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Toward a Standard of Care for Pain

By Narda G. Robinson, DO, DVM, MS, FAAMA

In his autobiography “What I Have Lived For,” humanitarian Bertrand Russell reflected on his past, writing:

“Three passions, simple but overwhelmingly strong, have governed my life: the longing for love, the search for knowledge, and unbearable pity for the suffering of mankind. … Love and knowledge, so far as they were possible, led upward toward the heavens. But always pity brought me back to earth. Echoes of cries of pain reverberate in my heart. … I long to alleviate the evil, but I cannot, and I too suffer.”¹

Many veterinarians similarly experience unbearable pity for the suffering of animal kind. Unlike Russell, who longed to reduce suffering but could not, we hold in our hands, hearts and minds a dramatic capacity to intervene on behalf of animals and lobby for better treatment, whether in the feedlot, the research lab or in the veterinary clinic. 

We can upgrade standards of care from within our profession or wait for them to be imposed by public pressure. For better pain management in particular, science supports it, caregivers want it and we can provide it.  

Ethics of Pain

It’s unclear why some veterinary patients are sent home to live a life of chronic pain after not receiving adequate pre-emptive, intraoperative or postoperative analgesia. That prompts one to ask what the medical or ethical justifications might be for letting animals live in pain.

Similar frustrations exist in the human medical community regarding insufficient pain control by practitioners who lack adequate awareness and education in pain medicine. This problem led the National Pain Foundation to assemble a Pain Patient Bill of Rights.² 

The bill highlights the “five pillars” of pain management:

• Emotional and cognitive comfort. 
• Physical restoration by means of therapy and rehabilitation measures. 
• Pain medication. 
• Interventional pain procedures (e.g., injections, regional blocks, epidural analgesia). 
• Integrative pain medicine approaches such as acupuncture and manual therapy.³ 

5 More Rights

Whether pain management can be considered a human “right” remains unresolved; it is questionable whether a parallel set of veterinary patient rights to proper pain management would be upheld by the profession.⁴

At the very least, welfare standards advocated for animals used for food should apply to companion animals. Back in the 1970s, the Farm Animal Welfare Council assembled a list of “five freedoms” for farm animals.⁵ Thirty years later, these freedoms still ring true no matter the animal’s role in life: freedom from hunger and thirst; freedom from discomfort; freedom from pain, injury or disease; freedom to express normal behavior; and freedom from fear and distress. 

Based on the five freedoms and the five pillars, a starting point emerges around which to begin discussion for standards of care regarding veterinary patients’ pain management:

1. Caregivers should receive pain management information and have their questions answered before invasive procedures are performed on their animal.

Pre-emptive and intraoperative analgesia increases the likelihood of effective pain relief after surgery and reduces the risk of the animal developing chronic pain.⁶ 

In human medicine, “Failures of pain management can have catastrophic consequences for patients and for health care institutions.

Undertreatment may also lead to patient suffering, surgical complications and other negative treatment results. Pain is not just a background noise ... to be stoically ignored or endured; it is the cause of somatic failures and expensive hospitalization and of patient resistance to treatment.”⁷   
 

2. Options for the treatment of pain should include collaborative, science-based integrative medicine and multidisciplinary efforts.

Nonpharmacologic modalities including medical acupuncture, massage and other physical medicine approaches can boost pain control without risking further drug-related adverse effects (e.g., constipation from opioids).^8-9 A paper on the law and ethics of pain treatment in humans holds that physicians are required to disclose the options, risks, benefits and consequences of alternative treatment methods if the medical community deems them feasible.¹⁰

3. Caregivers should receive details about the source of their animal’s pain and be educated about the potential cause of that pain, how to avoid causing it in the future and how to monitor for signs of recurrence. A comprehensive physical examination needs to include a myofascial palpation examination to identify soft tissue pain because it cannot be detected sufficiently otherwise.

The satisfactory prevention and treatment of pain involves identifying the affected tissue and type of pain likely to be or that are being experienced.¹¹ 

Neurologic and myofascial palpation examinations yield vital insights as to why a dog no longer willingly goes on walks or jumps into a vehicle. Effective neuromodulatory interventions such as acupuncture, massage and laser therapy require identification of the sources of discomfort for optimal results.¹²

4. Patients should receive routine assessment for pain at their regular check-ups and frequently after surgery. This allows veterinarians to institute or modify analgesic measures.
 
