This may surprise you, but there are trends in veterinary medical practice … just as there are in fashion, nutrition, or dog breeds. And this new trend is disturbing …
I work primarily as a referral practice. So my patients are treated by other veterinarians … usually a general practitioner or a specialist. All of my clients come to me because they want their animal to feel better. They’re often afraid their pets are in pain or they’re not improving as hoped. Other times the veterinarian offered no further options.
So I’m able to observe the trends in prescription medications used to treat various conditions. One such trend over the past few years is in the treatment of pain.
Pain Serves A Purpose
Pain is a big topic. There are many different types of pain, including …
- Emotional pain
- Nerve pain
- PTSD pain
- Muscular pain
- Post-op pain
- Traumatic pain
- Disuse pain
Most people fear pain. Just the thought of pain can trigger memories of it. And this can produce somatic pain (meaning skin, tissue, muscle or joint pain). One of the biggest worries my clients have is not knowing their animal is in pain … or not doing anything to relieve it.
Pain does serve a purpose in the body. Imagine you burn your hand on a hot surface. The hot burning sensation stimulates your pain receptors to signal your brain. So your brain tells you to remove your hand from the hot surface. Pain also discourages you from moving in ways that may damage your joints and tissues.
Pain is a subjective experience. It has significant cross-cultural and cross-linguistic differences. For example, many languages have words for different types of pain. These illustrate significant cultural differences. How about other species? Species that have evolved to live a very different lifestyle from humans? How do they subjectively experience pain?
At one time, veterinary medicine didn’t consider pain at all. Experts believed animals didn’t feel pain … and they didn’t have emotions. So it’s a big step forward to acknowledge that animals feel pain, suffer and have emotional lives like we do.
And it’s exactly this position that makes me worry about the current trends in pain management I’m seeing.
Pain Medications For Dogs
There are several classes of pharmaceuticals used to treat pain in dogs.
One of the major classes of pain meds is non-steroidal anti-inflammatories (NSAIDs). These are drugs like …
Vets mainly prescribe NSAIDs for acute post-op pain and chronic arthritis pain. They’re the aspirin and Tylenol of veterinary medicine.
The second common class is steroids …
These are powerful anti-inflammatories – and immune suppressants when used at high doses. They’re used for disk herniation, autoimmune conditions, and even some cancers.
The third common class of drugs used for pain relief is opioids:
They bind to opioid receptors and turn off pain pathways to the brain. Even though the cause of the pain may still be there, the brain doesn’t recognize it as pain.
There’s a lot of information coming out about NSAID side effects. And of course we know the long-term effects of prednisone. These include inhibiting the pituitary-adrenal axis, iatrogenic Cushing’s disease, shutting down the adrenals, and suppressing the immune system.
But I think it’s very important to examine the drugs being prescribed in place of NSAIDS and prednisone. It’s happening even when inflammation is the underlying cause of pain … like arthritis and intervertebral disc disease (IVDD). And it’s happening even when NSAIDs and steroids can be effective for these problems.
The New Trend In Veterinary Pain Drugs
There are several drugs that are new to veterinary medicine, but not new to human medicine. They’re being routinely prescribed for pain in dogs:
- Gabapentin (anticonvulsant)
- Trazodone (antidepressant)
- Amantadine (antiviral)
- Tramadol (opioid)
- Methadone (opioid)
There are many unanswered questions about these drugs:
1. Are they really effective for pain relief?
2. Do they improve the patient’s quality of life?
3. What are the side effects?
4. Are they being used in situations where anti-inflammatories would be more effective? (For example, a herniated disk where paralysis is a risk.)
These drugs are relatively new to veterinary medicine. They’re being used “off-label” … because they’re not FDA-approved for veterinary use. Off-label prescribing isn’t unusual … but it means there are very few, if any, studies done on their use in dogs.
So we don’t know the risks for dogs, or if they’re even effective.
Multiple Drug Prescriptions Make The Problem Worse
The current veterinary trend is to use several drugs at a time to achieve a layering effect. Initially one drug may be prescribed. But if the patient still shows signs of pain (often subjectively observed by the owner) … another drug gets added to the mix.
