Pill Poppin' Pets

Now that we know more about how and why pain happens and is perceived, we can talk about how to treat pain.

Different types of pain come from different places. Remember the pain starts at the receptor somewhere out in the body and is then carried upwards towards the brain with a couple of junctions along the way. Depending on the patient, nature of the pain, and duration of the pain, we may change exactly how we treat different pets with similar problems.

Classes of drugs:
Local anesthetics
Lidocaine, bupivocaine, carbocaine are all examples. These drugs work by short circuiting the nerves carrying the signal. If they can't generate an electrical charge, the signal never makes it upstream. This can be done locally (like the spray you spritz into your throat when it's sore) or injected near a nerve (like when we do ring blocks for declaw procedures) or into the spinal column itself. Anywhere the drug goes, there will be no pain sensation generated. These drugs don't last long. For instance, lidocaine only lasts a couple of hours. Bupivocaine lasts about 12 hours when injected.

NSAIDs
Non-Steroidal Anti-Inflammatory Drugs. These are drugs like ibuprofen (for PEOPLE ONLY), carprofen (Rimadyl), meloxicam (Mobic, Metacam), and ketoprofen (Ketofen, Orudis). This is a class of drugs that is very popular because they work well and are available over the counter on the human side. NSAIDs work by blocking the enzymes that generate pain causing chemicals and decreasing the amount of pain generated. NSAIDs work out at the SITE of where the pain is starting. NSAIDs are usually our first-line pain medications for osteoarthritis, post-operative pain control, and trauma pain management. They are often used in conjunction with a narcotic.

CAUTION: NSAIDs are a class of drugs that can be fantastic in dogs and cats, however, they must be used with caution and ONLY under the advice/supervision of your veterinarian. Cats in particular are sensitive to this class of drugs. DO NOT GIVE ANYTHING OVER THE COUNTER WITHOUT FIRST TALKING TO YOUR VETERINARIAN.

Narcotics
Also referred to as opiates because most all of these either came from or are related to opium and its derivatives. Opiates function in large part in the spinal cord. They decrease the amount of pain signal that is allowed to jump from the nerve carrying the signal from the periphery to the nerves in the spinal cord. They work in a couple of other places as well (brain).

Opiates are fantastic for all kinds of pain, from mild to severe. Opiates also have the unfortunate side effect of being prone to addiction because of the change in brain chemistry that happens with chronic use. Because they simply block the receptors in the central nervous system, the receptors can respond by making more of themselves. This means it takes more drug to work. We refer to this as tolerance of the drug. We have to increase doses to match. Bigger doses, longer term use and we're now talking addiction. Addiction does happen in our pets. It "looks different" because your dog won't loose his job, family, house, and friends over addiction, but the underlying physiologic response is the same - the body NEEDS the drug after it has had the drug for a period of time. Long term use of opiates must only be done under the direct management of your veterinarian.

Opiates are frequently combined with NSAIDs (think Percocet, Vicoden). This accomplishes two things - first, it provides two modes of pain control in one pill. They ALWAYS work better together than either one will work alone. It also makes them hard to abuse because the more NSAID you take, the more likely you are to have problems with the NSAID. It also makes it hard to cut the drug for street sale.

Opiates are all Scheduled drugs. This means the DEA tracks each and every tablet and drop of narcotic produced in the USA from the manufacturer to the patient. Your veterinarian has to keep lots of records on controlled/scheduled drugs. The more likely a drug is to cause addiction or abuse, the more tightly the DEA is in control of it.

Tramadol (Ultram) has become a darling of veterinary medicine. It is not a narcotic, but is narcotic-like. It also has some nifty effects in the brain where it increases seratonin levels. So even if you're in pain, you don't care (sort of). Because it's cheap, effective, and not controlled we veterinarians LOVE the stuff. Rumor has it that tramadol may become a controlled drug. We'll see. We'll still use the heck out of it, but it will make our lives a bit more difficult.

