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Peter Weinstein, DVM, MBA, spoke alongside Kelley Detweiler, an expert on Drug Enforcement Administration (DEA) regulatory compliance, about best practices for maintaining controlled substance logbooks during a session at the Fetch dvm360 Conference in Kansas City, Missouri. In addition to general logbook compliance, the presentation covered how to handle and reconcile discrepancies, and the DEA’s position on hub loss and substance waste.

Weinstein and Detweiler began their presentation with a brief section about frequently asked questions (FAQs), addressing some common misconceptions. They explained that, according to Title 21 of the Code of Federal Regulations, logbooks are not required to be bound, but they must be maintained in a manner that does not allow any log sheets to be loose or falling out of order. They also must be secured in consistent chronological order for the current 2-year period, according to Detweiler. Logbooks should also be stored close to where DEA-compliant controlled substances are being used, they are not required to be locked up, and they should never leave the premises.

Perhaps the strongest point of emphasis throughout the pair’s discussion regarding DEA-compliant logbooks was the significance of the entries consistently balancing out to 0. The DEA does not want variances. Similarly, it is their recommendation to never leave blanks in logbooks. If a practice is documenting waste, rather than leaving a field blank as in indication that there was no waste, filling in a "0" as a record that there was no confirmed waste was advised.

“[DEA]-compliant logs should tell the story of the controlled substance usage from the point of acquisition to the point of administration, dispensing, or disposition,” Weinstein said during their session at the Fetch dvm360 conference. “Disposition could be wasting, and/or expiration.”

For more information, Weinstein and Detweiler debunked myths and misconceptions surrounding DEA regulation in a 

According to DEA regulations, a full inventory of all controlled substances must be conducted biennially at a minimum following the date when the initial DEA inventory was conducted. Though, Weinstein compares waiting until the last minute to complete biennial inventory to getting taxes together each year on April 14, knowing they are due on April 15.

The speakers discussed conducting controlled substance reconciliations on logbooks, which is the process of comparing the actual amount of physical inventory "on-hand" against the amount of inventory that should be on-hand according to the logbooks, Detweiler noted. They compared to a checkbook of every drug from a specific category. If a practice is not reconciling their controlled substance logs on a regular basis, there would be no way to identify discrepancies or to identify if their logs are consistent with their inventory. Weinstein recommended that reconciliation logs be conducted by an authorized user and a witness, preferably on camera for an extra layer of security.

“So, the more you do a reconciliation, the more likely you are to balance out,” Weinstein said. “Don’t you hate it at the end of the day, when you’re balancing out the drawer, and there’s a penny off? Well, how about if that penny is 1 cc of fentanyl… what do you do to resolve [that]?”

In their session, the pair also recommended that reconciliations be conducted, at minimum, weekly. Although the DEA does not set forth a specific frequency for conducting reconciliations, the more often you reconcile the better. Frequency should be determined based on the size of the practice and volume of controlled substance use. If it's a large practice with higher controlled substance usage, reconciliations should be conducted daily or, if possible, at the end of each shift. In general, the more controlled substances a practice uses, the more often they should reconcile.

Detweiler stressed the urgency of recognizing discrepancies. “Because remember, if something doesn’t jibe, you have 24 hours to make notification to the DEA,” she said. “And that registrant who’s holding the bag needs to know immediately, because it affects their entire license and livelihood.”

What is an acceptable amount of hub loss?

“So, the DEA recognizes that hub loss exists,” Detweiler said during the session. “However, they do not specify a certain amount of hub loss that is allowed, they do not provide how it should be calculated, and they will check how you are accounting for hub loss for things that do not balance out to 0 in your logs.” She explained that, with different substances, often depending on the viscosity, and with different needle gauges, hub loss will vary. Her advice for determining acceptable hub loss is to establish a consistent formula for calculating it. “The DEA wants to know that you’re not predetermining amounts, and that you have a formula,” she said.

She recommended multiplying the number of pokes by whatever amount was determined for hub loss on a specific container or bottle for liquid controlled substances. If the resulting number from your calculations is within 10% of where it’s supposed to be, in most cases that would be considered typical hub loss. Practices should always determine hub loss amounts according to a specific container, and should be prepared to explain those calculations to the DEA with a well-documented formula for how that calculations was determined.

“So, basically, [number of] pokes [multiplied by predetermined amount],” Detweiler clarified. “[If the result is] within 10%, over or under of where you should be, you’re most likely good. If it’s not within 10%, it should be investigated for potential significant loss.”

