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Pain Points

By Graham Garrison
December, 2018
An opioid shortage has left veterinarians frustrated and scrambling for alternatives

Chances are, your veterinary practice customers are feeling the squeeze. Opioids that have been part of a standard of care for years are harder to come by, and judging by at least one recent survey, veterinarians are worried about the impact it is having on the way they deliver care to their patients.

In September, Wedgewood Pharmacy released results of a national survey of veterinarians on opioids. According to “The Impact of Opioid Shortages on Veterinary Medicine,” a large percentage of veterinary professionals say they have had difficulty obtaining necessary supplies of several opioids they consider important to their practice, and their patients’ health.

The opioids include hydromorphone, morphine, fentanyl, hydrocodone, and oxymorphone. According to the veterinarians who responded to the survey, shortages of these opioids have caused:

  • The use of less effective, non-narcotic alternatives such as NSAIDS (83 percent);
  • Increased patient suffering (71 percent);
  • Use of a local anesthetic (49 percent);
  • Postponed procedures (26 percent); and
  • Patient deaths (3 percent)

“Animals cannot divert medications,” one veterinary professional commented. “Veterinary medicine has taken a long time to get to the point of addressing pain adequately. Please don’t take that away! The amount of opioid diversion is an epidemic, no doubt, but please don’t punish our patients for this!”

Cause and effect
According to JAVMA News, the ongoing drug shortage is partly a consequence of manufacturing problems at a Kansas production facility purchased by Pfizer in 2015. Within two years, veterinarians started seeing their supplies of fentanyl, hydromorphone, and morphine dwindle and dry up. As a result, veterinarians are rationing their remaining drug supplies and relying more on nonopioid alternatives, JAVMA reported.

Making matters worse, in July, Pfizer halted sales and shipments of injectable opioid drugs to veterinary clients citing supply shortages resulting from manufacturing delays. Pfizer, the largest U.S. manufacturer of injectable opioid products, doesn't anticipate resuming sales to veterinary customers until May 2019 at the earliest, according to JAVMA News. (Editor’s note: Pfizer is not affiliated with Zoetis).

Meanwhile, veterinary professionals say that limited access to Class II opiates is creating practice related and medical problems. According to the Wedgewood survey findings, the key impact of reduced supplies of opioids for veterinary use “is pain, suffering, and death of animals because alternatives are not as effective for anesthesia, analgesia and sedation.

Michael Blaire, R.Ph., FIACP, vice president, Government and Regulatory Affairs, noted, “Shortages limit therapeutic choices and are especially problematic given the number of species veterinarians treat – from tiny kittens to large dogs, horses, and even elephants – and how different species react to opioids or their alternatives. Shortages demand that veterinarians frequently change medications and pain-management protocols, and this increases the risk of medical errors.”

Evaluating alternatives
Joyce A. Login, DVM, senior manager of veterinary specialty operations at Zoetis, says veterinarians are definitely having anxiety related to the opioid shortage. “But it’s not the end of the world, and I think we need to take a step back,” she says.

Veterinary medicine has become very reliant on opioids because they are excellent drugs, but there are still plenty of ways that veterinarians can manage pain for their patients in an excellent way that may or may not include opioids, she says.

Currently the opioids and other injectable anesthetics that are FDA-approved for companion animals are not on backorder and are in full supply. These include the Zoetis injectable sedatives, analgesics and anesthetics, Login says. “We make a number of opioids for animals that aren’t under these constraints because we manufacture them ourselves.”


These include:

  • RIMADYL® (carprofen)
  • SIMBADOL™ (buprenorphine injection)
  • TORBUGESIC® -SA (butorphanol tartrate, USP)
  • KETASET® (ketamine HCL injection, USP)
  • PROPOFLO AND PROPOFLO 28 (propofol injection)
  • TELAZOL® (tiletamine and zolazepam for injection)
  • DEXDOMITOR® (dexmedetomidine). Dexdomitor is an alpha-2 agonist, not an opioid, however it is a good alternative to opioids because it is an analgesic and sedative for dogs and cats.

Part of the problem is that some veterinarians may not be aware of the options available to them. “We have a number of ways that we are trying to get the message across,” Login says. Manufacturers and distributors can suggest several webinars, meetings, and conferences that talk about multimodal pain management – other types of modalities – to decrease the amount of opioids. “There are a number of resources that veterinarians can turn to in order to find ways to manage pain in an excellent way without using a large amount of opioids,” she says. (See sidebar)

According to the AVMA, support from a board-certified veterinary anesthesiologist can be particularly helpful as veterinarians work to implement new approaches to pain management and anesthesia in their practices. The AVMA partnered with VetBloom to offer a webinar on opioid-minimal anesthesia. The webinar was available free of charge for VMA members through the end of August 2018, and now may be accessed via VetBloom for a nominal fee (https://vetbloom.com/?category=5&keyword=opioid+minimal+anesthesia&cond=advand&search=Search).
 

