Substance Use Prevention Training...Prevention Training Thank you, Merck Animal Health! John Ford 720-666-5635 [email protected] Senior Territory Manager –Equine (Colorado) Susanne

Substance Use Prevention Training

Thank you, Merck Animal Health!

John Ford720-666-5635

[email protected] Territory Manager – Equine

(Colorado)

Susanne Jobson828-337-7976

[email protected] Territory Manager

(Denver and Northern Colorado)

Representatives

Marion Weston, MBA719-238-5338

[email protected] Territory Manager(Denver South to Pueblo)

Teresa Adams720-505-1017

[email protected] Territory Manager

(Western and Southern Colorado)

Debera A. Butler, [email protected]

Companion Animal Senior Professional Services Veterinarian

Earl Gaughan, DVM, [email protected]

Equine Senior Professional Services Veterinarian

Professional Services Veterinarians

Presenters: Jason Beaman, DO, MS, MPH, FAPA, Oklahoma State UniversityRick Allen, RPh, FSVHP, DICVP, Pharmacist Colorado State UniversityStacy Meola, DVM, MS, DACVECC, Wheat Ridge Animal HospitalKatherine Garcia, MA, LAC, MAC, Peer Assistance Services

CVMA Substance Use Prevention Training

Presenters

Introduction and objectives

• Legal requirements for Colorado veterinarians• History of the opioid epidemic• Best practices for veterinary opioid prescribing• Effective use of the PDMP• Recognition of Human Substance Use Disorder• Treatment options for Human Substance Use Disorder• Referral options for humans with suspected Substance

Use Disorder

Requirements for Colorado veterinarians

• Obtain 1 or more hours of CE (this training provides 2.5 hours), on: • Best practices for veterinary opioid prescribing• How to use the Prescription Drug Monitoring Program (PDMP)• Recognition of Human Substance Use Disorder• Referral options for humans suspected of Substance Use Disorder

• Be prepared to submit documentation verifying you attended this training

• Continue to practice veterinary medicine using:• Up-to-date pain management strategies for your patients• Best opioid prescribing practices

Brief history of the human opioid epidemic in the United States

Jason Beaman, DO, MS, MPH, FAPAAssistant Clinical Professor

Chair, Dept. of Psychiatry and Behavioral SciencesOklahoma State University

History of the opioid epidemic: 1890s-1910s

First opioid epidemic:

• 250,000 opioid addicted individuals in U.S. by 1900

• Opium was made illegal in 1909

• Harrison Narcotics Tax act of 1914 made it illegal to prescribe opioids for maintenance of addiction

History of the second opioid epidemic: 1970s

• Returning soldiers from Vietnam

• Largely heroin

• Dr. Vincent Dole published a paper on the efficacy of methadone maintenance in 1965, which lead to the legalization of methadone maintenance treatment by the FDA in 1972

History of the current opioid epidemic: 1990s

History of this opioid epidemic: 2010-present

What we should do to combat this as a society

•Require CE for all opioid prescribers to understand risks versus benefits of using these medications

•Restrict initial dispensed prescriptions of oral opioids to 7 days

•Review and re-evaluate all ongoing prescriptions to decrease potential for diversion and aberrant use of opioid medications

•Use resources such as the PDMP as one point of data in guarding against drug diversion and aberrant use

Best practices for veterinary opioid prescribing

Rick Allen, RPh, FSVHP, DICVPPharmacist, Colorado State University

College of Veterinary Medicine


In Colorado, veterinarians are regulated by . . . • Department of Regulatory Agencies (DORA)• State Board of Veterinary Medicine (SBVM)• Federal law (via DEA, FDA, et al.)

…as part of a multi-pronged approach to mitigate the opioid epidemic in our state.

Veterinarians have different best practices from human health care practitioners.


