Dogs in overdrive
The sounds of spring and summer can spell misery for dogs with noise aversion and their families. While loud noise any time of year can trigger fear, it's the thunderstorms, outdoor festivities, and Fourth of July fireworks that make those seasons a minefield.
In a June 2016 Harris Poll Online survey, 44 percent of owners reported their dogs had signs of noise aversion. The poll was commissioned by Zoetis, which, a month earlier, had launched a new type of drug to treat the behavioral and clinical signs of noise aversion.
Dr. Sharon Campbell, Zoetis' companion animal medical lead for analgesia, sedation, anesthesia, and behavior, told JAVMA this May, "As much as the dog is suffering with noise aversion, the family often suffers, too," whether it's loss of sleep during a nighttime episode or the dog breaking loose and being hit by a car.
"After a while, if these dogs go untreated or are treated ineffectively, it puts a strain on the human-animal bond that gets worse with time."
Phobic responses in dogs are generally associated with loud noises such as thunder, fireworks, or gunshots, according to the Merck Veterinary Manual, as well as the stimuli associated with these events, including rain, lightning, and pressure changes.
Some dogs react with overt signs of fear such as hyperactivity, panting, pacing, destructive activity, or escape behavior. Others have signs so subtle they can be missed, such as lip licking, yawning—even immobilization. Dr. Campbell said, "They're almost comatose, because they don't respond. Their eyes are dilated, and they are completely immobilized. It's essentially a panic attack."
Teaching the client techniques
In the veterinary behavior clinic at the Chicago Center for Veterinary Medicine, a satellite of the University of Illinois College of Veterinary Medicine, Dr. Kelly Ballantyne, a diplomate of the American College of Veterinary Behaviorists, has a caseload largely of dogs with fear-related aggression, but at this time of year, at least 30 percent of her patients are dogs with noise aversion. Often, patients come in with multiple issues.
By the time they turn to a veterinary behaviorist such as Dr. Ballantyne, most clients have tried a lot of things, so she listens to what triggers they have observed and what solutions have and haven't helped.
"We talk a lot about how they can manage the pet's home environment and how they can teach their dog to relax," she said.
Playing white noise or music and establishing a safe place for the dog to retreat to, such as an interior room, help manage the home environment. Dr. Ballantyne might also work with the owner on behavior modification techniques. For example, she shows clients how to teach their dog to relax on a specific mat or a bed that can become a safe spot.
Dog anxiety vests such as the ThunderShirt work for an occasional patient in conjunction with other treatments, but if they were a silver bullet, she doubts most of her patients would need to see her. She has also met some noise-averse dogs that are frightened by the sound of the hook-and-loop fasteners and other dogs that become frozen in place when the vest is applied.
"So it's important for clients who are trying out these interventions to assess their dogs," she said. "Do they look relaxed, or do they look frozen but not comfortable?"
She said a lot of her clients journal and keep a log of their pet's behavior so she can track the effectiveness of their interventions. "It might be as simple as them scoring the dog's response to a storm on a scale of 1 to 5. As we're implementing treatment, we have them keep monitoring so we know if those numbers are changing and if we're making a good difference," she said.
Some of her patients with mild fears respond positively to the Adaptil pheromone or a mild nutraceutical such as Zylkene from their veterinarian. For moderate to severe fears or phobias, she said Adaptil should be used as an adjunct to medication.
She explores medication options with clients whose dogs have intense responses to a noise, have generalized their fear to stimuli such as dark skies, have hurt themselves, or are having a prolonged recovery.
"My treatment is going to be different for the dog that is scared every single night versus the dog that is scared just in response to thunder," she said.
One of Dr. Ballantyne's patients was hiding in the bathroom every night. "It started in relation to storms, and we perceive that he learned that nighttime predicts bad weather and scary events," the veterinarian said.
His owner had tried a few medications that helped with storms but caused the dog to be off balance and too sedate. Then, Dr. Ballantyne prescribed Sileo, a drug new to the market.
Sileo enters the scene
Zoetis launched Sileo in May 2016 after the Food and Drug Administration approved it as the first drug to treat the behavioral and clinical signs of noise aversion in dogs. It was approved as a new use for an already approved drug. Sileo is a low dose of the commonly used anesthetic drug dexmedetomidine, an alpha-2 adrenoceptor agonist.
Veterinarians prescribe Sileo as an oromucosal gel that the pet owner administers between the dog's cheek and gum via a needleless syringe. According to Zoetis, the drug typically takes effect within 30 to 60 minutes and lasts two to three hours. Unlike tranquilizers such as acepromazine, it is an anti-anxiety drug.
Dr. Ballantyne said that after her client gave her dog Sileo, "The storm hit, and he noticed the sound of the thunder but went back to what he was doing, which was huge. Now he's hanging out with his family in the evening and being his normal, happy self."
She has prescribed Sileo quite a bit and has used it on her own dog, who has a fear of fireworks.
