Leading Off: Putting the new pain management guidelines into practice

You and your clients know that pain hurts. Clients want you to help them do the right things for their pets,1 and they expect you and your healthcare team to make pain management recommendations. Luckily, the American Animal Hospital Association (AAHA) and the American Association of Feline Practitioners (AAFP) have just put together new guidelines for pain management, which cover types of pain, recognition and assessment, and intervention (visit www.aahanet.org to view the guidelines).

Robin Downing, DVM, a diplomate of the American Academy of Pain Management, is the past-president of the International Veterinary Academy of Pain Management and the hospital director of the Windsor Veterinary Clinic, Windsor, Colo. She is also a member of the Veterinary Medicine Practitioner Advisory Board.

GOOD MEDICINE

Pain management is good medicine. Uncontrolled or poorly controlled pain is pathologic and carries with it serious medical consequences. In human medicine, pain is considered the fifth vital sign and must be evaluated in every patient assessment. The consequences of untreated pain include decreased sleep, chronic fatigue, increased circulating cortisol concentrations, delayed healing, decreased or loss of normal behaviors, decreased activities of daily living, and increased suffering. The American Veterinary Medical Association (AVMA) states that pain management is consistent with the veterinarian's oath.

GOOD BUSINESS

Managing pain is also good business. Practicing good pain management demonstrates increased compassion for patients and clients. Increased compassion builds relationships with clients and bonds those clients to the practice. This commitment to doing more for our patients leads to increased client visits and increased revenues.

Even a conservative example can demonstrate the fiscal benefits of perioperative pain management. If a practice performs 750 surgeries a year and the veterinarian gives each patient an injectable postoperative analgesic for $15 and sends several doses of oral pain medication home for $40, the simple decision to provide greater comfort to patients in pain provides an additional $30,000 of annual gross revenue for the practice.

In addition, when every member of the veterinary healthcare team is involved in recognizing and treating pain, there is increased job satisfaction. Increased job satisfaction leads to decreased staff turnover, saving businesses money. Relieving patients' pain helps everyone feel good about the jobs they do.

IMPLEMENTING THE GUIDELINES

These five tips will help you put the AAHA/AAFP Pain Management Guidelines for Dogs & Cats into practice.

1. Adopt a pain scoring system for the practice team to use.

There is not one right answer in choosing a pain scoring system, so choose a system that the entire team will use. If you choose a 0-to-10-pain scale, spend time at team meetings introducing the scale. Demonstrate how to touch and manipulate patients to look for pain. Talk through and explain your pain assessment in the examination room for the benefit of both the client and the team member.

2. Create and deliver pain management protocols for every surgical patient.

All pain is not created equal. A pain management protocol is a template to adjust to meet each patient's needs. For example, the pain management protocol for a superficial laceration should differ from that for an ovariohysterectomy and from the protocol for a tibial plateau leveling osteotomy. James Giordano, PhD, a pain practitioner for people told me that "pain management is an ongoing clinical experiment with an 'n' of one."

Use the available resources such as the new pain management guidelines when building your pain management protocols. Excellent texts include the Handbook of Veterinary Pain Management by Drs. James S. Gaynor and William W. Muir and Pain Management for the Small Animal Practitioner by Drs. William J. Tranquilli, Kurt A. Grimm, and Leigh A. Lamont. Internet resources include the Web sites for the Veterinary Anesthesia & Analgesia Support Group (www.vasg.org) and the International Veterinary Academy of Pain Management (www.ivapm.org).

Some veterinarians still say that surgical pain management is optional and that the pet owner should decide whether to administer it. I disagree. Relieving pain is a medical decision that must be made by a medical professional. Our patients need and deserve mandatory pain management in the perioperative period.

3. Assess pain in every patient at every visit, and document it.

Apply your chosen pain scoring system. At every outpatient visit, assess the animal for pain, and record the finding in the medical record. Each pain assessment is important, but trends are even more important for patients with chronic pain—are they improving or worsening?

Similarly, surgical patients with acute pain need to be assessed at regular intervals during their hospital stays and need to have their results recorded in their medical records. Seeing trends allows the practice team to understand the success of a perioperative pain management plan.

4. Remember the three Rs of chronic pain management: recheck, reassess, and revise.

For patients with chronic pain, pain management is often a moving target. Patient pain management needs may change with the seasons, the temperature outdoors, and the patient's activity level. Managing chronic pain remains a dynamic process that relies on the three Rs:

• Recheck the patient at regular intervals. Schedule the next recheck before the client leaves at the end of a visit;

• Reassess the patient's comfort level, based on the current therapeutic plan;

• Revise your pain management plan according to the patient's needs.

5. Join the International Veterinary Academy of Pain Management (IVAPM).

The entire veterinary healthcare team is welcome to join the IVAPM. IVAPM members have access to sections of the Web site containing downloadable pain management training programs and links to articles of interest. And members can subscribe to Veterinary Anaesthesia and Analgesia at a discounted rate. The members' list serve actively discusses pain cases of interest, new applications of old medications, and nonmedical pain management.

The IVAPM is developing a credentialing pathway for interested veterinarians and veterinary technicians to demonstrate expertise in pain management.

IT STARTS AT THE TOP

Making pain management a priority in your practice means every team member has an important role to play in identifying pain in every pet. Since the team walks in the shadow of the leader, a commitment to pain management and prevention starts at the top. Relieving pain is compassionate care at its best and is both a quality-of-care and a quality-of-life issue. Inspire your team to share your passion for doing the right things right for pets in pain!

REFERENCE

1.The path to high quality care: practical tips for improving compliance. Lakewood, Colo: American Animal Hospital Association, 2003.