The recognition and treatment of pain in both human and veterinary medicine is undergoing a revolution of sorts. Old ways of thinking are being replaced by new, and at TotalBond Veterinary Hospitals we have made it a passionate point to stay on the cusp of pain relief and prevention, and in fact TBVH is considered a leader in veterinary profession. Aside from the latest research, medications, and modalities (including but not limited to medications, acupuncture, therapeutic laser, biologic therapy, and much more) that are used to address pain, we are talking here about simple attitude and philosophy.
We find it simply unacceptable that an animal would be in unnecessary pain. That is as plain and simple as it gets. Therefore we do not wait to see if a patient necessarily “appears” to be in pain (research clearly shows that because of adaptive behaviors in animals, even a well-trained human observer cannot reliably identify which pets are “in pain” and which are not). If logic would dictate that a procedure (e.g. surgery) or a condition (e.g. arthritis) activates nerve endings and would result in pain, then that patient will get medication for pain as a routine part of the procedure or condition. Period. For chronic pain, we are also committed to offering novel interventions drawn from the most recent experiences and evidence in human and veterinary medicine.
Philosophically we cannot accept the notion that your pet sits in pain, and as a result (research also tells us) recovers more slowly and with higher risk for complications from the stress that inevitably results. An animal is just as vulnerable and no more understanding of the fear and pain involved in illness, injury, or surgery (even if elective) than is 4 month-old baby undergoing the same. We would no sooner withhold pain medication from one of our patients than you would if you had a child that got sick, hurt, or needed surgery.
To be truthful, the changes in veterinary medicine regarding control of pain are not yet universally accepted or implemented. TotalBond Veterinary Hospitals' progressive and prioritized thinking regarding the recognition, prevention, and treatment of pain is mirrored by some, but not all practices. You may find that our philosophy here is something that separates us from the rest of the field.
Dr. Epstein at TotalBond Veterinary Hospital at Forestbrook was among the first “CVPP’s” (Certified Veterinary Pain Practitioner), served as President of the International Veterinary Academy of Pain Management, and continues to be an authority and prominent author and national/international lecturer in this area.
TBVH adheres to the principles found in the 2015 AAHA-AAFP Pain Management Guidelines (for which Dr. Epstein was the primary author!)
Our pain management systems and protocols are multi-modal, integrated, and balanced, utilizing both pharmacologic and non-pharmacologic modalities:
Pharmacologic: various medications administered either IV, in joints, near a nerve, under the skin, or orally; and in the hospital or at-home on an out-patient basis, all depending on the patient’s circumstances and needs. These include but are not limited to: NSAIDs, opioids, Alpha2 agonists, Local/Regional blocks, spinal cord modifiers, adjunctive agents, disease-modifying osteoarthritic agents, biologic therapeutics, Dorsal horn spinal modulators.
The International Association for the Study of Pain defines pain as:
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
However, an important addition was made in recent years, because it reflects the reality of non-verbal patients…including animals! “The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment.”
The important point is that pain is a conceptual sense, always subjective to the individual, always unpleasant, always elicits a cascade of stress chemicals and hormones, and is always both an emotional and physiologic experience.. and that in animals, it can be sometimes very difficult to know with certainty how much pain is being experienced.
Sometimes, pain is good; it protects us from further tissue damage (no one keeps their hand on the hot stove!). This would be considered “normal” or “adaptive” pain. But depending on its type, intensity, and duration, pain can become bad, dangerous, harmful, debilitating, and self-perpetuating, not only to one’s state of mind but to the body itself; we call this “maladaptive” pain. Preventing and treating maladaptive pain is a key part of both acute and chronic pain management.
Dogs and cats are non-verbal, so they can not tell us directly! But they can “speak” to us through the absence of normal behaviors or the appearance of new ones.
Onset of New Behaviors:
Absence of Normal Behaviors:
Osteoarthritis (OA) can be particularly difficult because the onset is so gradual – but many, many dogs and cats have OA joint and behavior changes even in young-middle age – it is not just for older pets!
