Trends in the number of patients linked to potential vet-shopping behavior in the United States (2014-2019)

OBJECTIVE To estimate the number of patients linked to vet-shopping behavior (the solicitation of controlled substance prescriptions from multiple veterinarians for misuse) in the United States using 2014–2019 data and characterize mandates for veterinarians to examine prescription drug monitoring programs (PDMPs) before prescribing controlled substances as of April 2021. SAMPLE National database reporting prescription dispensing from 92% of US pharmacies from 2014 through 2019. PROCEDURES The annual number of patients with dispensed prescriptions for opioid analgesics, opioid cough-and-cold medications, or benzodiazepines from ≥ 4 veterinarians was calculated. State veterinary medical associations were contacted for information on veterinarian PDMP use mandates. RESULTS From 2014 through 2019, the number of patients with prescriptions for any class of controlled substances from ≥ 4 veterinarians tripled from 935 to 2,875 (+207.5%). The number of patients with opioid cough-and-cold medication prescriptions from ≥ 4 veterinarians rose from 150 to 1,348 (+798.9%). The corresponding number for benzodiazepines rose from 185 to 440 (+137.8%). The corresponding number for opioid analgesics peaked at 868 in 2016 before decreasing to 733 in 2019. In April 2021, 10 states mandated veterinarians to examine PDMP records of owners or animals before prescribing controlled substances; 3 mandates excluded benzodiazepines. CLINICAL RELEVANCE Vet shopping in the US may be increasingly common. Mandates for veterinarians to examine PDMPs before prescribing controlled substances might facilitate detection of this behavior. However, benefits of mandates should be weighed against their potential burden on veterinarians.

Between Prohibitionism and Religious Freedom: The Legal Disputes Concerning an Ayahuasca Church and the United States Government

This article focuses on the legal disputes between the U.S. government and the Centro Espírita Beneficente União do Vegetal (UDV), as well as on the regulation of the religious use of ayahuasca by the Drug Enforcement Agency (DEA). Our aim is to present the main issues that were at stake throughout the dispute, especially the relationship between the limits of religious freedom when associated with the use of controlled substances.

Crack 2.0

The 1984 Sentencing Reform Act charged the U.S. Sentencing Commission with developing sentencing guidelines that advanced the purposes of sentencing under 18 U.S.C. § 3553(a). After the Supreme Court cases Booker, Kimbrough, Gall, and Spears, it is now well established—at least with federal drug trafficking offenses—that the Commission did not fulfill that directive. The magnitude of that failure (coupled with some of Congress’s own misguided decisions) has previously been highlighted by the evolution of federal crack sentencing policies, the Fair Sentencing Act, the related line of Supreme Court cases, and more recently the First Step Act. Congress’s compromise correction of over twenty years (essentially a generation) of a failed war on crack did nothing to further correct similar defects with federal drug sentencing policies for other controlled substances—particularly with respect to methamphetamine. Given the resurgence of methamphetamine trafficking, use, and prosecutions, this paper will analyze post-1988 federal methamphetamine sentencing policy to illustrate how the drug-type, quantity, and purity model for punishing drug trafficking offenses still produces unwarranted sentencing disparities between similar controlled substances or different forms of the same controlled substances—and in the end plainly fails to effectively deter the targeted criminal conduct or advance the purposes of federal sentencing under 18 U.S.C. § 3553(a).

The role of profiling of drugs, psychotropic substances and precursors in combating their illegal trafficking

Recently, there is a negative trend in the world – increasing number of synthetic drugs, psychotropic substances and precursors in the illicit trafficking of these substances. Specially equipped underground laboratories for their drug production are being set up to meet the demand for synthetic drugs. Synthetic drugs and psychotropic substances produced in underground laboratories can be synthesized in various ways. Various precursors and reagents are used for their synthesis, which leads to the appearance of impurities in the final product. Impurities help to determine the ways of synthesis of the illegal substance, the origin of the precursors, provide information about the location of production. Due to the presence of impurities, the connections between the removed substances are revealed. Specific impurities are used to determine the route of production, which, combined with other forms of investigation, will help to link different batches of a prohibited substance to the specific person who manufactured them. Impurities associated with the synthesis of substances seized in illegal laboratories are so-called marker compounds. They are a kind of marks that guide the expert chemist on the specific method used by criminals to obtain the substance. Marker compounds are of the greatest importance for the accurate establishment of the synthesis method. Marker compounds are determined by impurity profiling of samples of the prohibited substance. The main purpose of the profiling of impurities is to assist law enforcement agencies in combating the illicit manufacture and circulation of controlled substances. The results of research and information on the circumstances of the confiscation should be recorded in the relevant created electronic databases. In the profile database, two samples of a substance with a similar chemical profile can be linked together from the manufacturing stage to the distribution stage. Data on impurity profiles and fillers can be used to estimate the batch size, time and area of drug distribution. Databases are needed for use by law enforcement agencies in operational and investigative work. Databases are needed for the timely detection and liquidation of underground drug laboratories. The above aspects emphasize the importance of cooperation between investigative, operational services and forensic agencies in the process of effective detection and cessation of crimes related to the distribution of controlled substances.