Concluding their presentation, Weinstein and Detweiler stressed the importance of documenting waste, even if that means writing “0.” Additionally, Detweiler encouraged the audience to add side comments, because there's no such thing as over-documenting. They also recommended including the date and initials next to any corrections or cross-outs so that everyone knows who to ask if they have questions. Some additional tips for success include:

Properly account for document, and don’t predetermine, hub loss

Ensure proper documentation of any discrepancies and make sure the DEA registrant receives a copy of it as soon as possible

“So, we know that this is not a lot of fun, but it’s really, very important,” Weinstein said, wrapping up the session. “It’s very important for you and your practice, it’s important for your team, it’s important for the profession, and it’s important for the community in which you work.”

Weinstein P., Detweiler K. Oh My Log! Championing Logbook Success. Presented at: Fetch dvm360 Conference; August 23-25, 2024; Kansas City, MO.

Articles

Record-keeping for DEA-compliant controlled substances was discussed in a session at the Fetch dvm360 Conference in Kansas City

Best practices for logbooks

The focus of the 2024 Hill’s Global Symposium—a major free global educational resource for veterinary professionals—will be the gut microbiome-organ connection. This year's event, ‘Nourish the Gut, Nurture the Future,’ draws on Hill's research into microbiome health. It will offer a platform for experts in the US to discuss the significance of the gut microbiome and its role in pet health care, according to a Hill’s Pet Nutrition release.

The symposium will allow participants to gain insight and learn about practical applications to help guide clinical decision-making and overall pet wellbeing, according to Hill’s.

 The event will be livestreamed from October 24 to October 25, 2024.

"The microbiome is a trending focus in human health, and Hill's Pet Nutrition is proud to assemble leading minds to bring this emerging topic into deeper focus for the veterinary community," Karen Shenoy, DVM, US chief veterinary officer at Hill's, said in the release.

 "We're bringing this powerful content to an even broader audience this year through livestreams in both Spanish and English. I'll be hosting the English stream, and I'm excited about our plans for guest appearances from the speakers and sharing extra tidbits to make the virtual experience as engaging as it is informative."

The symposium will have more than 17 professionals, including Hill’s scientists, per the company. These specialists will discuss how the gut functions as a key organ affecting the overall health of dogs and cats. Speakers will also provide recent updates on the gut microbiome’s connection to the kidneys, brain, and skin.

The potential for the gut microbiome to help modify disease and maintain health in cats and dogs

A therapeutic approach to balancing waste products through the gut-kidney axis

The role of the microbiome in managing chronic stress in cats

"Supporting veterinary professionals is a key priority for Hill's Pet Nutrition, and the Hill's Global Symposium reflects that commitment by providing emerging, functional knowledge about the microbiome and how to make use of it in clinical practice," Jolle Kirpensteijn, DVM, global chief veterinary officer at Hill's, said in the release.

 "We are grateful to all of the speakers for dedicating their time and expertise to help veterinary professionals better understand the power of nourishing and managing the gut microbiome."

Although the gut microbiome of cats and dogs has an impact on their overall health, they are not the only animals whose health is impacted by their gut flora. A recent 

 showed that the gut microbiota of Thoroughbred foals has an effect on their health later in life. The study found that foals with less diverse fecal bacterial communities faced a much greater risk of developing respiratory issues later in life, as well as problems related to soft tissues and orthopedics.

Hill’s global symposium will explore the power of the gut microbiome-organ connection to improve pet health. News release. Hill’s Pet Nutrition. September 10, 2024. Accessed September 10, 2024. 

https://prnmedia.prnewswire.com/news-releases/hills-global-symposium-will-explore-the-power-of-the-gut-microbiome-organ-connection-to-improve-pet-health-302243665.html

Bautista-Alejandre A. Can the gut microbiota of foals impact their health later in life? 

. August 19, 2024. Accessed September 10, 2024. 

https://www.dvm360.com/view/can-the-gut-microbiota-of-foals-impact-their-health-later-in-life-

The event hosted by Hill’s Pet Nutrition will explore the connection between the gut microbiome of cat and dogs and their overall health

Global symposium on animal gut microbiome is announced

Virbac, a global animal health company, has announced a strategic alliance with the Association for Pet Obesity Prevention (APOP) in an effort to confront the growing threat of pet obesity in the United States. In their collaboration, Virbac plans to develop educational resources and tools for both veterinary practices and pet owners. The resources will look to address the root cause of pet obesity, emphasizing the importance of tailored nutrition to maintain pets’ metabolic health following the spay or neutering procedure.

