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Family Pet Animal Care - Pain - June 2016

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Family Pet Animal Care 
Pain. Is. Bad.

by Dr. Michael Trapani

There. I said it! Pain is BAD. Bad, bad, bad, bad, bad! Pain is bad for the body and bad for the soul. Pain hurts! Pain takes the joy out of life. Pain creates misery. It’s no fun. 

I’ll get letters from the Pro-Pain Party: “But it doesn’t kill you! It must make you stronger!” they will say, “No pain, no gain!” they will claim, “It builds character!” someone is sure to suggest, and “I can’t get a new tattoo without it!” is certain to come up. What else can they say? It’s an election year, that’s their platform. We’ve heard the pro-pain propaganda all our lives: Grin and bear it, tough it out, it only hurts for a minute, it’s just part of life, it’s not that bad, and it hurts me more than it does you. Uh. Huh.

I don’t care what anyone says: Pain is bad. That’s my story and I’m stickin’ to it.

Veterinarians take a different view of pain: Pain is not something we treat. Pain is something we prevent proactively and by every means possible, whenever possible.

The nervous system, and every part of it, is smart. Every nerve fiber and every nerve ending learns. When stimulated by prolonged or repetitive pain signals, neurons improve their activity with practice and quickly become really, really good at perceiving and transmitting pain signals. Body parts are mapped on to specialized areas of the spinal cord and brain. Over time, chronic pain gets written onto those maps in a situation similar to phantom limb phenomenon, where an amputated limb, though removed long before, can still itch terribly, even though there is nothing to scratch. It isn’t the missing limb that itches, it’s the brain or spinal cord map to which that limb once connected. Pain does the same thing.

Veterinarians know that when we prevent pain and suppress the amplification of pain perception that our patients will be more comfortable, heal faster, and be less stressed. When we prevent pain up front, the nervous system won’t have so much chance to practice, and will be less effective at feeling the pain later. This strategy applies to every level of nervous system function.

Let’s say we’re managing one of our anterior cruciate repair surgeries: We have to open the knee joint, move things around, drill holes in the bone, run heavy monofilaments through heavy connective tissue structures… it’s gonna hurt. A lot.

But we start pain control in advance. Our patient will be pre-treated with an NSAID pain reliever and a hefty dose of narcotic before surgery (pre-emptive pain control).They will be anesthetized (elimination of perceived pain), but we know that even though the patient is asleep, the nerve endings in skin and deep tissues will still feel pain, so topical narcotics will be applied to the interior wound surfaces to moderate nervous tissue pain signaling at the site. A constant rate IV infusion (CRI) is given during surgery to deliver additional narcotic, along with a local anesthetic agent and NMDA receptor agonist to decrease spinal cord and other nervous tissue pain processing. When our patient’s wound is closed, a long acting local anesthetic will be injected, keeping the surgical site numb for several hours.

The narcotic CRI is continued overnight and the patient monitored for signs of discomfort. If pain becomes evident after surgery, additional injections of narcotic are given, along with additional doses of NSAID, as needed to keep our patient cozy and comfortable. In the morning, maintenance doses of oral NSAID and narcotic will be started and the patient’s pain monitored to determine whether they are comfortable enough to go home. Most animals transition readily to oral pain prevention and are weaned off CRI and narcotic injections in time to go home that afternoon. Whenever needed, additional pain relief modalities, such as laser therapy, are also applied: patients get whatever they need to keep them comfortable and out of pain.

Aggressive pain prevention applied early in the course of treatment will decrease pain perception later, improving patient comfort, decreasing stress, speeding healing, and allowing for shorter hospital stays. The result is a happier patient, a shorter recovery period, and a decreased cost of treatment. When dealing with pain, prevention is the best cure.