Amantadine and Gabapentin
Amantadine and gabapentin are medications that are used along WITH other pain medications. Both of these (although through different actions) help to change the way the brain and spinal cord react to CHRONIC stimulation of pain pathways. Chronic pain can cause these pathways to be "turned on" all of the time. Over time, these pathways can be permanently turned on or can be so freaked out that they don't know how to tell the difference between a little pain and a lot of pain. In some cases of chronic pain, amantadine can bring huge relief where our usual arsenal of drugs isn't cutting it anymore. These drugs take time to work and aren't used in the acute "I gotta have pain control NOW" setting.

Multi-modal pain control:
This concept means that we try to attack pain from different angles. When I am doing a painful procedure to a toe, for instance, I may do a local block at the level of the toe to try and block the signal from starting. I will also use a narcotic at the time of the procedure to help block any signal that makes it past my local block. I'll also give an NSAID so that when the local block wears off, the NSAID has had time to block the inflammatory chemicals from being made and the patient is, in theory, not painful. I've now blocked the pain signal at just about every available level. By using all three, I can use less of each and have a much better effect than I would by using only one drug alone.

There are literally entire books published on this subject, so I'm not trying to cover it all. Just trying to give you more information.

One last thing:
Some veterinarians still offer pain medications as "optional" after surgical procedures. Others make it a requirement. I require it and without fail I would have a few owners get upset that they were being sent home with pain medications when the pet didn't "look painful." 99% of the time, the complaint is that they have been asked to pay for the medication. Remember that pets don't show pain the way we do. They may be in significant pain, but not show it in an obvious way. Painful animals usually rest more than usual, have trouble getting comfortable, have increased breathing and heart rates, may refuse to eat, and may be more aggressive than usual. Cats are especially bad about hiding pain. They will seem to just be sleeping more than usual, when they are actually in quite a bit of pain.

Because it's nearly impossible to predict which pets will be more painful than others, we should ALWAYS TREAT THE PET AS IF THEY ARE PAINFUL. If pain medications are optional for you - TAKE THEM!!!!!!!! If they aren't optional - TAKE THAT AS A SUGGESTION AND USE THEM AS DIRECTED! Bone pain/amputation pain is usually the worst, followed by supporting muscle pain, neurologic pain, and organ pain. Trust me, after I have removed your dog's uterus, she's painful. After a de-claw (amputation), I can GUARANTEE your cat is painful.

Well controlled pain = faster healing time (well documented that this is true!), less stress, lower stress hormones, less susceptibility to secondary infection, and a happier pet!

AMH

OUCH! That Hurt! Pain Perception and Control

In this post we'll talk about what pain is and how it is perceived. Next post I'll talk about some specific pain medications and methods for dealing with pain.

We've all felt pain. Pain can be acute (cut finger, broken leg, twisted knee) or can be chronic (spinal pain, compressed disk, arthritis). Different types of pain require different approaches. I thought I'd do an overview of different types of pain management and talk a little bit about the way animals perceive pain.

First thing first. Let me say this loud and clear. ANIMALS FEEL PAIN.

All of us mammals are essentially wired the same way. The nerve endings, nerve fibers, and nerve junctions are all pretty darned similar. So a broken leg hurst no matter what species you are talking about. Where's the difference between people and animals?

Animals PERCEIVE pain differently than humans.

Even though we are wired the same, that signal has to be interpreted by the brain for you to have concious knowledge of that pain. This explains why I have seen many dogs walk into the emergency hospital DANGLING A LEG behind them. It is also why I've seen a cow get their horns sawed off and they walk right out into the field and start eating as if nothing ever happened.

There have been many excellent studies looking at pain perception in various animal species. Each have these have shown that animals definitely perceive pain. However, there is a difference in what kind of pain they perceive and what it does to their body.

Every individual is different.

Some people have a very high pain tolerance and don't seem to hurt too badly even though they have a broken arm. Others cry and are severely affected by a paper cut. This is also true in our pets. Some require more pain medication than others.

The Anatomy of Pain:

Pain perception starts at a nerve ending somewhere out in the body. Let's use the toe as an example. When the pain receptor is triggered (like the toe is squished or the skin is cut), those receptors fire off a signal to the spinal cord. The signal is linked in the cord to another nerve that sends the signal up to the brain. Once in the brain, the signal is perceived both consciously and sub-consciously. This is an over simplification, but the point here is that pain happens at multiple, yet different levels in the body. When considering the pain in the toe, there are at least three locations that I can treat to eliminate the pain being "felt" or "perceived" by the individual.

