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Pain: See it. Treat it.
Matt Brunke, DVM, CCRP, CVPP, CVA
Diplomate, American College of Veterinary
Sports Medicine and Rehabilitation

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A little about me..... I like to keep busy

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Goals for today
-Defining pain and some pain terms
-Types of pain
-Signs of pain
-Scoring pain
-Treating pain. Why? How?
-Fundamentals
-Advanced therapy

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Definition and Obligation
-Is an unpleasant sensory and emotional experience associated with an actual or potential tissue damage or described in such terms as damage.
-To advocate on behalf of beings who cannot advocate for themselves. Every single patient treated by veterinary healthcare teams will experience pain at some point in its life. It truly is our obligation to be as aware and active in our pursuit of pain as possible.

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"I can't stand to see an animal in pain. Give him something so it won't hurt during the race."

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Additional Terminology
-Analgesia
-Insensibility to perceive pain WITHOUT lack of consciousness. Pain reliever.
-Anesthesia
-Loss of feeling with the use of drugs
-Sedation
-Relaxed or sleepy condition from the use of drugs

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Additional additional terminology
-Multimodal analgesia
-Simultaneous use of more than one drug with different actions. Potential for dose reduction
-Pre-emptive analgesia
-Done to stop an unwanted act of pain.
-Hyperesthesia
-Pathologically oversensitive to a painful stimuli
-Allodynia
-Pain response from a non painful stimuli

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Types of pain
-Subacute - ER setting
-Acute - less than 3 weeks
-Chronic - more than 3 weeks - DJD
-Muscular/Skeletal - fracture vs. DJD
-Visceral -asthma vs. COPD, FB vs. Splenic mass vs. GDV, glaucoma
-Neuropathic - “Windup”, hyperesthesia, allodynia
-Cancer - metastatic disease, high calcium, tumor growth
-Surgical/perioperative - cutting things can be painful

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SEPTEMBER IS ANIMAL PAIN AWARENESS MONTH
THE MOST COMMON SIGNS OF PAIN IN YOUR PET
-DECREASED ACTIVITY
-Take notice if your pet is not playing as much as usual
-RELUCTANCE TO JUMP UP ONTO SURFACE
-This especially applies to cats
-DECREASED APPETITE
-This can signal mouth pain
-OVER GROOMING OR LICKING A PARTICULAR AREA
-Can be a sign of referred pain
-DIFFICULTY STANDING AFTER LYING DOWN
-is a sign of osteoarthritis
-NOT GOING UP OR DOWN STAIRS
- this could be an early sign of osteoarthritis
IF YOU NOTICE ANY OF THESE SIGNS, PLEASE CONTACT
YOUR VETERINARIAN.
- BROUGHT TO YOU BY IVAPM
INTERNATIONAL VETERINARY ACADEMY OF PAIN MANAGEMENT

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Signs of pain
-Hiding, biting, scratching, chewing, whimpering, limping, grunting, grinding teeth, restless, reluctant to move, sleeps more, growling, ears pinned back, hunched, howling, mydriasis, vomiting, diarrhea.
-Hissing, trembling, accidents in house, panting, decreased activity(less jumping) decreased appetite, withdrawn
-Tachycardia, tachypnea, elevated BP
-Turning up the gas.....(anesthesia vs. analgesia, hypotension)
-LOTS of signs. Some are obvious. Some are subtle.
- Muscle atrophy, elbow flexion, hip extension, check the ears(otitis), open the jaw - A good complete physical exam.

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What’s the cause?
-DJD, neoplasia, pancreatitis, parvo, GDV, pneumonia, HBC, ileus, thrombus, IVDD, scalpel blade, fractures, blocked (cats and dogs), whelping/queening, otitis, dental disease, glaucoma, amputation (overuse of other limbs), spondylitis, LS, diabetes (neuropathy), blood draws, catheters.
-We didn’t plan.
-The potential for pain is everywhere.

