“As such, Horsemen are advised to exercise extreme caution when using these products in close proximity to a race,” the advisory states.

Under the Horseracing Integrity and Safety Act (HISA), caffeine is a Class B controlled substance, which comes with a possible 15-day suspension and $1,000 fine for a first offense.

The advisory shows pictures of two tubs of substances broadly labelled “EPO-Equine,” each labelled to sell for $525. EPO is the shortened version of Erythropoietin, a type of protein called a growth factor.

EPO stimulates the bone marrow to make red blood cells, which contain a protein called haemoglobin that carries oxygen around the body. As such, EPO is widely known as a performance enhancing substance.

When asked if EPO had also been detected in the two substances, CHRB equine medical director, Jeff Blea, simply said that “just caffeine” was detected.

The two substances, said Blea, were found during a barn search conducted at Los Alamitos. “It was not related to a caffeine positive,” he said, declining to say whose barn was searched.

“This one I think has been around for a long time,” said Blea, about the “EPO-Equine” product. “The caution is, be careful what you're giving your horses.”

When asked about the suggestive labelling, Blea said that he had called and emailed the company but didn't receive a response.

“It's all about marketing, right?” said Blea. “They're trying to sell a product.”

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While discussing his thoughts on the rollout of the Horseracing Integrity and Safety Act's (HISA) drug control program, Ferraro shared his fears that the new federal rules on joint injections were weaker than had previously existed in California.

“It's a step backwards,” Ferraro said. And this regulatory reshuffle, he added, could lead to an increase in California of irreparable musculoskeletal injuries, especially of the fetlock joint.

“California is the point of the spear in terms of dealing with the public and the liability of horse racing,” said Ferraro, advocating for federal adoption of California's joint injection regulations. “I think they should use us as a sort of leader in animal welfare and jockey welfare.”

Ferraro's comments re-ignited a debate that has been simmering away in some fashion or other for decades. Just take the New York Task Force report into the rash of fatalities that bedeviled Aqueduct during the winter of 2011-2012.

“The Task Force believes that the use of systemic or intra-articular corticosteroids may have impaired veterinarians and trainers in accurately assessing horses' soundness leading up to a race,” the report found.

“The Task Force also believes that the use of these medications too close to the race may have limited the ability of the NYRA veterinarians to identify the presence of pre-existing conditions disposed to progressing to catastrophic injury.”

The New York Task Force's findings frame a key bone of contention among trainers, veterinarians and regulators: What is a smart regulatory timeframe for limiting joint injections before workouts and race days?

HISA's joint injection rules bar joint injections within 14 days prior to post-time, and within seven days of an official workout.

In California prior to HISA, the intra-articular corticosteroid fetlock injection rule mandated a 30-day stand down period prior to racing, and all corticosteroid joint injections had a 10-day stand down before workouts.

After those rules were adopted, the number of irreparable fetlock injuries in California had fallen off precipitously. Experts point to this as a prime example of the long-term systemic effects from corticosteroid usage.

Even so, there remains some skepticism within the industry that California had indeed got it right.

Mark Casse | Sarah Andrew

“Thirty days is ridiculous,” said trainer Mark Casse, who argues that such a rule is difficult to police. “What happens is, when you make rules that you cannot really enforce, it only makes the bad guys better because they don't care.”

Another key point in this whole debate? Not all joint injections are made equal.

In the decade since the New York report was issued, veterinary experts describe a shift away from corticosteroids towards hyaluronic acid joint injections, and biologic therapies like IRAP and platelet-rich plasma (PRP) injections.

They don't mask injuries the way corticosteroids can and are better at promoting joint health and healing in a way more advantageous to the horse in the long term, say proponents of these therapies.

Nevertheless, these same proponents voice frustration that the rules governing joint injections often treat corticosteroids and biologic therapies as equals.

“A lot of these injections are actually helpful, especially when you're doing PRP or you're putting [hyaluronic] acid in there,” said Casse, about biologic therapies. “I can tell you for a filly like Tepin, we would put acid in her ankles. We probably did it 20 times and she ran for years.”

Corticosteroids

Internationally renowned orthopedic surgeon Larry Bramlage is among those experts who believe HISA has got its rules surrounding corticosteroid joint injections about right.

“I think it is a good approach to being able to treat the joint that has been properly examined,” said Bramlage, who explained that corticosteroid joint injections should never be part of a “routine training program,” no matter the stand down time. “You want plenty of time to reassess the condition of the joint without the corticosteroid masking anything.”

Part of Bramlage's reasoning is how the marketplace for corticosteroids has evolved from high-dose, long-lasting versions like Methylprednisolone acetate–also called Depo-Medrol–to lower-dose, shorter acting corticosteroids like Betamethasone and Vetalog.

What kind of difference are we talking about? “We tend to think in terms of volume injected into a joint,” said Bramlage. Depo-Medrol can come in doses as strong as 40 milligrams per milliliter (mg/ml). Betamethasone, on the other hand, typically comes at a strength of 6 mg/ml.

“The original one–and as it turns out the most harmful one–was Depo-Medrol. When I was a student, we would put as much as two cc's [cubic centimeters] of Depo-Medrol when we were treating a joint,” explained Bramlage.

“But it's very long acting,” he added. “Its crystals are absorbed very slowly, so it can be found up to three months in the joint after you put it in. And that is a big disadvantage.”

Dr. Larry Bramlage | Horsephotos

Bramlage believes that the new wave of corticosteroids continues to play a role in managing the sorts of routine aches and pains that accompany high stress training programs.

“If you let inflammation go unchecked within a joint, it can eat up the articular cartilage. So just leaving a joint seriously inflamed without treating it with anything is also not the best route once you know there is no structural damage,” he said.

And the use of a low-dose, short acting corticosteroid like Betamethasone within a week of a timed workout, Bramlage said, is “a medically sound” approach if the joint has been properly assessed beforehand.