Ever had novacaine at the dentist? This is an anesthetic that numbs up the nerves at the sight that the medication is given. That way, the nerves never get a chance to fire.

Ever taken an ibuprofen? Drugs like this work by keeping the chemicals that stimulate the pain signal from being produced. The idea is that if you decrease the chemicals, you eliminate the pain signal all together. In other words, by cutting inflammation, it reduces the stimulation of the signal, and reduces pain. (NSAIDs, COXIIB)

Ever had morphine? Narcotics main action occurs in the spinal cord, although they do a fair amount in the brain as well. Narcotics keep that signal from jumping from the nerve that sent the signal to the nerve that carries the signal to the brain.

And then there are the drugs that affect the brain chemicals that make us either more sensitive to pain or take away that sensitivity. In other words, they help change whether or not we give a damn that we're painful.

So in people and in animals, there are many, many different places that pain can be modified. This helps explain why there are such different responses from different individuals. Depending on your body chemistry, your brain chemistry, your specific genetic make up, you may have more or less sensitivity to pain. Cows are NOT as sensitive to pain as poodles. It's a fact. They both FEEL pain, but they don't PERCEIVE it the same.

Acute pain is handled differently than chronic pain. Over time, these pathways I've described above can become hyper-active or can be blunted. So chronic pain may require different targets to get the pain response to either shut down or start up. Acute pain can be easier to manage for this reason. The pathways are more predictable and we can use drugs in the short term (narcotics that sedate) that wouldn't be smart to use long-term (narcotics and addiction).

I'll stop there for now. Next post we'll talk about specific pain medications and how they can help.

AMH

Over the counter pain medications

I am frequently asked if a pet can take anything over the counter for pain. Typically, the answer is NO. In cats, the more specific answer is not just no, but NO!


Dogs and cats are so very, very physiologically close to us in many ways and yet worlds apart in others. One of the big differences has to do with the way their livers process certain toxins (or drugs). Because of this, drugs in the Non-Steroidal Anti-Inflammatory Drugs (NSAID) designed for humans are exceptionally bad for dogs and cats. Instead, drugs had to be developed that they could tolerate. These drugs are all prescription and there are no over the counter equivalents.


Ibuprofen is horribly unpredictable in dogs and can easily be toxic at a single dose. Some dogs tolerate fairly high doses before they get sick. Since you can't predict this, it's not safe to give at any dose. Acetaminophen (Tylenol) is rarely used in dogs, and then only if required because it is in a combination with a narcotic (like Vicodin). Dog livers tolerate it OK, but not well enough to comfortably use it any more than you have to. Do NOT give tylenol to your dog.


But to all rules, there are exceptions. Dogs can tolerate aspirin. Small doses, at least. Before we had canine specific drugs, aspirin was commonly used. The problem with aspirin is that the side effects all happen at doses lower than those required to provide pain relief. Tummy upset and disruption of clotting are the two biggest side effects we are concerned about. Aspirin is a potent inhibitor of platelet function. It's why people take tiny doses daily to help prevent heart attack or stroke. Because aspirin is associated with such potential for problems, I'm not even going to mention a specific dose. There is the occasional dog that can tolerate aspirin quite well and does well on it as a pain medication. This is the exception and those patients are at higher risk of bleeding.


In cats, however, there are no exceptions. DO NOT give your cat anything over the counter. Period. A single Tylenol is fatal. Aspirin has to be given with extreme caution. Ibuprofen is likely to be fatal. I repeat - DO NOT give your cat anything over the counter. Nothing. Nada.


There are some great prescription drugs designed to work well with dog and cat livers. This class of drugs still requires care when using, but the veterinary drugs like Rimadyl (carprofen), Metacam (meloxicam), Deramaxx (deracoxib), and Previcox (firocoxib) are all fantastic in the right situations. Because they are SO safe relative to the over the counter options, it simply isn't worth the risk of giving anything else.


AMH

Declaw

Since I'm doing two declaws today, I figured I'd make this my first entry.

