IN recent years the Association of Veterinarians in Industry (AVI) has been giving its members a chance to step outside the veterinary industry and look at it from a different perspective.
Such was the case with the AVI spring meeting where having first discussed the work of the VSHSP (Veterinary Surgeons Health Support Programme), we then heard from Inspector Paul Richards of the Metropolitan Police before seeing a presentation from a speaker on a more distantly-related area.
The VSHSP provides a safety-net for the very small proportion of veterinary surgeons who succumb to addiction in its various forms and in comparison to other organisations attempting to cure addiction its success rates are good.
Whilst the numbers of addicts being treated are low, just as they are for doctors and pharmacists, it needs to be remembered that the figures only reflect those individuals receiving help through the VSHSP. These individuals do not typically seek help without persuasion; instead they are referred by friends, family or even the RCVS.
So at the end of our first session we were faced with some questions before taking “a look from the outside”. Despite the low numbers, does the veterinary profession have a problem? Do the numbers of addicts just reflect the increasing incidence of substance abuse in society generally?
What controls are needed?
And even if the latter is true, given that veterinary surgeons have access to drugs that are unavailable to other members of society, what controls need to be in place to ensure both medicines availability and that the occasional infrequent transgressor is directed towards appropriate intervention?
Inspector Paul Richards started his talk by asking the audience if the police had the legal powers to inspect veterinary practices today. Answering his own question, he went on to talk us through the legislation, demonstrating that the police do have the power to inspect both doctors’ premises and veterinary premises.
Historically, they rarely used to bother because their principal concern is the protection of the public and in his words, “Whilst veterinary surgeons occasionally kill themselves, they rarely kill anyone else.” Apparently the police thought the same about doctors – and then Harold Shipman popped up.
The police know there is a problem with ketamine abuse and Inspector Richards showed us some pack shots, although I inferred from his presentation that they suspect the supply is not coming through veterinary practices. But Inspector Richards said that the police are more concerned with heroin and crackcocaine as these cause more damage and are the source of more crime.
The bottom line then was that the police expect the veterinary profession to self-regulate. But if there is ever a “Shipman-type problem” (i.e. public affected), if they use the powers that they already have to enter veterinary premises and inspect the records, they will then expect everything to be in order.
So we moved on to drug abuse in athletes. Professor David Mottram of Liverpool John Moores University talked us through the various ways sportsmen abuse their bodies to stay ahead of the game and the hurdles that the IOC faces in turn in order to stay one pace ahead of the drug cheats.
The latest hurdle appears to be the abuse of human growth hormone, for which at present they do not have a reliable test. Due to a slightly mischievous question from a member of the audience, we also touched on the debate about whether it’s acceptable for some sportsmen to use drugs to enhance their performance, e.g. if they are only playing sport for social reasons.
The talk was interesting in its own right, whether you were interested in links with the veterinary field or not; another AVI colleague commented to me afterwards, “I could listen to his stories all day.” For me, though, I was struck with the parallels with the other presentations.
We accept performance enhancement in chickens through the use of antibiotics unrelated to those used in humans. In America they have accepted the use of anabolics to improve the performance of beef cattle and bovine somatotrophin to improve the performance of dairy cattle.
If you are writing a safety expert report for a veterinary dossier, “performance” is one of the criteria the European legislation requires you to consider and, of course, some substances used therapeutically such as clenbuterol will also enhance performance.
We don’t accept performance enhancement in greyhounds, or racing horses, although I suspect that the vets who set up Liverpool vet school might have had to accept “performance enhancers” in the working horses at Liverpool docks had suitable substances been available at the time.
Is the off-label use of Viagra a recreational misuse or a performance misuse? Off-label is off-label, but does it matter if your intentions are honourable? Maybe all these things depend on context, expectations … performance pressure.
