Pain management: The positive effects on your practice and patients

While many perceived obstacles to implementing a comprehensive and integrated pain management system exist in a veterinary practice,1 expense or lack of profitability should not be among them. Indeed, pain management provides one of those rare convergences of benefit for the pet, reward to the veterinarian and staff, satisfaction for the client and boost to the economic health of the practice.

Pain management strengthens veterinary practices directly through a fee-for-service construct, but it can lend several other, less-obvious economic advantages. Chief among these is the enhancement of job satisfaction. Team members are often highly intuitive about their patients' comfort and will score them as more painful compared with veterinarians' assessments.2 Team members can also be more aware than veterinarians of clients' distress about their pets' discomfort. Team members who subsequently struggle with the ethics and patient-care consequences of a poorly conceived or implemented pain management system can leave a practice prematurely, requiring replacement and, in turn, potentially causing a significant economic penalty to the practice.

More pain management resources

Pet owners are generally very sensitive to the comfort and abilities of their pets. Practices that enjoy and promote a culture emphasizing pain control are apt to increase client satisfaction, as well as referrals of like-minded pet owners—the A+ clients we all desire and actively seek.

Finally, there's direct remuneration for providing pain management services. The client fee may be calculated based on the cost of goods but also should be commensurate to the value to the patient, which is often high.

Improving both patient care and a practice's vitality

The profit margin on most pain management drugs is often quite satisfactory (although arguably the least profitable among them are the highly effective and commonly used NSAIDs). Whenever a special technique (vs. a simple injection or oral prescription) is required for delivery, fees should reflect the additional supplies and, most important, the expertise required to use them. Such special techniques include epidurals, constant-rate infusions (CRIs), local or regional nerve blocks and infusion catheters.

The prospects of simultaneously improving both patient care and practice economic health are almost boundless. For example, there are pain management opportunities for even the most common, seemingly mundane procedures such as gaining vascular access. Properly applying a commercial topical lidocaine-prilocaine product on the shaved skin over the vein of choice can save the patient the discomfort of indwelling intravenous catheterization while minimizing the anxiety associated with restraint to accomplish the task (anxiety itself has been demonstrated to enhance pain3). The ease of catheter placement diminishes not only the patient's stress but also stress on team members performing and assisting with the procedure. In properly premedicated patients with preapplication of topical lidocaine-prilocaine, it becomes possible for one skilled technician to place their intravenous catheters, without an assistant to restrain the patients. Charging even a small fee for this substantial patient and staff benefit, when repeated hundreds, if not thousands of times a year, will bring income to the practice commensurate to the value to the patient.

The same construct applies with the routine use of local and regional blockade to surgical incisions and major wound repair. Mastery of the tool's many applications is within the ability of any primary care clinician. Examples include simple line or paraincisional blocks; intratesticular, intra-articular, intercostal, pleural, peritoneal and epidural blocks and diffusion catheter application. The cost of materials, lidocaine and bupivacaine is minimal, yet locoregional anesthesia demonstrably lowers postoperative pain scores and simultaneously minimizes the quantities of required systemic analgesic medications, limiting the potential for adverse effects. The value to the patient can be unmistakable, as can the benefits to the practice.

Value of specific pain management medications

Evidence supports the simple act of adding subanesthetic doses of ketamine to perioperative fluids in a CRI to have a preventive effect on postoperative hypersensitivity. A patient receiving an infusion of 10 μg/kg/min during surgery, even if continued at 2 μg/kg/min maintenance rate overnight, will consume only small amounts of ketamine, an inexpensive drug. Modest fees charged for the customary catheter, administration set, infusion pump and fluid for every surgical procedure contribute to practice profitability, while protecting the patient from hyperalgesia.4 More aggressive CRIs are described using ketamine, along with morphine and lidocaine, for extremely painful surgeries.5 The addition of each drug will prompt a fee accordingly.

