June 18, 2012
Veterinarians say pharmacists change prescriptions without asking
By: Edie Lau
For The VIN News Service
Veterinarians in Oregon have reported to state pharmacy regulators concerns that retail pharmacists are making unauthorized changes to prescriptions written for animal patients, apparently out of ignorance of veterinary pharmacology.
VIN News Service photos
Costco is one of a growing number of national chains with pharmacies now filling veterinary prescriptions. In one store in Washington state, where the warehouse retailer is headquartered, Costco advertises the availability of veterinary drugs with a posting in the pet-goods aisle, on the pharmacy signboard and through a sign by the pharmacy cash register.
The changes they report involve altering prescribed dosages or switching the medication itself — for example, by substituting one type of insulin for another.
Gary Schnabel, executive director of the Oregon Board of Pharmacy, said for a pharmacist to make such changes without permission from the prescribing doctor is unequivocally wrong.
“It’s a direct violation of the pharmacy practice (act) and pharmacy rules,” he said. “That would be a violation in every state. The pharmacist is supposed to prescribe the drug in conjunction with the prescriber’s instruction. Period.”
Schnabel could not confirm that violations actually are occurring, however; he said he is unaware of a formal complaint being filed in his 18 years with the pharmacy board.
“We have not seen an actual event that we can investigate,” Schabel said. “... We can’t say that this is happening or we know it’s happening. All we can say is that we’re hearing about it from veterinarians. ... I don’t say I don’t believe them,” he added. “I just don’t have it documented.”
Two veterinarians from the Oregon Veterinary Medical Association (OVMA), along with OVMA Executive Director Glenn Kolb, met in May with Schnabel and the pharmacy board’s director of compliance, to discuss the problem. The group agreed to collaborate on educating and raising awareness among pharmacists, and Schnabel underscored the need of veterinarians to formally report suspected violations.
Although fielding questions from pharmacists unaccustomed to dispensing drugs to pets isn’t new for veterinarians, the frequency with which veterinary prescriptions are misunderstood appears to be rising as pet owners shift to retail pharmacies for their pets’ medications, practitioners say. Traditionally, pet owners obtained medications directly from veterinarians.
The issue of misunderstood animal prescriptions is not particular to Oregon. Veterinarians from across the United States — and occasionally from Canada and the United Kingdom — have posted about the subject on message boards of the Veterinary Information Network (VIN), an online community for the profession.
Dr. Sheri Morris, president of the OVMA and owner of Willamette Valley Animal Hospital near Salem, Ore., said the problem is driven by broad market trends.
“I think it’s because of the aggressiveness of human pharmacies to go after veterinary business, that’s what’s brought it to a head,” Morris said. “It used to be that it happened so infrequently that no one did much about it.”
In Morris’s hospital earlier this year, one doctor had an experience in which a pharmacist changed the type of insulin prescribed for a diabetic cat. The veterinarian prescribed glargine; the pharmacy provided NPH. The pharmacist “convinced (the cat’s owner) to buy it because it was less expensive,” Morris said.
“But they are completely not interchangeable, so we sent her back to the pharmacy, telling her, ‘No, you need to get what’s in the prescription,’ ” Morris recounted.
Morris said glargine is longer-acting, which is especially important with veterinary patients. As any cat owner can imagine, the fewer injections required a day, the better. In addition to having a shorter duration, NPH has been found to be less effective in diabetic cats, Morris added.
The client later informed the veterinarian that the pharmacy would not refund her money for the insulin it wrongly had provided. “So not only did she buy an $80 or $75 bottle of insulin, she then had to go back and buy a $130 bottle of insulin!” Morris said.
Morris said her clinic did not file a complaint against the pharmacist because it lacked all the details. She tried later to contact the cat owner but could not reach her.
Morris and other veterinarians said they fear the problem of pharmacists making unauthorized changes or otherwise misunderstanding veterinary prescriptions will only worsen, owing to a confluence of events:
Independent pharmacies have given way to pharmacies owned by national chains, which, according to the National Association of Chain Drug Stores, now fill more than 72 percent of prescriptions in the United States each year. A common perception is that pharmacists who work for chains doing high-volume dispensing are less likely to develop the long-time personal relationships with patients and doctors once common with pharmacists working under independent ownership.
