Transcript

Krysten Bennett: The opioid epidemic has had widespread effects on not just human medicine, but veterinary medicine as well. Professions, ranging from simple drug shortages to internal diversion. To drug shopping by pet owners. As a result, practices have had to make a lot of changes, not only to comply with new regulations, but more importantly, to do their part to prevent drug diversion and overdose deaths. But how has Animal Care been affected? In today’s episode we continue our 2024 MVC Preview Series with Dr. Jane Quandt.

Mia Cunningham: Dr. Quandt is currently a tenured professor in comparative anesthesia at the University of Georgia College of Veterinary Medicine. She’ll be joining the list of speakers at the 2024 Midwest Veterinary Conference, specifically in anesthesia and pain management track of programming.

KB: She’s joining us to share a sneak peek into her sessions and discuss with us the use of opioids and alternative options.

MC: Welcome to the show, Dr. Quandt.

Jane Quandt: Thank you for having me.

MC: Would you mind just taking a moment to tell us a little bit about yourself, your background, and your experience in veterinary medicine?

JQ: Yeah, well, I’ve been in the game for a long time. I graduated from Iowa State University in 1987, and then I was in practice for a year. I went to the University of Minnesota to do an anesthesia analgesia residency and also got my Master’s in anesthesia at that time. I then went to the University of Georgia. I was there for a while, and then I decided I needed to do a second residency in emergency and critical care to improve my handling and how to keep the more critical patients alive and doing well. And I completed that at the University of Minnesota as well. Then I was there for ten years, and an opportunity came to return to the University of Georgia. So I escaped the Minnesota winters, and I’ve been now here at the University of Georgia for the last 12 years.

KB: Awesome. Well, you’ll be covering a range of pain management topics for us at MVC. But for today’s show, we wanted to focus on your first two sessions, which will discuss the opioid crisis within the context of veterinary medicine. So to kick things off, can you explain some of the problems that have arisen within the profession as a result of this crisis?

JQ: So I think we’re probably all aware that opioids are sort of the plague of humanity right now. It’s affected veterinary medicine, and we used to be able to get multiple opioids, carfentanyl predominantly, for the use in our large exotic species. It’s hard to do a dart gun with a 60 cc syringe, right? So we needed these ultra-potent opiates. They’re no longer available to us because of this crisis. I think we also have to be very mindful of accounting for all of our opioids. And so one of the things I’ll discuss is we use a kickback system that you actually have to have a password or a fingerprint to get in. It accounts for every CC. It’s an easier way than the old-fashioned process of writing it in a book, and it kind of helps us because we have such a large volume. We don’t want diversion right to humans. So I think it’s made us a lot more aware. We use a lot of fentanyl in our anesthetic practice, and that’s the number one drug right now that’s really out there on the streets. Another drug that has gotten a lot of airplay lately is xylazine ; we thought xylazine , which is a large animal sedative, analgesia. And I would say 95% of all horse veterinarians have xylazine . There’s now a human abuse drug. And the problem with xylazine , it’s not meant for humans because it causes severe cardiovascular depression, i.e., you die. And in human medicine, they don’t have a reversal agent like we do in veterinary species because you have to assume every illicit drug is contaminated. You don’t get pure heroin. You’re not going to get pure fentanyl. And a lot of times now it’s mixed with things like cytosine. So I could give you all the naloxone I had, and it wouldn’t reverse cytosine. And you still are a fatality because of that. And now the move is afoot. Should xylazine become a controlled drug? I think that will greatly impact our abilities in large animals, especially if it becomes controlled. And how do we account for that? For example, in our university, all our drugs are kept locked up, even xylazine  because of these concerns and some of the other drugs, special K ketamine because it’s hallucinogen, that’s also a drug of abuse. So we have to be really aware of how good are we at maintaining control of our drugs? Who gets them? And people know veterinarians have those drugs. So how can we safeguard? And the other thing we have to unfortunately watch is could we tell if someone that we’re working with is using drugs? Are they diverting that to themselves? What are the signs? There are things to look for. Unfortunately, I’ve been involved with a couple of those, which is unfortunate, but it happens.

