I would request a statement similar to the one below in the buprenorphine section allowing for the use of buprenorphine for a period of longer than 7 days if being used for chornic, palliative care. Although it is not used often, I have used chronic buprenorphine for renal failure cats with severe arthritis that cannot be managed on other available pain medications. We see these cats at least monthly and continue to monitor pain and quality of life. All clients sign a pain managment contract, modeled on similar contracts in human medicine, discussing the risks and benefits of opioid therapy, the responsibility for the security of the drug, and proper disposal of any unused drug.

For any prescribing of a controlled substance beyond 14 days, the veterinarian shall develop a treatment plan for the patient, which shall include measures to be used to determine progress in treatment, further diagnostic evaluations or modalities that might be necessary, and the extent to which the pain or condition is associated with physical impairment. 

For continued prescribing of a controlled substance, the patient shall be seen and reevaluated at least every six months, and the justification for such prescribing documented in the patient record.

i day YES to the changeThe proposed new text seems to be what a lot of veterinarians are already doing. Yes, owners don’t like bringing their pet for a reevaluation they think the practice is only doing it to make money. But when the dr  has the owner sign the pain management contract they should be briefed about the fact it’s the Law. Most owners will have no issues, those who do will NOT get their medication for their pet and documention should be noted. I say YES to the change. Maybe add that any dr found not complying will be fined and may have their license suspended or revoked.

Thank you for seeking public comment on this regulation. I'm an emergency veterinarian in NoVA and wanted to say that I appreciate extending prescriptions from 7 days to 14 days as I feel this helps post-op patients who may need pain medication for a bit longer. I'm not often involved in chronic pain management or hospice care, as I tend to refer owners back to their primary care veterinarians for that, but I do appreciate the provision allowing for chronic administration of these medications not just for chronic pain, but for conditions requiring cough suppression. I feel that these regulations are very reasonable in stipulating for rechecks and monitoring to document continued need for opioid based medications. 

I support the regulations as written with one exception.  It is very rare, but due to unique features of feline metabolism and pain relief challenges, there are times when chronic use of buprenorphine is indicated. Under item E. 2. , I think there should be provision for extending buprenorphine use beyond 7 days without a re-examination.  As written, it could be interpreted that an examination would be required every 7 days.

Hate to bring this up, but what prevents a client from taking their pet to multiple vets for controlled substance dispensing.   Should these pets be microchipped and entered into some kind of database to prevent this?

14 days is more reasonable and I second Dr. Carmack's comments.

Thanks, Dani

The way the proposed regulation is written it places a significant burden on veterinarians treating feline patients and owners of feline patients. Buprenorphine is the most commonly used pain medication in feline patients because it is effective, safe, easy for owners to administer, and reasonably priced. Other alternatives like NSAIDs carry a greater risk to the feline patient and many owners refuse to use them.  Having to bring a feline patient back to the clinic after only 7 days of treatment will cause cats to suffer from pain as owners will simply not bring them back due to the hassle.

I urge the regulatory committee to provide an exception to the 7 day rule for buprenorphine for chronic pain (arthritis, pancreatitis) and for hospice patients allowing a 14 day supply to be obtained at each refill as long as there is a treatment plan in place and there is a valid client-patient relationship. For patients with chronic conditions or under hospice treatment, physical exams could be required every 6 months instead of yearly. 

I think there should be a waiver on the limitation of 7 and 14 days for initial dispensing of opioids if a pet is diagnosed with a terminal condition.

I already had a case where I diagnosed a dog with end stage cancer and dispensed opioids for pain control. This dog was in a lot of pain, and I was forced to make the dog and owner return in 7 days for another recheck exam. I felt horrible putting the dog through this.

If a pet is terminal and the focus is palliative care only, it is cruel to make the pet return to the office in such a short time frame.