Veterinarians are unique among health care professionals because:

• Prescribing of opioid medications to veterinary patients requires the establishment of a Veterinary-Client-Patient Relationship (VCPR)

• Veterinary patients cannot administer their own drugs – which leads to increased potential for diversion/use of drugs by human owners

• Some clients may harm patients to obtain drugs


Understand how to assess pain

• Differs by species of the patient

• Good guidelines come from:• American Animal Hospital Association• American Association of Feline Practitioners• International Association of Veterinary Pain

Management


Understand opioid pharmacology in veterinary species

• Opioids are effective for ACUTE pain – not for CHRONIC pain• Drugs that are safe and effective in people are NOT the same as for

veterinary patients• Dogs have a high FIRST-PASS effect• Therefore, oral opioid use in dogs is likely

NOT EFFECTIVE FOR PAIN CONTROL


Opioids in veterinary medicine should be used judiciously . . .

• In acute surgical recovery and peri-operative time frames

• For acute pain management with high potential for resolution of pain

• As needed, with careful monitoring and clear ongoing expectations, for:• Cancer• Palliative/hospice care• Other terminal conditions


In all other cases, consider NON-OPIOID methods of pain control

• Schedule II drugs with low bioavailability and limited to no use in outpatient veterinary medicine: Oxycodone, morphine, hydrocodone, fentanyl patches

• Schedule II anti-tussives:• Hydrocodone Combination Products (HCPs) such as hydrocodone plus homatropine• Less potential for human diversion; used primarily as anti-tussives• May not be carried by human pharmacies

• Controlled drugs currently approved for use in veterinary medicine:• Butorphanol• Buprenorphine• Remember off-label use is permitted


RESEARCH SHOWS: NSAIDs WORK WELL IN DOGS. . . TRAMADOL DOESN’T.

Excellent choices for pain control that are effective include:

• NSAIDs• Gabapentin• Amantadine


Important pain control considerations:

• Anxiety treatments – may help with pain control due to psychological effects of pain

• Avoid benzodiazepines – contribute to human opioid-related deaths

• Consider use of anxiety treatments that are effective for pets:• Trazodone• Dexmedetomidine and other alpha-2 drugs• Daily-use antidepressants for long-term treatment


Important pain control considerations:

• Weight control, proper diet, exercise to promote mobility• Environmental enrichment• Long-acting local anesthetic pain control modalities• Explore other adjunctive pain-control treatments

• Laser therapy, acupuncture, turmeric, CBD, and hemp-based cannabinoid pain control options may prove effective


Proper opioid prescribing steps: From DORA’s Veterinary Policy for Prescribing and Dispensing Opioids (Dec. 2017)

Documenting all these steps in your medical record can help protect you legally! • Before prescribing• At time of prescribing• During ongoing treatment


Before prescribing:

• Valid VCPR must be established• FULLY ASSESS your patient before initiating treatment:

• Pain assessment including pain score• Function assessment to evaluate treatment efficacy• Complete work-up to make most accurate diagnosis

• Access the Prescription Drug Monitoring Program (PDMP)• Set expectations with your client for treatment efficacy,

duration, and completion/discontinuation


Accessing the PDMP is part of your assessment when weighingthe risk versus benefit of using a medication.

As of 2018, Colorado Revised Statue 12-280-404:

• Allows veterinarians to query their patients’ records (since 2017)

• Allows veterinarians to query their clients’ records (since 2018)


At time of prescribing:

• Consider utilizing non-opioid methods of pain control first• First prescription (in most cases) is to be for no more than

7 days’ duration (per Colorado Revised Statute 12-30-109)

• Communicate with your client about:• Dose, frequency, safe storage• Potential for human diversion/misuse• How to properly dispose of medications no longer needed

• Set a plan to re-evaluate the patient’s ongoing needs


• WHENEVER POSSIBLE: Prescribe opioid medications through a human pharmacy

• ONLY prescriptions filled at a human pharmacy will be recorded in the PDMP file for the patient

• KEEP IN MIND that prescriptions filled from pharmacies within veterinary hospitals WILL NOT be recorded in the PDMP


DURING ONGOING TREATMENT: Prior to refill / change in dose, frequency of treatment / throughout treatment duration . . .

