Pain Management

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Overview:
“Pain” is a perception that the brain creates from input called “nociception” (pronounced no-si-sep-tion). This is the physiology term to describe the chemical processes that are at work in the body that receive a stimulus, modify it, and transfer it to the brain for interpretation and reaction. The stimulus can be physical, temperature, chemical or inflammatory damage to tissues. The brain processes this nociceptive input, mixes it with other data, and creates the perception we call pain. Everyone’s pain perception and reaction to it may be different.
Not all pain is bad—pain lets us know that something may be harming our bodies that we need to stop. But “pathologic pain” is a type of pain that is no longer serving this helpful purpose. Most of the pain issues we are likely to encounter with our pets in the medical situation are examples of pathologic pain.
Pain can be caused by many things:

• physical trauma, such as falling down or being hit by something
• internal organ problems, such as intestinal upset or kidney blockage
• surgical procedures, such as abdominal surgery or bone surgery
• brain or spine problems, such as a slipped disc, pinched nerve or headache
• degenerative changes, such as arthritis and joint damage

Signs and Symptoms:
Common pain behaviors are:

• growling and/or purring (cats)
• not grooming (cats)
• not moving from one spot (cats)
• squinting (cats)
• crying and/or whining (dogs)
• glassy-eyed, vacant look (dogs)
• hunched up body (cats and dogs)
• restlessness and changing positions a lot (dogs)
• shaking and trembling (dogs)
• hiding (cats and dogs)
• irritable or aggressive (cats and dogs)
• no appetite (cats and dogs)
• protecting the hurting body part (cats and dogs)

During and right after a painful injury or other illness, the body responds in several ways; the heart and breathing rate go up, muscles tense, endorphins (natural pain killers) are released internally. But after awhile, other stress hormones are released as the pain continues. This is when the down side of pain starts to outweigh the earlier benefits. The bad effects of pain include:

• no eating or drinking
• poor intestinal function, poor nutrient uptake
• increased risk of infection or delayed wound healing
• poor hygiene and ability to move around
• inability to sleep
• irritable or aggressive behavior, preventing nursing care or therapy

Any one or all of these complications may be present and may risk the recovery of your pet. Sometimes it means your pet does not recover; sometimes it means treatment is more prolonged, intensive, invasive, ineffective or costly. Painful illnesses in a pet’s life may make future illness or injuries more difficult to treat. Your pet may have a bad memory of veterinary care he/she received, and be fearful or aggressive the next time they need treatment.

Not all pain is created equal. Some is short-lived (like an injection), some is manageable w/ accommodation (like limping to relieve a sore ankle), and some is incredibly severe (like a broken back that makes a pet bite their owner when being helped). If pain goes away quickly and is minor enough, the negative impact is slight. As the duration and/or severity of pain rises, all of the negative impacts start to add up, and pets need our help.

Treatment:
There are several stages in a pet’s medical experience when we can address pain; each stage is an opportunity for providing treatment or “analgesia” (i.e. pain relief) and having a plan for each stage allows us to keep each treatment to a minimum (less risk, less cost).

• “Pre-emptive” analgesia means pain medications are provided before your pet is exposed to painful procedures, like surgery.
• Physically restrain them; essentially force them to experience the painful experience. This might be appropriate for a simple injection, for example, one that has a mild and very short duration of pain associated.
• Make them unconscious at the brain level, so they don’t perceive the pain at that moment. This is usually called general anesthesia. This might be appropriate for diagnostic tests that may hurt while they are being performed, but don’t hurt when they are over (an endoscope procedure, for example.)
• Ongoing pain; usually this pain starts high and tapers off over a variable timeframe (hours, days, weeks). During these early hours and days when a pet is in the hospital and under 24-hour supervision, we can continue to strike the pain pathway in multiple locations. This “multimodal analgesia” is more effective and safer for your pet. In hospital treatments might include, for example, IV drips with continuous pain medications, frequent injections of pain medications that work in different ways, and supportive physiotherapy such as optimal bedding, ice pack therapy, and massage.
• Pain at Home; once out of the hospital or home from the day-clinic, our options for managing a pet’s pain are narrower, but a multimodal analgesia approach remains the most effective. Multiple oral medications that work in different ways and the same simple physiotherapy techniques can reduce the pain a pet is experiencing well into the at-home period.

We can treat one or more steps in the pain pathway so that your pet does not feel pain while it is being applied, but also so that pain is stopped or minimized after the test or therapy is over. This combination approach, called balanced anesthesia, allows us to not only use smaller, safer drug doses, but it appears to be the most effective approach for procedures, such as surgery, that will hurt even after the cutting has stopped.

 

[Kvet Forum]

Additionally, techniques such as acupuncture may be used by trained veterinarians to act as an adjunct to certain acute and chronic pain management protocols. Acupuncture may control pain and inflammation by stimulating the endocrine, nervous and immune systems to activate self-healing. This technique has been shown effective in the pain management of various musculoskeletal and soft tissue injuries.

Pain medications and techniques should be viewed like antibiotics—part of the treatment. Some clinics and hospitals will itemize these charges while others will simply include the therapy as part of advanced anesthesia or hospitalization charges. Different veterinarians will prescribe different medications or use different techniques based on their expertise, experience and/or knowledge. There are current “standard of care” guidelines in the veterinary medical field, but there are no “the best” protocols. A pain management plan must be tailored to your pet, their medical condition, and their pain; charges for these services will vary from patient to patient.

A pain management plan must also be supervised to allow for modifications as your pets response unfolds; the time-frame may be over minutes, hours or weeks depending on the medical condition and pain being treated. Pain is a common component of illness, injury, and medical therapy. It starts with some sort of insult to the body, becomes perceived by the body as the signals travel thru the nervous system, and ultimately alters the physiology and behavior of your pet. It is not a pleasant thing to experience, and if it is severe or prolonged can be quite difficult to tolerate. Exactly when the pain experience becomes true “suffering” is variable from patient to patient, but it can usually be agreed upon that avoiding, preventing or reducing pain is preferred.

The veterinary profession is sufficiently advanced to recognize and successfully manage pain in our patients. We have medications, techniques and experience that can be customized to the species and the medical condition; current standard of care allows for the vast majority of patients to be made comfortable the majority of the time. Pet owners should feel empowered to be part of the medical decision-making regarding this, and other, aspects of their pet’s medical care. From the common spay procedure to the complex trauma case, reserve the time for these pain management discussions with your primary care veterinarian or your veterinary surgeon.