Every animal hospital in the world is a target for this kind of problem. Owners cite behavior issues, severe pain or seizure activity that’s only in evidence in the home environment. They often exit the hospital with a paper script or a bottle of pills for their pets' troubles.
All hospitals keep track of these drugs. Smart hospitals may even let the pharmacist do it for them (at our hospital we refuse to stock phenobarbital, sedatives or opiates in their pill form). Even then, however, it’s entirely possible that the pets will never see the pills. After all, we know humans have a way of taking their troubles to task with drugs veterinarians have prescribed for their pets. (Indeed, one of my client's children once attempted suicide with the dog's seizure medication.)
That’s why we keep careful notes on these cases. We count out the refills and the reception desk red flags owners who ask for more refills than are due them. We perform careful physicals and log serial bloodwork results with the due diligence of a tax attorney. And we trust. We have to. We can only hope the pills are going down the right hatch for the right problem.
Lately, we’ve had a couple of clients whose pill vials were lost or who took it upon themselves to increase their pets doses, necessitating additional refills. On a cases by case basis, we make a determination as to whether we will allow these clients to continue to receive refills on behalf of their pets.
There’s nothing worse than denying a pet a needed medication, but these are red flags for owner abuse of medication. They cannot be ignored or swept under the rug. They require uncomfortable confrontations with owners involving careful questioning with potentially disastrous results when they quickly realize our concern is not merely for their pets.
Some owners get angry and belligerent. And we lose them. No one likes a thinly veiled discussion over potential drug abuse––even when it’s clear we have their best interest at heart. And personally, I can’t abide this kind of stress.
That’s why lately, I’ve taken to referring these clients to specialists, citing a need to have their pet evaluated by a higher authority before more medication can be prescribed. “I’m just uncomfortable with dosing him at a higher level,” I say. Or, “I believe we’ve hit that point we discussed earlier where it’s clear he needs better care than I can provide.”
This way 1) the problem is in the hands of someone with a more objective point of view than mine, 2) I can offer the owner the benefit of the doubt on the drug thing, 3) the pet gets even better care than I can provide by virtue of the specialist’s higher education in the matter at hand and 4) zero confrontation.
That is, until this week’s owner of a storm phobic dog. We’d recommended behavior modification along with a variety of non-sedating alternatives. After a month, the owner claimed nothing worked. A behaviorist was recommended and sedatives were prescribed to add into the regimen only during storms.
But after a month-long supply of sedatives for storm phobia dematerialized in two weeks––and we’d had no storms––I had to wonder. So “no more drugs, I said. not until we can establish a better understanding for what’s happening through the veterinary behaviorist. After all, it’s cruel to keep her sedated her whole life.”
Sounds reasonable, right?
Not for this owner. She didn’t want to take no for an answer, insisting that the dog did not have a behavior problem and did not need to see a specialist. “Well, then, even more to the point,” I said. “I cannot legitimately prescribe a sedative––or any other drug––if either of us is uncomfortable with the goals of this treatment.” Here’s where she took another tack and suggested that the “legal limits” for sedative dosing, as I had explained we’d reached, could be mitigated by writing the script in the name of her other dog.
Seriously?
Then she got angry. Very angry. I don’t think she’ll be back. But she’ll probably get what she wants somewhere else. They always do when they’re so determined. Further, I feel terrible that the dog might be suffering without the [possibly] perfectly appropriate sedatives. In the absence of behavior modification (which I’m not at all sure the owner undertook), most of these cases will continue to suffer.
Yet even if the drugs are truly going to the dog––especially so, perhaps––how can anyone expect a veterinarian to shrug off a patient’s well-being (and risk her license along the way) on an owner’s adamant position with respect to a controlled drug?
Sometimes you just cant win.
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This was great to read about from a vet's perspective, I have a dog with a seizure disorder and even when she was first diagnosed and seizing multiple times a day, she's never had one at the vet's office. (Luckily?), I caught a seizure on video and showed my vet. I have wondered before if they would be so nice about refilling her prescription every two months if they didn't have that proof that she has seizures. Like you, my vet does not carry phenobarbital in pill form. I have to go to the pharmacy next door to pick it up. They do, however, check her levels every few months, so I think they would notice if she wasn't taking the pills.
