The Holistic Way
Reprinted from Dog Fancy
In veterinary medicine we are often called upon to prevent or treat pain in our patients. Unfortunately, this has been a neglected area of patient care in the past. Recently, with the arrival of several new medications to control pain, doctors are developing analgesic (pain-relieving) protocols for their patients.
While the use of these new medications can be quite beneficial, too often they are prescribed for the control of chronic pain when other safer alternatives exist.
In practice, we must distinguish between acute and chronic pain. Acute pain usually follows an injury. The injury can be accidental as in the case of a sprain, strain, or fracture, or intentional, as in the case of a surgical incision. Chronic pain is usually associated with arthritis or periodontal disease.
Conventional medications including opioids (drugs similar to morphine) and non- steroidal anti-inflammatory medications work very well in the pet with acute pain. In my practice, I actually try and practice preventive analgesia, administering pain-relieving medications before I intentionally do something (such as surgery) that might cause pain. This
pre-emptive analgesia decreases the need for extended post operative pain and is a very holistic way to approach pain relief using medications.
Chronic pain is another matter. While medications can be useful, I believe the most holistic approach is to use pain relieving medications on an "as needed" basis, preferring other more natural approaches for chronic pain relief.
Most animals with chronic pain, especially that from arthritis, show slower movements, difficulty getting up and down, may wince or growl if touched or handled over the painful part, and may show exercise intolerance. Dogs showing any of these signs should be evaluated for determining the exact cause of their pain.
The main benefits of a natural approach to pain relief is the obvious lack of side effects that can be seen with conventional drugs, including sedation, gastrointestinal ulceration, kidney or liver disease, and the potential to damage already diseased cartilage in the arthritic pet.
There are several options for treating the pet with chronic joint disease and pain. These include acupuncture, magnetic therapy, homeopathy, herbal therapy, and the well accepted use of nutritional therapy. No one therapy fits every pet, and the ultimate decision as to which therapy should be tried depends upon a number of factors, including cost and convenience for the owner. It is beyond the scope of this article to discuss these treatments in depth, but I would like to briefly review nutritional therapies, as these are the therapies I and other holistic doctors most commonly use to control pain in dogs with chronic arthritis.
The most well known nutritional supplements include shark or bovine cartilage, glucosamine, and chondroitin supplements. These supplements are used for 2 purposes. First, as with conventional analgesic medicines, these supplements can relieve pain and inflammation without the side effects mentioned above. Second, unlike conventional therapies that can actually further damage the joint cartilage, these therapies supply molecules to nourish and heal the cartilage. These popular complementary therapies are also most well known to conventional veterinarians and are employed by many conventional doctors as first-line therapy for dogs with chronic arthritis.
This means that even if your doctor is not a holistic doctor per se, he is still likely to be able to prescribe one of these nutritional supplements to help your pet.
One word of caution is in order. I do not recommend giving your pet the cheapest supplement available. There is no quality control oversight in the supplement market, and there are certainly some less expensive supplements that may not offer your pet the highest quality ingredients. Stick with supplements made by quality companies you or your doctor know have the reputation for quality.
Thanks to both the newer medications and the number of complementary therapies available to help us with pain control, it is extremely rare that any dog who is properly treated should have to suffer with chronic pain.
Pain Control In Dogs And Cats
Dogs and cats experience pain just as humans do. Dogs and cats can suffer setbacks in true medical conditions due to
persistent pain. Pain in dogs and cats can be acute due to surgery or trauma or it can be chronic due to joint and bone pain. The same drugs used to control pain in people can be used successfully in dogs and cats. Dogs and cats often require more medication per pound to relieve pain. Pain in dogs and cats is a legitimate reason to dispense medications. We must learn to cue on other factors than we do in people when judgeing the degree of pain in a dog or cat. This article gives the names, classes and doses of many drugs used to control pain in dogs and cats. Many veterinarians do not pay enough attention to pain suffered by dogs and cats.
Those of us who work with pets know that dogs and cats experience pain similar to human beings. We cannot prove this scientifically. But when we are closely attuned to a four-legged friend we know when they are uncomfortable and troubled by pain.
Acute or sudden pain can be the result of surgery or sudden damage to any of the major organs, muscles or bones of the body. Chronic pain is often the result of arthritis of the spine or joints of the leg.
Pain-relieving drugs are referred to as analgesics. Controlling pain actually improves the outcome of disease or surgery. Whenever possible, it is better to give pain-controlling medications early rather than waiting until pain becomes severe. It is also safer to give lower doses of two different pain-controlling medications that work through different pathways rather than a high dose of a single medicine.
