"Under Care" guidance, controlled drugs, can you help me implement this?

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Ben Walker — Tue, 14 Nov 2023 15:54:52 GMT

[quote userid="5012" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242857#242857"]My understanding is that we need to see an animal to prescribe the drug, and enter an active prescription into the clinical notes, as we will need to do with anti-parasitics from 12th January. That prescription could be worded to supply 6 months worth to be dispensed in 6 instalments of 28 days at a time, but would need to include the total number, and full instructions[/quote]

I think the RCVS’ guidance could be clearer, but the legislation supports your view. The requirements come from:

1. The VMR (2013) which states we can only prescribe following a clinical assessment of an animal under our care;

2. The RCVS who have made declarations of what they consider clinical assessment and under our care to mean (clinical assessment now requiring a physical exam for certain classes of drug); and

3. The Misuse of Drugs Regulations (2001) which governs the prescription of CDs. They state “in the case of a prescription for a total quantity intended to be supplied by instalments, contain a direction specifying the amount of the instalments of the total amount which may be supplied and the intervals to be observed when supplying”.

One prescription can cover multiple episodes of supply. With “repeat prescriptions” we usually mean that the prescription can be supplied against X times, but the client can decide on the interval. The RCVS guidance refers to “instalment prescriptions” for CDs where we specify the instalment amount and interval. The terms aren’t set in legislation, but it’s not a bad way to view it.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Tue, 14 Nov 2023 12:10:31 GMT

[quote userid="2675" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242855#242855"]

Another case of gold plating the law. The actual part of the regulations from vmd covering prescribing and dispensing is one page (schedule 3). There are no restrictions on how often etc you have to see a patient for it to be under care. The only restrictions are dispensing controlled drugs to be limited to 28 days at a time and a written prescription may not exceed 6 months.

Everything we have seen has been unnecessary.

[/quote]

The confusion seems to be around the issue of prescribing vs dispensing of Phenobarbitone.

Some feel that they need to see a patient every 28 days to re-prescribe?

Others feel they can prescribe more than 28 days worth anyway if they trust the client?

Others feel they can carry on as before, as long as the patient is seen every 6 months they can dispense more.?

My understanding is that we need to see an animal to prescribe the drug, and enter an active prescription into the clinical notes, as we will need to do with anti-parasitics from 12th January. That prescription could be worded to supply 6 months worth to be dispensed in 6 instalments of 28 days at a time, but would need to include the total number, and full instructions.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Richard Carter — Tue, 14 Nov 2023 07:28:54 GMT

Everything we have seen has been unnecessary.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Mon, 13 Nov 2023 21:08:55 GMT

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242835#242835"]I think you have this wrong.[/quote]

But that is the issue.

I am one of 7 vets working for a small group at the moment, and we all have a different opinion on what we can or cannot do under the new guidance. It is so ambiguous and badly written. There needs to be clarity.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Beats — Wed, 08 Nov 2023 21:56:07 GMT

[quote userid="8958" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242833#242833"]So in the case of gabapentin etc that are at the moment dispensed 6 months at a time between examinations, where a months worth is dispensed at a time, these animals are going to require examinations every 2 months?[/quote]

I think you have this wrong.

you, as a vet, can prescribe 6 months of 100mg gabapentin twice daily as a longterm treatment if you wish, you can request that that prescription is dispensed in monthly installments and not all at one time. You have to make the prescription at the time of physically touching the animal however. Not really any change there other than wishing computer record of your prescription to be more clear to an outside observer, while falling short of actually being a valid written prescription.

You could further change that prescription after a phonecall a week later with the owner and issue "a" (one and only one, so the RCVS say verbally) further prescription for gabapentin 100mg three times daily and dispense monthly off that prescription instead.

If, during a further phonecall another week later, you want to change to 200mg twice daily instead, say as the owner finds three times daily doesn't fit their lifestyle and 100mg twice daily was not as effective, you cannot do that without the dog being presented to you.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Wed, 08 Nov 2023 21:11:58 GMT

[quote userid="8958" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242833#242833"]

So in the case of gabapentin etc that are at the moment dispensed 6 months at a time between examinations, where a months worth is dispensed at a time, these animals are going to require examinations every 2 months?

