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How do we recognise, assess and treat chronic pain in companion animals?

What is pain?

Pain has been defined by the IASP (International Association for the Study of Pain) as “An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 1994). A more recent addition to the IASP’s definition has been; “The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment.” This shifts the onus onto veterinary professionals to realise that a patient who may be expected to be painful (for example following major surgery), yet is not necessarily demonstrating classical signs of pain, should be regarded as requiring analgesia.

An alternative definition attempting to define pain in animals is “an aversive sensory and emotional experience which elicits protective motor actions, results in learned avoidance and may modify species specific traits of behaviour including social behaviour” (Morton et al., 2005). This is arguably a better working definition as it takes into account the altered behaviour commonly seen in animals experiencing pain, although the sensory and emotional components are still difficult to evaluate.

What is the difference between acute and chronic pain?

Acute pain is provoked by a specific disease or injury, serves a useful biologic purpose, is associated with skeletal muscle spasm and sympathetic nervous system activation, and is self-limiting. (Grichnik and Ferrante, 1991). Acute pain is a necessary evolutionary trait allowing localisation of trauma/injury plus the ability to gauge the likely severity of the inciting cause. The definition of chronic pain has traditionally been based on time (typically between 3 or 6 months). However perhaps a better definition would be pain that extends beyond the expected period of healing. This indicates that chronic pain is pathological in nature and serves no useful biological purpose. Nevertheless, definitions are not always helpful to us as clinicians. For example osteoarthritis (OA) pain which is chronic in nature yet appropriate to the disease especially during ‘flare ups’.  In this case it is appropriate to say that OA pain is nociceptive (caused by inflamed or damaged tissue activating nociceptors) despite the chronic nature of the condition and that the pain is ‘appropriate’ to the condition, whereas chronic (pathological) pain is neuropathic (caused by damage to or malfunction of the nervous system). The accompanying article The phsysiology of acute and chronic pain” by Ian Self may be accessed here.

Why does Chronic Pain develop?

Chronic pain arises following acute pain and may result from;

1. Long term inflammatory conditions e.g. OA (Brown et al., 2008)

2. Neoplasia (Brown et al., 2009) resulting in persistent yet ‘appropriate’ nociceptive and inflammatory pain

3. Damage to or pressure on neural tissue (Brisson 2010; Plessas et al., 2012) producing neuropathic pain

4. ‘Pathological’ pain which persists after the original injury has healed which is commonly seen in humans (Katz & Seltzer 2009) but which has not been directly reported in the veterinary literature. One or more mechanisms of central sensitisation may contribute to any type of persistent pain.

Why is pain detrimental and why should we treat it aggressively?

If we accept that pain exists in animals the same as it does in humans, we should also ask if it has any useful functions and why we need to treat it. Ethically, veterinary professionals have both a professional and moral duty of care to animals. On entering the profession, UK veterinary surgeons take an oath to “ensure the welfare of animals committed to my care” (RCVS). In addition, most small animals are our companions and rely on us to protect their welfare, including their day to day requirements and freedom from pain. It has been argued that animal pain is ‘worse’ than human pain. Animals are thought to live in the ‘now’ and, unlike a human being in pain, are unlikely to be aware that the pain is only temporary and will be relieved given time or treatment (Robertson 2002).

As stated above, pain does serve a useful biological function in allowing us to locate and ‘deal with’ an area of damage. However, once the cause of the pain has been identified and the underlying condition addressed, treated pain serves no further useful function and there are a number of well-recognised physiological consequences of untreated pain (Self and Grubb, 2019). These include release of catecholamines, pituitary hormone and establishment of a catabolic state leading to weight loss and potential wound breakdown, inflammatory cytokine production and poor immune function. Overall, these physiological changes associated with poorly controlled pain increase post-operative complications in surgical patients, as well as causing client dissatisfaction with the veterinary practice. 

