How many different medications can you put on one prescription?

This would count as a veterinary prescription, even where the human-licenced medicine is not itself prescription-only.

Human-licensed medication could be prescribed under step (c)(i) (in Great Britain) or (b)(i) (in Northern Ireland) of the prescribing cascade, however, the justification in this case would also need to account for why a veterinary medicine (authorised for that species and condition, or for another species or condition) could not be used.

There is specific information regarding prescribing human-licensed paracetamol on the RCVS website.

Additionally, the VMD has provided guidance on the use of medicines commonly found around the home:

In exceptional emergency circumstances, you may judge there is a need to alleviate a pet’s discomfort until a home visit can be made or the animal brought to the surgery. You could recommend that an animal owner use a human medicine that they already have in their possession, such as antihistamine tablets. This does not mean a pet owner should be encouraged to go into a pharmacy and ask for a human medicine for their pet.

POM-Vs

This part of the guidance is currently under review. Please follow advice from the VMD on this issue until the review is complete. If you require any further information, please contact the Advice Team.

Prescription validity refers to the time in which the medicine must be dispensed, otherwise the prescription will no longer be valid.

A written prescription for a POM-V that is not a controlled drug is valid for 6 months (unless a shorter period is stated).

Where a written prescription includes a repeat, as long as the first dispense takes place during the validity period, the rest of the prescription may be dispensed outside of the validity period.

Controlled drugs

A written prescription for a schedule 2 or 3 controlled drug has a validity of 28 days (unless a shorter period is stated) and is not repeatable.

Where more than 30 days’ worth of CDs are prescribed and the client requests a prescription to be fulfilled elsewhere, unless there are exceptional circumstances that mean this is not appropriate, you should issue the client with an instalment prescription to be dispensed by a supplier of their choice in order to reduce the risk of misuse.

You should bear in mind that instalment prescriptions are not commonly used in this way in human medicine and, as such, pharmacists used to dealing with prescriptions from doctors may approach these with caution.

Please remember that instalment prescriptions are instructions to supply and must be followed to the letter. You should therefore ensure the client is fully aware of what you have stated. If you have said that a specific amount must be supplied on a specific date, then that’s what the dispenser must follow. When an instalment prescription is used, the client isn’t able to get it filled a day earlier or later for convenience, so you should consider this lack of flexibility before issuing one.

In line with RCVS guidance, veterinary surgeons may make reasonable charges for written prescriptions, but must not discriminate between those who are supplied with a prescription and those who are not, in relation to fees charged for other goods or services.

Out-of-date stock

Destruction - The legal requirements to witness the destruction of Schedule 2 CDs apply to stock. This refers to CDs that have not been issued or dispensed to a patient.

However, any leftover medicines, for example liquids, which are still required for use, are considered as stock. A witness is required if these are to be destroyed on expiry or for other reasons.

The following are examples of out-of-date stock:

• The remains of bottles of Ketamine, Methadone, or Fentanyl 28 days after broaching.
• Any other Schedule 2 CDs that have passed their expiry date.

There are commercially available denaturing kits, and these can be used to destroy out-of-date stock CDs and returned CDs. Veterinary surgeons should follow the instructions for use and disposal specific to the kit, as these may differ depending on the kit used.

Recording - The VMD advise that a record must be made of the date of destruction and the quantity destroyed, which the witness must sign. The witness, if an independent veterinary surgeon, should record their RCVS number and confirm their independence in writing in the CD register. The VMD also say that the following information should be recorded: name of the CD, form, strength and quantity, and the signature of the professional destroying the drug.

Expired stock should not be marked out of the running balance in the CDR until it is destroyed.

Returned drugs

Destruction – Any CDs returned to the practice by clients should not be re-used and should be destroyed as soon as possible. The VMD advises that the CD must be clearly labelled as a return and stored in the CD cabinet – but separated from practice stock CDs to avoid potential dispensing errors or re-use.

Recording - The VMD advise that the requirements to witness and record the destruction of CDs do not apply to returned CDs. However, they advise that it would be good practice for veterinary surgeons should consider making a record of any CD that is returned and having the destruction witness by another member of staff and signed against. This can be recorded in a separate book or sheets designed for that purpose.