Neil

[/quote]

No.

My take on this, is that we have to see a patient to prescribe CD's (except in exceptionional circumstances), but that could be a 6 month supply, with 28 day amounts being dispensed every 28 days.

for example: a prescription for 336 x 30mg Epiphen (Phenobarbitone), dose 1 tablet twice daily, to be dispensed in installments of 56 tablets every 28 days.

I also gather from the guidance that there has to be an active prescription (as above) in place to be able to dispense. it is not enough to just write "ok for the next 6 months"

That said, every colleague I speak to has a different take on this, the guidance being so ambiguous.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Neil Wheadon — Wed, 08 Nov 2023 17:00:24 GMT

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242832#242832"]I read this wording differently to how the RCVS intended it, but I was verbally assured that the emphasis was intended to be on the "a" to mean that one and only one further prescription for a controlled drug is allowed between physical examinations.[/quote]

Neil

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Beats — Wed, 08 Nov 2023 14:14:46 GMT

"it is acceptable for a vet to issue a further prescription for a controlled drug previously prescribed"

see point (3) of my summary at start of thread of how I understood things.

I read this wording differently to how the RCVS intended it, but I was verbally assured that the emphasis was intended to be on the "a" to mean that one and only one further prescription for a controlled drug is allowed between physical examinations.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Wed, 08 Nov 2023 14:02:10 GMT

I've taken this from the RCVS website.

You must always perform a physical examination in the following circumstances:

when prescribing controlled drugs (unless there are exceptional circumstances)

Under the new guidance, it is acceptable for a vet to issue a further prescription for a controlled drug previously prescribed, however, the vet should carry out a clinical assessment to ensure they have enough information to do so safely and effectively.
For all controlled drugs, in most situations veterinary surgeons should only prescribe 28 days’ worth of treatment. The exception being where there are long term ongoing medical conditions, for example, when treating epilepsy in dogs.
If more than 28 days’ worth of treatment is prescribed, the prescribing veterinary surgeon must be sure the owner is competent to use the medicine safely.

So, I, and many I work with, are more confused than before.

Can we continue to prescribe CD's without seeing the patient? (1 says we must examine the patient, and 2 says we can issue a further prescription?? which is it?)

Can we prescribe more than 28 days worth of Phenobarbitone for ongoing stabel epileptic patients? (3 says 28 days, except where on longterm therapy?)

Seems a lot of confusion at the coalface, what are others doing?

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Gillian Mostyn — Tue, 31 Oct 2023 11:28:58 GMT

[quote userid="5012" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242733#242733"]

How are folk getting on with the new guidance?

It seems that it is being ignored by many?

[/quote]

We're doing free 5 min checks for those that wouldn't have otherwise had to come in yet, with a script then put on record, or I'm writing an instalment prescription for controlled drugs.

Its a pain, but its not being ignored. Neither do we want the abuse from making everyone pay a full consult - which I can completely understand their annoyance with.

It should all be sorted soon as we've already been doing it for 2 months.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Tue, 31 Oct 2023 10:25:20 GMT

[quote userid="9515" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242736#242736"]I don't really do any first opinion work now but the places I have been are working to get it in place for the start of January/February when the regulations come into force after the extension. [/quote]

It is only the guidance around the prescribing of anti-parasitics that has been delayed until 12th January, 2024.

All of the remaining new guidance, including the requirement to physically examine an animal prior to prescribing controlled drugs, came in to force on 1st September.

I am following the guidance, but it has and is causing problems with some clients, who don't see why they and their pets need to be seen sooner than the usually 6 months. Some colleagues are letting some of these slip through this time, I'm not.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Richard Carter — Sun, 29 Oct 2023 14:21:56 GMT

I find it interesting that the VMD have stated they do not intend to change the current regulations on prescribing.

I suppose the bigger issue are these practices with no permanent vets. Perhaps time for these to have their license pulled?

Even if you go through all the writing of a prescription nonsense, as the law currently stands, pom drugs can still only be dispensed by a. A RCVS registered vet; b. Staff under the direction of said vet; c. A pharmacist on receipt of a prescription from RCVS vet. Nurses etc are still not allowed to dispense pom drugs even off a prescription.