If the corticosteroid is eliminated from the horse's system enough to be undetectable in a test, he added, and the horse is still exhibiting signs of lameness, then there is a strong possibility the lameness is tied to some deeper-seated structural problem. A burgeoning stress fracture, for example, or abnormal bone remodeling. “That is the rationale for the stand down time,” he said.

The modern short-acting corticosteroids “reduce the inflammation and then get out of the way so you can read the joint again,” explained Bramlage. “And if there is a physical injury, a structural problem of some kind, it'll show up again.”

Other veterinary experts in the field have a slightly different take.

Though a corticosteroid won't necessarily show up through testing after seven days, it can still impart a systemic effect on the horse through effects like decreased inflammation in the joint and reduced lameness, said veterinarian Wayne McIlwraith, a distinguished professor at Colorado State University and like Bramlage, internationally renowned in the field.

As an example, McIlwraith cited a study he was involved in from 1997 where researchers studied the effects from triamcinolone acetonide joint injections–drugs which come under the trade names Vetalog or Kenalog. The horses were suffering osteoarthritis in the knee and were injected at 14 days and 28 days after the study start.

“We showed that lameness was significantly reduced at day 70–42 days after the second injection,” said McIlwraith. He described these effects as reduced inflammation in the joint fluid and in the joint lining membrane, as well as beneficial effects on the articular cartilage.

These effects were seen “whether we injected the osteoarthritis joint or we injected the opposite normal joint,” McIlwraith said. “In other words, a systemic effect that was very long lasting.”

McIlwraith and his fellow researchers used the same study design on Depo-Medrol–then considered the most potent corticosteroid available. They found “significant deleterious effects” to the joint cartilage in both the osteoarthritic joint and the opposite “good” joint, he said.

“The bottom line is that all the tissues of the musculoskeletal system are being exposed to the multiple complex effects of corticosteroids,” he said.

The fetlock has long been the Thoroughbred racehorse's Achilles heel. As an example, fetlock failures constituted in California nearly 60% of all musculoskeletal injuries that proved fatal during the 2018-2019 fiscal year, according to CHRB data.

The CHRB instituted its 30-day standdown regulations for corticosteroid fetlock injections on Oct. 19, 2021.

In the 20 months preceding that date, there were 83 catastrophic fetlock failures statewide, according to CHRB data. In the 19 months after that date, there were 24 catastrophic fetlock failures statewide.

Dr. Wayne McIlwraith | Colorado State University

Zeroing in specifically on Los Alamitos, the number of catastrophic fetlock failures dropped from 21 to just three during those two same periods of time bookending the rule change.

California's tightened joint injection rules have been just one part of a suite of stricter drug and equine welfare and safety rules instituted in the state over the past few years.

But for the likes of McIlwraith and Ferraro, the remarkable drop in irreparable fetlock injuries is due largely to one thing–the stricter corticosteroid joint injection regulations.

“I think we can relate this knowledge to our data in Southern California showing that injection not being allowed for 30 days in the fetlock has reduced the incidence of catastrophic injury,” said McIlwraith.

Indeed now, Ferraro advocates for the total elimination of corticosteroid use in all joints in racing and training.

“I would argue, look at our results. We didn't really have a breakdown problem with fetlock joints [in California],” said Ferraro. “In other words, if you're going the corticosteroid route, then that horse ought to be given significant time off, which means sending him to the farm.

“You can't legislate good judgment,” he added. “Corticosteroids in the hands of a wise, experienced equine veterinarian, you could probably do fine with it. But we put in this legislation because we know good judgment is not something that's always [wielded on the] backside.”

Which leads to alternative therapies to corticosteroids.

Biologic Therapies

“What you're trying to do is either slow something down or speed up something, and the goal is to slow the bad stuff down and speed up the good stuff,” said Bramlage, of the role of veterinary intervention with biologics. “[They] don't work by stopping things. They try to augment healing, not only block the mediators of inflammation.”

In explanation, Bramlage pointed to how the joint protects itself from harm and degeneration by naturally producing hyaluronic acid in the joint fluid, along with a class of molecularly heavy proteins called proteoglycan in the cartilage.

White Abarrio | Coady Photography

But corticosteroids hinder the body from producing both hyaluronic acid and proteoglycans. As such, hyaluronic acid is frequently used in combination with corticosteroid joint injections.

“You're essentially artificially adding hyaluronic acid because the corticosteroids are going to slow or stop the manufacturer of hyaluronic acid in the joint when you put them in,” Bramlage said.

When it comes to the use and efficacy of biologic treatments on racehorses, there seems to be a broad and largely favorable consensus among veterinary experts.

“You get your results from them because they stimulate healing within the joint. They calm the membrane down, and they help the cartilage surfaces. In other words, you could say they're a form of nutrient for cartilage, whereas steroids are a toxin to cartilage,” said Ferraro.

Should biologic therapies and corticosteroids joint injections be treated the same by regulators?

“No,” said McIlwraith. He explained that through research and through widespread clinical use, these therapies have been shown to have “uniquely beneficial” and other specific effects, but “no significant” negative effects.

“They are less potent immediately compared to corticosteroids which means that they are not going to be useful if used in an 'inject and race or work soon after' manner, which has been a philosophy of use by some,” said McIlwraith.

But under HISA's current rules, all joint injections are indeed treated the same. This means that biologic treatments like IRAP and PRP injections require the same 14 and seven-day standdowns for races and workouts respectively as corticosteroids.

HIWU has suspended 40 horses from racing for 30 days due to joint injections within seven days of a timed workout. Equibase only publicly maintains 60-days' worth of workout data. With what information is still available through Equibase, at least one horse on the list was injected one day before a workout. But HIWU does not publicly detail what kinds of joint injections were administered to these horses–corticosteroids or biologic treatments.

Efforts are underway to potentially modify HISA's joint injection rules.

