Maine’s New Drug Law: Veterinary Visits Get Complicated….Part 2

Maine’s New Drug Law: Veterinary Visits Get Complicated….Part 2

Why are the legislators in Maine including veterinarians in a bill that is geared towards stemming the opiate epidemic?

The nation has an opioid abuse problem and it’s naive to think some animals owners have never diverted their pet’s medication or sought drugs for the animal when it’s really for them. To vet shop, however, requires more than doctor shopping. When doctor shopping one much be a very good actor. If you have a history of chronic pain even better. Veterinarian shopping requires a prop; your animal. It means establishing a profile for your pet at numerous veterinary practices. It means paying multiple veterinary bills to get drugs which A. aren’t really the type an addict wants and B. could be obtained cheaper on the street or through friends.

It’s not uncommon for veterinarians to prescribe painkillers to animals that suffer from chronic pain or that have undergone surgery. In some cases, these painkillers can be opioid-based. But what our legislators fail to take into consideration is the dosing difference between humans and animals; the dosing difference between felines and canines. And unlike a human who can “act” the part of a person in pain and verbalize their symptoms, animals can’t. Because they cannot communicate, non-verbal cues are the best way to determine the severity of a pet’s pain regardless of what the owner says. The veterinarian listens to the owner describe what Pup or Kitty are doing but then does a physical assessment of the animal. The last two decades have seen a huge change in the way veterinary medicine addresses pain in an animal. Whereas the previous line of thinking was Animals don’t feel pain” or “Keep them quiet and it will speed their healing because they won’t move around much”. Thankfully the veterinary profession has embraced the idea of pain management for both large and small animals and several pain scales are currently in use. Colorado State University Veterinary Medical Center uses this scale to evaluate acute pain in kittens and this one to evaluate acute canine pain.

A November 2015  publication from JAMA  gives an excellent overview of how pain is assessed and evaluated in animals whether it’s acute as in surgical or chronic like osteoarthritis. And if one is fortunate to live in a progressive area, there are even pain management clinics for animals like the one at Cummings Hospital which is part of The Veterinary School of Medicine at Tufts University in Massachusetts. More than ever, veterinarians are aware of the pain in animals whether it be a broken leg, advanced arthritis or cancer. This excellent article, The Hurt Unlocker, by Genevieve Rajewski, Editor for Tufts Veterinary School, gives a great overview of pain in animals and how it’s best managed.

PL 488 requires the following parameters for veterinarians:

  • All veterinarians who prescribe opiates or benzodiazepines must register as data requesters with the PMP
  • All veterinarians must check the records of the individual seeking care for the animal, and if appropriate the owner, prior to prescribing opiates or benzodiazepines. A valid state or federal photo ID should be checked, and a birthdate and the full name must be acquired in order to check the PMP of an individual. This would also apply to anyone you had to drop off or pick up Fido.
  • All written prescriptions must include a DEA number.
  • All prescriptions intended for use by an animal must indicate such use on the prescription.
  • Diagnosis and exemption codes are not required for veterinary prescriptions.
  • As of July 1, 2017, veterinarians with the capability to prescribe electronically will be required to do so. In April 2017 a waiver is expected to be released that will allow veterinarians without the capability to apply to be exempt.
  • The Aggregate Morphine Milligram Equivalent for the person who either owns the animal or is transporting.  The 100 MME/daily limit would include the anticipated new prescription.
  • The number of prescribers currently prescribing controlled substances to the individual.
  • The number of pharmacies currently filling prescriptions for controlled substances for the individual.
  • Veterinarians will be required to complete three hours of CE (continuing education) related to the prescription of opioids by December 31, 2017, and subsequently every two years. **