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The fourth vital sign
-In vet med its after TPR. In humans BP gets #4, pain #5.
-AAHA requires pain scoring as part of its accreditation standards, and is part of their Pain Management Guidelines

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Pain Grading
-Acute or Chronic? Usually subjective.
-Visual Analog Scale (VAS)
-Numerical rating scale (NRS)
-Simple Descriptive Scale (SDS)
-Glasgow Pain System
-Force plate? Sensors? Thermal imaging?
-CSU Canine and Feline Acute and Chronic Scores

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Pick one and use it
Acute
[Colorado State University Logo]
Colorado State University
Veterinary Medical Center
Feline Acute Pain Scale
Rescore when awake
Animal is sleeping, but can be aroused - Not evaluated for pain
Animal can’t be aroused, check vital signs, assess therapy
Pain Score
0
1
2
3
4
Example
[5 pictures of cat showing different behavior]
Psychological & Behavioral
Content and quiet when unattended
Comfortable when resting
Interested in or curious about surroundings
Signs are often subtle and not easily detected in the hospital setting; more likely to be detected by the owner(s) at home
Earliest signs at home may be withdrawal from surroundings or change in normal routine
In the hospital, may be content or slightly unsettled
Less interested in surroundings but will look around to see what is going on
Decreased responsiveness, seeks solitude
Quiet, loss of brightness in eyes
Lays curled up or sits tucked up (all four feet under body, shoulders hunched, head held slightly lower than shoulders, tail curled tightly around body) with eyes partially or mostly closed
Hair coat appears rough or fluffed up
May intensively groom an area that is painful or irritating
Decreased appetite, not interested in food
Constantly yowling, growling, or hissing when unattended
May bite or chew at wound, but unlikely to move if left alone
Prostrate
Potentially unresponsive to or unaware of surroundings, difficult to distract from pain
Receptive to care (even mean or wild cats will be more tolerant of contact)
Response to Palpation
Not bothered by palpation of
wound or surgery site, or to
palpation elsewhere
May or may not react to palpation of wound or surgery site
Responds aggressively or tries to escape if painful area is palpated or approached
Tolerates attention, may even perk up when petted as long as painful area is avoided

Growls or hisses at non-painful palpation (may be experiencing allodynia, wind-up, or fearful that pain could be made worse)
Reacts aggressively to palpation, adamantly pulls away to avoid any contact

May not respond to palpation
May be rigid to avoid painful movement

Body Tension
Minimal

Mild

Mild to Moderate
Reassess analgesic plan

Moderate
Reassess analgesic plan

Moderate to Severe

May be rigid to avoid painful movement

Reassess analgesic plan

RIGHT LEFT

Tender to palpation
Warm
Tense

Comments

© 2006/PW Hellyer, SR Uhrig, NG Robinson

Supported by an Unrestricted Educational Grant from Pfizer Animal Health

Chronic

Many signs of chronic pain are non-specific; rule out anxiety, poor general health, and systemic disease as part of a full workup.

Colorado State University
Veterinary Medical Center
Feline Chronic Pain Scale

Pain Score
0
1
2
3
4

Example
[5 pictures of dog showing different behavior]

Psychological & Behavioral
Happy, energetic
Interested in or curious about surroundings
Responsive; seeks attention

Subdued to slightly unsettles or restless
Distracted easily by surroundings
Responsive; may not intimidate by surroundings

Anxious, uncomfortable
Not eager to interact with people or surroundings but will look around to see what is going on
Loss of brightness in eyes
Reluctant to respond when beckoned

Fearful, agitated, or aggressive
Avoids with people and surroundings
May lick or attend to painful area

Stuporous, depressed
Potentially unresponsive to surroundings
Difficult to distract from pain

Postural
Comfortable when resting
Stands and walks normally
Normal weight bearing on all limbs

Stands normally, may occasionally shift weight
Slight lameness when walking

Abnormal weight distribution when standing
Moderate lameness when walking
May be uncomfortable at rest

Abnormal posture when standing
Does not bear weight on affected limb when walking
Guards painful area by shifting position

Reluctant to rise and will not walk more than 5 strides
Does not wear weight on limb
Appears uncomfortable at rest

Response to Palpation
Minimal body tension
Does not mind touch
No reaction to palpation of joint

Mild body tension
Does not mind touch except painful area
Turns head in recognition of joint palpation

Mild to moderate body tension
Doesn’t mind touch far away from painful area
Pulls limbs away during palpation of affected joint
Reassess analgesic plan