A red-lined version of HISA's ADMC program recently shared with the TDN prohibits horses administered a fetlock joint injection from racing for 30 days, and from working for 14 days. For all joints other than the fetlock, the current restrictions–14 days from racing, seven days from working–remain in place.

According to this red-lined version, the rules still don't differentiate between corticosteroids and biologic therapies.

CHRB equine medical director Jeff Blea sits on HISA's anti-doping and medication control (ADMC) committee.

Though Blea was speaking on behalf of HISA, he said his personal opinion was that the federal ADMC program should be altered to mirror California's rules, which allow biologic therapies to be used unrestricted on any joint before a workout.

“We should want to be promoting biologic therapies because I think it's beneficial not only in the short term but the long term,” he said.

At the same time, not all veterinary practitioners agree with all aspects of the CHRB's rules on joint injections. If a horse is injected three times into the same joint within 60 days in California, the horse is automatically placed on the vet's list for 30 days.

This rule went into effect in the state on July 1 this year. And it has curbed Southern California veterinarian Ryan Carpenter's use of biologics, as it fails to distinguish between those sorts of injections and corticosteroids.

Dr. Jeff Bleu | AAEP

“It essentially has eliminated our use of IRAP, which is designed to be done once a week for a loading dose and then monthly after that,” said Carpenter.

“The unfortunate thing is that rule has actually incentivized people to not use biologics and put them back towards corticosteroids,” said Carpenter. “My corticosteroid use has increased since that rule has come in effect and would have loved to have stayed on the biologic route because I think it's better overall.”

When asked about this criticism, CHRB executive director Scott Chaney argued that the 60-day period was specifically chosen to still permit the use of biologic therapies while curbing excessive injections into the same joint.

“Even if it's not degrading the joint, clearly it's not working if you're having to mess with a specific intra-articular space over and over again within a short timeframe,” Chaney said.

More broadly, Chaney's thoughts about corticosteroid use in racing align with Ferraro's.

“Corticosteroids are unnecessary in horseracing,” he said, calling this issue a “litmus test” for HISA. “Our horsemen in California have been there and done it. We're four years into this,” he said.

“But it seems like horsemen around the rest of the country need a 'come to Jesus' moment because they're still clinging to the belief that they need corticosteroids to work a horse or run a horse. That's absurd. Any horseman or veterinarian who tells you that, they do not know what they're talking about.”

`I Would Put This Stuff In The Water'

It turns out the evolution in the use of joint injections in human athletes—and aging athletes in particular—appears remarkably similar to that of the racing world.

Andrew Pearle is the Chief of Sports Medicine at the Hospital for Special Surgery, the country's top orthopedic hospital. He is also a team physician for the New York Mets.

Pearle's area of expertise? The human knee.

“When I'm giving a steroid injection, I typically give 80 milligrams of Kenalog. It's a really good injection, particularly if there's fluid on the knee. It's certainly highly effective. In fact, there was a Nobel Prize given for the development of cortisone,” he said.

But there's a caveat.

“It's got these downstream negative effects with repeated use, and many of us don't like to give more than two shots over a lifetime in a joint,” Pearle said.

Instead, said Pearle, human medicine had moved towards alternative joint therapies like gel shots, PRP and hyaluronic acid.

“I tell patients if I could put this stuff in the water and feed it to everybody,” he said, “I would.”

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Dr. Jeff Blea, the equine medical director for the California Horse Racing Board (CHRB), released the following statement Saturday:

“Three horses arrived at the Del Mar Race Track from Churchill Downs on Tuesday, Nov. 29. Due to the recent EHV-1 issue identified at Churchill Downs, the horses were placed in a quarantine barn with biosecurity measures implemented upon arrival, which continue to remain in place. Since their arrival, all three horses remain healthy and show no clinical signs of illness. Furthermore, bloodwork has been and continues to remain normal.

“The horses were tested for EHV-1 at UC Davis and all horses were negative for EHV-1 in blood. However, one horse, Wakanaka, was mildly positive on a nasal swab sample with a very low viral load. The viral load was too weak to differentiate between neuropathogenic and non-neuropathogenic EHV-1. This is only one test at a single time point, so we will continue to monitor the situation. Out an abundance of caution, Wakanaka will not be allowed to compete in the Dec. 4 Matriarch S. as planned.”

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The reason, according to staffers and commissioners who spoke during the Nov. 22 monthly meeting, is that the CHRB has been proactively advancing safety and medication rules for the past few years, and a number of those regulations eventually got adopted as models for HISA rules.

So if or when an expected mandate for HISA to cease operations gets handed down by the Fifth Circuit on that mandate's Jan. 10 due date, the CHRB will essentially just go back to relying on a similar, in-state framework of rules that aren't too different from HISA's.

“We've been participating with HISA. We've been supporting them. We will continue to do so until told otherwise,” said the CHRB's equine medical director, Dr. Jeff Blea.

But, Blea added, “It's nice to know [that] in all actuality, HISA's safety program and medication rules are not that far different from where California is.”

Mindful that a Pandora's box of varying legal and political scenarios could still affect the future of HISA between now and when HISA's Anti-Doping and Medication Control rules go into effect Jan. 1, the CHRB voted 4-0 on Tuesday to opt in to the 2023 voluntary implementation agreement that encompasses national oversight by both the HISA Authority and the Horseracing Integrity and Welfare Unit (HIWU), which will enforce the new drug rules.

“Just to clarify, HISA medication rules go into effect Jan. 1, and the court [mandate] is Jan. 10. So those 10 days for sure, we're operating under the medication rules of HISA,” said chairman Gregory Ferraro, DVM. “And then, depending on what [a higher-court ruling or a legal stay or Congressional action] is, we go from there.”

Blea described to commissioners how he was in attendance at the annual convention of the American Association of Equine Practitioners (AAEP) in San Antonio, Texas, on Nov. 18 when news first broke about the HISA unconstitutionality ruling.

Blea said the convention was “fully staffed” with HISA Authority executives at that time, including HISA chief executive officer Lisa Lazarus and HIWU executive director Ben Mosier.

