What Are Best Practices Regarding Opioids in a Veterinary Hospital?

• Split up ordering, storing, and logging responsibilities.

• Order small bottles and lots; use ampules.

• Get to know your client.

• Make sure your prescription pads are on lockdown.

• Install and use security cameras over the drug lockbox and the treatment areas.

• Use two safes, one for back stock and one for daily use.

• Every DEA registrant needs her or his own “working inventory.”

• Take inventories quarterly.

While these aren’t laws or regulations, they are good ideas to keep your practice on the right track. First, let’s consider when we should be using opioids and whether or not we need to continue using opioids in practice.

In my practice of veterinary medicine, I reach for opioids and controlled substances less and less. The risks outweigh the benefits in most cases and every case should include a risk/benefit analysis. The medical benefits of opioids in most canines are just not there. And with the ongoing nationwide opioid crisis, the risks are only increasing.

I always consider alternatives to opioids and controlled substances when they are applicable and that allows me to be more judicious with my dispensing and prescribing. This shift in medicine has caused me to rely on the latest and greatest information from my local specialists. Most specialists appreciate hearing from referring doctors, and they will certainly fill you in on the current thinking on opioids and controlled substances for use in your practice.

Ordering

Let’s now discuss best practices for ordering in your practice. This step has huge potential for diversion and we want to limit the possibility of those opioids getting out in the supply chain.

The best practice is to have different team members 1) place the order and 2) receive the controlled substance into inventory and do the stocking & recording in the logbooks.

Why? It prevents one person from ordering and then not entering drugs into inventory. I’ve seen several diversion schemes based on this simple task in veterinary practices.

Also, order small bottles and lots. If you do keep tramadol on hand, use the 100-count bottles, not the 1,000-count. They are easier to count and inventory and there’s less likelihood of a handful of pills coming up missing at counting time.

Use ampules. I know that the ampules are annoying and hard to break but they're designed to reduce diversion because they are essentially one use only. For a busy practice manager or practice owner presented with 222 Forms at the end of the day, it’s easy and tempting to slap your signature on there and head home. Take the few seconds to review the 222’s, make sure your ordering manager is ordering the appropriate drugs and that it doesn’t have the possibility of diversion.

Remember that the 222 Forms are for schedule 2’s and 2N’s, the ones with the highest likelihood of addiction.

You may be wondering how those ordering diversion schemes inside a hospital don’t get noticed, because someone has to pay for all those drugs. Well, the answer often is that no one was checking or paying attention to the invoices, they were just paying the bills as they came in. Keep a close eye on the invoices from your distributors. It’s easy to miss one order in the middle of tens of thousands of dollars in drugs and supplies.

Dispensing

When you are dispensing opioids or controlled substances from the inventory, make sure that you get to know your client.

Remember, the law requires that you form a Veterinary-Client-Patient-Relationship (VCPR) every time you dispense opioids. But even more so, watch for those clients that you don’t know. They may be traveling, they may be transient, or just new clients so keep an eye out for any red flags.

Also, remember that emergency visits have the highest odds for clients to be drug shoppers and this is where it becomes hard. We as veterinarians just want to trust people but we shouldn’t always make that our default position.

Some states require a pick-up log for dispensed opioids just like they do in human pharmacies where the client has to show their photo ID so that a dispenser knows exactly who is walking out the door with the drugs. Remember, it may be a spouse or partner or family member that is the actual abuser.

You may come to the decision simply not to dispense opioids anymore. It’s really getting to the point where the benefits and profit margins are less and less. It’s actually easier to shift some of the liability and the expense of dispensing these controlled substances over to human pharmacies. It’s not fun to give away the revenue stream but the margins on these drugs is pretty thin especially if you consider the team member’s time to order, inventory, log, and input data into the PDMP.

Prescribing

If you are sending prescriptions out the door, that’s fine -- just make sure that your prescription pads are on lockdown just like the actual drugs. Also, never ever pre-sign prescriptions pads and let your team members fill out the drug information. This is a prime area for diversion and prescription fraud.

Maintain a relationship with your local pharmacist. I know that some veterinarians and pharmacists have had tension in the past but it’s nice to get to know them on a first-name basis. They will be watching prescriptions for controlled substances closely and they will notify you if something doesn’t line up or if they come across a prescription with your name on it, just to make sure that you actually authorized it. They are just trying to do their job in controlling the opioid crisis as well.

Administering Controlled Substances In-Hospital

Here, we'll discuss administering drugs to patients while they are in the practice, possibly for pre-anesthetic or treatment use. Keep those drug cabinets locked during the day. Do not leave syringes or bottles lying around.

When you can, spot-check nurses that are giving controlled-substance injections. They can use that time to divert by not actually giving the drug and pocketing it later.

This is probably the biggest tip: Install and use security cameras over the drug lockbox and treatment areas. They are cheap, easy to maintain, and definitely slow down diversion.

Watch the sharps containers if controlled substances waste is going in there. Another common tactic is for an abuser to go into your waste containers and fish out the syringes.

Storage of Controlled Substances

Use two safes, one for back stock and one for daily use. A large volume of controlled substances does not need to be on the practice floor for everyone to access.

Store the logs and the drugs in separate locked cabinets so that if someone wanted to steal drugs and then falsely account for them in a patient record they would have to get the keys for both. 

An electronic lockbox is ideal because it limits the number of people who have access and the lock codes can be changed occasionally. Don’t hide lockbox keys in the same place for 20 years. Everyone in the practice eventually learns where they are hidden.

If you have a smaller safe, it should be bolted to the wall or the floor. Put those security cameras over the drug storage area and get those expired drugs out of the lockbox as soon as possible.

Inventory and Record Keeping of Controlled Substances

Every DEA registrant needs her or his own “working inventory.” That way, they are each responsible for keeping their own inventory correct. When a registrant is working, that’s the inventory that’s used.

Yes, it does mean that larger practices have multiple open vials and bottles, but these drugs are usually cheap and it’s better in the long run because inventory control is much tighter. This practice shifts liability away from the main practice owner or registrant over to some of the associates.

If you're doing this and are transferring Schedule 2’s to another registrant’s inventory, you must fill out and submit that 222 Form.

We like to number each bottle or vial with a unique identifier as soon as it’s received into inventory. Each bottle is opened in order and has its own logbook page. Once it’s emptied, we place that page into separate record storage. This allows us to track the bottles much more efficiently and take inventory much faster.

I also suggest that you take inventory much more frequently than the regulations require. Remember the advice to take an inventory every two years? A best practice would be to take an inventory once per quarter, that seems to be the sweet spot for our practices.

Be sure to record any waste, shortages, and other discrepancies into your inventories as soon as they occur. You will be surprised how much injectable is lost in the hubs and needles, and you should note that occasionally.