Moderate body tension
Tolerates touch far away from affected limb
Vocalizes or responds aggressively to palpation of affected joint
Reassess analgesic plan

Moderate to severe body tension
Dislikes or barely tolerates any touch (may be experiencing allodynia, wind-up, or fearful that pain could be made worse)
Will not allow palpation of joint
Reassess analgesic plan

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Canine Acute Pain Scale

Rescore when awake
Animal is sleeping, but can be aroused - Not evaluated for pain
Animal can’t be aroused, check vital signs, assess therapy

Pain Score
0
1
2
3
4

Example
[5 pictures of dog showing different behavior]

Psychological & Behavioral
Comfortable when resting
Happy, content
Not bothering wound or surgery site
Interested in or curious about surroundings

Content to slightly unsettled or restless
Distracted easily by surroundings

Looks uncomfortable when resting
May whimper or cry and may lick or rub wound or surgery site when unattended
Droopy ears, worried facial expression (arched eyebrows, darting eyes)
Reluctant to respond when beckoned
Not eager to interact with people or surroundings but will look around to see what is going on

Unsettled, crying, groaning, biting or chewing wound when unattended
Guards or protects wound or surgery site by altering weight distribution (i.e., limping, shifting body position)
May be unwilling to move all or part of body

Constantly groaning or screaming when unattended
May bite or chew at wound, but unlikely to move
Potentially unresponsive to surroundings
Difficult to distract from pain

Response to Palpation
Nontender to palpation of wound or surgery site, or to palpation elsewhere

Reacts to palpation of wound, surgery site, or other body part by looking around, flinching, or whimpering

Flinches, whimpers cries, or guards/pulls away

May be subtle (shifting eyes or increased respiratory rate) if dog is too painful to move or is stoic
May be dramatic, such as a sharp cry, growl, bite or bite threat, and/or pulling away

Cries at non-painful palpation (may be experiencing allodynia, wind-up, or fearful that pain could be made worse)
May react aggressively to palpation

Body Tension
Minimal

Mild

Mild to Moderate
Reassess analgesic plan

Moderate

Reassess analgesic plan

Moderate to Severe

May be rigid to avoid painful movement
Reassess analgesic plan

Tender to palpation
Warm
Tense

Comments:

© 2006/PW Hellyer, SR Uhrig, NG Robinson
Supported by an Unrestricted Educational Grant from Pfizer Animal Health

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Some pain grading questions
-Who? Everybody! (Vets, LVT’s, assistants, OWNERS)
-What? The patient.
-When? Each appointment (OP) Every 1 (inpatient)
-Before surgery, after surgery, end of the day (pre-emptive...)

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Grading questions
-Where? In the medical record. Treatment sheet (along with TPR)
-Why? Consistency, improvement, regression. Change meds?
Is what we are doing working?

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Treating Pain
-Drugs Opioids, NSAIDs, other
-Different routes of administration - IV, IM, epidural, oral, topical (EMLA cream), local
-Environmental (hospital) - cage size, blankets, lighting, sound
-Environmental (home) bedding, stairs, flooring, harnesses
Basically we want to......

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Minimize Stress
Because that’s so easy...

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Pain pathway
Perception 3rd Order Neuron
Perception(cerebral cortex)
-Anesthetics
-Opioids
-a2 antagonists
-Benzodiazepines
-NSAIDs

Modulation(spinal cord)
Dorsal Horn of Spinal Cord
Modulation Spinal Cord
-Local Anesthetic
-Tricyclic Antidepressants
-Cholinesterase inhibitors
-NMDA antagonists
-Opioids
-NSAIDs
-a2 antagonists
-Anticonvulsants

Transmission
1st order Neuron (primary afferent)
Transmission(sensory nerves)
-Local Anesthetic
-a2 antagonists

Transduction
Transduction(sensory nerve endings, nociceptors)
-Local Anesthetic
-Opioids
-NSAIDs
-Corticosteroids

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Wind Up
-Sustained stimulation of receptors causes dramatic changes in the second order neurons - Central sensitization (or wind-up).
-N-methyl-D aspartate receptors in spinal cord are activated by glutamate.
-Increased activity in the dorsal horn leads to
-Exaggerated responses to normal stimuli (hyperesthesia)
-An increase in the size of the receptive field (recruitment)
-Reduced threshold for activation by non-nociceptive input

