Advancing pain management through integrative and multimodal approaches

On this episode of the Vet Blast podcast, host Adam Christman, DVM, MBA, sits down with Bonnie D. Wright, DVM, DACVAA, to unpack practical, evidence-based approaches to multimodal analgesia. They explore how acupuncture, shockwave, laser, pulsed electromagnetic field (PEMF), and guided motion complement pharmacologic therapies for both acute and chronic pain, as well as how clinicians can translate these tools into accessible, cost-sensitive treatment plans owners can participate in.

Below is a partial transcript, edited lightly for clarity and flow:

Adam Christman, DVM, MBA: What do you know about multimodal analgesia in veterinary medicine? I know we've covered different aspects of this, but we have never had the one and only Dr Bonnie Wright in the house to talk to us. Welcome, my friend. Thank you. I'm glad I'm sitting down. I'm honored that I'm sharing the screen with you right now. Is really what it is.

Bonnie D. Wright, DVM, DACVAA: That is silly. Thank you for being—

Adam Christman, DVM, MBA: Here, really. Thank you for all the great work that you do. And to the listeners, just get a listen of just a little bit of the wonderful work that our colleague has done. Dr Wright, was born and raised in Albuquerque, New Mexico, and she accomplished her DVM at Colorado State University and a residency in anesthesia and critical patient care at the University of California, Davis. She's lived in Colorado since 2001 and part time in Hawaii since 2017. She's board certified in veterinary anesthesia and analgesia, and she's earned her certificate in medical acupuncture, veterinary pain practitioner, canine rehabilitation practitioner, canine rehabilitation therapist and advanced training in canine musculoskeletal imaging and regenerative medicine. My goodness, she practices and teaches in the areas of anesthesia, pain medicine, the sciences of nonpharmaceutical pain medicine, evidence-based acupuncture, regenerative medicine and rehab, balancing love of both teaching and practice. She constantly learns from both her patients and her students. She's on the lead faculty for the evidence-based veterinary acupuncture program, which we're going to talk more about. And she also has two adult sons, several wonderful dogs, a fabulous horse, and an unknown number of wild hogs and turkeys. She spends time exercising and building her off grid Hawaiian farm with her wife and scent-trained service dogs. Oh, my goodness. How do you balance all of this? I'm exhausted. I love it. Well, let's, let's go into a little bit of the pain management, because I'm really excited to learn more about this, and I want to kind of back up a little bit—what's involved in being an integrative pain management specialist?

Bonnie D. Wright, DVM, DACVAA: I think with the word integrative, it is multimodal — beyond just what we think of pharmacologically as using different drug classes, but really recognizing that in most forms of complex pain, you need both pharmacologic and nonpharmacologic tools, and you are integrating those in a way that optimizes both and neglects neither.

Adam Christman, DVM, MBA: I'm curious what got you involved in that.

Bonnie D. Wright, DVM, DACVAA: Well, as an anesthesiologist, we're always asked to help with pain cases, but at the time, I was much better at the pharmacologic side, because that's what I was taught. And I found myself struggling when it came to chronic pain, because a pharmacologic tool by itself tends to not be a big enough toolbox. And so, the first thing I learned was medical acupuncture, and started becoming fascinated by how it worked and how it was using the same neurotransmitter systems, and I realized we needed a voice in our world that could speak scientifically about what nonpharmacologic modalities were doing. And so, I went running down that road.

Adam Christman, DVM, MBA: I love it, fantastic. And let's tell a little bit about that, about the science behind [nonpharmaceutical] therapies. What do we know about that?

Bonnie D. Wright, DVM, DACVAA: You know we know a lot of things physiologically. So, a lot of models that look at a particular system, and if you modify that system, what happens more globally in the body. What we have less of is the more comprehensive, randomized, controlled clinical trial in our species of interest for a variety of reasons. And one is that with complex interventions, like a lot of the nonpharmacological things, where you're modifying homeostasis, it is harder to measure that in a predictable, evidence-based way with a good placebo control. And so, it really limits the way we were used to getting our science for a number of things that are more complex than simply giving a drug or doing a surgery and immediately looking at outcomes—it's harder to measure.

