to curb the opioid problem we are going to tie the veterinarian's hands regarding pain control in a 10-lb cat? I do not believe the new regulations are necessary nor a good idea. Nor will they solve the problem.

I agree with my two colleagues who have voiced their opinions thus far.  I do believe the regulation in terms of dispensing this medication in particular is an overreach.  The small quantities of medication dispensed to patients, generally cats, is highly unlikely to be used to effect in addicts.  All the while, this adds further burden to the veterinarian in terms of workload and gives the regulatory agencies one more tool to fine or penalize them.  Instead, the state should focus on prescriptions provided by medical doctors and the pharmacists dispensing them and the possible role the insurance companies play in how much is dispensed.  Common sense should dictate that a prescription of 60 tablets of oxycontin to a human patient is excessive compared to the  relatively few doses of 0.09 mg of buprenex dispensed to a cat.  

While I appreciate and am deeply concerned re: the opioid crisis in the US, I completely agree with the others that have comment (and the many that are thinking the same thing and not posted), the veterinary community is NOT the cause of this crisis and this definitely seems like a knee jerk reaction.  

Regulation and oversight is necessary for those prescribing and dispensing controlled substances.  And if/when the human medical field back tracks on the over prescribing of opioids in particularly, veterinary medicine may become more vulnerable for those with addictions to seek out these medication (and some may already though currently low risk).  

Having a currently veterinary client patietn relationship is standard practice to continue the authorization of any medication in veterinary medicine and this should be continued and potentially more defined for those cases that require a controlled substance chronically. 

Additionally, documenting that risks associated with these medications and proper handling, storage and disposal is reasonable and a way the veterianary community may participate in health education for the pet owning community.  

Pump the brakes and revise the current proposal to a be more reasonable and not overreaching.   

I can certainly appreciate trying to reduce opioid abuse in humans, but once again trying to treat veterinary medicine the same as human medicine has resulted in regulations that are unnecessarily and excessively cumbersome. In fact, I am convinced that the net result of this arrangement is that pets that need opioids to control their pain are not going to get them.

I have already had clients change their mind about getting tramadol or buprenorphine for their pet when they discover that they will have to come back in a week for another physical exam. People have very busy lives, and pet owners are notorious for not being able to identify signs of pain in their pets. Most people are not going to take time off from work to have a pet seen that looks fine to them.

Assuming the pet is brought back for the repeat exam one week later, one of two things are going to happen. (1) The pet's pain has not improved in which case I will probably prescribe more and/or stronger pain meds, or (2) They have improved in which I case I will give them more of the drug they already had. If a pet owner is stealing and using their pet's pain meds, requiring this recheck exam one week later does not stop this from happening.

I agree with my colleagues who state you just have to trust the doctor to make appropriate recommendations following standard of care. If abuse is suspected, then investigate that particular doctor. But requiring everyone to suddenly jump through these arbitrary hoops only makes things more complicated and does not really fix the problem.

Dr. Kathy Kallay

I agree with previous comments that the veterinarian's role in the tragic and serious opiod epidemic occuring in the citizens of the Commonwealth and across the land is infinitesimal. As I read over the proposed regulations I wondered why they were necessary as it was spelling out standard practice for all the veterinarians I know. Veterinarians recognize that opiods are addicitve and do not prescribe longterm supplies. When requests for refills are made, red flags go up and the animal is reassessed. Unless the patient has a chronic condtion as described, no long term opiods are prescibed. Most dogs with bronchitis or CHF are small and the doses likewise small. It is therefore easy to spot owner abuse and refuse to make refills before the appropriate time. While I know there must be some veterinarians that overprescribe opiods, the number is extremely small. These proposed regulations add an unnecessary burden unfairly on professionals that are not part of the opiod epidemic in Virginia. They will have no measurable or usefull effect on stemming opiod abuse in humans. Continuing education for veterinarians would be a more effective and measured way than regulation.

This is just another example of how Veterinarians get caught in the crossfire of regulatory policy that targets physicians with poor investigation into how DVM's prescribe Buprenex and the quantities involved. This drug is typically used short term in cats following surgery and the quantities tend to be quite tiny and much less than the amount an addict would seek. I am very glad that there has been an exception applied so we can continue to use the drug but I think the emergency regulations concerning prescribing the drug are not really necessary and DVMs are already in compliance. It would be really nice if the folks that write regulations and laws would use a bit of common sense and think about how changes affect all aspects of the health profession. It seems that the left hand and the right hand just don't know what the other is doing and I am afraid it applies to all aspects of our government.

I applaud the efforts to help, even in a small way, to attempt to control the epidemic of opiod abuse.

