Pain in the ...
After multiple gum grafts, I can tell you that oral surgery is much more painful than childbirth. In addition, my daughter recently had her wisdom teeth extracted, and I was totally appalled at the cavalier attitude that her oral surgeon took regarding pain management (my first periodontist had the same attitude, but the one I have now totally gets good pain control!). Now, I realize that I don’t deal with pain management the way surgeons and anesthesiologists do, but I think veterinarians are much more cognizant of pain management than most of our human counterparts. As a profession, we have come a long way in understanding and managing pain, and this week, I want to talk a little about what we have learned.
We used to use the terms “acute” and “chronic” pain, but this refers strictly to time. The more current terms used to describe pain are “adaptive” and “maladaptive”. Adaptive pain is pain that serves a biological purpose of signaling actual or impending tissue damage. Maladaptive pain is basically the nervous system gone haywire. This means that the pain persists even after the problem has resolved, or the pain is much worse than expected.
There are really 3 principles for pain management. First, pain control is good medicine. When animals (including people) become painful, it induces a stress response in the body. This leads to increased cortisol release, decreased GI motility, sodium retention, and ultimately decreased healing. Prolonged stress is detrimental to every organ system in the body. So, patients that are non-painful and comfortable have better illness outcomes than patients that are painful.
The second principle for pain management is plan for continuous pain control. If lapses in pain control occur, patients can experience “wind up.” Then, it can be difficult to gain good pain control again because “wind up” leads to maladaptive pain.
The third principle for pain management is multimodal therapy makes for better pain control. Basically, we need to incorporate drugs with different mechanisms of action to achieve the best results. We can use NSAIDs, opioids, nutraceuticals, acupuncture, laser therapy, and pulsed electromagnetic field therapy.
Non-steroidal medications (NSAIDs) are the cornerstone of pain management. They reduce pain associated with inflammation. In fact, they are the only class of pain medication that reduces inflammation. They can’t be given to patients with gastric ulcers, and they can adversely affect kidney and liver function, requiring periodic monitoring of lab work with chronic use. There are multiple good veterinary NSAIDs on the market including Deramaxx®, Previcox®, and meloxicam.
Opioids provide the greatest amount of analgesia as a class of drugs. Within this class, the different drugs provide varying degrees of sedation versus pain control. Some of the drugs are completely reversible, and others are not. Opioids always slow the heart rate, but generally, they don’t decrease the contractility of the heart, output of the heart, or perfusion of blood from the heart. Drugs in this class include fentanyl, hydromorphone, oxymorphone, morphine, methadone, butorphanol, and buprenorphine. These are all controlled drugs, and they must be used with caution because of the potential for human abuse.
Nutraceuticals can be beneficial in long-term pain management. These products include glucosamine, chondroitin, MSM, and green-lipped mussel. Unfortunately, most of these products take days to weeks to see the full effects. Obviously, some products will work better than others, and unfortunately, there is no regulatory body for the manufacturing of nutraceuticals. Here are some websites where you can check on specific products: www.consumerlab.com, http://nccam.nih.gov, and www.quackwatch.com.
Acupuncture has been used for centuries to treat pain as well as a wide variety of other conditions. There is no single mechanism to explain why acupuncture works, but it is likely the interaction of the nervous system, endocrine system, and immune system.
Laser therapy is often referred to a cold laser, soft laser, or laser acupuncture. This uses low power lasers to alter cellular function. Therapeutic laser has been shown to be useful in treatment of acute pain associated with osteoarthritis and tendinopathy.
Pulsed electromagnetic field therapy uses electric current to promote healing. This treatment modality works by affecting calcium binding in the body which leads to the production of nitric oxide. Nitric oxide decreases pain, improves blood flow, and reduces edema.
To wrap this up, pain management is good medicine. We need to customize a pain treatment plan to fit each individual’s need. Continuous control of pain is extremely important to prevent “wind up” and maladaptive pain, which is difficult to bring back under a patient’s pain threshold. Usually, an NSAID and opioid work best when paired together, and by incorporating other pain management modalities such as nutraceuticals, acupuncture, laser therapy, and pulsed electromagnetic field therapy, we can enhance pain control and promote healing.