Older cats with osteoarthritis or chronic pancreatitis, as well as those who have oral cancers and many other cancerous conditions may require chronic narcotic therapy -- and buprenorphine is the safest, most effective and if used transbuccallly, the easiest for owners to administer. While we may be seeing these cats regularly (weekly initially in treatment, then often monthly once treatment is complete), cats and their owners do not appreciate having to come in to the hospital for a physical exam weekly just to continue their necessary pain medications. I would urge the Board to make an exemption for cats with chronic, debilitating, painful, and terminal illnesses allowing veterinarians to be able to prescribe and dispense buprenorphine for longer than seven days. Monthly recheck exams would enable us to maintain good control of these tiny volumes of dispensed buprenorphine, as well as enabling us to check on a patient's welfare and adjust treatment plan to suit. 

I believe a mandatory 7-14 day limit on opiates is highly impractical for many feline patients due to behavior/anxiety with transport out of the home environment or for large dogs with serious mobility issues.  The drug I see this most referring to would be buprenorphine or tramadol for chronic pain conditions.   In general I have a very good grasp on those particular cases who get larger prescriptions at a time and pay attention to the timelines for amounts prescribed vs. refills ordered and have not gotten any feelings of diversion from my personal experience with our clients.

Overall I support tightening regulations on dispensed schedule II-IV drugs.  However, I do not feel veterinarians are part of the reason for the opioid crisis in the Common Wealth or in the country, but we should safe guard that we don't become part of the problem.  I think tightening dispensed duration and quantity is good as well as re-evaluation time periods and documentation.  I do agree with other comments that extending the Buprenex dispense duration and re-examination requirements for chronically ill cats would improve care and quality of life, especially since quantity and strength is so low.  To re-examine a cat every 7 days for Buprenex is not practical.  For documented chronically ill cats, a 30 days supply followed by a re-examination is more reasonable with a maximum dispensed amount of 3mg (10 ml of 0.3mg/.ml) per 30 days.  Well below the abusable amount for a human. 

Part D does not specify the number of days of continuation of treatment, whereas Part B specifies continuation of treatment beyond 14 days.  What is the specific number of days with regard to part D?  Can the re-evaluations be done in person, on the phone, by email, or text, video, or Skype?  What is the name of the offense if these regulations are not followed?  In the proposed changes, there is now no mention of extenuating circumstances being allowed in part A3.  This needs to be included but also defined.  Part C states that we have to discuss known risks and benefits of these drugs with owners.  Since these drugs are being used in an extra-label manner and none has been approved for use in animals, who will tell us what constitutes the known risks and benefits of these drugs in animals?  We are being expected to explain something for which there is no evidence base.  For E2, this should be changed to allow 14 days or more as determined by the patient and the vet and the owner.  Related to proper disposal, what are real options for clients/owners?  The handout that we are instructed to give to clients does not provide actual options.  It directs clients to go to a website for further information.  Who has the burden of discussion and documentation when there is an off-site pharmacy filling these prescriptions?  We need clear guidance related to documenting and managing the various numbers of days in the regulations/proposals related to initial visit and re-evaluations.  Real life does not happen on day 1, day 7, and day 14.  How much leeway do we have to accomodate patients and clients/owners around work schedules, holidays, travel, and so on?  If Fido gets 7 days' worth of meds and doesn't need them again until 6 weeks later, is this 6 week date considered "prescribing beyond 14 days"?  Or is it considered to be an initial evaluation and we all have to start over with documentation and rule-following?  These regulations place an undue and misplaced burden on veterinarians who want to relieve pain and suffering in animals.  We are not the source of the opioid addiction crisis in humans.  They are abusing heroin and fentanyl according to reports of which I am aware.

We have created a form for our clients to sign which includes information about the dispensing regulations, disposal information and recheck requirements.  We are unclear as to how often such a form should be renewed (yearly?) and whether it applies to individual patients or whether it applies to individual clients (who may have multiple pets on opiods).  We also provide care for rescue groups who periodically have patients that require opiod dispenses.  Do we need to create a form for each patient or for the rescue group itself ... and who should sign the form (Director of resuce, Kennel manager or foster)?

All pertient medical information (diagnosis, dispense, recheck requirments, etc.) are recorded in each patient's chart, as per the regulations.  Our form is silimar in content to the "Prescription Medication Safety for Veterinarians" form on the DPH website.  The owner signs to acknowledge that they have recieved and understand the information.