Chronic Pain


Your starter kit

Matt Gurney
BVSc CertVA DipECVAA MRCVS
RCVS & European Specialist in Veterinary Anaesthesia &
Analgesia
 Overview


•  Measuring chronic pain
•  Drug management
•  Prescribing considerations
•  Other essentials & ‘nice to
haves’

•  www.nwsurgeons.co.uk
•  www.ava.eu.com
 Are we on the same page?


•  Chronic pain is usually described as ‘pain that

persists beyond the normal healing time’.
 What matters?


•  For us? •  For clients?
•  Assessing pain •  Ask your clients what
•  Manage expectation concerns them
•  First of all, do no harm •  Number one answer?
 You already have a caseload


•  She’s just a bit lame •  He’s just old
Pain is what the patient says it is


 Pain is not always obvious


•  Osteosarc vs visceral neoplasm
 Let’s be objective
•  Give me numbers!
•  Canine Brief Pain Inventory
•  Helsinki Chronic Pain Score
•  LOAD
•  Health Related QoL (HRQoL)
•  Visual Analogue Scale
CBPI
CBPI
 CBPI

Brown, D. C., Boston, R. C., Coyne, J. C., & al, (2008). Ability of the canine brief pain inventory to detect
response to treatment in dogs with osteoarthritis. Journal of the American Veterinary Medical Association,
233(8), 1278–1283.

Brown, D. C., Boston, R., Coyne, J. C., & Farrar, J. T. (2009). A Novel Approach to the Use of Animals in
Studies of Pain: Validation of the Canine Brief Pain Inventory in Canine Bone Cancer. Pain Medicine, 10(1),
133–142.
Madden, M., Gurney, M., & Bright, S. (2014). Amantadine, an N-Methyl-D-Aspartate
antagonist, for treatment of chronic neuropathic pain in a dog Vet Anaes Analg
 Identify pain behaviours


•  7yo JRT spinal pain

•  Hides away when door bell rings

•  Avoids other dog

•  Loss of normal behaviours

•  New behaviours
 Combining Pain Scales


•  13yo Samoyed
•  Hepatopathy
•  Hypertension
•  Responded well to acupuncture
•  O reluctant to medicate
•  CBPI 32/40, 46/60
•  Deteriorating QoL
 Helsinki Chronic Pain Score


•  11 questions
•  Scored 0 – 4
•  30/44
 HRQoL


•  How can QoL help?

•  Improve or guide tx decisions

•  Deal with owner concerns
•  Most owners prefer QoL over time
 HRQoL
Anal sac carcinoma Osteosarcoma

31 6
HRQoL

CBPI 2/40 35/40

1/60 60/60
 Interventions


•  Applicable to all chronic pain
•  Analgesics
•  Effective weight management
•  Proper exercise
•  Physical therapy
•  Diet
•  Lifestyle modifications
Interventions


 Drugs

Where do I start?
•  Prescribing concerns
 Drugs

Where do I start?
•  Multimodal or staged?
 A simple start


•  2yo FN Lab elbow pain
•  Thoracic limb lame
•  Effective weight
‘She’s lame but not
management
painful’
•  Proper exercise
•  Firocoxib 14d
•  Physical therapy
•  Reduce to minimally
•  Diet effective dose?
 Pain management is long term
•  NSAIDs
•  Dose reduction less effective than continuous
(more dropouts)
•  NSAID reduction w maintained efficacy is
possible (avoid <60% initial dose)

•  Add an adjunct? When? What?

 Multimodal from day 1?
•  Dose reduction less effective than continuous
•  Most dogs present w a flare up
•  Pain breakthrough has occurred

•  Role for regular reassessment

•  Repeat pain scoring
 Multimodal from day 1?
•  Dose reduction less effective than continuous
•  Most dogs present w a flare up
•  Pain breakthrough has occurred

•  With severe pain you have

no choice
 Start with NSAIDs?

•  There is excellent evidence that NSAIDs are

highly efficacious.
•  There is very little evidence regarding safety &
efficacy beyond NSAIDs and opioids
Any animal in pain should be given an NSAID
unless you can find a very good reason not to.
Drugs


We need to use NSAIDs in cats too
NSAID License indication

Surgical procedures in cats (ortho or STS)

0.2mg kg pre op follow w oral
Longterm administration

Pain & inflamm assoc w ortho or STS

2mg kg SQ 30 min before & rpt day 2
6d total course

Lascelles, B. D. X., Court, M. H., Hardie, E. M., & Robertson, S. A. (2007). Nonsteroidal anti-inflammatory
drugs in cats: a review. Veterinary Anaesthesia and Analgesia, 34(4), 228–250.
What next/instead of?


 Tramadol


An increased proportion of non-AVA members (59.5 per
cent) reported the perioperative prescription of tramadol
for dogs undergoing orthopaedic surgery, compared with
AVA members (24.1 per cent; P ≤ 0.0001)

Murrell J, Hunt J, Lascelles D (2015) Survey on analgesia in small animals. Vet Rec 172(17):457
 Tramadol in hip OA


•  Drug groups •  Outcome measures
•  Carprofen •  PE
•  Tramadol •  CBPI
•  TRPV1 antagonist •  Activity monitoring
•  Placebo •  Gait analysis
•  Population
•  Rescue analgesia
•  49 dogs w OA
Malek, S., Sample, S. J., Schwartz, Z., & al, E. (2012). Effect of analgesic therapy on clinical outcome
measures in a randomized controlled trial using client-owned dogs with hip osteoarthritis. BMC Vet Res 8 185
Parameter Outcome
CBPI
•  Drug groupsImproved •  Outcome
mobiity w carprofen (p = 0.01) and tramadol (p = 0.001)
Interference & severity scores impr w carprofen measures
Tx effect seen in all groups

•  Pain
Use of rescue Decreased rescue use w carprofen (p = 0.001)

•  Limb function
Activity NSSD any group but carprofen + day time activity
High individual variability

ABT-116 is not as effective as carprofen or tramadol for treatment of hip arthritis pain
A placebo effect is evident
 Does tramadol improve NSAID
analgesia?


