The significance of veterinary-client-patient relationships (VCPR) is being elevated to a new level as Canadian veterinarians strive to fulfill their obligations for oversight of medically important antimicrobials in the global battle to check the spread of resistant bacteria.
By the end of this year, veterinarians must have records on file to validate VCPRs before prescribing antibiotics. Purchasing supplies from a vet clinic or taking the odd cow or calf in for treatment doesn’t necessarily constitute a valid VCPR.
According to the Canadian Veterinary Medical Association (CVMA) a legitimate VCPR must be backed up by evidence of relevant and timely interactions with clients and their animals such as farm visits, clinic appointments, consultations, individual animal or herd examinations, lab reports or production record reviews, sufficient to show the veterinarian has taken the steps necessary to establish medical need to prescribe and dispense pharmaceuticals.
He or she should also be available for followup consultations, especially in cases involving adverse reactions or apparent treatment failures.
Veterinary medicine is a provincially/territorially regulated profession, so the exact definition of VCPRs varies from one jurisdiction to another.
In the interest of helping Canada meet its obligations to preserve the efficacy of antimicrobials in veterinary and human medicine, the CVMA has spent the past two years developing a common framework that provincial/territorial veterinary associations can use to develop their own standards in this area.
Of course, it also has had to coincide with the federal government’s Antimicrobial Resistance and Use in Canada: A Federal Framework for Action, released in October 2014, and the Public Health Agency of Canada’s action plan in March 2015.
Veterinary oversight of medically important antimicrobials given to animals in feed or water has been a requirement since December 2016.
Similarly, any new medically important antimicrobial approved by Health Canada for use in animals has only been available with a veterinary prescription since 2004.
As of the end of this year, the requirement for a vet script is being extended to over-the-counter antimicrobials as well. This mirrors changes in the U.S. and the CVMA considers it to be an important additional responsibility for veterinarians to demonstrate improved antimicrobial stewardship.
Stewardship in practice starts with deciding whether prescribing an antibiotic is the best course of treatment and if so, selecting the most appropriate drug, dose, duration and route of administration to optimize treatment while minimizing the risk of resistance. It’s also incumbent upon veterinarians to consider alternatives, such as vaccination, management or facility changes as well as other types of products.
Dr. Troy Bourque, the CVMA’s immediate past president and a practicing veterinarian in Alberta, says provincial veterinary associations are at various stages as far as implementing oversight of over-the-counter drugs as are the governments in terms of legislating the change.
Alberta veterinarians, for example, have been overseeing non-prescription antibiotics for the past 10 years, when the CVMA developed its prudent-use guidelines for beef cattle, dairy cattle, poultry and swine. Any antibiotic sold from a veterinary establishment in Alberta already requires a prescription and valid VCPR in order for a veterinarian to prescribe any antibiotic.
Dr. Steve Hendrick with the Coaldale Veterinary Clinic at Lethbridge explains that provincial veterinary associations are responsible for ensuring their members meet professional standards, including those for VCPRs and oversight of antimicrobial use.
Whether or not a veterinarian is willing to establish a VCPR with you depends on his or her knowledge of the species and license category.
Since the Coaldale clinic is licenced by the Alberta Veterinary Medical Association as a food-animal practice and the clinic’s veterinarians chose to focus exclusively on cattle, they would not be able to form a VCPR with you to care for horses or dogs, for example.
A provincial association may specify exemptions to the VCPR requirement. The College of Veterinarians of Ontario, for instance, allows veterinarians to treat animals in emergency situations without having a VCPR with the owner.
Hendrick says VCPRs with feedlot clients are well defined by virtue of their regular visits and formal reports. Although written health protocols don’t constitute a VCPR in and of themselves, they are part of the record and use of certain drugs for treating common diseases may be a step in a protocol.
VCPRs with cow-calf clients are formed by making notes after every contact with producers whether by phone, at the clinic or during farm visits, most commonly for preg checking and semen testing nowadays, Hendrick explains. Those visits give him an opportunity to discuss herd health issues, vaccination programs and management practices, as well as to acknowledge common diseases and strategies for handling them as situations arise between times.
Veterinarians are also responsible for working with clients to tailor disease prevention plans for their operations. A plan could include giving medication as a supplement in the feed or water as a preventative measure to ward off disease. He provides the required veterinary oversight by working with the client’s nutritionist to review the concentration of any antimicrobial called for in the ration before issuing a corresponding prescription.
“VCPRs and veterinary oversight are about safeguarding antibiotics. If a veterinarian has never been to your farm or seen the animal you won’t be able to just walk in and get a prescription,” he adds.
The hot-button topic at the moment is whether having oversight of antimicrobial use with the legal authority to write prescriptions and dispense pharmaceuticals will make veterinarians the exclusive sellers of antibiotics.
This could become a barrier to access for those who rely on feed mills for supplements or local retail outlets that have historically had the authority to sell the older over-the-counter antibiotics and pre-mixed medicated supplements, such as milk replacer and chick starter.
One of the framework’s suggested standards is that a registered veterinarian, having determined the need and written a prescription, must give a copy to the client if the client wants to purchase the medication from a legitimate source other than the prescribing veterinarian. However, the prescribing veterinarian is responsible to meet all oversight requirements, regardless of where the client gets the prescription filled.
According to the framework, dispensing a prescription is a unique activity with a full set of responsibilities under provincial/territorial authority and may only be performed by a registered veterinarian or a registered pharmacist in accordance with provincial/territorial legislation.
This could mean that retail outlets would need to establish a pharmacy with a qualified veterinarian or pharmacist on staff to fill prescriptions for antibiotics in any form. Pharmacies in the true sense of the word fall under Health Canada’s jurisdiction with another set of rules.
Bourque acknowledges that the oversight of dispensing antimicrobials is a concern for veterinarians across the country, and says provincial/territorial governments, not veterinary associations or the federal government, need to look at who can fill prescriptions for antibiotics and how oversight of dispensing is done.
“This is where there is uncertainty. Dispensing is an activity that must have oversight because of the risk to public health when antibiotics are used in food animals. Dispensing from a veterinary clinic has oversight by the province’s veterinary association act and regulations. The profession does not care who sells the antibiotics. We care a great deal about who fills prescriptions,” he explains.
Hendrick’s hope is for a balance between safeguarding antimicrobials to minimize antimicrobial resistance and misuse of drugs, but at the same time, not making it so onerous that the welfare of animals is compromised because they don’t get appropriate and timely treatment.
The framework is available on the CVMA’s website.