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Could Carprodyl Kill your Dog?

The headline in today's Daily Mail is typically attention-grabbing: "Could the drug that cost this beloved pet its life
kill YOUR dog too?" The article tells the sad story of a thirteen year old Labrador who died after taking pain-relieving
medication prescribed by her vet. There's no doubt that many owners of elderly, arthritis-ridden dogs will be rushing to
their vets this week to find out if their own pets are at risk of the same fate.
So what is this drug? Why do vets prescribe medicine which may risk such a severe reaction? And when they do use it,
why don't they tell owners about the potential dangers?
First, the medication was Carprodyl, a generic form of a chemical called carprofen, which is part of a group of drugs
known as non-steroidal anti-inflammatory drugs (NSAIDS). Carprofen has become perhaps the most widely used pain
relieving medication used in veterinary medicine since it was launched as "Rimadyl" by Pfizer, around fifteen years
ago. The patent on the chemical has now lapsed, so a wide range of cheaper generic alternatives have become available.
Most vet clinics in the UK are likely to sell some version of the product.
Second, why do vets prescribe it? Simply put, because it's the most effective way of treating arthritis in dogs. Many
millions of older animals have been given extra, pain-free life thanks to this type of medication. Three years ago, a
major review was published in the Vet Record, comparing the wide range of treatments available to help dogs with
the common, painful, debilitating problem of arthritis. The review gathered together the results of research papers
published between 1985 and 2007, attempting to derive the best science-based opinion of the best treatment method.
The conclusion? There was strong evidence that carprofen and two other commonly used drugs from the same group
were "effective in moderating the clinical signs of osteoarthritis". There was only weak or moderate evidence that other
treatments were effective. The conclusion for any vet reading this paper was clear: carprofen and other similar drugs are
the most effective way of helping animals with arthritis.
Obviously, an effective drug needs to be safe, so what about those risks? While it's true that all drugs in this group can
have undesirable and potentially life threatening consequences, the incidence is very low. The most common side effect
is gastric irritation: affected dogs suffer from gastroenteritis which usually resolves when the medication is stopped.
Much more rarely, there's a very low risk of kidney failure associated with non-steroidal anti-inflammatory drugs. The
cause of this is complicated: it's more common in geriatric patients suffering from underlying heart, kidney or liver
disease, but it can seem to happen in a random fashion. To minimise this risk, vets may suggest blood or urine tests
before starting a dog onto anti-arthritis medication. Such tests don't completely remove the small risk, and they add
significantly to the cost of treatment for a pet, so they aren't always done.
So finally, why don't vets always tell owners about the potential dangers of such medication? There's a lot of variation
in what happens here: some vets do take the time to tell owners about every possible side effect of every drug that's
used. The problem with this approach is that it's time consuming, leading to longer (and more expensive) consultations
for owners. Most owners don't particularly want to hear a long list of potential side effects that are unlikely to happen,
and they're happy to trust that the vet, on balance, feels that the medication is most appropriate having taken all the risks
and benefits into account.
Vets may also feel that detailed listings of potential adverse reactions may lead to unnecessary worrying for an owner,
so they just mention the most common side effects ("stop the tablets and let me know if she gets an upset stomach").
Sometimes a compromise may be to hand out the package insert with the tablets: the owner can then read the full list of
possible complications if they so wish (and if they have a magnifying glass).
I feel very sorry for the owners of any animal that suffers the consequences of a serious adverse reaction to medication.
There's no easy answer here, but there's a simple message: if you want to know about potential side effects of any drug,
ask your vet. We're happy to tell you if you're happy to listen. It's likely that the same treatment decision will still
be made, but at least, in the rare instance of a severe reaction, you won't have that awful sense of unfairness that you
weren't told about the risk.

The headline in today's Daily Mail is typically attention-grabbing: "Could the drug that cost this beloved pet its life kill YOUR dog too?" The article tells the sad story of a thirteen year old Labrador who died after taking pain-relieving medication prescribed by her vet. There's no doubt that many owners of elderly, arthritis-ridden dogs will be rushing to their vets this week to find out if their own pets are at risk of the same fate.

So what is this drug? Why do vets prescribe medicine which may risk such a severe reaction? And when they do use it, why don't they tell owners about the potential dangers?