"I think Sileo is a great treatment option because it decreases the fear. Most of the patients I've used it on are showing minimal side effects, and they look a lot more comfortable during a noise event," she said.
Safety of Sileo
Dr. Sara Bennett is an ACVB-certified veterinary behavior specialist based in the southwest Indiana town of Evansville and is a member of the behavior advisory board for Zoetis.
"Sileo is very safe. I think veterinarians get a little worried about it because it's dexmedetomidine. Veterinarians have lots of experience with that drug, given by different routes, particularly injection, and we use it for sedation. But because Sileo is absorbed transmucosally, the bioavailability consequent to that route is much, much lower," she said.
In a few cases where owners said their dog had become too sedate, she told them to reduce the dose by a dot the next time. The syringe uses a dot-dosing system based on the dog's weight.
On May 23, the FDA issued a warning to dog owners and veterinarians about accidental overdoses that have resulted from the ring-stop mechanism not properly locking at the intended dose (see sidebar).
Dr. Bennett said a few patients, usually small dogs that are less inclined to tolerate their mouths being handled by their owner, have swallowed a dose rather than allowing it to be absorbed, but with no effect.
"If it's swallowed, it does pretty much nothing because it goes through first-pass metabolism with transformation in the liver and is broken down before it ever gets through the targeted areas of the body," she said.
She lets owners know that it is normal for vasoconstriction to cause their dog's gums to pale on the side where the drug is administered.
It is important to choose the patient population appropriately, Dr. Bennett noted. Sileo has not been evaluated in dogs younger than 16 weeks of age and should not be used in dogs with certain conditions, such as cardiovascular, respiratory, liver, kidney, or gingival disease.
Noise aversion case studies
At AVMA Convention 2016, Dr. Bennett presented a continuing education session on noise aversion case examples, describing the short-term management of each patient to overcome the immediate threat and the long-term interventions to resolve the problem. Some of those cases are posted with videos at sileoatwork.com. They also serve to educate the public on the various signs of noise aversion.
In her patient population, dogs are often affected by multiple triggers. She recommends Debbie Jacobs' fearful dogs website, which offers support, advice, and resources for these dogs' caregivers.
Dr. Bennett uses a systematic approach for treating noise aversion. She teaches the dog to relax on cue; some of her clients call it doggy yoga. She ensures there is a safe place for the pet to retreat to and avoid the intensity of the noise, even something like the Thunder Hut, a type of cave made of sound-dampening foam.
Behavior modification might also involve classical conditioning, such as pairing noise with petting or food.
Many times, she discusses medication options such as Sileo, benzodiazepines, or the antidepressant trazodone to give situationally before or during an event. Then she looks at adjunct options the owner might want to try, from natural supplements such as milk-protein derivatives to pheromones to a body wrap such as the ThunderShirt or Storm Defender Cape.
She finds that dogs refractory to treatment often respond well to Sileo. At the Chicago-area Golden Retriever rescue As Good as Gold, where she is sometimes called to help, dogs with severe noise aversion are often puppy mill dogs with global fear. Most become adopted into permanent homes with her help and Sileo.
The veterinarian-client conversation
A market research study done internally by Zoetis found that 40 percent of dogs with signs of noise aversion are taken to a veterinarian, owners try to help 20 percent themselves, and 40 percent go untreated.
Dr. Ballantyne has seen studies that found 50 percent of dog owners have a dog that fears noises.
"Asking (the client) about behavior at every visit and using open-ended questions such as 'What concerns do you have about your dog's behavior?' for one, gives them the opportunity to ask, and two, normalizes it," she said.
Dr. Campbell believes Sileo has facilitated conversations between pet owners and their veterinarians as well as increased owners' awareness of noise aversion triggers and behaviors. Zoetis created a simple questionnaire for clients, downloadable for free, that some veterinarians say they print and ask clients to fill out for any dog they bring in over 6 months of age. The questionnaire responses can lead to a conversation about noise aversion.
Unless prompted, most pet owners don't bring up noise aversion with their veterinarians, Dr. Campbell said at a CE session she and Dr. Bennett presented at AVMA Convention 2016 on how to have conversations with clients about noise aversion. She told the packed audience it's a matter of shared decision making. "The key concept is you're shifting the paradigm from a vet-centric conversation to a relationship-centered conversation."
Dr. Campbell told JAVMA that sometimes the reason veterinarians are reluctant to bring up behavioral questions is that they don't feel they have adequate training.
Zoetis has worked with Dr. Jane Shaw, an associate professor of communication at Colorado State University College of Veterinary Medicine & Biomedical Sciences and an expert in veterinarian-client-patient interactions, on the Frank Communication Workshops and Modules.
Dr. Shaw worked with Suzanne Kurtz, PhD, at the Washington State University College of Veterinary Medicine to help adapt for veterinarians the Calgary-Cambridge Guide Dr. Kurtz helped develop for physicians.
