pain management Archives - Page 2 of 2

Challenges of Animal Pain: 4 Management Tips

Tony Johnson, DVM, DACVECC
Let’s just get this right out of the way first: animals feel pain.

They have different pain tolerances, just like people do (if I step on my pit bull Gwen’s toe, she never notices, but if I accidentally do the same to my Pomeranian, Turley, she’ll scream, run and hide, and not speak to me for days) but sensing pain comes hand-in-hand with having a complex neurosystem and a big brain.

The challenge for us as veterinarians is how we detect and react to their pain.

To address the complexities of animal pain and its management, the International Veterinary Academy of Pain Management (IVAPM) has declared September to be Animal Pain Awareness Month. (https://ivapm.org/animal-pain-awareness-month/) It’s also Pain Awareness Month for another group of big-brained animals – people.

Treating animal pain will always involve some guesswork until someone develops a way for dogs and cats (and horses and iguanas, etc.) to point to their anatomy and say “It hurts right here, doc.” Until that beautiful day, we have to tease out the sometimes-subtle signals of discomfort and adopt a trial-and-error approach, backed up by science whenever possible.

As an ER clinician, acute pain is what I deal with most. I do see animals with chronic pain, and try to help whenever I can, but for those patients I encourage pet owners to seek the counsel of their family veterinarian, since chronic pain will take a solid partnership spanning weeks or months – things that are impossible in the rushed setting of the ER.

With that as preamble, I’ll share some tips from 25 years of ER pain management.

If a condition is known to be painful, treat for pain. Blocked cats are painful. Pancreatitis is painful. Pyelonephritis hurts. Some diseases have pain baked in, and treating pain should always be part of the initial management plan, yet I very often see pets with diseases such as pancreatitis and urethral obstruction go without pain medication. Until the disease has calmed down, assume pain is present and treat for it.

Recognize the signs of pain. Is that cat sitting at the back of the cage hissing because he is afraid, or is it pain? Is the usually sweet and slap-happy Golden now snapping at the kids because his ears hurt? Recognizing an animal in pain is an important first step in managing pain. A trial of pain medication (perhaps even combined with appropriate sedation) can help tease out the complex web of animal pain responses and decrease the fear, anxiety, and stress of painful conditions and hospitalization. Using a validated pain scale (available at https://ivapm.org/, and many other places) can also help to quantify and track pain during treatment.

AAHA, in 2015, developed guidelines for small-animal practitioners that clearly outline ways to monitor and manage pain: https://ivapm.org/wp-content/uploads/2017/03/2015_aaha_aafp_pain_management_guidelines_for_dogs_and_cats-03.10.17.pdf

Use the right class of medication for the disease. Let’s look again at blocked cats and patients with pancreatitis. A blocked cat who is non-azotemic and going home might benefit from an NSAID used cautiously. A blocked cat with a K+ of 8 and a creatinine of 4? The medical board will be knocking at your door if you give an NSAID.

Same holds true for a dog with raging pancreatitis. If he’s vomiting every time the wind blows, an NSAID will only make matters (way) worse. Opioids have minimal GI effects beyond constipation (which I have not seen as a major problem), and we use tons of opioids in the ER and ICU to manage pain. Our brains (and those of our patients) are hard-wired to receive opioids – it’s a gift from evolution and nature. Use it.

Why do brains have receptors for chemicals produced by a poppy largely grown in the Middle East? I have no idea, but for the sake of my patients I am thrilled that they do, and I make use of it every day I am on the clinic floor.

The opioid crisis has certainly made giving opioids a challenge, with increased regulation and paperwork and changes in the supply chain making some drugs unavailable. Try to keep abreast of what’s on and off the market and do your best to make sure you always have a few options for good pain control on hand. I think every hospital needs to have a full mu agonist such as fentanyl, morphine, or hydromorphone on hand for treating severe pain. Butorphanol is great as an adjunct for sedation for minor procedures like lacerations, but it’s just not potent enough for cases of moderate to severe pain.

Sometime more is more. Treating pain with multiple different approaches can result in better pain control and lower doses of any individual medication. Using a lidocaine sacrococcygeal block to help unblock a cat, combined with a full mu agonist like fentanyl, or an opioid agonist/antagonist like buprenorphine, can treat pain from different angles, as well as make unblocking easier.

