How to Manage Narcissistic Personality Disorder
Veterinary Business Advisors, Inc.
*Principles of this blog are based off the National Business Institute’s course on “Dealing with Narcissistic Personality Disorder in the Legal Practice: Clients, Counsel, and Others”.
Whether a client or a coworker, unhealthy narcissism can derail an otherwise straightforward experience together.
In 2020, there were 7 million American adults who have NPD or narcistic style. People who have this tend to see others as objects for their personal gratification, or as potential threats. Their world view tends to be win or lose. When those diagnosed with NPD, behavior traits include:
- Lack of empathy
- Grandiose sense of self-importance
- Excessively concerned about their image
- Dirven to seek attention and admiration
- Largely superficial relationships
- Feel entitled to manipulate or exploit others
- Rarely admit they are wrong
- Become enraged when they feel disrespected or humiliated
- Play the victim or martyr
How do you know or feel in the presence of narcissists? You can feel often belittled, under scrutiny or even judged, as if nothing you are doing is good enough, among many other feelings. Unfortunately, narcissists hide behind a façade of fear.
Working with Narcissists & Communicating with Clients with NPD –
The Narcissist’s Code – have you ever had a client or colleague that you sense may exhibit these traits? It’s helpful to know what may be motivating them, especially if it’s not obvious. One of the key points is that image is everything for them. Next is getting attention – it’s often when they feel listened to or admired – they feel expansive and fueled. If they are not at the center of attention, they can feel depressed, and often aggressive. Honesty is optional for them! Narcissist’s can be great liars as they seek image enhancement, being incredibly convincing in the moment. Next, they tend to believe others are either against them or out to get them. Narcissists tend to be driven by emotions and impulses. Winning is everything for them. Knowing these traits can allow you to be aware, and even create strategies to respond.
What could this look like with a potential client? Clients could think they know more or better than you as the veterinarian or technician, and will even demean or manipulate other members of your staff. They expect to be admired and rules are an exception to them.
Key Tip: A practical tip to respond include sharing that their treatment doesn’t feel respectful, which can ultimately interfere with helping them achieve their goals.
|Argue with them
||Authentically praise their strong points
|Try to get them to accept responsibility
||Educate them on possible consequences, then let them choose
|Take what they say personally
||Recognize that they are like this with everybody
|Argue for a win-win approach
||Focus the narcissist on his/her interests rather than what the opposing party receives
|Respond to dramatics or ultimatums
||Return to the narcissist’s goals and interests
|Take the bait when criticized
||Reassure them that you are on their side, and refocus on the case
|Overlook any failures to follow your policies
||Document, document, document. Make exceptions to your policies sparingly, if at all.
It can often be incredibly mentally and emotionally draining when dealing with someone who exhibits NPD. It’s important however, to hold onto your voice and set boundaries. It is not your responsibility to fix them. Dr. Dan Neuharth shares the “11 Things NOT to Do with Narcissists”:
- Don’t take them at face value
- Don’t over-share personal information
- Don’t feel a need to justify your thoughts, feelings or actions
- Don’t minimize their dysfunctional behavior
- Don’t expect them to take responsibility
- Don’t assume they share your values and worldview
- Don’t try to beat them at their own game
- Don’t take their actions personally
- Don’t expect empathy or fairness
- Don’t expect them to change
- Don’t underestimate the power of narcissism
Many of this can be easier said than done, but try to remember: in most cases, it’s not your responsibility to satisfy their cravings for admiration and praise. We can have compassion for the suffering of narcissists, but it does not mean excusing them for their narcissistic actions. Rather, focusing on the patient or case at hand, focusing on facts and trying a tip or two from the above table.
Compensation Best Practices in 2021
Veterinary Business Advisors, Inc.
It would be so simple if practice owners could open a fortune cookie for each one of their employees and find the method by which to fairly compensate them. While there are commonly accepted methods of compensation, their implementation in veterinary practices varies because different entrepreneurs have different business goals. Also, “fairness” is a relative term that introduces variability into an equation that might otherwise be consistent from practice to practice. This article describes the factors that practice owners should consider when determining compensation for veterinarians and paraprofessional staff.
Below is a table that provides a snapshot of current key indicators available for small animal companion practices. It is not meant to be all-inclusive, but rather to provide some guidelines that enable managers to take the practice’s compensation pulse. They can then determine if the practice is on track for the next year or needs to perform some diagnostics to prevent a fiscal derailment. Veterinary Compensation
Many periodicals and books discuss the factors one should consider in establishing a compensation policy for veterinarians. Of particular importance is the question of whether compensation should consist of a fixed salary, a percentage of the revenue generated by the veterinarian and collected by the practice (i.e., commission-based), or a combination of the two. If a commission-based component is present, it is also important to consider how the revenue figure will be calculated. Will it be limited to revenues generated from professional services, or will it include revenues generated from items like over-the-counter medications and foods? Percentages can also vary in relation to the magnitude of the revenue number that is generated. Implementing compensation systems in practice requires attention to the details of production calculation and timing of payment. The key to remember is there is NO one size fits all when determining the appropriate compensation for veterinary and non-veterinary staff. There are numerous factors that go into assessing the actual method used for compensation, which often requires the assistance of an advisor.