I agree with all of the propsed regulations, except for the reqirement for our patients to return in 7 and 14 days for the first refills, especially for tramadol.  Most of us know our patients well, and prescribe tramadol for specific reasons.  (For instance:  Older arthritic dogs with elevated liver enzymes.)

Having to return in 7 & 14 days is an unnecessary burden on most pet owners.  In addition to the inconvenience, many see it as a financial burden as well.

My proposal would be that we should be able to prescribe a 14 day supply at first, require one recheck at 14 days, and then be able to refill monthly, with required rechecks every 6 months.

Stphanie A. Chmiel  DVM

Points other commenters have made are excellent. The most difficult part of the Emergency Regulation is the requirement to recheck in 7 days. Asking us to examine these patients for which opiates have been prescribed every 6 months is good medicine, plus we should be seeing these (typically) older patients that often anyway. In replacment of the 7-day recheck requirement, I'd prefer a rule requiring us assure the refills are being filled "on-time" with some defined "wastage" percentage of the amount dispensed. The occasional pill is wasted and the occasional volume of a liquid solution is lost, so there would need to be some leeway that allows us some professional judgment that the drug isn't being abused and that we can refill as needed for 6 months. Requiring a recheck seems optional to me because generally we're not prescribing amounts of opiates in quantities to be abused, especially if we're closely monitoring refill timing.

I have read these proposed regulations multiple times.  They appear to be in line with the way the majority of veterinarians already practice.  I agree, that it is unlikely that veterinary medicine is contributing to the opioid crisis in any meaningful way.  However, I don't see a problem with adherence to best practices and I think these regulations delineate best practices. This is an opportunity to highlight how carefully veterinarians consider their patients' needs and how appropriately our profession addresses pain and use of all modalities to bring comfort to our patients. We are and should be an example to other professions. Most of the commenters are concerned about the reevaluation of the patient, and this being a deterrent to appropriate use of these medications.  As I read this, the reevaluation at 7 and/or 14 days could be done as a phone conversation to check on progress and response to the treatment.  I do not see a requirement for an office visit or physical examination except for the original prescription and then every 6 months for chronic prescriptions.  Perhaps the wording in these sections could be made more clear.  Section A2 says "shall perform a history and physical examination", Section A4 says "reevaluation of patient" (but does not say physical exam) and section B says "seen and reevaluated".

My dog is almost 12 years old and he is terrified of the vet's office. I feel bad every time i have to make him go in, which i try to limit to once per year or less.  He is in the twilight of his life and I like to be able to provide him with pain medication because as a larger breed his hips and joints bother him now.  My vet office charges a significant cost just for an office visit--so before the vet sees my dog, runs any tests, asks any questions or prescribes any medication I'm already out of pocket $$.  If vets are going to be limited to prescribing a certian amount of pain medications AND they are going to require owners to bring their pets in every six months, there are goign to be owners who simply allow their pets to be in pain due to the additional financial strain of taking off work and paying for an office visit twice per year.  If you are an addict and want pain medication, what difference would bringing your pet in every 6 months make?  If you want pain medication for yourself you would be more willing to jump through hoops and pay more money.   

Although I live in Maryland, my veterinarian is in Virginia (VCA Alexandria Animal Hospital).  This is because I am convinced they provide me with high quality care, and I had a bad experience when I switched to a Maryland vet after moving here, so I drive back to Virginia.  I spend THOUSANDS of dollars a year there, since I have several elderly cats with chronic conditions.  These conditions include those which cause pain (arthritis); I also lost a cat to cancer and needed pain control for him and for a cat that threw a blood clot.  Although none of my pets are currently on opiates, I want to comment because it could happen any time with this old, sick crew.

I am against this regulatory change for two reasons, in order of importance:

1.  It will not make a significant contribution to reducing the opioid crisis.  The doses of these drugs prescribed for our pets are very small, would not be affective for humans, and if on some weird off-chance a human decided to swallow their pets entire week or months presciption to get an effective dose for themselves, this would become readily apparent t the prescribing vet because the owner would be contacting them asking for refills long before due, etc.

More importantly, the contribution veterinary drugs make to the opioid crisis is through DRUG DIVERSION by practitioners and staff.  This regulation will not do anything to stem that, and will create complications for veterinarians and clients seeking to provide adequate pain control for pets.  Lets put the regulations and effort where it can make a difference - identifying and stopping drug diversion by practitioners.

2.  It may lead to unintended consequences that harm pet health.  As the owner of cats, I am very aware of the dangers that Metacam and other NSAID pain control options pose for them.  If, due to the regulatory complications of prescribing a drug like buprenex, veterinarians beging prescribing more metacam, the result will be cats in kidney failure and angry clients.  By the same token, another potential consequence of this rule will be that veterinarians do not provide pain control for patients at all.  This will take us back to the dark days when our pets were expected to suffer without aid.  Many of hte pets in my charge over the years have had multiple extractions during dentals, some have had abdominal surgeries.  I cannot imagine how horrible it would have been if they had either not had pain control, or had a form of pain control that threw them into organ failure.