Look for creative ways to address pain, using different techniques such as local blocks, epidurals, and topical lidocaine patches. Combining classes of drugs such as NSAIDs and opioids, in carefully selected patients, can achieve results that higher doses of either drug can’t achieve.

I have found that learning new techniques can be a great way to fend off burnout and makes me feel as if I am growing as a clinician. Learning new pain management skills aids me in fulfilling my obligation to alleviate animal suffering. Enrolling in CE classes, attending online seminars, and even brainstorming with colleagues can open new worlds to the clinician who wants to learn and grow. It can also make great financial sense to a practice, as owners now accept and even expect advanced pain-control modalities.

The IVAPM offers consultations in pain management and pathways to become IVAPM-certified as a pain management practitioner. (More info at https://ivapm.org/).

We all want our patients to live long, pain-free lives. Learning about pain and learning new ways to manage pain and recognize it will serve our patients better and help us grow as doctors and people.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Dr. Tony Johnson, DVM, DACVECC, is a 1996 Washington State University grad and obtained board certification in emergency medicine and critical care in 2003. He is currently Minister of Happiness for VIN, the Veterinary Information Network, an online community of 75,000 worldwide veterinarians, and is a former clinical assistant professor at Purdue University School of Veterinary Medicine in Indiana. He has lectured for several international veterinary conferences (winning the small animal speaker of the year award for the Western Veterinary Conference in 2010) and is an active blogger and writer.

Treating Cats With Chronic Pain: What to Consider

Kim Campbell ThorntonSeptember is Animal Pain Awareness Month. As pet care professionals, you know better than anyone that dogs and cats experience pain and discomfort. You also know how difficult it can be sometimes to recognize and manage chronic pain, especially in cats. Too often, pet owners assume that cats normally become less active with age, but changes in a cat’s behavior can be subtle signs of chronic pain from injury or illness.

Pain Goes Unnoticed

Chronic pain in cats is commonly underdiagnosed. Cats are so good at hiding their discomfort that it can come as a surprise to owners and even to some veterinarians to learn that they might be in pain. Owners aren’t always aware that syndromes such as glaucoma or diabetes are accompanied by pain.

Many behaviors can indicate pain in cats, including changes in functional mobility such as decreased grooming or difficulty in jumping on or off furniture; changes in sleep patterns or locations; changes in posture when sitting or sleeping; hiding; changes in litter box habits; unusual reluctance to be petted or groomed; and poor appetite. Anything that isn’t normal for a particular cat should be considered a possible sign of pain.

Causes of Chronic Pain in Cats

Many common feline diseases can cause chronic abdominal pain. Cats with this type of pain may not eat well or are nauseous and lethargic. Unless the pain is severe and constant, though, it may not be obvious when you palpate the cat.

Even once it’s identified, the level of pain can be difficult to assess. It can be a good idea to have owners keep a diary of the cat’s behaviors over a period of time or to have them complete a questionnaire.

Multimodal Relief

Managing chronic pain usually involves several types of therapy that all work together to help relieve discomfort. A combination of medication and physical therapies such as acupuncture, massage, or other rehabilitation techniques is usually most effective. Some trial and error may be necessary to find what works best.

We asked Alicia Z. Karas, DVM, DACVAA, at Cummings School of Veterinary Medicine at Tufts University, about her experience in recognizing and managing chronic pain in cats.

What should people know about pain in cats?

The first one is recognizing that the cat has pain. The cat might have arthritis, a degenerative joint condition, but nobody’s figured that out because the cat doesn’t limp. It might do things like not jump or not groom well. The other is not recognizing that a given syndrome is accompanied by pain. For many years, in dogs and cats, we thought of glaucoma as being something that threatened vision, but we know from people that glaucoma causes pain in humans and it’s a really difficult type of pain to treat. In cats and dogs, if they have an end-stage [case of glaucoma], we’ll take the eye out. Anybody who’s an ophthalmologist or who has removed an eye in an animal with glaucoma probably has heard from the owner that once that happened, the animal returns to almost a younger animal. They’ve had that chronic pain hanging over them, and once that was gone and that surgery has healed, they found their behavior much less inhibited by pain. So thinking about the fact that having skin disease or ear disease or eye disease or intestinal disease might not just be a problem for weight gain or thriving health but that it might impact pain is an important factor in terms of a barrier to pain treatment in animals.

What are some of the challenges of managing pain in cats?

