Pain Management – A Review and What's New

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A REVIEW & WHAT'S NEW
PAIN MANAGEMENT
Mylissa Fitzpatrick LVT, CVPP, VTS (ECC)

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 Pain: why we treat it
 Overview of physiology of
pain
 Why management of pain
is important
 Pain recognition & scoring
 Modalities to treat pain
WHAT WILL BE REVIEWED....
9/26/2023
PAIN MANAGEMENT: A REVIEW AND WHAT'S NEW

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9/26/2023
 Go over some new drugs available
for the treatment of pain
 Discuss new equipment for drug
administration

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 *All previous laws were aimed at preventing animal cruelty but none addressed pain
 1985 amendment of the Animal Welfare Act stated that “there was a need to control Laboratory Animal Pain not directly required by
the need of the research”
 2007 AAHA pain management guidelines
 2015 AAHA pain management guidelines – UPDATED
 2022 AAHA pain management guidelines – UPDATED

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 ADAPTIVE
 “OUCH” response
 Appropriate pain response to
noxious stimuli
 Self-preservation
 MALADAPTIVE
 Abnormal response
 Serves no purpose
 Neuroplasticity
 the ability of the nervous
system to change
by reorganizing its structure,
functions, or connections
 Recruitment of other nerves to
carry pain signals
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 Initiates a stress response
 CV Stress can cause arrythmias
 Overstimulation of the sympathetic
nervous system
 Increases cortisol in the body
 Delays and inhibits wound healing-
increase risk for sepsis
 IT HURTS!!
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 Allodynia
 pain due to a stimulus that does not normally
provoke pain
 Hyperalgesia
 Abnormally heightened sensitivity to pain.
 Windup (Central Sensitization)
 When spinal neurons are subjected to repeat
or high-intensity nociceptive impulses, they
become progressively and increasingly
excitable even after the stimulus is removed
 the presence of hyperalgesia and
allodynia collectively
 Anhedonia
 the inability to feel pleasure
COMMON PAIN TERMS
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THE PAIN PATHWAY
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Transmission
*Pain impulses are transmitted from point of
origin to the spinal cord
Modulation
*impulses are either inhibited or amplified
Perception
*pain is recognized by the brain both physiologically and emotionally
Transduction
*Pain stimulus is converted into a nerve
impulse

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Canine
 PE Signs
 Temp, HR, RR, BP
 Behavior
 Loss of shake, abnormal posture, withdrawl or attention
seeking, crying out
Feline
 PE Signs
 Temp, HR, RR, BP
 Behavior
 Purring (self-soothing), aggressive, Facial expressions
RECOGNITION OF PAIN
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PAIN SCALES
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FELINE
GRIMACE
SCALE
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FELINE FACIAL EXPRESSIONS

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9/26/2023

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 https://www.felinegrimacescale.com/practice-your-skills
TEST YOUR SKILLS!!
9/26/2023

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GET THE APP!!
9/26/2023

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COLORADO STATE ACUTE PAIN SCALE
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SHORT
FORM OF
THE
GLASGOW
COMPOSIT
E PAIN
SCALE
(GCPS-SF)
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 Use one designated pain scale
 Train and Practice
 Acknowledge
individual interpretation
 Know the difference
between pain, anxiety, &
dysphoria
 Unsure? - Talk to your
team, treat symptoms, and
PAIN SCALES AND SCORING
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PAIN, ANXIETY, OR DYSPHORIA
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WHAT'S IN YOUR TOOL BOX?
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PHARMACEUTICALS
NON PHARMA
INVASIVE TREATMENT
MARKET
NEUTRICEUTICALS
• SUPPLEMENTS
• CBD
MEDS
• Oral
• Injectable
• Topical
• "ACTION" THERAPY
• Massage
• Acupuncture
• LLT
• Surgery
• Joint injection
• Regenerative
medicine (PRP/Stem
cells)