National starting salary information is generally published annually in the Journal of the AVMA. (See: Employment, starting salaries, and educational indebtedness of year-2013 graduates of US veterinary medical colleges, October 1, 2013, Vol. 243, No. 7, Pages 983-987; Employment of male and female graduates of US veterinary medical colleges, JAVMA October 1, 2011, Vol. 239, No. 7, Pages 953-957.) See also the latest biennial edition of the American Animal Hospital Association’s Compensation and Benefits-An In-Depth Look and the AVMA’s Economic Report on Veterinarians and Veterinary Practices (Wise, J., Center for Information Management, AVMA, Shaumberg, IL (Tel: 847-925-8070). Two periodicals, Veterinary Economics and Veterinary Hospital Management Association Newsletter, also regularly publish helpful articles. In addition, Wutchiett Tumblin and Veterinary Economics published Benchmarks 2019 Well Managed Practices.
Paraprofessionals are often compensated on an hourly basis and the industry has yet to develop widely adopted performance-based compensation models. Paraprofessionals generally report low job satisfaction and high turnover rates. In the 2016 NAVTA Demographic Survey, 38% of veterinary technicians left the practice due to insufficient pay, 20% due to lack of respect from an employer, 20% from burnout and 14% because of the lack of benefits. Full time technicians reported a salary between $15-20 per hour, while part-time technicians reported $14-16 per hour. After taxes, even the well-paid veterinary technicians are only slightly above what is considered the poverty line for a family of four in the United States ($24,300).
According to the United States Bureau of Labor Statistics, the median pay for veterinary technicians was $16.55 per hour in 2018. By comparison, a JAVMA published study on Jan. 1, 2016 of certified veterinary technician specialists reported that the weighted mean pay rate in 2013 was $23.50 per hour.
In AAHA’s 2020 Compensation & Benefits survey, average veterinary employee turnover was 23%. Turnover was 32.5% for receptionists, 23.4% for veterinary technicians, 10.3% for managers, 16% for associate veterinarians, and 32.9% for all other staff. To compare with the national workforce, Compdata’s Annual Compensation Survey showed that national average turnover was 15.9% in 2010 and 19.3% in 2018. The chart above can be helpful to calculate a practice’s turnover expenses. Turnover is a pervasive and expensive problem that can be mitigated by learning how to properly motivate employees.
Originally Published in Today’s Veterinary Business October 2019
Millennials are often in the news—and they have been for quite some time now–with countless articles discussing their impact in the workforce. But what about Generation Z? This is the group of people born between about 1995 and 2010. They’re also in or entering the workforce, and their perception of the world and their participation in the workplace is definitely different from that of the Millennials who came before them.
Gen Z, as they’re called,
is about 57 million strong in the United States. Other names include
Post-Millennials, Founders, Plurals, the iGeneration, and the Homeland
Generation. This article will describe, overall, what they value and how they
perceive life, with the understanding that not everyone in this generation (or
any other generation, for that matter) ever thinks exactly alike.
Values & Behaviors
An in-depth survey of
this generation conducted by McKinsey & Company determined that Gen Z has
several core behaviors in common, each of which center on their search for
truth. They avoid labeling; opting to focus more on individuality, honesty and
competence of people. Thus, making them more willing to understand different
types of people; enabling them to differences of opinion and interact with
organizations that don’t match their personal values. They want to spend their
energy on causes that matter, such as homelessness, poverty, world hunger,
identity, human rights, and gender equality. They want brands to behave in
ethical ways, being transparent, and having actions match what company
As such, it makes sense
that diversity is considered the norm by this generation, to the degree that
Gen Z often don’t readily think about the demographics of a group, whether that
means racially, or religious preferences or sexual orientation. To put this
into perspective, Business Insider and Axios predicts that by 2045, the United
States will be majority minority; meaning, this may be the last generation
where the majority of people in the United States identify as white and, for
much of Gen Zs’ lives, the president identified as a black man.
Additionally, Gen Z
expresses a desire to be financial stable; this, combined with their
aforementioned appreciation for diversity and the changing demographics in the
United States, likely attributes to their overall mix of beliefs and can
include fiscally conservative points of view combined with socially liberal
Overall, Gen Z can be
considered pragmatic, practical, and analytical; believing that most conflicts,
including global issues, can be solved through effective uses of communication.