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Great. What do we do now?
-Now we know. (and knowing is half the battle)
-We strike first. (pre-emptive analgesia)
-We strike as a team from many angles. (multimodal analgesia)
-Modulation of pain signals in the pathway are mediated by transmitters such as
-Opioids
-Alpha-2
-GABA
-NSAID

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Opioids
-The backbone of most analgesic plans (acute pain, surgery)
-Premed - lowers the amount of other drugs needed.
-Great for pre-emptive analgesia
-Butorphanol, Buprenorphine, Morphine, Hydro, Fentanyl
-Rapid onset, reversible (Narcan), IV, IM, epidural, PO, SL, CRI,
transdermal
-Simbadol ––(buprenorphine, inj, Abbott, SID) FDA approved for
cats for pain control

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Local anesthetics
-Lidocaine 2 minute onset, 90 minute duration
-Bupivacaine 5-7 minute onset, 4 hours duration
-Combo the two? Slightly longer onset than L alone, won’t last as long as B.
-1cc/10lbs for dogs, ½ that for cats.
-Infiltration (line blocks, splash blocks, dental, testicular, pedicle), soaker catheters
-IV (lidocaine only, with opioid, ketamine)
-Ring blocks (declaws),regional infiltration
-Intra abdominal (pancreatitis)
-Intra articular? Chondrocyte damage
-How? Blockade of the message to the dorsal horn.

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Wound Diffusion Catheters

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New Options
-NOCITA is a long-acting local anesthetic that gives you the control of extended release bupivacaine, providing up to 72 hours of post-operative pain relief with one dose.
-Extended duration of action assists in preventing analgesia gaps in the first 72 hours post-surgery
-Single treatment administered during cranial cruciate ligament surgery closure into the tissues for post-operative pain control
-The extended-release bupivacaine technology used in NOCITA consists of multivesicular liposomes composed of hundreds to thousands of chambers per particle, encapsulating aqueous bupivacaine.

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Aratana - Nocita
Skin
Subcutaneous Tissue
Facia
Musculature
1. Fascia Layer Infiltration
2. Deep Subcutaneous Tissue Infiltration
3. Superficial Subcutaneous Tissue Infiltration

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NMDA unwinding the wind
-Amantadine
- Oral, 3-5mg/kg/ SID-BID
- Dogs and cats.
-Ketamine
- Microdose. (sub anesthetic) 0.6-1.2 ml in a one liter bag
- Balanced anesthesia/post-op analgesia
- Not a standalone (multimodal)

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Alpha 2 agonists
-Anesthesia and or analgesia
-Dexdomitor, Xylazine
-Careful with cardio patients
-Transient hyperglycemia
-works on islet cells
-Heart rate will be low. What’s the BP? Quality over quantity

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Alpha-2
-Pre-med, part of induction, “rescue” peri-operative
-CRI, epidural, sedation
-Decrease dose when potentiate with opioid (HR won’t be as low)
-Reversible both the anesthesia and analgesia…

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Alpha 2
Intra-Op
-HR goes up, patient starts to wake up?
-Turn up the gas? Risk of hypotension
-Propofol? Good choice-IV
-Alpha-2 micro dose-IV in the lingual vein

Post-Op
-Dysphoria vs. Pain
-Ace? But still painful
-Benzo? But still painful
-Hydro/Morphine? Probably the cause.
-Butorphanol-Agonist/antagonist - short acting. Good for post-op
-Use an Alpha 2! Get both effects.