Chain pharmacies, including Walgreens, Wal-Mart, Target, Kroger and Costco, have aggressively entered the veterinary pharmaceutical market. But pharmacy education has not kept up. Knowledge of veterinary pharmacology is not required to become a pharmacist.
Legislation pending before Congress would promote the shift of veterinary prescriptions out of clinics and into “human” pharmacies. The Fairness to Pet Owners Act, or H.R. 1406, requires veterinarians to provide pet owners with prescriptions whether requested or not, along with a written notice that they may fill the prescription elsewhere.
That pharmacists schooled only in human pharmacology would question some veterinary prescriptions isn’t surprising. That’s because differences in species may result in very different needs in dosing and medication type.
Gigi Davidson, director of clinical pharmacy services at the North Carolina State University Veterinary Teaching Hospital, said dogs, for example, have nearly 30 percent more blood per kilogram of weight than people. “So if you put the same amount of drug, per kilogram of weight, in a dog, then theoretically it achieves a 30-percent-less blood concentration right out of the gate,” she explained.
Dogs also have a faster glomerular filtration rate than humans, meaning that they filter fluid through their kidneys more rapidly. Given a drug excreted in urine, a dog will eliminate the drug at a rate two-and-a-half to almost three times that of a person, Davidson said.
Therefore, in the case of dogs prescribed medications commonly taken by people, such as to regulate the thyroid or control seizures, doses for some dogs may be much higher than for humans. An alert pharmacist will notice this, and one who is unfamiliar with veterinary pharmacology might raise an eyebrow.
The question is whether the pharmacist assumes the veterinarian made a mistake and “fixes” it without further investigation or calls the prescribing doctor to double check.
Davidson doesn’t doubt some pharmacists change prescriptions without asking. It’s happened with prescriptions written to clients of her teaching hospital.
Although her hospital has its own pharmacy — staffed by pharmacists trained in veterinary dispensing — clients sometimes opt to buy their drugs elsewhere, she said.
“We have experienced this a few times and in all cases, the pharmacist assumed that he/she knew what the veterinarian meant,” Davidson said.
In one example she gave that occurred many years ago, a dog suffering from Rocky Mountain spotted fever was prescribed Chloramphenicol, an antibiotic. The pharmacist, figuring the veterinarian accidentally misplaced a decimal point, reduced the dose tenfold.
“The dog’s condition significantly changed; we almost lost it,” Davidson said.
Chloramphenicol also happens to be fatally toxic to one in 10,000 people, and therefore is rarely prescribed for humans, she added. Consequently, the drug is not kept on pharmacy shelves in great quantities, if at all.
“We did call (the pharmacy) and talked to them about it,” Davidson recounted. “It was an honest mistake. He was working with what he had on the shelf. He said, ‘I could not imagine a scenario where a dog about the size of a human would need 40 capsules a day and a human would need four.’ You could see how you might think that. But if you’ve been exposed to veterinary medicine for 10 minutes,” she added, “you’d know there are a lot of things (like that).”
Dr. Laird Goodman, a veterinarian in Beaverton, Ore., said questions from pharmacists about veterinary prescriptions are nothing new, but he remembers a time when more pharmacists called with their questions instead of assuming they knew the answers — or, almost as troubling, raising doubts in their customers’ minds about their veterinarians’ competency.
“Now they’re saying to the owner, ‘Hey, you better check with your vet, this seems like an awful high dose,’ ” Goodman said.
He described a recent incident in which a patient’s owner was advised by the pharmacist to lower its medication dose. The patient was a middle-aged dog that suddenly developed seizures. Goodman placed the dog on phenobarbital, an anticonvulsant drug. The client asked that the prescription be called into Costco.
Goodman said he advised his client that the dog might be sedated by the drug for the first week or two, but that it would adjust and behave normally after that. However, the next time the owner was at Costco, she stopped by the pharmacy and told a pharmacist, “My dog is really sleepy on the medication; is this OK?”