First, the medication was Carprodyl, a generic form of a chemical called carprofen, which is part of a group of drugs known as non-steroidal anti-inflammatory drugs (NSAIDS). Carprofen has become perhaps the most widely used pain relieving medication used in veterinary medicine since it was launched as "Rimadyl" by Pfizer, around fifteen years ago. The patent on the chemical has now lapsed, so a wide range of cheaper generic alternatives have become available. Most vet clinics in the UK are likely to sell some version of the product.

Second, why do vets prescribe it? Simply put, because it's the most effective way of treating arthritis in dogs. Many millions of older animals have been given extra, pain-free life thanks to this type of medication. Three years ago, a major review was published in the Vet Record, comparing the wide range of treatments available to help dogs with the common, painful, debilitating problem of arthritis. The review gathered together the results of research papers published between 1985 and 2007, attempting to derive the best science-based opinion of the best treatment method. The conclusion? There was strong evidence that carprofen and two other commonly used drugs from the same group were "effective in moderating the clinical signs of osteoarthritis". There was only weak or moderate evidence that other treatments were effective. The conclusion for any vet reading this paper was clear: carprofen and other similar drugs are the most effective way of helping animals with arthritis.

Obviously, an effective drug needs to be safe, so what about those risks? While it's true that all drugs in this group can have undesirable and potentially life threatening consequences, the incidence is very low. The most common side effect is gastric irritation: affected dogs suffer from gastroenteritis which usually resolves when the medication is stopped. Much more rarely, there's a very low risk of kidney failure associated with non-steroidal anti-inflammatory drugs. The cause of this is complicated: it's more common in geriatric patients suffering from underlying heart, kidney or liver disease, but it can seem to happen in a random fashion. To minimise this risk, vets may suggest blood or urine tests before starting a dog onto anti-arthritis medication. Such tests don't completely remove the small risk, and they add significantly to the cost of treatment for a pet, so they aren't always done.

So finally, why don't vets always tell owners about the potential dangers of such medication? There's a lot of variation in what happens here: some vets do take the time to tell owners about every possible side effect of every drug that's used. The problem with this approach is that it's time consuming, leading to longer (and more expensive) consultations for owners. Most owners don't particularly want to hear a long list of potential side effects that are unlikely to happen, and they're happy to trust that the vet, on balance, feels that the medication is most appropriate having taken all the risks and benefits into account.

Vets may also feel that detailed listings of potential adverse reactions may lead to unnecessary worrying for an owner, so they just mention the most common side effects ("stop the tablets and let me know if she gets an upset stomach").

Sometimes a compromise may be to hand out the package insert with the tablets: the owner can then read the full list of possible complications if they so wish (and if they have a magnifying glass).

I  feel very sorry for the owners of any animal that suffers the consequences of a serious adverse reaction to medication. There's no easy answer here, but there's a simple message: if you want to know about potential side effects of any drug, ask your vet.  We're happy to tell you if you're happy to listen. It's likely that the same treatment decision will still be made, but at least, in the rare instance of a severe reaction, you won't have that awful sense of unfairness that you weren't told about the risk.

If you are concerned that your dog is ill or sick please use our interactive dog symptom guide to find out what you should do

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How can you tell if your pet is in pain?

