Modern Veterinary Medicine Has Made Great Advances In Pain Control – WHY Has It Not Found Its Way To Most Clinics?
As a chronic severe pain patient myself, I have a very sincere and personal interest in pain control. I have studied this subject and focus on practical methods for controlling pain in all animals, but especially those nearing the end of their life. I cannot stand to see an animal in pain and 70-80% of our senior pets have some disease process that generates pain. These include cancer, arthritis of both the limbs and spinal column, spinal disc disease, stroke, old injuries, chronic infections and the list goes on.
Please do not let your pets suffer with pain, either because of not knowing the signs of pain, or by believing that something you bought over the counter is working. So often I hear of a pet owner giving “a half an aspirin or glucosamine” for their dogs severe pain. These things are practically useless, especially in any case with moderate or severe pain. Over-the-counter supplements are also a waste of your money. You would be far better off spending that money on things that actually work.
Also, because you have been prescribed Rimadyl® or the generic Carprofen, or some other type of non-steroid anti-inflammatory drug (NSAID), do not think this will be your pain control plan forever. It may have some initial beneficial effect, but as pain gets worse with time, these drugs will most likely become inadequate and must be supplemented with other more specific and more powerful pain relief.
I also recommend that you not blindly giving something that was prescribed years ago but has not been updated or supplemented with newer meds. Pain is a symptom that requires your full attention and for you to be a strong advocate for your pet. Don’t be embarrassed to study and ask very pointed questions of your pet’s doctor. If they do not welcome this type of questioning, or if you are a bit afraid to ask them, then you owe it to your pet friend to find a veterinarian that will welcome your concern about pain management and one who will explain the approach they are taking.
Further, do not fall for the all of these questionable “sciences” that simply do NOT have the vast amount of evidence of effectiveness for your mainstay of pain control. These things include foolishness like homeopathy, reiki therapy, aroma therapy, herbs, LED lights – and there are more. There are some non-traditioinal practices like animal chiropractic and acupuncture that may have some place in initial therapy and may help with minor pain. But, just as with NSAID’s, they may offer a brief and minor bit of relief, but they are not, I repeat, not for long term or moderate to severe pain.
Please be aware VERY few supplements or natural ingredients actually control pain. If you feel you simply must use such things, then make sure they do no harm (some do) and also please make them a part of a real medical regime. Do not rely on herbal or holistic cures for very serious pain. In my personal experience, I’ve tried many of these alternative medicine modalities and they have done absolutely nothing to control pain. My best advice is to save your money!
If you would like to read more on the lack of effectiveness in alternative pain medications, see this site: The Skept Vet. http://skeptvet.com/Blog/
Over the past decade treating pain in pets has gained more recognition in veterinary practice, but far too often I see pets at the end of their lives in horrible pain – and they have been that way for months or years. Most of these pets have been seen by a veterinarian but the pain is simply not being treated, or treated effectively. Our animal patients deserve better – especially our seniors. I’ve written this article specifically because I think you should know how pain is treated by veterinarians who are taking the time and making the effort to learn this ever changing part of medicine.
In most cases, the pain I see with long standing disease (as in the case of pets at the end of their life) can be controlled if only the doctors would invest time and study to learn the changing medical science of analgesia. Then take the steps necessary to apply the methods, modalities and medications we have today. Pet owners often tell me they know their dog is in pain and they are dutifully giving the “pain pill” their veterinarian prescribed. Yet, the pet is still in awful pain. Sometimes I hear pet owners are giving “some sort of supplement”they found at a pet store (most don’t know what that is) or even a human medication from their medicine cabinet. But in nearly all of these cases, whatever is being given is not working and the pet is still in pain. Sadly, very often by the time I see them, the pet needs drastic intervention or euthanasia.
Multi-Modal Pain Management
Think what could have been done years ago to give a painful animal some relief and “more good days, then bad ones” had they been on a proper pain management protocol. The answer to controlling pain lies in something called Multi-Modal Pain Management – the same concept is used by human physicians who specialize in pain management. The idea is very simple. Multi-modal pain management means we use several medications and supplements that work at different parts of the pain pathway. This allows the veterinarian to target parts of this pathway, and to decrease the overall amount of some of the drugs that can be harmful long term. By approaching the pain generators in this way, the overall effect if much more pronounced.
How Do I Know My Pet Is In Pain?
Now is a good time for a reminder; pets display outward signs of pain differently. Some pets will definately tell you when they hurt, most, however, are very stoic and you just don’t know. It usually takes the trained eye of a veterinarian to see subtile signs of pain. Chronic pain is also compensated for by the pet over time. So that small limp may not necessarily become a big limp or a cry out of pain. It may simply become a new way of walking to “compensate” for the pain. This compensation is often the reason people believe their over-the-counter remedy works. Mild pain is sometimes hard to see, but changes in your pets routine or appetite may be a clue. With more moderate pain you will see a limp, stiffness, inability to jump like they used to, loss of stamina, laying down while on a walk and more obvious signs like these. With severe pain a loss of appetite is almost always seen, dogs in bad pain may cry out, not sleep well, avoid stairs or even normally fun things like petting or playing. Worse yet, they may pant or shake to show they are hurting. It is not that common for dogs to cry out, but if they do, they are in the severe pain category and require immediate intervention.