The Maine Veterinary Medical Association has even “helped” veterinarians by preparing a presentation  plus consent form for the humans to sign which gives the veterinarian or his designate permission to access the person’s drug records. What exactly does that mean? If narcotics are being prescribed, the human bringing the animal in or picking the animal up must consent to have their drug records accessed by someone in the veterinary practice. Let’s think about this for a minute. Your dog has surgery and because of the postoperative pain, the veterinarian wants to prescribe tramadol, a Schedule III narcotic as of 2014. Because of work hours, you ask your neighbor to pick Fido up. Imagine their shock when they have to fill out the consent form, show their driver’s license or another form of photo ID and wait while their drug profile is accessed and evaluated by a veterinarian, highly trained and skilled in animal medicine. And if the veterinarian calculating the human dosage determines your neighbor is at the top of the 100 MMEs daily allotment and the tramadol for your dog would exceed that amount, legally they can’t prescribe it. Also, a veterinarian had no way of knowing why a person is on the controlled drugs; only that they are. Based on numbers found in a database, a highly skilled veterinarian is being ordered by the State of Maine to practice veterinary medicine but use human protocols. In short, they are being mandated to practice outside their scope which is a violation. To ask a veterinarian who as I outlined in my previous post has extensive knowledge of animal physiology to prescribe pain medication for an animal based on how much of the daily allotment a human already has prescribed for them by a medical doctor is absolutely ludicrous.

Then there is palliative care for an animal with an end-stage disease that is painful. The State has not set any exemptions for veterinarians but has for human doctors.

Prescribers are exempt from the limits on opioid medication prescribing established in this rule if:

  1. Pain associated with active and aftercare cancer treatment. Providers must document in the medical record that the pain experienced by the individual is directly related to the individual’s cancer or cancer treatment. An exemption for aftercare cancer treatment may be claimed up to six months post remission

  2. Palliative care in conjunction with a serious illness;

As someone who had a beloved dog diagnosed with canine lymphoma in October 2015, I would have been beyond furious if her oncologist couldn’t prescribe opiates for her as she neared the end ~ simply because my daughter or I were at the top of the daily allotment. 

Addiction is an epidemic that can no longer be ignored. However the welfare of innocent animals should not be impacted, veterinarians mandated to operate at best, on the fringe of their scope of practice, nor our guarantee of privacy under HIPAA violated because neither veterinarians nor their staff is bound by HIPPA regulations.

Yet the State of Maine is doing all of these things.

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Maine: Passed A Law That Could Harm Animals And Their Veterinarians…Part 1

Maine: Passed A Law That Could Harm Animals And Their Veterinarians…Part 1

Like nearly every state, Maine is dealing with an opiate and heroin epidemic. In 2015, Maine experienced 272 overdose related fatalities.

In an effort to combat the opiate epidemic, the Maine Legislature enacted   P.L. 2015, ch. 488 (An Act to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program) which became effective January 1, 2017. PL 488 affects nearly all facets of healthcare by establishing specific rules for prescribing and dispensing controlled medications. It defines the protocols that must be followed and sets prescription limits on how much opiate a patient may legally be prescribed to take per day. This is called the Aggregate Morphine Milligram Equivalent and the total daily amount allowed is 100 Morphine Milligram Equivalents (100 MMEs).

PL 488 mandates that whenever a medical provider prescribes a controlled substance, they first check the PMP (Prescription Monitoring Program) to review the MME for the patient, what controlled drugs the patient is currently taking, who prescribed them and the pharmacy that filled the prescription. They must calculate if the drug they want to prescribe will, when added to the patient’s current daily MMEs, increase the allowed 100 MMEs and if so, not prescribe it. They must note if there are multiple prescriptions, providers or pharmacies. If the provider notices anything in the patients PMP profile that raises a red flag, they are required by law to report it to the PMP Coordinator. There are of course many other components to PL 488 but I only want to touch on the highlights and how it impacts Maine residents who are pet owners in addition to veterinarians. Yes, that’s correct ~ veterinarians because Maine’s Legislatures have determined that the inclusion of veterinarians in PL 488 will help reduce the opiate epidemic. I disagree because including veterinarians in PL 488 creates two major violations. First, however, I’d like to walk you through a veterinarian’s education.