And also our clients, and some of our clients can be what we call shopping. They go to one veterinarian, say their dog’s painfully, get a script for something, go to another veterinarian, and repeat the story and are actually diverting the drugs to themselves, not the dog or a cat at all. So we have to know how much we’re dispensing. Where is it going? For example, we’re very cautious in sending home fentanyl patches. That’s pure fentanyl. It’s easy to peel off the dog and put it on a person. So where is it going? Who’s getting a hold of that? So I think those are things we have to be aware of. And we don’t think of things like gabapentin, right? How many veterinarians use a lot of gabapentin for chronic pain, and we all like it for the small domestic cat that’s actually a puma. He’s just masquerading as a domestic shorthair cat is really a fierce wild cat. And gabapentin helps. But gabapentin is also used as a drug of abuse because it extends the effect and the duration of, say, the fentanyl. So we can’t send home a big bottle of gabapentin because it might get diverted. 

So I think there are things that we don’t always take into account and how vast the drug problem really is and how do we deal with it? Or if our dog comes in, it’s a police dog, and he got exposed to a massive amount of an opioid. How do we treat him? What are we looking for? And those are also things that we have to take into account, not only the personnel part of it but the animal point of it. So that would be where some of the conversations we’re going to have, and unfortunately, we’re going to see huge numbers, thousands of people that die every year from drug overdoses.

MC: Yeah, I’m glad you touched on that because when I talk about it a little bit, just in terms of being able to recognize some of the signs of abuse or addiction, not only in coworkers, but as you see clients that come into the practice. Can you talk a little bit more about that and if there’s a way that doctors can take action?

JQ: I mean, it’s up to the pet owners, for example, here in Georgia. I would be suspicious if I had a client in the middle of the summer that has long sleeves. It’s like it’s 90 degrees here in the shade. You wouldn’t be wearing long sleeves, right? What are they trying to hide or the dog never gets better. Right? He’s continually being painful, but he’s the man over that, like days ago. Why is he still needing that? Or unfortunately, is there some malicious intent? The dog keeps getting injured, and it’s the owner doing that to get medication or they specifically ask for a certain drug. They don’t ask for an analgesic. They might say, my dog needs tramadol, my dog needs a fentanyl patch. Like, why are they specifically asking for that? Because they’re going to use it. That’s fine to them. So if they’re specific or they get a little belligerent, like my dog really is painful. He really does need this. And I might say, Well, let’s try an NSAID. And they’ll say, No, that’s not going to be good enough. That makes me a little red flag like most of us use NSAIDs, and they work really well. Why do you think it won’t work in your dog or this dog should not be painful? It’s a week later. Right. 

So those are some little like, ooh, what’s happening here? I’m not in the people business per se. I can’t say you have to go to a counselor. You know, I don’t have that ability, but I might say you can’t get any more. But then that makes me a little bit worried about what’s going to happen to the dog. And I don’t know that we have a good outlet in the sense of they haven’t done anything criminally wrong that I can see. And most places don’t have counselors. Hey, you need to talk to someone. But do I alert the family member? Again, legally, I’m not sure what my abilities are in some of those cases, but I can say no to the drugs. I can say no not to give them. 

But unfortunately, I don’t have an outlet to put your name out on the list so that every veterinarian knows that, right? So if someone comes in, I’ve never met them before. The dog’s still painful. I would ask, Well, what about your previous records? Know, I try to find out what’s the previous records, what’s the previous drugs? And again, if they’re specific, like they say, I need this drug. That’s a red flag to me because most of the time, especially at a university, it’s a referral, right? So there should be a pattern of some previous veterinary visit that I should be able to call that veterinary and say, Hey, what’s happening here?

Now, if they say they’re new in town, then we have to start with a full exam. You know, you can’t just get drugs for me without me looking at the dog, right? I’m not just going to refill that. I think that’s the other thing we could say. You only get a certain number of these drugs and there’s not going to be a refill. If you need more, I need to see the dog. You can’t just get an automatic refill. I mean, we all know dogs that are on like Lasix or else might for long term management. They can just get a refill. I may not need to see the dog every time, but if it’s something that could be diverted, yeah, I probably need to see that dog and make sure that is truly a requirement. So I think that’s another thing we can do. Charge them for that visit that may or may not deter them. You have to actually bring the dog in. We actually have to have a record of what’s happening with that dog or cat that they truly need this medication. And I know you don’t send the whole bottle home right then three days home, that’s all you get.

KB: Do you think that happens a lot, that pet owners will actually hurt their animals in order to get opioids?

JQ: I don’t think it happens a lot, but I don’t think we should say it never happens. I think it’s something we have to have in the back of our minds that if this dog continually is injured, why does that keep happening? But I think it has at least be on our list.

