VetInfo Digest August 2002
This Month:
Online and Mail Order Pharmacies (really)
Ethical Choices in Veterinary Medicine
Providing for Pets When Pet Owners Die
This Month's Note:
Some of you noticed last month that I had intended to include information on Internet and mail-order pharmacies in the July issue and included it in the Table of Contents. There wasn't room in the VetInfo Digest when I went to convert if from one long document to a newsletter, though. So it is this month's topic, instead.
Michal and I plan to divide the www.vetinfo.com web site into three separate web sites over the next six months. We will have a site for cat information, a site for dog information and a site for information about veterinarians and veterinary practice. Subscribers will have access to all three sites. Ultimately, we hope to produce a newsletter for cat information and a separate one for dog information. We have not decided how to handle postal customers who would like to receive both newsletters but we'll iron that problem out over time.
Please bear with us as we make the conversion to separate sites. It is highly likely that there will be some glitches in the process. Hopefully, we will have better organization of our information and less confusion over which information applies to dogs and which information to cats when we are all through.
Online and Mail Order Pharmacies
Most clients intially look into online or mail order pharmacies in an effort to save money on medication costs. We have checked the online prices of a number of Internet based pharmacies over the last couple of years, because we have a growing number of clients who utilize these pharmacies. We have been surprised by the wide variation in pricing between pharmacies and even the pricing differences for different product lines on a single web site. Sometimes our clinic prices are actually less expensive than the online price, especially when the cost of shipping is considered. Other times, there are good deals online. Often, an Internet pharmacy site will have cheaper prices for one product, such as Topspot (tm) but may charge more than we do for another product, such as Interceptor (tm).
Some of the "good deals" online don't look as good when closely examined, though. Several Internet based pharmacies have been caught substituting drugs not approved for use in the United States for approved versions here, which is a violation of federal law and usually negates any responsibility for the drug's actions on the drug manufacturer. Package directions in kilograms for heartworm prevention medications are not the expected dosing measure for the U.S. even though they are easily understood throughout most of the rest of the world, so here in the U.S., they are a good sign that an unapproved medication has been sent.
Television commercials say that the medications are up to 50% less than the fees charged by your vet. This sounds pretty good but it isn't true for the fees charged by most veterinary hospitals. I'm willing to bet there are a few veterinary hospitals who could advertise honestly "up to 50% less than the online pharmacy" and be just as accurate. Comparison shopping is the only way to be sure that you are getting the best price, if that is your goal. Don't accept advertising claims at face value. Check your vet's price and the price at more than one mail order or Internet pharmacy.
Internet and mail order pharmacies have caused a change in the way that prescriptions are handled. States, and even countries, are beginning to realize that they must come up with guidelines for veterinarians to help in dealing with the changes. At the present time, though, there seems to be very little consensus of opinion among veterinarians, their clients, the pharmacies and the agencies that regulate the sale of medications on how to deal with online prescription filling. This situation has occurred for a number of reasons but the major factors are the speed at which Internet based pharmacies can change policies and sales techniques, coupled with the sudden ability to reach markets consisting of millions of people instead of hundreds or thousands in a specific neighborhood. When big markets, with the potential for huge profits beckon, rules will be bent to facilitate greed.
Most prescriptions are given out in veterinary offices during the course of a visit, in response to the need for a medication that is uncovered during the examination. The veterinarian provides a written prescription or calls a local pharmacy for the client's convenience. In this relationship, the veterinarian initiates the prescription request. If the veterinarian stocks the medication at the practice and the client does not specifically request a prescription, it is unlikely that the option of a prescription will even be offered. However, it is an option in most instances.
Mail order pharmacies have existed for as long as I have been in practice. In the catalogs from these companies there was usually a section for prescription drugs and it usually had a warning that a prescription form from the veterinarian had to accompany the order or it could not be filled. I don't remember a mail order pharmacy ever calling my practice to ask if it was acceptable to dispense a medication for a client. They were willing to try to entice customers with either lower prices or the convenience of home delivery, but they did not make a major effort to circumvent the traditional prescription process.
