Dr. Richey: You, as various "support staff" have various roles in tonights topic. UNDERSTANDING what we are doing and how we do it is important for you as well as US! This could easily be a 2 hour verbal lecture! So, how many of you are in practices that utilize some sort of pain management either BEFORE the patient is induced for surgery or after?

All: Answers included striving for a pain-free hospital, including pain meds going home with pets post op, torbugesic only for post declaws (up to TID for 2 days); Fentanyl patches for orthopedic and other major surgeries, ketoprofen, aspirin in dogs, torbugesic and Demerol, buvipicaine for orthopedics, send home a pet tinic/torbugesic mixture for oral use, torb/ace for preanesthetic then home on aspirin/codeine.

Dr. Richey: There are 4 modes or modalities to consider: Transduction, transmission, modulation, and perception.
1. First is what happens at nerve ENDINGS and is reduced by things like cold and lack of movement of area. NSAIDS (i.e. ketoprofen, aspirin, etc.) act here as to steroids and antihistamines.
2. Second is transmission of the impulse up the nerve to the spinal cord. This can be affected by local anesthetics injected around the nerve (nerve block) or as an epidural
3. Third is what the spinal cord does with the information, i.e. amplify it or dampen it. It is affected by the vast array of drugs we put in the epidural/spinal space (except locals) as well as by some effect by parental opioids and Tylenol.
4. Fourth is what the brain does with the information to say "THIS HURTS" and is manifested by behavior as well as sympathetic responses such as increased heart rate (HR), increased respiratory rate (RR), and increased blood pressure (BP). It is affected by drugs such as anesthetics, sedatives, opioids, alpha-2 agonists, etc. They do NOT produce ANALGESIA here, but do affect HOW the patient responds to the stimulus
The BEST analgesic protocol will do 2 things:
1. Affect as many of these modes as possible
2. Be in effect BEFORE the stimulus is there (i.e. surgery) since it takes far less drug to PREVENT pain than to STOP pain.

Dr. Richey: Which practices give pain meds BEFORE surgery? and prior to what procedures?

All: Responses ranged from 99% of all surgeries to only for declaws and orthopedics

Dr. Richey: How do you base a patient's comfort level post surgery (i.e. abdominal or exploratory surgery)? How do you assess pain?

Responses:
1. Based on behavior and the fact that most seem to want to eat, drink, and move around soon after recovery.
2. Pre-op meds are used in all cases, followed by initial post op pain relief, then client consent to continue pain relief for the entire hospitalization of the pet.
3. Use a pain assessment chart for each animal post surgery. Chart rates the pain by a number system and allows you to determine if pain relief is needed. Medicate accordingly.

Dr. Richey: In a very large spay study, it was found that nearly all dogs APPEARED normal whenever people were present. BUT, then it was just the dog and the cam corder, they displayed CLASSICAL signs of pain! I propose instead that if pain has been inflicted on a dog (or cat or whatever), pain IS PRESENT. Period.

Question: Is there a danger to animals giving them pain medication? (with added conversation of personal experiences of surgery/dentistry and pain meds needed)

Answer (Dr. Richey): ALL patients, be they 2 or 4-legged, have different tolerances to pain. That is the perception part though. The other 3 modes (nociception or noxious stimuli) still occur and are detrimental to the patient.
Another view would be - How many of you routinely administer antibiotics to sick or even not yet sick patients (i.e. spays, dentals) without a positive blood or tissue culture? I will bet all of you do. I know I do, day in and day out. YET, we have a MAJOR problem in this world with bacterial resistance to antibiotics. To the point PEOPLE die routinely as a result. BUT, we have NO problem with our patients becoming "addicted" or adversely affected in virtually any other way by use of pain medication.

Dr. Richey: Can anyone give me ONE reason we should withhold pain medication in a post operative patient that WE don't think is painful?

Response: How can we know what an animal is really feeling? Very ethnocentric of us!

Dr. Richey: The point is...we as a profession, have CONVINCED ourselves, and our employees, AND our clients, that "dogs don't feel pain the same as we do." However, they are wired exactly the same way we are! So, we NEED to give pain meds after a noxious stimulus has been inflicted even if they "act" OK. Because they are for the most part ACTING.