Through simple conversations, they are able to learn, strategically gather
information, and make highly informed decisions about what their next step(s)
About 36 percent of Gen Z
will be in the workforce by the year 2020. According to statistics quoted by HR Magazine in November/December 2018,
58 percent of them hope to own a business someday (and 14 percent of them
When looking for
employment, here’s what matters to Gen Z:
- Good salary: 35%
- Enjoyable work environment:
- Flexible schedule: 14%
- Opportunity to create new
- Chance to learn new skills: 8%
- Community focus: 7%
Most have been exposed to
the internet and social media their entire lives, making Gen Z very comfortable
with the virtual world and with seamlessly crossing from online to “offline”
experiences. This ease will certainly have an impact on how technology will
continue to evolve in the workplace.
More specifically, Gen Z
have always lived in a world where information comes at them, fast and furious:
they’ve learned to rapidly process information but may not have long attention
spans. They multi-task, shifting from one activity to another, often in a way
that people from previous generations may find distracting.
Millennials have done an
excellent job of shedding light on the high costs of higher education plus the student
loan debt incurred from the pursuit thereof. From this observation, many from
Gen Z may choose to not pursue traditional educational pathways. People of Gen
Z may, instead, opt to go straight into the workforce, attend classes online, pursue
entrepreneurship, or choose paths that vastly differ from the paths ventured by
Assuredly, Gen Z will
have a significant impact on the development of workforce, as companies need to
manage complex, multi-generational teams consisting of younger Baby Boomers,
Gen Xs, Millennials, and Gen Zs. Each generation has different values, workplace
expectations, life goals, and more. For example, people of Gen Z have a strong
desire for work-life balance and appreciate developing personal, and
maintaining, technological connections. In fact, AdWeek recently reported that
Gen Z are 1.3 times more likely to buy products if their favorite celebrity
advertises it on social media. This is important for companies, as company
branding and marketing primarily occur on social media and, as such, if your
company has no social media footprint, then your chances of reaching Gen Z
diminishes; this represents a significant shift from strategies enacted by past
In light of this,
companies must find strategic ways to take advantage of the human resources
they currently have. For instance, employ a strategy that combines mentoring
and reverse mentoring; where those who are from Gen Z can educate those from
other, older generations and vice versa. Thereby preventing, and potentially
wholly avoiding, generational gaps and conflicts that damage productivity,
efficiency, and workers’ value.
Alternatively, you can
cater to Gen Z’s interest in forming a personal connection. When they work for
a company, Gen Z has been shown to prefer regular, in-person feedback from
their supervisors; this feedback can be short and sweet, as long as it’s prompt
and regular. They also want to interact directly with managers often, even
multiple times daily. This shouldn’t be surprising, given that they are used to
texting, conversing on social media, and so forth, which can be considered real-time
When your practice is
recruiting new employees, it can help to think of it as a brand, and then
demonstrate your brand visually to attract Gen Z job candidates. Think about
what makes your practice unique, what makes it interesting. How can the
candidate you’re interviewing contribute to your practice? Make that clear.
of Gen Z typically read online reviews about companies before they interview
with them, and they are attracted to reviews that show how the workplace can be
a fun place to be, even when working hard at the job. Flexible schedules and
paid time off are attractive to many Gen Zs.
Young adults from this
generation often make great employees; especially because Gen Z has the ability
to adapt to change in the way that would make most people from older
generations uncomfortable. You can consider them to be “radically inclusive”;
wherein they value individual expression and don’t readily distinguish their
online and offline experiences in the way that other generations do. They don’t
differentiate between their friends in the physical world and those they’ve
only known online. This is likely true, at least in part, because of the
rapidly changing technology that’s always been part of their lives which likely
contributes to their ability to quickly learn, their comfort levels with
technology, and how much they can contribute to a company’s bottom line.
Although they bring
strengths to the workplace, they may need guidance and training on soft skills
that previous generations possessed so readily possessed. These are skills like
how to handle clients calling your practice and how to respond to them via
email, to name a couple. You’ll have to think of other ways to truly address
these areas that caters to their inherent abilities like instructional videos,
role-plays with co-workers, or even one-on-one training could be appreciated by
this tech-savvy generation.
What happens when you die? Will your heirs receive a fair price, or any price for your investment in the practice? Will they remain locked into that investment forever? Will your heirs collect profits from the practice? What if the other partner (who is getting paid under his practice employment contract) has voting control and decides not to distribute profits?
If your heirs are to be bought out, who sets the purchase price? How and by whom is it paid? If part of the purchase price is paid with a promissory note, is same secured? How? What if the practice is not profitable enough to pay the note?
What happens when your partner dies? Your deceased partner’s heirs are now your new partners.
Barring a fluke, your new partners will not be veterinarians. Does your State permit non-veterinarian practice owners? Will they want to be bought out or stay and collect profits from the practice? (Without contributing to profit generation of course.) If the deceased partner was a large shareholder, or the majority interest holder, the heirs will also inherit your deceased partner’s voting rights. Do you want to share practice management with, or be managed by, such persons? What if the heirs squabble among themselves, leading to management paralysis and/or litigation? Do you fancy having the practice run by a court-appointed receiver?
