Nine Steps for Pain-Free Nine Lives
By Jane Brunt, DVM For Veterinary Practice News
Posted: January 30, 2014, 3:10 p.m. EDT
Do you think cats feel pain? Does everyone on your team think that? What do your clients think about pain in cats, and what do you say to them to make them think that?
Because owned cats outnumber dogs in the U.S. and Canada, that makes them the most popular pet in North America. Still, they receive far less veterinary care than their canine "cousins”–according to recent studies, about 50 percent less.
In recent years, a lot of good things have happened to improve cat health–research, guidelines, continuing education, feline practice board certification, feline health initiatives, new medications and products, and even a collaborative feline health and welfare organization, CATalyst Council. So what advances have you made in your practice to identify and treat cats in pain?
If you think you can do better, here are nine steps to take to show that you are committed to caring for cats. With compassion, collaboration and consideration of creature comfort, you’ll be seeing them throughout their nine lives.
1 Team agreement: Cats DO experience pain, just like dogs and people.
This can start as a simple written, electronic or walk-around survey of your staff. Try using an open-ended question like, "What do you think can cause pain in cats?” While this seems like a rhetorical question, with everyone weighing in, the foundation for agreement makes the next steps easy.
You could use the survey findings to begin your next staff meeting, or even do the survey there and have someone take notes on a flip chart (seeing is believing).
A lot of good things have happened to improve cat health in recent years –research, guidelines and continuing education.
It would be helpful to have key people work with you in advance so they know the desired outcome–calm and comfortable cats!
2 Understand common causes.
While the team may have already identified common causes of pain, including wounds, fractures and other injuries, surgical procedures, oral disease, even pancreatitis and inflammatory bowel disease, once you list all the common causes, one of your helpers can reference the AAHA-AAFP Pain Guidelines with other causes less frequently considered.
Causes of acute pain may be more obvious than conditions that cause chronic pain, so everyone’s opinion matters.
"What pain does your grandmother have?” might be relevant for younger team members. Again, keeping score and listing what they’ve come up with will start "outside the box” thinking about pain in cats.
Finally, ask what’s painful in a dog that’s not on your list so far, and ask if that might apply to cats as well.
3 Recognizing and scoring pain in cats.
What’s different about how cats show pain is that they may just withdraw and seem to "sleep” when their eyes are closed and they lay curled up. This classic cat response is often overlooked and is the basis for the commonly cited comment that "Cats hide their pain.” The truth is that they are showing signs of pain, and it’s your job as a veterinary professional to recognize the subtle signs.
Another common misinterpretation with cats in pain is that arousal with vocalization–yowling and growling–is seen as aggression. Remember that some cats in pain purr!
If it’s unclear if a patient is aroused because of fear or pain, treat the cat for pain with a fast-acting opioid, wait 20 to 30 minutes and assess again.
Experts will tell you there’s no single system for identifying pain in cats, but they’ll all agree that a change in the cat’s behavior can be a clue if you know what to look for.
One basic system of pain scoring is a numeric "Simple Descriptive Scale” where the observer assigns a value on a 0-to-4 scale interpreting no pain (0), mild pain (1), moderate pain (2), severe pain (3) or the worst possible pain (4).
As a more objective measurement, observe behavior changes such as decreased appetite, grooming and interaction with the cat’s environment or its caretaker, use of the litterbox, changes in posture or facial expression and response to palpation and touch. These signs can all be scored and recorded in the patient’s file (understanding that interpretations are subjective).
Examples of pain scoring tools can be found in the resources listed below. What’s important for your team to understand is that just as with following serial creatinine levels or blood pressure, pain scoring at each visit or throughout an illness or injury provides a baseline for identifying pain and monitoring its progression and the patient’s response to therapy.
4 Gain owner agreement: "Of course she’s less active–after all, she is getting older.”
If the owner thinks her 11-year-old calico is finally behaving because she no longer jumps on the kitchen counter, she needs to think again. It’s not because she’s gotten the message that jumping on the counter is unacceptable–cats like to get up on things so they can look down. It’s probably because the cat has arthritis and it’s too painful to make that leap.
The other end of the spectrum–and perhaps the most significant–is the owner who thinks the cat is in pain with something that may seem insignificant to you. "Doctor, she’s been licking her side more than usual,” but you can’t find anything abnormal. What have you said in the past?
"Everything seems OK, so just watch it” or "If it gets worse let me know.” Because many cat owners are observant if they think their cat is in pain, you need to listen and strongly consider that they may be right.
Pain in cats is important, real and can be managed. When you do, you’re a hero to the cat and the client.
5 Medical therapies: NSAIDs, opioids and beyond.
OK, everyone’s on board for recognizing pain in cats and the need to treat it. How do you do that?
With cats and medications, the two most important considerations are, first, is it safe, and second, can you get the medication into the cat?
And even if the answer to both is "yes,” you still have to consider how getting it into the cat affects the relationship between the cat and its owner.
Asking a client to give a bitter pill twice a day to a cat with a painful mouth is not in anyone’s best interest, so you may need to consider alternatives. When your team reviews the AAHA/AAFP Pain Guidelines, you’ll see there are many classes of medications.
Opioids like buprenorphine are widely used in cats and two NSAIDs are labeled for short-term use in cats: meloxicam (Metacam from Boehringer-Ingelheim) and robenacoxib (Onsior from Novartis). In any case, understanding the potential for adverse events, educating your team and informing your client are essential.
Another key concept is targeted therapy, where a combination of medications is used to target different points along the pain pathway from local inflammation and pain sensation to nerve transmission to central (brain) processing of the pain. Used together, lower dosages of the agents may be even more effective than a single agent. Historically called "multimodal pain management,” the "targeted therapy” terminology is considered more meaningful by many experts.
Finally, keep in mind that there is no "one size fits all” when it comes to pain, and every feline patient must be considered as a unique individual. Analgesics, anesthetics, anti-inflammatories and anxiolytics are some of the classes and characteristics of the many drugs available, though few are FDA-approved for use in cats.
6 Nutrition and nutraceuticals.
Glucosaminoglycans and other nutritional supplements have been widely used in both human and veterinary medicine with variable responses.
Many companies market different forms of the so-called "joint supplements” for use in chronic joint and bladder pain (idiopathic and interstitial cystitis may respond). Some pet foods–both commercially available and therapeutic–have added various nutritional supplements, which is great for cats if they eat the food.
What’s important for you to be dogged about is the quality control that goes into formulating and testing these products.
7 Adjunctive therapies: Acupuncture, therapeutic laser, physical therapy.
Just as in dogs and people, alternative modalities for managing pain in cats are available. Be sure to check your state’s Veterinary Practice Act to determine what professionals are able to perform such therapies. Make sure you review their qualifications, have communication with, and receive reports from, the practitioner.
8 Monitor and measure.
Establishing a baseline for pain in cats at any life stage will help to identify when pain occurs and whether the pain management is effective and safe.
With cats’ unique metabolic pathways, you should follow physical and metabolic response through serial pain scoring and laboratory results. Many veterinary reference labs offer drug monitoring profiles.
9 On the horizon for pain management in cats.
The FDA has indicated that new medications for pain in cats and dogs, if approved, will be brought to market. As dogs still corner the market on pain, frequently the label claims will show as approved "for use in dogs only,” while we know that many are (and likely will be) used in cats.
The more you and your team are able to understand and manage feline pain, the more you will see the need and create the demand.
It’s up to you to be a champion for cats.
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