More than 399,000 people died from overdoses involving prescription and illicit opioids from 1999-2017.[i] There are many efforts to educate physicians and dentists about their roles and responsibilities in addressing this national crisis. But what about veterinarians? Animals, like humans, may receive opioids for pain. Veterinarians and veterinary clinics can be registered with the US Drug Enforcement Administration and in many states can administer, prescribe, stock, and dispense opioids. As efforts to educate and monitor opioid prescribing by medical and dental providers have increased, individuals may try to covertly access opioids for their own use from their pets or other animals.[ii] In addition, leftover opioids from veterinary prescriptions can also result in diversion, misuse, or inadvertent exposure for members of the household. Access to opioids in the workplace can also lead to misuse by veterinary staff leading to overdose and death.

A 2014 online survey of Colorado Veterinarians[iii] found:

• 13% of surveyed veterinarians were aware that an animal owner had intentionally made an animal ill, injured an animal, or made an animal seem ill or injured to obtain opioid medications.
• 44% were aware of opioid abuse or misuse by either a client or a veterinary practice staff member.
• 12% were aware of veterinary staff opioid abuse and diversion.
• 62% believed that they had a role in preventing opioid abuse and misuse.
• 73% indicated that their veterinary medical school training on opioid abuse or misuse was either fair, poor, or absent.
• 64% said that they had not completed continuing education on best practices for prescribing opioids since entering practice.

A study in Pennsylvania investigated the volume of various opioids available through veterinary sources by inventorying the controlled substance records of a single veterinary hospital during an 11-year period that paralleled the rise of the opioid crisis. The study included 134 veterinarians (71% women) with 366,468 patient visits. During the study period, 2007-2017, the hospital veterinarians prescribed 105,183,689 tablets of tramadol, 97,547 tablets of hydrocodone, 38,939 tablets of codeine, and 3,153 fentanyl patches to dogs (73%), cats (23%), and exotic animals (5%).[iv] Overall, morphine milligram equivalents (MME) use (a measure of potency) increased 41%. Veterinary visits increased by 13%. These data suggest increased vet visits to obtain more and stronger opioids. While prescriptions for opioids rose at the veterinary hospital in the study, prescriptions decreased from doctors and dentists in Pennsylvania during this time period.

The Food and Drug Administration offers guidance in The Opioid Epidemic: What Veterinarians Need to Know. The FDA provides the following information on how to tell if a client or employee is potentially abusing opioids.

Some warning signs that a client is potentially abusing opioids may include:

• Suspect injuries in a new patient
• Asking for specific medications by name
• Asking for refills for lost or stolen medications
• Pet owner is insistent in their request

Some warning signs that veterinary staff may be abusing opioids include:

• Mood swings, anxiety, or depression
• Mental confusion and an inability to concentrate
• Making frequent mistakes at work
• Not showing up for work

The role of opioids in veterinary staff suicides must also be examined. Suicide is more likely among veterinarians than among the general population — 1.6 times more likely for male veterinarians and 2.4 times more likely for female veterinarians.[v] Veterinary technicians and technologists are also more likely to commit suicide than the general population — 5.0 times more likely for males and 2.3 times more likely for females. Vet technicians and technologists most often died from opioid poisoning (see related blog).

Although extensive efforts have been made in educational campaigns about opioid misuse directed toward physicians and dentists, similar programs have not been replicated for veterinarians. There is a need for a broader discussion about the use of prescription drug monitoring programs (PDMP) by veterinarians and what use is most appropriate for logging prescriptions of scheduled drugs into state PDMP systems. Currently, only 20 states require veterinarians to report their opioid prescribing to the state’s PDMP.[vi]   Some states allow veterinarians to access a PDMP report for any person who brings an animal to a clinic. In addition, because much of the prescribing, dispensing, and administration of DEA-scheduled drugs by veterinary practices does not flow through commercial pharmacies, there is a need to reexamine efforts to ensure the highest standards of inventory stocking, tracking, and security from the time these medications reach the clinic to the time they are either dispensed or returned to the supplier. This should include enhanced workplace policies, practices, procedures, training, and monitoring to mitigate the risks of diversion and misuse by both clinic staff and clients. State PDMP systems can serve as a valuable resource that is available to veterinarians in almost every state.

More research, surveillance, and public health efforts are needed to understand the scope of the problem and design system-level interventions. Are you aware of efforts happening in your state to prevent opioid misuse in veterinarian practices? Please share in the comments below.

For more information:

Prescription Opioid Epidemic: Do Veterinarians Have a Dog in the Fight? American Journal of Public Health

FDA-The Opioid Epidemic: What Veterinarians Need to Know

AVMA- Opioid Resources for Veterinarians

NIOSH- Opioids in the Workplace

The Center for Health, Work & Environment is a NIOSH-funded Total Worker Health® Center of Excellence and supported through a Cooperative Agreement. This blog is part of a series highlighting extramural research funded by NIOSH through the Office of Extramural Programs.

References

[i] Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. WR Morb Mortal Wkly Rep. ePub: 21 December 2018

[ii] Food and Drug Administration. Statement by FDA Commissioner Scott Gottlieb,MD, on the FDA’s new resource guide to support responsible opioid prescribing for pain management in animals. http://www.fda.gov/NewsEvents/

[iii] Mason et al. Prescription Opioid Epidemic: Do Veterinarians Have a Dog in the Fight? AJPH September 2018, Vol 108, No. 9

[iv] Clarke, DL et al. Trends in Opioid Prescribing and Dispensing by Veterinarians in Pennsylvania. JAMA Network Open. 2019;2(1):e186950. doi:10.1001/jamanetworkopen.2018.6950

[v] Witte TK; Spitzer EG; Edwards N; Fowler KA; Nett RJ. Suicides and deaths of undetermined intent among veterinary professionals from 2003 through 2014. J Am Vet Med Assoc 2019 Sep; 255(5):595-608.

[vi] National Alliance for Model State Drug Laws. States with authority to require veterinarians to report to PMP. http://www.namsdl.org/library/17DE8759-65BE-F4BB-A5D78AD0A1CC1A12/. Published July 2013. Accessed December 6, 2018.