N.H. veterinarians avert mandate to prescreen for drug seekers
Update: Gov. Chris Sununu signed HB 291 on June 17.
Veterinarians and several like-minded lawmakers want to amend a new law that requires practitioners to consult the prescription records of animals and their owners before prescribing tramadol and other opioid analgesics to patients.
Officials with the State Veterinarian's Office and New Hampshire Veterinary Medical Association finalized a bill this week to remove veterinarians from compliance with the state’s Prescription Drug Monitoring Program, or PDMP, thereby exempting them from having to view the prescription drug records of their clients. Sponsored by Rep. Carol McGuire, HB 291 is in the House Committee on Environment and Agriculture. Three other legislators have signed in support. A hearing is scheduled Jan. 24.
Lawmakers adopted the prescreening mandate in June, requiring regulatory boards to develop rules to order dentists, optometrists, physicians, veterinarians and others in health care to check the prescription records of patients before sending them home with Schedule II, III and IV opioids for pain. Veterinarians and their counterparts in human medicine already log the prescriptions they write into the PDMP.
The requirement to screen prescription records before scripting out takes the state's oversight a step further in New Hampshire, where opioid addiction reportedly is rampant. The veterinary profession has a responsibility to help ensure that owners aren't diverting or abusing their pets' prescription medications, supporters of the mandate contend.
Not at the expense of clients' privacy, veterinarians counter. In November, leaders in organized veterinary medicine testified before the legislature's Joint Committee on Administrative Rules, citing ethical and pet identification concerns. State Veterinarian Dr. Stephen Crawford, who serves on the Board of Veterinary Medicine, posited to the committee that veterinarians aren’t trained to assess the prescription records of humans. He called making such medical determinations "illegal."
Others likened viewing the prescription records of owners to having pediatricians consider the prescriptions of parents before prescribing to their children. Dr. Thomas Candee, who resides in New Hampshire and operates a mixed-animal practice just over the Massachusetts border, was among those who expressed reservations to lawmakers. "This is a lawsuit waiting to happen," he stated.
The prescreening mandate went into effect Jan. 1, but the committee agreed to grant veterinarians a temporary reprieve. The passage of HB 291 would do so permanently.
"We want to be part of the solution, not part of the problem, but veterinary medicine has our own unique situation," said Dr. Jane Barlow Roy, NHVMA past president. "We don't know how the legislation will be received."
By phone, Candee said he appreciates efforts to curb drug abuse but fails to see how checking the prescription records of owners is appropriate. The law is fraught for veterinarians, he said, because it was written with physicians in mind: "Ninety percent of the opioids that people take, we’re not even familiar with. They want us to make a determination that there might be a problem with a client. That's not something we're trained for.
"We should not be looking into the records of owners and making medical judgments about them," he added.
Unlike in human medicine, opioids are uncommonly used to treat veterinary patients with chronic pain. However, injectables such as morphine, fentanyl, buprenorphine, butorphanol, hydromorphone, and oxymorphone are often administered in-house.
Buprenorphine is sometimes prescribed, but tramadol is the most popular outpatient pain medication, largely because it comes in pill form.
Drug abusers like to crush those tablets and snort them, said Michelle Ricco Jonas, manager of the PDMP, which operates under the New Hampshire Board of Medicine.
Ricco Jonas rejects the argument that veterinarians can’t recognize drug abuse in humans or that checking the prescription histories of clients is a privacy violation.
"Any veterinarian with some medical background can surely figure out if a client is abusing drugs," she said. "We’re not asking veterinarians to look at their clients’ health records. We want them to look at their prescription histories for controlled substances."
Ricco Jonas contends that exempting veterinarians from the reporting process leaves a gap in the prescription-monitoring system. "Tramadol is just as abused as other drugs," she stated. "We need veterinarians on board to help stop it."
New Hampshire isn't the only state asking veterinarians to screen prescription records. A new law in Maine also requires veterinarians to do the same. However, rules for the program were not written by the mandate's Jan. 1 effective date. The screening requirement is on hold — for now, said Dr. Anne del Borgo, Maine's delegate to the American Veterinary Medical Association.
Del Borgo shared her concerns with AVMA officials during a meeting Friday in Chicago. "Maine just put in place a law that's very restrictive and, of course, requires veterinarians to check an online database for our clients — not the animals — to see if they have any flags. I'm not sure I have the right to be seeing this ... the client is not my patient," she said.
Asked if Maine's inititative is in any way tied to New Hampshire's, del Borgo shrugged. "I don't think so," she said. "It's coincidental timing, but I'm not that surprised. All of New England is having an opioid crisis."
Not screening but already reporting
PDMPs exist in some form in almost every state. The online databases are designed to track the use of controlled substances, allowing health-care providers and authorities to identify suspected over-prescribing, diversion and abuse cases.
According to the U.S. Centers for Disease Control and Prevention, 37 states have operational PDMP programs and only some expect veterinarians to participate. Eleven states — Alaska, Arkansas, Delaware, Georgia, Maryland, Montana, Nebraska, New Jersey, South Dakota, Washington and Wisconsin — have enacted legislation to establish a PDMP, but they're not yet in operation.
Missouri is the only outlier, though there is political pressure to change that. The District of Columbia doesn’t have a PDMP, either.
In New Hampshire, Mike Blichmann spends three to five minutes logging each prescription written at Cilley Veterinary Clinic, where he works as a hospital manager, into the PDMP database. After two years, he’s developed a system for streamlining the online reporting process, which can experience glitches.
The mandate, he said, has somewhat changed the dispensing and prescribing practices of veterinarians. To avoid the hassle that goes along with dispensing tramadol and other opioids in-house, it’s become more common to send clients to retail pharmacies for the medication.
"If the animal's stable, we can call a prescription into the pharmacy and then it’s [the pharmacy's] job to do all that paperwork," he said.
Candee, too, leans toward non-opioid analgesics or writing a prescription. The latter "leaves it up to the pharmacist to record, rather than my practice," he said.
The push to pre-screen prior to prescribing puts New Hampshire veterinarians in "a tough spot," said Barlow Roy, the NHVMA officer.
"Do we just advise veterinarians not to prescribe opioids?" she mused. "We don’t want to be accused of adding to the opioid problem and not fixing it. The argument on the other side is, are we doing a disservice to our patients who need these medications? Are we going against our oath and our practice act to take care of these animals?"
Even if New Hampshire veterinarians were to pre-screen, the endeavor to create a viable database for tracking the prescription drug histories of patients is complex.
Unlike humans, animals do not have social security numbers, official first and last names or even owners. "What would we do in cases of joint custody?" asks Barlow Roy. "And birthdates. They’re often unknown and arbitrary."
While those concerns might be legitimate, Barlow Roy fears that they read as mere excuses to a public that supports the prescription prescreening of animals and their owners.
"Veterinarians are getting a bad rap in the state for fighting this," she said.