The new trend in veterinary medicine

Big Pharma is tapping a market filled with patients who cannot talk back

I am a unicorn in the veterinary profession at this point. I am a solo practitioner, making house calls. Yes, I read the James Herriot series “All Creatures Great and Small” in elementary school and decided that was what I wanted to do when I grew up. I am doing it, except, instead of the countryside in Yorkshire, I am doing it in south Florida, a wild and woolly melting pot of international cultures. I only see small animals, no calf pulling in the middle of the night, and I use acupuncture and herbal medicine as my top two treatment modalities.

I will admit it is a small practice, but over 22 years I have built up a wonderful, dedicated clientele who trust me with their beloved pets and refer friends and family. I will often go several months to a year with a stable caseload, my schedule filled up. Then, as patients improve, or make their way across the Threshold to the Otherworld, there comes a time when I need to fill in the open spots. This past month has been one of those times.

During the pandemic, I was hesitant to add new clients, so I was a bit overdue. I was effectively out of the loop of conventional veterinary medicine for the past couple of years. Leading up to the lockdown, I did have two cases that alerted me to a troubling new trend. Two of my geriatric patients, both small breed dogs, one 16 years of age, the other nearing 17, were taken to emergency clinics, one for constipation, the other for a first-time seizure. Both received methadone at the emergency clinics, and both dogs died from what appeared to be classic opioid overdoses according to the medical records: respiratory depression, apnea then cardiac depression followed by asystole.

What struck me was the use of methadone, a drug utilized, nearly exclusively, for the government-funded heroin rehabilitation program. It is a potent opioid, long-acting, lasting 24 hours, and more addictive than heroin. In human medicine, on “Opiate Equianalgesic Dosing Charts”, there are cautionary notes about using methadone:

“4 Caution: Methadone is appropriate for chronic stable pain in an opioid-tolerant patient, but is usually avoided in opiate-naïve patients. Convert & titrate slowly (over 3-6 days) due to long biphasic half-life; beware of cumulative effects in first 3-10 days.”

UNC Health Care Guideline Opiate Equianalgesic Dosing Chart University of North Carolina Hospitals & Therapeutics Committee

Several questions came to my mind:

1. Why is methadone being used in the first place? Who is recommending it to ER veterinarians and why?

2. Why is it being used in older, frail patients with potentially compromised respiratory, cardiovascular, renal, and/or hepatic systems?

3. Why is a constipated dog administered opioids, which are known to cause constipation?

4. Are the staff and doctors trained to monitor patients who are given high-potency opioids like methadone?

5. Do the clinics have the reversal agent, Naloxone, on hand, and do they know how to use it effectively to prevent overdoses?

6. And finally, are these high-potency opioids, which can lead to respiratory depression and death, really necessary in the first place in many of these patients?

I was so disturbed by the second case, I called the owner of the clinic to discuss the issue with her. It took some persistence on my part to reach her, and I was initially met with resistance and defensiveness. I eventually managed to talk with her and communicate my valid concerns.

---

Fast forward to 2022 when I began accepting new patients into my practice. Interestingly, out of the seven new cases I have recently taken on, five of them were prescribed or administered some version of what I am calling “the new drug regimen”.

What is the “new drug regimen”?

The drugs involved have all been around for quite some time in human medicine, but they have only recently found their way to veterinary medicine. In the human world, many of them are now being flagged for side effects, either in law-suit settlements or black box warnings by the FDA. Human patients are speaking out about addictive potential of the meds and adverse mental health effects.

Books are being written about them, movies made, and podcasts abound about the difficulties humans are having while on many of these medications and the difficult withdrawal symptoms when attempting to stop taking them.

What is interesting is the correlation between problems on the human side and the introduction of these same medications to veterinary medicine. My favorite example is the drug gabapentin. The same year gabapentin was involved in a $46 billion settlement was the year it first appeared in a veterinary journal editorial suggesting it may be good for neuropathic pain and had minimal to no side effects. It is now one of the most prescribed drugs in veterinary medicine.

*the lawsuit involved the false marketing claim that gabapentin was labeled for neuropathic pain.

I discovered all of this information from the human medicine world when I went to research the medications that my new patients were being prescribed. I could find very little information about these medications in the veterinary medical literature, because there are very few studies that have been done.