Regarding osteoarthritis, 20% of adult dogs (Johnston 1997) and over 22% of adult cats (Bennett et al., 2012) demonstrating radiographic signs of degenerative joint disease. Effective management of pain in such conditions is imperative for the welfare of affected animals; dogs affected by osteoarthritis have been identified as experiencing decreased quality of life, compared to unaffected dogs (Wiseman-Orr et al., 2006).

Chronic Pain Recognition

One of the most important breakthroughs in small animal pain medicine has been the introduction of validated pain scoring systems which have allowed us to attempt to quantify acute pain and adjust analgesia accordingly, (see “Practical acute pain assessment” by Carl Bradbook, which may be accessed here) always bearing in mind that companion animals which are expected to be painful but score low on pain scales should always be given the ‘benefit of doubt’ and analgesia should be administered. 

Unfortunately, no such ‘whole body’ scales are validated for chronic pain in dogs. However, several validated scales do exist for assessment of OA pain (White and Hunt, 2019), including:

Liverpool Osteoarthritis in Dogs questionnaire (LOAD) (https://dspace.uevora.pt/rdpc/...)

Canine Brief Pain Inventory (CBPI) (http://www.vet.upenn.edu/docs/...)

Helsinki Chronic Pain Index (HCPI) (https://www.fourleg.com/media/...)

American College of Veterinary Surgeons Canine Orthopaedic Index 

Client Specific Outcome Measures (CSOM) 

In cats, there are no universally accepted scales for OA pain however the following are examples of published scales;

Feline Musculoskeletal Pain Index (FMPI) (Benito et al., 2013) https://painfreecats.org/

Client Specific Outcome Measures (CSOM) (Lascelles et al., 2007)

Another major concept when dealing with chronic pain of any cause is quality of life or ‘suffering’. There is growing recognition, as in human pain medicine, that while it is not always possible to fully eradicate pain, the emphasis should be on the impact of the pain on the individual’s daily life and allowing the patient to cope with their condition. To this end, validated quality of life scales, such as the online Vetmetrica HRQOL system are likely to become increasingly important when dealing with patients experiencing chronic pain.

http://www.newmetrica.com/

Chronic Pain – Current Treatment Options

Based on White and Hunt, 2019

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed medications for treating chronic pain in dogs and cats producing a peripheral anti-inflammatory effect and can cause a reduced sensitisation within the CNS.  There is significant inter-patient variability in terms of efficacy and side effects. In animals that show a lack of response to one NSAID, it is worth considering swapping to another for an improved response allowing a 5-7 day washout period between the drugs (Kukanich et al. 2012). 

Paracetamol is widely used in human pain treatment but at the current time there is no evidence to support the use of paracetamol in osteoarthritis in dogs. Nevertheless, in the author’s experience it appears to provide good if variable analgesia for chronic pain conditions when administered at appropriate doses. There is a licenced form or paracetamol ‘Pardale’ which also contains codeine. Paracetamol should be avoided in cats.

Steroids can be of use if the chronic pain has an inflammatory component but are not a commonly used first line treatment because of the side effects associated with long-term use. Similarly, long-term administration of opioids in cases of chronic pain is uncommon because of the side effects caused by these drugs although they may be of use in a multi-modal approach in cases of flare ups. 

Tramadol is an atypical synthetic opioid (Kukanich & Papich 2004) however there is a large variability in uptake and the author finds that it has extremely limited efficacy in the treatment of chronic pain in dogs. It can be useful in cats, but the side effects such as dysphoria and agitation often mean treatment has to be withdrawn. Tramadol alone is unlikely to be efficacious for treating chronic pain. 

Gabapentin has been successfully used as a first line treatment in animals with neuropathic pain (Grubb 2010) and can be useful in managing chronic pain especially in cats unable to tolerate long term administration of NSAIDs (Robertson 2008). Pregabalin is similar to gabapentin, both being structural analogues of GABA. 