If the heirs are to be bought out, who determines the purchase price? How and by whom is it paid? If there’s a note, is it secured? How?
What if you are permanently disabled? Will you receive a fair price, or any price for your investment in the practice? Will you remain locked into your investment forever? Will you collect profits from the practice? What if the remaining partner decides not to distribute profits?
If you are to be bought out, who sets the purchase price? By whom and how is it paid? If there’s a note, is it secured? How?
What if your partner is permanently disabled? Will your disabled partner want to be bought out or stay and collect practice profits (without generating any of same)? A disabled partner’s interests will be different then yours, so if he was the managing and/or majority partner, how will he run the practice? Will he be able to run the practice? What if the disabled partner is mentally disabled?
If your disabled partner is to be bought out, who determines the purchase price? How and by whom is it paid? If there’s a note, is it secured? How?
What if your partner goes nuts? You don’t want a mentally unstable person practicing veterinary medicine. But if such partner is the majority partner you can’t fire him, because he, not you, controls the practice entity. The same problem arises for equal partners. Sure your mentally disabled partner could voluntarily remove himself, but can you rely on that? What if the majority partner has a guardian? How will the guardian run the practice? What if the majority partner or guardian fires you?
What if your partner should be fired as veterinarian-employee? Suppose your partner becomes lazy or his child becomes ill and decides to work significantly less hours or stop working altogether. Suppose your partner becomes a substance abuser and consequently unfit to practice veterinary medicine. Or he steals from the practice. Or he harasses employees and/or abuses clients and/or patients. The foregoing would be grounds for terminating a veterinarian employee. But if your partner is the majority or an equal partner you can’t fire him (as explained in the preceding paragraph).
What if you no longer get along? Should the practice be dissolved? If not, who should leave? At what price should the departing partner be bought out? How and by whom is it paid? If there’s a note, is it secured? How?
In a 50/50 practice how are disagreements handled? What happens when each party has equal voting/management rights and a serious disagreement arises? How will the resulting deadlock be resolved?
What if your partner wants to drop out, buy a boat and sail around the world? Should your partner be permitted to withdraw? If not, how do you keep your partner from just resigning as an employee (in light of the constitutional prohibition of involuntary servitude)?
What if your ex-partner discovers he’s chronically sea-sick and comes back to set up a veterinary practice next store (using the client list he kept when he left)?
If a partner is permitted to withdraw, who determines the purchase price? By whom and how is it paid? If there’s a note, is it secured? How?
What if your partner divorces? If the divorced spouse has, or is awarded, a portion of your partner’s practice equity interest, the divorced spouse becomes a partner. Ménages à trois make great literature and film themes but ALWAYS end badly.
What if your partner goes bankrupt? Do you fancy your partner’s creditor as your new partner? It won’t be fun to have a bank running, or having a say in running, the practice. Worse, the bank likely will want to sell your partner’s share to a competitor.
Who’s got the land? The small animal practice’s most valuable asset is its location, because most clients won’t travel far for pet treatment. As zoning restrictions get ever tighter, good practice locations become ever rarer (and more expensive). If, as is frequently the case, one partner owns the practice premises, what happens when he dies, is disabled, withdraws, resigns, divorces and/or goes bankrupt?
What if another veterinarian wants to buy your partner’s interest in the practice? Should your partner be allowed to sell without your approval? Should you have a right of first offer? A right of first refusal?
IF YOUR PARTNER IS NOT YOUR RETIREMENT PLAN, THEN WHO IS? If you don’t have a firm agreement with your partner to sell your practice interest to him (or someone else) upon your retirement, then how are you going to retire using your investment in the practice as your nest egg? What if both partners want to retire at the same time?
Choosing the correct structure for your veterinary practice is an important decision with consequences reaching far into the future. Selecting your practice structure is definitely not a “do it yourself” project. Substantial tax, legal and accounting expertise is required. Veterinarians nevertheless need to stay active in the process to ensure the experts’ narrow technical proposals get folded into a coherent plan that reflects your needs and goals.
- It’s Mostly About Tax. Tax considerations are the primary drivers in choosing a legal structure for a veterinary practice. The two key aspects are taxation of income/profits and taxation upon the sale or transformation of the practice. Don’t paint yourself into a corner by choosing a business structure without establishing a succession or exit strategy. Exit strategies should focus not only on your richly deserved retirement, but also on contingencies such as death or disability). Since the transformation of an existing business structures in anticipation of a sale or the buy-in of a new partner usually triggers adverse tax consequences, it is usually better to choose an initial structure with the necessary flexibility to handle new arrivals, departures and divestitures at minimum fiscal cost.