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Opioid Dysphoria
Post cruciate surgery with CRI containing morphine
Notice confusion, lack of eye contact

IV Butorphenol given
5 minutes later

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How I dose Dexdomitor IV
-Observe them first. Scared? Stressed? Aggressive?
-Big dogs 3 5 micrograms/kg
-Little dogs 5 10 micrograms/kg
-Cats 10 20 micrograms/kg
-Standard 0.5mg/ml = 500 micrograms/ml
-New 0.1mg/ml = 100 micrograms/ml
-My “rescue” 0.3ml of standard in a sterile glass tube with 2.7ml saline. Now 50 micrograms/ml. 0.1ml/10lb intra-op or post-op

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NSAIDs
-Non-Steroidal Anti Inflammatory Drugs
-Treats the pain AND it’s SOURCE.
-K9 Rimadyl, Deramaxx, Metacam, Previcox
-Feline Onsior, Metacam (inj only)
-My first choice in arthritis (anti “itis”)

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NSAID
-Watch renal and hepatic function (Prior, 2 4 weeks, then q 6-12 months)
-GI side effect potential, bleeding potential
-Long term therapy may be needed
-Helps with wind up

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Not recommended when
-Hyperbilirubinemia
-Elevated ALT, AST and GGT
-If any of these are elevated alone or in combination, with or without signs of hepatic disease
-Albumin decreased - Recommend workup for renal, GI or hepatic dysfunction
-Clotting disorder
-Elevated ALP with clinical signs of liver or Cushing’s disease

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ALP is elevated, but normal dog
-Could be Benign Nodular Hyperplasia
-Is fairly common in older dogs
-ALP can be 2.5x to >10x normal
-Ultrasound and Bile Acids to rule out other disease
-Additional diagnostic as needed
-Consider NSAIDs if no other underlying disease detected
-Monitor to ensure no further elevation or other abnormalities (within 10 30 days, then periodically)
-Any further increases in hepatic enzymes warrants further evaluations

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My NSAID Rules
-Use one or two in your clinic. Be comfortable with them.
-Don’t mix NSAID & NSAID. Don’t mix steroid & NSAID.
-It’s not working. Can it handle it alone? Do we need a helper? (gabapentin, amantadine)
-Client handouts, emails and “if vomiting, diarrhea, dark tarry stools STOP med and CALL OFFICE” on EVERY LABEL.

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More rules
-Use manufacturers dosing. Tapering to “least effective” could bring back windup, and we under diagnose pain already…
-If I have to change NSAID (or to/from pred): washout (5-7 days) bridge (Codeine, gabapentin, buprenorphine, Tylenol)
-I stick with brand names. - Product support, reliability.
-Break a tablet in half is it equally distributed?
-Have a problem? Report it

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What is GALLIPRANT?
-First in class non-cyclooxygenase (COX) inhibiting, non-steroidal anti-inflammatory drug (NSAID) in the piprant class.
-Still treat like any other NSAID
-Give on empty stomach
-Takes 2-3 weeks to see effect
-Antagonizing the prostaglandin E2 (PGE2) EP4 receptor.
-Not for post-surgical pain

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Aratana - Galliprant

p.42

Monitoring patients on analgesics
-Agent
-Opioids
-Local Anes
-NSAID
-Alpha-2-Agonists

Adverse Effect
-Sedation, respiratory, depression, low BP, dysphoria, panting, hyperthermia
-None unless via CRI. Then nausea, seizures, vomiting, other neuro
-Vomiting, diarrhea, GI bleed, renal issues
-Bradycardia, cardiac arrhythmias, hypertension, peripheral vasoconstriction

Monitoring
-Mentation, BP, RR, temp
-Muscle tremors and GI signs
-Hydration, BP, stool quality, urine output
-Heart rate, BP, femoral pulse rate and QUALITY

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Tramadol DON’T BOTHER
-Opioid in people
-Opioid in cats (good luck giving it)
-SSRI in dogs!
-Controlled in many states
-Cats 1 2mg/kg BID
-Dogs 3 7mg/kg QID

p.44

Gabapentin
-Neurontin - anticonvulsant
-Pre operative pain? Maybe
-Postoperative analgesia and chronic pain (DJD?), neuropathy
-5-10-20mg/kg BID to TID. Start low, increase every 7-10 days (night time dose first - worst side effect is sleepiness)
-Titrate coming OFF of it as well - seizures…..?
-There is a human suspension withOUT xylitol
-Controlled in Virginia as of July 1, 2019
-NO studies on efficacy in dogs - all anecdotal

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Other drugs adjunct therapy
-Lyrica Pregabalin. Compound? $$$
-Amitriptyline 1-2mg/kg BID
-Acetaminophen 10-15mg/kg TID (dogs only, rescue)
-Codeine - 1-2mg/kg BID TID
-Aspirin/dog aspirin? No proven benefits. Proven ulcers.
-Prednisone/ Dex - anti-inflammatory. Side effects, cartilage damage, muscle loss.