• Re-evaluate for pain score, function of patient, improvement that you can document• Re-query the PDMP for both patient and client periodically• Collaborate with other members of the healthcare team

• Other veterinary providers• Staff within your hospital• Pharmacists

• DOCUMENT ALL STEPS IN THE MEDICAL RECORD

Best practices for veterinary opioid prescribingDURING ONGOING TREATMENT:

• Discuss ongoing treatment options and alternatives with client as patient’s disease progresses or improves

• Withdraw treatment if not effective or no longer needed• Consider changing treatment if aberrant use of medication

is suspected

• Openly discuss your patient’s Quality of Life (QOL) as needed• Use written/visual QOL assessment tools to illustrate• Educate your clients on proper disposal of medication in

the event of euthanasia

Use of the Prescription Drug Monitoring Program (PDMP)

From DORA’s Veterinary Policy for Prescribing and Dispensing Opioids

Stacy Meola, DVM, MS, DACVECCAssociate Medical Director

Wheat Ridge Animal Hospital

Use of the PDMP

Purpose of the PDMP

• Prevent aberrant use of opioids and other controlled drugs

• Provide reports to prescribers on their prescribing trends

• Centralizes Rx drug history for each patient and client

• Helps prescribers determine if aberrant medication use is occurring

Use of the PDMP

What veterinarians MAY access:(codified in Colorado Revised Statute 12-280-404)

• Patients’ records of controlled substance prescriptions (since 2017)• Clients’ records of controlled substance prescriptions (since 2018)

Veterinarians MAY access this information if, “the veterinarian, in the exercise of professional judgment, has a reasonable basis to suspect the client has misused the patient’s medication or mistreated an animal.”

Use of the PDMP

When to access the PDMP:

• Prior to the first prescription for a given patient/condition• Periodically during ongoing treatment• Any time aberrant use of medication is suspected

Remember that misuse and diversion of controlled drugs OFTEN starts with a valid, legal prescription.

PDMP account registration and maintenance

• Required for veterinarians with a personal DEA number• You can be referred for review by State Veterinary Medical

Board if you do not register/maintain your account

• NOT required, and NOT available, to veterinarians without a personal DEA number• You may be able to register as an authorized user under

another veterinarian at your practice

PDMP account registration and maintenance

• Registration takes about 5 minutes on average: • colorado.pdmpaware.net

• Call Appriss for tech support (available 24/7)• 855.263.6403

• General PDMP administration questions:• [email protected]

How to perform a PDMP search

• To check client’s history: • Enter first name, last name• Use “Partial Name Search” to remove search requirement for birthdate or

driver’s license number• Match address/phone number to identify your client from search results

• To check your patient’s history: • Enter animal’s name as “first name”• Enter owner’s last name as “last name”• Use “Partial Name” search to look up patient without birthdate

Use of the PDMP

Your level of ALERT and CAUTION should increase when:

• An opioid Rx request is submitted over the weekend or late in the day• You have a new client/patient• The client/patient are geographically far from home• The requested Rx was denied by another veterinarian or pharmacist• The requested dose/frequency/quantity to be refilled do not make sense• You receive multiple requests from clients at the same

address on the same day• The client has a history of fraudulent activity

If a client appears to be misusing medication…

If you do NOT suspect criminal activity:

• You MAY contact other prescribers and pharmacies that appear on the client’s PDMP file to voice your concerns

• Remember: Veterinarians are NOT bound by HIPAA, therefore there is nothing you MUST do

If you DO suspect criminal activity

• Contact local law enforcement and file a police report

Recognition of Human Substance Use Disorder



Neurobiology of addiction

• Activation of the reward circuit

• Alteration of receptor densities

• Alteration of neurotransmitter levels

Addiction is a brain disease that has behaviors as visible symptoms.