Pain, while common, remains underdiagnosed in veterinary patients and particularly in geriatric individuals.¹³ Not looking for it and not asking about it translate to not knowing about it and not treating it.

5. Caregivers and veterinarians need to communicate openly about pain.

To stop underdiagnosing and undertreating pain, veterinarians need to use the tools already readily available (i.e., broadened examination skills, acute and chronic pain scales and recommended analgesic regimens for perioperative and long-term care).¹⁴  

Veterinary educational institutions can do their part to graduate cadres of pain-conscious veterinarians by improving student exposure to pain assessment and treatment measures during every clinical rotation as part of a system-wide, team approach to pain. 

Establishing a standard of care, let alone a bill of rights, for the treatment of pain in animals may seem incendiary to some. Nevertheless, a law review detailing the liability effects of developing pain management standards for human medicine stated that “bioethical debates help shape the development of accepted professional standards which, if violated, often form the basis for imposition of civil, criminal, and administrative penalties. … [W]here ethical debates do not result in an overall consensus with respect to the appropriate professional standard under consideration, legislatures and regulatory bodies will often step in to fill the gap.”¹⁵ 

In human medicine, “Failure to properly manage pain—to assess, treat and manage it—is professional negligence.”¹⁶ The American Medical Association Code of Ethics states, “Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care.”¹⁷ 

At the same time, however, “Medical practice at all levels lags behind these ethical expressions of the duty to treat pain.”¹⁸

Let’s hope that veterinary practice leads and not lags in embracing opportunities to find and eliminate pain and to develop standards that reflect our commitment to eliminating suffering. <HOME>

Narda Robinson, DVM, DO, Dipl. ABMA, FAAMA, offers an evidential and scientific perspective on trends in complementary and alternative veterinary medicine. She oversees complementary veterinary education at Colorado State.

This article first appeared in the June 2010 issue of Veterinary Practice News. Click here to become a subscriber.

FOOTNOTES

1. Russell B.  The Autobiography of Bertrand Russell.  July, 1956.  Accessed here on April 26, 2010.

2. National Pain Foundation.  Pain Patient Bill of Rights.  Accessed here on April 26, 2010.

3. National Pain Foundation.  NPF’s policy statement.  Accessed here on April 26, 2010.

4. Hall JK and Boswell MV.  Ethics, law, and pain management as a patient right.  Pain Physician.  2009;12:499-506.

5. Rollin BE.  Veterinary ethics and production diseases.  Animal Health Research Reviews.  2009;10(2):125-130.

6. Farsi M and Gitto L.  A statistical analysis of pain relief after surgical operations.  Health Policy.  2007;83:382-390.

7. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

8. Greene SA.  Chronic pain: pathophysiology and treatment implications. Topics in Companion Animal Medicine.  2010;25(1): 5-9.

9. Etzioni S, Chodosh J, Ferrell BA, et al.  Quality indicators for pain management in vulnerable elders.  JAGS.  2007;55:S403-S408.

10. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

11. Grubb T.  Where do we go from here?  Future treatment strategies for chronic pain.  Topics in Companion Animal Medicine.   2010;25(1):59-63.

12. Grubb T.  Chronic neuropathic pain in veterinary patients.  Topics in Companion Animal Medicine.  2010;25(1):45-52.

13. Etzioni S, Chodosh J, Ferrell BA, et al.  Quality indicators for pain management in vulnerable elders.  JAGS.  2007;55:S403-S408.

14. Grubb T.  Where do we go from here?  Future treatment strategies for chronic pain.  Topics in Companion Animal Medicine.   2010;25(1):59-63.

15. Stark SE.  Bio-ethics and physician liability:  the liability effects of developing pain management standards.  St. Thomas Law Review.  Spring, 2002.  14 St. Thomas L. Rev. 601.

16. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

17. American Medical Association, Code of Medical Ethics.  1996:40.  Cited in:  Furrow BR. Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

18. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

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Toward a Standard of Care for Pain