I’m occasionally asked about “Edibles”. In a state that allows medical and recreational marijuana, I have found that even high doses of CBD’s (the extract promoted as having pain relief effects) do not have sufficient analgesic effect to be reliable medications. CBD’s are also quite expensive, no studies have been done to prove any effect, and there are hundreds of chemicals in these extracts and no one can tell you what they are doing. As for pain relief, all the evidence is purely testimonial – and that is not science. Even in human medicine we simply don’t have adequate research data to know dosage and predict reactions. Consequently veterinarians are reluctant to prescribe it, especially considering the likelihood for abuse.
As I mentioned earlier, many experts believe acupuncture and chiropractic methods fall into this same questionable category. While many believe these methods have some helpful effect, and perhaps they do “help” early on and with mild pain symptoms, please do NOT rely on them as your mainstay of real pain control for serious pain! There is also a large illegal trade in people who hold themselves out as these professionals but do not have the proper certification by the state. Even human chiropractors, for example, will charge you handsomely for a “manipulation” for your dog or horse, but the only thing that gets manipulated is your trust and your wallet. It is against the State Board of Veterinary Medical Examiners for a human chiropractor to be paid to apply their practice on animal patients. Even veterinarians who do this practice should have gone through years of strict and rigorous training to obtain proper certification. Many veterinarians practice chiropractic without any extra certification or training. While not illegal, it is a misrepresentation and perhaps worse – so be careful when you allow anyone to perform “manipulations” on your pets or horses.
So what is real pain medical therapy that goes beyond what many veterinary clinics believe is a standard course of pain drugs? Here is a quick look at just a few of the drugs and modalities that can be used in a real multi-modal approach to pain.
NSAIDs: These letters stand for Non Steroid Anti-Inflammatory Drug. (you can think of aspirin, ibuprofen, and celecoxib or “Celebrex”) These drugs are very popular first line pain medications and included Rimadyl® and Metacam®, the newest is Meloxadyl®. There are many others we have to choose from. The dose is fixed and should be followed carefully. NSAIDS are generally not given to cats! But cats now have a new NSAID made and approved just for cats called Onsior®.
The most popular brand we use in veterinary medicine is called Rimadyl®. The active ingredient is “carprofen” and some find the use of the generic carprofen works fine for their dogs and it is much cheaper. I always start all pain cases on the brand name drug to see if we get relief. We can change over to a generic once we know it works. In some cases I’ve found the generic simply will not give the dog the same relief as Rimadyl. Metacam and Meloxadyl are highly effective NSAID’s and they work in a very similar way but many veterinarians save them for use in difficult cases because of the expense. With all these drugs we must monitor liver function in long term use.
Rimadyl® is dosed at 2.0 mg per pound once a day, OR 1.0 mg per pound twice a day. Don’t confuse this with kilogram dosing. It is given at 4.4 mg/kilogram once a day or 2.2 mg/kilogram twice a day. Long term therapy can cause liver issues, so pets being given any form of carprofen should have lab tests done between 6 months and one year depending on their age. If it becomes a problem, this drug is stopped and we move to other drugs in this multi-drug program.
Gabapentin is a drug that has been used for many years in humans called “Neurontin”. The newer form is Lyrica. Gabapentin works very well in dogs and it is inexpensive. It must be dosed properly and started correctly in the first few weeks but is often highly effective. If your veterinarian has prescribed gabapentin, then I am very happy, but I want you to be sure you are on the right dose. A suggested starting dose is 5-10 mg/kg twice a day. (divide your pet’s weight in pounds by 2.2 to get kilograms. For example, a 50 pound dog is 22 Kg). Always start with the evening dose as it causes sedation and they will sleep through this sedation at night. After about a week you can add in the morning dose. Also if you increase the dose, then make that increase starting at the night time dose. If too much sedation occurs, then lower the dose. The dose can safely be increased as needed (usually by 25-50% every 7-14 days) until an effective level is reached. Also you can increase the dose by adding in a mid-day dose of the medication.
Often, moderate pain can be well controlled with an NSAID and gabapentin. I’ve seen old arthritic dogs that can no longer climb stairs, begin to go up a short set of stairs with little struggle and begin to play again, just on these two drugs when dosed properly!
Opioid Analgesics are commonly used in human pain. Hydrocodone is the most common. This drug can help ease severe pain dramatically, but does make the dog a little sedate. These are federally controlled drugs and your veterinarian will probably have you sign a form stating you will make sure the drug is used for it intended purpose. The most common form used by veterinarians is Tramadol®, or Ultram®. It works well IF doses correctly. I can count on one hand how many times I’ve seen dogs sent home with Tramadol where the dose and frequency on the label directions are correct. The curious issue here is the way dogs metabolize this drug. If not given at least three to four times a day, then there are gaps of time when the dog is in pain. And for some reason veterinarians are intent on under-dosing this drug. In dogs, a starting dose of 3-5 mg/kg THREE times a day works well and then if pain persists or becomes more severe, then you can dose this drug up to 5 mg/kg FOUR times a day. If you use less than that and you are not achieving analgesia.
