In 1940 C.S.Lewis, probably best known for his series ‘The Chronicles of Narnia’, published a book entitled ‘The Problem of Pain’. In it he sets out with compassion and insight to answer the crucial questions of why we encounter or endure suffering. Alongside chapters, amongst others, on human pain, heaven and hell he also includes one on animal pain.
‘The problem of animal suffering is appalling … so far as we know beasts are incapable of either sin or virtue: therefore they can neither deserve pain or be improved by it.’
(The Problem of Pain, chapter 9)
Thankfully, in today’s veterinary world we are addressing animal pain and suffering seriously. No longer do we believe that “a little pain is a good thing, it encourages them to rest”. Now we must accept the moral imperative to treat it and appreciate the benefits of a recovery as free from pain as possible. This will lead to a quick return to full health whether that be from disease or our surgical interventions and the amelioration of chronic pain from long-term conditions is of utmost importance.
It was with these goals in mind that we tackled the problem of pain under the expert guidance of Gwen Covey-Crump. We looked at the pathophysiology of pain, how pain is assessed and scored, the pharmaceutical and physical treatment options open to us and the role of nutraceuticals. The day ended with a run through the pain consult and palliative care.
‘Pain is not a problem if we do not look for it’. We were reminded that pain is common and is multi-dimensional. Just because we do not, or choose not to, recognise it does not mean it does not exist and causes much suffering. Acute pain is generally hard to miss but chronic pain is slow to develop and is often masked by behavioural adaptations. We must make the effort to notice the non-verbal signals that our patients elicit. ‘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.’ (IASP)
‘The strain of pain lies mainly in the brain’. Pain of itself is protective, associated with healing and adaptive. Chronic pain results from a maladaptation of these processes. In looking at the neurological pathways involved with pain we saw just how complex a system exists with receptors, transmitters, modulators and feedback pathways. Whether you believe in the existence of a Creator God or not you can not deny the beauty and complexity of the systems.
‘When you can not measure it … you have scarcely advanced to the stage of science’ (Lord Kelvin). A number of validated pain scoring systems (CBPI, CSOM, etc.) now exist in dogs and cats. These are an invaluable aid in assessing the effectiveness of any treatment regime. These use evaluation at home by the owner the person best placed to make judgements. They go equally with the detailed history and physical examination in the clinic where static, dynamic and gait assessments should take place alongside the vital palpation.
‘There is no magic pill’. There is a paucity of POM-V drugs available though they include NSAIDs, COX-2 inhibitors and paracetamol. The use of off-licence medications must be justified and informed consent obtained from owners but they adds considerably to the armoury. Opioids, NMDAr antagonists, gabapentin and local anaesthetics should be considered within a multi-modal approach to treatment. A new group of drugs, Pripants, are available in USA but not yet in UK.
‘Good intentions of the few clouded by many’ (Pain Management in Small Animal Medicine by Steven M Fox). The fastest growing group of healthcare products are the nutraceuticals which by nature are unable to claim medical efficacy and are unregulated. However, EFAs found in many plant and animal sources have a range of benefits for our patients though work still needs to be done on determining the optimum levels of Omega 3 and Omega 6. Others include chondroitin, glucosamine and curcumin.
‘Motion is Lotion’. Cage rest is only appropriate in a small number of, usually, acute cases. Over-restriction leads to myo-fascial pain, reduced range of movement, weight gain, muscle loss and low mood. Remember that adipose tissue is itself inflammatory and that obese dogs often have wasted muscles. Exercise (which can be recorded by activity monitors such as ‘Fitbark’) helps to control chronic pain but should be given evenly throughout the day and week, should be controlled and should include a mental exercise component.
Non-pharmaceutical pain management is vitally important as part of the multi-modal approach. Weight and dietary management, physical therapies and acupuncture are routes to be considered. Fats should be the main source of calories, carbohydrates (many of which are pro-inflammatory) should be controlled and protein levels, especially high quality protein, should be adequately maintained in older dogs. Acupuncture and physiotherapy are specialist fields that can give much positive input to the treatment and control of pain and referral is done ‘the sooner, the better’.
‘Rome was not built in a day’. The pain consult needs to engage the client, with expectations being managed, suitable assessment tools being used and involvement of the whole veterinary team. Treatment is likely to be a long-term process with a gradual refining of the modalities used to determine the best approach. Regular follow-up is essential and careful counselling used, at the appropriate time, around palliative care and the consideration of euthanasia.
It was obvious throughout the day that pain management needs to be so much more than a few platitudes and pills. There must be an effort and willingness from professionals and owners to control this most debilitating of conditions.
Veterinary Christian Fellowship would like to extend its grateful thanks to Gwen for all her work in putting together the day’s teaching, to Animalcare for their sponsorship and to all the delegates for their involvement in the programme. Further information on VCF CPD may be had from John cpd@vcf.org.uk or on any other aspect of VCF from Ali secretary@vcf.org.uk