Dr. Campbell said Zoetis sends colleagues and customers to the Frank Workshops for intensive training on communication skills.
"Dr. Shaw has actors play the role of the pet owner, and it's up to you as the veterinarian in this role-playing situation to tease out what are the true underlying causes or concerns that pet owner has," she said.
"The premise is that, although the veterinarian is the medical expert, the pet owner is really the expert for that pet," Dr. Campbell said. "We want to make sure that in that conversation with the pet owner, that they are with you along that journey, so that they know what your concerns are and you know what their concerns are."
Anything less could lead to decreased client satisfaction and compliance, she said.
Dr. Shaw told JAVMA that an example of an open-ended inquiry to start a behavior dialogue would be "When there are loud noises, what behaviors do you see in your dog?"
Additional information on the Frank Workshops is available.
Quantifying behavioral signs
"I have some patients that are afraid of the click of ice cubes in the fridge," said Dr. Theresa DePorter. "I have some that are afraid of the classics—wind, thunder, lightning, fireworks."
Dr. DePorter is board-certified by the ACVB and the European College of Animal Welfare and Behavioural Medicine. She works in southeastern Michigan at one of the largest specialty referral hospitals of its type in the Midwest. Her cases are complex; some dogs are referred from four or five hours away. Often, noise phobias are a factor with her patients. Most have generalized anxiety.
Dr. DePorter says the profession needs a system to quantify behavioral signs, and new technology is promising to help meet these goals. She will speak July 24 at AVMA Convention 2017 in rooms 205-206 on "futuristic technology that is here today for monitoring behavior."
"My dream goal for behavior is that we have some way to communicate numerically or with a graph and to share with someone else how severe a behavior case is," she said. "If I call a veterinarian and say a dog has a BUN of 200, we're quickly thinking in the same way, whereas to even begin to discuss a dog with a noise phobia and how severe the anxiety is, we don't have good numbers and ways to share that information."
One of the technologies she will profile is Vetrax, a new monitoring system analogous to the personal activity trackers, such as Fitbit, used by people.
Dogs can respond to noise events by shutting down and hiding, for example, or by becoming hyperactive. "So we start to put activity monitors on those dogs, the outliers—the dogs that show more extreme behaviors, and Vetrax monitors the dog's activity so we can get how many steps they're moving and when they're doing it, and plot it over time," Dr. DePorter said.
One case involved a 15-year-old Siberian Husky with a history of noise phobia that manifested as crouching. But, when Dr. DePorter put an activity monitor on the dog, she said, "We noticed that, on a particular day, the activity monitor showed this 15-year-old dog walked 15 miles."
According to Dr. DePorter, "The owner said she had been at a wedding that day," and further questioning made it clear the dog's hyperactivity was not the result of noise phobia, eventually leading to a diagnosis of pain and separation anxiety. That's why, Dr. DePorter said, it's important to journal over time the nature of storms and noise events and a dog's corresponding activity.
Another innovation is the ZenCrate, she said, describing it as a wooden box that gives the dog a safe place to go when afraid of noises. It's insulated, and the padded bottom restricts vibration. When a dog steps in, the crate begins playing bioacoustic music. (It's not being shipped yet but can be preordered.)
The product Through a Dog's Ear is classical music that purportedly reduces anxiety in dogs and helps block out sound. It is bioacoustically adjusted to create "a consistently calm auditory environment," according to the product website, throughadogsear.com.
Sound therapy is one way of modifying the dog's environment to decrease noise impact. Simultaneously, Dr. DePorter uses medications such as anxiolytics, and pheromone supplements, as indicated by severity of the pet's anxiety. Also important is behavior modification—teaching and building positive associations.
"I teach the dog that something wonderful happens—you get a Kong with some peanut butter in it—when a storm happens," she said. "All these things come together to give the dog a coping strategy."
Such was the case with Sterling, a 13-year-old Labrador Retriever owned by Dr. Kate Reynolds of Clarkston, Michigan. Dr. Reynolds said, "I tried treating his anxiety prior to seeing Dr. DePorter, but I knew I needed help when he began to destroy things."
Dr. Reynolds adopted Sterling in 2004 after the veterinary hospital where she was interning saved him from a parvovirus infection. He has been her constant throughout her career and many life changes.
"Dr. DePorter not only helped me manage his anxiety through the use of pharmaceuticals and supplements, pheromones, music, and positive reinforcement training, she also helped me be more compassionate with him and with myself. As a veterinarian, I tend to be a perfectionist," she said.
Dr. DePorter said, "Mostly, his emotional distress has been treated with compassion for his fears. He has been given tools to help him reduce his own fear and live in confidence he will be protected when there is a storm."
Because Dr. DePorter taught her so much about behavior, Dr. Reynolds said, "My entire practice style has changed in the course of the last four years, and I like to think that our profession is moving toward a kinder, gentler way of practicing medicine, which will make it a more effective way to deliver quality care."