Not entirely sure why RCVS has come up with current guidelines, who it benefits and what the dreadful crime was being committed even the vmd inspectors were unaware of.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Sarah Keir — Sun, 29 Oct 2023 12:02:41 GMT

I don't really do any first opinion work now but the places I have been are working to get it in place for the start of January/February when the regulations come into force after the extension.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Sun, 29 Oct 2023 11:44:06 GMT

How are folk getting on with the new guidance?

It seems that it is being ignored by many?

My understanding, is that it is now a requirement that an active presciption has to be in place to be able to prescibe Phenobarbitone (or any other schedule 3 controlled drug), and that requires a physical examination of the patient. It is not enough to have written in the notes things like "ok for Epiphen for 6 months"

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Wed, 20 Sep 2023 09:30:55 GMT

[quote userid="4181" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242504#242504"]

Always be more careful about wanting overly prescriptive guidance, as it leaves little room to apply professional discretion

[/quote]

I tend to agree, but at the moment there seems general and widespread confusion as to what can or cannot be done.

[quote userid="4181" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242504#242504"]Hmm, you're not dispensing the 1st instalment of your CD prescription within 28 days of making that prescription, so you really need a new one[/quote]

Yes, you're right, and sorry an oversight on my part.

Helps to clarify Lucy's question though, in that it is (probably) OK to prescibe or rather dispense within 28 days of the initial consultation.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Rob Loxley — Tue, 19 Sep 2023 12:55:32 GMT

[quote userid="5012" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242502#242502"]the guidance too vague[/quote]

Always be more careful about wanting overly prescriptive guidance, as it leaves little room to apply professional discretion

[quote userid="5012" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242502#242502"]In this example, my interpretation of the guidance would be yes you can prescribe Phenobarbitone, as it was specifically discussed at the appointment and you were awaiting lab work to exclude any extra cranial causes before commencing treatment.[/quote]

I'd agree that's within the spirit of the rules, though the letter of the rules probably is that you write a prescription for phenobarb on the system at the time of the consult (contingent on bloods being normal), or when the bloods came back.

[quote userid="5012" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242502#242502"]What would happen if it were 6, 9, 12 weeks later? or if the case was picked up by another veterinary surgeon?[/quote]

Hmm, you're not dispensing the 1st instalment of your CD prescription within 28 days of making that prescription, so you really need a new one

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Tue, 19 Sep 2023 11:03:20 GMT

[quote userid="10320" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242501#242501"]Alright, another one - epileptic cat, seen for clinical exam, bloods to rule out systemic disease done, and starting treatement with phenobarbitone discussed at the time, but between waiting for the results and owner going on holiday it's now 3 weeks since we physically laid hands on the cat. Prescribe and dispense now based on recent PE and plan formulated at the time, or re-examine? [/quote]

The list of possible scenarios is endless, and the guidance too vague.

In this example, my interpretation of the guidance would be yes you can prescribe Phenobarbitone, as it was specifically discussed at the appointment and you were awaiting lab work to exclude any extra cranial causes before commencing treatment.

What would happen if it were 6, 9, 12 weeks later? or if the case was picked up by another veterinary surgeon?

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Lucy Fleming — Tue, 19 Sep 2023 10:41:13 GMT

Alright, another one - epileptic cat, seen for clinical exam, bloods to rule out systemic disease done, and starting treatement with phenobarbitone discussed at the time, but between waiting for the results and owner going on holiday it's now 3 weeks since we physically laid hands on the cat. Prescribe and dispense now based on recent PE and plan formulated at the time, or re-examine?

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Michael Woodhouse — Tue, 12 Sep 2023 20:37:08 GMT

[quote userid="6386" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242401#242401"]if I have a client whose cat has never been seen because they can't get it in a basket, does that count as an exceptional circumstance to dispense Gabapentin to facilitate transport in a situation where that cat really needs vet attention? Does animal welfare trump everything?[/quote]

I also believe this is ok.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Clive Ansell — Tue, 12 Sep 2023 17:47:09 GMT

[quote userid="6386" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this/242401#242401"]Regarding the OP, if I have a client whose cat has never been seen because they can't get it in a basket, does that count as an exceptional circumstance to dispense Gabapentin to facilitate transport in a situation where that cat really needs vet attention? Does animal welfare trump everything?[/quote]

Yes it is.