KB: And what about diversion internally? Do you see any of that happening like within the staff?

JQ: Unfortunately, I’ve seen it a couple of times and that’s one thing where good records in. For us, the comeback system helps because it has cameras on it and you have to have an I.D. to get into it. And so we were able to catch a couple in that way because they put in, for example, I need this drug for this patient. And it flagged because that patient is actually deceased. Oh, well, that’s like a red flag or the state patient’s actually an exotic species that I would never use this drug in. And so our system flags that pharmacy catches it and says they come to me and say, would you ever use this drug out? No, I wouldn’t. So that was a help for us then, that to catch that.

Now, if you have just a notebook, that could be a lot more difficult. Right. To catch those some of those things. And unfortunately, some of the drugs are clear in color. So one trick is you pull out your diverted quantity and you put saline back so the volume stays the same, right? So now you can keep the volume, but then you notice that, hey, this isn’t seeming to work. Dogs don’t get mental disease like they were before. So you have to have that suspicion and then the behavior of the individual might lead you to suspect. Right. They don’t show up to work. They seem better after they’ve been gone for a little while. Then some of the signs of addiction might be present. Kind of scary stuff, actually.

KB: Absolutely. It seems like there’s so many different ways to exploit it from both sides.

JQ: Yeah. So I think that’s really on us to be watchful of that and limit the number of people that can have access to those medications. So maybe everybody can have access to the NSAIDs, but not everybody has access to the schedule to opioids that would help narrow it down, that kind of thing. Again, it might depend on your state law, but all our drugs are kept locked up. I’m not saying it couldn’t happen, but that helps slow it down a little bit at least.

MC: But I am curious when you think about anyone who might have access to those drugs and would be using them for the purposes of whatever versus giving them to the diversion, But like, are there doctors that have things in place to get their staff assistance with their drug addiction?

JQ: Yeah, For example, we have counselors, we have the health center, so they go into rehab programs. I think university is probably easier to have all that established. But yes, there are programs. It depends on where you’re at, how strong those programs are or who actually runs them. And those people would have to be willing to accept that, right? You can’t force someone, but you can pull them off the floor or they’re not allowed to have access again. And they have to demonstrate rehabilitation. You can terminate their job, you know, hey, you’re not safe.

KB: And is it a requirement that you have to report a theft like that?

JQ: Yeah. If you have it through theft, you would have to report that because they’re scheduled to drugs. Like if someone steals aspirin, nobody’s going to care. Somebody steals a bottle of morphine, someone’s going to care. And we’re fortunate here that we have in-house on staff a pharmacist, and they help monitor that. But yeah, a theft like that would have to be reported.

KB: Some of the other problems that the crisis has caused, such as drug shortages and increased regulations, how are practitioners working around things like that?

JQ: It really depends on your state. Now, Georgia is pretty specific again, because the university we use so much, which is why everything has to be locked up and accounted for. The state requires that it’s a quantity issue as well. We just use so much. So that makes a difference. It only makes a big difference from federal if they’re all scheduled to drugs.

And that’s a federal thing like morphine is schedule to it doesn’t matter what state you’re in. So that’s going to be different. It’s not every state has some of the more minor drugs to the same schedule. For example, Propofol may not be a schedule three in every state, but it’s a schedule drug for us. 

How do practitioners get around it? I think that could be a problem for schedule two. Drugs. In certain drugs, you have to have them behind two locks. So a locked drawer with a locked box inside that kind are Quebec has the lock and then you have to have a password and a fingerprint to get in so it can be time-consuming. You can’t just have it open on the shelf, but it’s for safety’s sake to do that.

In the olden days, we could have drugs sitting out on the shelf. We’re not allowed to do that anymore. It all has to be accounted for, and we’ve gone a step further and put all our drugs, even the non-scheduled drugs in that respect, because our state wants accountability shortages. Yeah, we have some drugs we can’t get anymore. Like some of the opioids aren’t as easily available. So you have to make do you get more creative with local locks, other anesthetic agents besides opioids to try to get around that, but still provide an effective analgesic for your patient? So we’re doing a lot more local blocks, see our eyes, lidocaine, ketamine, things of that nature to prevent us from having to use so many opioids.

KB: So in your sessions, will you be talking about any of those other drug options that practitioners can use in place of opioids?