Learning new modalities
Awareness of alternatives is one challenge. Simply changing habits may be another. “It’s understandable because the opioids are excellent tools,” Login says. “Opioids really do manage pain probably the best way possible.”

New modalities of care require a relearning of sorts. “It’s reexamining things we know, but maybe we’ve just forgotten about how to treat pain,” Login says. “There are ways to use products together that are synergistic; they can work better together than they do separately. Or there are other opioids out there that can be used that aren’t the main ones we look at.”

There are ways to control pain that are not necessarily just related to opioids, says Login, like local anesthetics. “So I think remembering what we know about pain, and how we can use all the different tools in our tool box, is important. We need to take a deep breath and remember that we still do have plenty of options.”

The role of DSRs
Talking with a veterinary practice about the opioid shortage and their pain protocol might be a little daunting for distributor reps, but it’s an important conversation to have. The best way to have a DSR enter this conversation is to find out what the veterinary practice needs, says Login. “Not to necessarily get into the technical aspect of how to do their process or surgical procedures, or what they can do for pain control, but asking open-ended questions.” For instance:

  • “Can you tell me what your protocol is for surgery, and what you use?”
  • “What do you feel that you’re missing?”

It may be as simple as asking directly: “With the opioids not being as readily available, what are you doing to overcome that?” And “How can I help?”

Veterinary practice supply partners can help customers during this time of disruption with alternatives, resources, and most of all, “knowing they are not out there by themselves,” says Login.



Pet Owners and the Opioid Abuse Epidemic
Opioid overdoses continue to increase in the United States for both men and women and most age groups, according to the Centers for Disease Control and Prevention. Drug overdoses have dramatically increased over the last two decades, with deaths more than tripling between 1999 and 2016. In 2016, more than 63,000 people died from drug overdoses – more than 42,000 of these involved prescription or illicit opioids.

In August, Newsweek reported that veterinarians in Colorado are concerned that some pet owners may be intentionally harming their animals in an attempt to get hold of prescription opioids, according to a survey conducted by researchers at the Colorado School of Public Health (CSPH).

The survey involved 189 vets, 13 percent of whom reported that they had seen a client who they believed had intentionally injured a pet, made them ill, or made them appear unwell, to obtain drugs. In many of these instances, Tramadol, the most common opioid stocked by veterinary practices, is the target. Nearly 45 percent of the participating vets knew of a pet owner or member of their team who was abusing opioids, while 12 percent said they were aware of a staff member that was giving out opioids for illicit use or abusing them.

According to the AVMA, there is heightened awareness on the part of veterinarians due to the opioid abuse epidemic on the human health side. “However, there appear to have been few confirmed cases of owners deliberately injuring their pets for this purpose. We have heard from more veterinarians saying that they suspect some pet owners may be using their pet meds and asking for refills sooner than normal, or that they’ve lost or spilled the medications.”



Opioid Alternative Resources
The following are resources you can show your veterinary practice customers regarding opioids and alternatives.

According to the AVMA, veterinarians can pursue non-opioid alternatives for pain management and anesthesia, such as those listed in guidance developed by groups such as:

Visit the AVMA website at avma.org/opioids <https://www.avma.org/KB/Resources/Reference/Pages/opioid-resources-for-veterinarians.aspx?utm_source=vanity&utm_medium=direct-entry&utm_campaign=opioids&utm_term=print&utm_content=opioid-resources> for the latest opioid-related information and resources, including AVMA’s policy on the veterinary profession’s role in addressing the opioid epidemic, a back-office flyer to help veterinarians and veterinary staff prevent drug diversion, and state-by-state information on opioid-related CE requirements and prescription drug monitoring programs.

Distributor reps can contact a Zoetis Professional Services Veterinarian for: FAQs Analgesia, Sedation and Anesthesia: Making the Switch from Medetomidine to Dexmedetomidine. (Supplement to the Compendium for Continuing Education, Vol 31, Jan 2008.). The best contact is for Veterinary Medical Information Product Support (VMIPS): (M-F 9AM - 7PM EST) at 1-888-ZOETIS1 (963-8471).

Vetgirl Webinar: “Analgesia in an opioid shortage: Yes we can!” Dr. Tamara Grubb, DVM, PhD DACVAA reviews how to provide analgesia and anesthesia in the face of the opioid shortage, in a webinar sponsored by Zoetis. Visit: https://vetgirlontherun.com/june-21-2018-analgesia-in-an-opioid-shortage-yes-we-can%e2%80%a8/ 

Veterinary Anesthesia Support Group VASG: http://www.vasg.org/

AAFP Feline Anesthesia Guidelines: http://journals.sagepub.com/doi/abs/10.1177/1098612X18781391

Topics: Trends, Pain Management

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