I'm not a fan of declawing cats. That's not to say I won't do it when requested, but I do try to talk people out of it. Any readers in the UK will note that it's actually illegal to declaw a cat in the UK. Different states (California included) are considering outlawing declaw procedures as well.

Here's the thing - cats have claws. They're born with them. They use them. One thing you have to consider when you get a cat is how much you REALLY like your furniture. They may very well do some damage. But they're cats.

My personal decision is to just live with it. I still get grumpy and scold the cats when I see them damaging something, but I also accept that it's part of my life with my cats.

Others feel that they want to enjoy life with a cat and if the cat destroys something, they can no longer enjoy the cat and would have to "get rid" of it. Proponents of declawing argue that if a little surgery is required to keep a cat in a loving home, so be it.

Declawed cats should not be outdoor unsupervised. Period. Think long and hard about if you want your cat to be indoor only or indoor/outdoor. Declawed cats aren't helpless. They can still use those back claws to fight or climb, but they are at a significant disadvantage and it's not fair to them.

There are options to declawing:

Soft Paws - These are little kitty nail caps. They go on similarly to fake nails on people. You have to change them out every 6 weeks, but most cats don't mind them and you can get them in all kinds of fun colors. This way your cat can be color coordinated to the home! You can even give them special colors to be more festive during a holiday season. Some cats are personally offended at the idea of colors, so they might prefer clear nail caps.

Nail trimming - If you start working with them as a kitten, this is much easier. You'll probably have to trim the nails every 2-3 weeks. You can't use human nail clippers! Especially on big nails. Kitty nails are laminar and if you clip them with human clippers you'll just cause it to shatter. Use sharp kitty clippers instead.

Scratching posts/kitty furniture - you can find all kinds of devices geared to help distract your cat and get them to scratch on their own toy instead of your furniture. There are sissal pads you can hang, cardboard blocks, and even GIANT carpet covered kitty houses. (If anyone has a good experience with one type of scratching accessory over another - let us know!) I've even built one myself. Put it in a location the cat wants. You may have to move it from time to time in order to get the cat interested again. Cover the thing in kitty weed (catnip) if necessary. A stoned kitty is a happy kitty! The little sissal blocks are convenient because you can hang or set up those right next to the area the cat is scratching (i.e. hanging it on the couch arm).

Declaw procedure:

Declawing a cat involves amputation of the last bone in the toe. This bone is very small in a kitty and the nail grows from this bone. I'll try to find some pictures. There are several techniques to accomplish the declaw, but the end result is that the last bone is amputated and the resulting defect in the toe is closed with either glue or sutures.

I've had the opportunity to use a surgical laser on declaws over the past two years. I'll NEVER go back! If you need to declaw, definitely seek out someone using the laser for the procedure. It's dramatically better. Less pain, less bleeding. They do great! If it weren't for the laser, I think I would have sworn off declaws all together three years ago.

Let's talk pain - This procedure hurts. There's no way around that. The standard of care for these guys is to use local anesthesia so they do not feel the foot for several hours post-op. This only lasts 12 hours if the right drugs are used. Declaw cats MUST be on some kind of narcotic pain medication. Some hospitals use a patch that provides continuous doses of a narcotic called fentanyl. Others use a drug called buprenorphine. This is a very popular drug in kitties.

I also use a drug called Metacam. It's an NSAID (non-steroidal anti-inflammatory drug) and as such, you have to be careful with it in kitties. In europe, Rimadyl is also labeled for cats. This drug in combination with a narcotic is fabulous. Many practitioners are still very wary of NSAIDS in cats of any kind and will not use them for safety concerns. I use the drug in small doses and find it very safe.

When your kitty comes home from a declaw they MUST BE IN A RESTRICTED ENVIRONMENT. Many hospitals will keep them for several days post-op as well. If they are allowed to jump or run around they WILL cause problems. Make sure you give the pain medications are prescribed and don't stop early. This is an amputation, remember. They deserve the pain medications.

Occasionally some kitties have chronic pain associated with the procedure. Other complications include infection in the toe, bleeding, or refusing to use the litter box. You must change the litter to something like compressed paper or shredded paper. Clay, clumping, or dusty litter will only cause crud to get stuck up in the toe.

Once they heal most cats do just fine.

Talk at ya soon.

AMH