Where an animal has died part way through treatment, the VMD recommends that the prescribing veterinary surgeon should consider making every effort to recover and destroy any remaining product.

Residual or waste drugs

Destruction - There is no legal requirement to have the disposal of waste product witnessed. Residual CDs are not usually denatured using kits because, as their destruction is required daily, this would prove too costly. Instead, residual drugs can be rendered irretrievable by collection into cat litter. Periodically, this cat litter is then sent as pharmaceutical waste through the waste contractor.

Recording - Any medicine left over in an ampoule, vial, or injected into fluids to make a constant rate infusion, which is considered unusable, is considered waste product (as opposed to practice stock). Both the amount administered, and the amount denatured should be recorded on the same line of the CDR to ensure that the running balance tallies – e.g. if 10mg morphine is dispensed to a patient but only 5mg is administered the record should show that 5mg was given and 5mg was wasted. Doing so ensures that the whole vial or ampoule is accounted for in the CDR. It is good practice for the entry in the CDR to be double signed.

Schedule 2 Controlled Drugs (CD) must be destroyed in the presence of a witness. A witness can be a veterinary surgeon who is independent from the practice where the CD is destroyed. This also applies to Schedules 3 and 4 CDs that have been prepared extemporaneously for use under the Cascade. To be considered independent this vet:

• Must not demand or accept any form of payment, beyond that which is reasonable to cover travel costs.
• Must record their RCVS number and confirm their independence in the CD register.
• Must have no personal, professional, or financial interest in or relationship with the veterinary practice where the drug is being destroyed (for example, temporary staff and family members of staff are not considered to be independent; ‘family member’ refers to spouse, partners, parents, siblings, children or other relatives).
• Must not share stock with or provide services (with exception of the function as a witness to the destruction of CDs) to the practice where the drugs are being destroyed.
• May work for the same franchise or corporate group provided the practices have a different owner and are separate legal entities.

To maintain independence, the vet destroying the CDs should not use the same witness repeatedly for the destruction of CDs at their practice.

The VMD guidance on the disposal of controlled drugs provides further examples of when a vet would be considered “independent”.

One practice may supply to another practice to relieve a temporary supply shortage, without a Wholesale Dealers Authorisation. This exemption from the VMR is intended to prevent shortages of available medicines causing animal welfare problems and should not be a regular occurrence.

Veterinary surgeons are required to store CDs securely and appropriately in a suitable cabinet to prevent unauthorised access. The following CDs are legally required to be stored in a locked container which is compliant with the Misuse of Drugs (Safe Custody) Regulations 1973:

• All CDs in Schedule 2 (with the exception of quinalbarbitone)
• CDs in Schedule 3 containing buprenorphine, diethylpropion, flunitrazepam and temazepam

The RCVS considers it advisable for all CDs in Schedule 3 to be stored in the CD cabinet. The Safe Custody Regulations describe the requirements for CD cabinets, safes and rooms and the standards to which they must be manufactured or built.

A T28 exemption certificate is what practices need in order to be able to denature controlled drugs for disposal in compliance with the Misuse of Drugs Regulations 2001. Practices can register for the exemption online through the Environment Agency here. Some corporate bodies will register all their practices, and other practices will need to do so on an individual basis. The registration process is free of charge and lasts for 3 years.

Having a T28 certificate does not change the requirements for witnessed destruction.

Once a veterinary surgeon has met their ‘under care’ obligations pursuant to the Veterinary Medicines Regulations 2013 (as amended), and Chapter 4 of the supporting guidance to the Code of Conduct, they may delegate the dispensing/supply of those POM-Vs or veterinary medicinal products under the cascade to a team member.  In order to do this, the prescribing veterinary surgeon must authorise each transaction individually before it is supplied (see next section for further information) and be satisfied that the person handing it over to the client is competent to do so. For the veterinary surgeon to be satisfied the person dispensing must have knowledge of practice protocols (i.e. trained) and there must be a SOP in place.