Gabs October 17th, 2009 11:47:16 AM
I hate these sort of situations-not really what you get taught in vet school either.
On a similar note, a place I saw practice with recently had a client on the books who they suspected of Munchausen's-by-Proxy (this was only after months of accumulating situations btw, not an suspicion the vets made lightly AT ALL). A really difficult situation where they were reluctant to overmedicate an animal they suspected was perfectly healthy (and the medication had its own side-effects), but at the same time were also worried in case they were wrong and undermedicating a possibly sick animal.
You're right in that sometimes you just can't win.
Sian October 17th, 2009 12:39:37 PM
I always wondered if vets have this problem. Guess now I know.
dr sara October 17th, 2009 12:41:50 PM
After several years of keeping my severely allergic bulldog on a high dose of hydroxyzine (100 mg/day), my vet cut the dosage in half. The symptoms increased, I complained, I got a month back on the higher dose, and then back to the lower dose. I certainly wasn't taking the antihistimine. In fact, sometimes when I ran out, I gave the dog some of my own hydroxyzine prescription. So rather than fight, I gave her 50 mg in the morning, and benedryl in the evening. Not ideal, but it was the best I could do. Usually the vet and I saw eye to eye, just not on this issue.
Susan October 17th, 2009 01:04:41 PM
As a new, potential client, who would not take "no" for an answer, and left a number of vet clinics, never to return...
I would like to know if it's commonplace for veterinarians to refuse to talk with an animal's prior veterinarian for an animal's treatment history, especially when it's been less than textbook.That's the problem I ran into.
I had a regular vet, who saw my dog. He had problems, took a year of trial and error to finally hit upon the solution. After a couple years of successful treatment, I had to move.
After moving, I was not willing to start from scratch again. My solution was to take time off work, load up my dog and off we'd go, on a very long drive back to his old vet where his treatment could continue uninterrupted (luckily, it WAS within a day's driving trip).
What surprised me was that none of the local veterinarians would even talk to his prior vet. Not one single phone call. No letters. Nothing. They would not accept *any* information from her. She was willing, they were not.
Is this a legal issue? Or was there something else going on, that we don't see from the client side of the fence?
Thanks for taking the time to write and help enlighten us.
Perri October 17th, 2009 02:10:09 PM
Perri: I dunno but that makes no sense to me. You ignore someone else's workup at your own peril. Sure, sometimes you really DO have to refresh things a little––as in, labwork more than 2 months old for a diabetic or more than 6 months old for another chronically on meds. But that's as far it often goes.
A whole new set of films, CTs, MRIs, specialized labwork etc. is only usually undertaken 1) should the problem not have been diagnosed/resolved or 2) when a specialist comes into play, which usually presumes that 1) is still in play.
Many veterinarians work well with one another. Some do not. It's like kindergarten. I think you just got unlucky.
Dr. Patty Khuly October 17th, 2009 02:52:29 PM
Sian: We had one case of MBP. It was odd. We always managed, however, to do right by the cat...one way or another (at least while she was under our care). There's not much you can do about these except acknowledge they exist and keep an open mind about the possibility. When they do show up, cases like these have no recourse (no child protective services, for example) so it's up to the vets and staff to get extra caring and creative. Ultimately, these people are very sick and the best you can do is befriend them and speak your mind. Sugar pills work wonders, too. (That last part is tongue in cheek but not far off from what has to happen sometimes.)
Dr. Patty Khuly October 17th, 2009 02:56:36 PM
We had a related problem in a rescue group I volunteered for. They opened a shelter in an industrial zoned area, which was necessary zoning for the shelter. No people around the neighborhood at night. They had repeated break-ins, inspite of security systems, causing a lot of damage, by people who were apparently looking for narcotics. This shelter didn't stock any narcotics though. As one of the board members said, you can't get high on strongid.
Mary October 17th, 2009 03:10:18 PM
hmm, besides Mary's comment above, this blog reminded me of an old time memory while working in rescue.
Another member was doing foster care with an unsocialized rescue that required attention. She was dosing this dog "ace" on a daily basis and I wondered how she could have such a "supply" to do so.
I agree, it must be an issue sometimes. I even suspect that non-narcotics/scripts may be abused from time to time: heart meds, kidney, etc.