“Thirty minutes prior to the start of the meeting the announcement came out, so it was just a little bit of everybody [being] on their heels,” Blea said. “Their approach was, 'We're moving forward, we're pressing on, we'll discuss these issues with veterinarians and the veterinary community.'

“So right now it's 'business as usual,'” Blea continued. “Everyone's seen what's in the mainstream press, and it's an attorneys' field day. As it stands now, from a medication standpoint, we'll be under HISA rules for 10 days [in 2023] depending on what the courts rule. Same thing with the safety standards.”

Blea noted that even as the AAEP convention unfolded amid the legal blow to HISA, the CHRB was repeatedly referenced during a keynote address for being ahead of the curve on equine safety and welfare initiatives.

And during the professional meet-and-greet portions of the convention, Blea said he repeatedly had his brain picked by colleagues who wanted advice on how to introduce CHRB-styled reforms in their home states.

Amanda Brown, the CHRB's staff counsel, offered a legal perspective on HISA's possible path forward–or what happens if that entity is forced to shut down. She noted that a separate Court of Appeals case over HISA's constitutionality has arguments pending Dec. 7, this time in the Sixth Circuit.

“So there is a chance that the judge there rules [that HISA is] constitutional [and] we have two competing decisions,” Brown said. “Ultimately, I expect they'll ask the Supreme Court to review it.”

But in the meantime, Brown said, “Everything from HISA says that they're still going to roll out the Anti-Doping and Medication Control program Jan. 1 [and] HISA has indicated that they are going to exhaust every avenue to either get a stay or a reconsideration before that time. So it's kind of up in the air what's going to happen.”

Prior to the unanimous vote on the issue, Ferraro asked Brown is there was any legal downside to opting into the HISA and HIWU agreements in the event that those entities do get shut down. According to the HISA budget, California's financial assessment for 2023 is $7,344,139.

“I can't speak to the [CHRB's] payment portion of that, but no, the agreement would be void and there would be nothing for us to enforce,” Brown said. “We'd go back to our California rules, pre-HISA. Which for us, is probably easier than other states.”

Cynthia Alameda, the CHRB's deputy executive director, picked up on the topic of assessments where Brown left off.

“We're collecting payments currently for the first assessment [that covered the final six months of 2022],” Alameda said. “They're coming in a little bit behind, so I don't think that it would be difficult for us to kind of regroup and ensure that all of our stakeholders didn't pay any fees that were unnecessary.

“So I don't think there is any negative in entering into the agreement,” Alameda continued. “It also gives our stakeholders an opportunity to come back in December to present how they would like to fund the assessments. They did it through market access fees on the first assessment, so I'm sure they would need to present that to us as well, just so we're ready in January if everything goes forward.

“If HISA [being] unconstitutional [was upheld], we would cease collecting funds,” Alameda said. “I don't know what would happen with the ones that have already been paid for the first six months, because it was kind of to handle the setup costs, so I don't think those would be recouped. That's just me guessing, though.”

Blea added at a different point in the meeting that there is one difference in the CHRB and HISA rules that he is actively trying to address before it becomes an on-track issue in 2023.

“The confusion for veterinarians is detection time versus thresholds,” Blea said. “The [HISA] detection times are based on a European model. So I'm going to recommend people push their medication administrations back further, and I'm in the process of doing some calculations and trying to figure it out to give them some information proactively to avoid any problems.”

The four CHRB commissioners voting unanimously for the HISA opt-in were Ferraro, Oscar Gonzales, Damascus Castellano and Brenda Washington Davis.

Commissioners Dennis Alfieri, Wendy Mitchell and Thomas Hudnut were absent from the meeting.

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In a settlement with the medical board, Blea agreed to continuing education classes in record keeping, a remittance to the VMB of $131,464 for the investigation costs, and a three-year probationary period.

Those believing the return of Blea to his prior role would bring an end to the veterinary medical board's regulatory inroads into the state's racing industry would be sorely mistaken.

The medical board has ongoing cases against at least nine other backstretch veterinarians in California, and the nature of some of the accusations–often identical in nature to those leveled against Blea–reveal a yawning schism between the veterinary board and the CHRB concerning approaches to standard equine veterinary care.

Until these differences are rectified, the legal ramifications hang like a Sword of Damocles over not just the state's racetrack practitioners but the performance horse veterinary community in general.

“It's been very unusual,” says David Foley, executive director of the American Association of Equine Practitioners (AAEP), about the nature of the complaints against Blea and some of the other backstretch veterinarians.

“If the veterinary medical board is going to interpret the rules in a companion animal manner towards equine practitioners, nobody's going to want to practice in California,” Foley says.

Areas of Conflict

The main areas of disconnect with the medical board–at least where the CHRB is concerned–surrounds the use of what the VMB terms misbranded drugs like Thyro-L, non-FDA approved compounded drugs and the correct nature of the veterinarian-patient-client relationship. More broadly, the disconnect also ensnares the prophylactic use of medications and record keeping differences between small and large animal veterinarians.

In the process, these areas highlight often conflicting sets of rules between these separate state agencies throwing the work of backstretch practitioners into confusion and possible professional jeopardy.

In short, some of the veterinarians with pending cases face a conundrum should they settle with the VMB and return to work under probation: If they then continue to practice under the CHRB's standard of equine veterinary care-but against the VMB's interpretation of the rules-they could face stark professional consequences.

The VMB deems Thyro-L, or thyroxine, misbranded under the Federal Food, Drug, and Cosmetic Act. And in laying out its accusations against some of the veterinarians, the medical board argues that the use of such misbranded drugs is prohibited through statutes written into the California Health and Safety Code.

Specifically, the code states that it is “unlawful for any person to receive in commerce any drug or device that is misbranded or to deliver or proffer for delivery any drug or device.”

