1. Pain Management for Dogs and Cats
Heather Lindell
PharmD, BSPH, RPH, DICVP, FSVHP
University of Georgia

2. Disclosures
Heather Lindell “declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.”
The American College of Apothecaries is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

3. Learning Objectives
At the conclusion of this program, the participating pharmacist or technician will be able to:
Describe signs associated with two sites of pain in the dog.
Explain the challenges faced when assessing an animal for pain.
List three drugs commonly used to treat pain in dogs and cats.
Describe toxicities noted in animals associated with pain medications.
Discuss the legalities associated with extralabel drug use in animals
Counsel the animal caregiver with medication safety use tips when using pain medications in animals.

4. Definition of Pain in Animals
Pain in animals has been defined as “an aversive sensory and emotional experience representing an awareness by the animal of damage or threat to the integrity of its tissues; it changes the animal’s physiology and behavior to reduce or avoid damage, to reduce the likelihood of recurrence and to promote recovery; unnecessary pain occurs when the intensity or duration of the experience is inappropriate for the damage sustained or when the physiological and behavioral responses to it are unsuccessful at alleviating” the pain.
V. Molony, J.E. Kent, Assessment of acute pain in farm animals using behavioral and physiological measurements. J Anim Sci 1997, 75:

5. Types of Pain Two Components of Pain Sensory Affective
Neural processing of noxious stimuli (nociception)
Affective
Unpleasant sensory and emotional experience (pain perception)
Journal of Feline Medicine and Surgery 2015, 17:

6. Types of Pain Two Common Pain Categories Acute Chronic
Does not outlast the healing process (3 months)
Chronic
persists beyond the expected healing time for an injury
V. Molony, J.E. Kent, Assessment of acute pain in farm animals using behavioral and physiological measurements. J Anim Sci 1997, 75:

7. Types of Pain Terminology
Inflammatory Adaptive Pain
Nociceptive Adaptive Pain
Pathological/Maladaptive Pain
Neuropathic Pain
___Hypersensitivity to pain such as hyperalgesia and allodynia that can result from severe nerve and tissue damage (windup pain)
___Activation of the immune system in response to injury, infection or surgery
___Neural signals in response to external noxious stimuli (heat, cold)
___Caused by lesions or dysfunction of the nervous system C A B D

8. Pain Assessment Pain assessment is the “fourth vital sign”
Pain scoring tools
Acute ≠ Chronic
Canine ≠ Feline
Journal of Feline Medicine and Surgery 2015, 17:

9. Pain Assessment Challenges of Pain Assessment Nonverbal patients
No gold standard
Varying degrees of validation
Behavioral differences
Coping mechanisms

10. Time for a… ?

11. The most accurate method for evaluating pain in animals is;
Force plate analysis
Observation of behavior
Analysis of physiological parameters
Monitoring heart rate
All of the Above
None of the Above

12. Pain Assessment Behavioral Keys to Consider Maintenance Loss
Development
Photo by Jennifer Lindell
Journal of Feline Medicine and Surgery 2015, 17:

13. Common Sites & Signs of Pain
Aural
Ocular
Oral
Gastrointestinal
Neurological
Dermal
Musculoskeletal
Urogenital
Photo by Jennifer Lindell

14. Time for a… ?

15. A sign of pain in a feline may include;
Failure to groom
Inappetence
Urinating outside of the litterbox
A and B Only
All of the Above
None of the Above

16. Treatment of Pain Approach to Pain Management (PLATTER) PLan
Pt specific pain assessment and treatment plan
Anticipate
Preventative or treatment
TreaT
Treat based on type, severity and duration
Evaluate
Evaluate efficacy and appropriateness
Return
Follow-up
Journal of Feline Medicine and Surgery 2015, 17:

17. Treatment of Pain Advantages of Pain Medications
Successful Case Outcomes
Enhanced Quality of Life
Limit Further Damage
Life Sparing
VCPR

18. Treatment of Pain Applications of Pain Medications
Pre, Intra and Post Surgery
Pre and Post Procedure
Acute Management
Chronic Management

19. Time for a… ?

20. A multimodal pain strategy involves;
Delaying pre-operative pain-modifying medications
Medicating many animals at one time
Using a post-operative pain-modifying medication
Using more than one class of pain-modifying medications