People with health insurance must be tempted to do the opposite--I have been, especially for a seemingly unresolved UTI with one of my dogs!
Oh, how about the abuse "within" the profession, scary and horrors there. A few publicized arrests make you wonder how many animals were "deprived" of needed controlled substances??
Or how about lack of checks & balances of non-existent, expired, or limited DEA licenses? Vets have it made in that department---patients can't talk!
Barbara A. Albright/NH October 17th, 2009 05:46:01 PM
I do wonder how prevalent drug abuse is within the vet community. I remember a vet acquaintance of mine about 10 years ago talk about how classmates of his in vet school used to dry out ketamine on cookie sheets and snort it....
certainly drug abuse within the human medical community is a fairly well known thing....
LorriM October 17th, 2009 08:51:30 PM
Thank you so much for your reply. I'd like to think you're right and that I just ran into a series of bad luck tries, and (should the need arise again) the future still holds potential for cooperation.
Perri October 17th, 2009 10:04:58 PM
If the pet's owner is really asking for something far above and beyond the normal, I would be suspicious, but, in general, I find that small animal vets are much more controlling of animal rx's than large animal vets--to the detriment of the pet. If I call my horse's vet and tell them that I need a new bottle of ace for the up-coming hurricane season, I'm told to come pick it up at the office. Same for Adequan, Rompun, bute, banamine or dex ... etc. For my cats, they have to have an office visit for /any/ drug, even for a well-established issue. I've never figured out why this is, but it's been true everywhere I've lived. Small animal vets seem to operate under the general assumption that pet owners have no idea what they're doing, and the pets are often the ones who end up suffering because of this assumption.
My friend ran into this problem recently. She has a *severely* anxious/agoraphobic dog (too scared to leave the yard despite extensive behavioral training) who gets some sort of xanax equivalent as needed. My friend has only filled the rx twice in two years, but she recently went to the vet to get a new rx because she was going on vacation and wanted to bring her dog with her (rather than kennel the dog). The vet refused to renew the rx, and my friend's dog ended up vomiting and crapping in the car and all over the rental house for four days straight. I'm not clear how the vet's refusal to listen to the owner benefited the patients (dog and owner) at all. In contrast, my parents' vet is a lot more trusting. My parents' dog is terrified of wind and is suffering from doggie alzheimer's. The kindest thing my parents can do is to give him xanax to calm his fears; even if he needs 3-4 pills some days, the vet doesn't complain.
This was also an issue for me recently. When my elderly renal failure cat was sick, he was receiving a very small dose of a benzodiazepine to stimulate his appetite. Each time I needed a few more pills, I had to drag the poor cat 30 minutes to and from my vet, who would check his respiration, charge me $85, and send us away with a script for 4 more pills (the cat got 1/8 of a pill as needed). The vet certainly couldn't think that I could be abusing the small amount of drug he was prescribing for an 8-lb cat. Unless the owner is acting outrageously, I can't see a valid way for a vet to claim the high road when denying a prescription.
Vets need to ask themselves what the bigger risk is: that the owner will take the pet's drugs (which are generally too small a dose to be physiologically effective for a true drug addict), or that the pet will go without a treatment that it needs to be comfortable. In general, my experience is that small animal vets end up punishing the pets for the potential sins of the owners.
Sarah October 17th, 2009 11:10:33 PM
Wow, interesting, Sarah. I have to agree that the large animal veterinarians I have known over the years have been much more willing to dispense drugs freely. Is it a dose/size issue? An owner education issue? A transportation issue?
Consider that most large animal owners are far more educated (on average) about their charges. They have to be. Medicine can be so much more expensive/inaccessible for a variety of reasons. The way I see it, the relationship between the owner and vet in this setting has always been more of a partnership than in small animal medicine. To my side's detriment, I'll agree.
However, I've got to think there's also some degree of 'old timer' mentality amiss when someone will dispense 180 pills of ace at a time without a valid VCPR (veterinarian client patient relationship). There are some ground rules all of us must follow according to our state laws, after all.
As to dragging your pet back and forth for more valium when it's clear that 1) your pet has an established diagnosis and 2) there's no need for serial reexaminations, that's asinine. The way to do it is to authorize the pharmacy to refill monthly at a certain rate.
