A closer look at the new veterinary pain management guidelines

The importance of administering both local and locoregional anesthetic blocks with every surgical procedure. The value of nonpharmacologic intervention when treating certain conditions. Recognizing and treating maladaptive pain. Maximizing safe use of NSAIDs. Recognizing behavioral changes as pain indicators. This is just a small sampling of the new pain management guidelines recently introduced by the American Animal Hospital Association (AAHA) and the American Association of Feline Practitioners (AAFP).

The 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats consolidates the robust research that has been published on this topic in the past three years. The new guidelines update those released in 2007.

“The 2007 guidelines provided the foundation and framework [to which] the 2015 guidelines can now give legs and direct recommendations for the busy clinician, raising the pain management bar throughout the profession,” says Mark Epstein, DVM, DABVP (canine and feline), CVPP, co-chair of the committee that developed the 2015 guidelines.

The role of the 2007 guidelines was to describe and define the broad principles of applied pain management in companion animals, a field Epstein says was in its infancy at that time. “There were few tools and astonishingly little scientific evidence regarding the assessment of pain, nor upon which to base specific treatment recommendations-a problem that has been greatly remedied over the intervening years but which will continue to evolve,” says Epstein, the medical director of TotalBond Veterinary Hospitals, Gastonia, North Carolina. 

Also, in 2007 there was almost no information on pain management in cats, he continues, but that's changed in recent years. “Modern day, for both dogs and cats, we have an increasingly strong handle on the recognition and assessment of pain; the best, highest, wisest use of opioids, NSAIDs, local anesthetics and other pain-modifying analgesic drugs; and, critically, nonpharmacologic modalities to prevent and treat pain.”

The new guidelines provide evidence-based recommendations for the most common reasons companion animals experience pain, including acute postsurgical pain, and in the area of chronic pain, degenerative joint disease (DJD). 

“There is increased awareness of how common DJD is in cats,” says Ilona Rodan, DVM, DABVP, co-chair of the guidelines committee. The new guidelines contain two sections, one each for canine and feline, to help clinicians diagnose and treat joint disease, which the authors called one of the most significant and underdiagnosed diseases of companion animals.

A team-based approach is best

Emphasized in the new guidelines is the critical importance of all members of a pet-care team, including owners. “Behavior is the key to recognizing and assessing pain,” says Rodan, a feline specialty behavior consultant and founder of Cat Care Clinic in Madison, Wisconsin.

“For example, in cats, where the signs of pain are subtle, owner input is critical to help identify pain,” Rodan says. “Does the cat have a decline in its normal behaviors, such as appetite or grooming; a start of new behaviors, such as being more clingy or withdrawn; or behavior problems? A cat that stops using the litter box may have a painful bladder condition or a condition that makes it difficult for the cat to jump into and out of the box.”

Such behaviors, when noticed and then reported by the owner, can help direct the veterinary team's attention to pain as a possible cause.

Moreover, the new guidelines note that every healthcare team member should have a defined role in pain management. “Medical rounds and staff meetings are effective tools in making sure that all staff members are aware of the individualized pain management needs of every hospitalized animal,” note the guidelines' authors. “Each healthcare team member should be able to recognize pain-associated behavior in animals … and how to respond appropriately.”

The authors offer a list of suggested pain management responsibilities for each team member, including veterinarian, technician and patient-care personnel.

Continuum of care

An ideal pain management plan, the authors note, should include anticipation, early intervention and evaluation of response, the latter of which should be considered a credible pain assessment tool. Says Rodan, “It's not enough to just use analgesia, but rather it's essential to return to the patient and reassess acute and chronic pain.”

She offers the example of a cat with DJD that is started on medications and for which the owner provides a litter box with a low lip. “The cat must be rechecked and reassessed to see if it's still painful, and other medications may be indicated,” Rodan says. “Once comfortable, the cat should be brought for periodic visits to ensure that it remains pain-free.”

The 2007 guidelines introduced nonpharmacologic interventions, but the 2015 guidelines give them a more prominent place. Cold compression for surgical incisions, weight management and optimization, and exercise therapy all can play a role in effective pain management. And treatment options such as acupuncture, physical rehabilitation, myofascial trigger point therapy, therapeutic laser and other modalities are gaining acceptance among the veterinary community.

How an animal is handled also plays a role. “Gentle handling versus heavy restraint can greatly impact the comfort of the pet,” says Rodan. “Having ramps or pet steps to allow the pet to get to its favorite spots greatly improves its quality of life as well as comfort.”

A multimodal approach to medications

When discussing pharmacologic options, the new guidelines call for a balanced or multimodal strategy using several classes of pain medication. For example, while the 2007 guidelines acknowledged the usefulness of local anesthetics, the new guidelines are far more assertive by stating that local and locoregional anesthetic blocks should be performed with every surgical procedure when possible.

The previous guidelines gave a brief description of various drugs and drug classes, while the new guidelines summarize current best evidence on various analgesic medications. For example, “with regards to NSAIDs, the clinician is given straightforward guidance on how to maximize safe use of this important drug class,” says Epstein.

In addition to NSAIDs, the new guidelines summarize the latest research on opioids, local anesthetics, α-2 adrenergic agonists, and individual drugs, such as ketamine, gabapentin and tramadol, to name a few.

Regarding perioperative pain management, the authors point to an evidence-based approach that guides clinicians to shape their own protocols, and a similar treatment is given to DJD in both dogs and cats.

“The choice of medication should be based on anticipated pain levels and individualized patient needs,” the authors state. “Anticipatory analgesia provided prior to pain onset is more effective than analgesia provided once pain has occurred, contributing to both a dose- and anesthetic-sparing effect.”

Pain scores

The 2007 guidelines stated that pain should be considered the fourth vital sign after temperature, pulse and respiration and directed that every patient be assigned a pain score. “However, the clinician might say, ‘Fine, but how does one assign a pain score?'” notes Epstein.

While there still is no gold standard for assessing animal pain, the guidelines' authors point to several credible online resources for scoring acute postoperative pain, including those offered by Colorado State University, University of Glasgow and UNESP-Botucatu in Brazil.

A table also directs clinicians to several multifactorial measurement instruments for assessing chronic pain-including the Helsinki Chronic Pain Index, Canine Brief Pain Inventory and Cincinnati Orthopedic Disability Index-that utilize primarily pet owner observations and input. 

“The use of pain scoring tools can decrease subjectivity and bias by observers, resulting in more effective pain management, which ultimately leads to better patient care,” the authors say.

Takeaways

Epstein calls the new guidelines “a force-multiplier for the busy practitioner” in that they serve several important functions:

> Promote a pain-aware culture in practice, in which the entire team (including the pet owner) is involved.

> Provide a quick reference on pain assessment, as well as the toolbox of pharmacologic and non-harmacologic interventions.

> Provide guidance on an evidence-based approach to prevention and treatment of surgical and DJD-related pain.

Says Rodan, “Continued updates in canine and feline pain management provide veterinarians with the tools to improve patient care, job satisfaction, and the quality of the life of their patients and the relationship they have with their people.”

Donna Loyle is a Philadelphia-based freelance writer and editor who specializes in medical, veterinary and fitness topics. She is the former primary editor of the North American Veterinary Licensing Examination.