It was a challenging week providing pain management to some of my veterinary patients this week. I always try my best to use multimodal pain control and to be preemptive in pain management. They teach us in vet school to “Never chase pain”! This past week I said goodbye to a beloved diabetic patient. He lost the battle with bladder cancer that was unrelated to his diabetes, and his discomfort led to our decision to say goodbye. I also had several big surgical patients who required good pain management. And I treated several dogs riddled with arthritis and have serious orthopedic pain. Regardless of whether a pet is diabetic, we will at some point or another need to manage pain. I want our readers to be savvy with current analgesia options!
Back when I graduated vet school in the early 90’s the use of narcotics was pretty limited. Back then pets might have gotten some Butorphanol (a very mild narcotic) before a routine procedure, but in recent years we’ve come a long way, baby! I routinely give injections of Hydromorphone before simple surgeries like spays and neuters or dentals requiring extractions. If a pet has surgery I will nearly always send home an oral narcotic (such as Tramadol) or place a Fentanyl patch if I expect a higher level if pain. Just this year a 24-hour narcotic injection was FDA approved for kitty cats. In my opinion, narcotics are crucial for pain relief. They tend to cause some drowsiness, but when a pet is in severe pain I figure it is okay to take a little nap. As much as I rely on narcotics, we can do better! We nearly always couple narcotics with anti-inflammatories.
NSAID stands for “non-steroidal anti-inflammatory drug”. Common examples would be Rimadyl, Metacam, and Deramaxx. Inflammation is a big trigger of pain. If we decrease inflammation, we help to limit the pain. Of course, sometimes we will use a steroid as an anti-inflammatory, but steroids oftentimes have harsher side effects than NSAIDs. Additionally, we try our best to avoid steroids with diabetic patients as steroids can unravel diabetic control. Whether NSAID or steroidal anti-inflammatory, the potential organs of damage are the GI tract, the kidneys and the liver. If we use other modalities of pain control, we can sometimes decrease the dose of the anti-inflammatory drug.
Gabapentin use is “extra-label” use for dogs and cats. Veterinarians probably don’t utilize this medication often enough! It’s not the first thing we reach for, but when we have chronic pain conditions and aren’t managing the pain adequately with the drugs listed above we reach for this. It is best for neuropathic pain. Neuropathic pain is the when nerves are injured or confused and send inappropriate pain signals to the brain. Diabetic nerve pain is one such pain, but chronic arthritis is perhaps the most common veterinary indication for Gabapentin use. I’ve had clients tell me they saw no improvement at all and other clients tell me it is a wonder drug for the pet’s arthritis pain. Sedation is the most common side effect. Veterinarians need to be careful not to use any Gabapentin products that have xylitol in them. It is an inexpensive medication and can be very effective for chronic pain situations.
I purchased a class 4 cold laser for my own practice over a year ago. It works very well for pain relief! I have no doubt that it works, but the mechanism of action still seems a bit like voodoo to me. Therapeutic lasers decrease pain signals from reaching the brain and also decrease inflammation and edema. I use my laser most commonly for arthritis patients, but I also use it on most of my surgeries and dental extractions. One of my surgeries this week was removing bladder stones from a Yorkie. I had my veterinary nurse laser it (8 inches away with the big laser head) while I held the urinary bladder outside the abdominal wall. It visibly became less edematous. How cool is that! That’s the 3rd bladder surgery this year where I’ve used the laser and could tell a difference in edema within a minute. Modern technology rocks! Due to the expense of the machine, you might need to call around town to find a larger clinic that can support the expense of a laser.
This is a pain management modality that can be harder to find. Or, I should say it’s harder to find a veterinarian skilled in acupuncture. Last year I looked for an acupuncture class near my home… There was a 2-year waiting list and the weeklong class cost over five grand. It’s not a mainstream treatment for pain, but it will likely emerge as pet owners become more savvy in vet care for their aging pets. Learning acupuncture points for pain relief is definitely on my bucket list.
Local blocks and Lidocaine patches
Oh how I love local analgesics! Whenever I can incorporate Bupivicaine or Lidocaine into a surgical procedure I do. I use a lot of nerve blocks in my practice, especially during dentals. If we can make an area numb, even if a pet is anesthetized, we help prevent the pain cycle from starting. Additionally, using local anesthesia means we can keep the pet at a lower level of anesthesia. Orthopedic surgeons may use Lidocaine patches under splints. I have Lidocaine patches in my own clinic, but I’m often afraid to use them because they could be toxic if a pet chewed it off and ate it. I personally don’t do orthopedic surgery and rarely utilize splints. Nonetheless, I love the idea of Lidocaine patches.
If pain is from arthritis, we can achieve some pain relief from oral supplements. Omega 3 fatty acids help to decrease inflammation. Other than fish breath and a few calories, there really isn’t a down side to using them. Most folks have heard of glucosamine for arthritis. Glucosamine products help increase the viscosity of joint fluid. Additionally, good nutrition and antioxidants can’t help but improve joint health.
The next time your sweetie has a procedure, ask your vet what the pain management protocol will be. Preventing and controlling pain should be the standard of care in veterinary medicine these days.
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NOTE: Consult your veterinarian to confirm that my recommendations are applicable for the health needs of your pet.