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 NSAIDS
 Rimadyl®(carprofen)
 Metacam® (meloxicam)
 Onsior® (robenacoxib)
 Galliprant® (grapiprant)
 Local Anesthesia
 Lidocaine
 Bupivacaine
 Nocita
 “ODD BALLS”
 Gabapentin
 Tramadol
 OPIOIDS
 Methadone
 Fentanyl
 Hydromorphone
 Buprenorpine
 Butorphanol
 NMDA ANTAGONISTS
 Amantidine
 Ketamine
Click to add text
Pharmaceutical
Options
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 Most commonly prescribed
 Most amount of side effects
 GI ulcerations, renal/ hepatotoxicity, hypocoagulation
 Caution with:
 Other Drugs – corticosteroids, K+ sparing diuretics
 Liver/ kidney impairment
 Pregnancy – PDA closure, renal development
 1 dose post C-section is OK - minimal excretion in
lactation
• Ex. Rimadyl®(carprofen);
Metacam® (meloxicam); Onsior® (robenacoxib); Deramaxx® (deracoxib)

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Aspirin Meloxicam, carprofen
Robenacoxib,
Deracoxib
COX1 COX2
COX 2 Selective
COX 2
Preferential
COX 1 Selective
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THE "WEIRD" NSAID
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• AKA Paracetamol, Tylenol®
• Not a True COX inhibitor – only blocks
the Cox 3 enzyme
• Does NOT have anti-inflammatory
properties
• Good for mild pain & fever reduction
• Can use as cross-over med during
NSAID washout period
• Caution in hepatic disease- requires
hepatic biotransformation
• Canine dosing- 10-15mg/kg PO q 8-
12hrs

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9/26/2023
• prostaglandin receptor antagonist
(PRA), a non-COX inhibiting NSAID
• specifically targets the EP4 receptor
• Safe for long term usage
• Dosing: 2 mg/kg PO SID
*Kirkby Shaw K, Rausch-Derra LC, Rhodes L. Grapiprant: an EP4 prostaglandin receptor antagonist and novel therapy for
pain and inflammation. Vet Med Sci. 2015 Dec 21;2(1):3-9. doi: 10.1002/vms3.13. PMID: 29067176; PMCID: PMC5645826.

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FENTANYL
 Duration: 15-30min
 CRI Dose: 1-50mcg/kg/hr - will decrease
MAC
 IV, IM, CRI, PATCH
 Watch for bradycardia, resp suppression
MORPHINE
 Duration:2-4 hours
 CRI Dose:0.05-0.2mg/kg/hr
 Usually used in conjunction with lidocaine
& ketamine in CRI
 IV, IM CRI, Epidural
 Watch for Respiratory depression
 Can cause Histamine release
OPIOID
OPTIONS
Pure Mu Options

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METHADONE
 Has NMDA receptor antagonist &
SRI properties
 Dosing: 0.1-1mg/kg
 IV, IM, SQ
 Expensive/ backorder concerns
HYDROMORPHONE
 Dose: 0.05-0.2mg/kg q4-6hr
 IV, IM, SQ
 Can cause vomiting/ nausea/
dysphoria
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OPIOID
OPTIONS
Pure Mu Options

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BUPRENORPHINE
 PARTIAL MU AGONIST – Used to treat mild- moderate pain
 Simbadol®
 Duration:24 hours
 Give SQ
 Buprenex®
 Duration: 6-12 hours
 Dosing: 0.005-0.03 mg/kg - IV, IM, SQ, TM (Cats)
 Watch for hyperthermia in cats
BUTORPHANOL
 AGONIST/ANTAGONIST - Kappa agonist/ mu antagonist
 Torbugesic®, Dolorex®
 Duration: 45-90 minutes
 Dosing:0.1-0.5mg/kg - IV, IM, SQ
 drugs can partially reverse the effects of a pure
mu opioid.
 Not a great option for pain
9/26/2023
OPIOID
OPTIONS

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Butorphanol
Your VERY painful patient
9/26/2023

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LOCAL ANESTHETICS
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9/26/2023
LIDOCAINE
 Can be given as CRI -(1-5mg/kg/hr)
 As local block:
 rapid onset (<5minutes)
 45-60 minute duration
 Canine Dosing: 1-10 mg/kg
 Caution in Cats
BUPIVICANE
 delayed onset (~20 minutes)
 longer duration (~ 4 hours)
 Dosing 1 mg/kg
NOCITA®
 a liposomal encapsulated bupivacaine
 72 hours of local anesthesia for post-operative patients
 5.3mg/kg