- Liability Shield. In some structures such as partnerships, the owners are personally liable on their individual assets for the debts of the business. In others their personal assets generally are not at risk. Business structures, however, do not insulate veterinarians from liability arising from malpractice claims. But the shield works for almost all other claims, which in our litigious society are increasingly frequent. Unless you are an equine or food animal veterinarian, you generally have greater exposure to claims from your client’s “slipping and falling” in your hallway, than malpractice.
- Flexibility and Formalities. Some structures allow more management flexibility and/or are less burdensome to administer than others. Veterinarians generally tend to ignore formalities which is a serious mistake. Courts regularly have looked past the liability shield and held owners personally liable when the owners have failed to observe the formalities separating their personal affairs from those of the practice entity.
The accompanying table compares the more common business structures from a liability, management and formality perspective (in simplified form). Following is a brief and much simplified overview of the tax characteristics of each entity.
- Sole Proprietorships. Since sole proprietorships are not legally separate from the single owner, there is no separate tax return. The practice’s profits are included in owner’s total income and are taxed at his ordinary income tax rate. In addition to federal and (if applicable) state income tax, the owner must also pay self-employment tax equivalent to the payroll taxes due as if the owner were an employee of the practice.
Upon the sale of the sole proprietorship practice’s assets, the IRS will recapture all depreciation/amortization deductions taken by the owner/seller thereof and tax such amount at the seller’s ordinary income tax rates. In the unlikely event that any gain remains on the assets (after adding back any depreciation/amortization to their respective “bases”) they will be taxed at the lower 20% long term capital gains rate (assuming the relevant holding period is met).
The buyer receives a “step-up” (increase) in his basis in the assets proportional to the amount of (purchase price allocated thereto) allowing him to re-depreciate/amortize them. Thus, asset sales usually are a better deal tax-wise for the buyer than for the seller, and all other things being equal, buyers will prefer to purchase assets rather than stock (in a C corp).
- Partnerships. Partnerships are “pass-through” or “flow-through” entities for tax purposes, meaning that each partner includes in his own taxable income the profits (or losses) of the partnership, which are taxed as ordinary income at the partner’s individual rate (much like the owner of a sole proprietorship). Note that each partner’s share of partnership income is taxable each year, whether such share was distributed to the partner or retained in the partnership. If the latter, then the partner may not have the cash to pay the tax.
A consequence of the pass-through principle is that the sale of partnership interests are treated for tax purposes similarly to the sale of the underlying assets of the partnership (i.e., the assets are subject to depreciation recapture as in sole proprietorships).
- Corporations. All corporations must file separate tax returns.
- “S” Corporations. “S” corporations are corporations that elect to be taxed as a partnership. As “pass-through” entities, profits will be taxed in the hands of the shareholders whether distributed or not. An advantage of S corporations is that shareholders may take a portion of their profits as “S corporation profit,” free of payroll or self-employment tax (i.e., subject only to income tax). Profit corresponding to what the veterinarian shareholder would have earned as an employee is subject to payroll taxes in addition to income tax. (Sole proprietorships on the other hand must pay self-employment tax on all profits.) S corps are popular with veterinarians for this reason.
- “C” Corporations. “Plain vanilla” corporations (called “C” corporations to distinguish them from “S” corps) are not “pass-through” entities and are subject to corporate income tax, usually at the 35% rate for veterinary practices. Distributed profits (dividends) are taxed as ordinary income in the hands of the shareholders. This “double taxation” discourages the distribution of C corporation profits. On the plus side, C corp profits are not taxed until distributed, pension plan contributions are not subject to the S corp limits, and employee-shareholders’ health benefits are not taxed. Veterinarians wishing to maximize their benefits will choose a C corp over an S corp.
If the holding period requirement has been met, the sale of C corporation stock is taxed at the favorable 20% long term capital gains rate. The buyer does not receive a step-up in the basis of the underlying assets since he is buying the corporation stock. (The buyer can under certain circumstances elect to treat the transaction as an asset sale for tax purposes (a.k.a. a Section 338 election).)
- Limited Liability Companies. Limited Liability Companies are very quite tax-wise. Single member LLCs can elect to be taxed either as a C corp or a sole proprietorship. Multi-member LLCs can elect to be taxed either as a C Corp or a partnership. Unfortunately, not every state allows veterinarians for form LLC (ie, California).
- A Word Regarding Real Estate. If the practice owns its own real estate it’s better placed in a separate entity held by the owner(s) or held individually by the practices owner(s). This allows the owners to receive rent (which will be deductible from the practice’s income). Moreover, placing the real estate and the practice in the same legal entity frequently leads to problems because the buyer can’t afford to buy the real estate in addition to the practice.
Choosing the correct business structure for your practice is important. Don’t treat it lightly.