It is hard to objectively judge the severity of pain in human beings and even more difficult to do so in animals. Our thresholds to pain differs markedly between people and from one animal to another. Pain perception depends on species, breed, age, gender, time of day and individual temperament. Pain may be experienced more at an animal hospital than at home. Young animals tend to have a lower threshold to pain. Older and debilitated pets may not show much response to pain but feel it just the same. Hunting and work breeds of dogs are more stoic and resistant to pain than toy and miniature breeds. Signs of pain are subtler in cats than in dogs.
If anything, we veterinarians probably underestimate the degree of pain our patients are in because we do not have direct ways to measure it. You, the pet’s owner, is more likely to notice signs of pain because you are more attune to your own pet.
Signs of pain vary greatly from pet to pet. Some articles claim a five-fold difference between individuals. Cats in pain are more stoic than dogs and mask pain more effectively. They will
often hunch up when the pain is in their tummies and be reluctant to move. Some cats hiss if a painful site is touched and become unresponsive to affection and petting. Other cats become aggressive and belligerent when in pain. Some pets in acute pain cry and whine. Other pets will lick and groom an area that is painful. This grooming can lead to self-mutilation of an area. Other pets tremble and move with their stomachs tensed up. Some will show lameness of an affected leg while others become aggressive, pant, grimace or pin their ears down. Any sudden behavior change can be a symptom of pain. Excessive salivation, licking of the lips, dilation of the eyes, rapid breathing and increased heart rate may all be attributed to pain. Pets that are in pain may not eat. Some do not sleep well while others stop grooming and appear dejected. Pain can cause an increase in body temperature (fever), respiration, heart rate and blood pressure.
With the pain of hip and spinal arthritis in dogs one can see if your pet is unwilling to rear up on its back legs for a treat. I will often pinch the toe of a pet that appears to be in pain to judge the severity of the pain. If the cat or dog reacts to the toe pinch then I assume the severity of its other pain is less than that of the pinch.
Pain alone can actually change the results of blood chemistry analysis. Dogs and cats in pain may have elevated blood sugar. Their blood cortisol (steroid) and white cell levels can increase. Pain can also interfere with the immune system, increase the risk of infections and slow the healing of wounds and surgery.
Complete elimination of pain is often impossible and undesirable but it can be minimized with medications. There are five major classes of medicine that can be used to control pain in dogs and cats. Many of these medications can must be used in cats with extreme caution.
There are some general rules when using pain control medications in dogs and cats. The first is to try to give the medication early before the pain becomes too intense. The second is that it is usually safer and more effective to give two or more medications that have different modes of action rather than a higher dose of a single medication. Older patients should receive lower doses less frequently than younger more robust pets. It is also wise to check kidney and liver function when using pain control medications in older pets.
Pain control medications I use in pets
The classic drug of this group is morphine (Oramorph SR, Roxane). Although it is a
centuries old drug, it is still quite effective. Morphine is usually given to dogs by injection at 0.05 mg/pound up to three times a day. The oral dose in dogs is 0.75 mg/pound twice a day up to a maximum of 15 mg/dog. All drugs of this class lower the sensitivity of the brain to pain. Side effects of this group of drugs are nervous system depression, respiratory depression, lowered blood pressure, constipation and behavioral alterations. All opioid drugs mimic natural chemicals produced in the brain. Drugs of this class must be used cautiously, or not at all, in cats.
Meperidine (Demerol) is an injectable drug that is one fifth as powerful as morphine. It is an excellent drug for controlling pain for short periods in dogs. With time, dogs become resistant to its action. The dose of this drug in dogs is 2-4 mg/pound given intramuscularly or orally every 4 hours. The dose in cats is 1-2 mg/pound.
Oxycodone HCL (Roxicet, Percocet, Percodan, Tylox) is a derivative of the opium alkaloid, thebaine. I use this drug frequently in dogs but have no experience using it in cats. In dogs, it is better to use preparations of the drug that are free of acetaminophen or aspirin. It is an excellent drug for
alleviating the pain of terminal cancer in my clients. I also use it following orthopedic bone surgery and for occasional use in arthritic dogs that can not tolerate non-steroidal anti-inflammatory drugs such as aspirin or Rimadyl. The oxycodone component in this formula, 14-hydroxydihydrocodeinone, is quite bitter so some dogs spit up the tablets. I get around this by using the tablets as a rectal suppository. It is also effective if it is allowed to
dissolve in the pet's mouth. I dose dogs at 0.05 mg/pound. When dogs are in severe pain, I use up to four times this dose up to three times a day.