Adam Christman, DVM, MBA: Yeah, excellent. Okay, so you touched a little bit about acupuncture. We know there is plenty of evidence-based medicine and the use of acupuncture for multiple cases, so share with us a little bit of best use cases and any stories that maybe you have witnessed along your wonderful career.

Bonnie D. Wright, DVM, DACVAA: I think that the way to see acupuncture is as a modifier of homeostasis. Bodies, when we're young and healthy, have a pretty normal homeostasis, but as you deal with sickness and injury, you can form homeostatic loops that are less functional or less comfortable. And acupuncture is a way of bringing those homeostatic loops back to something closer to where they were when you were a healthy individual. And so, it's really tapping into the neurochemistry of the body, which means, if it's a homeostatic system, acupuncture is going to be pretty good at it. And so, pain is the obvious one—an important homeostatic system that, with multiple things that happen over a lifetime, can spiral in a way that creates worsening pain after an event, but also very much as we age and we accumulate multiple events. So pain, I would say—I quote—things that aren't based on, like a study about how often I think acupuncture will help a particular thing, and pain is up in the 95% plus category; we can almost always influence pain, and we actually have, you know, Medicare coverage for things like low back pain in people now for acupuncture, as you said, sort of helping to buoy up that concept. I think some of the other homeostatic systems that are pretty clearly affected are the function of nerves. So, when you have neuropathies, a spinal cord disease and changes in the nervous system, acupuncture is also—because of that homeostatic system—really successful at that as well.

Adam Christman, DVM, MBA: Love it. I'll share with you I had back surgery earlier this year, you know, awful with, like that, worst pain I've had, and recovery, they recommended acupuncture. So I went, and I got to tell you, like, it definitely helped speed the recovery. And, you know, less pharmaceutical for sure. And you know, I don't know if you know, I have dachshunds, so insert wherever you'd like, right? But my gosh, it's, it's a, it's a nonnegotiable, is what I say to my patients too, when we talk about especially for the back dogs…For many years post op, they recover. I'm curious to get your experience on this too. But they definitely recover beautifully, more comfortably, and they're back to normal function, I would say, much better before I was doing acupuncture on them. So, what are your thoughts on that?

Bonnie D. Wright, DVM, DACVAA: I think that's great, and I love the fact that you're talking about it not as a replacement, but as something that works with it. And sometimes, when we add something on to something else, you don't know which one made the biggest difference—was that the surgery? It was faster; certainly, when you're forced to use it by itself, like if surgery isn't an option, or once a surgery has failed and that patient isn't doing well, the fact that we can even see acupuncture working in those settings is really good. But again, I love the idea that you're presenting this as this integrative approach.

Adam Christman, DVM, MBA: Yeah, and I'm seeing a lot more in practice. I'll tell you this over—I think I would say post-COVID, the past five years, it's not been like, "well, here's your option." It's like, "this is the treatment plan," and it's already embedded within the plan. And pet owners love it. Dr Wright, love it. They're like, "Oh, thank you. I've been reading up on this. I've been asking my neighbors about this. I was in Facebook groups about this," and I love that we're already talking about, which we're going to go into in a moment. But like shockwave therapy, laser therapy—they really enjoy and appreciate that.

Bonnie D. Wright, DVM, DACVAA: Well, I think that when we give pet owners the ability to do things that they are more integral in, which is multiple physical medicine things, and acupuncture is one. Because even though they're not doing the needling, they're usually there. They're seeing the effects. We're training them as to how to see what might occur over the days after we give acupuncture. It, in a way, helps reduce caregiver burden. It's another cost, and that's one of the aspects of caregiver burden, but there's this very positive relational piece of it with the owner and the animal, as well as the acupuncturist and the animal, that is often really rewarding on each level—for the practitioner, the patient and then the pet owner, right?