If a young person thinks they want to become a veterinarian, they should begin preparing in high school by paying attention to their performance in science courses, such as chemistry, biology, and physics. This same attention applies to math courses; trigonometry, geometry, and algebra. After high school graduation the student attends a 4 year college to earn their bachelor’s degree where they take the prerequisite courses for admittance into veterinary college.These consist of many advanced science courses, such as biochemistry, organic and inorganic chemistry, and physics. They are necessary to prepare the student for the vigorous coursework in veterinary college. Prospective veterinarians must complete a doctor of veterinary medicine degree. Typically, a doctorate in veterinary medicine takes four years to complete. Of these four years, three are spent on classroom training where students take courses in animal anatomy and physiology. They also take courses on disease diagnosis, prevention and treatment. After completing three years of classroom training, students take another year left to complete their degree in veterinary medicine. The fourth year is typically spent getting practical, hands-on training. This takes the form of a one-year clinical rotation in a veterinary medical center or veterinary hospital to gain experience in a variety of areas of veterinary medicine. After graduating with a doctorate in veterinary medicine, veterinarians are not yet able to open a practice. Before practicing veterinary medicine, graduates must pass the North American Veterinary Licensing Examination and any applicable state exams. Their path is definitely not a short one but throughout it is focused primarily on one thing ~ animal anatomy, physiology and wellness. 

Maines’s new PL 488 and its impact on veterinarians is such. If an owner takes their pet to be seen and the veterinarian feels it necessary to prescribe a narcotic or benzodiazepine for your pet, they must first do a check on the owner with DHHS to determine if the owner is taking a controlled substance. As I previously mentioned I still need to clarify the parameters but the fact that a veterinarian or perhaps his staff has the power to access a person’s prescriptions is a huge HIPAA violation. But I digress. Let’s use a hypothetical situation. The owner has an anxiety disorder for which he takes Valium on a daily basis. He also has a severe back issue (long-term) so is on hydrocodone for pain control. His cat is hit by a car and taken to the vet where she undergoes successful emergency surgery but because her injuries are severe, the vet prescribes a pain medication; hydrocodone. Would the fact that the owner is on hydrocodone prohibit the vet from prescribing it for the cat’s postoperative pain? If so, would he be allowed to prescribe a different pain medication such as tramadol which also falls in the opiate category? Is he is prohibited from prescribing any narcotic because the owner is on two (2)?  Or is it only if the owner is on the same drug? If his prescriptive powers are limited because the owner is taking a controlled substance, what criteria is used to determine if the animal can or cannot get a prescription?

Whilst I understand the opiate epidemic our country is tackling, how can a veterinarian or anyone for that matter be absolutely certain that a person who is taking several controlled drugs is abusing or trafficking? Plus the thought that an innocent animal might have to suffer needlessly because his owner is on a controlled substance is not only abhorrent but inhumane.  I want to know if it’s possible for the check to be done during non-business hours when DHHS is closed. Does the veterinarian’s office have to speak directly to a DHHS employee or is the information accessible online? And if it is accessible online, how can we, the human patient, be assured it’s secure? If the drug check on the owner can’t be done when DHHS is closed, then what happens to the animal who is in pain?  Any pet owner knows that many accidents happen at night, weekends or holidays when government agencies like DHHS are closed; what then?  Going back to HIPAA, who has authority within the veterinary practice to request the DHHS information? Can a receptionist do it? A vet tech? Or only the veterinarian? Finally, I do not understand how PL 488, a state law, can override HIPAA, a federal law enacted in 1996 by Congress and signed into effect by then President Bill Clinton. Under HIPAA an individual’s medical and other health information including prescriptions is private and protected. The Privacy Law sets limits on who can look at and receive our health information such as covered entities and their business associates. As a nurse and former Union representative, I am extremely familiar with HIPAA. In light of PL 488, however, I reviewed it once again and nowhere did I find where veterinarians, veterinary technicians, or veterinary employees of any type are entitled to our records in any form. Additionally, PL 488 is, in essence, requiring veterinarians to understand human medication dosages compared to animals which often differ greatly.

I chose a veterinary team for my German Shepherd based on their reputations and expertise in animal physiology, not human. I value all members of her team despite being in different practices because of their knowledge. Having said that, I expect they keep current with the newest modalities of treatment for my dog. They work long hours yet now the State of Maine expects them to undertake additional training in order to understand and monitor the Prescription Monitoring Program (PMP)?  A program historically used only for humans?

This is ludicrous. There has to be a middle ground, a way the government, human healthcare providers, and law enforcement can work together in an effort to reduce the rampant drug abuse without violating a person’s rights or including veterinarians where there is potential for an animal to suffer because “something” raises a red flag when in reality it could be legitimate.