“Our collaboration with APOP underscores Virbac’s commitment to positively changing the landscape on improving the health and well-being of pets through targeted interventions,” Fabrice Payot, DVM, vice president new business at Virbac, said in a news release.

 “It’s so important for veterinarians and their clients to understand the root cause of obesity, and how metabolic changes [that] occur after the pet has been spayed or neutered [can] trigger weight gain. We can help make a difference by tailoring their diet to one that is higher in protein and lower in carbohydrates. We are also passionate about educating pet owners so they can make informed decisions.”

A 2022 study conducted by the APOP concluded that 59% of dogs and 61% of cats in the United States classified as overweight or obese.

 Both dogs and cats saw slight increases from the same study conducted 4 years earlier, up from 56% and 60%, respectively.

 In contrast, a 2023 APOP survey found that just 28% of cat owners and 17% of dog owners acknowledged that their pets were overweight.

Similarly, 84% of dog owners and 70% of cat owners assessed their pets’ body condition as healthy, but less than 50% of respondents reported that their veterinarians discussed their pet’s ideal healthy weight at their annual appointments.

The contrast between pets that are overweight or obese and pet owners that acknowledge their own pet’s obesity exemplifies the lack of awareness that this partnership looks to address. The partners believe that educating pet owners early in the pet’s life will make a difference and prevent pets from becoming overweight.

“We are excited to welcome Virbac, as they will enhance our ability to address pet obesity through innovative nutrition solutions, and providing [veterinary practices] with dietary interventions, tools, and support,” Ernie Ward, DVM, CVET, founder and president of APOP, said.

 “We are incredibly excited to work with Virbac’s global network of experts and innovators to help achieve our goals.”

Citing the fact that pets are more likely to become obese following spay and neutering procedures, Virbac offers a pet food line specifically formulated to address the metabolic needs of spayed and neutered pets. The food has lower carbohydrates and higher protein and fiber levels.

 Their partnership with APOP, a company that has been raising awareness about pet obesity since 2005, is their next step in raising awareness about the importance of pet nutrition in obesity prevention.

Press Release: Virbac Partners with Association of Pet Obesity Prevention to Increase Awareness, Importance of Pet Nutrition. News release. Association for Pet Obesity Prevention. September 5, 2024. Accessed September 9, 2024. 

https://www.petobesityprevention.org/articlesandnews/press-release-virbac-partners-with-association-of-pet-obesity-prevention-to-increase-awareness-importance-of-pet-nutritionnbsp

2022 Pet Obesity U.S. Prevalence Survey. Association for Pet Obesity Prevention. 2022. Accessed September 9, 2024. 

https://www.petobesityprevention.org/2022

Ward, E. 2023 Pet Weight Management and Nutritional Survey. Association for Pet Obesity Prevention. 2023. Accessed September 9, 2024. 

https://www.petobesityprevention.org/2023

About APOP. Association for Pet Obesity and Prevention. Accessed September 9, 2024. 

https://www.petobesityprevention.org/ourmission

Virbac and the Association for Pet Obesity Prevention will raise awareness about pet nutrition  

Partnership emphasizes importance of nutrition in preventing obesity

Alfie Dukes. (Photo courtesy of Alex Dukes and Virginia Tech)

In February, Alfie, a 6-month-old Belgian cross colt arrived at the Marion duPont Scott Equine Medical Center (EMC) in Leesburg, Virginia In very poor condition, including active signs of respiratory distress. In dire need of emergency treatment, Alfie presented with an uncertain vaccination and deworming history, nasal discharge of pus and mucus, respiratory distress, fever, numerous papilloma, and elevated serum amyloid A (SAA). According to Virginia Tech, Alfie was very quiet and dull when he arrived at the facility.

Alfie was purchased by Alex Dukes of Lincoln, Virginia, at an auction in December 2023. Before being shipped to Dukes, the Belgian cross colt was held in a holding facility in Arkansas. Alfie arrived at Virginia in February, already ill.

Suspected of being infectious and contagious, Alfie was immediately placed in the EMC’s isolation facility—a biosafety level 2 building that has individual stalls, each equipped with their own ventilation and heating supplies. Emily Schaefer, VMD, DACVIM (LAIM), DACVECC, clinical assistant professor of equine emergency and critical care at Virginia-Maryland College of Veterinary Medicine’s EMC, found that Alfie had a low-grade fever, an abnormally low heart rate, and signs of lower respiratory disease.

Moreover, the Belgian cross colt had many papilloma—small, gray, irregular skin protrusions that resemble warts—on his muzzle and lower lip, which suggested a potential viral infection. Alfie also had a lymph node underneath his jaw that was swollen and somewhat firm, though it did not seem to cause any discomfort, according to a news release.

