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'We're in a crisis': Veterinarians on the 2nd line of opioid epidemic

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'We're in a crisis': Veterinarians on the 2nd line of opioid epidemic

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Massachusetts State Police Trooper Brian Cooper displays a dosage of Naloxone during a training session with his K-9, Drako, in Revere, Mass.

Source: Associated Press

The impact the opioid epidemic has had on the human population is indisputable — as many as 115 Americans die each day because of opioid addiction — but the U.S. Food and Drug Administration and veterinarians are now becoming more vigilant about the myriad ways abuse of these powerful drugs is affecting the pet population.

As a result of the human epidemic, companies such as Pfizer Inc. and Elanco Animal Health Inc. have pulled veterinary opioid products from the shelves. This, in turn, has created a shortage of opioid painkillers for animals that has left some vets scrambling to come up with new treatment options for their patients.

The FDA in August issued guidance warning veterinarians to be vigilant about storing, using and prescribing opioids to ensure the products are not being diverted to humans. The guidance was the first time the FDA has spoken of the issue, and Commissioner Scott Gottleib said the agency must examine all possible access points for opioid drugs to effectively mitigate the crisis.

"We recognize that opioids and other pain medications have a legitimate and important role in treating pain in animals — just as they do for people," Gottlieb said. "But just like the opioid medications used in humans, these drugs have potentially serious risks, not just for the animal patients, but also because of their potential to lead to addiction, abuse and overdose in humans who may divert them for their own use."

An opioid shortage

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Only two opioid products are currently approved for animal use, including one only for use in cats.

Source: File photo

Only two opioid products are currently on the market for animal use as of Aug. 20 according to the FDA: buprenorphine for cats, and butorphanol for cats, dogs and horses. Buprenorphine is marketed as Simbadol by Zoetis Inc. A human formulation is also marketed by a number of companies as a mild opiate given as a substitute to patients addicted to heroin or other opioid painkillers. Zoetis also manufactures butorphanol as Torbutrol, which was originally marketed as a cough suppressant for dogs. The drug has since been used as an analgesic.

Gottlieb said companies are "making business decisions about discontinuing the marketing of these products in the context of the current epidemic." Pfizer in July suspended sales of opioids for veterinary use, according to the Veterinary Information Network. Elanco also discontinued its fentanyl medication, Recuvyra, in 2016, according to a company spokesperson, citing a "variety" of reasons. Elanco continues to offer non-opioid pain management products such as Onsior, which treats post-operative pain in cats and dogs.

Wildlife Laboratories withdrew an application for its carfentanil drug in March, the FDA said. The drug — which is 100 times more powerful than fentanyl — is no longer FDA approved for animal use.

Opioid medications are rarely prescribed in veterinary medicine when they are available, according to American Veterinary Medical Association President John de Jong. But the drugs are nevertheless an important component of pain management for animals.

De Jong said animals have a higher pain threshold, and he personally has not had "too much trouble" finding alternative medications amid the shortage. But anesthesiologist Andrea Looney, who directs anesthesia services at Massachusetts Veterinary Referral Hospital in Woburn, Mass., described the shortage as having "the rug pulled out from under us." Clinics and anesthesiologists that specialize in surgical operations may regularly experience a higher need for opioid medications.

"We're in a crisis, no question about it," Looney said. She disagreed with de Jong's opinion that animals have a higher pain threshold and said that animals instinctively hide pain as a matter of survival. "I guarantee you they feel the same pain we'd feel, and we're not unlike human anesthesiologists in that we have to turn away cases if we don't have the drugs to treat them."

Looney, who also serves on the Humane Society Veterinary Medical Association leadership council, said her practice has used alpha 2 agents, anti-inflammatories, local blocks and different forms of infusions to cope with the shortage. While Looney does not believe opioids can be replaced for all applications, she has found lipophilic or liposomal encapsulated, non-opioid medications useful in covering pain for two- to three-day periods.

Using pets to obtain opioids

For vet practices that do use opioids, de Jong described a careful storage system that mirrors those seen in human medical practices. Opioids must be securely locked away and "immovable" within the practice to protect against illegal obtainment by individuals outside and even within the clinic. An Aug. 8 study published in the American Journal of Public Health highlighted opioid abuse among veterinary staff as a possible issue, though de Jong said he has only experienced suspicion of staff abuse once, 20 years ago.

Veterinarians have also seen pets being used as gateways for owners to access opioid medications, Looney said. She has seen owners come in to her practice with fictional scenarios about their pets "at least once a week."

"It's not beyond a person to come in with a veterinary patient and say the animal is sick and hurt, and give abnormal signs that are infactual in an effort to gain access to certain drugs," she said. "We've seen it more commonly in the last decade — in a big city, that could very well be daily."

In August, WGN9 and Science Daily reported that veterinarians in Colorado and Idaho suspected pet owners of purposely injuring companion animals to obtain opioid prescriptions. Looney has only seen this once in her 25 to 30 years of practice, while de Jong has never seen such a case in his own practice.

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Heather Severt, the West Virginia state director of the Humane Society, said she has not seen a bump in reports of humans trying to access opioids through veterinary care in her state. West Virginia had the highest rate of opioid-related overdose deaths as of 2016.

"West Virginia faces many economic challenges, and people wouldn't be able to afford the medications out-of-pocket," she said. "Insurance isn't likely to cover animal medications."

But Severt has noticed an uptick in abuse cases in counties experiencing the epidemic most acutely.

"I've seen the statistics of drug abuse per county, and the counties with high rates of overdose are the same counties from which I get the most calls and emails with complaints of animal cruelty," Severt said. Animals can be abandoned, and are sometimes seized by animal welfare authorities due to neglect.

Accidental exposure

Another impact to animals is accidental exposure to opioids, especially for animals on the front lines of combating the epidemic: police dogs.

"If a police dog finds narcotics and gets into them before the handler can turn them away, [the dog] will become just as toxic and will go under depression and sudden reversal," Looney said. "How we get them out of that crisis is similar to that of a human."

Because dogs have their noses to the ground to sniff out signs of drugs, which can be difficult to visibly detect in such small but toxic quantities, the potential for emergency situations is very high, according to a 2017 CNN article. K-9s showed signs of overdose during a search warrant in Florida in 2016, alerting police officers and first responders to the dangers of exposure to even mere grains of substances like fentanyl. Police dogs in Colorado are now accompanied by handlers carrying Narcan, a nasal spray that reverses opioid overdose in people, CNN reported.

The FDA update cautioned pet owners to secure their medications accordingly to prevent unintentional scenarios where animals may be exposed to opioids.

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Sixteen states have prescription drug monitoring programs that allow veterinarians to check for the pet owner's opioid records if they suspect drug abuse. But Looney said these laws are a "dicey area," as veterinarians are unaccustomed to, and perhaps uncomfortable with, seeking out human medical history. De Jong also noted the process is very "labor-intensive," as veterinarians do not have the same reporting software as physicians. Health privacy laws such as HIPAA also give vets pause, he noted.

Severt, de Jong and Looney all agree that education is key. Severt said cross-training would be helpful for law enforcement and for the general public, including education on how opioid abuse can impact animals.

"It's about gaining more knowledge and experience in not using opioids," Looney said. "It's about being very cautious with what we prescribe to veterinary patients, just fearing that those same drugs might be diverted to humans in the household."