•  Drug groups •  Outcome measures
•  Firocoxib •  Pain
•  Tramadol •  Limb function
•  FT combo
•  Population
•  TPLO
and tramadol surgery
administration 10/gp
Davila, D., Keeshen, T. P., Evans, R. B., & Conzemius, M. G. (2013). Comparison of the analgesic efficacy of perioperative firocoxib
in dogs undergoing tibial plateau leveling osteotomy. J Am Vet Med Assoc, 243(2), 225–231.
Parameter Firocoxib Tramadol Combination
Glasgow Pain Scale > 6 4/10 8/10 6/10

•  Outcome measures
Higher pain scores in tramadol group vs firocoxib (p = 0.004)

•  Pain
Glasgow Pain Scale > 8 1/10 4/10 1/10

•  Limb function
Greater use of rescue analgesia in tramadol group (p = 0.04)

Limb function

‘Dogs treated with tramadol alone used their operated limb the least for the greatest amount of time’
 Should we use tramadol?


•  Consider metabolism
•  Consider dosing frequency
•  Be upfront with owners
 Where does paracetamol fit?
•  Questions

•  Dose? 10-30mg/kg q8-12h

•  Codeine in Pardale?
•  Use beyond 5d?

•  Concurrent steroid use

•  NSAID intolerance
•  Never in cats
 Amantadine


>  Acts at the NMDA
receptor
>  Receptor
responsible for
central sensitisation

Lascelles, B. D. X., Gaynor, J. S., Smith, E. S., Roe, S. C., Marcellin-Little, D. J., Davidson, G., et al. (2008). Amantadine in a
Multimodal Analgesic Regimen for Alleviation of Refractory Osteoarthritis Pain in Dogs. J Vet Int Med 22(1), 53–59.
 Amantadine


•  Drug groups •  Outcome measures
•  Meloxicam •  CSOM - activity
•  Meloxicam + amantadine •  CSOM – behaviour
•  Population •  Vet exam
•  Dogs w OA refractory to
NSAID
Lascelles, B. D. X., Gaynor, J. S., Smith, E. S., Roe, S. C., Marcellin-Little, D. J., Davidson, G., et al. (2008).
Amantadine in a Multimodal Analgesic Regimen for Alleviation of Refractory Osteoarthritis Pain in Dogs.
Journal of Veterinary Internal Medicine, 22(1), 53–59.
Parameter Outcome

•  Drug groupsSignif improvement in amantadine

CSOM activity
•  Outcome
group day 21-42
measures
CSOM behaviour NSD between groups
•  Pain
•  Limb function
Lameness Amantadine group less lame by day 42

The ability to perform everyday activities in subjects with mobility impairment was improved by the addition of
amantadine to the NSAID therapy
 Second line in cats?
•  Tramadol 2-4mg/kg thermal
antinociception
•  Analgesic efficacy variable
•  Amantadine 4mg/kg
•  May reduce opioid dose
•  Gabapentin 10mg/kg
•  Efficacy doc in trauma cats
 Gabapentin for neuropathic pain


•  Drug groups •  Outcome measures
•  Gabapentin •  QoL related to clinical
signs
•  Topiramate
•  Population
•  Client-owned dogs w
CM-SM

Plessas, I. N., Volk, H. A., Rusbridge, C., et al (2015). Comparison of gabapentin versus topiramate on
clinically affected dogs with Chiari-like malformation and syringomyelia. Vet Rec
Parameter Outcome

•  Drug groups41.3±21.3 mm
Mean VAS before carprofen
•  Outcome measures
Mean VAS 7d carprofen 40±23.3 mm
•  Pain
•  Limb function
Gabapentin 2wks 30.6 ±21.4 mm

Topiramate 33.2 ±23.4 mm

Significant improvement in QoL was observed after gabapentin compared with baseline.

Plessas, I. N., Volk, H. A., Rusbridge, C., et al(2015). Comparison of gabapentin versus topiramate on
clinically affected dogs with Chiari-like malformation and syringomyelia. Vet Rec
A chronic pain ladder?


Other useful additions
Always consider
Tricky additions
 Essential additions
•  Further reading
•  Epstein et al (2015) AAHA/AAFP Pain Management Guidelines
Journal of the American Animal Hospital Assoc 51 (2) 67-74
•  Mathews, K., Kronen, P. W., Lascelles, D., Nolan, A., Robertson, S.,
Steagall, P. V., et al. (2014). Guidelines for recognition, assessment
and treatment of pain: WSAVA Global Pain Council members and co-
authors of this document:. Journal of Small Animal Practice, 55(6),
E10–68
 Conclusions
•  Mechanisms of chronic pain are diverse
•  Specialist anaesthetists are always on hand!
 Chronic Pain

Your starter kit
Matt Gurney
BVSc CertVA DipECVAA MRCVS
RCVS & European Specialist in Veterinary Anaesthesia
& Analgesia