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The drug-resistant client: Why pet owners refuse anti-anxiety medicationsand what to do about it
When veterinary clients refuse drugs that can ease patient fear and enhance staff safety, its time to pull out all the stops. Heres a plan for how to do it.
Benzos for my baby? Not a chance. (Aaron Amat/stock.adobe.com)Advances in animal behavior have helped veterinarians provide less-stressful care to many patients both large and small. The ability to correctly read the body language of stress before it reaches aggression-and then respond to it by changing something about the environment in the exam room, treatment area or hospital ward-help keep staff safe and prevent aggression.1 There are some cases, though, in which reducing environmental stress is not enough to produce a non-anxious or non-aggressive animal.
Specific handling techniques to reduce patient stress can also create a calm care experience. Training staff in correct towel-wrapping methods to limit patient movement and appropriate ways to reward patients greatly reduces patient stress and aggression during veterinary care visits. Advanced skills in Low Stress Handling will lead to a less-stressful exam for an unmedicated animal.
But when you're presented with a patient whose anxiety is increasing to the point of aggression despite a less-stimulating environment and high rewards, appropriate anxiety-reducing medication is needed for improved patient welfare.2 Better understanding of both animal behavior and pain management has provided veterinarians with a broad base of medications to use in these cases.
The case for pre-visit pharmaceuticals
Pre-visit pharmaceuticals are given to create a less-anxious and easier-to-handle animal. These medications must be given a few hours before the veterinary exam. They don't reduce the need for less-stressful handling or a less-stressful environment; rather, the medications are tools to prevent the damaging effects of stress-increased heart rate, struggle that can lead to injury and retaining a memory of fear associated with the veterinary practice.
Before the profession developed greater awareness of the need for less-stressful veterinary care, the use of pre-visit medications was limited to strong oral sedatives such as acepromazine-one of the few oral sedatives approved for veterinary use (Editor's note: And we now know that it's not a great option for fear; here's why). Today, there are recommendations for other medications such as trazodone, gabapentin, alprazolam and clonidine. These medications are not veterinary-approved and are used off label. There are few if any documented studies of how any of these drugs affect behavior.3
It's therefore important to know your drugs and how effective they are for modifying specific behaviors. Trazodone is a popular drug to reduce physical activity, but it's not a sedative. In other words, it will not by itself prevent a dog from lunging up to bite you. Alprazolam will help reduce fear but may disinhibit aggression. When prescribing these medications, tell the client why you've chosen a certain drug and what to expect as the response. It's best to have the client give a trial dose to see the effect on the animal.
Why clients might be resistant
A number of clients are resistant to pre-visit medications, for varying reasons. Many have been prescribed the same drugs we would like to use for their pet, and if the client didn't like how the medication made them feel, they'll naturally be concerned that their pet will have the same experience. Asking a client to sign a waiver for off-label drug use can also cause concern. And some clients simply don't want their pet to be affected for hours when the medication is needed for just a 15-minute appointment.
Take the time to ask the client why they're hesitant about a medication. Listen more than you speak. Then suggest an option that addresses what they're fearful about. For example, if the client is afraid of how the medication will affect the pet, offer day care and give the trial dose at the clinic. You can observe the response, take a video to show the client-you may be able to provide the care that day as well. You can also empathize with clients who worry their pet will feel as weird as they did on a med. Discuss the differences in animal and human metabolism.
It's possible you may not have an answer to the client's specific fear. Even so, you'll often influence someone to take your recommendation just by listening attentively and compassionately.
A plan for minimizing medications-with limits
So what should you do if the client is still drug-resistant after that initial conversation? The first step is to strictly follow low-stress care practices. Know the handling techniques-how to immediately recognize triggers and eliminate or reduce them. Early use of pheromones and transmucosal pain medication or topical anesthetic will work quickly to reduce aggression and anxiety. (Even drug-resistant clients often accept these forms of medication as they are immediate, short-acting and local to the source of pain.)
Be sure to verbalize what you're seeing in the animal's response to touch and examination. This is how you educate your client about your efforts both to reduce stress and to recognize the body language of stress in our patients.
In my practice, about 85% of patients experience reduced signs of anxiety and aggression without needing medication when we follow the principles of Low Stress Handling. The remaining 15% still need medication or supplements to provide mental calming. Verbalizing what we see, and pet owners' witnessing our adaptation to the patient to reduce the stress, helps our clients understand why medications or supplements are still needed for care.
But many of my clients are still drug-resistant. Why? It may be the rural, small-town, conservative approach to life here in Tuscola, Illinois, where I live. Many farmers tough out injuries-so why can't their animals do the same?
In these cases I often find that a supplement will overcome the client's drug resistance and reduce anxiety and mild aggression in the patient. The supplement does not have the potential side effects a drug would, won't cause disinhibition of aggression and is more readily accepted by the client than a prescription drug.
We also create a clear, specific outline on how the client should prepare for the exam. Scheduling appointments during a quiet time in the practice, fasting the patient and bringing its favorite treat along are all important components of the plan.
But there are still a handful of patients who need meds for their welfare and ours. The supplements and plan are not enough to prevent bite risk. And this is where I draw the line on drug-resistant clients-when either patient or staff safety is at risk. If a dog or cat is struggling, urinating or cowering despite receiving less-stressful veterinary care, I will stop everything and require my staff to stop as well. I tell the client that this experience is harming the patient's heart and joints and creating a firm memory indicating that it needs to stay panicked or aggressive.
If the client still will not accept the need for medication, then I refuse care. I often mention the $350,000 average educational cost to create a DVM or $50,000 cost to create a licensed technician and note that my practice cannot afford to lose either.4 At this point, many clients agree to use the medications. If they don't, I refer them to a house call veterinarian.
We cannot force our clients to take our recommendations. We can ask why they are resistant and listen. We can think of ways to address the fears. In the end, my own negotiating position was this: The less medication I was allowed to use, the more I needed the client to cooperate by bringing in a prepared patient, scheduling when it was best for the pet (not the human), and being flexible with unusual areas for exams such as outside behind the dumpster.
We should not use medications as an excuse not to expand our Low Stress Handling knowledge. But creative, empathetic use of both less-stressful care and appropriate medications can help reduce client drug resistance.
1. Foote S. Job stress of veterinary staff in small animal practice. J Assoc Vet Tech Educ 2019;Summer:4-9.
2. Lloyd J. Minimising stress for patients in the veterinary hospital: Why it is important and what can be done about it. Vet Sci 2017;4(2):22.
3. Shell L. Psychotropic agents; 2019. Merck Veterinary Manual website. www.merckvetmanual.com/pharmacology/systemic-pharmacotherapeutics-of-the-nervous-system/psychotropic-agents. Accessed Sept. 12, 2019.
4. AAVMC cost comparison tool; 2019. Association of American Veterinary Medical Colleges website. www.aavmc.org/students-applicants-and-advisors/exploring-the-cost-of-a-veterinary-medical-education.aspx. Accessed Sept. 12, 2019.
Dr. Sally J. Foote is a certified animal behavior consultant with expertise in Low Stress Handling. She has practiced in general medicine for over 30 years, including ownership of Okaw Veterinary Clinic in Tuscola, Illinois, one of the first Low Stress Handling Certified Clinics in the United States, where she developed a medical record system for recording the positive reinforcers for the veterinary exam. Dr. Foote is also past president of the American Veterinary Society of Animal Behavior and executive director of Cattle Dog Publishing, the legacy of Dr. Sophia Yin.