Some veterinarians still make pain control a client option. The availability of pharmaceuticals and the knowledge to mute pain pathways allow veterinarians to tackle acute and chronic pain more effectively than ever. So why not adopt a multimodal pain control protocol? Steps to Control Chronic Pain Make an accurate diagnosis after considering all of the animal’s adverse health influences. . Manage all aspects of disease along with pain. . Control weight. . Use a polysulfated glycosaminoglycan (PSGAG), which can be administered subcutaneously. . Make sure the animal’s home has nonskid flooring and raised food and water dishes. Slings should be used when appropriate. . Apply heat/cold. . Break the pain cycle. Choose medications that target different areas—inflammatory pain, for example. . After function is restored, use physiotherapy. These can include hydrotherapy, therapeutic strength building, acupuncture, low-level laser, low-level ultrasound and stretching. . Always use the lowest effective pharmaceutical dose. Some specialists contend that practicing without employing all necessary pain control options violates the veterinary oath and morals. Educating clients about pain control before providing cost estimates that break out pharmaceutical prices keeps pain control from appearing optional to owners. The theory is that when owners look to shed expenses, they can decline or question the need of a service, but when it comes to pain control, experts say, look elsewhere to cut expenses. “When I speak at conferences and ask the audience who has downloaded the pain management guidelines [published by the American Animal Hospital Association and the American Association of Feline Practitioners], five veterinarians out of a room of 200 raise their hands,” says Robin Downing, Dipl. AAPM, CVA, of Windsor Veterinary Clinic in Windsor, Colo. “I’m always astounded that in a profession where the patients cannot speak for themselves, we aren’t doing everything we can to control patient pain.” Financial constraints can prompt veterinarians to whittle away at their desired protocols. “If I’m going to call myself a professional, I’m going to make the best medical decisions for my patients and not allow an owner to make a medical decision,” Dr. Downing says. “The worst offense comes when veterinarians X-ray the clients’ wallets on the way into the office, making assumptions on what they will pay for before it’s been charged.” Mark Epstein, DVM, Dipl. ABVP, agrees that owners’ financial restrictions are often more perceived than real, adding that the lack of early pain control in chronic pain cases can lead to a fatal outcome. “Many animals may be euthanized early because they can no longer get around from chronic pain such as osteoarthritis,” says Dr. Epstein, president of the International Veterinary Academy of Pain Management (IVAPM) and medical director of Total Bond Veterinary Hospitals and Forestbrook Carolinas Animal Pain Management in Gastonia, N.C. “If we got away from using the term ‘chronic’ and said ‘disability,’ which better defines the condition, owners may recognize the severity of the issue,” Dr. Epstein says. “This is a disability. It gets worse if gone untreated, altering animals’ movement and even behavior.” Multimodal/Chronic The multimodal approach is gaining popularity with the help of the IVAPM, which establishes and raises the standard of care in animal pain management. “The IVAPM provides veterinarians with access to information, research and data that reports on the most updated recommendations,” Epstein says. “It offers a certification program for veterinarians that requires an exam, which if passed will earn the title of certified veterinary pain practitioner.” Veterinarians often have to get creative with techniques for certain patients, finding ways in which the animal will respond and the owner will comply. “We use physio balls, Cavaletti rails, treadmills and balance boards, among other things, to help reduce patients’ chronic pain,” Epstein says. “Animals tend to respond to positive reinforcement like a treat.” Darryl Millis, DVM, Dipl. ACVS, a professor of orthopedic surgery and director of physical therapy at the University of Tennessee, says he found that one feline patient wanted to be in its carrier, so he placed the carrier at the end of Cavaletti rails, forcing the cat to walk through them to reach the goal. “Owners and veterinarians often feel cats are difficult to encourage to exercise, but using the right tools [can work]. Try opening the canned food in a different room than the animal is in. That encourages extra movement when he comes looking for dinner,” Dr. Millis says. Weight maintenance is an important part of the multimodal pain control, so much so that if Slentrol must be used, Millis asks the owner to make a donation to the World Hunger Foundation. “People go to bed starving every night, but we have to give our pets medication [because] they’re so overweight,” Millis says. “In many cases, access to too much food is making U.S. animals unhealthy.” One of the veterinarian’s go-to pharmaceuticals to help reduce chronic pain symptoms quickly is gabapentin. The drug is used in human medicine to treat seizures and neuropathic pain, diabetic