ANOTHER NOTE OF CAUTION: if your veterinarian calls this drug into a human pharmacy, the pharmacy will often question the dose because it is not what a human would receive. They do not understand animal pharmacology. There are even cases of human pharmacies CHANGING the doctor’s orders on a prescription because they think it is wrong. So double checking would be a good idea.
I often use Tramadol only as a “break-through” pain medication when the base is an NSAID and Gabapentin. If pain becomes severe, then Tramadol on a regular basis WITH these other two medications will become the daily routine to control such pain.
Other opioids that are used in veterinary medicine include; morphine, codeine, hydrocodone, hydromorphone, fentanyl and buprenorphine. All vary in their effectiveness and how there are metabolized by either dogs or cats. They must be given with veterinary supervision, never “off the shelf” because you have it at home for your own pain!! Again these are controlled drugs and must be given carefully.
Steroids can be used the short term and are given orally or by injection. They are not analgesics (purely pain relief drugs), they work on pain solely as a strong anti-inflammatory drug and are highly effective. The down side is that they should not be used long term, or if necessary then in lower doses. In a hospice or end-of-life situation, then I am less concerned about dose or length of treatment. Here the main goal is to keep the pet comfortable.
Omega 3 fish oil is an outstanding way to help with the inflammation that accompanies most pain generators. You should find the highest quality medical grade fish oil so that it is pure and effective. I do not recommend an inexpensive brand on grocery store shelves. In researching this topic I’ve found that Nordic Naturals Omega Pet® is the best. It is hard to find in a store, but if you use “Nordic Naturals Pet” in your search box, you will find it online. For pain, use the maximum labeled dose and you may go from once a day to twice a day.
Duralactin is a milk protein that contains factors that reduce the movement of white blood cells into an inflamed area thus relieving pain. Results are seen in 4-7 days with peak effects in 10-14 days. It comes in a chewable tablet or a powder and your veterinarian can get it for you. This is a part of a multimodal pain program, and not to be used as a single treatment.
Amantadine is an antiviral drug that has been found to block very special receptors at nerve transmission sites and help with pain management. Some find it effective and others do not. It is something to try in the multimodal plan for long term pain cases.
Adequan® Injections are only used in selected cases where the pain is in the joints. The drug actually helps protect and rebuild the damaged cartilage in arthritic joints. Your veterinarian must give it by intramuscular injection only. It is used in horses and dogs and can be highly effective in this type of pain. It is relatively expensive so you want to gauge the effectiveness of the injections and makes sure you are seeing relief within a month to 6 weeks.
Class IV Laser Therapy is a relatively new physical modality used in veterinary medicine and many find it highly effective in all types of pain. It is called “photo-modulation” and is carefully dosed at the site of the suspected painful joint or tissue. There are Class IV laser devices that are powerful and are known to penetrate skin and tissue in order to get to the source of the pain. On the other hand, there are very inexpensive “knock-offs” that have no studies to prove they do anything other than create a red light at the end of the cable. LED lights are also completely not effective. I’ve seen these things sold at fairs and trade shows, but they are a complete scam.
Physical Therapy: Various forms of practical PT can be used in dogs such as swimming, heat, cold, range of motion, water treadmill work, weight bearing controlled exercises etc. The problem is finding a properly certified animal Physical Therapist who really knows their science and how it is applied to animal patients. So far many cities do not have such a professional. I am concerned about human Physical Therapists who claim they are certified to apply their science to animals, but are not.
Please be very cautious when hiring anyone that claims to be a physical therapist in veterinary medicine. Unfortunately in both Physical Therapy and in chiropractic, human certified professionals can hold themselves out as veterinary therapists and they may, or May NOT have such certification. A human Doctor of Chiropractic who is not properly certified and works on animals is doing so illegally and may be brought before the state licensing board! Unfortunately our state licensing boards don’t have the time, money or the will to prosecute these cases and illegal therapy procedures happen every day. It is very disappointing. So you must be the one who investigates and carefully decides.
Not all of these medications are used in a typical case requiring multimodal pain control, but this does show you there are many other things to try besides the standard “pain pill and NSAID” that many veterinarians prescribe as a matter of routine. Your pets deserve their care giver properly use the multimodal approach to pain treatment and that will most likely happen if you do your research and then insist your doctor help you – or find one who will!
Dr. Jim Humphries has been a veterinarian for 40 years and provides hospice and end of life care for pets in the Colorado Springs area. He has served in the US Army Veterinary Corps, and as the veterinarian at CBS News and CNN. He is a consultant for several veterinary pharmaceutical companies. In addition to practice, he also serves as a Visiting Professor at the College of Veterinary Medicine at Texas A&M University. www.HomeWithDignity.com