Oxymorphone (Numorphan) is a semi synthetic opioid ten times as strong as morphine. It is given by injection and its effects last 4-6 hrs. It is a good drug for postoperative pain in dogs and cats. It can be given subcutaneously and intramuscularly to dogs and cautiously to cats at 0.05 mg/pound.
Fentanyl (Duragesic, Janssen Pharmaceutica, Sublimaze injection) is a synthetic opioid 100 times more potent than morphine and 500 times more potent than meperidine. It is available in transdermal patches, which allow the medication to flow continuously through the unbroken skin into the body. It is an excellent treatment for pain in dogs and cats. It is sold in adhesive “patches” that can be fastened to the shaven chest or arm of pets. It is sold in sizes that deliver 25, 50, 75 and 100 micrograms of the drug per hour. The 25 mcg/hr patches work well on 8-12 pound cats when only half the protective liner is removed. I find it best to cover the patch with an elastic bandage. The primary market for these patches is in controlling the pain of cancer in human beings. The fur stubble interferes somewhat with delivery of the drug so that 50 mcg/hr human patches actually deliver about 37 mcg/hr in pets. It takes up to 24 hours after application for the full effect of the patch to be felt. A single patch blocks pain for 24 to 72 hours so the patches need to be changed every two to three days.
Butorphanol (Stadol, Torbutrol, Torbugesic-SA, Ft. Dodge/Wyeth,)
This is one of the few opioid drugs that work consistently well in cats. This opioid agonist-antagonist is administered by injection or intranasal spray. It is suggested that it be given to cats and dogs subcutaneously at 0.15 mg/pound up to three times a day. It produces analgesia within 20 minutes after injection and relieves pain for up to 8 hours. It can also be given orally. It has a lower incidence of side effects than traditional opioids. Some side effects that are occasionally seen - especially in cats - are dilation of the eyes, disorientation, swallowing and licking and pain at the injection site.
Buprenorphine (Temgesic, Vetergesic)
I have never personally used buprenorphine in pets. This opioid drug is also administered by injection and as sublingual tablets. It is suggested that it be given to cats and dogs by intramuscular injection at 0.0025 mg/pound up to four times a day.
Non-steroidal anti-inflammatory agents (NSAIAs):
This class of drugs blocks the production of pain-inducing chemicals in the body called prostaglandins. There are two types of prostaglandins in the body. The first, known as COX-1 (cyclooxygenase-1) mediated are necessary to protect the lining of the stomach and small intestine as well as blood clotting and protection of the kidneys during periods of low oxygen. The second, or COX-2 enzyme mediated prostaglandins block the inflammatory processes that lead to pain. Older, more traditional NSAIs such as phenylbutazone and aspirin inhibited both COX-1 and COX-2 enzymes. Therefore they prevented the formation of both good and bad prostaglandins and produced side effects that included stomach and intestinal ulcers and possible kidney damage. These side effects occur more frequently in dogs than in human beings. There are no early warnings that bleeding, vomiting and diarrhea will occur and these drugs must be stopped at the first sign of these side effects. To minimize these side effects, I give medications that limit stomach acidity (cimetidine, ranitidine) whenever I use the older NSAIAs. Some veterinarians give the synthetic prostaglandin, mistoprostol with NSAIAs to coat and protect the stomach and intestines.
NSAIAs help reduce pain and fever. NSAIAs are well absorbed when given orally. They are eliminated by liver and kidneys. Some NSAIAs including ketoprofen, carprofen and piroxicam actually protect the cartilage that forms joints. I do not give them after major surgery because all NSAIAs can increase bleeding time.
Aspirin (acetylsalicylic acid) is the oldest and best-known NSAIA. It can be dangerous when used in cats so I never use it although some veterinarians administer buffered aspirin to cats at 5 mg/pound every two or three days. About half the dogs tolerate aspirin given at 5-10 mg/pound twice a day. Slightly higher doses are needed if enteric-coated aspirin is used.
Phenylbutazone (Butazolodine) is another older NSAIA agent used in veterinary medicine for over thirty years to treat arthritis. It is approved for pain control in dogs but not cats. Its side effects in dogs can include ulceration and bleeding of the stomach and intestines as well as anemia. In dogs, we administer phenylbutazone orally at 4-8 mg/pound up to twice a day with a maximum of 800 mg per dog.