SIMPLIFIED PARTIAL COMPARISON OF DIFFERENT BUSINESS STRUCTURES
(Ex tax issues)
|Structure or Entity Type\Issue
No entity; business co-mingled with personal assets
|No liability shield
|None. Just open your door and you’re in practice!
|Corporations (“C” or “S” Corp) A Professional Corporation (“PC”) is identical to a C Corp in all respects except that only members of the same profession (e.g., vets) can own its shares
|Shareholder not liable for debts/liabilities of corporation (unless “corporate veil is pierced” because shareholders fail to separate their personal affairs from corporations (e.g. by ignoring formalities)
||Must file documents with state secretary of state. Formalities are the most cumbersome of all entities. Less formal flexibility re management/profit sharing issues
|Limited Liability Company (LLC)
(Created to provide more management flexibility than S Corp and “pass through” tax treatment )
|Member not liable for debts/liabilities of LLC (subject to piercing corporate veil doctrine)
||Must file documents with state secretary of state; but management, profit sharing can be flexible.
||Partners liable for debts/liabilities of Partnership; no liability shield
||Must file documents with state secretary of state, but management; profit sharing can be flexible.
 Salvation lies in adequate malpractice insurance.
 The basis of an asset is it’s original cost to the owner, as adjusted pursuant to IRS rules.
 Because veterinary practices usually are personal service corporations.
 Limited partnerships are different from general partnerships. An LLP generally is formed among several limited partners who are normally passive financial investors and one general partner responsible for managing the enterprise. Limited partners normally are not liable for the debts/liabilities of the LLP, whereas the general partner is. Contrary to the motion picture business, real estate or oil and gas exploration, LLPs may not be appropriate for a veterinary practice where all the members are actively engaged in the enterprise.
Updated December 2018
Cannabis products in the veterinary industry have become a hot topic in the media lately and little is known about the products on the market, including their safety or efficacy. Here we will explore how cannabis products have gained popularity, the scientific backing behind treating veterinary patients with cannabis, and the legal ramifications that can result from using these treatments. Unfortunately, while cannabis may have potential for treating ailments, the products on the market are illegal as well as potentially dangerous. Therefore, veterinarians should not stock, treat with, or recommend cannabis products, as this usage could result in a formal investigation by the veterinary board in the state in which they are licensed.
Back in 2016, the Colorado Veterinary Medical Association made an official statement explaining a veterinarian’s obligation to educate companion animal owners about the potential risks and benefits of marijuana products in a way that is consistent with an appropriate veterinarian-client-patient relationship. Colorado law has not yet changed in this regard. Effective January 1, 2019, the state of California will become the first state in the nation to legally allow their veterinarians to educate their clients about the topic of cannabis treatments for their pets. For the first time, a veterinarian in California will not face a potential penalty for having the discussion.
Growth in Popularity of Alternatives to Medications
As pet lovers, it is our primary goal to keep our furry friends happy, healthy and pain free. However, in a world of ever-changing trends, how do owners know what is best for their pets and what is just the newest health fad? Traditionally, veterinarians have been sought out to help guide these decisions but, in this changing climate, reliance upon Dr. Google is becoming more common – and vet visits are becoming less so. An increasing number of people are searching for natural alternatives to medications, and opting for diets for their pets that are grain-free, raw and antibiotic-free. Pet owners are also more commonly using their own homeopathic remedies. While these trends are mainly driven by consumerism and distrust in big pharma, the growing desire for at-home remedies can result in unsafe, unethical and even illegal outcomes.
Veterinarian Responses to Fads
Veterinarians must rely upon scientific research and laws as guidance. Fortunately, with two of the more well-known fads, scientific evidence is relatively cut and dry: grains are not evil and eating raw meat can cause a slew of health problems, such as contracting salmonella. However, when it comes to homeopathic remedies for fleas and ticks, joint pain, dry skin and even neurologic conditions, the evidence is much harder to come by. This is largely due to the lack of regulations on many products that consumers are using for remedies. There are no FDA regulations, for example, on essential oils, herbs or nutraceutical pills, meaning there is no regulatory body confirming what is on the label; therefore, nothing confirming what is in the bottle.
Despite the lack of FDA regulation and any associated concerns expressed by veterinarians, the desire to use natural derivatives is growing among pet owners. And, one specific derivative is getting plenty of press lately: cannabis.
Two Types of Cannabis Compounds
Cannabis, dating back 6,000 years, is the only plant genus that contains the molecular compounds called cannabinoids. The two most notable compounds are tetrahydrocannabinol (THC) and cannabinol (CBD). While poorly divided, taxonomically speaking, cannabis is easily divided into two broad types based on the biochemical make-up. These two divisions are commonly referred to as marijuana and hemp.
The U.S. Drug Enforcement Administration (DEA) classifies Marijuana as a schedule 1 drug, which falls in the same category as heroin and cocaine. Due to its recreational use, it is the more well-known of the two cannabis plants. Marijuana contains high amounts of THC, the psychoactive cannabinoid, and low amounts of CBD, the anti-psychoactive compound.