21. Treatment of Pain Advantages of Multimodal Strategy
Targets Multiple Sites in Pain Pathway
Potential Lower Dose
Minimize Side Effects
Journal of Feline Medicine and Surgery 2015, 17:

22. Treatment of Pain
Prescribed Pharmacologic Pain-modifying Therapy Pharmacists Likely to Dispense
Controlled Substances
NSAIDs
Corticosteroids
Neuropathic Pain-modifying Medications

23. Treatment of Pain
Pharmacologic Pain-modifying Therapy Pharmacists May Get a Prescription For
Controlled Substances
Fentanyl
Hydrocodone/Acetaminophen
Buprenorphine
Tramadol

24. Treatment of Pain
Pharmacologic Pain-modifying Therapy Pharmacists May Get a Prescription For
NSAIDs
Carprofen
Deracoxib
Etodolac
Firocoxib
Grapiprant
Meloxicam
Robenacoxib
Photo by Jennifer Lindell

25. U.S. Approved ORAL NSAIDs for Dogs and/or Cats
Treatment of Pain
U.S. Approved ORAL NSAIDs for Dogs and/or Cats
Medication
Canine
Feline
Carprofen
Deracoxib
Etodolac
Firocoxib
Grapiprant
Meloxicam
Robenacoxib
Photo by Jennifer Lindell

26. U.S. Approved ORAL NSAIDs for Dogs and/or Cats
Treatment of Pain
U.S. Approved ORAL NSAIDs for Dogs and/or Cats
Medication
Acute
Chronic
Carprofen
Deracoxib
Etodolac
Firocoxib
Grapiprant
Meloxicam
Robenacoxib
Photo by Jennifer Lindell

27. Treatment of Pain
Pharmacologic Pain-modifying Therapy Pharmacists May Get a Prescription For
NSAIDs
Ophthalmic
Flurbiprofen
Diclofenac

28. Treatment of Pain
Pharmacologic Pain-modifying Therapy Pharmacists May Get a Prescription For
Corticosteroids
Prednisone
Prednisolone
Fluticasone
Journal of Feline Medicine and Surgery 2015, 17:

29. Treatment of Pain
Pharmacologic Pain-modifying Therapy Pharmacists May Get a Prescription For
Neuropathic Pain-modifying Medications
Amantadine
Gabapentin
Tricyclic Antidepressants
Journal of Feline Medicine and Surgery 2015, 17:

30. Treatment of Pain
Other Pain-modifying Therapies Veterinarians May Use in Clinic
Weight Management
Acupuncture
Physical Rehabilitation
Thermal Modification
Laser Therapy
PSGAG
Feline anti-NGF antibody (NV-02)
Stem Cell Therapy

31. Treatment of Pain
Non-Pharmacologic Pain-modifying Therapy Pharmacists May Get a Request For
Nutritional Supplements
Wraps
Gentle Handling Techniques
Pet Food

32. Treatment of Pain Pet Food Read Veterinarian’s Treatment Sheet
Life Stage of Animal
Breed and Activity Level
Clinical Condition of the Animal

33. Treatment of Pain Pet Food United States Pet Food Label Requirements
Principal Display Panel
Product Name
Designator
Net Weight
Information Panel
Ingredient Statement
Guaranteed Analysis
Nutritional Adequacy Statement
Feeding Guidelines
Manufacturer or Distributor

34. Time for a… ?

35. A pain medicine commonly used in humans that can be fatal to a feline after one dose is;
Meloxicam
Aspirin
Acetaminophen
Hydrocodone
None of the Above

36. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
Acetaminophen
Felines
Methemoglobinemia
Aspirin
Felines and Canines (used cautiously)
GI Ulceration, Nephrotoxicity

37. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
Benzocaine
Felines
Methemoglobinemia
Phenazopyridine
Felines and Canines
Canines
Hepatotoxicity and rhabdomyolysis
Keratoconjunctivitis sicca

38. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
NSAIDs to avoid
Propionic Acid Derivatives
Ibuprofen
Naproxen
Pyrazolon Derivatives
Phenylbutazone

39. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
NSAIDs to avoid
Ibuprofen
Dogs
GIU > 50mg/kg Acute, >5mg/kg/day Chronic
ARF >175mg/kg
CNS > 400mg/kg
Cats
Half the dose of dogs and ARF most common

40. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
NSAIDs to avoid
Naproxen
Dogs
GIU & ARF > 5mg/kg
Cats
More sensitive than dogs to toxicity

41. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
NSAIDs to avoid
Phenylbutazone
Dogs
GUI
ARF
Blood dyscrasias
Cats
Cats more sensitive than dogs

42. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
NSAIDs to avoid
FDA warning of topical flurbiprofen
FDA Warns of Illnesses and Deaths in Pets Exposed to Prescription Topical Pain Medications Containing Flurbiprofen
April 17, 2015

43. Toxicities and ADEs of Pain-modifying Agents
Active Ingredient
ORAL NSAIDs lab test recommendation
Medication
Carprofen
Deracoxib
Etodolac
Firocoxib
Grapiprant
Meloxicam
Robenacoxib
“All dogs (cats) should undergo a thorough
history and physical examination before the
initiation of NSAID therapy. Appropriate
laboratory testing to establish hematological
and serum baseline data is recommended
prior to and periodically during administration
of any NSAID.”

44. Time for a… ?

45. Toxicities and ADEs of Pain-modifying Agents
Which excipient can be found in commercially available gabapentin solution that can cause hypoglycemia and hepatic toxicity in dogs?
Sucrose
Methylparaben
Xylitol
Maltitol

46. Legalities Laws to Live by… FDA-CVM USDA-CVB EPA DOJ- DEA
State Board of Pharmacy
State Board of Veterinary Medicine

47. Legalities
Animal Medicinal Drug Use Clarification Act of 1994 (AMDUCA)
ELDU
VCPR
Compounding
Prohibited List

48. Legalities Extralabel Drug Use (ELDU) VCPR Assumes Responsibility
Sufficient Knowledge
Available for Follow-up

49. Legalities State Law Prescription Requirements VCPR
Legitimate Medical Purpose
Photo by Jennifer Lindell

50. Legalities Show Animal Considerations (Dogs) AKC July 2016 Rule Book
“A dog is considered changed in appearance by artificial means if it has been subjected to any type of procedure, substance or drugs that have the effect of obscuring, disguising or eliminating any congenital or hereditary abnormality or any undesirable characteristic, or that does anything to improve a dog’s natural appearance, temperament, bite or gait. Even procedures, substances and drugs which are absolutely necessary to the health and comfort of a dog shall disqualify that dog from competition if the former had the incidental effect of changing or even improving the dog’s appearance, temperament, bite or gait.
There may be cases in which a veterinarian has prescribed some drug as being necessary for the health of a dog. In such cases, the veterinarian’s advice should be followed, but the dog should be withheld from competition in dog shows until all possible effects of the drug have worn off.”

51. Legalities Show Animal Considerations (Cats)
The Cat Fanciers’ Association Rule Book
“The plucking of buttons or lockets; the use of any device, substance or chemical; e.g. tranquilizer, hormone, anti-histamine, that will alter the natural actions or appearance of a cat or kitten, is forbidden including the surgical alteration to the cat’s anatomy such as cropped or stapled ears, docked or shortened tails. Evidence of such, as determined by the personal opinion of the judge, will result in the immediate disqualification of the entry in that ring.”

52. Legalities
Case Study
A client comes to your window and says she thinks her cat needs some human labeled OTC aspirin for her cat because she noticed her cat limping today. She said she read online that this is used short term for cats. You would;
Look up the cat dose for aspirin and tell her to use the human labeled OTC aspirin in her cat.
Look up the cat dose for aspirin and tell her you will compound it for her since she would need a smaller, measurable dose.
Suggest she use OTC ibuprofen instead.
Refer her to the cat’s veterinarian.