No, the pharmacist is said to have replied; he allegedly advised her to halve the dose.
Goodman said the dog was on the reduced dose for about a month. The next time he saw it, it was having intractable seizures. “Once we lose control of seizures, it can be hard to regain control,” he said. Ultimately, the dog was euthanized.
Goodman couldn’t say that the dog would have been fine had it been given the prescribed dose, but getting a sub-therapeutic dose clearly didn’t help.
He tried to follow up with the pharmacist. When he called the Costco and explained what had happened, he said he was told, “Nobody here would do that.” Goodman said he didn’t file a formal complaint because he expected the dispute would devolve into a case of “he said, she said.”
Costco’s media contact and a corporate pharmacy official did not return repeated calls by the VIN News Service seeking the company’s perspective.
In another case that Goodman said happened to a colleague, a pet owner with a prescription for Rimadyl was offered Metacam instead because the pharmacy didn’t have Rimadyl on hand.
Apart from being categorized as non-steroidal anti-inflammatory drugs (NSAIDs), they are not the same. “They’re completely different,” said Davidson, the NC State veterinary pharmacist. She said Metacam “can potentially be a lot more toxic to the kidneys in some animals, and it’s almost a 20-fold difference in dosing on a milligram per kilogram basis.”
Fortunately, Goodman said, the client did not take the substitution but rightly contacted her veterinarian.
Another potential source of misunderstanding for pharmacists with veterinary prescriptions are differences in abbreviations used by the two professions.
Veterinarians are taught to use the abbreviation SID, derived from the Latin semel in die, meaning “once a day,” in dosing instructions.
Pharmacists are more accustomed to the abbreviation used by physicians to mean the same thing, QD, for quaque die.
“I spent the first 10 years of my career trying to get veterinarians to stop using SID, which was kind of arrogant of me,” Davidson said. “Now I’ve spent the last 20 years trying to get pharmacists to understand it.”
In defense of pharmacists, some veterinarians point out that while veterinary prescription misunderstandings may not be rare, neither are they rampant.
In a comment posted on VIN in November, Dr. Karen Comer, an internal medicine specialist in Tacoma, Wash., wrote:
“I have been scripting out the majority of my prescriptions for 10-plus years. The occasional call I get from a pharmacy is to request substitution because they do not have the particular formulation that was specified on the prescription. I cannot recall any incidents of serious adverse reactions related to dispensing of an incorrect dose or medication. There have been a (very) few times when an incorrect dose was dispensed but because I alert clients to what they should receive it was noticed and corrected quickly.
“I suspect the incidence of incorrectly dispensed medications from a human pharmacy is no greater than that dispensed from a veterinary clinic.”
With retail pharmacies taking a greater role in filling veterinary prescriptions, though, the potential for irregularities may be growing, as suggested by a letter obtained by the VIN News Service that was sent by Novartis Animal Health to Costco last month.
In the letter, dated May 16, Dr. Jim Blacka, vice president of sales for Novartis Animal Health, informs the company that it has received reports of customers receiving prescription products without a prescription, and of a Costco in Honolulu dispensing prescription products in plastic bags without its FDA-approved packaging and labeling.
“... in view of these reports,” Blacka wrote, “we have serious concerns that our products are not being dispensed or recommended in accordance with our product label and have taken steps to inform the appropriate regulatory authorities of our concerns.”
The letter was address to Caryn Fry in the Costco Pharmacy Division. Reached by phone by the VIN News Service, Fry said she does not work in the pet medications area and had referred the correspondence to the vice president of operations in the pharmacy department, Richard Stephens.
Stephens did not return calls from the VIN News Service.
At Novartis, Blacka referred queries to corporate communications. Company spokesman Joseph Burkett did not respond to questions.
The letter to Costco also points out that Novartis markets its products exclusively through licensed veterinarians, raising the question of where Costco obtains its veterinary medications. The question is a huge and complicated issue that touches virtually all retailers selling veterinary therapeutics because most animal-health pharmaceutical companies have the same policy as Novartis of selling products only through veterinary channels.