Other clinical signs Alfie was exhibiting included wheezes and “crackles” sounds coming in his lungs when breathing, and a wet, productive cough accompanied by a loud mucous rattle in his trachea.

The Belgian cross colt was diagnosed with bacterial bronchopneumonia with a suspected pulmonary abscess after chest ultrasound images confirmed these suspicions. Pneumonia with the presence of a pulmonary abscess indicates a localized bacterial infection within the lung tissue, according to the release.

Schaefer suspected that Alfie also had a respiratory virus, considering his history of extensive travel, interactions with other horses, stress, age, and unreliable vaccination records. According to Virginia Tech, Alfie was very anemic and in poor physical condition, which Schaefer believed was caused by a mix of malnutrition and the systemic wasting disease cachexia, generally present in underfed animals, which made Alfie highly susceptible to refeeding syndrome.

According to Virginia Tech, refeeding syndrome is a dangerous condition that can be life-threatening.

 It results from the rapid reintroduction of food following a period of malnutrition and is marked by severe electrolyte imbalances.

Following regular bloodwork monitoring, the EMC team discovered early evidence of refeeding syndrome on Alfie’s 6th day of treatment.

He was also diagnosed with equine influenza virus, also known as horse flu, a highly contagious respiratory disease that is spread via droplets from an infected animal’s coughs and sneezes.

 The disease, much like the seasonal flu in humans, can also be spread via infected objects. Equine influenza can spread not only in horse, but closely related animals, such as donkeys and zebras, according to the United States Centers for Disease Control and Prevention.

“Equine influenza is a common respiratory virus in young horses experiencing stressful situations, and like many other respiratory viruses, influenza can predispose horses to secondary bacterial infections,” said Schaefer, in a news release.

Alfie received close 24-hour monitoring for several days. Given Alfie’s risk of refeeding syndrome, the team at EMC had to avoid offering him unrestricted hay and grain to ensure safe weight gain, despite Alfie clearly needing calories. Alfie’s diet consisted of 1% of his estimated body weight of soaked alfalfa cubes. His response to refeeding was carefully monitored, according to the release.

The young equine was given antimicrobials for pneumonia, anti-inflammatories, and vitamin administration. He was also administered mineral oil and water through a nasal tube and began a 5-day deworming treatment thereafter. Alfie’s feed ration was raised once daily to avoid refeeding syndrome, and regular grass hay was introduced.

After switching to the care of Stasia Sullivan, DVM, MS, DACVS, DACVECC, Alfie’s diet was slowly replaced with a fully alfalfa one and a plan to supplement phosphorus was created.

The young equine was eventually released from the hospital and went to his new home in Virginia. With the guidance of a veterinarian, Dukes followed a comprehensive feeding, exercise, and medical plan. Alfie’s body condition was rated at 1/9, so it was anticipated that it would take up to 8 months for him to achieve his optimal body weight.

Six months later, Alfie is spending time in his home pastures, running happily, with a friend mule according to a release.

“Thanks to the awesome care he got he has made a miraculous recovery,” said Dukes, in a news release. “We weren't sure whether he'd make it, but now he is a happy little boy, spending his days prancing around his field with a new friend.”

“Alfie has an excellent mule companion who he adores and who is teaching him how to be a normal baby horse,” Dukes continued. “My sincerest thanks to everyone involved in Alfie's care—he wouldn't still be here today if it weren't for you all.”

Rough start in life sends 6-month-old Belgian cross colt to Virginia Tech equine hospital for emergency treatment. News release. Virginia Tech. August 28, 2024, Accessed September 9, 2024. 

https://news.vt.edu/articles/2024/08/vetmed-emc-success-story.html

About horse flu. United States Centers for Disease Control and Prevention. Accessed September 9, 2024. 

https://www.cdc.gov/flu-in-animals/about/horse-flu.html#:~:text=Equine%20influenza%20(horse%20flu)%20is,a%20low%20risk%20to%20people

A 6-month-old Belgian cross colt, diagnosed with equine influenza virus and refeeding syndrome, is months into his recovery road

Young equine makes long recovery journey after serious illness

In what could be a breakthrough in veterinary regenerative medicine, an Osaka Metropolitan University-led team of researchers have successfully generated footprint-free, high-quality feline induced pluripotent stem cells (iPSCs).

 The feline iPSCs, generated in-part from feline uterus-derived cells, could be maintained under feeder-free and chemically-defined conditions. The study, which marks the first time feline iPSCs have been successfully generated, could also have significant implications on the future of feline chronic kidney disease therapy.