Internet pharmacies have been much more aggressive about the sale of prescription medications. To the best of my knowledge, these pharmacies were the first to advertise that they would call or fax your veterinarian to get approval of the prescription, making it unnecessary for the client to ask their veterinarian for a prescription and also making it possible for them to advertise that the use of their pharmacy eliminated the need for an office visit at the vet's.
Unfortunately, the situation is really not that simple. Prescription medications are controlled by the FDA and various state agencies. In order for a veterinarian to dispense these medications, or to write a prescription for them, there must be a valid doctor/patient/client relationship. This means, in its most basic sense, that your veterinarian must have examined your pet and prescribed the medication based on a recognized need. In many instances the requirements are more specific than this. Laboratory tests, follow-up visits, or other requirements may be part of the manufacturer's recommendations or the regulatory agency's policies.
Perhaps the most controversial of these requirements is heartworm testing prior to refilling heartworm prescription medications. I had a short and inane conversation once with the state inspector who was examining my medical records for a patient during the inspection of my hospital. He wanted to know why I dispensed enough heartworm medication for a patient for 18 months in one entry. I told him the dog lived on a sailboat and was currently at sea -- and had been for over a year. He was satisfied by this answer but I asked him what the legal requirements were for prescribing heartworm medication. His reply was "a valid doctor/client/patient relationship". I asked him what that meant, exactly. His reply was "nobody knows for certain, the Board decides on a case by case basis whether a proper relationship exists when a complaint is filed". So I asked him if a yearly visit would suffice. His reply was "probably, but who knows?". So I asked him what procedure I could follow to ensure that I did not run afoul of the Board of Veterinary Medicine's prescription policy for heartworm medications. He said that they had always recognized a yearly heartworm examination and recording of the patient's weight as a valid sign of a proper relationship for dispensing heartworm medications. Except that he said it this way, "see the dog, write down its weight and do a heartworm check every year." This was a long time ago, during the time when only daily heartworm medications were available - but many veterinarians got this same message during that time. With the newer heartworm medications I believe that most state boards would accept a longer interval between testing but that most would require at least enough of an examination yearly to ensure that the weight of the patient has not changed and that the patient is still alive.You might have thought that I was kidding about the end of the last paragraph but I'm not. Ensuring that medications are not misused is the whole idea behind having prescription medications. This means that it really is important for the veterinarian to know that he or she is prescribing medication for a patient that actually exists. The stickiest situation I ever had in this regard was pain control for a patient of mine who was dying of bone cancer and whose owner was a recovering narcotic addict. The pharmacy called and refused to fill the prescription until I verified that the patient was alive. They did this every time that I wrote a prescription for the pain relievers for the dog, until it died. I saw this dog on a weekly basis for approximately three months as it was the only way to ensure that he was receiving the medications and that they were not being diverted. Obviously this isn't the same as writing a prescription for antibiotics but they can be misused and often are misused, as well.
Several of the flea and tick products sold through veterinarians are not FDA approved medications. They are EPA approved and are essentially over the counter medications that the manufacturer chooses to sell through veterinarians. This may be to help limit liability from misuse or in the hopes that veterinarians will help ensure that the medications are used properly, enhancing the success rate for the product. When these products are sold online a prescription is not required but the product should be inspected to be sure that it is a version approved for use in the United States or the country in which you reside.
As soon as the advertising slogan "Avoid a visit to your vet" caught on, there was a problem. For the first time that I can recall, I was getting faxes from companies asking me to sign and fax back a prescription for a patient whose owner hadn't even talked to me prior to dealing with the pharmacy. No one had checked to see if the patient's medical history justified the prescription or not. We were caught in a bind. Do we call the client directly or do we fax back a reason for refusing the prescription, as the fax from the pharmacy requested? At first we just faxed the form back, stating our reason for refusing the prescription when it was necessary to do so -- or giving approval when it was appropriate. Then it occurred to us that we weren't seeing these clients coming in for examinations when we refused the prescriptions and that sometimes we weren't seeing them in the future when we did give approvals, either.
