Put the Pain Score into the record each time a patient comes in.
Pain management is about quality of life.
But pain discussions have become a pain. So many articles, so many opinions, so much chatter about so many drugs. What is a clinician to do?
Michael H. Riegger DVM, Dipl. ABVP
To simplify, we need a veterinary pain-score system that is not unlike the in-room human hospital posted system.
The first real discussions of pain came with the British. James Herriot and his series of books starting in the pre-WWII years with "All Creatures Bright and Beautiful..." discussed pain relief in so many ways.
Impressions of colic pain relief also came along with the British at the Day Crowhurst Practice in Newmarket in the 1970s. They played pain relief like a fiddle. They knew which drugs provided relief for this and that – and when they failed they knew which was a surgical case and which was not. They were able to separate small-bowel from large-bowel diseases with the aid of response-to-pain medication.
The impression left to the observer was that 80% of equine colics merely need the pain cycle broken to effect a cure.
So today we have so many choices, so many tools, and so many opinions. The opinions we face come from academia — research, pharmaceutical companies, piles of scientific materials mingled with testimonials, and, of course, anecdotal reports. Together these items have muddled the pain-management picture.
What is the human field doing? Morphine is still widely used, but a morphine therapeutic dose really can make one sick. Still, its use continues, despite many smoother analgesic protocols and drugs.
Why does morphine use continue when there are so many new generations of narcotic drugs out there just waiting for use? Cost containment is a basic answer.
Thankfully, veterinarians can use narcotics as we see fit, but humans cannot use the full range of oral analgesics until a human is in hospice care.
One veterinary concept seems secure: To control pain requires a combination of tactics and drugs.
And, we should focus on quality-of-life issues, not cost issues.
Table 1 Pain Score Indexing
When reading veterinary literature, certainly even the industry pain experts do not all agree on tactics and drugs. It can be confusing.
As an example, when butorphanol came on the market for horses, the listed dose was 50mg intravenously. For those of us who started using that dose, we had horses falling off the end of the needle. Scary. With further "field" experience, we could play the fiddle with butorphanol to use 10, 20 or 30mg to help relieve pain and aid in the diagnosis of the equine acute abdomen.
Now, fortunately, a timely discussion of pain is included in the sixth edition of Stephen Ettinger's "Textbook of Veterinary Internal Medicine."
For those who are critical of butorphanol, it is an excellent reminder that various opinions exist.
So what are we to do? Follow these seven practical steps:
1. Know NSAIDs.
Pick three, use them, rotate them, KNOW THEM. Know when complications arise and readily discuss issues of efficacy, expectations and potential complications with staff and clients.
2. Know narcotics.
Pick three, use them alone, use them in combination with NSAIDs, and rotate them. Be ready to discuss therapeutic strategies and potential for complications openly with staff and clients.
3. Employ the 100 Rule.
Set out to catalogue 100 patients in each of the 10 categories in Table 1 and how they were managed. Track results. Get family input because life at home will reveal different results for the various patients in various situations.
4. Adjust therapy for chronic pain.
Chronic pain can come in any of these 10 pain levels. So for each chronic pain patient, especially Cauda Equina patients, adjust therapy on a weekly, monthly and semi-annual basis.
5. Use a pain score system.
Look to Table 1. Photocopy it. Edit these categories to your liking. Then put a pain score on each entry into the medical record.
Put the pain score right next other vitals:
Heart Rate____, Temperature ____, Respiration____, Pain Score ____, Weight____.
Put the pain score into the record each time a veterinary patient comes in — whether it's for a broken nail, an annual visit (looking for arthritis), a medical case or a surgical case. Get into the habit of assessing pain and recording it regularly.
6. Merge pain techniques.
Merge your favorite pain-relief techniques with NSAIDs and narcotics. Some of us like MSM, glucosamine, chondroitin, massage, physical therapy, yucca, local injections of lidocaine-type products, cortisones and Adequan products. (Of course, help your clients take weight off of those heavy patients.)
Pick up either Dr. William Muir's writings (Ohio) or Ettinger's Sixth Edition, Chapters 4 and 5: Pain Identification and Pain Management. Make them the policy for your practice.
Dr. Riegger, dipl. ABVP, is the chief medical officer at Northwest Animal Clinic Hospital and Specialty Practice. Contact him at www.northwestanimalclinic.com, Riegger@aol.com, telephone and fax (505) 898-0407. Find him on AVMA's NOAH as the practice management moderator. Order his books "Management for Results" and "More Management for Results" by calling (505) 898-1491.