Domino-sleeping It seems a simple enough task, to be able to tell when your pet is in pain but actually it can be a lot harder than you think. Animals have been programmed over millions of years of evolution to hide when they are sore or in discomfort, otherwise predators and competitors would pick up on the signs and target them. So, as owners, we need to be vigilant to quite subtle changes in our pet’s behaviour that could indicate they are in pain, and ensure they don’t suffer in silence. Depression Most of us assume that if an animal is in pain they will cry out or whine but actually the opposite is true. Chronic (low grade and continual) pain is very depressing and often animals learn to cope with it and show few outward signs of a problem, other than maybe being quieter than normal or sleeping more. The problem with is that this sort of pain is common in older pets, for example with arthritis, and this is what we expect them to do anyway. However, even in excruciating pain our pets can be very quiet and withdrawn. I once saw a cat with a very badly broken leg who had managed to drag himself home, curl up in his basket and was so calm his owner didn’t think he was in any discomfort, until she saw the x-rays! Often with this type of pain, it is not until you give your pet some pain killers, and see the difference in their behaviour, that you realise how sore they were in the first place. Lameness A very common sign of leg pain, from pulled muscles to arthritis, is limping. Other than this the pet can seem quite well and cheerful, and often won’t respond to the leg being moved about or felt, which can lead to their owners thinking they aren’t in any pain, when nothing could be further from the truth! Lameness is a very common problem and if it lasts more than 24 hours (even if it is intermittent) the pet should always be checked over by a vet. Smelly Breath All pets have smelly breath to some degree (!) but halitosis can often be the only sign, without looking in their mouths, which some pets are reluctant to let their owners do, of painful teeth problems. Often people assume if their pet is eating then they aren’t in any dental pain but this isn’t the case, as an animal’s drive to eat will always overcome any soreness. In fact, if a pet does stop eating because of mouth pain, it is likely to be excruciating and will have been there for some time. Other signs of mouth pain include tartar build up on the teeth and swollen gums. If you are concerned, most vets run free dental clinics, so give them a ring and pop along. Weight Loss Bunnies Our smaller pets, like rabbits and guinea pigs, are even better than cats and dogs at hiding when they are sore because, as prey animals, if they show any signs of being ill, they will be quickly singled out by predators. So their owners have to be even more vigilant to spot problems. In fact, it is not uncommon for these pets to be brought into our clinics close to death, their owners distraught that they have missed signs of a problem or thinking they have fallen ill very quickly, when it is more likely they have been poorly for a while but have managed to hide their symptoms. However, one thing which always happens if these animals are in pain or poorly is that they will lose weight, even if they appear to be eating normally. So, weighing your small pets regularly is a great way of monitoring them and any changes in a downward direction should always be taken seriously. Our pets can’t speak for themselves and in many cases are too brave for their own good; trying to pretend that everything is fine when in fact they are in pain and suffering. So, all good owners should be alert to the small changes that could indicate a big problem and make sure they get them treatment they need and deserve. If you are worried that your pet may be in pain, please contact your vet. If any other symptoms are present why not check the urgency of the problem by using our Interactive Symptom Guide?
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When Liver Meets Lungs – Diaphragmatic Hernia in a Cat