Intraoperative and postoperative microdoses of medetomidine (0.25 to 1 μg/kg intravenously, synergistically with opioids already administered as part of a multimodal pain management plan) have been extremely valuable tools in my practice. A 44-lb (20-kg) dog might receive as little as 0.01 ml at minor cost to the practice, but it provides exquisite analgesia, sedation and patient recovery. Even small fees for each administration of a dexmedetomidine microdose will more than recover the cost and contribute to the practice's vitality.

Modern veterinary pharmacies can now stock and dispense tramadol, gabapentin, amantadine, amitriptyline and other medications indicated for pain, all at customary markups and typically well within the range of client acceptance. Once a veterinarian is familiar with the use of these drugs, the practice (or the local human pharmacy) will realize the profits from prescribing them; the choice, then, should be an obvious one.

In 2007, a Veterinary Economics analysis described a canine ovariohysterectomy (opioid, NSAID, line block, ketamine CRI), a feline dental with extractions (NSAID, opioid, ketamine CRI, maxillary block) and a multimodal perioperative protocol in fracture repair (NSAIDs, opioids, morphine-lidocaine-ketamine CRI; note that an epidural, while not mentioned, would have also been an indicated procedure). The cost of goods was calculated as $6.33, $11.29 and $32.38, respectively, and at generally accepted client fees, an extremely respectable return can be anticipated.6

Other pain management therapies

Not every aspect of pain management is pharmacologic. We ignore the physical medicines at our patients' peril. Physical rehabilitation need not be an "all" (via referral to a certified practitioner, though this is often the preference) or "none" (client declines the referral, or it's unavailable) proposition. Basic techniques with simple equipment and skill sets can demonstrably enhance patient mobility, ability and comfort. Once rehabilitation techniques are learned and used, they can contribute to practice income. Acupuncture also has become a profit center for many practitioners.

Nutritional products, whether to promote weight loss (diets or medications such as dirlotapide) or to support joint health and offer an NSAID-sparing approach to osteoarthritis (eicosapentaenoic acid-rich diets), can also be dispensed from the practice.

More advanced pain management techniques are open to primary care clinicians as well, including autologous stem cell transplantation (for more, visit vet-stem.com).

In general, each patient and the practice can benefit by implementing a "Rule of 3 or 4 or so"—that is, even for the most routine of surgical or painful conditions, a minimum of three often simple interventions would be used. And the more potentially painful the surgery or condition, the more interventions are used on the patient's behalf.

A sophisticated, but not necessarily complex, pain management culture in a practice can benefit all stakeholders involved in patient care, starting with the patient itself. The investment is little more than the time and energy to learn the principles and applications of multimodal pain management.

Indeed, pain management is a vivid reminder that good medicine contributes to a practice's economic health. Every veterinarian can easily find the resources to advance both. Where will you begin?

Dr. Epstein is president of the International Veterinary Academy of Pain Management and medical director at the Total Bond Animal Hospital in Gastonia, N.C.

REFERENCES

1. Lascelles BDX, Capner,CA, Waterman-Pearson AE. Current British veterinary attitudes to perioperative analgesia for cats and small mammals. Vet Rec 1999;145(21):601-604.

2. Coleman DL, Slingsby LS. Attitudes of veterinary nurses to the assessment of pain and the use of pain scales. Vet Rec 2007;160(16):541-544.

3. Martenson ME, Cetas JS, Heinricher MM. A possible neural basis for stress-induced hyperalgesia. Pain 2009;142(3):236-244.

4. McCartney CJ, Sinha, A, Katz J. A qualitative systematic review of the role of N-methyl-D-aspartate receptor antagonists in preventive analgesia. Anesth Analg 2004;98(5):1385-1400.

5. Muir WW 3rd, Wiese AJ, March PA. Effects of morphine, lidocaine, ketamine, and morphine-lidocaine-ketamine drug combination on minimum alveolar concentration in dogs anesthetized with isoflurane. Am J Vet Res 2003;64(9):1155-1160.

6. McLain Madsen L. The economics of pain relief. Vet Econ 2007;48(6):30-35.