53. Legalities Case Study Refer her to the cat’s veterinarian
Remain compliant with AMDUCA
ELDU
VCPR

54. Compounding Need for Compounding No Product Available
Increase Compliance
Photo by Jennifer Lindell

55. Compounding Compounding Considerations Best Interest of Animal Safety
Effectiveness
Stability
Similar Product
Pharmacogenomics

56. Compounding Review of <795> Nonsterile Compounding Simple
Moderate
Complex

57. Compounding Review of <795> BUD in Absence of Stability Data
Nonaqueous Formulations
6 months or not later than time remaining on API
Aqueous Oral Formulations
14 days when stored at controlled cold temperatures
Aqueous Topical/Dermal, Mucosal Liquid and Semisolid Formulations
< 30 days
USP-NF May 1, 2011 update

58. Compounding Case Study
Fluffy the 3.8kg male neutered cat went to the vet for a dental cleaning and possible extractions. Fluffy had dental scaling to remove dental tartar, dental polishing, and three infected, loose teeth extracted.
Pain management for surgery given in the veterinary office included multimodal injectable therapy of ketamine, hydromorphone, diazepam and meloxicam. Fluffy also received two local anesthetic blocks (right maxillary and left inferior alveolar) with bupivicaine.
What pain therapy might you recommend for Fluffy after this extensive dental procedure?

59. Compounding Case Study
The DVM prescribed 0.01mg/kg of buprenorphine 0.3mg/mL to be given buccally every 6 to 8 hours as needed to control pain for 3 to 5 days.
Products available;
Injectable buprenorphine 0.3mg/mL
Compounded buprenorphine 0.3mg/mL

60. Compounding Case Study Buprenorphine 0.3 mg/mL Buccal Solution
Final Volume (mL)
Buprenorphine 2 mg 1 2
Deionized Water (mL)
Syrpalta (mL) 6 12
Dissolve desired number of tablets in corresponding amount of deionized water (see chart above)
Add necessary amount of Syrpalta to make final volume needed (see chart above)

61. Resources and References
Looking Up Pain-Modification Doses for Dogs and Cats
Donald C. Plumb. Plumb’s Veterinary Drug Handbook
Mark G. Papich. Saunders Handbook of Veterinary Drugs
Merck Veterinary Manual
Compendium of Veterinary Products.

62. Resources and References
Looking Up Toxicities
Lynn R. Hovda, et al. Small Animal Toxicology
MICROMEDEX® Solutions. POISINDEX ®
Pet Poison Helpline.
The American Society for the Prevention of the Cruelty to Animals (ASPCA)

63. Resources and References
Reporting ADEs
Call the Company
FDA-CVM, Form FDA 1932a.

64. Resources and References
Looking Up reported ADEs
Package Insert
FDA-CVM Cumulative Adverse Drug Event (ADE) Summaries Report

65. Conclusions Counseling Tips for NSAIDs
Review patient’s medication profile. Check drug interactions such as concurrent use of steroids which can increase the likelihood of an adverse event. Call veterinarian if a potential interaction is found.
Add labeling to prescription bottle such as “Do not give with other non-steroidal anti-inflammatory or steroid medicines unless instructed by and under the supervision of veterinarian.”
Review patient’s disease state profile. Ensure checkups and laboratory tests at veterinarian’s office are being performed.
Add labeling to prescription bottle such as “Discontinue medicine and call veterinarian if vomiting, dark/tarry stools or decreased appetite occur.”
Utilize package client information sheets or FDA-CVM CISs

66. Conclusions Counseling Tips
Use only as directed by and in/on the animal prescribed by the veterinarian.
Keep the products stored in a safe place away from children, animals and other human drug products.
Add labeling to the bottle “FOR ANIMAL USE ONLY.”
Dispose of unused medications in a safe manner away from the reach of children and animals.
Consult veterinarian before adding any other drug products, including over-the-counter products.
Recognize behavior changes in your pet.
Call veterinarian if side effects are noted.

67. Conclusions Counseling Tips
Enrich the pet’s environment to encourage activity.
Gently use slings to help your pet maneuver.
Cover slippery floors with texture.
Add ramps or steps up to the pet’s favorite bed or windowsill.
Use raised food and water dishes if indicated.
Use a litter box with lower sides.
Maintain a healthy diet for your pet recommended by your veterinarian.
Maintain recheck appointments so the veterinarian can reevaluate the patient and adjust the pain treatments as needed.

68. Time for your… ?

69. Need More Information?
Heather Lindell PharmD, BSPH, RPH, DICVP, FSVHP University of Georgia