I called the Virginia Board of Veterinary Medicine and asked them what I should do about requests for prescriptions initiated by the client and relayed to me through a mail-order or online pharmacy. Virginia has no clear policy on this issue at the present time but they are working on one, at least. The present guidelines are to ask the client to come in for a written prescription and to hand it directly to them, as long as we would provide the medication if they were purchasing it from us. If we would be asking for an examination or lab tests in order to prescribe the medication from our office, then we should refuse to write a prescription and inform the client of the needed procedures. This prevents diversion of the medications from invalid prescription requests, as well.
When the online pharmacy tells you that they will have "their vet" write a prescription for a medication that your veterinarian won't approve, what should that tell you ? I think that it shows that the pharmacy has little regard for the safety of your pet or the safety of anyone else who might be affected by a misused medication. If their ethical standards are this low, should you trust them to provide necessary medications for your pet's health? Personally, I don't think so. There are plenty of online pharmacies. Find one that is more ethical. If your pet's weight has changed, if there is a better medication for his or her condition or if precautionary laboratory testing has not been done, or if your dog's condition has changed in some way that requires medication changes, there is a chance that your pet will be harmed by medications prescribed without proper veterinary care.
As long as the medications that a client is seeking to purchase from the Internet are necessary prescriptions and have been made appropriately, there are some very good things that Internet pharmacies can do. One of the advantages of being able to reach millions of customers is that it is possible to stock and sell medications that are not used with great frequency. The size of the customer base makes it less likely hat a loss will be incurred by stocking these infrequently prescribed medications. We often utilize mail order or Internet based pharmacies to obtain medications for our patients which are no longer available from the original manufacturers. Sometimes we utilize these services to try to provide a way for a client to afford medications that are too expensive otherwise. An example of this is fludrocortisone acetate (Florinef Rx), which is used to treat Addison's disease. This medication is costly to use on a long term basis when the brand name Florinef is used for a large dog. The compounded version, available from several mail order pharmacies, can be as much as 90% less expensive. It is possible to test for the proper effect of the medication in the office or through a reference lab, so it is possible to have the cost savings and still be assured that the medication is working properly.
I know that many of the medications that I dispense are not given to the pet because it is inconvenient to do so, or because the pet is actually dangerous to administer oral medications to. I try very hard to remember to ask every client, at least once, if they can actually give the medication to their pet if I dispense it and I ask them to tell me if they are having problems. It is possible to provide an alternative for many medications. When this is not possible, we utilize the services of a compounding pharmacy, sometimes an online one, to make the medication into a form that the client can administer. Cats being given methimazole (Tapazole Rx) for hyperthyroidism often become difficult to pill. We have been using methimazole mixed with a transdermal gel that is applied to the skin and is absorbed through it, taking the medication into the cat's body. This is much easier for most of our clients who are having difficulty administering the medication. If there is not a compounding pharmacy in your town or region, this can be a lifesaving service that an online or mail-order pharmacy can provide. Many medications can be made into transdermal preparations but it is important to understand that there is not a lot of evidence to support effectiveness in cats or dogs, except for a limited number of medications. Still, if you can't get a medication into your pet at all, this is at least something worth trying.
Finally, there are a few specialty medications that are difficult to obtain without using a pharmacy that handles the medication. Some chemotherapeutic agents are difficult to find and leuprolide (Leupron Rx), used in ferrets for hyperadrenocorticism is available in ferret sized doses from a mail order pharmacy, which is much more convenient for our practice and saves our clients considerable expense over paying for an entire bottle of the medication every time we have to use it.
I think that online and mail-order pharmacies are probably here to stay. For a little while, they are going to generate some friction between veterinarians, the pharmacies and their clients. As state and federal regulatory agencies sort out the regulatory issues and provide better guidelines for dealing with the pharmacies this situation should improve.
Many veterinarians are upset by the very availability of purchasing flea and tick products or heartworm medications online. They may resist providing you with a prescription for these products in some cases. As long as you have met the normal prescription guidelines for a practice (if they would dispense the medication to you from their clinic) it is considered to be unethical in most states for a veterinarian to refuse to write a prescription. It is important to realize that your veterinarian may not be trying to be difficult by insisting on a heartworm examination prior to writing a prescription, or verification of a pet's weight or physical status, if it has been more than a year since the last heartworm examination or if there is uncertainty about a pet's weight or ability to tolerate medications. Making sure that a prescription is proper for a patient is part of the veterinarian's responsibility, too. If it is obvious that your pet meets the prescription guidelines and your vet is still upset when you shop elsewhere for medications, you may have to consider how valuable the relationship is to you. If your vet is great otherwise but resents it when medications are purchased elsewhere you may have to accept that higher medication costs are part of the cost of keeping up the veterinarian/client relationship. If this really bothers you, then it may be necessary to find a vet who has a more accommodating attitude toward online shopping.
