2022 AAHA Pain Management Guidelines for Dogs and Cats

This is the executive summary of the 2022 AAHA Pain Management  Guidelines for Dogs and Cats. These updated guidelines present a practical and logical approach to the assessment and management of acute and chronic pain in canine and feline patients.

Executive Summary

Disclosure: These guidelines were prepared by a Task Force of experts convened by the American Animal Hospital Association. This document is intended as a guideline only, not an AAHA standard of care. These guidelines and recommendations should not be construed as dictating an exclusive protocol, course of treatment, or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to each individual practice setting. Evidence-based support for specific recommendations has been cited whenever possible and appropriate. Other recommendations are based on practical clinical experience and a consensus of expert opinion. Further research is needed to document some of these recommendations. Because each case is different, veterinarians must base their decisions on the best available scientific evidence in conjunction with their own knowledge and experience.

This executive summary provides selected highlights of the extensive information and recommendations in the guidelines. It is not a replacement for reading the guidelines in their entirety. For the full guidelines, see the AAHA website aaha.org/pain-management or the March/April 2022 issue of JAAHA.

These guidelines are supported by generous educational grants from Arthrex Vet Systems, Boehringer Ingelheim Animal Health USA Inc., Elanco, and Zoetis.

These updated guidelines present a practical and logical approach to the assessment and management of acute and chronic pain in canine and feline patients. Diagnostic guides and algorithms are included for assessment of both acute and chronic pain, and pain-assessment instruments for pet owners are described. Expert consensus emphasizes proactive, preemptive pain management rather than a reactive, “damage control” approach. The guidelines discuss treatment options centered on preemptive, multimodal analgesic therapies, with a tiered decision tree that prioritizes use of the most efficacious therapeutic modalities. The benefits of defined pain management roles for each practice team member and the value of client education are also discussed.

Key Takeaways

Train and prepare the whole veterinary team to understand and appreciate the procedures and diseases that can be associated with pain, and to proactively manage diseases early.

  • Engage the owner as a team member in recognizing and managing pain.
  • Use available tools and recommendations to assist with pain assessment.
  • Practice preemptive, multimodal management based on a tiered approach to pharmacological and nonpharmacological treatments.
  • Re-evaluate patients regularly and adjust treatment plans accordingly.

Pain management is presented as a therapeutic continuum consisting of assessment, treatment, reassessment, and plan revision. Two concepts underlying this approach are preemptive analgesia to minimize pain onset and nociceptive pathology, and a multimodal treatment strategy to offset over-reliance on any single drug with the attendant risk of side effects. The guidelines reflect that, with respect to chronic pain, most is known about the assessment and treatment of musculoskeletal pain (namely, osteoarthritis). The guidelines are not intended to provide all-inclusive pharmacologic information or a comprehensive review of feline-friendly handling techniques, nor do they attempt to present a comprehensive description of specific painful conditions.

Proactive pain management means understanding when pain may be present, proactively assessing for pain, and educating the veterinary team and pet owners about pain assessment. Ideally, a veterinary technician would serve as case coordinator to educate and engage clients. Patients would be reevaluated regularly or as necessary. To optimize adherence with veterinary recommendations, owners must understand the reasons for early intervention, and therapy should minimize the financial, physical, emotional, and logistical burden placed on caretakers.

Pain Assessment Toolbox

The pain assessment toolbox is based on the following principles:

  • The practice team must consciously create a shared approach to pain management and client communication, particularly for the assessment, interpretation, and explanation of acute and chronic pain.
  • The physical exam must extend beyond handling to include observation of posture, gait, and behavior.
  • Emphasis on behavioral observations, including those reported by the owner, will not increase the time needed for exams.
  • Across all principles, the assessment of pain is different between cats and dogs, requiring different tools, observations, and communication techniques.

GettyImages-1210600134.jpgWe must switch our focus from damage control pain management to proactive pain management.

These principles function with the knowledge that the presentation differs between acute and chronic pain, requiring a distinctly different approach for assessment and communication with pet owners.

For each species, an extensive table summarizes the various pain assessment methods and tools. This is followed by a flow diagram that represents a logical approach to assessing and monitoring acute or perioperative pain and chronic pain.

For cats (Table 1) and dogs (Table 2), the assessment methods and tools used include physical examination, clinic observation, physiological variables, wound palpation, home videos and photos, monitoring activity, and clinical metrology instruments (CMIs). For dogs (Table 2), force plate and pressure-sensitive walkways are also used. For each method or tool, the table indicates whether it is used for acute or chronic pain, who uses it (veterinarian, technician, owner, etc.), ease of use, purpose, and validity.

Flow charts following the tables (Figure 1 for cats, Figure 2 for dogs) provide separate flows for acute and chronic pain. The charts emphasize owner involvement as well as follow-up and reassessment.

Following each set of tables and figures is a discussion of factors that affect pain assessment in cats or dogs and recommendations for implementing pain assessment in practices.

