Inside the multimodal pain toolbox for patients

Pain management is a team approach; it takes the client, professionals, and patients to help ensure that pain treatment and management are possible. So it is important for them to have the right toolbox.

In the blurb from a recent episode of The Vet Blast Podcast presented by dvm360, host Adam Christman, DVM, MBA, and Matthew W. Brunke, DVM, DACVSMR (Canine), CCAT, Fellow IVARPT, took a deep dive into what exactly a multimodal approach means, why exactly arthritis is painful, and more.

Adam Christman, DVM, MBA: We throw out the [phrase] “multimodal approach” [in] pain management a lot. And I feel like—from my colleagues [who] are generalists like me—we think…are we going to do a [nonsteroidal anti-inflammatory drug], a nutraceutical, and maybe we just stop there? So walk us through…some of the options that are out there.

Matthew W. Brunke, DVM, DACVSMR (Canine), CCAT, Fellow IVARPT: Let's start off with my favorite field, which is arthritis. We can blend back into multimodal for other things, but multimodal—at its heart—is a team approach. You have to look at the whole patient. You can't just say, “Hey, here's a pain medication.” We know there are 4 or 5 different pain pathways. We know there are different levels. Are we having pain at the level of the surgical site—or arthritic joint, in this case—or is it more pain perception up in the brain and along those areas? So we need a team approach, and that may…take a little…longer. So we just have to figure out what the patient really needs and then address the patient as a whole.

Christman: Yes. And you recently just wrote a paper on joint injections, right?

Brunke: So there's a great article—well, I thought it was great. We had really good team effort from 2 of my interns, Emma J. Fralin, DVM, and Gabriela M. Medrano Valencia, DVM, CVA. Both helped me with a paper [about] the latest evidence of joint injections for managing arthritis that was in dvm360 just recently.²

Christman: What does that entail? What does it talk about?

Brunke: So that's really cool, right? And thanks for this, Adam. Look, the standard of care in horses for managing arthritis and synovitis, which we're going to get into in a minute, is joint injections. The standard of care for humans is joint injections. But nobody injects joints in small animals. I think that needs to change, because, Adam, did you get into vet med to push pills?

Christman: No.

Brunke: Did you get into vet med to euthanize animals over arthritis?

Christman: Oh gosh, no.

Brunke: OK. There was a study out of the UK that [showed that] 40% of dogs in the study were euthanized just because they [had] arthritic pain that couldn't be managed.

Christman: Oh gosh.

Brunke: So we need to be thinking about joint injections as internally targeted therapy, right? We'll talk about some external targets like laser and shock wave as well, but…this is because I'm going to ask another fun question for everybody to think about. We all get taught that arthritis is a cartilage disease. Right, Adam?

Christman: Yes.

Brunke: OK, Adam. Back me up. You went to Iowa State [University]. I went to Ross [University]. But they also taught us that cartilage does not have nerve endings.

Christman: Right.

Brunke: OK. Adam, why is arthritis painful?

Christman: I don’t know, why?

Brunke: It's OK. I'm going to tell you why. The most amount of nerve endings are in the synovium, the joint capsule. We don't get taught that, so we have to think about the joint capsule as providing the microenvironment for a healthy joint. If we can keep the joint capsule happy, we can make better joint fluid, [and] we [can] have less pain [and] better mobility. So the whole root of it is [that] arthritis is not a cartilage disease [but] a synovial disease.

Christman: Well, I love that. So when we're doing these joint injections, Matt, we're going right into that…joint capsule.

Brunke: Exactly. We're doing them under sedation, because in human medicine, they're like, “Cool. Stare at the ceiling, and here's this big, giant needle. Also, drive yourself home.” We can't do that with our dogs and cats. I inject cat joints, too, for arthritis. We sedate them, find our landmarks, get some joint fluid out so we know we're in the joint, and we could always send that off to the lab if we need to.

But now we put in an injectable. What do we put in? Do we put in cortisone? Do we put in stem cells? Do we put in Synovetin? Do we put in Arthrosamid? Do we put in all these other things to address the microenvironment [at] that joint? And we put it right where it needs it.

Want to hear the rest of this conversation? You can listen here, or wherever you listen to podcasts.

References

1. McCafferty C. Modern multimodal pain management for patients. dvm360. September 30, 2025. Accessed February 19, 2026. https://www.dvm360.com/view/modern-multimodal-pain-management-for-patients
2. Fralin E, Valencia G, Brunke MW. Pain management in veterinary medicine: what’s new?. dvm360. September 10, 2025. Accessed February 19, 2026. https://www.dvm360.com/view/pain-management-in-veterinary-medicine-what-s-new-