Large animal veterinarians have been dealing with clients acquiring medications, vaccinations and even surgical equipment for use on their own livestock for as long as I have been in practice. Twenty-four years ago, when I was working at mixed animal practice in Illinois, large animal veterinarians were still as upset about this practice as small animal vets currently are. I remember being at the practice late one night when the phone rang. I answered it and an excited client began an explanation of how he had ordered vaccinations for his horse. When he gave the vaccine the horse started looking pretty bad and he wanted to know if the vet I worked for at the time would come out to see the horse. In one of the starkest examples of how badly veterinarians can take this sort of thing, the vet said, "Tell him to call Omaha Vaccine (tm) and see if they provide emergency services for their patients." Large animal vets have gotten used to the situation and rarely get too upset anymore, though. Small animal vets will eventually do the same.We have adjusted the prices in our veterinary practice to reflect the reality of the current veterinary market. We charge more for our examinations, diagnostic skills and surgical skills than we did in the past and less for our vaccinations and medications with a high turnover rate. This means that we can write prescriptions for any medication without worrying about the economic impact on our practice. Our clients can shop around and try to find the best deal on medications without hurting our bottom line too much. Often, our prices are competitive with the online pharmacies and sometimes are significantly less. Sometimes there are very good deals online, though. This seems to be especially true for medications that require frequent refills, such as carprofen (Rimadyl Rx) and thyroxine (Soloxine Rx). It is worth checking with your vet to be sure that the claims of advertisers of much cheaper prices are true. Some vets choose to match any online price rather than have their clients shop online. We choose to control the prices to the best of our ability and to support our client's decision to use a less expensive source when we can't provide a medication for an acceptable profit at the price that the Internet pharmacy can. This serves our practice and the client's needs better than competing and losing money or refusing to cooperate with prescription requests. The increase in professional fees is the cost of having cheaper medications but it is a compromise that doesn't seem to upset our clients.
Making Ethical Decisions about Pet Care
Risk analysis is not the only problem in veterinary medicine that can be difficult for pet owners and veterinarians. Another problem that can be very hard to get a firm grip on is the ethics of treating a pet who has no say in the care provided. When is pain relief necessary? When is the discomfort associated with chemotherapy or radiation therapy justified and when is it not? Would your pet rather have orthopedic surgery or live with a chronic orthopedic problem? Should you treat recurrent cystitis in cats or wait for the symptoms to resolve on their own? Is it best to consider euthanasia when a faced with an incurable illness? These are all difficult questions at times.
Veterinarians and pet owners are both hampered in providing care for pets by the inability to actually talk to dogs and cats. For veterinarians this causes problems with medical issues such as deciding when to provide pain medications and limits the ability to do effective rehabilitation for orthopedic injuries. For pet owners the harder issues of when to consider euthanasia and whether to pursue uncomfortable treatments such as chemotherapy are more likely to be complicated by the difficulty in communicating with pets. It would be a lot easier to put a pet through chemotherapy if a person could be certain the pet thought it was worthwhile.
I have clients who will never consider euthanasia under any circumstance. They may have religious beliefs that make them avoid this option or they may be unable to bear the responsibility of decision making of this magnitude. It is hard for me to watch a patient suffer through terminal liver or kidney disease and it is at these times that I ponder the ethics of making a pet do so. When it is clear that there is almost no hope for recovery and a condition is painful or very uncomfortable for the pet then I believe that euthanasia is justified. Even though many of my patients seem to be able to communicate to their owners when they are tired of dealing with a terminal illness it would be better if they could just say "Let me go." Until they can, it is just necessary to recognize that the pet owner is ultimately responsible for this decision. When euthanasia isn't an option, we just work hard at controlling the pain and discomfort associated with the illness that the pet is suffering from and hope that we are effectively controlling any suffering.
