by Veterinary Practice News Editors | September 1, 2009 11:21 am
Relying on an animal’s physical cues to determine its level of pain and educating clients to detect the pain can be a challenge.
Experts say the best route to achieving pain control in the non-verbal patient is a thorough and accurate diagnosis coupled with veterinary and client education.
Keeping an open mind on all avenues of pain relief is essential. While one patient may have an unfavorable response to a drug or therapy, the same option could alleviate discomfort in another patient.
Experts say so many pain control options are available that close to 100 percent of patients can be helped through a multimodal approach.
“Pain control has been available in the industry for quite some time, but veterinarians and owners sometimes miss out on opportunities,” says Robert Stein, DVM, CVA, CCRT, Dipl. AAPM.
“Quite a few clients don’t let you go all the way with pain control, which is why veterinarians must be educating clients on ways to determine pain in the canine and feline patient and be open-minded in offering a variety of pain control options.”
Difficulty in assessing the degree of pain has long been a problem. Clients often don’t bring pets to the practice until a disease that causes chronic pain has progressed.
“Even in human medicine, X-rays can show that arthritis disease, for example, has been in place for months even though pain is only recently apparent,” says Dr. Stein, who owns Amherst Small Animal Hospital in Snyder, N.Y. “This may be due to their genetic code making them less responsive to pain. If this occurs in animals in addition to their natural masking of pain, they can be well into disease progression before they even make it to the practice.”
Practices across the U.S. use a variation of Colorado State University’s pain level charts, which demonstrate mild to severe pain in dogs and cats. The charts detail posture, movement, vocalization and behavior that may indicate the animal is uncomfortable.
Pediatric medicine offers some tips for treating patients who cannot pinpoint pain or its severity, but the comparison is not parallel, says Butch KuKanich, DVM, Ph.D., Dipl. ACVCP.
“With pediatric medicine, doctors have a first-hand understanding of pain receptors and how humans perceive that pain,” says Dr. KuKanich, assistant professor of pharmacology at Kansas State University. “In veterinary medicine, we don’t know how a dog feels when poked with a needle. There are some correlations, but pediatric medicine isn’t as parallel as we’d like.
“It can be difficult to judge pain with any given animal responses. The animal may have an injury that would presumably make it be in moderate pain but not show signs of it. On the flip side, minimally injured animals can vocalize and demonstrate signs that would indicate severe pain.”
Keeping abreast of new drugs and new uses for existing pharmaceuticals is one way to assist patients’ pain control needs.
Non-steroidal anti-inflammatory drugs, or NSAIDs, are popular because they give consistent, predictable results and the minimal dosing promotes good client compliance. But the drugs come with a price.
“The concern is that 1 to 3 percent of dogs have adverse effects to these drugs,” KuKanich says. “Adverse effects are primarily gastrointestinal, causing diarrhea and vomiting, but long-term use of the drugs can lead to acute renal failure or exacerbate existing renal disease. It is essential that owners are made aware of the possible side effects before prescribing the NSAID and that bloodwork is performed prior to the regimen.”
A surgical patient’s pain management can be accomplished more effectively through multiple drug intervention.
“Veterinarians are still using butorphanol as a pre-med and that is a poor choice,” says Robin Downing, DVM, Dipl. AAPM, director of the Downing Center for Animal Pain Management in Windsor, Colo. “But combining lidocaine with bupivacaine allows for a fast-acting drug with a short duration to immediately act and a slower-acting drug to span the length of the procedure. Making the incision area numb is the gold standard in preventing pain signals to the brain.”
Dr. Downing suggests using an epidural or constant rate infusion (CRI) throughout the surgery and, if necessary, overnight, weaning the animal off CRI drugs gradually and sending it home with a NSAID.
“CRIs aren’t used as frequently as they should be because there is a misperception that it is a difficult method of pain control, when it’s not,” Downing says. “Calculating the appropriate drug dose for continuous use and combining with sterile saline reduces the amount of gas anesthesia needed and controls pain more efficiently.”
Simple exercises such as range of motion can help ease stiffness and pain and reduce swelling. Using heat or ice also can help decrease pain.
“It is my experience that many general practitioners are unaware of the benefits of rehab for pain management,” says Julia Tomlinson, BVSc, MS, Ph.D., Dipl. ACVS, CCRP, CVSMT.
“You do not need specialized equipment for a lot of basic therapies that help to reduce pain,” says Dr. Tomlinson, president of the American Assn. of Rehabilitation Veterinarians. “You do, however, need training and guidance to avoid making things worse. A rehabilitation veterinarian can use modalities such as electrical stimulation, ultrasound and laser to relieve pain and restore mobility.”
A general practitioner not trained in rehab should be aware of nearby certified rehabilitation veterinarians.
“The advantage of seeing a veterinarian trained in rehab is that pain management is multimodal,” Tomlinson says. “In debilitated patients, we can reduce the need for potentially harmful medications. However, rehab is not a replacement for all pain medications.
Rehabilitation allows patients to go for walks again, get back on the couch and play. Pain medications alone will not do that because a patient loses strength and mobility.”
Lasers and Acupuncture
Low-level laser therapy, also known as cold laser therapy, is revered by veterinarians who trained in and use it. Laurie Coger, DVM, of Bloomingrove Veterinary Hospital in Rensselaer, N.Y., says therapeutic lasers are a godsend for agility dogs and other active pets.
“The laser treats immediate pain, speeds healing and reduces the duration of pain,” Dr. Coger notes. “I use supplements, diet control and some NSAIDs along with laser therapy for a well-rounded approach.”
Lasers have been shown to be effective in cats, who tend to have fewer pain relief options when compared to dogs. Easily annoyed patients may find the treatment more tolerable as well.
“Some lasers require an inch lead way between it and the patient’s skin,” says Brian Pryor, Ph.D., president of LiteCure LLC, which makes the Companion Therapy Laser. “We recently released a glass ball attachment that allows the laser to be directly applied to the patients’ skin. In small animal medicine, the beam goes through the static optic ball so the practitioner doesn’t need to worry about distance, and the animal receives a pain-relieving massage simultaneously.”
Being open-minded can mean the difference between life and death. When a canine patient, Ginger, entered Stein’s Amherst Small Animal Hospital, she was scheduled for euthanasia because of lancinating intervertebral pain that did not respond to traditional medications.
“Ginger is evidence that electric acupuncture isn’t voodoo medicine,” Stein says. “Her previous veterinarian was against acupuncture completely and said surgery was the only solution.
“We treated the dog with one session of therapy and she was like a new dog in hours. The treatment was given three years ago and the dog is pain- and drug-free today. The main ingredient in achieving patient pain control is educating yourself and clients on all available options.”
This article first appeared in the September 2009 issue of Veterinary Practice News
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