One of the examples cited on the RCVS website is just that, a difficult cat that needs a one off sedation prior to transport to the surgery for examination.

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Kate Richardson — Tue, 12 Sep 2023 14:07:15 GMT

Beats said:

18. For angry cats needing transported to the clinic, I need something other than a 100mg gabapentin to leave out for the owner to collect.

Still absolutely OK. Unconvinced it does very much......

Michael Woodhouse I have some cats who require 200mg, it does work, just variable in which dose works for which cat

Regarding the OP, if I have a client whose cat has never been seen because they can't get it in a basket, does that count as an exceptional circumstance to dispense Gabapentin to facilitate transport in a situation where that cat really needs vet attention? Does animal welfare trump everything?

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Rob Loxley — Tue, 12 Sep 2023 07:44:46 GMT

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]For angry cats needing transported to the clinic, I need something other than a 100mg gabapentin to leave out for the owner to collect[/quote]

this would be an accepted reason to dispense prior to examination, if your clinical assessment deems appropriate?

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]A change of brand of phenobarbitone would necessitate a physical examination most likely[/quote]

Unless you write your prescription for the active rather than brand

RE: "Under Care" guidance, controlled drugs, can you help me implement this?

Michael Woodhouse — Mon, 11 Sep 2023 23:28:53 GMT

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]4. A repeat prescription is not possible, but a prescription in "installments" is fine. The difference being saying 60xepiphen 30mg 1BID, repeatable every month for total 6 months is NOT OK, but saying 1800xepiphen 30mg 1BID to be dispensed in installments every 30 days is OK.[/quote]

A repeat prescription was never allowed for schedule 3 drugs - so that includes your Epiphen/Phenoleptil. 28 day supply with a prescription valid for only 28 days. Instalments allowed, but first lot must be collected in the 28 day validity of the prescription being made. I always found it frustrating the Phenoleptil came in strips of 10 and we dispensed in 28d lots. 7's would be much better.

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]tarting lifelong epiphen for epilepsy - please continue to dispense monthly for 6 months, review in 6 months or sooner if side effects or poorly controlled."[/quote]

Again, has never been legal.

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]15. For patients on gabapentin, it is probably simplest to discontinue it as it probably does very little for the marjority of them.[/quote]

Disagree - I find it very useful.

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"] For patients on Pardale-V they can be prescribed paracetamol instead.[/quote]

I'm not sure 'hassle' is a reason to deviate from the cascade. I never consider Pardale V a controlled drug as shedule 5 and basically no restrictions, but it is an interesting point. Especially if the RCVS expect us to treat it this way. Happily will give out 2 months worth. One to discuss in the practice, I think.

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]18. For angry cats needing transported to the clinic, I need something other than a 100mg gabapentin to leave out for the owner to collect.[/quote]

Still absolutely OK. Unconvinced it does very much......

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]13. Teleos has no present means in the form we have it to make any of this possible in an efficient and timely manner.[/quote]

Also a frustrated Teleos user. I'm investigating the use of the repeat meds tab and possibly some pre-typed text in a word document so can be easily copied and pasted. For farms we are using a separate prescriptions tab.

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]11. A change of brand of phenobarbitone would necessitate a physical examination most likely.[/quote]

That would depend whether your prescription stated the product name or the trade name. I believe if you state drug name then you could use any phenobarb.

[quote userid="12930" url="~/f/non-clinical-questions/30766/under-care-guidance-controlled-drugs-can-you-help-me-implement-this"]The precise level of detail to be contained in this computer-record "prescription" is somewhere between an actual valid written prescription that could legally be dispensed upon, and the implicit, seemingly unambiguous, prescription to be interpreted by yourself or another vet at your clinic familiar with you ways[/quote]

Again, I suspect a deliberate act to allow a colleague to dispense within your practice, but not someone who has obtained the animal's record. I think quite sensible.