Profiles in Animal Pain Management

Leading experts discuss the advances we’ve made in recognizing and treating pain in animals and the work that remains to be done.

For Dr. Robin Downing, the answer to effective animal pain management isn’t a choice between science-backed medicine or holistic care. That creates a false dichotomy, Dr. Downing said, as if the two areas are binary choices. Instead, veterinarians have a responsibility to approach care from a complementary perspective.

“When I use the term holistic, I actually spell it differently – whole-istic, looking at the whole patient.”

Modalities like physical medicine (massage, joint mobilization, myofascial trigger point release, stretching, medical acupuncture) and technology-driven medicine (extracorporeal shock wave therapy, targeted pulsed electromagnetic field therapy, or alpha stem therapy) complement the medicines and nutraceuticals delivered to patients. It points to a visual of spokes on a wheel. The patient is the hub, and the modalities are the individual spokes.

“We’re doctors,” Dr. Downing said. “We are science-trained, and we need to be data-driven because our patients and clients need and deserve no less than that from us. We are treating the whole patient with complementary modalities of care … As these complementary opportunities expand, we veterinarians have an obligation to demand manufacturers provide us with data that can support our decisions to include such care in our multimodal pain management strategy.”

In a series of articles for this issue of Vet-Advantage, Dr. Downing and several other experts share their best practices, experiences, and hopes for animal pain management.

Main image photo credit: istockphoto.com/BigshotD3

 

Windsor Veterinary Clinic

 

A Journey Toward Understanding

How one practitioner has made the practice of animal pain management the foundation of her veterinary practice.

After graduating from veterinary school in the mid-1980s, Dr. Robin Downing started her career all on her own. Her first job was as an ambulatory companion animal-focused practitioner in North Central Wyoming. She drove 3,200 miles a month and served 10 communities, focusing on cats, dogs and some equine patients.

About a year and a half into practice, she met a dog that would change her life.

Sheba was a little Red Heeler that lived and worked on a ranch. Usually at night Sheba would sleep in the house with the family, but at the end of one workday she had crawled under the front porch of their home. Sheba had a bowel obstruction and was in excruciating pain. She was either going to die of a gastrointestinal rupture or die from the pain itself.

Dr. Downing said she felt cast adrift with trying to figure out what to do for Sheba. “Here I was a year and a half into practice, all on my own,” she said. “I had been taught in school that animal pain wasn’t all that important. But I had this patient in front of me that was going to die without an intervention.”

One of Dr. Downing’s clients was a general human surgeon in the area, so she reached out to him for advice. “He was so kind, and willing to take my call in the middle of a panicked afternoon and speak with me about Sheba. I asked him, if Sheba were your patient, what would you do for her?”

Following the conversation, Dr. Downing put a treatment plan in place that the owners accepted. Sheba had bowel resection surgery, intravenous morphine and some follow-up medication. Within two weeks, Sheba was back on her feet running around the ranch.

Dr. Downing credits Sheba with changing her life and creating a transformational conversion to better understand the importance of pain and pain management in animals, especially companion animal medicine.

 

Trendsetter

In 1991, Dr. Downing moved to Colorado and purchased the Windsor Veterinary Clinic. She took with her the lessons learned from Sheba and other pets in Wyoming and applied them to her clientele. But more than that, Dr. Downing expanded her knowledge and practice at the industry level. In the late 1990s, she was invited to join Pfizer Animal Health in their Compassionate Care 2000 Initiative. This was just ahead of the release of a chewable form of anti-inflammatory pain reliever called carprofen, she said. The brand was Rimadyl in the United States.

“That’s where I met a cadre of veterinarians who were absolutely on the bleeding edge of changing the veterinary world’s understanding of pain management, how animals change their interactions with humans when they’re in pain. It was in that context when I realized I was called to this work of moving the boundaries and frontiers of pain management in animals forward – not just embracing appropriate and essential pain management in my own practice for my own patients, but that I needed to make a difference on a global scale.”

