Palliative approaches to chronic pain

By Tyler Carmack, DVM, CVA, CVFT, CTPEP, CHPV, CVPP

Osteoarthritis (OA) affects an estimated one in five dogs over one year old, and the prevalence climbs steeply with each subsequent decade.¹ In cats older than 10, radiographic evidence of degenerative joint disease appears in 60 to 90 percent of patients, yet feline OA remains one of the most underdiagnosed conditions in companion-animal medicine.^2,3 By the time a patient reaches the geriatric stage, OA is rarely an isolated finding; it coexists with renal disease, hepatic compromise, cognitive dysfunction, neoplasia, and the cumulative physiologic toll of age.

For these patients, the clinical question shifts from cure to comfort: How do we preserve function and quality of life for as long as possible? This is the territory of palliative pain management, care delivered with realistic expectations, grounded in honest conversation with caregivers, and oriented toward daily living rather than curative endpoints. Palliative care is not a separate discipline reserved for specialists; it is a way of practicing that draws on a multimodal pharmacologic toolkit, an integrative mindset, and a communication style that treats the household as the unit of care.⁴

Reframing the goal: Comfort and function, not cure

Caregivers often arrive in one of two mindsets: relentless optimism a single medication will be a sufficient "fix," or resignation the patient is "just old." Both invite gentle reframing. A palliative model accepts joint changes are chronic and progressive, and no intervention will restore cartilage lost over a decade of activity. It also rejects the assumption decline is a passive process. Geriatric OA patients respond, often dramatically, to thoughtful and layered medical care.

Setting expectations early lays the foundation for everything that follows. Establish a quality-of-life baseline using validated tools, such as the Canine Brief Pain Inventory,⁵ the Liverpool Osteoarthritis in Dogs scale,⁶ or the Feline Musculoskeletal Pain Index,⁷ so that subsequent visits track meaningful change rather than relying on caregiver memory.

General quality-of-life tools also help measure the impact of disease and treatments on the family. Schedule rechecks in advance and invite the family to reach out proactively at the first sign of a slip in comfort or function.

Building a multimodal pharmacologic foundation

Single-agent therapy is rarely sufficient as OA progresses. The pathophysiology spans peripheral nociception, central sensitization, neuropathic contribution, and ongoing inflammatory drivers, and each lever responds best to its own pharmacologic class. The principle of multimodal analgesia, lower doses of multiple agents acting on different points along the pain pathway, is especially valuable in geriatric patients, where reducing the burden on any single organ system pays dividends.⁴

NSAIDs

For most canine patients, a maintenance NSAID remains the cornerstone of treatment. Carprofen, meloxicam, deracoxib, robenacoxib, and the EP4 receptor antagonist grapiprant each have evidence behind them;⁸ selection is often less about efficacy than about cost, formulation, and how the medication aligns with the patient's renal, hepatic, and gastrointestinal profile. Polysulfated glycosaminoglycan injections,¹⁵ omega-3 fatty acid supplementation,¹⁶ and a quality oral joint supplement round out a strong foundation. Baseline bloodwork, periodic monitoring, and honest caregiver conversations about how the risk-benefit calculus shifts over time are part of responsible long-term use.

Adjunctive therapy

When NSAID monotherapy begins to plateau, adjunctive treatments earn their place. Gabapentin is believed to address the neuropathic component that often emerges in chronic OA, particularly in cats.⁹ Amantadine, an N-methyl-D-aspartate (NMDA) receptor antagonist, helps unwind central sensitization and is most useful when a previously effective NSAID begins to lose ground.¹⁰ Anti-nerve growth factor (anti-NGF) monoclonal antibodies (mAbs), bedinvetmab for dogs¹¹ and frunevetmab for cats,¹² have meaningfully expanded what we can offer, providing monthly subcutaneous control with a tolerability profile well suited to the older patient. They are particularly valuable in cats, in which long-term NSAID use is constrained by renal considerations.

Acetaminophen deserves a deliberate place in the canine palliative toolkit. At appropriate doses, it provides analgesia without significant risk and pairs well with an NSAID (or a steroid) in dogs experiencing breakthrough discomfort.¹³ Acetaminophen is, of course, contraindicated in cats and warrants the same level of caution as opioids in households where both species share a medication shelf.

In advanced or refractory cases, subanesthetic ketamine is also worth considering. A sub-anesthetic constant-rate infusion delivered during a half-day hospital visit can interrupt windup pain and reset central sensitization for weeks at a time.¹⁴ Anecdotal intermittent subanesthetic ketamine injection protocols exist and are worth exploring for patients that cannot tolerate hospitalization. Ketamine is not a first-line intervention, but in a plan that already includes an NSAID, gabapentin, amantadine, and a monoclonal antibody, it can be the lever that returns a patient to comfortable mobility.

No single treatment will rescue a painful patient, but each contributes to the cumulative effect that defines successful palliative management.