Up a TreeOne evening whilst playing outside, a little 6 month old kitten (let’s call her Tilly) climbed up a tree. A rather inexperienced hunter, when she saw a little birdie on the end of the branch she reached out to get it and, crash! The branch was too thin to support her weight and she fell to the ground. Now what they say is often true, cats do tend to land on their feet, but not always and poor Tilly landed on her side. She got up though and ran into the house, so her owner assumed she was OK. A few hours later her owner noticed that she was quieter than normal and not interested in her dinner. She was also breathing faster than normal but otherwise seemed OK, purring and affectionate, so her owner went to bed and planned to take her to the vet if she was still not right in the morning. As you could probably guess, at 8:00 the next morning I got a phone call from Tilly’s owner, as she had not gotten any better overnight - she was still very quiet and breathing even faster than before. We told her to come straight down and we would take a look right away. A few minutes later Tilly arrived, looking quite sorry for herself, but still happy enough to give me a little purr. I did a full physical exam and found her to be in good health except for her breathing, which sounded quieter than normal through the stethoscope. Her respiratory or breathing rate was very high and she seemed to be struggling to get enough air in. She also seemed depressed, certainly not what I would expect of such a lively young kitten. Once we were certain that everything else seemed to be OK, we gave her some pain medicine and then a little bit of sedation so she would sit still while we took some x-rays of her chest. What we found was no surprise given her history, but still always comes as a bit of a shock when we see it – Tilly had a diaphragmatic hernia. What is a diaphragmatic hernia? The diaphragm is a large, thin muscle that separates the chest cavity (with the heart and lungs) from the abdomen (with the stomach, liver and intestines among other things). It is normally an air-tight barrier which allows the chest cavity to achieve negative pressure, in other words there is pressure on the lungs to expand out rather than collapse in. When the diaphragm moves down with each breath, the lungs move with it causing them to expand even further when you breathe in. And when it moves back up again, it helps the lungs to contract so the air is forced out when you exhale. Without a diaphragm or with a damaged one you can still breathe, just not very well, and this is what poor Tilly was experiencing. A hernia is the protrusion of an organ through a hole in the body cavity which normally contains it. In the case of a diaphragmatic hernia, a hole develops in the diaphragm which allows the organs of the abdomen to enter the chest cavity. As you can imagine, this is neither good for chest, as the invading organ takes up precious lung space, nor for the organ itself as sometimes its blood supply can get cut off in the process. Some diaphragmatic hernias are emergencies and need to be corrected immediately, while some can go on for weeks without anybody even noticing, it depends on the size of the hole and which organs get displaced. Some animals are even born with them. In Tilly’s case, the sudden pressure on her belly from hitting the ground caused her diaphragm to tear and some of her liver to move up through the hole. It was a serious condition but not a life-threatening emergency, and it has been shown that there is a higher success rate in some cases if surgery is done after 24-48 hours, so she was scheduled for surgery to repair the hernia the following day and kept in hospital under close observation until then. [caption id="attachment_1805" align="aligncenter" width="640" caption="This is an image of Tilly’s chest – the dotted line shows where the diaphragm usually sits and the solid line shows Tilly’s diaphragm, with the liver sitting inside the bulge. A relatively easy but dramatic diagnosis!"]This is an image of Tilly’s chest – the dotted line shows where the diaphragm usually sits and the solid line shows Tilly’s diaphragm, with the liver sitting inside the bulge.  A relatively easy but dramatic diagnosis![/caption] So what happened? We took Tilly to surgery the following day and once we could see inside, the extent of the injury became apparent. There was a 5 cm tear in the diaphragm muscle, and about half of her liver was now sitting right next to her lungs! We were able to carefully pull the liver back into the abdomen and sew up the hole, making sure that all the organs looked happy and healthy before finishing the surgery. Our nurse did a fantastic job keeping Tilly stable under the anaesthetic, and even had to breathe for her for a few minutes while we sewed up the hole. Just before we woke her up, we inserted a needle into the chest to drain out all the extra air so that her chest cavity could regain its negative pressure. Her breathing was immediately improved, and stayed that way throughout her recovery. The next day she was eating and even trying to play with the notes on her cage, so she was able to go home. It has now been nearly a week and Tilly is still doing really well. Her owner says she is even trying to climb things, despite being told that she must stay very quiet to allow her injuries some time to heal. If only you could explain to her how she got into this trouble in the first place! All the best to brave Tilly and her brave owners, I expect she will make a full recovery and be back to her usual kitten acrobatics in no time. If you are worried about any problems with your cat, talk to your vet or try our Interactive Cat Symptom Guide to help decide what to do next.
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Pain Part 2: Getting rid of pain