Addiction is different than intoxication

• Intoxication is a temporary state directly related tothe immediate effects of the substance

• For opioids: Euphoria, sedation, analgesia

• Addiction is defined as a Substance Use Disorder in the DSM-5i.e. Alcohol Use Disorder, Opioid Use Disorder

• The Hallmark is a problematic pattern of use as documented by 2/11 symptoms within a 12 month period

11 signs of Opioid Use Disorder, defined in DSM-5

1) Opioids taken in larger amounts or over a longer period of time than intended

• Taking more than prescribed• Taking routinely despite being prescribed PRN• Continued use outside of the prescribed window

2) There is a persistent desire or unsuccessful efforts to cut down or control opioid use

• Patient admits they want to stop, but can’t• Unsuccessful treatment programs• Hospitalizations, meetings, etc.


3) A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects

• Small jobs/panhandling to get the next dose• Criminal activity• Excessive time incapacitated from the dose

4) Craving, or a strong desire or urge to use opioids

• Patient tells you that they have craving• Strong sense of anxiety to use


5) Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home

• Missing work, deadlines because intoxicated or hungover• Terminations/dismissal from school• Change in roles at home because of lack of responsibility

6) Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids

• Arguments about use with friends and family • Uses anyway despite consequences of use• Multiple legal problems related to use


7) Important social, occupational, or recreational activities are given up or reduced because of opioid use

• Withdrawal from common gatherings• Birthdays, holidays etc.• Withdrawal from social groups• Unemployment

8) Recurrent opioid use in situations in which it is physically hazardous

• Driving• Heavy machinery• Supervision of children


9) Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

• Overdoses• Told by a physician not to use• Told by a mental health provider not to use• Direct health consequences of use:

• Hepatitis/HIV• Liver failure• Endocarditis


10) Tolerance, as defined by either of the following:

• A need for markedly increased amounts of opioids to achieve intoxication or desired effect• Increasing doses• Transition to stronger opiates

11) Withdrawal, as manifested by either of the following:

• The characteristic opioid withdrawal syndrome• Abdominal cramping, nausea, and vomiting• Piloerection and yawning

Social signs of addiction: Medical vs. non-medical

Personality changes. . . Angry, demanding, selfish, intoxicated

Unusual favors. . . Housing, transportation, money

Secretive behaviors. . . Territorial about space, frequently absent, vague about details

Stealing. . . Cash, small items, becomes more severe over time


In yourself or a family member/loved one:

• Be honest about the signs you are seeing from the list

In a colleague / coworker:

• Mood swings• Confusion / inability to concentrate• Making frequent, uncharacteristic mistakes• Habitually not showing up for work


In a client:

• Asks for a specific drug by name• Request refill due to lost or stolen Rx• Has seen multiple veterinarians recently• Is geographically distant from their home (except on vacation)• Anxious behavior or hyperactivity displayed during appointment

Treatment options for addition



Brain disease: Remodeling the reward circuit

The Reward Circuit is stimulated by . . .

Food

Drugs

Sex

Social interaction

The Reward Circuit . . .

• Tells individual what behaviors to repeat to obtain the reward again

• Builds pathways and connections in the brain that remain long-term

• Long-lasting brain changes with addition include• Activation and upregulation of the Reward Circuit• Alteration of receptor densities• Alteration of neurotransmitter levels

• Specific receptor sites in the brain lead to addiction• OPIOIDS• Nicotine, alcohol, cannabinoids, PCP, stimulants

Addiction treatment: Steps• Starts with recognizing this as a

medical problem

• Begins with detoxification in acute treatment phase

• Ultimate treatment goal: Long-term abstinence

• Over time, even severely affected brains can heal

Detoxification in acute treatment phase

• Any human opioid use >/= 14 days carries risk of withdrawal symptoms

• Psychologic effects (usually last longer)• Physiologic effects (shorter duration, may be severe)• Depending on the drug, these . . .