Through the years, Dr. Downing has worked with several pharma partners who have had a place at the pain management table to develop new treatments for pets. For instance, years ago she worked with Schering Plough on what at the time was an innovative non-steroidal anti-inflammatory drug called Zubrin. More recently, she was involved in bringing Zoetis’ Simbadol, a long-acting pain relief product for postoperative pain in cats, from molecule to market. She’s also worked with companies on science-driven nutraceuticals and helped a Colorado-based company by evaluating a CBD product in her practice.

“My voice in these contexts is the voice of my colleagues,” Dr. Downing said. “I don’t work in industry, and I don’t work for these entities. They may sponsor talks that I provide, and they may give me an opportunity to interact and interface with my colleagues to raise awareness about innovations and how better to utilize pain management tools. But my credibility resides in the fact that I deliver unbranded messaging. I’m doing what my audience members are doing every day, and that’s making life better for pets and the people who love them.”

Hub and spoke

Dr. Downing possesses two human pain management credentials. It was during the acquisition of those credentials that she did a deep dive into various aspects of human pain management and how it could translate into veterinary medicine. Through that research, she developed a pain assessment tool that could be used for animals and published her findings for the rest of the veterinary medicine community.

The most important tenant to pain management is understanding that every single patient, on every single visit, needs and deserves to have a pain assessment, she said. Once practitioners establish that they have a patient who is uncomfortable in some way, the next step is to try to identify the source of their pain, and then if possible, the actual cause of their pain. Did they trip in a gopher hole and sprain a shoulder? Or are they experiencing the chronic pain of osteoarthritis?

The next step is to create a multimodal pain management strategy for that patient. This will include medication to break the pain cycle. A non-steroidal anti-inflammatory drug remains the cornerstone of that work, Dr. Downing said. “This medication addresses the pain associated with inflammation. Next, with chronic maladaptive pain, we need to address the neurologic aspect of pain with a medication to modify and modulate the central nervous system. The most effective medication for that purpose is gabapentin.”

But veterinarians can’t stop there. For instance, there are excellent science-based nutraceuticals to help with various aspects of the pain experience. There’s physical medicine – both technologies that can help, as well as hands-on care like medical acupuncture and medical massage.

Essentially, the patient is like the hub of a wheel, and each of the modalities becomes a spoke on that wheel.

One of her favorite patient success stories using this process is a Dachshund named Critter, who at 15 years old was referred by a colleague for a wheelchair fitting because he couldn’t use his back legs. During the evaluation, it was apparent that Critter’s profound pain was prohibiting him from walking. So, they initiated a multimodal pain management strategy. Before the treatment, Critter hadn’t been able to use his rear legs at all. But less than 24 hours after the pain management treatments began, he was back on all four feet.

“My very favorite part of Critter’s story is that not only did he resume his ability to be a dog, but when Critter died, he died at 21 years of age, six years later, because he needed a pacemaker – not because he was dealing with pain that could not be taken care of.”

 

State of the art, state of the heart

Dr. Downing believes in a blend of state-of-the-art and state-of-the-heart care. State-of-the-art care means following the science. Veterinarians have an ethical obligation to upgrade and update technology, procedures, medications, vaccines, protocols, and equipment, as those things change and evolve, she said.

State-of-the-heart care means focusing on the human animal bond. Windsor Veterinary Clinic’s motto is that they celebrate, protect and share the special love of animals. “I have a relationship-based practice,” she said. Many clients have been with her for the 32 years the clinic has been open, including multiple generations of clients. “At one point I had a family where I saw the grandparents, the parents and the children who were all pet owners, all three generations.”

There are several industry initiatives related to the human-animal bond that Dr. Downing helped form. She was on the founding board of advisors for the Fear Free movement in veterinary medicine. “Fear Free medicine is all about taking the ‘pet’ out of petrify and putting the ‘treat’ into treatment. I’m still involved intimately with that organization.” Both Windsor Veterinary Clinic and the Downing Center for Animal Pain Management were the first Fear Free certified practices in the state of Colorado, she said.

Windsor Veterinary Clinic and the Downing Center were also the first Gold Level American Association of Feline Practitioners Cat Friendly Practices in the state. “We create an opportunity for cats to have a good experience when they come with their humans,” Dr. Downing said. “We build relationships not just with the clients, but with the patients as well. Very often cats in my practice are willing to eat treats when they’re here. And if you know cats at all, when cats are stressed, they will not eat. So when they are willing to eat, it reflects that they are extremely comfortable.”