Hemp, on the other hand, is grown for its seed and fiber properties. Hemp has low levels of THC and high levels of CBD (at least when compared to marijuana). Unlike marijuana, it is not possible to get high off the hemp plant. In fact, you would die of smoke inhalation before reaching high enough levels of THC from hemp to achieve a recreational high. This is due to the low concentration of THC and the fact that CBD is the anti-psychoactive that blocks the marijuana high. Because of that, some people refer to hemp as “anti-marijuana.”
Industrial hemp usage is legal in the United States but, oddly enough, actually growing industrial hemp is illegal. In fact, since 1937, it has been illegal to grow any variety of hemp in the United States. Under current law, imported hemp products are subjected to zero-tolerance standards for THC, even though the average amount of THC in marijuana is 20%, while the average amount in hemp is 0.3%. Somewhat illogically, the United States government does not distinguish between these two very different plants grown for completely different purposes.
Note About State Laws
In 2017, the number of states permitting industrial cultivation of hemp exceeded the number of states that have legalized medicinal marijuana (33 versus 29 to date). So far, though, few farms have begun cultivating hemp due to resistance from the DEA. This is because, while legalized in certain states, both marijuana and hemp are illegal federally.
Cannabis for Human Medicinal Purposes
So, what is it in these plants that has led to medicinal use? About 20 years ago, scientists discovered a system in the brain that responds to the compounds found in cannabis, specifically in marijuana. The system is called the endocannabinoid system and has been shown to play a role in the cardiovascular, digestive, endocrine, immune, reproductive and nervous systems. The discovery sparked interest in finding specific chemicals in marijuana that could be targeted to treat specific conditions. Since that time, research on medical marijuana has increased significantly but, with the schedule 1 classification, doing approved research is still difficult.
While there are plenty of studies that show promising results in treating conditions, in order to officially conduct research on cannabis, scientists must first get approval from the DEA and the Federal Drug Administration (FDA). While such studies have shown that cannabis can help manage pain and muscle spasms in multiple sclerosis, as well as improve symptoms of schizophrenia and Tourette’s Syndrome, too few of the studies were controlled clinical trials with placebo treatments.
These results have been mirrored in the series of studies permitted by the DEA at the Center of Medical Cannabis Research, University of California San Diego. The conclusion of these 13 studies was broad but simple: “cannabis may be useful medicine for certain indications.” Many researchers worried about the risk to users, though, with some patients becoming addicted (10%) and others finding the effects “intolerable.”
FDA-Approved Marijuana Drugs for Humans
Despite the unanswered questions and research-related challenges, there currently are three FDA-approved drugs made from marijuana in the United States. Marinol and Cesament are used to treat nausea in chemotherapy and AIDS patients, while Epidiolex is used to treat children’s epilepsy. Furthermore, Sativex is a drug developed in the United Kingdom that has been approved in over 24 countries to treat muscles spasms from multiple sclerosis and cancer pain, and it may be approved in the United States soon to treat pain associated with breast cancer.
Cannabis-Based Products and Pets
Because of the clinical evidence performed to date and experimental evidence by marijuana users, who have self-treated successfully, it is no wonder that people want to use cannabis-based products to help their animals. Given how difficult it is to get research approved for cannabis use in humans, one can imagine the level of difficulty involved in performing cannabis research in animals.
The most commonly used cannabis products on the veterinary market for treatment of animals all contain CBD oil. CBD can be extracted from marijuana or hemp and has claims to treat numerous disorders, including behavioral issues, seizures and pain. While many veterinarians would welcome a safe and effective new way to treat diseases like arthritis or epilepsy, lack of legality and solid clinical studies makes the situation uncertain.
Veterinary uncertainty, though, has not stopped an array of products from popping up on the market. At conferences, one can be bombarded by naturopathic vendors that appear reputable, making claims on their products that cannot be substantiated. This makes it difficult to differentiate fact from fiction and, unless veterinarians are up to date on the current AVMA and federal standards, they may be tricked into stocking these products at their practices.
In a study that that was performed by the Department of Clinical Sciences and College of Veterinary Medicine and Biomedical Sciences at Colorado State University, published in the Journal of the American Holistic Veterinary Medical Association (JAHVMA) and Scientific Report, veterinarians were assigned three objectives: find out which cannabis products pet owners purchased, their reasons for the purchase and if they perceived a difference in their pet while using the product. The results of this study included 632 pet owners (88.1% dog owners, 11.9% cat owners) who have purchased hemp products from an online site. Most of the dog and cat owners (77.6% and 81.8%, respectively) indicated that they use the hemp product for an illness or condition diagnosed by a veterinarian.