The companies say that their products are most effectively and safely used when dispensed under a veterinarian’s guidance. Clinics have come to rely on pharmaceutical sales to help support their budgets, as well, although that's changing under competitive pressure.
Loss of pharmacy income is a sore point in the community, but trying to maintain hold of the market is not why Oregon practitioners are raising concerns about veterinary prescription problems, said Kolb, the OVMA executive director.
“We know (pet owners) will continue to fill prescriptions at retail pharmacies. We’re not looking to stop that,” Kolb said. “We’re looking for (pharmacies) to meet their responsibilities and obligations as far as doing it correctly.”
Leaders in veterinary pharmacology say the problem is that the typical pharmacist receives little to no training in the subject.
“There’s a need for pharmacists to get some rudimentary training that dogs and cats are not just furry little people, and there are some differences you need to be aware of,” said Donald Plumb, author of Plumb’s Veterinary Drug Handbook and a pharmacist who once served as director of the veterinary teaching hospital at the University of Minnesota.
Some retail chains offer continuing-education courses to their pharmacists but the quality is inconsistent, said Davidson. “They give enough information to be dangerous and they give enough misinformation to be really dangerous,” she said. “And it’s just not enough.”
Davidson said the Society of Veterinary Hospital Pharmacists, of which she is a member, aims to develop a comprehensive program to educate pharmacists that fill animal prescriptions. She's also seeing growing interest among pharmacy schools in adding veterinary training components.
Sometimes it takes an advocate on the faculty to make it happen. At the University of Findlay in Ohio, Kenneth Speidel, an assistant professor of pharmacy practice, successfully pitched the addition this fall of an elective on veterinary pharmacy.
Speidel said the program particularly makes sense at Findlay because the university offers degrees in equine studies and pre-veterinary studies, providing opportunities for collaboration with its pharmacy program.
Overall, Speidel said, veterinary pharmacy is overlooked largely because it’s not covered by the national test required to become a pharmacist — the North American Pharmacist Licensure Examination, or NAPLEX. “It is not uncommon in education to teach to the test, and sometimes you do not have the time to step outside of it,” he said. “I think that’s part of the problem. If we could increase the national standards to require this, that’s going to compel the colleges to teach it.”
Carmen Catizone, executive director of the National Association of Boards of Pharmacy, which oversees the NAPLEX, said the association stays abreast of trends in the profession through a survey of pharmacists. “We look at what pharmacists are doing on a day-to-day basis and how each of those tasks are critical to protecting the public health,” he said.
New activities that respondents broadly identify as critical or occurring frequently are incorporated into future examinations, Catizone said. “If veterinary medicine is a growing area, it will show up in the survey, and it will definitely come up in the NAPLEX,” he said.
He said surveys are conducted every five years; the most recent was completed two years ago.
The migration of bricks-and-mortar retail and Internet pharmacies into veterinary drugs has led the pharmacy association to learn more about the veterinary arena, Catizone said. However, he had not heard of the veterinarians’ complaints that pharmacists are making unauthorized changes. He said he finds the possibility stunning.
“If the patient had an injury, one, (the pharmacist) would be liable ... from a civil standpoint, and two, they could lose their license,” he said.
Catizone noted, however, that pharmacists are professionally and legally obligated to read prescriptions critically. If they think a prescription is incorrect or unsafe as written, simply following the doctor’s instructions does not relieve them of responsibility to the patient.
At the same time, they may not change the prescription without consulting the doctor, he said. If they cannot or choose not to contact the doctor, their option is to refuse to dispense the medication, he said.
Catizone said further that pharmacists should think twice about dispensing medications with which they are unfamiliar.
“Technically and legally, they could,” he said. “But I put myself in that situation: If I had a prescription for a chemotherapeutic agent and I wasn’t familiar with that agent because it wasn’t an area I’d kept up with or was involved in, I could dispense the prescription as written, but if the dosage was too high or something, I’m still legally responsible. ...
“If I don’t know what I’m doing, I shouldn’t fill the prescription.”
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