Using a multimodal approach to treat and manage pain

Q: DVM: What led you into pain management and anesthesiology?

James Gaynor, DVM, Dipl. ACVA, Dipl. AAPM

A: Gaynor: Actually, I started out in anesthesiology. It's like living physiology. With everything you do for the patient, you can see reasonably effective and measurable results. I like to get that rapid feedback.

Often, we had to treat postoperative pain. Frequently, after patients left my care, they would become painful, which is how I became more adamant about pain control in patients. Eventually, I began consulting on oncology patients that were months out of treatment and now had chronic pain. Up until that time, chronic pain management was a relatively untouched subject in the veterinary world. Today, many of the patients we see in our clinic have osteoarthritis, the most common source of chronic pain in dogs and cats.

DVM: How do you approach the assessment of pain on an initial patient visit?

Gaynor: We have an in-depth discussion with the client about changes he or she has seen in the animal's behavior and activity level at home. Animals do tell us when they're in pain; we just need to recognize how and what they are experiencing. It's important to define the signs, so we know what we're dealing with.

Animals tend to hide their pain in the presence of strangers because they don't want to show vulnerability. It goes back to animal behavior in the wild where they don't want to show weakness in the face of a potential predator. So some animals we see appear completely normal. That's why a thorough history from the client is so important. We ask about what's happening at home.

Helping them feel no pain: Postsurgical pain should be treated early and aggressively and, ideally, addressed before surgery with preemptive analgesia.

DVM: When a pet is presented with a traumatic, non-life-threatening injury, at what point do you institute pain management therapy? How important is timing?

Gaynor: As soon as the life-threatening aspect is taken care of, we start to treat for pain. For example, if the animal is bleeding or is not breathing well, we take care of that first, and then pain control follows quickly behind, because pain is detrimental to those patients.

DVM: It's been said that dogs and cats have a higher tolerance for pain than people? Is that a myth?

Gaynor: Based on videotapes we've seen of postoperative patients that have no human intervention, they do show signs related to pain if not treated appropriately.

Dogs and cats are very good at hiding pain. Again, it could be because they don't want to show vulnerability in a situation in which they feel threatened. So the idea that they have a high tolerance for pain may simply be a misperception. Maybe they have pain before they show any of it to humans.

DVM: Why do you think pain management has received so much attention in the past few years?

Gaynor: Little attention was paid to this topic during the previous decades. Our knowledge about pain has greatly expanded in recent years. Also, there are more drugs available for pain treatment, and even more in development, compared with 20 years ago. We can do a lot more for pain control these days.

DVM: When it comes to pain management after surgery, can you offer a tip for general practitioners?

Gaynor: Treat early and aggressively. Animals can have more pain than a veterinarian can perceive. I advise treating for pain before surgery. If you consider that an animal won't show pain easily, the veterinarian needs to be aggressive in this regard.

DVM: What role can veterinary technicians play in assessing and monitoring pain in patients?

Gaynor: They play a huge role. In fact, everyone in a practice plays a role. Because doctors are often busy doing a lot of other things, it's really the staff who may observe the pet more frequently and be better able to assess the patient's pain. They can alert the doctor by giving a description of what's being observed in the clinic and by the client at home. Receptionists can make notes on the animal's behavior in the waiting room. The entire team can provide important information to the doctor.

DVM: Tell us about your acupuncture practice. Are more clients requesting it?

Gaynor: Oh yes. Many more clients are asking for it and other nondrug therapies. I practice medical acupuncture that's based on physiology, not traditional Chinese medicine. We employ an integrated approach to pain management; that is, integrating acupuncture and drug therapy and other beneficial modalities for which there are reasonable data to believe they should help. Because few of the patients we see respond to just one treatment, we usually use a multimodal approach.

DVM: You've been using stem-cell therapy in recent years. What kind of results are you seeing with it? When is it most appropriate to use?

Gaynor: Most of the time we use it to treat osteoarthritis pain. We don't use it for regenerative purposes.

That said, in my world, stem-cell therapy is the gold standard for arthritis-related pain, because most of our patients respond extremely well to it. In fact, they rarely need the same joint retreated. I say rarely because the exceptions are working and service dogs that use their joints a lot. But for pet dogs, we have rarely treated the same joint twice.

DVM: Are there any other new or in-development procedures or treatments for pain management that you think hold promise?

Gaynor: We are seeing some exciting results with pulsed electromagnetic field therapy, which we do a lot of. The targeted version entails a magnetic impulse that focuses on one reaction and gives a cascading effect that helps reduce inflammation and improve healing rates. The data in humans are really terrific, and it's relatively new in both human and veterinary medicine.

I think, in general, veterinarians shouldn't discount new nondrug therapies. Also, I think we'll see a lot of new pain management therapies coming out in the next five to 10 years.

Editor's Note: James Gaynor, DVM, MS, is the president and medical director of Peak Performance Veterinary Group and Animal Emergency Care Centers in Colorado Springs, Colo. Dr. Gaynor is a Diplomate of the American College of Veterinary Anesthesiologists, a Diplomate of the American Academy of Pain Management, and a current board member of the International Veterinary Academy of Pain Management. Previously, he was section chief and associate professor of anesthesiology and pain management at Colorado State University.

Loyle is a freelance medical editor and writer in Philadelphia and the former primary editor of the North American Veterinary Licensing Examination.