“Especially in cats, chronic kidney disease and diabetes are serious problems,” Shingo Hatoya, Osaka Metropolitan University Graduate School of Veterinary Science professor, who led the study, said in a news release.

 “Establishing a method to have cells form a kidney or pancreas from feline iPSCs will be a challenge for future research. High-quality feline iPSCs made possible by this research are expected to be provided to researchers around the world for use in veterinary regenerative medicine research, understanding of the pathophysiology of genetic diseases, and development of new therapeutic agents.”

Although human iPSCs have been successfully generated in the past, research has proven the process to be much more difficult in cats. As a result, this achievement by the Osaka Metropolitan University research team marks a first in veterinary medicine. The researchers generated the feline iPSCs, derived from both embryonic and juvenile feline uterus-derived cells, using Sendai virus (SeV) vector, encoding 6 transcription factors—

 Transcription factors are proteins that bind to specific DNA sequences and control the transfer/transcription of genetic information from DNA to mRNA.

The researchers reported that these are the first high-quality iPSCs, although they exhibit properties similar to many human iPSCs. Included in these properties is the potential to form teratomas, which indicates that they can differentiate into a variety of cells. Additionally, the feline iPSCs do not have genetic footprints, which suggests a lower risk of forming tumors when implanted in cats. Though further research is required, their footprint-free nature implies there could be widespread application in veterinary regenerative medicine.

The team expressed the hope that their findings could have significant implications beyond feline medicine. With the significance of the findings, aforementioned similarities to human iPSCs, and conditions under which the feline iPSCs were maintained, the study could facilitate further research into this method’s viability both veterinary and human regenerative medicine.

Feeder-free induced pluripotent stem cells show promise for chronic kidney disease therapies in cats. News release. Osaka Metropolitan University. September 4, 2024. Accessed September 9, 2024. 

https://phys.org/news/2024-09-feeder-free-pluripotent-stem-cells.html#google_vignette

Kimura K., Tsukamoto M., Sugisaki H., et al. Generation of footprint-free, high-quality feline induced pluripotent stem cells using Sendai virus vector. 

https://doi.org/10.1016/j.reth.2024.08.012

Transcription factor. Phys.org. Accessed September 9, 2024. 

https://phys.org/tags/transcription+factors/

Team from Osaka Metropolitan University make breakthrough in feline induced pluripotent stem cell research

New study shows promise for chronic kidney disease therapies in cats

Weinstein and Detweiler shares common myths about DEA regulations, and correct them

Interview with Kelley Detweiler and Dr Peter Weinstein

During their lecture, Top 10 Veterinary DEA Violations, at the 2024 Fetch Kansas City conference in Kansas City, Missouri, Kelley Detweiler and Peter Weinstein, DVM, MBA, shared with the audience some common mistakes veterinary professionals make when it comes to DEA regulations. Throughout the lecture, the duo took turns sharing what the misconceptions are and what exactly the DEA protocol is for each. 

In an exclusive interview with dvm360 following their lecture, Detweiler and Weinstein shared the multiple fallacies involving DEA regulations within veterinary practice that they mentioned in their lecture to help give professionals a better understanding of what they are doing right with DEA regulations, and what they potentially could be doing wrong. 

: Peter, I am doing relief work, and, you know, I have a DEA registration in Missouri, where we're at, but I'm going over to Kansas, and it's fine if I can use a prescription pad at that facility, right?

 If you're going from Kansas to Missouri, which could be a matter of feet, and you're going to be practicing veterinary medicine there, and you do not have a DEA license in Missouri, no, you cannot. And if you do not have a DEA license at all, you cannot use somebody else's prescription pad. No DEA license—the only thing you can do is administer medications from another doctor's inventory at a hospital you are working. You cannot dispense, you cannot prescribe, and you cannot order.

r: Okay, so this is very annoying, all this record keeping stuff. So let me ask you a question. Our hospital is purchased by a consolidator, and we do an annual inventory; it is so pristine, it's very copious. Can't that substitute in for my DEA biennial inventory?

: Your annual inventory cannot substitute in for your DEA biennial inventory. But if you can do a DEA biennial inventory, you can use that one each time, because essentially, you're keeping things up to date. You have to use the DEA biennial inventory form upon which to keep track of your DEA biennial inventory. I love the fact that you're doing an annual inventory for your company, but it doesn't necessarily meet the requirements that the DEA would have.

Videos

Kelly Detweiler and Peter Weinstein, DVM, MBA, debunk common misconceptions and myths for veterinary professionals