I’ve written before about how confusing controlled substance ordering and handling can be. It takes a village to sort through all the rules and regs to play the game correctly and keep the overseers satisfied. In the United States (US), veterinarians can be licensed to obtain controlled substances (drugs) through the Drug Enforcement Agency (DEA). Drugs are classified by their human abuse potential, from class 1 (high abuse risk) to class 5 (low abuse risk). Only licensed veterinarians holding a DEA registration may work with controlled drugs. We do our best and when we know better, we do better. The goal of understanding these controlled drugs is to minimize the damage if you get something wrong. I strive to be perfect but it’s scary. I imagine I’m not alone in feeling this way.
The Companion Animal Euthanasia Training Academy (CAETA) has spent many an hour researching best practices for controlled substance use, avoidance of abuse, and good stewardship in this arena. Euthanasia solutions in mainstream small animal veterinary medicine are controlled. They include pentobarbital and pentobarbital-combination products. CAETA advocates for the use of pre-euthanasia sedatives and anesthetics too, many of which are controlled drugs (e.g. ketamine, butorphanol, midazolam). Controlled drugs are necessary in euthanasia work in one way or another. Methods either require a controlled drug to facilitate death, or methods require them to induce a deep state of sleep for the euthanasia technique to be safely carried out (e.g. unconsciousness required before potassium chloride injection).
I’m happy to share some of the controlled substance advice that CAETA has accumulated over the years. Much of this and more can be found in our 2-hour series on Controlled Substances, provided by Jan Woods with AskJanForHelp.com.
~ Weighing drugs: Practitioners may record liquid drugs either by volume used or by both volume and weight used. Recording the weight by grams (usually) is extremely helpful and increases the likelihood of accurate record keeping. When I started recording the weight, I found any discrepancies cleared right up in the log books. Each time the vial is drawn from, the weight can be recorded next to the volume used. It’s a gamechanger and drug monitoring agencies appreciate the due diligence.
~ Black bagging: In the US, controlled substances owned by one veterinarian should not cross into the space of another DEA registered location where drugs are held. An example will help illustrate what this means. Vet A registers his drugs at his home office and carries a collection of controlled euthanasia drugs in his mobile doctor bag. He enters into a veterinary hospital with his mobile bag of drugs where Vet B works and has her drugs registered with the DEA. Her euthanasia solutions are in the hospital drug safe. Vet A has just brought his registered drugs into another registered location. This is black bagging and should be avoided.
~ CSOS: The Controlled Substances Ordering System (CSOS) offers electronic ordering for class 2 (C-II) controlled substances in the US, that would otherwise require the use of a DEA-222 form. These are drugs like pure pentobarbital sodium (e.g. Fatal Plus). The electronic system requires pre-enrollment which takes a bit of time to complete, but once ready it is much easier and efficient to use than paper forms.
~ Decreasing controlled drug use: CAETA advocates for the selection of non-controlled substances for euthanasia whenever practical. For pre-euthanasia sedation purposes, these include phenothiazines, alpha-2 agonists, and the partial opioid agonist nalbuphine (all non-controlled as of March 2022). When reaching for the controlled drugs, we strive to achieve our pharmaceutical thresholds with the least amount possible. This being said, on many occasions I have reached for more drug to greater effect for my patient. Smooth induction into sleep and death is vital, meaning sometimes we reach for more than normal dosing suggests. And while Fatal Plus euthanasia solution is a C-II drug with more governmental oversight, its efficacy, diversity of technique choices, and low viscosity make it CAETA’s preferred euthanasia solution.