Building a pain management focused practice (Proceedings)

Pain management is a win/win situation for both the patient and the practice. The appropriately analgesed patient has a better quality of life and heals faster, while the practice increases profits and client satisfaction. There is no negative impact of good pain management in the practice and every practice should strive to have the best pain management practices possible.

Sequelae of pain

Untreated pain can lead to a barrage of behavioral, physiological, hormonal, metabolic and cellular responses that can lead to further deterioration of the patient's health and quality of life. Acute pain can serve a beneficial purpose if an animal perceived to be in pain prompts its owner or veterinary personnel to identify the cause and initiate appropriate treatment. On the other hand, pain in postoperative and trauma patients serves no purpose and should be anticipated and alleviated to allow resumption of normal function as quickly as possible. Chronic pain certainly serves no purpose and patients suffering from chronic pain should be managed in a way that allows appropriate exercise and activity without undue discomfort.

Replacing myths with reality - the need to educate colleagues and owners

Some animal owners and even some caregivers have perceptions about animal pain that are erroneous or outdated. Fortunately, the three recurring pain myths discussed below are rapidly giving way to scientific knowledge and new understanding of the nociceptive (pain) response in our patients.

Myth 1 — Animals don't feel pain.

It is well established that all mammals, including human beings and the canine and feline patients that predominate in companion-animal practice, share the same anatomical components of the nociceptive pathway (Figure 1). The nociceptive pathway consists of:

     • Transduction, the sensation of noxious stimuli perceived and processed by peripheral receptors

     • Transmission, the transmission of noxious stimuli along afferent pathways to the spinal cord

     • Modulation of noxious sensations by discrete neurological tracts within spinal cord pathways and the brain stem

     • Perception, the interpretation of noxious stimuli in the brain, resulting in the sensation of pain. Interpretation of pain may vary greatly between individuals and species.

Because animals have the same nociceptive or pain pathway that human beings have, we can be sure that animals do indeed feel pain.

Myth 2 — Animals tolerate pain better than people do.

Animals are often stoic while experiencing pain, a behavior that uninformed observers may assume means the animal is refractory or indifferent to pain. In reality, animals (1) have reasons to hide pain, and (2) may communicate pain in ways that people fail to recognize. In their environment, animals instinctively hide pain because it can be a sign of vulnerability to predators. When pain becomes so intense that it cannot be hidden, animals may not communicate their discomfort in a way that we recognize. An analogy would be a human infant crying in response to pain because they are unable to articulate their feelings as an adult would. An observer might not recognize the source of crying (since crying has many causes) just as an observer might not recognize the signs of pain in an animal. In this regard, there are three helpful pain-management guidelines:

     • Animals, unlike humans, are highly motivated to hide pain. Therefore, by the time we are able to observe overt signs, the pain is likely to be more intense than we think.

     • An animal's inability to communicate pain does not negate the possibility that pain exists and that the animal would benefit from analgesic treatment.

     • We should assume that an event that would be painful to a human being would also be painful to an animal, and this pain should be managed accordingly. We should utilize preemptive methods for pain relief based on the extent of a surgical procedure or severity of a medical condition rather than relying on physiological or behavioral signs of pain that may or may not be exhibited by the patient.

Myth 3 — Pain is beneficial in limiting an animal's movement during recovery from surgery or trauma.

In reality, animals in pain are often restless and agitated. If ambulatory, they commonly pace, circle, pant, and aggravate wounds and surgical sites. Conversely, animals that are comfortable following adequate analgesia are more likely to rest quietly without agitation or distress. Furthermore, untreated pain becomes a pathology in itself, manifesting as adverse side effects, including tachycardia, hypertension, tachypnea, gastric ulcerations, ileus, decreased renal function, catabolism, altered hemostasis, and impaired wound healing (see the section "Sequelae of Pain"). If limiting movement is necessary, various methods of restraint or immobilization, and chemical tranquilization are available. Veterinarians should endeavor to make their patients as comfortable as possible so they can rest and allow healing to proceed unimpaired by the effects of pain.

The comment of one expert in pain management provides additional insight:

"I have never come across a patient who has damaged a surgical site or pulled out implants as a result of being too comfortable, however, I have come across patients who have damaged a surgical site, traumatized a surgical site, or damaged implants as a result of being too painful postoperatively" (Duncan Lascelles, BSc, BVSc, PhD, MRCVS, Diplomate ECVS).