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THE ANTAGONIZER
THE ANTAGONIZER
THE ANTAGONIZER
THE NMDA RECEPTOR
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AMANTIDINE
 antiviral drug
 works by blocking the NMDA
receptors
 Used for neuropathic pain, windup,
allodynia, and opioid tolerance
 Dosing:3-5mg/kg PO SID
 ONLY USE AS AN ADJUCT THERAPY
9/26/2023
• Dissociative anesthetic
• administered as a bolus dose (0.5mg/kg IV)
• followed by a CRI (2-10mcg/kg/min) for
proper utilization as a pain management
tool.
• MAC reduction of 35%

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GABAPENTIN
 Anticonvulsant drug
 MOA-Ca+ blocker @ post-
synaptic dorsal horn in the spinal
cord
 Good for neuropathic pain,
anxiety, seizures -
Proven beneficial when used as
a multimodal option.
 Peak effects can take 24 hours to
reach as therapeutic blood levels
are reached
 Dosing: 5-10 mg/kg PO BID-TID
 Can cause sedation
 Human medicine
uses Flumazenil for reversal
of sedative effects!
TRAMADOL
 Canine
 Acts as an SSRI due
to inability to metabolize
to morphine in liver
 5mg/kg q6h is shown
to reach the same M1
plasma concentrations
that are effective in
humans.
 Feline
 Acts as a morphine
 Not palatable
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 Use of multiple drug classes to obtain optimal pain management with minimal side
effects
THE MULTIMODAL APPROACH
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Benefits
 down regulation of
an upregulated sympathetic nervous system
 Endogenous opioid release
 Manages pain by releasing endorphins
Considerations
 Specialized staff training
 Costly / Time consuming for the client
 Need a cooperative patient
 May need to find alternative veterinary practice
that offers service.
ACUPUNCTURE
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Benefits
 Manages pain by cellular absorption of light energy
and convert it into cell energy, suppressing pain and
reducing the inflammatory pathways.
Considerations
 Expensive equipment – Find a practice that offers
service
 Specialized staff training
 Costly & Time consuming for client
 Caution with use over tumors or surgical hardware
 Caution with Nocita®
 potential to cause toxicity due to liposomal
LASER LIGHT THERAPY (LLT)
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Benefit
 works by utilization of different exercises that
increase strength, range of motion, and flexibility
 Owners can do at home!
Considerations
 Specialized/ Trained staff
 Can have expensive equipment needs
 Willing/ cooperative patient
 Costly & Time consuming for client
 Find veterinary practice that offers service
PHYSICAL REHABILITATION
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Benefits
 Works by delivering high energy sound
waves to the injured area to promote
healing
Considerations
 Need expensive equipment
 Specialized/ Trained staff
 Patient may need sedation
 Can cause discomfort
 Can be loud
PULSE WAVE THERAPY
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Benefits
 Excites the nerve cell causing changes in cell membrane
permeability
- stimulates protein synthesis, osteosynthesis and fibroblast
formation.
 Causes skeletal muscle and smooth muscle contraction
 improves joint mobility, circulation and lymphatic drainage
Considerations
 Need specific equipment – Cheap!!
 Patient may not tolerate 9/26/2023
NMES -Neuromuscular Electrical Stimulation
TENS-Transcutaneous Electrical Nerve Stimulation
NMES & TENS THERAPY

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 Delivers electric micro-current to damaged tissue
 stimulates cellular repair by upregulating production of
endogenous nitric oxide (NO).
 signaling molecule
 Promotes wound healing by regulation of vascular
homeostasis, inflammation, and antimicrobial properties
 Assisi Loop® & Respond bed®
 runs for 15 minutes
 use 1-4 times daily as needed
 Battery lasts 3 weeks to 6 months – depending on usage
 Expensive!!
TPEMF (TARGETED PULSED ELECTROMAGNETIC FIELD THERAPY) TECHNOLOGY
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HOT/ COLD PACKING
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 Hot packing is for
chronic pain
 Associated with
joint/ muscle
relaxation
 Cold packing is for
first 72 hours post
injury/ surgery
 Reduces
inflammation