Patients are coming to me on 2, 3 and sometimes up to 5 different pain medications. The logic is that each drug handles a different part of the pain pathway.
But there are serious dangers in layering these drugs.
- There are almost no studies on the effects of the individual medications in dogs.
- There are no studies on the effects of using 3 to 5 of these drugs together.
So we don’t know if the liver and kidneys can metabolize them without damage … particularly in an elderly animal. We don’t know about synergistic effects between meds. Serotonin syndrome is often mentioned as a side effect of antidepressants. But we’re not told what to expect or how to treat it. And it can be life-threatening.
Opioid Overdose In Dogs
Even more important, and potentially life-threatening, is respiratory depression. Opioids can cause respiratory depression … especially when combined with other sedatives.
Respiratory depression is a breathing disorder that causes slow, ineffective breathing. And it leads to the cessation of breathing, which leads to death. In layman’s terms, that’s an opioid overdose.
So what about the overdose risk? Are the veterinarians who give high dose, long-acting opioids like methadone sending home Narcan? (Narcan reverses opioid effects like respiratory depression.)
One of my patients was released from a local emergency room after receiving methadone. The dog died from respiratory depression in the car … as the client was headed back to the ER because the dog couldn’t breathe.
A Poor Quality Of Life
Now, if dogs were up and walking and had a good quality of life on these medications, I wouldn’t be writing this article. But most of them are so highly medicated … they don’t even respond to a total stranger walking up to their bed, in their own house. If that doesn’t sound strange to you, remember that dogs are often territorial. Even friendly dogs will alert the rest of their pack to a stranger in the house. They should at least lift their heads up to acknowledge my presence.
Not only are they mentally sedated by these drugs, they’re often unable to stand on their own. Even if they can stand, they walk like drunken sailors. In a dog with a severe neurological condition, I would expect this. But many of these same patients return to normal mobility once the drugs wear off.
Why The Over-Prescribing Trend?
What I’m seeing these days is that pharmaceutical choices are driven by economics and marketing … instead of science or double-blind studies that test the efficacy and safety of drugs in dogs. Just one opinion piece, blog post or small study can change accepted treatment recommendations.
One case in point is Gabapentin being widely prescribed for pain relief … which it’s still not shown to help with. It’s not FDA-approved for dogs … but vets hand it out anyway, with almost no research to support it.
(I did find one small study that concluded: “As an adjunct to other analgesics and anesthetics, gabapentin, at the dose and frequency used in this study, did not provide a significant benefit for the management of acute perioperative pain in dogs undergoing forelimb amputation.”)
RELATED: Why I won’t prescribe Gabapentin …
Give The Right Drugs
Even as a holistic veterinarian, I recognize that occasionally drugs can be necessary. But they need to be the right drugs.
I’m not a fan of NSAIDS or prednisone … but with proper use, they can keep a dog up on all 4 feet walking. Invertebratral Disc Disease (IVDD) is one example.
I’ve had more than a few cases of IVDD come to me with dogs in so much pain they can’t walk. And the pain meds are not doing anything but sedating them … to the point that they won’t even eat.
Instead, a very short course of prednisone over 3-7 days can decrease the inflammation around the nerves and spinal cord. Then, along with acupuncture, laser and herbs, the dog can be up and walking. This can even avoid high-risk surgery down the road.
So, sometimes drugs have their place in treatment. Otherwise, animals might be paralyzed or in too much pain to move.
But I’ve seen too many cases lately where animals got the wrong drugs. Then the client was left with euthanasia as their only other option … because their dog was unable to stand, let alone eat, due to their drug-induced stupor.
The current mantra seems to be: If you can’t remove the pain, just sedate the pain away. As is typical in allopathic medicine … treat the symptom but forget about the root cause.
Natural remedies and treatments can often work wonders. But if your dog’s in chronic pain and you have to resort to drugs … be very careful about what you allow your vet to prescribe.
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Kate Boatright VMD. Managing invertebral disk disease: Do steroids have a place? dvm360. 2020 Jul;51(7)