On your friend's case: If the pet hadn't been seen for a long period of time that makes sense. Consider that we have legal obligations. I run across this problem every year right before hurricane season when everyone wants to stock up. It's worse with an impending storm. People don't get it that I cannot just hand over a script for xanax when I haven't seen their pet in 16 months. It's illegal. Period.
Dr. Patty Khuly October 18th, 2009 07:10:32 AM
LorriM: Yes, back in the 90s and earlier in this decade there was plenty of ketamine abuse among a certain set of people with access to this drug. It was not controlled by the DEA back then (it is now) and was thought to be very benign. Though it's not considered highly addictive and long-term effects of abuse have not been established, it's a clear violation of law.
No veterinarian is granted a license to self medicate, whether by grabbing an antibiotic off a shelf or by drying the "Vitamin K" out in a microwave so it could be crystallized and snorted (ouch!, I would think).
Honestly, however, I recall none of this happening at my school. (Though I did see it in college and later in business school.) Drug use in vet school, as far as I knew, was confined to marijuana and alcohol on the weekends. We just had too much work to do.
Though I knew of one vet student who downed a six-pack of beers daily she was an exception matched drop for drop (it seemed) by her brilliance. Can't say whether her alcoholism has progressed and whether she still retains her license but that was the sole case of outright abuse I ever knew of (with the exception of weekend binges).
Abuse of drugs, however, remains commonplace across all professions and there is plenty of evidence to support that the rate of abuse is higher among veterinarians than the general population. Same as with DMDs, RNs and MDs. It seems to revolve around the issue of access and though it's uncommon for licenses to get yanked, it's still the easiest way to have that happen.
That's why a review of veterinary Board hearings will reveal that drug abuse ranks high among the complaints that come up. It almost always gets ferreted out by staff and clients who have their veterinarians' best interest at heart. Interestingly, drug abuse is not commonly tied to poor performance, though it does happen as Barbara from NH can attest through her research on the subject.
Most of these cases are eventually resolved when the professional heads into a five year mandatory program run by almost every state. These programs have a much higher success rate than for the general population since dangling somebody's livelihood before them has a way of eliciting self-corrective behavior.
I'm glad you asked about this. It's an important subject.
Dr. Patty Khuly October 18th, 2009 07:35:29 AM
Dr. K, et al on the topic of veterinary abuse of drugs:
"It seems to revolve around the issue of access and though it's uncommon for licenses to get yanked, it's still the easiest way to have that happen. That's why a review of veterinary Board hearings will reveal that drug abuse ranks high among the complaints that come up."
You are of course, correct that this violation is the one that is most likely to result in license loss. And while allegations of drug diversion are definitely up there in terms of issues heard by vet board, as far as my research and reading has revealed, the number of consumer complaints filed about quality of clinical care issues far and away dwarfs drug diverson as an issue in your profession -- although the latter almost always is accompanied by the former. (kind of hard to be competent when you are high as a kite.)
The reason there are so many HEARINGS on drug diversion and abuse issues as a percentage of all enforcement actions taken is the high dismissal rate of consumer complaints about quality of care. And having become QUITE familiar with many complaints and evidence dismissed with "no violation found" on the issue of patient care, I am convinced that about half of the dismissed complaints are valid, warranting discipline.
This is coming from someone whose complaint DID result in some (albeit meagre) action from the board, so I am talking about the case of others, not my own.
The bottom line is: More often than not, vet boards tolerate loss of patient life due to sloppiness, failure to supervise unlicensed staff, substandard surgeries, misdiagnosis, etc. They don't tolerate drug diversion and abuse.
I'm not saying they SHOULD tolerate drug use, I'm just saying that . . . the priorities disturb me. The message it sends disturbs me.
And yes, shame on any person who is using their pet as an excuse to get their hands on drugs to take.
Stefani October 18th, 2009 10:06:52 AM
<<crystallized and snorted (ouch!, I would think).>> I hear you..NOTHING goes in my nose...when I was in college, I had staph and required a nasal flush before my peds rotation and I thought I would die even though it was a very easy procedure. my nose is a place for nothing...I can't imagine choosing to put something in there...
