Chapter 1
Advancing Veterinary Pain Management into a New Era

Patricia R. Zehna

The July 15, 2002, issue of the Journal of the American Veterinary Medical Association published an article authored by Benjamin Howard, MD, MPH, regarding the course of a human neonate pain management case. It was a call for pain management for those who have no voice and pointed out not only the medical but also the ethical reasons that we must ensure appropriate pain management for our patients.

A landmark case that established greater pain management practices took place in 1985. Jeffery Lawson, a 1-lb, 11-oz neonate, was operated on to correct patent ductus arteriosus and did not receive anesthesia for his operation (Lawson 1986). When he died a month later, his mother reviewed his medical record and discovered this fact. Jeffrey's neonatologist had reassured her at the time of the operation that he would receive anesthesia. She was moved to confront this practice and wrote of his account,

Jeffrey had holes cut in both sides of his neck, another cut in his right chest, an incision from his breastbone around to his backbone, his ribs pried apart, and an extra artery near his heart tied off. This was topped off with another hole cut in his left side for a chest tube. This operation lasted hours. Jeffrey was awake through it all. The anesthesiologist paralyzed him with a curate drug (pancuronium bromide) that left him unable to move, but totally conscious. When I questioned the anesthesiologist later about the use of this drug, she said that Jeffrey was too sick to tolerate powerful anesthetics. Anyway, she said, it has never been demonstrated that babies feel pain. Her neonatologist described the lack of anesthesia for surgery as based on "ignorance, hubris and barbarism". When her account was published in The Washington Post in August 1987, there was a public outcry and other parents spoke of their experiences. The routine practice of administering little to no analgesia for surgery in premature and critically ill infants caught the attention of the public and became a social issue.

(Lee 2002, p. 234)

While this is difficult to read, it is a very good illustration of our responsibility to provide appropriate pain management not only because it is the right thing to do for our patients, both medically and ethically, but also because their owners, our clients, trust us to protect their pets. They expect that we will follow the first axiom of medicine "first do no harm," and they assume that we are making their pets as comfortable as possible.

Each of our perspectives about the current status of pain management will differ due to a number of factors. We are influenced by the branch of medicine in which we chose to practice, the level of medical advancement where we work, the amount of time that we have practiced medicine, and even our own personal experiences with pain and pain management.

We are entering a new era of pain management in veterinary medicine and face the obstacles that go along with introducing new concepts. Many of the obstacles that we face are common to the human side of medicine; therefore, our research often overlaps.

The International Association for the Study of Pain defines pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment" (IASP 1994). In 1999, the Veteran's Administration declared "war" on pain by making it their fifth vital sign (Flaherty 2001). Since this time, veterinary organizations have tried to adopt pain as the fourth vital sign.

Several organizations have published "guidelines" for pain management in veterinary patients:

• The American College of Veterinary Anesthesiologists' position paper on the treatment of pain in animals (http://www.acva.org/docs/Pain_Treatment).
• AAHA/AAFP Pain Management Guidelines for Dogs & Cats (https://www.aahanet.org/Library/PainMgmt.aspx).
• International Veterinary Academy of Pain Management (IVAPM) has several position statement papers that are being prepared for peer review (www.ivapm.org).

We need to be aware of what is contained in each document so we can share ideas with our colleagues about how to implement this advice.

Although there have been many advances in human medicine, this excerpt from a 10-year-old medical journal is revealing about the pace at which medical professionals feel change is actually taking place.

"The evidence that physicians and nurses do not treat pain adequately began to appear in the medical literature nearly 30 years ago. In the following decades, the accumulated data showed that many types of pain- acute pain, cancer pain, and chronic nonmalignant pain- were being undertreated. The reasons offered for under-treatment usually characterized as 'barriers' to effective pain relief, were remarkably consistent across the literature. Despite numerous calls to educate health care professionals about pain management, only the rhetoric has expanded

(Rich 2001, pp. 151-152)".

Overcoming the Obstacles to Pain Management

There are many obstacles to effective pain assessment and administration. Some of these exist with good reason, and some are outdated ideas, habits, or lack of education. Veterinary technicians must have a good working knowledge of these obstacles so they can overcome them and advocate for their patients. We carry the responsibility to impart this knowledge to other hospital team members and provide accurate client education. As an educator and patient advocate, the technician is the solution to breaking down the barriers to effective pain management and raising awareness on behalf of their patients.

Veterinary technicians/nurses play an integral role in overcoming obstacles to pain management. An often referenced 1998 Canadian study revealed that veterinary practices that have trained veterinary technicians on staff practice better pain management. The quality of pain management in fact increased proportionately with the number of licensed technicians on staff and relative to the amount of continuing education (CE) the technicians received (Dohoo and Dohoo 1998).

Examining common obstacles is a good start in developing programs with which to educate our colleagues and clients.

Common Obstacles

• Inadequate knowledge of pain mechanisms and pain management options
• Difficulty with pain assessment
  • Pets mask pain
  • Wide variation between breeds and species
  • Objective tools are not available
• Fears about analgesic side effects and how to manage them
• Failure to make pain assessment and management a priority for every patient
  • Poor communication between staff members
  • Lack of a systematic and collaborative approach to pain assessment and management
  • Lack of consistent pain management protocols
  • Absence of accountability for pain management
• Client-related issues
  • Failure to recognize pain signs
  • Difficulty administering medications
  • Cost of pain medications and/or other treatment modalities

Knowledge

The technician/nurse can help identify specific ways in which to help facilitate the practice in overcoming these obstacles. Each member of the team should have not only a clearly defined role within the pain management team but also be given the knowledge with which to effectively carry out their role.

Pain mechanisms and pain management options can be better understood through required study of materials provided by the hospital. This can begin as part of an orientation and continue with on-the-job training and CE.

Each practice should have at least one technician who is assigned to oversee pain management education and ensure the hospital remains current with new research and recommendations.

The functions of the pain management technician/nurse should include:

• Providing CE opportunities on a regular basis either in house or utilizing other resources such as online CE, veterinary conferences, and local professional meetings.
• Hands-on training in pain recognition/differentiation including the use of pain scales and scoring systems.
• Leading the team in the research of pain management topics and techniques in order to keep the practice current and have scientific data available to support requests for pain management to the veterinarian(s).
• Acting as a liaison, meeting regularly with the veterinarian(s) in order to form a collaborative effort between the veterinarian(s) who carries the ultimate responsibility for pain management decisions and the support staff who provide frontline nursing care and therefore are usually the first to note changes in patient status. This will help the veterinarian(s) to make decisions regarding staff and their specific roles in regard to pain management decisions.
• Developing pain management protocols with the veterinarian(s) approval and systems of accountability for pain management and record keeping.

Larger hospitals may benefit from a pain team with several individuals (veterinarians and technicians) who partner to bring pain management to all patients in the practice. (See last section on forming a pain...