The integrative layer

Relying on pharmacology alone leaves real options on the table. Acupuncture,¹⁷ photobiomodulation (laser therapy),¹⁸ therapeutic ultrasound, and pulsed electromagnetic field therapy each has a growing body of evidence supporting their use in chronic OA. Their value in the geriatric patient is mechanistic diversity; they deliver analgesic and anti-inflammatory effects through pathways that do not tax the kidneys or liver nor compete with the patient's existing drug load. Offered as complements rather than substitutes, a weekly laser session and a monthly acupuncture visit do not replace the NSAID; they expand what the NSAID can accomplish. They also offer a meaningful way to engage families who feel hesitant about a purely pharmacologic approach.

Exercise as medicine

The most underused intervention in geriatric OA is structured movement. Caregivers, watching their dog limp after a walk, often respond by restricting activity. The instinct is understandable, but it tends to be counterproductive: disuse atrophy, loss of proprioception, and weight gain compound joint pain faster than the underlying disease.

Prescribe exercise the way you would prescribe medication, with a dose, a frequency, and a clear endpoint. For most dogs, that means two or three short, leashed walks each day on level ground, with terrain and duration adjusted to the patient's response. Underwater treadmill therapy, where available, is exceptional for offloading joints while rebuilding muscle.¹⁹ For cats, encourage low and accessible perches, food puzzles that require movement, and short play sessions with a wand toy.

Weight management is the other half of this prescription. Even modest weight reduction in an overweight OA patient produces improvements in lameness and clinical scores comparable to those achieved with an NSAID.^20,21 Reframing the conversation in those terms helps caregivers see what is actually at stake: feeding less is one of the most powerful analgesic interventions they can deliver. These conversations are best started early in the pet's life, since weight loss becomes considerably more difficult once mobility is limited.

Reinforcing the human-animal bond

Palliative plans succeed when they fold into the rhythms of a household rather than fight them. Ask caregivers what their pet loved before the disease progressed, and build the plan around protecting access to those activities. A dog that thrives on park visits does not need to be confined to a yard; the goal is to make a shorter, slower park visit possible. A cat that slept on a high windowsill benefits more from a graduated ramp than from a directive to stop jumping.

Home modifications, nonslip runners on hardwood floors, raised food and water bowls, orthopedic bedding, and low-grade stairs and ramps for cars and beds turn the house into a therapeutic environment. These conversations also give caregivers something concrete to do, which counters the helplessness that often accompanies a chronic, progressive diagnosis. Caregiving for an aging pet can strain the human-animal bond in many ways; where possible, prescribe treatment that strengthens the bond rather than adds to its weight.

Anticipating acute flares: The emergency medication kit

Even well-managed patients have bad days. A patient that slipped on tile, overdid it on a warm afternoon, or simply experienced a flare without an obvious trigger should not have to wait until the next business day for relief. Providing every advanced OA household with a written acute-flare protocol and, where appropriate, a pre-dispensed emergency medication kit turns those moments from emergencies into manageable events.

The exact contents will vary by species, comorbidities, and your formulary, but the principle remains the same: caregivers should have a dose or two of an additional analgesic class on hand, along with clear written instructions on when to administer, when to call, and when to come in. For dogs, that often means a small supply of gabapentin and acetaminophen with a written escalation plan, and in selected cases, a short course of buprenorphine with appropriate counseling.¹³ For cats, oral transmucosal buprenorphine and gabapentin fit the same role.²² The kit is also a teaching tool; it prompts a meaningful conversation about what a flare looks like, what red flags warrant a call, and what the family can manage at home.

Preparing proactively for end-of-life changes

Among the most compassionate things a clinician can do for a long-term OA family is to start the end-of-life conversation before the family needs to have it. Introduce and consistently revisit quality-of-life scales during routine rechecks, not in a crisis.²³ Discuss in-home euthanasia services available in your community, the value of a good-day-versus-bad-day diary, and the warning signs that signal the disease has outpaced the plan.

When acute decompensation does come, a fall the patient cannot rise from, a night of vocalizing pain, a refusal to eat that persists into multiple days, families who have already had this conversation make better decisions, more calmly, and with less regret afterward. Proactive end-of-life planning is itself a form of disease management for both the patient and the household.

The quality-of-life imperative

Palliative care of the osteoarthritic geriatric patient asks the clinician to hold two things at once: rigorous, evidence-based pharmacology, and an unhurried understanding of what daily life looks like in that animal's home. These techniques build naturally on what we already do well, and small additions compound into meaningful improvements in patient comfort and family experience. Done well, this is some of the most rewarding work in small-animal medicine. The patient moves and feels better, the family feels supported, and the relationship that brought them through the door in the first place is honored, all the way to the end.

Tyler Carmack, DVM, CVA, CVFT, CHPV, CPEV, CVPP, is the director of Hospice and Palliative Care for the Caring Pathways family of practices. She founded Hampton Roads Veterinary Hospice, an AAHA-accredited end-of-life practice, and has practiced hospice and palliative care exclusively since 2011. Dr. Carmack has served on the Board of Directors of the International Association for Animal Hospice and Palliative Care (IAAHPC) since 2016, in various roles, including serving as president in 2020 and 2025.

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