Sarah Andrew

Essentially, a drug is misbranded if its labeling proves false or misleading in any particular situation, says attorney Mike Casey, who represented Blea in his case against the veterinary board. This could mean that the drug has been proven effective in the treatment of ailments for which it hasn't been labeled, says Casey, or vice versa.

But confusingly, Thyro-L is labeled for use in horses to treat hypothyroidism–a relatively rare equine condition–if dispensed by a licensed veterinarian.

Furthermore, many equine veterinarians routinely use it to treat a variety of conditions, including insulin resistance, for which there's a body of research.

“Veterinarians have a wide authority to prescribe medications,” says David Ramey, president of the Los Angeles Equine Advisory Committee, who says the VMB's stance on Thyro-L runs “absolutely contrary to regular medical practice.”

Most pertinent for backstretch veterinarians operating in California within the last decade is how the CHRB has issued advisories outlining thyroxine use in racehorses.

The first such advisory came in 2014 following an agency investigation into a series of sudden deaths among Bob Baffert-trainees, which found that the uniform use of thyroxine among the horses in question is “concerning in horses with suspected cardiac failure.”

The CHRB's much tightened rules surrounding thyroxine use went into effect earlier this year.

“If the VMB truly believed that Thyro-L was prohibited in use by the FDA as misbranded, why didn't they simply pick up the phone and call the CHRB,” says Casey. “They've been aware of the concerns surrounding Thyro-L since 2013.”

As a non-FDA approved drug, thyroxine overlaps another key area of conflict between the two agencies-the use of non-FDA approved compounded medications, which is permitted in veterinary practice in California.

So, where does the conflict arise?

Look no further than the CHRB's own Rule 1867 (b) which states that “the possession and/or use on the premises of a facility under the jurisdiction of the Board of any drug, substance or medication that has not been approved by the United States Food and Drug Administration (FDA) for use in the United States.”

The veterinary medical board appears to interpret that rule categorically, stating in complaints against several backstretch veterinarians how no compounded drugs are FDA approved, even if compounded from FDA approved parent drugs.

The list of drugs the CHRB prohibits–at least according to the veterinary board–includes commonly used compounded medications like dantrolene, used on horses that tie-up, and naquasone, which ameliorates swelling.

Crucially, the CHRB's own interpretation of its rules follows existing state law, leaving the door open to backstretch practitioners using compounded medications so long as they contain FDA-approved parent drugs.

Indeed, just last month–seemingly with this interpretive discord in mind–the agency issued an advisory to its relevant stakeholders stating that while compounded medications are not FDA approved, the CHRB's “longstanding interpretation” of rule 1867 “is that lawfully prescribed, compounded medications which are manufactured according to Federal and State guidelines do not violate this regulation.”

The advisory continues: “The CHRB recognizes that compounded medications are necessary for the safe and effective treatment of horses. These medications contain approved Federal Food and Drug Administration (F.D.A.) substances, which have been compounded to achieve proper dosages for safe and effective equine treatment and are necessary for equine veterinarians to effectively treat various medical conditions.”

Furthermore, the CHRB has never filed a complaint for violation of 1867 (b), according to CHRB spokesperson, Mike Marten.

Which leads to the final area of tension-how to define the proper veterinarian-client-patient relationship on a racetrack backstretch.

As the veterinary medical board sees it, no veterinarian can prescribe, dispense or administer a medication without first performing three main tasks: examining the patient and documenting the findings, establishing and documenting a diagnosis, then communicating the best course of treatment with the client.

Among the list of common medications that backstretch practitioners allegedly issued without first performing these tasks includes acepromazine, a tranquilizer used routinely to keep horses calm, and GarstroGard, used to treat stomach ulcers.

But backstretch practitioners and performance horse veterinarians voice frustration with what they see as the VMB's narrow interpretation of this relationship.

The problem arises, says Ramey, because the Veterinary Medicine Practice Act-the overarching rules by which all licensed veterinarians must comport their business-is almost entirely geared around small animal practice.

“The practice act doesn't really address herd health,” says Ramey, who added the American Veterinary Medicine Association (AVMA) is currently reviewing its model practice act to possibly address this. “In herd health, animals aren't always treated individually every time.”

Indeed, California's current laws are “far easier to understand and follow for small animal practitioners (who typically see individual animal patients in a brick-and-mortar context) than they are for veterinarians who treat herds, such as equine or livestock veterinarians,” wrote Dan Baxter, executive director of the California Veterinary Medical Association (CVMA), in an emailed response to questions.

Another wrinkle in the picture, say experts, concerns the currently routine prophylactic use of certain medications in performance horses to avoid injury and the onset of common training-driven ailments.

A prime example in racehorses would be the use of acepromazine-or ace, for short-used ubiquitously during morning training to keep fractious horses calm and to minimize the risk of harm to themselves and others.

“They're saying you can't give GastroGard without listening to their gut sounds and without taking their temp' and what-not on every horse every time. But not every medication requires that degree of [daily diagnosis],” says John Madigan, professor emeritus at the UC Davis school of Veterinary Medicine, calling the VMB's recent actions “horrifically wrong,” due to what he sees as those unfamiliar with equine practice leading complaint investigations.

Who Wields the Stick?

One of the main questions that arise is this: To whose rules should backstretch practitioners adhere?

The CHRB strikes the note that neither agency appears to have “primacy” of authority when it comes to regulating backstretch veterinarians. “And that's the problem because in certain areas there seems to be a disagreement about interpretation,” says CHRB executive director, Scott Chaney.

Veterinary medical board spokesperson, Monica Vargas, equivocated, writing that while the VMB “cannot advise on CHRB enforcement of laws applicable to their licensees,” the VMB has jurisdiction over the practice of veterinary medicine in California “unless otherwise pre-empted.”

Legal pre-emption, in this case, appears to come in the form of the federal Horseracing Integrity and Safety Act's (HISA) racetrack safety rules, which went into effect July 1 and provides guidelines for record keeping and appropriate veterinary-patient-client relationships.

