Veterinarians are making huge strides in managing patient pain. But as the number of treatment modalities has increased, the amount of information veterinarians must learn and apply has also ratcheted up, along with the need to educate clients.
DVM Newsmagazine recently asked pain-management expert James Gaynor, DVM, MS, DACVA, DAAPM, to answer basic questions on the subject. Dr. Gaynor directs the Peak Performance Veterinary Group in Colorado Springs, Colo.
DVM: When addressing pain management, what's the most significant challenge for general practitioners?
Gaynor: The main challenge is recognizing changes in behavior and activities that are indicative of patients that are uncomfortable, and then making sure to get those owners back into the clinic with their pets for reassessment. Owners don't always know how the process works. They need to be educated. That's our job as veterinarians. When we're talking about chronic pain, this is something we don't fix. It's long-term management.
DVM: What about pain management for geriatric patients specifically?
Gaynor: All patients require the same level of care. It's about being cognizant of what an individual patient's underlying problems are. It is understanding what their underlying disease processes are and what their level of organ function is. Obviously, geriatric patients have more of those issues, such as liver, kidney, and GI problems. It's not that they require special care, but are just dealing with more health issues, more than likely.
DVM: Do breeds differ in their response to pain management?
Gaynor: Pain management is less breed-specific and more individually based. Many people think some breeds are more stoic than others. As practitioners we need to be careful and really look at every patient individually.
From one Labrador to another, we may have the same painful condition, but it can manifest itself differently in each patient.
DVM: What are some trends in anesthesia and pain management?
Gaynor: One of the great trends is the understanding of why it's important to manage pain. Ten years ago, veterinarians promoting pain management really had to convince their peers to treat pain. Now that's rarely the case. Most people recognize animals need to be treated for pain.
Today we're fine-tuning pain management. Today's best approaches to pain management differ from the best approaches 10 years ago. There are more pain-management modalities—drug and nondrug. We also have more knowledge about acute and chronic pain. Most acute pain can be treated relatively simply. If you follow basic principles, treatment should be very effective.
No patient should be euthanized just because the pet is in pain. There is always something we can do. That's different from what we were seeing just 10 years ago. Euthanizing a pet to spare it pain because "there is nothing left to do" shouldn't happen.
DVM: If you had one long-standing myth to bust about anesthesia and pain management, what might it be?
Gaynor: From an acute pain perspective, there's the myth that certain drugs with long-acting sedative effects also have long-acting analgesia. For instance, with butorphanol, some think it's a great pain reliever. But we know that in dogs, high doses provide analgesic benefit for only 40 to 45 minutes, even though sedation may last up to six hours. People get fooled into thinking that because the dog is sedated, it is therefore comfortable. That's long been a misunderstanding.
There's also a myth among owners that older animals have decreased function. Older animals slow down, but the decreased function may be related to their discomfort. They should be able to do virtually everything they did before, for a shorter time. For example, some think that cats don't jump on the counter anymore because they are getting old. It may be because they hurt.
DVM: I understand you're certified in veterinary acupuncture. How receptive are clients to this technique?
Gaynor: Veterinary acupuncture is an integrative approach to quality of life. Medicine, drug therapy—both veterinary and nonveterinary, acupuncture, therapeutic laser, physical rehabilitation, and stem-cell therapy are all viable modalities. We are combining them to find what is most appropriate for each patient.
And we've found that clients are receptive. They're curious as to how our nondrug approaches work, and we give them a physiologic explanation. In the case of acupuncture, there's a traditional Chinese medical explanation and a physiologic explanation. I give them both, but I focus on the physiologic.
DVM: What are some of the most significant benefits of veterinary acupuncture?
Gaynor: There are multiple ways we can affect the body on a molecular level to help it heal itself. Sometimes the body is better at healing itself with a little intervention than we are with big interventions. We are augmenting its ability to relieve inflammation, relax muscles, and alter pain transmission through peripheral nerves. Many patients are given acupuncture or laser therapy in addition to drug therapy because we're trying to provide the combination that works best for each pet.
DVM: Your practice was recently highlighted in a national publication for the use of stem-cell therapy. What more can you tell us about stem-cell therapy for pets?
Gaynor: Regenerative stem cell therapy involves taking the dog's own adult stem cells that live in adipose tissue, extracting them from the fat and injecting them intravenously or intra-articularly in higher concentrations than what the body would normally provide. Understand that this is autologous adult stem-cell therapy, not embryonic, which makes it a lot less problematic politically and physiologically.
This is another great way the body can help itself. Regenerative stem cell therapy has brought a lot of natural medicine-oriented veterinarians out of the woodwork. It's a nondrug approach. As far as we know and based on our experience, there are no adverse effects to giving dogs their own cells back. There are, of course, always risks with anesthesia and sedation. However, even that risk can be minimized tremendously.
The first two clinical investigations in which we participated have been published. These findings suggest that the vast majority of patients—about 90 percent—experience good or excellent results.
We now have enough experience to know which patients shouldn't get the therapy. A small group shows minimal to no response. We believe this is because there is little to no cartilage in their joints. But most patients respond significantly.
Most owners think stem cell-therapy for pets is something just short of a miracle. We recently did a 60-day recheck on a 9-year-old cocker spaniel. Prior to stem-cell therapy he was a little grouchy and not going up and down stairs. He had a decreased quality of life. After therapy, he's essentially a 4-year-old dog.
Stem-cell therapy appears to be the next big thing since nonsteroidal anti-inflammatory drugs. It's a boon, especially for patients with arthritis.
DVM: How has stem-cell therapy taken off in your practice?
Gaynor: Approximately 250 veterinarians have gone through the training to do stem-cell work. To date, our group has done more than 20 percent of the cases in the country. We got in on it very early. It is a growing part of our practice. We have one or two stem-cell cases a week. Now we have people who come from significant distances for us to do stem-cell therapy. This is by far the most exciting thing happening in veterinary medicine.
Skernivitz is a free-lance writer in Cleveland, Ohio.
Dr. James Gaynor bio
After graduating from The Ohio State University (OSU) in 1988, Dr. Gaynor spent a year in private small-animal practice in northeast Ohio before returning to OSU for a three-year residency in anesthesiology, where he also earned a master's degree in veterinary clinical sciences focusing on cardiac dysrhythmias. He is board-certified in veterinary anesthesiology. He is certified in veterinary acupuncture and is a Diplomate of the American Academy of Pain Management. Dr. Gaynor joined the faculty at Colorado State University in 1992 and was section chief and associate professor of anesthesiology and pain management until 2003 when he started the Colorado Springs practice Peak Performance Veterinary Group. He has published numerous papers on animal anesthesia and analgesia and is a leader in stem-cell therapy in pets.