Being a veterinary clinic that practices both state-of-the-art and state-of-the-heart care doesn’t happen overnight. It reflects making changes over time. Her clinic was one of the first privately owned veterinary practices to have an in-house laboratory in the mid-1990s, she said. The general practice and specialty center remain dedicated to being able to provide a diagnosis to a patient within 15 to 20 minutes with a full-service in-house laboratory that they’ve upgraded and updated to newer and better technology over time.

Dr. Downing said she was the first privately owned primary care practice to do cancer chemotherapy in Northern Colorado. They choreographed interactions with Colorado State University, which was the only other facility where their patients could receive cancer care. “Now, things have changed, so we have changed as well,” she said. “It’s no longer appropriate for me to provide chemotherapy in my practice, because I have colleagues in the area who can do a better job of that.”

And that’s part of Dr. Downing’s point – when the standard of care changes, no matter what area of practice, veterinarians have an obligation to change. “We must update what we do, how we do it, the care we provide, the pharmaceuticals we utilize, and the vaccines we use, and rely on our colleagues in our geographic area who possess skills and abilities beyond what we are able to provide in our practice,” she said.

 

Changing perceptions

There are two areas of changing perceptions when it comes to animal pain where Dr. Downing has seen improvements. The first is within the veterinary profession itself and the sharp contrast between what veterinarians were taught in the past versus the current understanding of how pain management is now a core competency.

“I spent a number of years sitting on the curriculum committee here at the College of Veterinary Medicine at Colorado State University, so I’m aware of this transformational change,” Dr. Downing said. “It’s fascinating to me that now pain management, both in the acute pain setting of surgery and anesthesia as well as the chronic pain setting, is a core competency in veterinary school curricula, and in veterinary technician school curricula.”

Veterinary medicine also now has an industry advocate in the International Veterinary Academy of Pain Management. Dr. Downing was one of the founders of the IVAPM and served that organization as its second president. The organization helps veterinarians and veterinary health care team members become facile and fluent in some of the more detailed and nuanced issues around pain management. The IVAPM has a certified veterinary pain practitioner credential developed specifically for multi-disciplinary certifications. Veterinarians and veterinary nurses, veterinary technicians, etc., can acquire that expertise to better understand the details of how to put pain management into practice.

The second area of changing perspective is what Dr. Downing said gives her the most hope for the future. Pet owners are, more than ever, tuned into their pets’ health. Much of this may have come as a byproduct of the pandemic when pet owners worked from home and were brought into a much closer relationship, day by day, hour by hour, with their animals. They were able to notice more details, subtleties, and changes in their pet’s health, which generated a fair amount of increased activity of getting the pet to the veterinarian.

There’s still plenty of education needed. Unfortunately, many pet owners still misperceive what they witness in their animals as the pet simply getting older. If their dog doesn’t walk as far, or their cat doesn’t want to sleep on the bed, the owners often have a misperception of that being age-related rather than pain-related. Here, educational resources from industry stakeholders can be helpful, such as Zoetis’ pet-owner facing RedFlag.com website that illustrates cat pain with animations and graphics.

“It’s been rewarding as a pain expert to see how our knowledge of pain awareness has evolved, and to witness how these client-facing, pet-owner facing resources are becoming available so veterinarians can partner with clients to raise awareness,” said Dr. Downing. “It’s about veterinarians accepting the responsibility to do a pain assessment for every patient, at every visit, whether they’re 8 weeks old, or 18 years old. By doing that systematic pain assessment every time, we learn what’s normal and abnormal in an individual animal, so that we can put in place a truly multimodal pain management strategy.”

West Delray Veterinary

 

 

A blend of traditional veterinary practices and integrative therapies has allowed Dr. Jonathan Block to help more people and animals. 

Finding a Balance

Jonathan Block, DVM, CVA, CCRT, believes in the benefits of integrative therapies for several reasons. Perhaps the most compelling reason is he’s experienced those benefits firsthand with his own health.