• Can take up to 6 days to peak• Can take up to 21 days to resolve


Withdrawal symptoms can be managed in 3 ways: (all are best handled within a medical setting)

• “Cold turkey”• Non-opioid Based Medically Assisted Treatment (MAT)

• Alpha-2 agonists• Natural opioids such as Kratom• Dopamine antagonists• Serotonin agonists

• Opioid-Based Medically Assisted Treatment (MAT) • Methadone – full agonist• Buprenorphine (Suboxone) – partial agonist with ceiling effect


Medically Assisted Treatment (MAT)

When used for initial detoxification, MAT helps to achieve better outcomes with:

• Decreased potential for rebound overdose

• Better retention of patients in long-term treatment

• Decrease in cravings

• Overall increased success with long-term treatment

Treatment to achieve long-term abstinence

• Long-term treatment follows detoxification• Best handled by a professional• Professional help will allow each individual to address:

• Addiction• Any co-morbid mental health issues that contribute

Severely affected brains can heal

•Reward Circuit

•Receptor densities

•Neurotransmitter levels

Referral options for humans with Substance Use Disorder in Colorado

Katherine Garcia, MA, LAC, MACPeer Assistance Services, Inc.

Veterinarian Peer Health Assistance Program

Colorado Revised Statutes 2018

Title 12

Professions and Occupations

Article 64

Veterinarians12-315-123. Veterinarian Peer Health Assistance Program

Department of Regulatory Agencies (DORA)

Veterinary Boards

Board Staff

Peer Assistance Services

Peer Health Assistance Programs

PHAP Staff

Peer Assistance Services, Inc.

• Services available at no cost for veterinarians licensed in Colorado• Funded through a portion of license fees • Available on a fee for service basis for veterinary technicians and

other staff members• This may be the best available resource for those who are:

• Struggling with a substance use or mental health disorder• You can refer: Yourself, a colleague, a staff member

Referral to Peer Assistance Services can save a LIFE!

Scope of work•Evaluation•Short-term problem resolution•Case management (Average 3–5 years)

◦ Referrals for treatment ◦ Monitoring

•Reporting to the Regulatory Board◦ Diversion; impairment in the workplace; board

involvement

•Education and outreach•Consultation

The number of professionals served has increased in the last five years.

660

783

952

9991023

500

600

700

800

900

1000

1100

FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19

PEER ASSISTANCE SERVICES, INC. 2020

PEER ASSISTANCE SERVICES, INC. 2020

0

100

200

300

400

500

600

700

800

FY 14/15 FY 15/16 FY 16/17 FY 17/18 FY 18/19

Nursing Professionals

Mental HealthProfessionals

Dentists

Pharmacists

Veterinarians

Veterinarian caseload

Total served FY 14/15 – 19/20 (3rd quarter) - 55

Board Ordered

82%

Voluntary18%

Principles of veterinary medical ethics of the American Veterinary Medical Association

“Veterinarians who are impaired must not act in the capacity of a veterinarian and shall seek assistance from qualified organizations or individuals. Colleagues of impaired veterinarians should encourage those individuals to seek assistance and to overcome their impairment.

Impaired veterinarian: A veterinarian who is unable to perform his or her duties in veterinary medicine with reasonable skill and safety because of a physical or mental disability including deterioration of mental capacity, loss of motor skills, or abuse of drugs or alcohol.”

Treatment and monitoring works!

80% of participants successfully complete their rehabilitation and monitoring contracts, maintain their

license, and contribute to the profession.

Peer Assistance Services, Inc.

2170 S Parker Road, Suite 229

Denver, CO 80231

303.369.0039

200 Grand Avenue, Suite 270

Grand Junction, CO 81501

970.986.4360

www.peerassistanceservices.org

http://www.peerassistanceservices.org/

Thank you from CVMA

• You have now fulfilled your training requirement for license renewal

• CVMA will keep a record of your completion of this training

• You will receive a CE certificate • You will also receive access to our Substance Use

Prevention Resource Library:• Full text of laws, statues, and regulations• Information on how to access/use PDMP• Reference for prescribing guidelines • Resources for referring humans for substance use

disorder treatment

Thank you!

Questions? Please contact us at [email protected] or visit colovma.org for more information.

Documents

Substance Use Prevention Training...Prevention Training Thank you, Merck Animal Health! John Ford 720-666-5635 [email protected] Senior Territory Manager –Equine (Colorado) Susanne