Piroxicam (Feldene, Pfizer) is a NSAIA that is a member of the oxicam group of drugs for use to combat arthritis pain in human. It is marketed in 10 and 20 mg capsules. Although it works well in humans I have found it to cause stomach distress in most dogs I have tried the medication on. The suggested dose for dogs is 0.15 mg/pound body weight every other day.
Carprofen (Rimadyl, Pfizer) was introduced for use in dogs in the United States in 1997. It and ketoprofen have the least known incidence of stomach and intestinal disturbances of all NSAIA mentioned in this article. Gastric ulceration is very rare with carprofen. In the U.S. it is approved only for use in dogs but some countries allow its use in cats as well. Carprofen inhibits COX-2 enzyme specifically and has very little effect on COX-1 so protective prostaglandins are spared. It is metabolized by liver and has half-life in the body of 10 hrs. It is a particularly good drug to treat osteoarthritis. It is also excellent for postoperative pain. At the doses we use it, this drug enhances joint function (by increasing the rate of polysufated glycosaminoglycan (PGAG) synthesis. Despite its safety it is a good plan to check liver enzymes from time to time in dogs that are taking this medication for long periods. The dose for this medication in dogs is 1 mg/pound twice a day. Where approved for cats the dose is the same but it should only be administered a single time.
Etodolac (Etogesic, Wyeth)
Similar to carbprofen in its actions, etodolac tablets are a nonsteroidal anti-inflammatory drug that can be given once daily to manage the pain and inflammation associated with osteoarthritis in dogs. The product is rapidly absorbed, has a long half-life, and can be given once per day with or without food. As with all NSAIs, gastrointestinal and renal side effects may occur. The most commonly reported side effects with etodolac tablets are vomiting, lethargy, and diarrhea. The dose in dogs is 5-7 mg/pound given once a day.
Flunixin meglumine (Banamine, Shering-Plough)
Flunixin meglumine is a potent injectable NSAIA, which is particularly good for intestinal pain. We use it frequently in treating the pain associated with parvovirus intestinal disease in dogs and for treating post surgical stomach pain. In dogs, the dose is 0.1-0.5 mg /pound. It is best not to give this medication for more than two or three days.
This is a great anti-inflammatory drug in humans but consistently causes ulcers in dogs after 2-6 weeks. A suggested dog dose is 6 mg/pound but even at 4 mg/pound this drug will cause erosions of the stomach as well as vomiting. At a dose low enough to not have these side effects, the drug probably does not relieve pain.
Ketoprofen (Orudis, Oruvai, Actron, Oruvail)
This drug is approved in the United States for use in humans and horses. It is a powerful anti-inflammatory, analgesic and antipyretic drug. It works great in humans for postoperative pain. In Europe and Canada it is approved for use in dogs and cats.
In dogs, the recommended dosage is 1 mg/pound injected subcutaneously or given orally the first day and 0.5 mg/pound thereafter for no more than two additional days.
Naproxen (Naprosyn. Alleve): This NSAIA is not approved for use in pets. One dose lasts 45-92 hours in dogs. So, if used, it should be given every second or third day. I am not familiar enough with this drug to suggest a dose.
Meloxicam (Metacam,Mobic, Borringer-Ingelheim,Merial)
This powerful antiarthritic medication is sold in 7.5 mg tablets in the United States for human use. It has been suggested that cats may tolerate this NSAIA. A suggested dose for use in cats is 0.1 mg/cat/day. Because felines have a deficiency in bilirubin-glucuronide enzyme in their livers, cats of any age particularly sensitive to all NSAIA. This is the only NSAIA that I can take without stomach upset. Recently, Borringer-Ingelheim/Merial received F.D.A. approval to market Mtacam for cats as a one-time, subcutaneous injection to be given for post-surgical pain. The recommended dosage is 0.14mg/pound body weight. If given more than one time or if other NSAIDs are given, kidney and liver toxicity may occur.
Tepoxalin (Zubrin, Schering Plough).
Deracoxib (Deramaxx, Novartis).
Ketamine (Ketaset, Vetalar), a commonly used general anesthetic in cats, has been found to reduce pain when applied topically. It is not very good for deep intestinal pain but is probably useful to treat a wide variety of chronic painful conditions.