I attended a continuing education seminar at which Dr. Carl Osborne from the Minnesota veterinary school was the speaker. He stated that he considered any decision made by a client of his to be ethical if they could honestly say that they would make the same choice if they were the patient and were faced with the same problems. This is a simple rule but it is effective for most circumstances. The major difficulty I face as a veterinarian is ensuring that the client really understands the problems facing their pet, knows the amount of pain or discomfort that might be present and is making an informed judgment. If these conditions are met and the client makes a choice that I disagree with, but which they obviously would make for themselves, then I have to admit that the difference isn't one of ethics in most cases, but just in the analysis of the situation.
Whether or not to provide pain relief is an example of a situation in which this same logic can be applied to make it easier to understand when pain is present. Many, perhaps most, dogs and cats are either good at hiding pain or poor at expressing it. For this reason, they may not appear to need pain relief even when they do. So I ask my clients, "If you just had this surgery would you need pain relief?" Most answer yes. "If you had arthritis severe enough to make it hard for you to get up out of a chair, would you take medications for it? Most answer yes. "If your skin was itchy all day and all night, how long would you tolerate that without finding a medication that controlled the itchiness?" Not long, for most of my clients. Providing comfort is a worthwhile goal and it justifies taking some risk of side effects from medications such as prednisone and carprofen (Rimadyl Rx).
Many pets do not receive thorough work-ups prior to the stopping of the diagnostic process. In some instances a "good guess" replaces lab work entirely. This is acceptable to some of our clients because they would avoid the cost of lab work and trust their doctor if they were making the decisions for themselves. However, if you really believe that a diagnosis should be confirmed, as closely as it can be, prior to the use of medications or surgery, it may be necessary for you to ask if testing has confirmed a diagnosis and if not, why not? You should be able to ask for testing that provides the level of confidence that you would require to make a decision if you were the patient.
I can not tell you the number of times that I have diagnosed lipomas, or fatty tumors, in dogs and to a lesser extent cats, and told the client that removal of this particular lump did not justify anesthesia. My standard advice is to wait until another procedure that requires anesthesia occurs and remove the lump then, if desired. Lipomas are almost always benign and removal is primarily a cosmetic procedure. That is really my best logical advice. However, when my fourteen year old dog developed a tumor on her shoulder last month and aspiration of it really seemed to indicate that it was a lipoma, I was not really happy leaving it alone. I decided that it wouldn't hurt to clean her teeth and remove the tumor at the same time. I probably would have put off the teeth cleaning for a few more months under other circumstances. Fortunately, she really did have a lipoma and I have to admit that I felt a sense of relief from the surgery that was more substantial than I felt from examining the aspirates from the lump. I think I'm going to have to amend my advice to pet owners to include offering the option to remove the lump if they are worried about it enough to justify it, even if my best medical opinion is that removal isn't necessary.
I can't let go of this topic without telling one of my favorite practice stories. I had an elderly client come into the practice one day and walked over to me in the reception room. He asked "Can you hear anything, Doc?" I couldn't. So he leaned a little closer and stuck his chest out a little. I could now hear an audible click that seemed to occur with each heart beat. "That's the sound of my new $50,000 heart valve, Doc. I told them I wasn't worth a dime over $10,000 and that they shouldn't do anything that cost more than that!".
I thought he was kidding. He wasn't. Looking closely, it was obvious he was still actually angry about the whole procedure, even though I knew with reasonable certainty that the procedure had really saved his life.
"I told them I wasn't going to pay them more than $10,000 and they could come and take the valve out if they wanted to. I told them an old fisherman like me just wasn't worth more than ten grand and I meant it."
Not many of my clients place such a finite value on themselves. But when he told me his dog wasn't worth more than $250 later on in the office visit, I was pretty sure that he had thought about the figure and that he was just following his own ethical code, even if I couldn't really understand it.
