Multimodal pain management can enhance your patient’s quality of life, build client relationships and generate revenue, according to Ralph C. Harvey, DVM, MS, DACVAA. At a recent CVC, Dr. Harvey said kitties in pain are prone to aggression and inappetence, take longer to heal, have a higher susceptibility to infection and are more difficult to medicate. By blunting the maladaptive neuroendocrine response associated with pain, we can improve patient recovery, attain better control of hemodynamics, help cats return to spontaneous feeding sooner, lower the risk of immunosuppression and reduce overall morbidity and mortality. Clients are happier and more likely to refer others to your practice, and compliance improves. The cat wins. The client wins. The veterinarian wins. The team wins. Here are seven ways feline pain management is better than ever.
1. Refined gentle handling techniques
Veterinarians benefit from using feline-friendly handling techniques, such as those developed by Sophia Yin, DVM, MS, Dr. Harvey says. Her video library on handling methods to reduce fear and pain is available on YouTube or Dr. Yin’s website, drsophiayin.com. Some examples of gentle handling include:
Providing protection and swaddling with towel wraps and garments such as a ThunderShirt, which have a calming effect on the patient and protect the handler.
Taking the top off of the cat carrier vs. dumping the cat out on the table.
Gently carrying the cat carrier so that the cat is not jostled inside—it’s not a pendulum!
Avoiding scruffing or stretching because of undiagnosed osteoarthritis (present in most older cats, Dr. Harvey reminds us).
Using synthetic feline facial pheromones such as Feliway (Ceva). Dr. Harvey explained that Feliway is effective because it tricks cats into thinking they’re in a safe environment that’s already been marked. Allow the alcohol to dissipate (about 15 minutes) before exposing the cat to Feliway, Dr. Harvey cautions, as cats may find the alcohol objectionable.
2. Improved tools to evaluate pain
By now you’re familiar with the concept that cats aren’t fractious, they’re fearful. Dr. Harvey would add that fearful cats may also be experiencing pain. With improved and recognized behavioral indices, veterinarians now have better ways to evaluate pain in feline patients.
Remember—classic pain behavior in cats includes:
> Loss of appetite
> Excessive licking and grooming
> Cessation of licking and grooming
> Hunched position
> Closed eyes
> Whiskers down
> Hissing or swatting when the affected area is touched
> Disassociation with the environment.
3. Validation of the facial grimace scale
I’m sure that you would agree that it can be a challenge to not only evaluate feline pain, but explain to a client that his or her elderly cat is suffering from chronic pain.
Have you ever heard, “But doctor, she doesn’t cry?”
According to Dr. Harvey, now there’s an easier way to graphically demonstrate to clients that their cats are in pain. Animals with uniform skull morphology, such as a cat or a human can be evaluated for pain with a grimace scale. (Have you ever seen that pain scale with faces on it in the emergency room?) It’s fairly easy to point to a feline grimace scale and show a client that their cat is painful, which opens the door to pain management—and to Dr. Harvey’s next point about new medication options.
4. New options for NSAID therapy
Nonsteroidal anti-inflammatory drug (NSAID) options have been fairly limited in feline patients. The introduction of robenacoxib (Onsior—Elanco) has made management of surgical and chronic pain in cats much easier. Robenacoxib is FDA-approved for once-daily administration up to three days for postoperative pain and inflammation in cats. Dr. Harvey says the drug demonstrates selectivity for tissues that are inflamed or infected and remains tightly bound to blood albumin until it reaches inflamed acidic tissues. It comes in injectable and small, palatable tablets, so it is easy to administer and has a high margin of safety.
Because of the drug’s high margin of safety, Dr. Harvey uses robenacoxib in an extralabel application for longer than three days in patients with chronic pain associated with arthritis or cancer or for palliative care. With extralabel usage, patient selection and informed consent are the keys to success, as well as regular follow-up physical examinations and bloodwork to adjust the treatment plan as required, Dr. Harvey says.
Any discussion of NSAID therapy in cats would be remiss without mentioning meloxicam. Dr. Harvey’s opinion is that the FDA-approved meloxicam dose in cats is too high. He used it at 0.1 mg/kg before converting to robenacoxib. Those who use meloxicam extralabel typically follow with 0.05 mg/kg the second and third day. If they want to use it longer, they should reduce the amount to the lowest effective dose and monitor the patient regularly with blood work. Of course all extralabel uses mandate good informed consent, says Dr. Harvey.
Although not an NSAID, gabapentin has become popular for chronic pain management, usually in conjunction with NSAID therapy. Dr. Harvey says the new pain management guidelines (see below) support the use and emphasize and the value of gabapentin for cats with degenerative joint disease.
5. Effective analgesia with opioids
Feline practitioners now have more options for pain management than ever. Buprenorphine is now available as an injectable (Simbadol—Zoetis), which provides 24 hours of analgesia with one injection and can be given once daily for up to three days. In cats, buprenorphine has a much higher ceiling effect than other opioids, is considered safe, and provides perioperative and postoperative analgesia. Because of the potential for drug abuse and accidental exposure in people, it must be administered only by veterinarians or veterinary technicians trained to handle potent opioids—it cannot be sent home for administration by the pet owner. Dr. Harvey recommends informing owners that their cats’ behavior will be different for 24 hours and to expect them not to be in pain and to seem euphoric.
Dr. Harvey is a fan of tramadol as an adjunctive analgesic in cats. Tramadol interferes with reuptake of serotonin and norepinephrine, relieving the affective (emotional) component of pain and suffering, and allowing cats to engage in life again. The downside to tramadol is that it’s not palatable. Some veterinarians have found success in coating tramadol in layers of frozen butter to allow for easy pilling. Dr. Harvey warns if the tramadol is compounded by a human pharmacy into a liquid, make sure it doesn’t contain xylitol.
6. New pain management guidelines
In 2015, the American Animal Hospital Association and the American Association of Feline Practitioners released updated pain management guidelines for dogs and cats that are available to everyone online here. This resource is filled with new knowledge, links and protocols, and reinforces the idea that pain management is central to veterinary practice.
7. Grumpy cat transformations
Chronic pain can cause unwanted behavioral changes, such as aggression and litter box problems. Dr. Harvey says that 90% of geriatric cats have radiographic evidence of degenerative joint disease1 and likely suffer chronic pain from osteoarthritis, and veterinarians know that cats are frequently relinquished or sometimes euthanized as a consequence of inappropriate elimination. So feline pain management is not only life-improving, it strengthens the client-veterinarian bond and the human-animal bond. Dr. Harvey would even go so far as to say feline pain management is life-saving.
1. Hardie EM, Roe SC, Martin FR. Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases (1994-1997). J Am Vet Med Assoc 2002;220(5):628-632.