Adam Christman, DVM, MBA: Yeah, I think pet owners want to be involved a lot more nowadays than they did beforehand, and some of these modalities that you can easily do at home, which is great, especially for I call them our frosted face patients or gray muzzles. Yeah. And so, okay, so we have other modalities as well. So, we, in addition to wonderful use of acupuncture, we got things like Shockwave, laser, TENS/PEMF — electrical modalities, what are some of those things with indications for and I think as general practitioners or new graduates, sometimes they get a little confused on what they should be reaching for. So, what does that look like?

Bonnie D. Wright, DVM, DACVAA: Yeah, I think that's a great point, and some of what you reach for will be what's available in your world. I'm grateful that, like, laser was kind of maybe the first non-pharma thing that really got promoted and helped people realize that there were nonpharmacologic approaches that could be added in. What I want people to think about is metered application of any form of energy to tissue can help modify that tissue. And so, when we're dealing with nonpharmacologic treatments across the board, we're dealing with a way of applying energy safely to tissue that will help that tissue to heal and to be more homeostatically balanced. And so, you can use light waves or photons—okay, are they light or particles? Doesn't matter. It's energy in the tissue that is influencing both the substrate of the fascia and the mechanoreceptors and those mechanical fields, as well as modifying the nerves. The same thing with adding waves of sound. So sound waves are going to create energy fields within a tissue, going to induce mechanotransduction, and that is going to lead to cascades like acupuncture that modify both the nervous system and also the myofascial planes that occur around those nerve endings to improve the overall pain, but also often tissue healing. Same thing with PEMFs — pulsed electromagnetic field therapies. It's using electricity in that field. With acupuncture, especially in neurologic cases, we will actually put electrical stimulation across our needles, and that can really help with some of the neurologic recovery. And so, for each of them, I would say, just think about that fact that you're using a metered application of energy, and then exercise—and exercise is an awfully easy thing to add back in. You know, even getting a weekend course in some methods of exercise and motion kind of helps reverse some of our early training that you should like put something in a cage and not let it do anything when it's injured, and can actually have huge differences that are pretty easy to institute pretty quickly. When I lecture, I try to give people a tool they can use right away. And a lot of the things require either a machine or more training, but not some of those really basic concepts that have to do with the animal creating motion in itself through things that are exercise or active stretching related.

Adam Christman, DVM, MBA: Yeah, fascinating. Do you find it a little bit confusing for vet students and veterinarians when you're combining both pharmacologic and nonpharmacologic? In other words, you're worried about potential adverse reactions. If I'm using opioids versus, you know, some of the traditional—well, some of the nonpharmaceuticals, such as shockwave laser, do they get worried that there might be some adverse reactions that can occur?

Bonnie D. Wright, DVM, DACVAA: I suspect there's some worry about that. I also think that we do a much better job of teaching this cellular, physiologic pharmacologic approach in veterinary school. And so as soon as people start trying to add some of the nonpharma, it feels more foreign. And I think some of the schools are coming around more with some sports medicine, but in general, we're still stuck a little bit in the way we were teaching. And so, then people feel insecure adding something that wasn't talked about very much in vet schools, but I do see a number of vet schools changing that. So, I think with that insecurity and maybe that feeling that they're oppositional to each other, which has been, I think maybe sometimes perpetuated in the past, and of course, I don't think is true, I think that's where some discomfort comes from.

Adam Christman, DVM, MBA: Yeah, and I think continuing education is doing a really good job in bringing that front and center, because, I think to certain generations of veterinarians, it's been many, many years, and obviously the science changes, and that's what I like about this podcast, is we're talking about evidence based multimodal analgesia, and I think it's kind of our due diligence as educators, all of us around, educate each other a little bit about some of the peer reviewed literature that's out there, showing the science and the mechanism of action to see how it works. I think tPEMF, for instance, just showing how nitric oxide uses its own body for those things, for healing and shock wave therapy, the different modalities versus use of laser. So, I do see a lot in continued education, which is great that it's really front and center. And you'll love this—it’s popular—those sessions, really?