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Pain Plan:
Set it and forget it…
-Not even close! Look again, look often.
-Change happens. You’ll eventually need to change your plan.
-Acute pain/hospital every hour, 4 hours. Before you leave.
-Chronic pain Weekly at first, then taper to every 3-4 weeks.
-Geriatrics - every 6 months, maybe more often.

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Epidurals with corticosteroids
-For Type 2 Hansen Discs/LS Disease
-LS space, standard approach
-Triamcinolone or DepoMedrol - particulate steroids better than the aqueous ones. (human studies/practice)
-1 mg/kg
-Potential for transient systemic side effects
-Rest and follow up with appropriate rehab

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Advanced therapy
-Look again - repeat PE, measurements, talk to owner (what changed at home), radiographs, MSK ultrasound, CT
-Second opinion - co-worker, VIN, IVAPM forum, call me.
-No seriously, call me (email if not urgent)
-More drugs? Oxycodone, Vicodin
-Need a break? Admit it. Then admit the pet. (your clinic or mine)
-Other modalities…..

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Such as
-Laser therapy
-ESWT (Extracorporeal ShockWave Therapy)
-Stem Cell Therapy, PRP (platelet rich plasma) DJD, sporting injuries
-Adequan Canine (PSGAG’s) I use this in cats too
-Intra articular injections (Hyaluronic Acid, Steroids, Regen Med)
-Diet (huge for obesity) Hill’s, Purina programs for DVM, LVT

p.50

And more
-Admitting a patient - gives owners a break (paralyzed dog, old dog with incontinence, peace of mind)
-Also allows for a CRI, IV therapy, rehab technician care.
-Food change (JM, J/D) Supplement change (DASUQUIN, Omega 3, SAMe)
-Traditional Chinese Veterinary Medicine (TCVM): acupuncture, herbal, food therapy
-Chiropractic care
-Massage therapy (you and your team may need one also)

p.51

Even more options
-Cerenia MAC sparing, presumed analgesic effects (GI, bladder in FLUTD cases)
-Methocarbamol (Robaxin) muscle relaxant, not true pain reliever… but can help (K9 10-15mg/kg TID)
-Myofascial Trigger Point Therapy
-Rehabilitation (Physiotherapy)

p.52

A multimodal approach
-The Integrative Medicine Wheel
-Surgery
-Pharmaceutical Drugs
-Herbal Medicine
-Nutritional Medicine
-Lifestyle & Behavior
-Mind/Body Medicine
-Energy Medicine
-Manipulative Therapies

p.53

Updated Guidelines

2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats*

Mark Epstein, DVM, DABVP, CVPP (co-chairperson), Ilona Rodan, DVM, DABVP (co-chairperson), Gregg Griffenhagen, DVM, MS, Jamie Kadrlik, CVT, Micheal Petty, DVM, MAV, CCRT, CVPP, DAAPM, Sheilah Robertson, BVMS, PhD, DACVAA, MRCVS, DECVAA, Wendy Simpson, DVM

https://www.aaha.org/public_documents/professional/guidelines/2015_aaha_aafp_pain_management_guidelines_for_dogs_and_cats.pdf

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Resources
-International Veterinary Academy of Pain Management (www.IVAPM.org)
-Canine Rehabilitation & Physical Therapy - Millis, Levine
-BSAVA Manual of Canine and Feline Rehabilitation, Supportive and Palliative Care - Lindley and Watson
-VIN (CRI calculator), DVM Calc (iPhone), UTCanineRehab.com, TCVM.com
-Handbook of Veterinary Pain Management – James Gaynor
-http://www.vasg.org - Veterinary Anesthesia and Analgesia Support Group -http://www.veterinarypracticenews.com/Abbott-Wins-Approval-of-Daily-Feline-Pain-Drug/

p.55

Any questions?
Laughter is not the best medicine,
Propofol is.

p.56

Contact Info
-DrMattBrunke@gmail.com
-DrBrunke.Wordpress.com