JQ: So I’m going to talk about two new drugs. One of them is called Zorbian, and it is a transdermal buprenorphine for cats. And we all know how much fun it is to try to pill a cat, especially if you’re a cat owner and not a veterinarian. Even US veterinarians don’t like to pill cats. But how do we get an analgesic in a cat, right? And we know we can maybe send home transmucosal buprenorphine, but you still have to get it in the cat. And there are subcu injections that can last 24 hours, but you still have to get it in the cat, whereas Zorbian, it’s buprenorphine, it is an opioid, but it’s not a schedule two and it’s almost put on like spot on, like a flea application. You put it on the back of the neck and it absorbs, and it’s good for four days of analgesia. So your cat’s analgesic, and you don’t actually have to touch the cat, which means compliance will be great. The idea is that you can give it before the procedure. It takes about 30 minutes to dry out and a couple of hours to come on board because it goes through the skin, and then it forms a depot, and then you’ve got four days of effective analgesia. We’ve been using it, for example, for dental space so you don’t have to send them home with anything. So I think that could be a real advantage because I think cats get shortchanged on getting analgesics. Cats hurt, first of all, but they’re not quite as demonstrative as dogs. And people just don’t know how to give any drugs to a cat, because it can become small whirling dervishes where this you don’t have to touch the cat. And he actually gets analgesia. So I think this could be a game changer for analgesia in cats. So we’ll talk a little bit about that. 

And then the other one is Zenalpha and it is an alpha two and we know some of the side effects are alpha twos or they have that vasoconstriction and then they get the reflex bradycardia and they’re hard to monitor, right? Because their pulse ox doesn’t look good because they’re so laser constricted and their heart rates are low. And Zenalpha actually has something called that an oxygen unit, which is a peripheral reversal agent. So we don’t get that basal of constriction, they don’t get that reflex bradycardia. So cardiovascular, they’re maintained a little better, but it has the central effects of a regular alpha two, its med determining in that we have sedation and analgesia. It’s meant for short term. That’s the other advantage of it. It lasts about 35-40 minutes. So if I want to do a cast change radiographs, remove some sutures, Zenalpha would work great. And because it’s short acting, most often you don’t have to reverse it. It wears off. Send the dog home. So I think there are some good reasons to use Zenalpha. So those are the two newest ones to talk about.

MC: What are some alternative methods of pain management that you’re going to cover?

JQ: One of the things that we do a lot more local blocks, for example, we do blocks for TPL. Also, you can do epidurals, you can do thermal sciatic blocks. We do something called a run block for the front leg radius ulna. Muscatine is medium blocks, so if you get a good nerve block, you don’t need that profound level of opioid analgesics because the animal can’t feel it. You’ve blocked it. And depending on what you use, you can get several hours worth of analgesia from that technique. And then when they do start being painful, you can go with a milder form of analgesia. We also do a lot of seizure eyes, constant rate infusions, and you can take those concentrate infusions into recovery. You decrease the dose, but you can still keep that on board. So again, you don’t need so much opioids. 

For example, when we do dogs with laryngeal paralysis, they get what we call a tie back to improve their ability to ventilate. We don’t use any opioids of the higher nature, i.e. schedule two or higher in those dogs because we don’t want them to pant or feel nauseous from those opioids. So we do the whole surgery. Lidocaine. KING, Utah phenol. So those kinds of things, ketamine to help. So there are surgeries that we can do without any opioids on the schedule to nature. Absolutely. Then we use a lot of alpha twos, Dex Magnetometer, for example. It provides good analgesia and is not a scheduled drug at this point.

MC: Now, do you find that those are as effective as opioids?

JQ: Well, this one is obviously an opioid, but if you do a good local block, that’s even more effective because it can’t feel anything. Right? For example, like if you go to the dentist and they block you, you don’t feel it at all. So that’s kind of the concept with if I have a fracture, I’m going to block it. And we have dogs that wake up, and they’re completely pain-free because they have a good local block.

MC: Is there an equivalent for humans so that I don’t eat sweets anymore? Is there a sweets blocker?

JQ: Yeah, I understand what you’re asking. That would be great. I haven’t found that one yet.

MC: Okay, let me know if you figure that out.

JQ: I could block your tongue, but then that might not be so great.

MC: Oh, there’s always a downside.

JQ: Yeah.