Xylazine (Rompun) is an alpha-2 agonist injectable sedative approved for use in dogs, horses and cattle. When given by intramuscular injection at 0.05 mg/pound, it is a very potent pain reliever. At this dose vomission is rare. I prefer incorporating this drug into my anesthetic protocols for dogs because pain relief persists long after the surgery is completed. I have not personally used this xylazine in cats for pain relief but several texts suggest a dose in cats of 0.05 to 0.5 mg/pound given intramuscularly. I avoid using maximum recommended doses of xylazine because such doses often affect breathing.
Medetomidine hydrochloride (Domitor, Novartis) is marketed as an anesthetic/analgesic for minor surgery in dogs. It is a potent a2-adrenoreceptor agonist. This drug slows heart rate and is excreted by the liver and kidneys. Because of this, it should not be used in dogs with heart, liver or kidney disease or in dogs that might go into shock nor in dogs that are highly excited. The dose suggested for pain relief in dogs and cats is an intramuscular injection of 5-10 micrograms/pound body weight. It can be combined with diazepam (Valium) given intramuscularly at 0.1-0.2 mg/pound or with butrophanol given at 0.1-0.2 mg/pound.
From studies in human beings we know that the tricyclic antidepressant, (Elavil), is also sometimes effective in reducing chronic pain. The dose in dogs is 0.5-1 mg/pound body weight. The dose in cats is 5-10 mg /cat per day.
Joint Protective (Chondroprotective) agents:
These nutritional supplements supply the body with the building blocks of joint cartilage. In theory at least, they should be helpful in relieving joint pain. These products are sold by veterinarians and over the counter at pharmacies. They are all non-toxic. They include polysulfated glycosoaminoglycans, glucosamine and chondroitin sulfate.
Ron Hines DVM PhD 4/10/05
PAIN RECOGNITION AND TREATMENT OPTIONS
Any form of inflammation is painful, in varying degrees:
HOD, Panosteitis, Arthritis, Fractures, Osteosarcoma
Severe otitis externa, otitis media and interna
Tooth root abscess, severe gingivitis, dental extractions
Corneal ulceration, glaucoma
Trauma: Bite wounds, abscesses, contusions
Hotspots, burns, insect bites
Bronchitis with much coughing/Tracheitis
Pancreatitis, Intestinal foreign body, GDV
Urinary tract infection/obstruction
Anal gland abscesses/fistulas
Postoperatively for most surgeries but the most minor mass removals on the skin
RECOGNITION OF PAIN:
Pets rarely vocalize when in chronic or gradual pain.
Watch their body language for hints:
squinting for pain in eyes or face
ears pulled back or hanging to the side
panting at rest
poorly or non-weight bearing on one or more limbs
decreased activity level or avoidance of certain activities
decrease or loss of appetite, drooling
body posture – hunched back may indicate back pain as in IVDDZ or abdominal pain as in pancreatitis, gastritis etc.
retention of urine or feces may be a sign of pain in bladder urethra or colon/rectum
In severe or acute pain you will see more dramatic changes:
touch avoidance, sometime with whimpering or aggression when touched or palpated
screaming in pain typically seen in dogs on awakening from surgery, puppies trying to walk with fractures and in cats straining to urinate when partially or completely obstructed
Apart from medications helpful in pain control,
there are several other options available for your pet.
OTHER METHODS OF PAIN CONTROL AND MANAGEMENT
MASSAGE, ACUPRESSURE, ACUPUNCTURE:
In recovery after orthopedic surgeries to decrease pain in affected limb and relief on other limbs, back and neck compensating for reduced mobility
In the management of arthritis, lumbar pain, helps to decrease muscle tension and cramping
Decrease of internal pain and anxiety in cases of pancreatitis, gastroenteritis etc.
VOM (Veterinary Orthopedic Manipulation) and CHIROPRACTIC
Especially useful in IVDDZ (intervertebral disk disease) or spinal misalignment. Helps decrease muscle spasms and realign spine, therefore helping pain in spine and extremities
COMPRESSES, hot and cold:
Cold compresses are most effective with acute inflammation after surgery, over joints or swellings, apply in form of ice cubes in moist towel or cold pack in moist towel for 5-10 minutes several times a day.
Hot compresses are beneficial to increase circulation to an area of poor healing, or long standing swelling, especially if alternated hot – cold – hot at 10-5-10 minute intervals.
Warm water application over acute burns (not cold water) will decrease long-term pain, blistering and scarring. The water must be as warm as the patient will stand for applied for as long as possible.
Marathon Vet Hospital