Question: I understand what you're saying about the pain, but what about the young spay/neuters and how active they are right after surgery...I would rather they NOT feel quite so excited!!

Answer (Dr. Richey): If you give them an opioid, they will NOT be excited. They will be sedate, due to the 'side' effect of sedation. So you kill 2 birds! Right? The above statement is one of the oldest wives' tales right up there with 'if a bitch mates with a non pure dog she can never have pure bred pups again!'

Dr. Richey: A few things about TORBUGESIC (i.e. butorphanol) - It is a good, but not great analgesic. It actually REVERSES the effects of the dog's endorphins! AND its duration of analgesia is only 1-2 hours, AND it is VERY poorly absorbed from the GI tract (well, not exactly true, but little gets into the blood stream to get to the CNS!). So, giving one or two injections every 4, 6, 9, hours is pretty darned useless. Giving one every 1-2 hours, maybe.

Question: What is the most affective pain relief? How does oxymorphone rank?

Dr. Richey: Depends on the pain! AND to be honest, the most effective is several!

Question: Doesn't this get expensive?

Dr. Richey: So does suture material, propofol, drapes, gloves, etc. Medicine costs money, period. We do have less expensive options and many work well.

Dr. Richey: Fentanyl and oxymorphone do EXACTLY the same thing at receptors and the receptors can't tell one from the other. BUT, as such, you can also result in an overdose if you use both. Overdoses are inconvenient, not life threatening.

Dr. Richey: Torbugesic and oxymorphone, if both are present at the receptors at the same time, the torb will indeed 'reverse' the oxymorphone. So timing is important. Torb is a mu antagonist, oxy is a mu agonist. MOST Of the analgesia of opioids comes from the mu receptor (as do most of the side effects).

Dr. Richey: SO, if money is a concern, which of the following is the cheapest to use?: Morphine, oxymorphone, fentanyl patch, butorphanol, buprenorphine, Demerol? Morphine is the cheapest, the syringe costs more than the drug. Torbugesic is the 2nd most expensive, fentanyl in the middle with buprenorphine. Demerol is expensive too due to its duration of only 2 hours. Oxymorphone is the most expensive. Remember to calculate in the duration time/how often it needs to be given to be truly effective.

Question: Does the controlled drug category factor in anywhere?

Answer (Dr. Richey): no, all DVMs (and VMDs) are required to have a DEA number anymore.

Dr. Richey: So, which is BEST? Depends on the patient AND the pain.. Morphine is the 'gold standard'
1. Orthopedic pain: morphine or oxymorphone, with an NSAID, all started BEFORE surgery are best, and an epidural intraoperatively of course.
2. Spays/neuters: patches work well, as does buprenorphine. Oxy/morph also work well and may be needed in patients like me!! (i.e. goldens, labs, other 'wimpy' dogs). And of course, NSAIDS, again started before surgery. In these locals don't work well for logistical reasons.

Dr. Richey: Moral of the story: Start your drugs, what ever they are, BEFORE the blade hits the skin! Once the blade hits, the cascade of events are already started and are much harder to slow and darned near impossible to stop. KEEP AHEAD OF THE PAIN!

Question: Do you have clients sign consent forms for fentanyl patch use on their pets? (for example, with respect to disposal, changing, etc.)? We had clients sign a waiver that said we had discussed the patch, it's narcotic potential, and disposal with them (i.e. in case a child got a hold of one or something) and it became part of the patient record.

Answer (Dr. Richey): Federal law says the patch can be flushed down the toilet if it is applied to you. More stringent requirements are due to personal comfort of the owner/veterinaian. Patches are best placed on shaved skin - preferably in an area the patient can't get to it, but near the surgical area works well too, since it's already shaved - after a light alcohol prep (not a scrub, just a wipe down of the area) to remove surface oils. (Note: Dousing the area with alcohol will impede the fentanyl's absorptiveness.)

STAY TUNED...Dr Richey will be hosting a credited CE seminar on anesthetics, especially the fentanyl patches, in Jan/Feb of 2001.

Note of thanks to Dr. Richey for giving of her time and expertise to VSPN and this chat. Thank you.

Attendees: Guest Speaker: Meghan Richey, DVM; Nanette, Ann, Beth, Carey, Gabrielle, Kelly, Sally