See these helpful sites to recognize the possibly subtle signs of OA in dogs and cats:
You are trying to attach a leash to the collar, and instead, the latch pinches your finger. Hard. The crushing effect destroys some tissue cells, which release chemicals that stimulate nerve endings. The impulse shoots up nerve cells (“neurons”) in your arm to the spinal cord. There they connect (“synapse”) onto other neurons there which then shoot an electrical impulse up to the brain. There, in the thalamus, you perceive the pain, but you cannot yet localize it; another synapse occurs and a third neuron carries the impulse to the cerebral cortex, where you can then tell where the pain is occurring and consider whether or not to swear an oath. Lastly, an inhibitory neuron travels back down the spinal cord to synapse in the spinal cord where the first neuron is connecting to the second; it releases chemicals that blunt some of the original impulse, causing some of the most intense immediate pain to quickly abate. All this happens in a nano-second.
Under-managed pain from surgery is a leading cause of long-term pain in humans…and we can only assume the same must be true for pets. Anesthesia (being asleep) is not the same thing as analgesia (not feeling pain)! Part of a comprehensive anesthetic and operative episode that places an emphasis on both safety and comfort must include multiple layers (types) of pain control that impede pain impulses at several different levels and through different mechanisms. These include, but are not limited to: aggressive use of local and regional nerve blockade (utilizing a electro-nerve location device); opioids, non-steroidal anti-inflammatories, spinal cord modulating medication, and unique instrumentations and availability of minimally invasive (laparoscopic) surgery.
The equation changes. Someone applies a vise to your finger, and it is tightened. The initial tissue damage occurs, as described above, but the vise stays attached. It never lets go. It continues to send impulses up the spinal cord, bombarding the second neuron with chemicals (“neurotransmitters”). This constant bombardment of pain impulses causes a new fiesta of neurotransmitters to be secreted, which in turns opens other receptors, allowing more and more impulses to travel up the spinal cord, even though the vise hasn’t changed. Same stimulation → more pain. A chemical caused Nerve Growth Factor is secreted, which brings other neurons to make connections to this pain pathway. Now, what was once just a “touch” neuron is now transmitting pain impulses. Neurons coming from other parts of the body begin to make connections here. Now, the pain seems to be coming from everyone at once…you can’t localize it just to your finger. The inhibitory neurons begin to lose their function. Abnormal electrical impulses begin to go back down the neuron in your arm, which then causes the release of more inflammatory chemicals which then cause even more impulses to back up to the spinal cord, continuing the cycle and worsening it. The pain becomes more intractable, more refractory to medications.
Replace “vise on the finger” with “arthritis in the hips” or “disc in the back” and you have an idea of what is happening with many of our pets, especially older ones. Furthermore, their adaptive mechanisms delude us into thinking that they are not nearly as uncomfortable as they really are. However, even though they can’t verbally report the pain that they are living with, we can intervene. The goal is not only to improve things in obvious ways for the immediate future, but to take a long view, interrupt where we can the otherwise inevitable chemical and biochemical chronic pain changes in the spinal cord. In this way we can dramatically improve quality of life, not only next week but years from now.
These techniques and modalities are a complement any pain management program, and sometimes are central to it. The evidence of benefit for physiotherapy is well-established in both humans and animals to improve strength and mobility. Science is also beginning to illuminate the underlying mechanisms in acupuncture and demonstrate effectiveness in a number of pain conditions. We are equipped to incorporate basic aspects of this modality into an integrated pain management program at our practices. When determined that a pet might benefit from a more comprehensive application of these modalities, a recommendation for referral may be made to certified practitioners of the discipline.
Pet owners are hearing and seeing more and more information about Regenerative Medicine for pets (dogs, cats and horses). This area can be confusing for pet owners AND their Veterinarians! Biologic and Regenerative medicine are terms that describe a form of therapy to help the body heal itself, in a safe and non-toxic manner. Either cells of the patient or other cellular technology are infused/injected. These therapies elicit a number of biologic responses, including the stimulation of growth factors, anti-inflammatory mediators, and in some cases the actual regeneration of tissue.
Pets with life-limiting conditions present a very special set of patients and circumstances. Cancer especially is unique in its ability to have a negative impact on quality of life, but on the other hand pet owners are often surprised to learn of our ability to combat it. Palliative care, however, uses the tools and resources at our disposal to minimize pain and discomfort without attempting to achieve cure of disease. Through a combination of in-hospital treatments, phone consults, and at-home visits, including for humane euthanasia when the need exists, we are uncompromising in our desire to help pet owners and allow their pet to live, and encounter death, with the greatest of grace and dignity.
For pet owners wishing a Pain Management Consult, feel free to contact our hospital.