Scott Chaney | CHRB

Indeed, “federal authority does pre-empt state law and state reg's,” says Chaney.

A HISA spokesperson told the TDN that the agency has not yet involved itself with the differences that have arisen between the VMB and CHRB.

For backstretch practitioners with cases from prior years open against them, however-along with the state's broad contingent of performance horse practitioners-HISA pre-emption is a moot point.

That's why California's equine veterinarians and leading equine veterinary bodies have been publicly sounding the alarm about the potential pitfalls of this schism since at least the January veterinary board meeting.

After that January meeting, the CVMA and other stakeholder groups asked the VMB if they could submit a presentation at the following April board meeting about their concerns. The board pulled that presentation prior to the meeting, however.

Asked why, Vargas responded that the presentation went beyond the scope of the request and included, among other things, discussion regarding pending disciplinary matters. “The Administrative Procedure Act prohibits the Board from receiving communications regarding the merits of any issue in a pending disciplinary proceeding,” wrote Vargas.

Interestingly, in a subsequent statement to its constituents, the CVMA took issue with that interpretation, writing that the VMB routinely holds policy discussions concerning the Veterinary Medical Practice Act, including while enforcement cases are simultaneously being conducted.

“If it were the case that the VMB could never talk about problematic regulations or statutes due to a risk of infringing on current disciplinary cases, then the VMB would not be able to function as a rulemaking body at all,” wrote the CVMA.

After that aborted presentation, the VMB assembled a two-person Equine Practice Subcommittee tasked with researching the equine practice regulations and statutes, taking “input” from relevant stakeholders, then “returning to the Board with particular recommendations,” wrote Vargas.

The VMB failed to answer other questions about specific goals of the subcommittee, including those about timelines and about whether the subcommittee's work could lead to amendments to the California Veterinary Medicine Practice Act.

Vargas did write, however, that at the upcoming Multidisciplinary Advisory Committee meeting this Tuesday, the Equine Practice Subcommittee will provide an “update on the issues the Board has directed the Subcommittee to research.”

One of these key stakeholders is the CVMA, which has already approached the VMB several times requesting an “in-depth look be taken at the aforementioned laws,” wrote Baxter.

“The CVMA will continue to engage the VMB in dialogue about the regulations and will strongly advocate for the veterinary profession,” Baxter added.

According to Chaney, the CHRB met with the subcommittee some two weeks ago.

The CHRB's goal for these ongoing negotiations, Chaney says, is “clarity” for licenced backstretch practitioner. “All racing veterinarians that I've spoken with want to comply with CHRB rules and vet' med' board rules, they just don't know what they are right now,” he says.

This “clarity” could come the way of changes to the California Veterinary Medicine Practice Act or to the CHRB's own regulations, says Chaney. But changes to these state rule books can be a glacially slow process.

In the meantime, backstretch practitioners with open cases against them face a Catch-22.

On the one hand, they're incentivized to settle their cases swiftly or even to defend themselves due to the VMB's right, if it prevails on any finding, to seek cost recovery, says Casey.

For Blea, that was a six-figure sum.

However, if the veterinarians settle with the VMB before these practical differences have been smoothed over, they face potentially serious consequences if they then return to active practice under a probationary period.

The VMB is “aware of that potential,” responded Chaney, when asked about this conundrum. But he was unable to elaborate on whether the VMB has proposed any timeline for resolving the agencies' differences.

Investigatory integrity

Which leads to concerns among certain stakeholders about the manner in which the VMB is conducting its investigations into California's backstretch practitioners.

According to both Casey and Blea, neither Blea nor the clients relevant to his case were interviewed as part of the investigatory process.

“At no point did anyone ever ask Jeff [Blea] what was the purpose of administering acepromazine. What was the purpose of administering aspirin powder. He was never asked at any point during the quote, investigation, end quote about anything in his medical record. Not once,” says Casey.

A busy backstretch | Sarah Andrew

“Neither were the trainers, the owners, the grooms,” Casey added. “No one.”

The TDN asked the veterinary medical board about these claims-including about standard investigatory procedures when a practitioner's veterinarian-patient-client relationship is in question-but the agency offered no response.

Other prominent figures in equine practice question the VMB's impartiality in these matters.

As someone frequently called upon to provide expert testimony in cases involving equine practice, Ramey responded to the veterinary medical board's open call for experts in Blea's case, he says.

Ramey told the TDN that when he saw the accusations against Blea, however, he spent an hour and a half explaining to two VMB attorneys that the accusations against Blea amounted to typical standards of care in horses facing rigorous training programs.

“These horses are at risk of developing certain problems, and you're trying to help mitigate that risk,” says Ramey, describing his version of the conversation with the VMB's attorneys.

“The next day they let me know that they did not need my services as an expert witness,” says Ramey, who added that he is “firmly convinced” that the VMB had a “pre-determined outcome that they were looking for.”

It should be noted that Ramey considers himself Blea's professional and personal acquaintance.

“I think it's important that the public is protected against poor veterinary practice,” he responded, when asked about how this relationship might color his opinions. “But [Blea's case] wasn't that.”

When asked about Ramey's claims, Vargas wrote that “As the adjudicator in administrative disciplinary actions, the Board does not participate in prosecutorial activity leading up to an administrative hearing. As such, the Board has no knowledge of expert witness preparation discussions for administrative hearings.”

In speaking with nearly a dozen equine practitioners or leading figures within prominent veterinary organizations, it's clear the ongoing philosophical and practical discord in equine practice has rattled the veterinary community in California.

Some veterinarians have already begun to question their professional futures in the state, says Madigan. “Unfortunately,” he adds, “a lot of veterinarians are thinking 'I just hope it doesn't happen to me.'”

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The additional information, however, mostly “fine-tunes” what was included in the original accusation against Blea and doesn't change the “big picture,” said George Wallace, Blea's attorney.