Amantadine is a NMDA antagonist drug and can be used alone for treating chronic pain or in conjunction with NSAIDs in dogs with chronic osteoarthritis pain refractory to NSAIDs alone (Lascelles et al. 2008). Although the most commonly recommended dose is 3mg/kg to 5mg/kg once a day, 2-10mg/kg two to three times daily has also been suggested (Pozzi et al. 2006). 

Amitriptyline is a tricyclic antidepressant used in humans for controlling neuropathic pain and one small study has documented its use in treating neuropathic pain in dogs at a dose of between 0.25mg/kg and 2mg/kg once a day to twice a day. It should not be used with tramadol or other drugs that inhibit serotonin and norepinephrine uptake.

In addition to pharmacological treatment, other management strategies need to be considered when dealing with chronic pain states, and the plan with OA pain should include analgesia, joint protection and nutritional support as well as therapies such as physiotherapy, hydrotherapy and acupuncture which play a large role in ensuring patient comfort. Environmental management is also vital – ensuring the patient can perform normal functions as easily as possible should be discussed extensively with the owners.

Conclusions

The importance of both acute and chronic pain recognition, assessment and treatment is increasingly recognised in companion animal medicine. In no small part this is due to increased knowledge about the detrimental effects of pain, improvements in communication to under and postgraduate veterinary professionals, increased numbers of licensed analgesic drugs and the introduction of validated pain scales. A 2013 survey showed almost ubiquitous use of analgesia for neutering cats and dogs (98% of respondents administering a non-steroidal anti-inflammatory drug (NSAID) [Hunt et al., 2015]). This is in contrast to a 1996/1997 survey by Capner and colleagues showing a much lower level of analgesic administration to cats and dogs undergoing routine neutering, with only 26% of cats receiving analgesia (Capner et al., 1999; Lascelles et al., 1999). There therefore seems to be significant improvement in the use of available analgesic agents, and further development in the delivery strategies of these drugs shows promise. There are interesting developments planned in this field which will continue to benefit veterinary patients.

Dogs exhibiting ‘prayer position’ typical of cranial abdominal or renal pain

Article by
Ian Self
BSc BVSc CertVA DipECVAA MRCVS

European Specialist in Veterinary Anaesthesia and Analgesia. Associate Professor in Veterinary Anaesthesia and Analgesia, School of Veterinary Medicine and Science, Nottingham

Originally published: Thursday, 18th July 2019

References

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Bennett, D., Zainal Ariffin, S.M. & Johnston, P., 2012. Osteoarthritis in the cat: 2. how should it be managed and treated? Journal of feline medicine and surgery, 14(1), pp.76–84.

Black, L.L. et al., 2007. Effect of adipose-derived mesenchymal stem and regenerative cells on lameness in dogs with chronic osteoarthritis of the coxofemoral joints: a randomized, double-blinded, multicenter, controlled trial. Veterinary therapeutics : research in applied veterinary medicine, 8(4), pp.272–284.

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Perspectives on Premeds – Alpha-2 Agonists

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This first article aims to provide a refresher on α2 agonists.

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We are ‘injecting’ a bit of fun into BSAVA Congress!

We will be ‘injecting’ a bit of fun into BSAVA Congress on our stand (stand 702).

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Alfaxan - now licensed for use in pet rabbits

Jurox Animal Health is delighted to announce that Alfaxan is now licensed for cats, dogs and pet rabbits. This is an exciting advance and could change the way rabbits are anaesthetised in the U.K.

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Best Practice Rabbit Anaesthesia Roadshows

Jurox Announces eight country wide events on Best Practice Rabbit Anaesthesia

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Considerations in Rabbit Anaesthesia at the 2017 London Vet Show

Jurox to host talks on Considerations in Rabbit Anaesthesia at the 2017 London Vet Show.

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Vets needing more support for anaesthesia

Jurox research reveals that veterinary professionals have questions about their anaesthetic protocols

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