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Re: whether you agree that acupuncture and manual therapy in veterinary medicine have merit in pain control. (the patient cannot tell you if it does, it is merely subjective on the part of the practitioner and the owner), I have seen research reviews showing mixed results for effectiveness of acupuncture in humans. However, I have not seen research refuting the findings of those who found increased endogenous opioids in the CSF of animals after acupuncture. This seems like a good reason to recommend acupuncture for pain. Re: manual therapy: if flexibility is restored to a neck, back, or limb after manual therapy, and there is no radiological or MRI evidence of arthritis, IV disc disease, fracture, etc., how can that be interpreted other than pain relief? Re: and based on that, how you can ethically promote it in teaching or practice. Based on the above, why shouldn't you do something that has the potential to increase their comfort? Nancy Scanlan, DVm, Mount Shasta, CA Posted: 6/19/2010 3:26:25 PM As I stated in my column, not looking for pain and not asking about it translates to not knowing about it and not treating it. How many veterinary students currently learn how to perform a myofascial palpation examination to identify soft tissue pain and dysfunction? How many can cogently discuss the benefits of neuromodulatory interventions such as acupuncture and massage for chronic pain? Effective and safe pain treatments can and often should include integrative medical approaches. Regarding your criticism of my asking whether veterinarians are doing enough to prevent, monitor, identify, and treat pain, implying that the status quo is sufficient, I contend that we as a profession need to broaden ours considerations to all of animal-kind. I draw from Bernie Rollin’s paper on “Veterinary Ethics and Production Diseases” [Animal Health Research Reviews. 2009;10(2):125-130]. Dr. Rollin wrote: “[P]roducers ignore questions of animal pain, fear, distress, confinement, truncated mobility, bad air quality, social isolation and impoverished environment unless any of these factors impact negatively on the “bottom line”…No one could possibly question that, regardless of one’s definition of welfare, good health is surely presuppositional to good welfare, and that production diseases are thus inimical to good welfare. And if the essence of veterinary medicine is to act like a physician for animals, it clearly cannot accept treating production diseases which are preventable by changing the system of production….It is conceptually and morally impossible for veterinarians to accept systems that make animals sick, rather than trying to change the system…I am not saying that veterinarians should fail to treat sick animals that are created by current production systems; in fact they need to add more treating of individual animals to the current emphasis on herd health….But I am saying veterinary medicine should not accept the status quo and band-aid pathogenic systems.” Dr. Narda, Fort Collins, CO Posted: 6/12/2010 8:36:12 AM Actually I have read some of your other articles. I am confused however, with your presentation. Perhaps I'm missing something, you promote certain forms of CAM yet do not promote others, which in the overall scheme of evaluating evidence, very little of it seems to apply to any evidence at all. What I'm getting is more like there are mountains of evidence suggesting more research is needed! Since you are teaching these methods, then is it not fair to assume there may be some bias in your evaluations? When you infuse acupuncture and massage therapy and other CAM methods into a standard of care for pain article, then you most certainly are talking about CAM AND conventional medicine. I think there's a fine line between a code of ethics and veterinary medicine and CAM and unproven methods. There's also a fine line between humans who can tell the practitioner if there has been an effect as opposed to animals who cannot. I do not disagree with you about some practitioners ignoring pain and subsequently ignoring treating pain. Your presentation however, implied that a larger majority of veterinarians do not treat pain control as a crucial element. Most of the article is quoted, referenced, it would be interesting to hear if you have a 5 pillars of pain management and whether you agree that acupuncture and manual therapy in veterinary medicine have merit in pain control. (the patient cannot tell you if it does, it is merely subjective on the part of the practitioner and the owner), and based on that, how you can ethically promote it in teaching or practice. Wendy R., Pullman, WA Posted: 6/11/2010 1:39:18 PM Wendy, If you read my other columns, you may be surprised to learn that we're more similar than different by sharing the desire to see veterinarians utilizing tested and proven techniques. As I said in my piece, "[A] starting point emerges around which to begin discussion for standards of care regarding veterinary patients’ pain management". This is not between CAM and conventional medicine at all. Both veterinary and human medicine have a long way to go to develop a standard of care for pain. As long as there continue to be practitioners who deny their patients pain medication, who refuse to admit their patients feel pain, and who omit a pain evaluation from their physical examination, there is a need to raise this discussion and begin working on a standard of care for pain treatment in animals. Otherwise, we're stuck with the status quo. That may work for you, but it doesn't for me. A good many practitioners indeed do provide excellent pre-emptive analgesia, intraoperative interventions, and post-op monitoring and pain alleviation. However, there is still a segment of our profession who fail to even recognize that pain medication is important at any time before, during, OR after surgery. I recommend that in addition to reading my other columns on acupuncture, massage, etc., you should investigate the articles I referenced in the footnotes. Then maybe we can have a decent discussion about what I actually wrote and the resources I utilized for the column. Dr. Narda, Fort Collins, CO Posted: 6/10/2010 9:30:28 PM