In fact for some of them, i.e. gabapentin and trazodone, when searched for on the internet, the same information, nearly word for word, is cut and pasted from article to article. Granted, these articles are meant to inform pet parents. But what is informing veterinarians writing the prescriptions?

When searching deeper into the scientific literature, very few, if any, safety or efficacy studies have been performed when it comes to using them in dogs and cats. The ones I did uncover, use ambiguous language, ultimately suggesting that more studies need to be performed.

The reason I am calling it “drug regimens” is that patients are usually prescribed not one drug, but multiple medications. The idea is to “stack” the medications so, for example, a medication is given to block every section of the pain pathway, from local receptors, to pain fibers, to central nervous system receptors. One patient may be taking an antiinflammatory, eg Rimadyl, an opioid, eg buprenorphine, methadone, an SSRI anti-depressant, eg trazodone, and gabapentin, for a total of 4 different medications, all at the same time.

There are two main categories where I am seeing these meds used:

1. Anti-anxiety protocols: gabapentin, Trazadone, Prozac, other SSRIs, benzodiazapenes, eg Valium, Xanax, Klonopin, among others.

2. Pain protocols: opioids including tramadol, methadone, buprenorphine, hydromorphone combined with gabapentin, amantadine, Trazadone, and others, e.g. good old NSAIDS and steroids.

The majority of cases I am seeing are not on one, or even two of these medications. They are often prescribed up to 3, 4, or 5, stacked on top of one another. It is as if no one is considering the synergistic effect of using these drugs together, or rather, a positive spin has been placed upon the synergistic effect, claiming greater efficacy is achieved by using multiple drugs while ignoring safety concerns.

What is not being considered is the fact that combining multiple CNS depressants can be extremely dangerous, leading to respiratory and cardiac depression, quickly leading to death. This is what is called a drug overdose and why people are warned against combining these medications.

When I looked up the medications in the human PDR I was met with black box suicidal ideation warnings, and extensive warnings about combining these different CNS depressants together. Prescribing more than one SSRI antidepressant can lead to something called serotonin syndrome, which can potentially lead to coma and death. And yet dogs are being prescribed long-acting SSRIs like Prozac with the short-acting SSRIs Trazadone and the pain drug Tramadol which can contribute to serotonin syndrome.

Where are these same warnings in the veterinary drug handbook?

A few can be found but to a much more limited extent, partially because the research has not been done on dogs and cats, and because dogs and cats cannot communicate their internal experience.

Are these drugs even necessary in the average case?

I have practiced for over 25 years, and before that worked in animal shelters for 8 years with highly aggressive dogs undergoing sedation and anesthesia. We never resorted to using these strong, powerful, potentially deadly medications. We used pre-anesthetic mixtures to sedate animals that were very effective without having to have Narcan on hand to prevent an overdose.

I have always been mindful regarding pain relief but have rarely reached for pure mu opioid agonists, except in extreme cases, i.e severe trauma, bone fractures, and orthopedic and neurologic surgeries, not extending for more than a few days at most.

So what has changed to necessitate the use of these types of pharmaceutical agents?

Are these medications, i.e. trazodone, being used and prescribed by shelters and rescue organizations?

If they are, are they under veterinary medical supervision? Are dog trainers recommending the meds without valid medical knowledge or supervision? (I am speaking of trazodone in particular).

What effects do these medications have on the brain development of young dogs?

This is a complete unknown, and may never be established. We do know these medications affect juvenile humans in more drastic ways than adults.

What is the end goal?

We also have to ask ourselves, as veterinarians and as caretakers of these other species, what is the end goal if the patient requires multiple medications to be comfortable? Will the patient eventually recover from the disease process or are we simply providing palliative care and to what end?

Animals cannot complain to their doctors about how the meds are making them feel. They just take the piece of cheese with the pill inside of it and swallow it to get the tasty treat.

What about the internal experience, mental and emotional, of our patients?

Our patients cannot talk and complain about side effects. They do not have the opportunity or the capability to give consent when it comes to taking pills and receiving injections. Furthermore, they do not have the ability to communicate any discomfort or troubling mental or emotional side effects they may be feeling internally from the meds.

I always ask myself, how would I feel with this treatment, on these medications?

If I were a dog, would I want to lay around drugged up all day long?