Dr. Block’s interest in integrative medicine dates to his college years. To maintain a healthy lifestyle while studying in college as a pre-med student and working as a veterinary technician on the side, Dr. Block adopted holistic and health-focused practices. Then as a veterinary school applicant, the year between college and vet school, he worked for a holistic veterinarian in Boulder, Colorado, who was one of the forefathers of integrating Chinese veterinary medicine, as well as herbal and nutritional medicine, into his veterinary practice.

The experience of working within his practice inspired Dr. Block so that when he enrolled in the University of Florida’s veterinary school, he helped start the Holistic Veterinary Medical Club, and corresponded and networked with other practitioners in the area. They put on a conference at the university for continuing education for veterinarians and brought in speakers that were at the top of their field at the time.

Once he was out of school and practicing, he slowly expanded his medical toolbox into integrative therapies. As owner of West Delray Veterinary in Delray Beach, Florida, these integrative therapies allow he and his team to meet the needs of a wider variety of patients and clients. “Basically, it allows me to help more people and more animals, which is really what it’s all about in our profession,” he said.

 

Integrative Modalities

West Delray Veterinary offers several integrative therapies to its clients, including acupuncture, laser therapy, and physical rehabilitation.

Acupuncture is an ancient Chinese medicine that involves stimulating points on the body by inserting needles, or applying pressure, electrical stimulation, or heat. This results in a physiologic response, either locally at the site of the stimulation, or centrally in the brain.

“The pain management actually happens in the brain, not at the site of the pain, and that’s sometimes a misconception for the layperson,” Dr. Block said. Pain medications typically cause a release of certain neurotransmitters like endorphins that bind to pain receptors and block the feeling of pain. “That’s actually how acupuncture works also,” he said. It causes a release of endorphins in the brain, minimizing pain. “Typically, that’s where the scientific validation lies with acupuncture.”

Dr. Block said one of the main benefits of acupuncture is it almost has no side effects. The most compelling group of patients that benefit from acupuncture are senior or geriatric pets. A lot of times not only are they arthritic, but they may be dealing with other age-related chronic issues like liver disease or kidney disease. “Often, those other disease processes will limit the amount of medications that we can use to manage their pain, and manage their comfort,” Dr. Block said. “That’s where modalities like acupuncture can be really beneficial, because they’re not systemic, they have no negative impact on the liver and the kidneys, so they are great ways we can manage pain, and maintain comfort and quality of life without causing detrimental side effects in other organ systems.”

Another modality that is useful in the case of age-related chronic issues is laser therapy. “Lasers are a common modality that we use with our physical therapy protocols,” Dr. Block said. “Sometimes we use it on its own.”

Laser is indicated for pain management and tissue healing. “Sometimes we use it for wound healing, after dentals at the extraction sites, or after surgery to laser the incisions. This helps expedite tissue healing. We also use it in almost all of our physical therapy patients to help manage joint pain, or muscle pain for various injuries or degenerative conditions.”

Dr. Block said there are a few contraindications for laser, mainly, the possibility of skin tumors or tumors in the abdomen. So, if a patient has a history of cancer, they are extremely cautious with laser therapy and may not use it at all.

Physical rehabilitation, or physical therapy (PT), has gained more interest in veterinary medicine in recent years, similar to how it gained support from surgeons in the 1980s to help patients recover from orthopedic procedures. “While that is not quite the standard yet in veterinary medicine, we’re almost there.” West Delray Veterinary offers PT to patients, and the surgeons the veterinary practice works with generally appreciate that they offer and recommend it.

“PT is really valuable,” Dr. Block said. “It provides a conservative medical management option before we get to the point where we’re recommending surgery. I think most veterinarians and most pet owners will agree that ideally surgery should always be the last option. Not only is it invasive and requires anesthesia, but it’s expensive as well. So, we’d like to try everything that we can before going down the path of surgery.”

PT is often recommended as a conservative approach. The client can try a few weeks of physical therapy and if the pet’s response is not what they’re hoping for, then they can always go down the surgery route with the veterinarian’s recommendation. “Once you commit to surgery, you can’t take that back, so PT offers our clients at least an option to be a little bit more conservative.”