<<Can't say whether her alcoholism has progressed and whether she still retains her license but that was the sole case of outright abuse I ever knew of (with the exception of weekend binges).>> I know a lot of professionals who drink too much IMHO...if you NEED to have it to relax...there IS a problem. I think that many people are ill equipt to deal with the emotional toll these jobs take. Either from the hours, the needs of the clients or the neglect seen.
<<Most of these cases are eventually resolved when the professional heads into a five year mandatory program run by almost every state.>> This occurs after they are "found out" though correct?
I think while some areas might be inclined to lead people to do the right thing in getting a professional to seek help, I'd have to say that would be the exception not the rule in my (just moved from ) area.
I saw a great deal of drug usage even among the HS students I came in contact with, and sadly not marijuana ..and huge amount of drinking...they suffered from over indulgent, participating parents with too much money and too little supervision.
<<I'm glad you asked about this. It's an important subject.>>
I agree and I appreciate your informative response. But it's important across the board not just in the case of vets...but I think you brought up some excellent points about pets and controlled substances. I have never had a pet that required any, and I find that a warm bed next to me and a pile of blankets solves the thunderstorm issues with my dogs. I tend to steer away from any medications unless necessary. Many are too hard on the liver. and I've had several cats respond very poorly to ketamin to the point where I don't allow it's use on my cats.
As far as patients go with the drugs though..an addict is an addict and will do anything for fix. It's a sad and equally disgusting thing to watch.
LorriM October 18th, 2009 10:35:36 AM
Stefani: I do not disagree at all...as you know. But in the defense of Boards with respect to their unwillingness to take most consumer complaints to the next level (sanctions, etc.)...Drug abuse is objectively verifiable. Incompetence for other issues is harder to prove.
But you'll also be surprised to hear that most medical personnel are turned in by their staff and colleagues...not because they're incompetent.
Indeed, research reveals that it's often the most high-performing professionals that abuse. The connection is unmistakable. After all, intelligence and a high personal drive are predisposing factors for drug abuse across the board. That much we do know.
Dr. Patty Khuly October 18th, 2009 11:35:04 AM
I agree,
Sometimes you just can't win. I couldn't even tell you how many clients have stormed out of our hospital because we told them exactly what they didn't want to hear. I like your approach of referring them to a specialist in some situations. I think that might have defused a few timebombs. As a pre-veterinary student, I've learned that veterinary medicine is just as much about the client as it is the pet. Even more so the client.
I'll be bookmarking this site, thats for sure!
-Garett Flores
Dog Breed Dictionary
Garett October 18th, 2009 12:43:49 PM
In my teens, I had an ortho surgeon who was self treating for chronic pain. I'd rather have him operate on me than anybody else I know. He was self medicating because his own doctor was under treating. Unfortunately, that same doctor ratted him out and they took his license. It's a sin not to treat chronic pain patients. Eons ago, I had a cat on pheonobarbs and it was the only thing we could find that kept her from being totally looney toons. Not long ago, an attorney who suffered from chronic pain was labeled as "drug seeking" and "doctor shopping" so couldn't get treatment. He resorted to street bought drugs. Caught, jailed... The prison physician actually treated his chronic pain with far more extensive drugs than his previous doctors and the ones he'd gotten for himself. Personally, I've been on 120 mg/day of oxycontin for nearly 2 years. It was the final and first effective treatment I'd had since my little run in with an 18 wheeler that instigated my own chronic pain. I've been script drug free for 7 years. However, I resort to incredibly high levels of ibuprofen and aspirin and suffer through drug holidays from those without any alternatives. I tend to get really cranky from pain and frustration, knowing that I could do so much more if only the pain were treated but it simply isn't worth the full time battle because then I wouldn't even have time to bathe! I could go on and on over the harm done by under or lack of treatment...
"how can anyone expect a veterinarian to shrug off a patient's well-being (and risk her license along the way) on an owner's adamant position with respect to a controlled drug?" You'll get no sympathy from me on this one because it wsa doctors who allowed the feds to step in and start running the show to the detriment of all patients and the patient/doctor relationship. As for shipping them off to a specialist, as far as I'm concerned, that sounds like under or lack of treatment based on preconceived ideas that all patients/clients lie and a weaselly excuse for not having a tough discussion. A discussion that wouldn't be nearly so tough if all of you would stand up to the feds and stop presuming things that aren't anything more than anecdotal and/or brought upon yourselves by making blanket assumptions about patients/clients.