Do dogs and cats experience withdrawal symptoms? addiction?

Just some things to think about, and for which we may never have the answers.

Here are 2 recent case examples I shared on social media recently:

CASE 1: a 1.5-year-old Male neutered Labrador retriever mix, 50 lbs

Adopted by my client. The trainer/rescue group sent the dog to its new home with two zip-lock bags filled with about 50 pills each. Written on the ziplock in Sharpie: Trazadone 100 mg. Give two tablets at night to sleep. The dog was also taking Prozac daily.

The dog was exhibiting very strange behaviors: highly reactive to shadows in the window, and loud noises would randomly startle him, as though his sensory perceptions were heightened. He would readily follow commands and then randomly space out, his attention wandering off as if no one was speaking to him, with a spaced-out look in his eyes.

I suggested weaning him off the meds. The owner decided to just stop them altogether, on her own, after she began working with a dog trainer and became more confident handling him.

She consulted with her son who is a human neuropsychiatrist and has experience using the drug in humans. He reported that at low doses Trazadone has sedative effects but unusual mental side effects are observed at high doses, especially in juveniles. He felt the 200 mg at night to sleep was an excessive dose. There was also a concern about combining two SSRIs together.

Dosing can vary from species to species but because there are no safety or efficacy studies of these drugs in canines, we have no data to look at. We do not know the withdrawal or clearance times of the drug. We do not know what kind of effect they may have on a given dog.

Ninety-six hours post discontinuation of both Prozac and Trazadone, the dog was listening, attentive, and very responsive to training. She is providing multiple enrichment activities, long walks twice a day, a backyard to run in, and a wading pool to swim in. My client plans on training him to be a performance frisbee dog. No drugs.

CASE 2: 3-year-old Dachshund, male, intact, acute intervertebral disk herniation.

Acute onset of severe back pain, normal motility. The general practitioner saw the patient in the morning and administered methadone for pain. In the afternoon, the neurologist examined the dog, suspected disk herniation, and recommended an MRI followed by surgical decompression. The owner preferred conservative management. The patient was prescribed prednisone, tramadol, and gabapentin, administered that day, while the methadone was still in effect. The dog became weak, wobbly, and unable to walk in hind-end by the time he left the neurologist.

Here is the patient on the client’s couch after coming home from the neurologist:

For three days he was experiencing what looked like a reflex reaction to low oxygen or apnea. As soon as his head would relax and lay down to sleep, he would slowly bring his head back up and open his eyes. He did not sleep for 3 days. It took 10 days to fully recover normal mentation after discontinuing the gabapentin and tramadol.

He continued to receive tapering doses of prednisone as an antiinflammatory to take pressure off the spinal cord, electroacupuncture, natural muscle relaxants, Chinese herbs, and CBD, for pain and repair.

He is currently standing on his own and on his way to walking again.

FINAL THOUGHTS:

Why has the use of these potent medications suddenly become necessary in the practice of veterinary medicine?

Who is creating and recommending these treatment protocols to veterinarians?

I attempted to find out the answer to these questions. I believe a part of the answer lies within the corporate buyout of veterinary medicine and the larger role that big business and big pharma have to play within the profession. They are remodeling veterinary medicine to look like the broken and corrupt human medical industry, insurance companies included.

I discovered a nonprofit veterinary association focused on pain relief, The International Veterinary Academy of Pain Management. They are behind the pain management tracks of many continuing education conferences. Upon reading the biographies of the Board of Directors, I discovered the President is working on several projects with the FDA, and the Executive Director is employed by Pfizer.

It is becoming more imperative than ever for pet parents to take a more active role in the medical advocacy of their pets, just as it has in human medicine. Search out second opinions. Educate yourself on the side effects and alternative medications and treatments. Ask questions and if you do not receive answers, seek care elsewhere.

My intention for calling attention to this issue is to open the discussion between veterinarians, pet parents, dog trainers, rescue organizations and everyone else involved in the animal care field.

We all need to do the best that we can for the animals under our care.

Thank you, Dr. Josie Beug

**Check out my following post One more market to sell drugs and devices following this. It is an interview I am sharing with a prior pharmaceutical sales rep explaining the ins and outs of the industry. It helps explain what is going on in veterinary medicine.