Building a pain management focused practice (Proceedings)


Building a pain management focused practice (Proceedings)

Pain management is a win/win situation for both the patient and the practice. The appropriately analgesed patient has a better quality of life and heals faster, while the practice increases profits and client satisfaction. There is no negative impact of good pain management in the practice and every practice should strive to have the best pain management practices possible.

Sequelae of pain

Untreated pain can lead to a barrage of behavioral, physiological, hormonal, metabolic and cellular responses that can lead to further deterioration of the patient's health and quality of life. Acute pain can serve a beneficial purpose if an animal perceived to be in pain prompts its owner or veterinary personnel to identify the cause and initiate appropriate treatment. On the other hand, pain in postoperative and trauma patients serves no purpose and should be anticipated and alleviated to allow resumption of normal function as quickly as possible. Chronic pain certainly serves no purpose and patients suffering from chronic pain should be managed in a way that allows appropriate exercise and activity without undue discomfort.

Replacing myths with reality - the need to educate colleagues and owners

Some animal owners and even some caregivers have perceptions about animal pain that are erroneous or outdated. Fortunately, the three recurring pain myths discussed below are rapidly giving way to scientific knowledge and new understanding of the nociceptive (pain) response in our patients.

Myth 1 — Animals don't feel pain.

It is well established that all mammals, including human beings and the canine and feline patients that predominate in companion-animal practice, share the same anatomical components of the nociceptive pathway (Figure 1). The nociceptive pathway consists of:
     • Transduction, the sensation of noxious stimuli perceived and processed by peripheral receptors
     • Transmission, the transmission of noxious stimuli along afferent pathways to the spinal cord
     • Modulation of noxious sensations by discrete neurological tracts within spinal cord pathways and the brain stem
     • Perception, the interpretation of noxious stimuli in the brain, resulting in the sensation of pain. Interpretation of pain may vary greatly between individuals and species.

Because animals have the same nociceptive or pain pathway that human beings have, we can be sure that animals do indeed feel pain.

Myth 2 — Animals tolerate pain better than people do.

Animals are often stoic while experiencing pain, a behavior that uninformed observers may assume means the animal is refractory or indifferent to pain. In reality, animals (1) have reasons to hide pain, and (2) may communicate pain in ways that people fail to recognize. In their environment, animals instinctively hide pain because it can be a sign of vulnerability to predators. When pain becomes so intense that it cannot be hidden, animals may not communicate their discomfort in a way that we recognize. An analogy would be a human infant crying in response to pain because they are unable to articulate their feelings as an adult would. An observer might not recognize the source of crying (since crying has many causes) just as an observer might not recognize the signs of pain in an animal. In this regard, there are three helpful pain-management guidelines:
     • Animals, unlike humans, are highly motivated to hide pain. Therefore, by the time we are able to observe overt signs, the pain is likely to be more intense than we think.
     • An animal's inability to communicate pain does not negate the possibility that pain exists and that the animal would benefit from analgesic treatment.
     • We should assume that an event that would be painful to a human being would also be painful to an animal, and this pain should be managed accordingly. We should utilize preemptive methods for pain relief based on the extent of a surgical procedure or severity of a medical condition rather than relying on physiological or behavioral signs of pain that may or may not be exhibited by the patient.

Myth 3 — Pain is beneficial in limiting an animal's movement during recovery from surgery or trauma.

In reality, animals in pain are often restless and agitated. If ambulatory, they commonly pace, circle, pant, and aggravate wounds and surgical sites. Conversely, animals that are comfortable following adequate analgesia are more likely to rest quietly without agitation or distress. Furthermore, untreated pain becomes a pathology in itself, manifesting as adverse side effects, including tachycardia, hypertension, tachypnea, gastric ulcerations, ileus, decreased renal function, catabolism, altered hemostasis, and impaired wound healing (see the section "Sequelae of Pain"). If limiting movement is necessary, various methods of restraint or immobilization, and chemical tranquilization are available. Veterinarians should endeavor to make their patients as comfortable as possible so they can rest and allow healing to proceed unimpaired by the effects of pain.

The comment of one expert in pain management provides additional insight:

"I have never come across a patient who has damaged a surgical site or pulled out implants as a result of being too comfortable, however, I have come across patients who have damaged a surgical site, traumatized a surgical site, or damaged implants as a result of being too painful postoperatively" (Duncan Lascelles, BSc, BVSc, PhD, MRCVS, Diplomate ECVS).