The most common conditions eliciting treatment in dogs included seizures, cancer, anxiety and arthritis. The illnesses or conditions treated in cats were comparable, with cancer, anxiety and arthritis as the most common. The most common side effects reported by both dog and cat owners were sedation and over-active appetite. When dog owners were asked about the perceived positive impacts of the hemp, they reported the highest impact in relief from pain (64.3%), followed by helping with sleep (50.5%) and relief from anxiety (49.3%). Cat owners perceived the highest impacts as relief from pain (66%), followed by reduced inflammation (56.3%) and help with sleep (44%). This information supports the growing anecdotal stories of the effects of cannabis in pets. In addition, this information provides a platform for researchers seeking to perform clinical studies on not only the effectiveness of hemp but also the adverse outcomes associated with the use of hemp.
Interestingly, this study also surveyed pet owners about their disclosures to their veterinarian about the hemp products used. Just under half of the participants had spoken with their veterinarian about the product, with most indicating that their veterinarian responded positively (61.7%), some expressing no opinion (30.7%) and very few responding negatively (7.7%). While most veterinarians would agree that anything having a positive impact on your pet is, in fact, positive, in this case, it is still illegal. In a recent article by the AVMA titled “Cannabis: what veterinarians need to know,” the AVMA cautions pet owners against the use of chews, oils and nutritional supplements containing CBD, citing the FDA as its regulatory beacon.
Currently the FDA does not approve the use of marijuana or hemp in any form in animals because of the lack of evidence about the safety and effectiveness of the products. The DEA stated in 2017 that “cannabinoids are not found in hemp, except in trace amounts. Therefore, extracts that contain more than trace amounts of cannabinoids must be part of the cannabis plants that are defined as marijuana and regulated as a schedule 1 controlled substance.”
In all this legislation, it might appear that hemp is unfairly getting a bad name; however, the ASPCA poison control center has recently reported an influx of calls and claims that ingestion of hemp-based CBD products causes the same clinical signs as ingestion of marijuana (products containing THC). It is not known whether toxicity is due to quality control issues in unregulated products, differing metabolism rates of CBD, or varying amounts of CBD in products despite label claims. The most common clinical signs include ataxia, depression, mydriatic pupils, hyperesthesia and urinary incontinence. While rare, other signs include vomiting, tremors and seizures with multiple deaths reported due to aspiration. For this reason, the FDA and AVMA caution pet owners against using these products and the FDA has issued numerous warnings to companies that sell products containing cannabidiol.
Effective January 1, 2019, veterinarians in California are legally allowed to talk to clients about cannabis and their pets. They can’t dispense cannabis products, nor can they administer them. However, a bill signed by Governor Jerry Brown in September 2018 will prevent state regulators from penalizing a veterinarian for discussing marijuana as a therapy for his or her clients’ pets.
This bill had received support from the California Veterinary Medical Association (CVMA), with the organization’s executive director pointing out that dispensaries have been selling the products, yet people couldn’t even talk to their veterinarians about whether or not they should be used on their companion animals.
The CVMA has until January 1, 2020 to develop guidelines about the specifics of cannabis-related conversations. What veterinary professionals in California cannot do includes:
- accept, offer or solicit any renumeration with someone with a cannabis license if they have (or their immediate family has) a financial interest in the transaction.
- discuss therapeutic potential of cannabis with a client if the veterinarian is employed by a cannabis licensee or if an agreement exists between the veterinary professional and the cannabis licensee.
- distribute cannabis advertising in California, in any form
Overall, studies indicate great potential for cannabis as a treatment modality. If research was less restricted, more safety and dosing studies could be conducted. This would likely help explain, and ultimately prevent, poison-related deaths and begin to address concerns.
What is important to remember is that pet owners aren’t the people who face significant consequences for trying these products. Although it is illegal to sell products containing cannabinoids, and illegal to purchase products containing them, the only parties as of now who have been threatened to be held legally responsible are veterinarians and the cannabinoid-producing companies.
Here is just one example of how a state medical board perceives veterinary use of cannabis-based treatments. The California Veterinary Medical Board states that, while marijuana is legal for adults 21 and over, cannabis is illegal for use in animals. They go on to say that “veterinarians are in violation of California law if they are incorporating cannabis into their practices” and, if the board received a complaint regarding treatment of an animal with a hemp- or marijuana-related product, they would be “obligated to conduct an investigation and take appropriate disciplinary action if the findings so warranted.”
In conclusion, the use of cannabis products for animals warrants the attention of veterinarians and researchers and could one day be a wonderful treatment modality, but it cannot currently be recommended or stocked by veterinarians. It is suggested that both the promises and perils of medical marijuana for animals point to the need for science-based education, regulation and research. So, while we all aim to do what is best for our patients, it is most appropriate to advocate for change while remaining within the confines of the law. It is possible that one day cannabis will be a legal and accepted treatment in the veterinary community, but many steps must be achieved before then.