Revealing Unknown Controlled Substances and New Psychoactive Substances Using High-Resolution LC–MS-MS Machine Learning Models and the Hybrid Similarity Search Algorithm

High-resolution liquid chromatography (LC)–tandem mass spectrometry (MS-MS)-based machine learning models are constructed to address the analytical challenge of identifying unknown controlled substances and new psychoactive substances (NPSs). Using a training set composed of 770 LC–MS-MS barcode spectra (with binary entries 0 or 1) obtained generally by high-resolution mass spectrometers, three classification machine learning models were generated and evaluated. The three models are artificial neural network (ANN), support vector machine (SVM) and k-nearest neighbor (k-NN) models. In these models, controlled substances and NPSs were classified into 13 subgroups (benzylpiperazine, opiate, benzodiazepine, amphetamine, cocaine, methcathinone, classical cannabinoid, fentanyl, 2C series, indazole carbonyl compound, indole carbonyl compound, phencyclidine and others). Using 193 LC–MS-MS barcode spectra as an external test set, accuracy of the ANN, SVM and k-NN models were evaluated as 72.5%, 90.0% and 94.3%, respectively. Also, the hybrid similarity search (HSS) algorithm was evaluated to examine whether this algorithm can successfully identify unknown controlled substances and NPSs whose data are unavailable in the database. When only 24 representative LC–MS-MS spectra of controlled substances and NPSs were selectively included in the database, it was found that HSS can successfully identify compounds with high reliability. The machine learning models and HSS algorithms are incorporated into our home-coded artificial intelligence screener for narcotic drugs and psychotropic substances standalone software that is equipped with a graphic user interface. The use of this software allows unknown controlled substances and NPSs to be identified in a convenient manner.

Pharmacists Without Access to the EHR: Practicing with One Hand Tied Behind Our Backs

Pharmacists are the most accessible healthcare professionals to the public, yet have the least amount of information from the electronic health record available to them. This lack of information makes ensuring that patients are receiving proper medications and monitoring for efficacy and safety a challenge, if not impossible in some situations. Having access to a national electronic health record would provide pharmacists with this needed information to truly engage with prescribers as fellow clinical experts in the field. Sharing prescription information for non-controlled substances would also decrease the likelihood of a patient receiving duplicative therapy from two prescribers or pharmacies that may not know what the other is doing. There are already examples of successful national data sharing including the Prescription drug Monitoring Program for controlled substances as well as the Veterans Affairs healthcare system. Therefore, our profession needs to push for nationwide access to patient electronic health records, which includes all healthcare providers. This will facilitate the inclusion of pharmacists in the optimization of the care of patients who need our expertise in managing their medication regimens as well as build better relationships with prescribing providers.

The Adoption and Increased Use of Electronic Prescribing of Controlled Substances

ABSTRACT The electronic prescribing of controlled substances (EPCS) is now becoming implemented in most health care practices and pharmacies in the United States. This review aims to detail the steps needed for EPCS adoption and synthesize the most current literature on the benefits and challenges associated with its adoption. Our systematic review of seven published studies from 1990 to 2020 notes the benefits of EPCS in the reduction of errors, fraud, overprescribing, cost and efficiency improvements. There is limited published evidence of challenges, such as the cost of implementation and prescriber burden. With EPCS becoming a nationwide process, further research needs to be conducted to maximize the effectiveness of EPCS and explore additional benefits and challenges. We used a modified version of the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system for systematic reviews highlighted in the “Cochrane Handbook for Systematic Reviews of Interventions” to assess the quality of the primary studies reviewed.1 Each author was tasked with determining the quality of each primary study reviewed and assigning a quality score of either high, moderate or low quality. Evidence stemming from randomized controlled trials starts as high quality while evidence from observational studies starts as low quality. Quality can be lowered by five factors: risk of bias, imprecision, inconsistency, indirectness, and publication bias and can be raised by a large magnitude of effect and a clear dose-response gradient. We extracted data from the text, tables and graphs of the original publications. Appendix A illustrates the quality of the studies. Databases reviewed included PubMed, Google Scholar, Cochrane and SCOPUS. The search was started in 1990, with the first wave of the opioid epidemic and the first published studies of e-prescribing, and continued to the year of 2020. The key phrases “electronic prescribing of controlled substances,” “e-prescribing of controlled substances,” “fraudulent prescribing of controlled substances,” “EPCS with PDMP,” and “drug interactions with e-prescribing of controlled drugs” were used as an inclusion criterion to search online scholarly databases for articles. Only primary and secondary data from reports, reviews and research studies written in English were included. The Centers for Disease Control (CDC), National Institute on Drug Abuse (NIDA), Drug Enforcement Administration (DEA), Substance Abuse and Mental Health Services Administration (SAMHSA), American Academy of Family Medicine (AAFP), and nationally represented health information networks were used to obtain updated statistics regarding EPCS.