Contradictions characterize pain management in companion animals
Pain management in dogs and cats is an area where vast differences exist among veterinarians, according to Dr. Peter W. Hellyer. Some use effective techniques whereas others provide minimal to no pain control.
In his overview of pain in dogs and cats, Dr. Hellyer discussed gains in pain management, following up with barriers that hinder treatment. Dr. Hellyer is an associate professor of anesthesiology at Colorado State University in the department of clinical sciences, College of Veterinary Medicine and Biomedical Sciences. He is a diplomate of the American College of Veterinary Anesthesiologists.
Heightened awareness and improved treatment of pain in companion animals are evident in scientific and review articles, textbooks, and continuing education lectures and workshops, he noted.
Position statements also reflect the current state of pain management, Dr. Hellyer said. The American College of Veterinary Anesthesiologists' position paper on treatment of pain in animals states that the prevention and alleviation of pain in animals is a central, guiding principle of practice. This past April the AVMA adopted a position statement acknowledging that animal pain and suffering are clinically important conditions that adversely affect an animal's quality of life, and methods to prevent and control pain must be tailored to the animal. The AAHA is also taking up this topic.
When Dr. Hellyer was in school, pain was not discussed as a topic unto itself. Earlier this year, a conference sponsored by Pfizer Animal Health for veterinary clinical educators addressed what pain-related topics should be taught in veterinary school. One of the observations was that topics given priority within the curriculum influence the clinical perspective of new graduates.
Despite these advances, the profession has deficiencies to address, he said. According to anecdotal evidence, many dogs and cats still receive little to no analgesia following surgery or trauma. Dr. Hellyer cited several surveys.
A Colorado State University survey showed that veterinary students, clinical faculty, and staff placed a high importance on pain in animals, and most believed that animals experience pain much the same as people do. The paradox of that survey, Dr. Hellyer said, was that their views on the circumstances that would prompt therapy varied widely, and thus, pain management was not uniform at the teaching hospital.
In a recent survey of British veterinarians, 30 percent believed "a degree of pain is required to stop the animal being too active post surgery." Yet, most small animals tend to sleep following surgery, Dr. Hellyer said, so that attitude is inconsistent with good medicine. Paradoxically, 95 percent of those surveyed believed that animals do benefit from perioperative analgesic therapy. Many of the British veterinarians considered treating surgical pain with nonsteroidal, anti-inflammatory drugs or opioids, but few administered combinations of different classes of drugs, which Dr. Hellyer called the cornerstone of current philosophies of effective pain management.
A survey that Dr. Hellyer called "another indictment of the veterinary profession's record of compassionate care" found that, of Canadian veterinarians surveyed, just under half used analgesics in their patients, and they tended to use them in all postsurgical patients or not at all. Analgesics were not administered to 16 percent of dogs and 30 percent of cats undergoing surgery associated with tissue trauma and pain.
According to Dr. Hellyer, the British and Canadian surveys revealed that female veterinarians and those who had graduated within the preceding 10 years placed more priority on postoperative pain. So did veterinarians who treated dogs and cats more than 75 percent of their time and worked with a veterinary technician, and veterinarians who had attended CE within the preceding 12 months.
In human medicine, some interesting parallels have occurred in pain management, Dr. Hellyer noted. For almost three decades, it has been recognized that the medical community undertreats pain in people. As a result, the Joint Commission on Accreditation of Healthcare Organizations elevated pain to the fifth vital sign, along with blood pressure, pulse rate, temperature, and respiratory rate.
"It comes down to good medicine," Dr. Hellyer said.
Barriers that account for the current situation in medicine include physicians' attitudes and aptitudes, lack of time, poor assessment of pain, patients' fear of addiction, fear of opioid side effects, and fear of government regulations and audits.
Some of the same barriers exist in veterinary medicine. Pain is an experience that does not lend itself to objective measurement, Dr. Hellyer noted, so the art of medicine should not be overlooked in favor of the science of medicine.
Dr. Hellyer offered suggestions for improvement, outlining the respective roles of various groups. Specialty colleges should set high standards for pain treatment and develop meaningful position statements, he said. Veterinary college faculty should promote the best pain management for animals at the teaching hospitals and adopt a philosophy that pain be considered the fourth vital sign, in addition to temperature, pulse rate, and respiratory rate.
If the AAHA were to endorse a philosophy that pain management is good medicine, he continued, it would help elevate the quality of care in private small animal practice. Private, federal, state, and university funding should be directed at research on animal pain management, and species-specific pain scales for various types of pain should be created.
The Drug Enforcement Administration and state pharmacy boards should work with veterinarians, Dr. Hellyer said, to decrease the burden and fear associated with prescribing controlled drugs for dogs and cats. Finally, clients need to be advocates for their pets in ensuring pain control.
In conclusion, Dr. Hellyer said, "Let this AVMA-sponsored symposium be a call to action to the veterinary profession and pet-owning public."