Value of specific pain management medications
Evidence supports the simple act of adding subanesthetic doses of ketamine to perioperative fluids in a CRI to have a preventive
effect on postoperative hypersensitivity. A patient receiving an infusion of 10 μg/kg/min during surgery, even if continued
at 2 μg/kg/min maintenance rate overnight, will consume only small amounts of ketamine, an inexpensive drug. Modest fees charged
for the customary catheter, administration set, infusion pump and fluid for every surgical procedure contribute to practice
profitability, while protecting the patient from hyperalgesia.4 More aggressive CRIs are described using ketamine, along with morphine and lidocaine, for extremely painful surgeries.5 The addition of each drug will prompt a fee accordingly.
Intraoperative and postoperative microdoses of medetomidine (0.25 to 1 μg/kg intravenously, synergistically with opioids already
administered as part of a multimodal pain management plan) have been extremely valuable tools in my practice. A 44-lb (20-kg)
dog might receive as little as 0.01 ml at minor cost to the practice, but it provides exquisite analgesia, sedation and patient
recovery. Even small fees for each administration of a dexmedetomidine microdose will more than recover the cost and contribute
to the practice's vitality.
Modern veterinary pharmacies can now stock and dispense tramadol, gabapentin, amantadine, amitriptyline and other medications
indicated for pain, all at customary markups and typically well within the range of client acceptance. Once a veterinarian
is familiar with the use of these drugs, the practice (or the local human pharmacy) will realize the profits from prescribing
them; the choice, then, should be an obvious one.
In 2007, a Veterinary Economics analysis described a canine ovariohysterectomy (opioid, NSAID, line block, ketamine CRI), a feline dental with extractions
(NSAID, opioid, ketamine CRI, maxillary block) and a multimodal perioperative protocol in fracture repair (NSAIDs, opioids,
morphine-lidocaine-ketamine CRI; note that an epidural, while not mentioned, would have also been an indicated procedure).
The cost of goods was calculated as $6.33, $11.29 and $32.38, respectively, and at generally accepted client fees, an extremely
respectable return can be anticipated.6
Other pain management therapies
Not every aspect of pain management is pharmacologic. We ignore the physical medicines at our patients' peril. Physical rehabilitation
need not be an "all" (via referral to a certified practitioner, though this is often the preference) or "none" (client declines
the referral, or it's unavailable) proposition. Basic techniques with simple equipment and skill sets can demonstrably enhance
patient mobility, ability and comfort. Once rehabilitation techniques are learned and used, they can contribute to practice
income. Acupuncture also has become a profit center for many practitioners.
Nutritional products, whether to promote weight loss (diets or medications such as dirlotapide) or to support joint health
and offer an NSAID-sparing approach to osteoarthritis (eicosapentaenoic acid-rich diets), can also be dispensed from the practice.
More advanced pain management techniques are open to primary care clinicians as well, including autologous stem cell transplantation
(for more, visit
In general, each patient and the practice can benefit by implementing a "Rule of 3 or 4 or so"—that is, even for the most
routine of surgical or painful conditions, a minimum of three often simple interventions would be used. And the more potentially
painful the surgery or condition, the more interventions are used on the patient's behalf.
A sophisticated, but not necessarily complex, pain management culture in a practice can benefit all stakeholders involved
in patient care, starting with the patient itself. The investment is little more than the time and energy to learn the principles
and applications of multimodal pain management.
Indeed, pain management is a vivid reminder that good medicine contributes to a practice's economic health. Every veterinarian
can easily find the resources to advance both. Where will you begin?
Dr. Epstein is president of the International Veterinary Academy of Pain Management and medical director at the Total Bond Animal Hospital
in Gastonia, N.C.