The prescribing and delegating veterinary surgeon will remain ultimately responsible, and their responsibilities associated with the prescription and supply of POM-Vs and veterinary medicinal products under the cascade, is set out at paragraphs 4.37 - 4.41 of Chapter 4, as follows:

4.37  A veterinary surgeon or veterinary nurse who is also an SQP who prescribes a POM-VPS veterinary medicinal product, or supplies a NFA-VPS veterinary medicinal product, and a veterinary surgeon who prescribes a POM-V or a veterinary medicinal product under the cascade is required:

1. before they do so, to be satisfied that the person who will use the product is competent to use it safely and intends to use it for a use for which it is authorised;
2. when they do so, to advise on the safe administration of the veterinary medicinal product;
3. when they do so, to advise as necessary on any warnings or contra-indications on the label or package leaflet;
4. to not prescribe (or in the case of a NFA-VPS product, supply) more than the minimum amount required for the treatment

4.38 The VMRs do not define 'minimum amount' and the RCVS considers this must be a matter for the professional judgement of the veterinary surgeon in the individual case.

4.39 The prescribing veterinary surgeon or SQP is required to be present when POM-Vs, POM-VPS, or NAF-VPS are handed over unless they have authorised each transaction individually before the product is supplied and is satisfied that the person handing it over is competent to do so.

4.40  Veterinary medicinal products must be supplied in appropriate containers and with appropriate labelling.

4.41  It is illegal under the VMRs to use or supply a veterinary medicinal product that has passed its expiry date.

Having prescribed POM-V medicines, if the veterinary surgeon is not present when there is a request for the medicine to be repeated, the veterinary surgeon must:

• Authorise each transaction individually before the medicine is supplied; and 
• Be satisfied that the person handing it over is competent to do so.

A veterinary surgeon could meet the requirement to authorise each transaction by:

• Handing over a medicine personally following a consultation, or instructing a fellow team member to dispense/supply the medicine;
• Making a note on a client’s record that repeat prescriptions could be supplied to the client;
• A team member taking a call from a client and putting a medicine aside for the veterinary surgeon to authorise before being supplied;
• In the case of a client unexpectedly coming into the practice, by a phone call to the veterinary surgeon, to authorise the supply.

Whichever method is used there must be an audit trail to show that the medicines has been prescribed by a veterinary surgeon.

Note:  A Suitably Qualified Person (SQP) in Great Britain, i.e., England, Scotland, and Wales under the Veterinary Medicines Regulations 2013 (as amended), is under similar requirements for the prescription and supply of POM-VPS medicines. These requirements are also a PSS Core Standard requirement for veterinary nurses who are also SQPs in Northern Ireland.

As per the RCVS Controlled Drugs Guidance, discrepancies between the amounts recorded as used, the volume of the product left in the vial, and the total stated volume must be avoided.  The Veterinary Medicines Directorate (‘VMD’) advise that pharmaceutical companies try to ensure that every bottle of medicine is precisely filled but some small variability may occur.  This may result in discrepancies regarding the amount of Controlled Drugs used when taking into consideration the volume remaining in the container.  There may also be some wastage within the needle and hub of the syringe each time the product is withdrawn, known as ‘deadspace’.  The Home Office has advised the VMD that discrepancies of up to 10% should not cause undue concern.  Reconciliation at the end of each bottle is recommended to avoid consolidation of errors.  Obviously, a balance of LESS than expected should be treated with greater concern.  While efforts should always be made to minimise wastage, the Home Office, the VMD, and RCVS Practice Standards Inspectors are all aware that some wastage due to deadspace will be unavoidable and these small discrepancies should always be recorded.

A Standard Operating Procedure (‘SOP’) should be in place, detailing what to do in the event of a discrepancy. The BSAVA state that one way of accounting for deadspace volume is to add this to each dose dispensed, but the volume is likely to vary, depending on the manufacturer of the needle and syringe, and the size of the syringe used - typically this is 0.05mls.

In reconciling, the RCVS recommends estimating by eye, making a scale on an empty bottle (for example), and then measuring a full bottle against it, or for more accuracy, weighing the bottles and recording weights.  Physically withdrawing remaining volume from a multi-dose bottle to allow for it to be accurately measured via needle/syringe, before returning the drug to the bottle, is not recommended, due to a health & safety risk of repeatedly drawing out volumes of controlled drugs, increasing the risk of them blowing back into someone’s face, and of course, increased wastage.