According to various leading veterinary medical experts, that big picture is one largely of lax record keeping.

What the amended accusation does, however, is set the ball rolling on a rough time-table leading to a full hearing, giving Blea 15 days with which to file a notice of defense.

Once Blea's notice of defense has been filed, the formal hearing is required to be scheduled within 30 days, said Wallace. But due to the complicated nature of the case, it will likely take longer, he said.

“We expect to oppose and refute most everything here when the appropriate time comes. It remains the case that the allegations of the Accusation are disputed, and will be either refuted altogether or shown to be consistent with the professional and legal obligations of equine veterinarians generally, and particularly of equine veterinarians at California race tracks,” Wallace wrote in an email, regarding the amended accusation.

Blea was put on administrative leave from his position as California horse racing's head veterinarian by UC Davis in January. As per an administrative law judge ruling from earlier this month, Blea's veterinary license is also temporarily suspended pending a formal hearing.

In the interim, Blea might still seek injunctive relief in the California Superior Court to lift the temporary block on his veterinary license due to the fact the suspension has “serious problems in terms of a lack of an evidentiary basis,” Wallace said. A decision on such a move could arrive by next week, he said.

After the administrative law judge's ruling earlier in February, CHRB executive director, Scott Chaney, explained that the agency was contemplating similar legal intervention in the Superior Court on behalf of Blea.

According to a CHRB spokesperson Wednesday, no decision had yet been made on the agency's legal approach in the case.

The veterinary board accuses Blea of a number of offenses, including allegedly administering drugs to racehorses without a prior examination to form a diagnosis and determine medical necessity, failing to establish “any” veterinary-client-patient relationship, and of issuing drugs that are not FDA approved for equine administration.

A subsequent TDN investigation found a broad consensus among veterinary medical experts that the infractions are largely matters of poor record keeping which typically result in punitive actions less severe than a suspended license.

Veterinary experts also suggested that the medical board's investigation into Blea potentially failed to account for the unusual nature of veterinary practice on the backstretch, where veterinarians with multiple barns under their care can build the sort of relationship with their animals that is absent from traditional small animal practice.

In its original argument for an interim suspension, the veterinary board claimed that Blea presents a “danger to public health, safety and welfare,” due to his oversight as equine medical director of the high-profile investigation into the death of the Bob Baffert-trained Medina Spirit (Protonico), the GI Kentucky Derby winner who collapsed and died after a scheduled workout Dec. 6 at Santa Anita.

The final results of that necropsy were issued to the public last week, with Medina Spirit's cause of death ultimately “undetermined.”

According to UC Davis, Blea remains on administrative leave, despite completion of the necropsy.

“The conclusion of the Medina Spirit necropsy does not affect the status of the equine medical director position. Dr. Blea's administrative leave continues. In the meantime, school personnel continue to fulfill the duties of the equine medical director for the California Horse Racing Board,” wrote a UC Davis spokesperson, in an email.

The amended accusation includes details that weren't included in the original complaint.

It states, for example, that Blea's veterinarian confidential reports revealed “clusters of equine patients were administered identical medications and treatments, at the same time, at the request of their trainers without medical necessity.”

Listed in explanation are the following substances that are commonly found along the racetrack backstretch: Adequan, Gastrogard, Aspirin powder, Acepromazine pills, Uniprim, Otomax, Legend (a hyaluronic acid), and Tucoprim powder.

The amended accusation also adds additional substances to those that Blea reportedly possessed or used that have not been approved by the FDA.

But as Bryan Langlois, former president of the Pennsylvania Veterinary Medical Association, had previously told the TDN, just because certain drugs don't have FDA approval for use in horses doesn't mean veterinarians are prohibited from prescribing them.

“A lot of drugs that are out there, they're FDA approved but only in certain species or only in humans. The companies never did the trials to test them in animals to get the FDA certification. So, a lot of times, we prescribe these drugs as off-label use,” Langlois had told the TDN.

“Usually, what that means is that there is no FDA approved equivalent out there for that species. The research has been done and the drug dosage has been worked out so that it can be used safely in animals, you just have to make the owner aware of the fact that you're using it off-label,” he had said.

Among the punitive outcomes the veterinary medical board is seeking against Blea is full revocation or suspension of his license.

The TDN asked Langlois to review the amended accusation. In a text, he explained that the nature of the allegations still don't rise to the level requiring immediate license suspension.

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Blea is facing eight causes for discipline, according to formal “accusation” documents issued in late December. Blea's veterinary license was suspended at an emergency meeting held on Christmas Eve. He has not been operating his racetrack practice since taking the job of equine medical director last summer.

“The UC Davis School of Veterinary Medicine is aware the interim order of suspension of Dr. Jeff Blea's veterinary license has been upheld and is monitoring the situation as the legal process moves forward,” Amy Quinton, a UC Davis spokesperson, told the LA TImes. “At this time, Dr. Blea remains on administrative leave. The School of Veterinary Medicine continues to fulfill its duties to provide equine medical director services for the CHRB.”

Blea has also been removed from his role overseeing the investigation into the death of Bob Baffert-trained Medina Spirit, who dropped dead after completing a workout at Santa Anita. The equine medical director is not responsible for actually performing necropsies or testing biological samples on horses who die in racing or training in California or elsewhere. Those responsibilities go to veterinary pathologists and toxicologists — in California, those duties are contracted to UC-Davis, though some samples have been shipped outside California in this particular case. The equine medical director would be responsible for gathering reports and interpreting them for presentation to the board and to the public.

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The commissioners and Executive Director Scott Chaney are optimistic that the interim suspension hearing held on Jan. 21 will overturn this initial decision. However, regardless of the outcome, Dr. Blea has their full support and confidence to continue in his role as EMD throughout the full adjudication process.

The commissioners are further committed to pursue appropriate legal avenues to protect the authority of the board, as well as preserve the contract with UC Davis, which appointed Dr. Blea as the Equine Medical Director for the CHRB.