Controlling What Happens to Your Pets if You Die
I practice in an area with a high percentage of retirees in the population. With an elderly client base, it is not unusual for clients to ask me to help them make arrangements for the care, or euthanasia, of their pets in case they die before their pets do. We have helped find pets homes and we have provided euthanasia services when it seemed most appropriate. However, the plans of some of our clients have been totally ignored, or even changed on purpose, by surviving family members, well meaning neighbors or even public health officials, in rare instances. It is best to have some sort of plan for providing care for your pets in the event that you die and to make sure that the plan will be implemented if at all possible.
The riskiest period for pets is actually the first few hours after their owners die. It is extremely important to make sure that everyone who might be contacted after your death is aware of your wishes concerning your pets. It is best if you can find someone who is willing to care for the pets for a few days to a few weeks while legal issues are settled and who has a strong enough personality to deal with whatever controversies might arise in trying to fulfill your wishes. This person should also live close enough to you to come and get the pets quickly to ensure that they are not picked up by animal control officers or overlooked by emergency care personnel and left to fend for themselves. It is horrible when a pet with medical problems ends up in a shelter without important medications such as insulin or pain relievers and without anyone having knowledge of the need for these medications.
Some of our clients really feel that the only solution to pet care after their death is to have their pets euthanized. Many people feel that their pets are so attached to them that they will not be able to survive without them. While this does sometimes work out to be the case, it is much more common for pets to adapt well to new homes, especially when they are somewhat familiar with the people caring for them, as often occurs when neighbors, close friends or relatives take over care. It is also important to note that if someone is willing to provide a home for a pet the legal system will tend to see the pet's best interest as having a new home over euthanasia. Therefore, if there are valid medical reasons for euthanasia, or if the pets would represent a significant burden on caretakers, it is important to be sure that these facts are known to persons who might be contacted upon your death. Think hard about this, though. Pets and new homes are more flexible than you might think at first.
There is potential for improvement in a pet's circumstances and for disaster when pets are left behind when their owners die. Pets are still considered to be property under the law. Due to this, the legal system does not always provide support for requests that pets be euthanized or even for adoption plans that are carefully laid out. Surviving relatives with a legitimate claim to property rights may be able to change the plans and pets sometimes end up in public care (pounds and shelters) before there is a chance to figure out what the owner's plans for the pets were. It is not possible to leave money directly to pet in a will in the United States. However, it is possible to establish trusts for pets in many states. It is also reasonable to transfer ownership of a pet to someone legally prior to your death, which by-passes a lot of problems. However, you should trust this person very much, because ownership provides the legal right for many options, including giving a pet away, selling it or even euthanizing it, regardless of your wishes.
There are some very good web sites with detailed information on the practical, legal and ethical aspects of providing for your pets when you are gone. These are web addresses for sites with good information:
http://www.sydneykirkland.com/animal.html This is the address for the law office of Sydney Kirkland, who provides legal assistance to pet owners for a variety of reasons, including providing for care after a pet owner dies.
http://www.abcny.org/pub-provforpet.html This is a very good, very detailed site from the Association of the Bar of the City of New York --- City Bar Online. It is probably most applicable to people who live in New York Cit, but it is very likely that your locality has similar laws.
http://www.hsus.org This is the web site for the Humane Society of the United States. It also has a good section on providing for pets after death.
It is almost impossible to absolutely insure that nothing will go wrong with your plans for your pet's care. However, by planning in advance for the care of your pets upon the event of your death you can give your pets the best chance at a good transition to a new lifestyle. Have a will and make sure that it contains provisions for the care of your pets, such as an Honorary Trust or one of the pet trusts allowed in many states. Keep in contact with the people who are likely to be caring for your pets after your death and make sure they are updated on your pet's medical needs. Talk to your vet about the kind of care you want to provide and consider making arrangements with your vet for care that might be necessary during the transition to a new owner, especially if you are aware that your death is imminent. Write a note that is kept with your lawyer, your friends or somewhere it is likely to be noticed that includes your veterinarian's name, permission to release medical records for your pets, describes their diet and any special care needs they have. It is not unusual for our elderly clients to take all of these steps to ensure that their pets are cared for. It would probably be best if everyone made at least the basic arrangements for their pet's care. Just like with insurance or wills, being prepared doesn't make it more likely that something will happen to you, so facing that possibility shouldn't be frightening -- and it may benefit your pets more than you can imagine.
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