When cats are resistant to being pilled, it can be a challenge. Sometimes cats need treatment for life and owners need to figure out how to get meds into the cat every day. Formulation of medication can also be a problem. One cat I treated with chronic post-trauma pain has to have one of her medications compounded because they don’t make the pills in a small enough size. They’re putting it in the food and the cat is eating it. Compounding can be very useful, but compounding medications has many drawbacks. It’s more costly, there is no guarantee that compounded medications will produce the same effects as the FDA-approved formulations, and the shelf life of compounded medications is much shorter.

What are some of the issues in treating chronic pain in cats?

A number of NSAIDs have been studied and approved for use in dogs, but that wasn’t done until fairly recently for cats. We’ve had two NSAIDs approved for use in cats for acute pain, but neither is approved for chronic use in cats in the United States, although NSAIDs are approved for long-term use in cats in Europe.

Are there other types of medications that can help cats with pain?

Gabapentin is an anti-seizure drug that was found serendipitously to have effectiveness for certain types of pain. Gabapentin can help cats with certain types of pain and is also something that can help sedate cats for car rides and vet visits. For smaller cats, though, this is a challenge because the smallest size pill that’s available is 100 mg. To reduce the amount we give requires it to be compounded or divided or made into a suspension that’s safe. People have also used tramadol in cats but it’s complicated by the fact that the taste is really bitter. We are using some things like amitriptyline, an antidepressant drug that isn’t used much for depression anymore but was found to have about five different ways that it could impact pain. It has potential use for chronic bladder pain, but some cats don’t tolerate it well. I have used other antidepressant-type drugs like Prozac in cats, at lower doses than for behavioral use, because it’s similar to amitriptyline, but maybe a little less complicated.

Can any supplements help with pain?

Cosequin is an oral joint supplement made for cats that can be useful for things like arthritis. There’s an injectable joint supplement called Adequan that is approved for use in dogs and is used off label in cats. And we’ll use things like fish oils and other supplement-type things as well.

What non-pharmacological treatments can help?

I use acupuncture in cats for chronic pain. I think that acupuncture can be very useful in cats. For acupuncture, you’d want to go once a week or once every other week at least for three to five sessions to see whether it’s going to have an effect on the cat, and then as needed, which might be monthly or every three months. It depends on the individual.

Can painful cats benefit from physical rehab?

I think people discount the benefit of physical rehab for cats, but I had one client who was pulling out all the stops for her older cat. She took him to a rehab specialist who was swimming him and doing massage and acupuncture and the cat had a really good response to that. It builds muscle, and muscle helps with joint problems. If you don’t have muscle because you haven’t been using your muscles, then you can’t support your joints, and your other muscles are really sore.

What can veterinarians suggest that owners do at home to help cats in pain?

When I see a cat for chronic pain—and I don’t see as many cats for chronic pain as I do dogs—I recommend a combination of lifestyle modifications. Those might be easier access to litterbox, ramps to furniture, and warm and cool places where they can go. Weight management is huge. If you have joint pain and you’re obese, you have way more pain than you need to because you can’t pull yourself around.

What else should be considered when managing pain in cats?

Probably the most important thing is to not be satisfied with the attitude “There’s nothing we can do.” With stomatitis, for example, taking all the teeth out is something that we commonly have done, and our dentists see at least several cats a month for this condition. If the cat isn’t a good anesthetic risk, there are medications that we don’t think of as traditionally analgesic. Certain antibiotics such as metronidazole have an anti-inflammatory effect. There are some times when joint disease affects cats and we might be able to do a surgery that helps them. We don’t do hip replacements in cats, but we can cut the hip joint and allow it to fuse and make a pseudojoint. That might help if there’s an instability. If there’s an ACL rupture or an unstable spine that’s causing back pain, surgery is the answer in combination with physical therapy and medication. I think that vets have a tendency to throw up their hands and say “It’s a cat, we can’t medicate it, there are no drugs approved for it, and it’s too much of a risk to use a medication.” Pressing on and saying ‘There is something I can do as long as I have the means or access to somebody who has different expertise’ is something that we can encourage.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Kim Campbell Thornton is content manager for Fear Free Pets and is a Level 3 Fear Free Certified Professional. She has been writing about dogs, cats, wildlife and marine life since 1985 and is a recipient of multiple awards from the Cat Writers Association, Dog Writers Association of America, and American Society of Journalists and Authors. When she’s not writing or editing, she’s competing in nose work trials with Harper, a Cavalier King Charles Spaniel.