Front Matter

480 Canine Sports Medicine and Rehabilitation

It is important to be mindful that there is rela-
tively little evidence‐based veterinary medicine
(EBVM); thus, guidance with regard to complex
clinical choices is in short supply. It is both the
blessing and the curse of contemporary medi-
cine that there exists an impressive array of
tools in the pain management toolbox.
What drug(s) shall we use? In what order? In
which combinations? For which type of pain? At
what dose? For how long? For these and many
other variables there are no simple answers in the
veterinary literature. The competing values of a
best evidence approach, personal experience,
and client values (preferences) will always be in
dynamic tension (Sackett et al., 1996) (Figure 19.1).
Pain is further complicated for veterinarians
as our patients are nonverbal, mirroring the
challenge in human medicine with nonverbal
subpopulations: neonates (Schechter, 1989), the
cognitively impaired (Cook et al., 1999), and the
elderly (Lovheim et al., 2006). In verbal patients,
pain is what the patient says it is; in nonverbal
patients, pain is what we say it is.
These collective challenges were recently
addressed by two industry expert panels and
their recommendations published in separate
comprehensive manuscripts to which the
reader is referred: the 2015 AAHA/AAFP Pain
Management Guidelines (Epstein et al., 2015), and
the WSAVA Global Pain Council’s Guidelines for
Recognition, Assessment, and Treatment of Pain
(Matthews et al., 2014). Clinicians often limit

pain medications for fear of adverse drug

effects (ADEs) or interactions (Belshaw et al.,

2016). Yet we must also consider the harm to the

patient if pain is inadequately managed. We

have an ethical obligation to minimize pain in

our patients, and to recognize negative medi-

cal, physiological, emotional, and even cogni-

tive consequences—the multidimensional

negative experiences—that are a direct result of

undermanaged pain.

Pain elicits a cascade of debilitating neuro-

hormonal effects that includes hypertension,

catabolism, immunosuppression, and worse.

With undermanaged pain, surgical patients

heal and recover more slowly, and may develop

chronic pain states and even severe, life‐threat-

ening complications (Anand & Hickey, 1992).

Chronic pain in humans is associated with cog-

nitive impairment including learning and

memory (Kreitler et al., 2007), and is comorbid

with clinical depression. For dogs, in the

extreme, underrecognized, underattended,

undermanaged pain can become a criterion for

euthanasia.

We know much about optimal pain manage-

ment in animals, but what we think we know is

dwarfed by what we do not. Literature must be

read critically, and any recommendations about

protocols, including those in this chapter, must

be considered analytically, with an open

mind  towards the viewpoints of others and a

commitment to continued learning.

Multimodal approach to pain

management

The principle is simple: relying upon one

modality or drug requires higher doses and/or

more frequent and/or prolonged administra-

tion to achieve the desired effect, while mini-

mizing the potential benefit and maximizing

the possibility of ADEs (Figure 19.2). With mul-

tiple modalities each affecting different aspects

of pain processing, including elements of cen-

tral and peripheral hypersensitization, require-

ments for each drug are reduced while achieving

superior effect and minimizing ADEs. Though

difficult to study, there is growing evidence in

the veterinary literature that this principle

applies in both the acute (Brondani et al., 2009)

and chronic (Fritsch et al., 2010) pain setting.

Individual

clinical

expertise

Best

external

evidence

Evidence

based

medicine

Patient values

& expectations

The EBM triad

Figure 19.1 Evidence, experience and client
expectations must all be addressed in pain management.