Clients are pleasantly surprised by the results. For instance, Dr. Block had a 10-week recheck for a middle-aged Yorkie who had torn her ACL, but was not a great candidate for surgery because of diabetes and liver disease issues. Instead, she did 10 weeks of physical therapy, and looked great afterwards. “I couldn’t tell that she was limping on her 10-week recheck,” Dr. Block said. “For all intents and purposes, we were able to recommend discontinuing physical therapy. She’s allowed to return to her normal lifestyle. Unless she has a reoccurrence of her clinical signs, she avoided surgery for now. So, the client was really happy, and the patient’s quality of life was excellent. I consider that a huge success story.”

 

Both/and

About 75% of what Dr. Block practices is general medicine and surgery. “I really believe and enjoy practicing Western medicine. I don’t want to lose sight of the science-based groundwork in being a diagnostician and being a general practice veterinarian.”

The integrative therapies complement his veterinary practice. It allows him to reach for some herbal and nutritional approaches to medicine that help prevent disease and help get patients set up with a healthy lifestyle. “The idea is that they experience less sickness, less injury down the road as they get older.”

On the human and animal side, we’ve fallen into a pattern of being reactive with our health care, so we don’t take too much time to live healthy lifestyles, Dr. Block said. “Then we get sick, and then we react to the sickness. We’re trying to shift that, and it’s the philosophy I take in veterinary medicine.”

Dr. Block prefers to coach clients on preventative medicine – not just vaccines and parasite prevention – but preventative medicine with nutrition, nutritional supplements, healthy lifestyle, etc. “Then hopefully, we get to a point where we’re experiencing less sickness, less disease down the road,” he said. “We’ll always need to manage some age-related issues, but taking an integrative approach gives us more treatment options.”

It’s a conversation clients want to have. More and more pet owners are coming to veterinarians asking about things like whole food nutrition, herbs and supplements. People are buying all kinds of supplements online because they get targeted by advertising, or even direct to consumer from companies.

Veterinarians, in turn, should be open to and prepared for these conversations.

“Veterinarians do need to be educated in these areas,” Dr. Block said. “The same thing happens in human medicine. Too often there’s a lack of education on the medical practitioner side and the client’s interests in these areas are not received by the practitioner because they don’t know about it, and blow it off because they haven’t learned about it in medical school or veterinary school. Then the client feels dismissed. It’s perceived as the medical establishment’s way or the highway, and that doesn’t resonate well with the client.”

The more information and advocacy for their pets that clients are coming in with, the more veterinarians need to be prepared to receive those questions, and work together with the client to meet their needs on how they want to approach their pet’s care.

That’s where integrative training really benefits veterinarians, Dr. Block said. “When a client comes into me and speaks to me about whole food nutrition or raw food nutrition, or comes to me asking me about a supplement, I at least have a foundation and knowledge base to be able to receive their questions and guide them accordingly so that they can approach their pet’s care in the safest and most effective way,” he said.

There’s no way for veterinarians to know the quality of every single nutritional supplement that’s sold on the internet. Instead, practitioners can simply respond with something like, “I support the use of probiotics in general; however, I have a high level of understanding with X, Y, and Z companies. Those are typically what I recommend, because I know that they have good quality control and that their products are safe and effective.”

“If clients are going to spend their money on something, at the very least we want to guide them down a direction where they’re getting a trusted, safe product that is effective for their pet,” Dr. Block said.

 

Medicine without judgement

Offering a blend of general medicine and integrative therapies has helped Dr. Block practice what he calls “judgement-free medicine.” Especially after COVID, the politics behind medicine have ramped up, even in the veterinary field. People now question things like vaccinations, dog food, heartworm prevention, etc. “Some of their questions are valid,” Dr. Block said. “And sometimes their questions or positions are not valid. But it’s an opportunity to educate.”

Even if clients are not interested in taking a veterinarian’s recommendations, the practitioner still has ways in which they can help. For instance, if a client won’t give their pet heartworm preventatives, then the veterinarian can recommend a heartworm test every three to six months. If the pet becomes heartworm positive, and they catch it early, then they can respond quicker to treatment and minimize the health consequence of that decision.

 

Noah’s Ark  Veterinary Hospital

 

 

Detecting and treating OA pain in feline patients takes a discerning eye. 