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THERAPEUTIC MASSAGE

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 STABILITY SUPPORT
 NON-SLIP SURFACES
 NAILS TRIMMED
 RAMPS
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 Thorough discharge with the client
 Cryotherapy/ Hot pack
 Restrict activity
 Anti-anxiety environment
 Rx mediations
 Oral
 Fentanyl Patch
 Follow up
 Recheck
AT HOME PAIN MANAGEMENT
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 Use of multiple drug classes to obtain optimal pain management with minimal side
effects
THE MULTIMODAL APPROACH
and other alternative
therapies
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 FDA-approved long-acting transdermal
buprenorphine for cats.
 Provides 4 days analgesia
 Topical liquid
 dries in 30 min
 effective in 1-2 hours
 Must wear PPE (gloves, protective
eyewear, lab coat)
 Caution in areas of skin irritation/ infection
ZORBIUM® (EXTENDED RELEASE TOPICAL BUPRENORPHINE)
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SOLENSIA® (FRUNEVETMAB INJ)
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*67% of cat owners experienced improvement in signs of their cat’s pain in the placebo group.
 Feline monoclonal antibody
 Binds to nerve growth factor (NGF) to block it’s
effects.
 A protein responsible for causing sensitization of
the nociceptors and release of inflammatory
mediators
 Administered as a monthly SQ injection
 7mg/ml - 1 ml treating up to 15.5lbs (7kg)
 Relatively inexpensive
 Opportunity to recheck patient monthly

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 FDA approved May 2023 - Not
available in US yet – possibly fall
2023
 canine monoclonal antibody that
binds & inhibits canine nerve
growth factor (NGF)
 Monthly 0.5 mg/kg SQ injection
 Supplied as a 5, 10, 15, 20 & 30
mg/mL single-use 1 ml vial
LIBRELA® (BEDINVETMAB INJ)
9/26/2023

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 Analgesic properties at sub-anesthetic doses:
 NMDA receptor antagonism
 direct inhibition of nitric oxide synthase
 prevents or reverses opioid mu-receptor
desensitization
 affects the degree of phosphorylation of down-
stream receptors
 activates serotonin and noradrenaline release, and
inhibits re-uptake
 0.5mg/kg SQ weekly or monthly
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LOW DOSE KETAMINE

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 SQ infusion delivery system
 48 hours of pain management
 Used for either ketamine or
hydromorphone
 Cheap!!
RX ACTUATOR®
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Pharmacokinetics of Hydromorphone in Dogs after Intravenous Bolus and Delivered Subcutaneously with the RxActuator Mini-Infuser® Infusion Pump INTERNATIONAL VETERINARY
EMERGENCY AND CRITICAL CARE SYMPOSIUM 2021 K. Messenger1 ; H. Enomoto1 ; H. Knych2 ; M. Papich1 1College of Veterinary Medicine, North Carolina State University,
Raleigh, NC, USA; 2College of Veterinary Medicine, University of California—Davis, Davis, CA, USA
Ketamine: A Novel Approach with a Familiar Tool—Part 1 Review of Ketamine and Chronic Pain INTERNATIONAL VETERINARY EMERGENCY AND CRITICAL CARE SYMPOSIUM 2022
Lindsey Fry, DVM, cVMA, CCRP, CVPP Red Sage Integrative Veterinary Partners Fort Collins, CO, USA
9/26/2023

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HTTPS://RXACTUATOR.NET/
9/26/2023

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 Practice pain recognition &
scoring
 SPEAK UP! Advocate for your
painful pet patient!!
 Use a Multimodal approach –
NOT JUST
PHARMACEUTICALS
 Communicate with your team
 Continue to follow the evolution
of pain management
TAKE HOME MESSAGE....
9/26/2023

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Mfitzpatrick@uvsonline.com
9/26/2023
**References available upon request**

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Pain Management – A Review and What's New