Factors Affecting Cats and Dogs

Pain assessment for cats is based on evidence from physical examination (including observation of behavior), owner input (including that obtained from standardized questionnaires and video), and imaging as indicated. For assessing acute pain and postoperative comfort in the clinic, palpation and CMIs should be used. Although radiographic imaging may be used in diagnosis, when assessing pain, it is important to prioritize the cat’s behavior over radiographic findings. Note that, in the clinical setting, pain assessment is affected by the cat’s stress level. In contrast to acute pain, owner assessment of behavior has a central role in the detecting and monitoring chronic pain. The guidelines remind veterinarians to recognize the value of their observations throughout a clinic visit when assessing cats, particularly for chronic musculoskeletal pain.

Pain assessment for dogs ranges from functional signs evaluated by owners and physical signs detected by clinicians to physiological signs measured by researchers. In the clinic, acute and perioperative pain assessment includes appetite, observation of demeanor, behavior, and palpation. Musculoskeletal pain (e.g., osteoarthritis) is the most common form of chronic pain in dogs. Observation is a critical part of the veterinarian assessment of chronic pain.

Palpation is the most widely used clinical method to detect pain in dogs. Medical imaging can confirm a suspected problem, but joint pain on palpation and radiographic signs of osteoarthritis often correlate poorly. Screening tools and owner responses to open-ended questions can raise issues that warrant specific questions.

Implementing Assessment

Pain scores should be recorded and communicated with veterinarians. Rounds are used to ensure continuity of care and to update pain management. Over the long term, owners can be given screening checklists, with results recorded in the medical record and reviewed at each visit. Palpation of limbs and the spine should be routinely done. Changes over time provide the impetus for changes in pain management.

Pain Management Toolbox

The centerpiece of the pain management toolbox is an extensive, three-tier decision tree for prioritizing use of the most efficacious therapeutic modalities (see Figure 3 with this article, below). Setting the stage for the decision tree is a brief discussion of guiding principles for developing a therapy plan and for treating (1) acute pain resulting from a known cause and (2) chronic pain.

painmgmtgl_figure3.pngThe tiered decision tree provides a wealth of information in an easy-to-use format. The “tree” resembles a table with three horizontal rows labeled Tiers 1, 2, and 3. Column headings organize the recommendations for cats and dogs, for acute pain of known or unknown origin, and for chronic pain. Within the table, visual cues like different colors are used distinguish pharmacological from other treatments, and icons indicate whether a treatment option provides high impact or places a high burden on the pet owner.

Thus, for example, opioids appear as a Tier 1 pharmacological option for acute pain in dogs and cats, nonsteroidal anti-inflammatory drugs (NSAIDs) appear as a Tier 1 pharmacological option for chronic pain in dogs and cats, and both opioids and NSAIDs are marked as high-impact treatment options.

The tiered approach is based on review of evidence-based veterinary medicine, literature from human medicine, practical considerations, and the clinical experience of the guidelines’ advisory panel.

Tier 1 represents the highest recommendation (with most evidence for effectiveness), although all therapies in the decision tree have some evidence to support their use. Tier 1 treatments are considered the mainstay of pain management. Clinicians may start with Tier 2 treatments, especially in combination with Tier 1 approaches. For example, both NSAIDs (Tier 1) and therapeutic exercise (Tier 2) may be implemented.

Providing greater detail about the recommendations in the decision tree, Figure 3 is supplemented by a discussion of treatments for acute and chronic pain, a pharmacologic update, nonpharmacologic modalities, and special considerations for feline patients.

Recommendations for perioperative pain are clear and direct: An appropriate starting point for every surgery is to plan on using opioids, an NSAID, and local anesthetics, in addition to cold therapy and appropriate nursing care. Local anesthetics are the most effective analgesic available in small animal practice, and they should be used in every surgery.

The pharmacologic update discusses notable changes and addresses persistent myths by drug class. For example, myths about opioid use in cats and gabapentin for chronic pain in dogs are discussed, and positive developments in local anesthetic techniques are noted.

Because nonpharmacological modalities are critically important, the guidelines advise veterinarians to be prepared with substantiated options. Here the discussion encompasses weight control, diet, exercise, rehabilitation, cold therapy, environmental modification, and acupuncture.

Cats benefit from safe and predictable environments that permit their perception of control to exceed their perception of threat. Thus, the value of treatments that cause anxiety, fear, or frustration must always be weighed against their negative consequences on the human-cat bond.

Practice Team Roles and Responsibilities

To help staff members understand the parts they play in the practice’s approach to pain management, they should be given role-specific instructions and training related to implementing an individualized pain management plan for each patient. The guidelines list important roles for team members.

Client Interaction

The client plays an important role by providing relevant patient history, participating in assessment and reassessment, and adhering to treatment recommendations. The guidelines offer several suggestions for client education, instructions, and follow-up. These range from written and verbal instructions on the pain management plan, to education about potential adverse drug effects, to hands-on demonstrations of how to administer medications, especially to cats.

Summary

Practices that implement an integrated approach to pain management ensure that all healthcare team members and their clients understand their respective roles in preventing and controlling pain in their patients and pets. This shared responsibility ensures that effective pain management will be a central feature of compassionate care for every patient. 

Hardesty_Constance-2017.jpg
Constance Hardesty, MSc, is an award-winning writer living in Colorado.

 

Photo credits: TatyanaGl/iStock via Getty Images, Gumpanat/collection via Getty Images, Albina Gavrilovic/iStock via Getty Images, w-ings/iStock via Getty Images

Advertisement

Close

Subscribe to NEWStat