Red Flags for OA Pain

When Dr. Matt McGlasson or another provider at the Greater Cincinnati area’s Noah’s Ark veterinary hospital listens to a client describe their cat’s behavior, they are looking for several tell-tale signs of osteoarthritis.

For instance, one red flag he hears repeatedly from clients is they believe their cat has simply gotten older, and as a result is hiding from their pet owners all the time. The clients assume this is just normal cat behavior, rather than a sign that the cat is in serious pain. “But when cats are in pain, sometimes they hide and keep to themselves more,” Dr. McGlasson said. Some of these older cats could be staying under the bed for six to eight hours at a time throughout the day.

Another behavior of cats with possible OA pain is that the pet hesitates, or has gotten slower, navigating the stairs. “Whereas young cats will just sprint up and down the stairs, a lot of cats with OA pain will stop every two or three steps and just sit there for a second,” Dr. McGlasson said.

Or, the cat no longer stands on their hind legs to play or swat at objects. Typically, cats like to sit up on their hind legs to bat at toys and play around. When cats have hip pain, they might still play with their toys, but do it at ground level, and on four legs.

Does the cat jump up on surfaces like they always have, or has it altered its approach? That’s also a red flag, Dr. McGlasson said. “Before they jump onto a surface, instead of running and jumping up, (cats with OA pain) may hesitate for 5 to 10 seconds before they jump. Sometimes they don’t make it all the way, and they have to pull themselves with their front legs. That’s a big one.”

 

Compliance

The good news is, with the right treatment, those cats can regain mobility and be back socializing and playing with family members again. Yet no matter the treatment, veterinarians will have to factor in compliance as to the best approach to recommend. Cats are notoriously hard to give medication to – even for providers.

“I’ve been a veterinarian for almost 20 years, and I have cats,” Dr. McGlasson said. “It’s really hard for me to give my cats medicine at home. It’s a failed attempt probably 15% of the time where they spit it out.”

Failure to administer the medicine can affect the health of the pet and sour the human-animal bond. Cats will often hide or run away if they know their owners are trying to shove a pill down their throat. “So, you have a compliance issue – if the medicine is not getting into the pet, then it’s not working – and you also have the issue of owners starting to kind of pull back and say, ‘I don’t want to do this to my cat anymore,’” Dr. McGlasson said. “Are the benefits worth this damage to the human animal bond? That’s definitely a challenge.”

Noah’s Ark was one of the first clinics to offer Zoetis’ veterinary exclusive Solensia drug for the control of OA pain in cats. Solensia™ (frunevetmab) is an injectable that can be administered at the clinic, so the pet owner doesn’t have to worry about administering it in the home. The clinical results to date have been positive, Dr. McGlasson said. “People are thrilled with the improvement of the human animal bond,” he said. “I’ve had more than one person say, ‘I feel like I’ve got my cat back again.’”

As a social media influencer, Dr. McGlasson has also heard positive feedback for the new treatment from cat owners across the nation. Dr. McGlasson uses Instagram, Facebook and even TikTok to raise awareness of OA pain and things to look out for, so he is in constant contact with “people who are obsessed with their cats.” He gets lots of feedback and firsthand stories on his posts about OA pain in cats. Owners are quick to share tips and reviews of products and procedures that have had positive effects on their beloved pets.

“The type of followers I have are very attuned to their cat’s behavior.”

 

OA-pain checklist

On its website catredflags.com, pet owners can take a test created by Zoetis to see if their cat is showing signs of OA-related pain. Does your cat have:

• Difficulty jumping up?
• Difficulty jumping down?
• Difficulty climbing up stairs?
• Difficulty climbing down stairs?
• Difficulty chasing moving objects?
• Difficulty running?

 

“A ‘yes’ response to any of the questions above may mean that your cat is in pain from osteoarthritis,” the website says. “Just as in humans, chronic pain negatively impacts your cat’s quality of life, not just physically, but also emotionally. The good news is that by identifying your cat’s condition, you and your veterinarian can develop a treatment plan for your cat.”

For more information, visit catredflags.com.

 

Photo credit: istockphoto.com/Kateryna Kukota