Pet owner expectations in managing pain

Pet owners are becoming increasingly aware that animal pain is a legitimate concern and can be managed. This is due in part to the emergence of analgesic drugs in human health care (and a corresponding increase in consumer advertising) as well as pain management education provided by the veterinarian and the veterinary staff. Clients have come to expect pain relief as a legitimate therapy for their pets. To illustrate, market research shows that:

     • 99% of pet owners believe spaying and neutering cause pain

     • 99% of pet owners want their pets' pain managed

     • 91% of pet owners assume their veterinarians are providing adequate pain management

     • 98% of pet owners are willing to pay an additional amount for pain management above and beyond the cost of the spaying or neutering

Thus, the veterinarian should establish pain management as an integral component of the practice's philosophy. According to this paradigm, surgery is not performed without anesthesia, nor are painful procedures performed without analgesia.

The doctor-client relationship is also improved when the pain management protocol is discussed. How will the patient respond? When will the patient need more medication? How do clients recognize animal pain or stress at home? When should clients contact the veterinarian? Dialogue surrounding these issues tends to build rapport with the client, create client confidence in the practice, and result in an informed client who is more likely to utilize the veterinarian's services. Involving the client in pain management can have a direct bearing on the business aspects of the practice. With this in mind, it is wise to involve the client in follow-up evaluations, especially when chronic pain is involved. Prolonged pain therapy without re-evaluation can lead to client confusion and potential patient toxicities and other undesirable side effects.

The business of pain management

As stated above, pain management is not only good medicine, it is good business as well. Clients understand pain and are willing to pay for pain management when they are adequately educated about pain in animals - and we shouldn't feel bad for charging for services and products that are GOOD MEDICINE. We charge for fluids, for antibiotics, for suture material, for anesthetic drugs, etc... because all of these are required for good medicine. As noted in the 'sequelae of unmanaged pain' section, pain itself causes many medical complications, thus, pain management is good medicine. We need to manage pain and charge for it.

Furthermore, good pain management creates cost savings in many different areas. For instance, a patient that has received appropriate pre-emptive analgesia will require less induction and maintenance anesthesia drugs, thereby saving on anesthesia costs. This patient is more likely to have a quiet, controlled recovery, thereby saving on technician costs. Rather than restraining patients during stormy recoveries, technicians can be utilizing their skills in areas more satisfying to them and more useful to the clinic.

Finally, the management of chronic pain - although sometimes difficult - can help to build devotion and satisfaction among your clientele. We have all seen the client joy and good-will for the practice as the client sees a loved pet return to a level of activity that they associate with a good quality of life or even 'happiness'. Often, the client didn't actually realize that the pet was in pain and it was up to us to identify the problem and educate the clients about chronic pain in animals and its effects on the pet's quality of life. Once pain is relieved and the clients can see the difference, the treatment of chronic pain is good medicine for the patient and an income builder for your practice. A good senior care questionnaire can be a very helpful in identifying chronic pain.

Implementing or refining a pain management program

To implement an effective pain management program in your practice, or to refine a program that is already in place, the following steps are often helpful:

     1. Include and educate the entire staff in your practice. Prevention and relief of acute and chronic animal pain and suffering should be a common objective of each animal caregiver. Technicians and nurses should be trained to recognize animal pain and provide appropriate nursing care. Administrative staff should be trained to educate the clients on the importance of pain management. Consider establishing a "Pain Team" in the hospital. This team will consist of pain management champions among veterinary and nursing staff that oversee protocol development and implementation.

     2. Develop and implement pain management protocols that place emphasis on preventing as well as treating pain in every patient. These protocols should be written out and posted to provide a readily accessible resource that enables the entire clinic staff to proactively play a role in pain management.

     3. Include follow-up pain assessments for patients while in the clinic and after discharge, and include the assessments in the patient's medical record. The staff and the pet's owner should be an integral part of this process.

     4. Develop rescue protocols that enable recognition and treatment of pain that is unresponsive to the standard pain management protocols.

     5. Develop discharge protocols that include analgesia so that patients leave the clinic with appropriate medications. Staff should be trained to explain how continued analgesic therapy facilitates recovery and to demonstrate how medications should be administered. Our paradigm should be that pain does not end at discharge.

     6. Develop chronic pain management protocols, including guidelines for involving the owner in the pet's therapy and educating the owner on pain recognition and treatment.

     7. Use consent forms and client education literature to emphasize the practice's commitment to pain management. Revise billing forms so that pain management is itemized. Do not position analgesia as optional to the client. Rather state that "our prices reflect appropriate analgesia to manage your pet's pain" (see Appendix 5)

     8. Assess and revise the practice's pain management protocols on a continuing basis in light of empirical results. Keep staff advised of revisions in the practice's pain management methods.