There have always been and will always be those who harm themselves with substances, script or not, and that includes those in nearly every profession. Those denied care or under treated WILL find some form of self medicating, script or not or through the most bizarre behavioral adaptations. (Pray tell why my poor Lab can't have something, why I can't have something on hand, to calm her nerves instead of regularly treating her poor raw paws for stress chewed wounds! I'll tell you why. Because it isn't worth the battle with the vet as it would obliterate a tenuous trust I have in him for the every day care when he immediately jumps into that "suspicious of my motives" mode.) While vets, doctors, and other medical staff may have "ready" access to drugs, I can assure you it is no more "ready" than the access most lawyers have and far less than can be obtained in the streets. I'm tired of seeing this issue convoluted into a denial of proper care for the ill and injured!
PJBoosinger October 18th, 2009 02:11:30 PM
I wonder how many vet hospitals are targets of theft by veterinary technicians? Are there any articles or studies?
At our hospital we drug-test before hiring, upon reasonable suspicion, and in case of a work-place injury. We've only had one case of narcotics missing, while waiting for drug testing results they were positive. So now we have a touch-pad narcotics cabinet that will soon have a security camera monitoring it.
Thank you for this article. We'll now look into any similar cases with clients.
Robert October 19th, 2009 07:22:36 AM
Robert: Studies? Dunno. I tried a quick search and found nothing in veterinary medicine. But anecdotally speaking, we seem to be constantly at risk. We've had one narcotics theft in the past five years and it was coupled with the presence of a new staff member and petty cash theft. Employee was fired (lots of other good reasons) and things resolved. We have no drug testing policy and frankly I don't want one. We have more secure lockboxes for everything now (cash and controlled drugs) and only the veterinarians have access to the latter.
Dr. Patty Khuly October 19th, 2009 07:37:53 AM
Robert, I see that as very wise. Why not? In a profession that handles drugs, money, and patients, I would think it a good policy to: run criminal background checks & drug testing.
The USPS does and has additional requirements such as "safe driving record", legal citizen status, too.
Might behoove the profession to weed out some "riff raff". Some states require proof of full DEA licenses or notification if surrendered. That should be mandatory too!
How about mandatory pharmacy licenses & all other state/federal required certification hanging on the wall in a prominent location? Human hospitals comply.
Barb A./NH October 19th, 2009 06:51:32 PM
It's a real problem -- deciding who you can trust and who you can't trust..... True for all of us, all the time. I see that as the key issue here.
One reason I keep my "primary care physician" (even though he has been promoted up to such high status that he never sees patients) is that he was willing to precribe codeine for me. I used to get headaches that codeine dealt with better than anything else.....
In the last 6 months of her life my 14-yr-old dog got recurrent bladder infections.
One time when she started peeing "too much," again, I just couldn't bring her and the sample in, and asked if they would please just trust me and give her the antibiotics.
I was a fairly long-time client at that point. On that day, that doc said "ok" and it made my life a lot easier. She trusted me to know when a recurrent problem was happening, again, and trusted me to treat as prescribed.
There are enough people out there who cannot be trusted that all of us get greater scrutiny and have to work harder to be seen as trustworthy. Alas.
Vicki in Michigan October 20th, 2009 01:19:29 PM
Dear Dolittler:
Thank you for this insight into your reasoning regarding pet medication. I especially appreciated this paragraph:
But after a month-long supply of sedatives for storm phobia dematerialized in two weeks--and we'd had no storms--I had to wonder. So "no more drugs, I said. not until we can establish a better understanding for what's happening through the veterinary behaviorist. After all, it's cruel to keep her sedated her whole life."
What is especially important in the above --besides your obvious sound common sense when it came to the lack of thunderstorms-- was your empathy for the animal. Humans, ultimately, do not yet know very much about consciounsness either their own or canine. Indeed, to assume that sedation "for her whole life" is cruel is the wisest route in the face of what we do not know about the dog's own experience of its consciousness. What is sad, but, alas, not surprising, is the woman's disregard for this question and ultimately her animal's whole well being (not simply its superficial behavior).
Sincerely,
Randolph
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