neuropathy, malignant pain, central pain, complex regional pain and trigeminal neuralgia, but few compelling studies exist that used the drug in veterinary medicine. However, many veterinarians use it to treat canine and feline chronic pain in chorus with other pharmaceuticals. “Gabapentin can be used perioperatively,” Downing says. “The research that was conducted using the drug perioperatively in veterinary medicine was orthopedic surgery, which in the study didn’t fare well. But it wasn’t used in high enough doses.” Multimodal/Acute Acute pain can be almost completely sidestepped when the appropriate drugs are administered at the right time, specialists say. “It was easy when we thought animals weren’t experiencing pain like us, but we were wrong,” Downing says. “A lot of excuses are made when not controlling pain the right way. Some veterinarians say they can’t put local anesthesia where the incision will be made because it distorts the tissue and delays healing, but that isn’t true. “Anesthesia needs to be administered before the incision is made to block signals of pain. Putting anesthesia on tissue after an incision is like locking the barn door after the horse is gone.” Opiates are the gold standard for managing acute and severe pain, experts say, listing morphine as an excellent premed option. Before cutting, a narcotic anesthesia induction and a local anesthetic should be administered. “Before deciding on a regimen, think about how discomforting the procedure is,” Downing says. “Are you performing an ovariohysterectomy on a 5-month-old or are you amputating the limb of a 10-year-old cancer patient? A constant rate infusion IV helps the patient recover from the painful experience. “Learning how to place an epidural would be a great investment in patients’ comfort. At this point, there isn’t compelling evidence that an NSAID given immediately before surgery is beneficial. In fact, there is an increase for an adverse event if an NSAID is given just before the procedure. Once the surgery and anesthetic event are over, giving the NSAID helps the body mitigate inflammation and perioperative pain.” Postsurgical thrashing or yelping isn’t just “part of anesthesia,” experts say. Special attention should be given to these animals to form an appropriate assessment. “An appropriately managed patient will not be vocal postsurgically,” Downing says. “Our recovery ward is the quietest place in the building. One way to decide if a patient is experiencing pain postsurgically or is dysphoric is to interact with them. “When you speak to the animal, does it stop vocalizing or continue? If it completely ignores you and continues to yelp, it is dysphoric. If it stops vocalizing, it is likely experiencing pain.” An effective multimodal postsurgical follow up can include using a therapeutic laser, icing the incision, acupuncture and emptying the bladder. Specialists say that recognizing patients’ chronic pain behavior remains an issue of concern when attempting to abate patient discomfort. Veterinarians need to educate owners on chronic pain as a long-term, often lifelong battle to convey the importance of rechecks. “Any time an animal changes its activity, it could be due to chronic pain,” says James Gaynor, DVM, MS, Dipl. ACVA, Dipl. AAPM, director of the Peak Performance Veterinary Group in Colorado Springs, Colo. “Older dogs may slow down, but it doesn’t mean they have to be in pain. These patients must be watched carefully, considering their pain will not lighten through healing or without intervention.” Testing Specialists say more testing on the pain drugs they use off-label would be a benefit. “The concept of multimodal pain control is sound, but for veterinary medicine many of the drugs haven’t been investigated for animal use,” Dr. Gaynor says. The pharmaceuticals are being used despite a show of efficacy. Considering the expense of a clinical trial, manufacturers don’t see a profit coming from conducting the research, some say. “It costs $50 million on average for a veterinary clinical trial,” says Butch KuKanich, DVM, Ph.D., an associate professor at Kansas State University. “If it costs 20 cents now for a pill, the company would have to charge $2 to $3 a tablet after the trial to cover its expenses. If the trial showed the medication worked, the company didn’t gain much. This is a major stumbling block when looking for evidence in the industry.” Who Is Right? In addition to a lack of pain-control drug testing, the fact that veterinarians don’t all agree is a concern for those looking for peer guidance. “If you speak with 10 different experts, you’ll get 10 different answers as to the best way of preventing surgical pain,” Dr. KuKanich says. “Who is right? I’d like to see a step-by-step explanation for controlling pain and know the minimum useful doses through maximum safe doses.” KuKanich says pain control is an area in which the profession is trying to catch up, but he notes that great strides have been made. “I like to quote a Robert Frost line when considering the level of pain control for patients: ‘We’ve got miles to go before we sleep,’ ” Epstein says. <HOME> This article first appeared in the August 2010 issue of Veterinary Practice News. Click here to become a subscriber.