KB: So in addition to the opioids, you’re also going to be presenting a few other sessions, which I understand are going to be geared primarily towards veterinarians and technicians as well. Can you give a brief summary of the other topics you’ll be covering?

JQ: I’m at UGA and, for reasons that are not clear to me, the bulldog was chosen as the mascot. I’m not sure a bulldog in the South is the best, but everybody wants a bulldog. And French bulldogs have become one of the pets d’jour. Right? Everybody wants the French bulldog.

KB: Yeah, aren’t they the most popular breed now? They unseated Labrador retrievers.

JQ: I’ll give you this. They are kind of cute. But what people don’t seem to always grasp is the first investment is when you buy them. The second investment is when you fix them because they can’t seem to breathe. We do a lot of C-sections on them. The quandary is they’re not the best anesthetic patients, but we do a lot of them. So we’re going to talk a little bit about how to anesthetize the brachycephalic patient. What are some little tips that we can use to make them not quite so stressful for us and them? And then how do we see that? We do a lot of them. So what are some tips to actually get healthy puppies? 

And we’re going to talk about we always hear about Apgar scoring in humans, right, and actually score them. Are they going to be good? Are they going to require more maintenance? So we have an app we’ll discuss about Apgar score in little puppies. When should we watch them? When are they most likely to be in trouble? 

And then we’re going to also touch a little bit on just breeds specificity since we’ve all had that owner that comes in and tells you my dog is sensitive to this anesthetic or they don’t do well with this anesthetic and there are some breeds in which that is actually true. And we’re going to talk about some of those that maybe, you know, here is a cat that has hypertrophic cardiomyopathy. What breed of cat is common for that? We need to kind of look for that. And we all know Dobermans have certain diseases like von Willebrand’s that you might have cardiomyopathy. And so there are some ways we can anesthetize them because we still probably have to do that even though they have these underlying conditions. So we’re in talk about some specific anesthetic problems based on breed.

MC: We know that you have extensive teaching experience. You’ve also won a couple of prestigious teaching awards. So, can you talk to us a little bit about your presentation style for our listeners can understand what they can expect by attending one of your sessions?

JQ: Yeah, I, I don’t do a lot of videos or polling, but I like interaction when I ask questions. I want people to actually give me some answers. I don’t like to call people out, but hey, if this what you have, let’s talk about it. I tend to be a walker. I don’t just stand behind the podium. I’m going to be out in front talking to you and asking some questions. I might throw in a little story: Hey, this is what we had. What do you think? That kind of thing. I like people to talk to me and ask me questions. Don’t be afraid to talk to me, because I always tell my students, You may know a lot, but if you don’t actually speak to me, I don’t know that you know anything. And if you have a question but not afraid to ask it, I can’t answer that or help us come to some kind of resolution. So don’t be afraid to speak up. I like interaction.

KB: Speaking of asking questions, do you have an online presence or an email that you would be willing to share with listeners who want to connect with you before or after the MVC?

JQ: I have an email. Yeah. I don’t do social media. I admit some people said, Why don’t you want people to find you? No, I really don’t! The people that I want to find me can. So, email is fine. I will make every effort to answer the emails within a day, depending on how busy I am.

KB: Okay, we’ll put that in the show notes for our listeners.

MC: Before we let you go, is there anything else you’d like to share with us?

JQ: All I can say is I’ve been in the game for a long time, and I had one resident that asked me when I graduated, and I told him 1987, and he said, “Oh, Dr. Quandt, that was the year I was born.” And it’s like, okay… But no, I still like being in the game. I like learning, and there’s always something new. And students will ask, “Have you heard about this?” No, but let’s hear about it. Let’s learn about it. So I think to keep learning is the biggest goal.

MC: Well, thank you so much for joining us today. We’re looking forward to seeing you next year.

JQ: Thank you. Yeah, I’m looking forward to it as well. I haven’t been to this meeting, so I’m looking forward to interacting with everybody.

KB: Being from Minnesota, you know what to expect. There could be snow. It could be cold.

JQ: Yes. I’ll bring a sweater and boots. I’ll bring boots. No open-toed sandals. I’m ready.

KB: Layers!

JQ: Layers. Yes. Yes, absolutely.

KB: Well, thank you again so much.

JQ: Thank you.

Dr. Quandt is speaking on Friday, Feb. 23, in the Pet Animal Anesthesia & Pain Management track (Sessions 339-344). This track will be recorded on site for the Virtual MVC beginning on Feb. 26.