I had two questions for Professor Mottram at the end which were, “When did wide-scale monitoring of athletes start?; and why, as presumably the evidence of misuse of drugs by athletes was very low at the beginning?” His answer was that the testing programmes started in the 1950s due to the misuse of drugs by a very few high-profile athletes, so yes, the incidence was initially presumed to be low.
As to why they did it, the IOC did it because they considered it essential that the image of the Olympic movement should not be tarnished. I thought that was an interesting message to be left with: the fact that it is difficult to get the evidence on which to base proportionate controls in order to address an illicit activity.
And yet you still have to show that you have appropriate controls in place, to maintain the perception that there is no problem and ensure that Inspector Richards’ colleagues have no reason to come avisiting or find nothing untoward if they do.
So at the end of all this we all were left to form our own ideas about what should happen to veterinary medicines’ control and inspections, and all I can do is offer you my own thoughts and leave you to form your own.
I don’t always argue for greater control in medicines; I am in print elsewhere arguing that if a veterinary practice has prescribed a NFA-VPS or POM-VPS medicine then that practice should not be obliged to do anything more than a pharmacist or SQP prescribing the same medicine. You might choose to for good commercial reasons but it should be neither a legal nor a professional obligation as anything else is not sustainable for veterinary practice.
Over-restricting sends the message that availability can also be a problem. We recently had a situation where Caroline and our children were away for the weekend whilst I was working and our five-year-old daughter developed cystitis. In fact, even had she been at home we would have had difficulty seeing our GP as his surgery is not open at the weekend now, and the local pharmacy shuts not long after noon on a Saturday.
So Caroline got hold of the emergency doctor and was sent to casualty department. The dipstick test showed that our daughter did indeed have a urinary infection and a course of paediatric trimethoprim was advised.
However, the pharmacy was closed and there was no 24-hour pharmacy nearby (little point in offering a prescription then, free or otherwise). They hunted around in the clinic and were able to unearth one bottle of paediatric trimethoprim.
So, good for us this time but not so good for the next child turning up in profound discomfort. Medicines control may have had to tighten up in the postShipman world, but this scenario is hardly a great outcome for patients in general.
Many of you will be familiar with the HACCP (Hazard Analysis Critical Control Point) principle used in the food industry where the bulk of quality assurance resources are directed towards the greatest risk. Given that resources are always finite, it would seem sensible to adopt a similar approach with veterinary medicines.
Paul Richards showed us that the police are not focused on veterinary controlled drugs at present, but that one case of the public being harmed can change all that.
With your HACCP hat on, ketamine is less of an issue than crackcocaine or heroin, because it is less dangerous to the public, and pethidine is abused less frequently by vets than ketamine.
The police visit…
But what happens if your boyfriend or girlfriend or son is involved in a car crash and the driver is found to have been taking ketamine? Maybe you are sure that it did not come from your clinic; but the police visit and you cannot reconcile your purchases with what you are using. What then?
Or maybe your daughter is at a party that’s raided; the police find controlled drugs and start tracing all the possible avenues of supply. Drug abuse is so widespread now that there is a good chance your family knows somebody who takes them, even if you are unaware of it.
Or maybe one weekend you employ a locum who is new to you, and after the weekend some controlled drug has been used but you cannot find any clinical records of where and for what reason.
So what would I be doing just now in order to stay ahead? Certainly I would want to ensure that my professional body did not impose obligations on me that were not imposed on other channels, so I guess the starting point would be to ensure that whoever represents me knows what the obligations imposed on the other channels are.
Following the HACCP principle, if I were you I would not expect to be obliged to account for every ml or mg of antibiotic used in every case of cattle pneumonia or canine dermatitis (there is an overage in many bottles of pharmaceuticals anyway), even if I had to accept batch recording.
But certainly, tomorrow morning I would check that my standard operating procedures for recording controlled drugs are effective, records are up to date and ensure that everybody knows why.
And no, I haven’t got any controlled drugs that I shouldn’t have. But how would you know?