Again, because of the unintended consquences and because it will not contribute to stemming the opioid epidemic, I ask you to drop this regulation.  Thank you.

Stefani Olsen

3004 Dawson Avenue, Silver Spring MD 20902

Client of VCA Alexandria Animal Hospital

I received the info from my vet at VCA listed below. On the surface I understand and I am in favor. However, at $100 visit this appears to be an effort to increase revenue flow for the largest held vetrinary company. While my current dog is young and healthy, I had two previous dogs that suffered from cancer and were treated during their surgeries with Tramadol and other meds. I believe the Board of Vet Medcine needs to strongly suggest that clinics allow for a certain amount of visits for pets being treated to encourage the clincs prescribing 7 day prescriprtions to  not use this as an opportunity to increase revenues. 

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For acute pain, a veterinarian may only prescribe a seven-day supply of a controlled substance containing an opiod. A veterinarian may prescribe an additional seven-day supply only after a re-evaluation of the patient.

For chronic conditions, in which a controlled substance containing an opiod is prescribed for longer than 14 days, the veterinarian must re-examine the patient at least every 6 months.

This is not a solution to a very real and oercieved problem. There is a lack of umderstanding of thes drugs and the use in Veterinary medicine.

The recent changes in controlled drug distribution will not affect the drug problem at all. The time and money wasted on a hand out and limiting prescription sizes and frequency will do nothing. 

The hand out's biggest educational impact will be in letting the layperson know they can use their pet's drugs. So the education, you could argue, will INCREASE abuse.

The time, effort, and money would be better spent on educating veterinary staff on drug seeking behavior and/or committing funds to treatment. 

Addicts and the black market will be completely unaffected by the changes. 

Research and the failure of the 40 year "War on Drugs" has shown that the only viable option for attacking the drug epidemic is better treatment options, decriminalization, and having positive social outlets. 

Addicts will find drugs as long as people can make money selling them.

These regulations will affect patient care more than decrease access to controlled substances. Having to reauthorize prescriptions, which is time consuming, will take away from more important duties of the veterinary staff. 

Working families will have difficulty getting refills and the limited supply will cost them more money in the long run, potentially taking away from their ability to afford other treatment or diagnostics.

The negatives far outweighs the positives:

Negative 

1) decreased access to pain management for our patients 

2) educating the public that these drugs can be abused in the face of prior ignorance 

3) time spent approving and refilling medication which takes away from patient care

4) money spent on rechecks and more frequent refills taking away from limited funds for diagnostics and treatment 

5) frustration and emotional impact of all of the above

6) new problems from attempts to get around these regulations 

Positive 

1) an insignificant decrease in drug circulation from clinic, pharmacy, and drug companies to the general public.

I strongly urge the board to reconsider these regulations. They impact patient care more than the opioid crisis, plain and simple.

Respectfully,

Mark M. Held, LVT

Veterinarians, I believe tend to be very careful with the usage of opiods. Buprinex usage is minimal for cats post surgically - and our compounding law in VA (another topic) minimizes this more than I would desire. Tussigon dispensing for cough is easily managed for our patients and typically it the small dogs and that is not the opioid the abuser is seeking. Occassionally, Tylenol #3 is used. Haven't used Fentanyl patches in years. I believe that our biggest concern for so-called/opioids getting in the hands for human use/abuse is with Tramadol. We veterinarians have quite a dosage range in which to use the medication and do need to be extremely careful with how we prescribe it because if we give too much flexability, then we can make it easy for the human use/abuse. But if we are truly monitoring for what works dosage wise for each patient, then we are performing our due diligence. My hospital had a client several years ago ask for a refill of Tramadol 15-20 days early ... I declined it and he came by very upset and was not nice to the staff ... 6 months later he came back and apologized and felt bad that he could not tell us that sooner due to legal advice ... they found out their dog walker was swiping Tramadol....  I do agree that we need to be better educated, as well as our staff, to be able to recognize those that are trying to use their pet for their own means. 

As far as 18VAC150-20-174 ....

A2 is a joke!! I will always prescribe as i see fit for that patient's immediate and long term need. 

B is a joke!!

C is a joke!!  ---  Benefits -- help my patient  -- Hello ... Mc Fly -- Pharmacies don't do this and your MD doesnt talk about disposal

Come to think of it ... most of this entire piece is a joke.

Honestly, the opioid epidemic is not really much of what we dispense in veterinary medicine --- the problem drugs are the very potent opioids --- Oxycodones, etc

Is this the kind of regulation a precursor to the Board telling us we must choose the cheapest and not necessarily the most effective course of treatment?