Bonnie D. Wright, DVM, DACVAA: Yeah, they are. Are very popular. And I know I mentioned this earlier about pet owners, but I really do think going to where their needs are, and we're in a time too. Dr Wright, we're talking a lot about spectrum of care, access to care, and what does this look like when we have all these different types of modalities out there, and some are like, well, what is this going to cost me? Is this going to be cost effective? What are your thoughts on that?

Bonnie D. Wright, DVM, DACVAA: I think that you know, cost is part of that equation, and caregiver burden, and so it is an important piece of it. That said, a lot of the modern drugs are actually quite expensive as well. So, it's both—that the cost financially is there and does it work or not? I think a lot of what is presented to clients has to be done in a way that is circumspect. You know, this is modifying homeostatic physiology, and it may or may not work in this patient. Here's the number of events that I think we should give this an opportunity to work. And if it hasn't by then, then we need to regroup. I often speak to clients about treating pain, in particular, as a ladder approach, where, you know, we might be doing some non-pharma and some pharma, but we're not going up all the rungs yet. We're not throwing the whole kitchen sink at somebody. We're going to decide based on this individual what is possible, and that is sometimes based on their socioeconomic position as well, in terms of what can or cannot be afforded. And then from that you can add to it when you fall short.

Adam Christman, DVM, MBA: Yeah, absolutely. And we have both acute and chronic pain management that we deal with. And where do we fall in when we're talking about integrative multimodal analgesia? Are there differences that you would use one versus the other?

Bonnie D. Wright, DVM, DACVAA: I think with acute and chronic pain, there's a pretty significant importance of adding the integrative piece. So, for acute pain, we do have better control often with our drugs, but we've also realized that opioids are maybe creating a lot more long-term damage than we realized, because they're neuroinflammatory. And so as veterinary medicine moves away from using opioids as heavily as it did in the past, it becomes more important to manage pain more globally, and so you'll see more reliance on drugs like ketamine. We've always had a good reliance on the nonsteroidals, I think, but adding things like ice therapy and some laser therapy into the perioperative period, I think are really critical and not that expensive, and people are really wrapping their brains around that, especially as people like me are out there teaching about the actual physiologic effects of those interventions. It just makes sense. So that's different tools than you might be adding for your chronic cases, where I think the reliance is probably even more important on some nonpharma, but I think that even in the acute pain setting, where our drugs do work better, we are able to titrate them better and do a better job by incorporating some of those tools.

Adam Christman, DVM, MBA: Yeah, excellent. And where do you see the future of pain management in veterinary medicine heading in, say, like, 5–10 years, what does that look like?

Bonnie D. Wright, DVM, DACVAA: You know, I just think that we're well on our way to people really understanding the physiologic effect of nonpharmaceuticals, because myself and a lot of other people are talking about it, especially as sports medicine grows. I think that that conversation will just become more smooth as it is more widely taught in vet schools, and as more practitioners are familiar with it. I think sometimes our non-pharma is also—I don't want to say polluted, but promoted by people that are selling a unit of some sort, PEMF or a laser, and once people are talking about it in a more academic setting, there will be less of the confusion based upon people that are selling a particular product. And so, I think that's going to help too. So rather than a big change in direction, I see it as being a lot bigger wave.

Adam Christman, DVM, MBA: Yeah, and you mentioned sports medicine—is there a difference where this might probably be a dumb question, because I don't know too much about sports medicine, but from a general practitioner's perspective, with sports medicine, what are the hot kind of modalities that you use a lot more in sports medicine than in, you know, non-sports medicine areas?

