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The holistic approach to pain relief

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01 April 2010, at 1:00am

DAVID WHITE summarises some of the take-home messages from an evening on small animal pain relief.

WHO could refuse a relaxing dinner in pleasant surroundings topped off by an orthopaedic expert to discuss any of those niggling questions you have on the subject of small animal pain relief? 

Clearly, this was an offer too good to miss and thanks to Merial’s innovative approach to CPD, I had a very informative evening with the additional advantage of a very good supper thrown in. 

The concept of the event was to invite a handful of local vets, all from different practices, to a restaurant venue in the Cambridge area to discuss aspects of applied analgesia in small animal practice. 

A local expert in the field of orthopaedics and pain relief, John Prior, from The Christchurch Veterinary Surgery in Ipswich, as a key attendee was a great source of expertise to offer some thoughtprovoking ideas and to stimulate the debate on pain relief in practice. 

John began by stressing the importance of the “holistic” approach to pain reduction and pain control. The discussion centred mainly on the approach to the dog but in some cases also referred to the cat.

Rather narrow approach 

John believes that in many cases the approach to analgesia in general practice often remains rather narrow, with an emphasis on routine premedication, post-operative analgesia, and the use of non steroidal antiinflammatories (NSAIDs) for chronic pain relief. 

He believes that there is often a reluctance to use a combination of medications and a combination of modalities such as physical therapies. 

Discussions turned to the importance of early diagnosis in helping to reduce the chances of the condition becoming chronic and consequently becoming much more intractable to pain relief. NSAIDs should be instigated even during the work-up of a condition and, if diagnosis confirms that surgical intervention is required, they should be continued up until and after surgery at least. This will help to reduce discomfort, encourage some mobility and rapid return to normality. 

John also steered the focus to the use of a combination of drugs to provide analgesia during the pre-, intra- and postoperative period. Most practices have their own pre-medication regime and NSAIDs should also be used during the pre- and post-operative phase, especially with recent advances in the development of NSAIDs. 

Combinations of oral and injectable carprofen and meloxicam (COX-2 preferential) can be used, or in the case of firocoxib (COX-2 selective), the oral product can be used two hours before surgery. 

During the intra-operative period, the use of local anaesthetics should not be forgotten and drugs such as lidocaine and bupivocaine can be given as regional blocks, nerve blocks and intra-articularly. 

Constant infusions of analgesics during and after surgery have become more commonly used in practice with the increasing availability and affordability of infusion pumps. Morphine, lidocaine and ketamine combination infusions (MILK) all provide excellent analgesia. 

Fentanyl patches are also particularly useful in cats, and although they take 12 hours to reach peak effect, they then last for about three days. 

Close monitoring required 

Post-operative analgesia requires very close monitoring of patients and this almost always relies on our well-trained and highly competent nurses. We all agreed that the nurse’s contribution to analgesia is invaluable and we should always take the time to listen to their advice and opinions. 

Analgesia at this stage usually relies on the continued effect of pre- and intra-operative agents, with incremental doses as required. Fluid therapy should be maintained until the animal is eating and drinking. 

I was particularly interested to hear John’s suggestion for the length of time we should be considering giving analgesia to our post-operative cases, especially orthopaedic cases. John routinely sends home his cases with at least four weeks’ worth of NSAID therapy, and in some cases longer courses can be given to ensure a smoother, sustained recovery. 

Multi-modality therapy should also not be forgotten during the orthopaedic postoperative period and as well as approaching the case pharmacologically, physical therapy is also essential. Before discharge, owners should be aware of the need for exercise control, but it is important that purposeful activity is encouraged. 

Short walks on the lead should be gradually increased, and walking on slopes or shallow steps can be introduced to encourage individual limb loading. Physiotherapy and hydrotherapy can be employed to encourage limb use and begin to reverse any muscle wastage present. Owners can use passive exercises to improve joint comfort before lead walks.

Long-term pain relief 

However, many factors influence the choice of NSAID such as the user’s experience of efficacy, practice policy, cost and any previous adverse effects noted in that patient. John pointed out that if a particular NSAID seems to have limited effect, it is worth trying a different NSAID, preferably of another class.    

Combinations of drugs can also give improved analgesia and can avoid the tendency to increase the NSAID dose. Paracetamol, tramadol, amitriptyline and gabapentin can all be useful additions to the analgesic regime. Amitriptyline and gabapentin are frequently used in neuropathic pain. 

All too quickly our discussions had to finish and a very pleasant evening meeting ended with our thirst for knowledge whetted but our hunger appeased with fine food. 

Merial and John Prior are to be congratulated for this innovative approach and for succeeding in maintaining our interest and attention for the entire evening. Indeed, I have already taken many of the practical tips back into the practice.