The post Dr. Jeff Blea Has ‘Full Support’ Of California Horse Racing Board appeared first on Horse Racing News | Paulick Report.

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Blea is facing eight causes for discipline, according to formal “accusation” documents issued in late December. Blea's veterinary license was suspended at an emergency meeting held on Christmas Eve. He has not been operating his racetrack practice since taking the job of equine medical director last summer.

Deputy attorney general Elaine Yan, representing the medical board, argued Friday that the allegations against Blea are violations of the veterinary medical practice act.

Meanwhile, Blea's attorney George Wallace argued that the allegations against the veterinarian do not meet the “extraordinary standard” generally required for the suspension of a veterinary license.

“You've had drunken veterinarians. You've had substance abusing veterinarians who you would not trust in a surgical suite. You have had grossly incompetent veterinarians who keep messing up even after the accusations have been filed,” said Wallace.

“In none of those cases has the veterinary medical board sought in interim suspension order. Dr. Blea is apparently the most dangerous veterinarian in existence in California, and the board has not articulated an actual present remotely likely danger that is posed by letting this disciplinary process go through the process of hearing the merits and a determination.”

Earlier this week, Dr. Gregory Ferraro, chairman of the California Horse Racing Board, called the recent investigation and action by the Veterinary Medical Board to temporarily suspend Blea's license an “unwarranted and unfair vendetta” that is “ill-advised and slanderous.” Ferraro said Blea has become a “pawn in a politically driven effort” to hurt horse racing in California. As a result of Blea having to be put on administrative leave from his post with the CHRB, Ferraro added, “the health and safety of racehorses are being compromised.”

Read more at the Thoroughbred Daily News.

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In short, the deputy attorney general Elaine Yan representing the veterinary board took a procedural defense of the petition, arguing that the allegations against Blea amount to violations of standards of practice within the veterinary community as codified in the veterinary medicine practice act.

“These guidelines emphasize the importance of examinations and diagnosis,” said Yan, before zeroing in on what she said is the “most important part” of the clinical guidelines.

“It states, and I quote, 'Documentation of the use of all prescription drugs should conform to the requirements of the applicable state veterinary practice act,'” said Yan.

George Wallace, Blea's attorney, argued that the allegations against Blea don't meet the “extraordinary standard” that is typically required to suspend a veterinary license, and that no formal hearing on the “merit” of the allegations has yet been conducted and thus proven.

“You've had drunken veterinarians. You've had substance abusing veterinarians who you would not trust in a surgical suite. You have had grossly incompetent veterinarians who keep messing up even after the accusations have been filed,” said Wallace.

“In none of those cases has the veterinary medical board sought in interim suspension order. Dr. Blea is apparently the most dangerous veterinarian in existence in California, and the board has not articulated an actual present remotely likely danger that is posed by letting this disciplinary process go through the process of hearing the merits and a determination,” Wallace added.

Administrative law judge Nana Chin has 30 days with which to issue a written ruling on the case. According to Wallace, he expects that ruling to arrive by the end of next week.

Earlier this month, the California Veterinary Medical Board announced that an emergency hearing had resulted in an interim suspension of Blea's veterinary license for a number of alleged offenses, including purportedly administering “dangerous drugs” to racehorses without a prior examination, without forming a diagnosis and without medical necessity.

The veterinary board also claims that Blea presents a “danger to public health, safety and welfare,” due to his oversight as equine medical director of the high-profile investigation into the death of the Bob Baffert-trained Medina Spirit (Protonico), the Kentucky Derby winner who collapsed and died after a scheduled workout on Dec. 6 at Santa Anita.

A TDN investigation into the accusations leveled against Blea found a consensus among veterinary medical experts that the infractions are largely matters of poor record-keeping which rarely, if ever, rise to the level of a suspended license.

The role of equine medical director is first appointed by the dean of UC Davis, who then contracts out the appointee's services to the CHRB.

Last week, UC Davis placed Blea on administrative leave pending a formal review of his veterinary license–this, despite the CHRB's arguments that the position isn't one that has historically required an active license.

At the beginning of Friday's hearing, an attorney representing the CHRB attempted to formally participate in the hearing by arguing that the veterinary board's actions to remove Blea from his equine medical director position constitutes regulatory overreach.

In response, deputy attorney general Michael Yi argued that it did fall within the veterinary board's purview because the statutory definition of the position means that Blea is actively “engaging in veterinary medicine by conducting his duties.”

Judge Chin, however, said that the sole purpose of the hearing was to examine the merits of the allegations against Blea.

“This is something that will have to be dealt with at a full administrative hearing where parties can argue whether that constitutes unauthorized practice of veterinary medicine,” said Chin, about whether the equine medical director position requires an active license.

This left deputy attorney general Yan to argue that an interim suspension of Blea's license was necessary in the event Blea returned to veterinary practice.

In doing so, Yan cited a passage of the veterinary board's petition for an interim suspension against Blea where he's alleged to have administered, from January 2021 through March 2021, medications to 3,225 horses. “This averages out to be 48 horses per day,” the petition states.

“The fact that he can go back to administering drugs to 50 horses a day, thousands of horses a month, at the behest of the trainer and not in the best interest of the horses, truly poses a serious danger to public and equine health if his license is restored,” said Yan.

Wallace argued that Blea, who hasn't practiced veterinary medicine since he took over as CHRB equine medical director last year, has no intention of returning to practice in the near future.

Wallace also suggested that the judge could “fine tune” an order to deny the interim suspension for Blea so that he could resume his equine medical director post, and still prevent him from returning to medical practice.

“But you shouldn't even get to that. You should deny this petition outright,” said Wallace. “And if you could, I would ask you to vacate the original suspension as improvidently granted retroactive to January third.”

Wallace added, “The board has not met the standard for this extraordinary imposition on quite possibly one of the finest veterinarians in America, and I would submit that this must be denied and repudiated in every way possible.”

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