Bonnie D. Wright, DVM, DACVAA: Motion. Exercise. Motion. I mean motion is so healing. There are papers across species that talk about the hypoalgesic or analgesic effects of motion applied by an individual moving through space. And so, sports medicine does a lot of that, and then a lot of the other parts of sports medicine where they are creating better comfort in joints or in tissues have an end goal of that piece of motion. And so, there's a huge overlap between pain medicine and sports medicine, because that's really what you're doing in a bigger way, because you're also trying to keep them moving through space and doing their jobs.

Adam Christman, DVM, MBA: I got to give a big shout out to Dr Leilani Alvarez. She was our keynote speaker a few weeks ago, and she talked about motion—just you got to move. And between that that resonated with me, and then also shout out to Dr Betsy Charles—we talked about our well-being, about movement, movement in general just feels so good to move. And when you have those down days, just keep moving and keep swimming is what she was saying.

Bonnie D. Wright, DVM, DACVAA: Right all the time, it's so overused, but motion in so many ways.

Adam Christman, DVM, MBA: Daily? Yep, yes, it's like the WD-40 to our joints and to our soul. I'll tell you that, right? Yeah, I just love that, the fact that that's the benefit of the human-animal bond too, especially with our dogs—we got to move and we got to move together. So might as well have good exercise and have them moving. And even to your point about some of these great exercises that you do in sports medicine, we can replicate them when we learn them at home, whether it be in cushions or pool noodles and things like that. But I just think there's such value, because again, in my world, I see a ton of dachshunds, and nothing is more heartbreaking. Those of you know, you know to see a dog that wants to move but can't, and when they have that ability to move—whether it be a cart or whatever that might be—they're like, whoa, back to the zoomies. I go—

Bonnie D. Wright, DVM, DACVAA: Huh? Yeah, yeah, yeah. And, you know, you mentioned application of these things at home, and mentioned, like, pool noodles and things, but I want to be really clear that it can be so much simpler than that. You know, I live in Colorado and Hawaii. Both places are big hiking places, and there's this thought, "Oh, well, we can't hike anymore because of X, Y or Z." And I really disagree. I think you have to titrate it carefully, but getting out and moving through space, hiking on a leash is actually, in most cases, a fairly safe activity. They're not running, they're not jumping, and they're stepping over things, and they're going around things, and so it doesn't even have to be as boring and deliberate as learning PT exercises at home—there's a lot of ways to apply motion within safe limits with guidance that are even fun.

Adam Christman, DVM, MBA: Yeah, I call it a safari—you take him for a hike—and there's wonderful substrates that they're getting involved in. And I let the leash go a little bit more for them and be more patient. I'm not on my phone, you know, I'm present. There's something to be said about then, right? Yes, you know. And I see that happening people or they're pulling away from something. I was like, "Wait, this is their motion. This is their way of scrolling through social media." Is letting them sniff. Yeah, totally, yeah. So, I love this. This is wonderful. So, Dr Wright, where can we learn more? Where would you recommend listeners to go?

Bonnie D. Wright, DVM, DACVAA: Well, you could go to Mistral Vet, but I'm pretty boring, so I would suggest that you go to Evidence-Based Veterinary Acupuncture, where I am just one of a very fantastic team that puts together that group. And that's really where you'll see the excitement—I am just one small sum of many parts.

Adam Christman, DVM, MBA: Oh, I'm telling—and by the way listeners, she's not boring. Let's listen to her bio. My goodness, you can definitely head on over to her website, and we'll put that in the show notes as well. Dr Bonnie Wright, thank you for all the great work that you've done for our profession. Continue to do, keep shining and keep moving.

Bonnie D. Wright, DVM, DACVAA: Thank you.

Adam Christman, DVM, MBA: Everyone, thank you for listening to the Vet Blast podcast with me, Dr Adam Christman. Tune in next time. Remember, take care of your animals and always stay pawsome.