Pain and pain relief are massive topics which can – and do – fill several textbooks. It’s way beyond the scope of a blog to go into all of the detail surrounding the use of painkillers, and so all I really want to do is to outline some of the different types of pain control that we can use, both in the surgery and as day-to-day treatments. Pain relief is one of the great success stories in medicine, and it’s no coincidence that some of my favourite drugs of all time are painkillers. Our advances mean that pain in our patients shouldn’t be accepted, and although sometimes we fail to control it, we should never stop trying. We use a number of different types of painkiller:
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Steroids
  • Opioids and opioid-like drugs
  • Others
NSAIDs These are the most widely-used type of painkiller and include (for humans) aspirin, ibuprofen and paracetamol. They act by stopping inflammation. They’re commonly prescribed for post-op pain and for joint problems and may be given for long periods of time. When you’re given painkillers to take home from the vets, they’re usually NSAIDs. Three things to really take on board with these drugs:
  1. Human drugs are not always safe for pets, so never give anything to your pet without talking to your vet first: half a paracetamol can kill a cat, a big dose of ibuprofen can do the same to dogs and even a solitary aspirin can be a lethal overdose for a toy breed, designed as it is for a much bigger animal (us). This is why we have veterinary-licensed drugs for our patients.
  2. Increasing doses won’t give more pain relief, and may cause side effects. If they’re not working for your pet, talk to your vet about alternatives.
  3. NSAIDs are most effective when given before the inflammation starts. It might seem odd to suggest giving painkillers before the pain even begins, but this is important in treating chronic, repeated and predictable pain like arthritis.
Two of the most common drugs we use are meloxicam and carprofen. Meloxicam usually comes as a syrup, which can be dosed very accurately, and carprofen is generally in tablet form. Both drugs may be used long term as a daily dose and both have been responsible for giving patients their lives back, sometimes for years. We’re also rediscovering paracetamol as an excellent addition to treatments in dogs. Recently, newer NSAIDs have been introduced which are labelled either as cox-2 inhibitors (e.g. firocoxib), or else dual inhibitors (tepoxalin). Essentially, these are just descriptions of which bit of the inflammatory cascade they act upon, and they’re designed to reduce some risks of side effects that we see with other NSAIDs. It’s arguable, though, as to whether they’re better at relieving pain than some of the older drugs. More recent still is Trocoxil, an NSAID for dogs which is only given once a month. The theory is that because it acts as a persistent block to inflammation, there’s no point where the vicious cycle of pain can really take a hold. The exact ins and outs of the drug are a bit too much to go into here, but as always, speak to your vet about this medication if you’re interested in finding out more. Do understand, though, that it’s not for every patient and your vet may have good reasons not to use it on your dog. Steroids Steroids are very powerful anti-inflammatories, which gives them painkilling properties. However, they also affect the immune system – many patients take them for allergies and auto-immune problems - and can have major side-effects when used long-term at high doses; they also can’t be given with NSAIDs and so for practical reasons their use as painkillers is limited. You may have experience of PLT (Predno-LeucoTropin), a medicine with a steroid component which can be great for chronic pain when other drugs seem to be failing. It’s been around for a long time, and many an experienced vet will recognise its usefulness. Opioids Opioids are a group of drugs which act to block the passage and brain detection of pain signals. The classic drug in this group is morphine, which still forms the basis for relief of severe pain in humans. These are very powerful painkillers indeed, although the degree of pain relief depends on whether they’re what we call a full-agonist or a partial-agonist. Drugs like morphine, pethidine and fentanyl are full-agonists, and tend to be used only within the surgery. They are subject to close control and are never dispensed. Generally they’re given by injection, although fentanyl is available as a long-acting skin patch, which has been very successful for use in trauma patients like RTA cats. Buprenorphine and butorphanol are partial-agonists and are often used as part of a pre-med before surgery. Buprenorphine is a great painkiller which is usually injected within the practice, but may occasionally be dispensed for oral, very short-term use. It is certainly useful in breaking pain cycles and allowing us to get onto more stable pain relief regimes. For in-patients where NSAIDs either don’t quite cut it, or else a combination therapy is needed, buprenorphine is an excellent drug. A drug that we’ll often use long-term in out-patients is tramadol. This is a human drug which acts in a similar manner to opioids, and has a number of significant advantages:
  1. It’s usually pretty safe, although it can temporarily knock some patients a little flat. Your vet should tell you about this when prescribing.
  2. It’s a GOOD painkiller
  3. As it has a different way of working to NSAIDs or steroids, it can be used in conjunction with many other drugs to create a better painkilling effect
Others Other drugs that we use act in novel ways, or else are designed for other purposes but just happen to help with pain control. These are important drugs, and whilst they’re described last they’re definitely not least in importance. In brief:
  • Local anaesthetics may be used in and around surgery, to numb the pain nerves. These tend to be injectable, although some creams are available which can be useful to pre-treat patients with needle phobias and the like.
  • Ketamine – yes, the horse tranquiliser – has been used for years in emergency medicine as a painkiller; it’s often included in battle packs for soldiers. Its use in our patients is quite specialised and confined to hospital environments.
  • Gabapentin. This is a very interesting drug indeed. It’s normally used as an anti-epileptic, but seems to have a great effect on pain of nervous origin (aka neuropathic pain), so can be useful for spinal and neurological conditions.
  • Cartrophen is an anti-arthritic drug (also sometimes used in bladder problems in cats) which has a number of effects on joints. It’s usually given as four weekly injections, followed by a variable period of remission. It can be very beneficial for some arthritis patients, but may need a little forward planning in its use, as its administration isn’t recommended at the same time as NSAIDs. It’s certainly a drug worthy of close inspection in long term arthritis cases.
Integrated methods of pain control Whilst it’s obvious that we have some great drugs for relieving pain, reliance on drugs alone in any condition is generally a limiting approach, as adding in other treatment types – or modalities - may offer greatly increased success rates. For example, in heart disease drugs may help to keep the cardiovascular system going, but are much less effective when used by themselves than in an overall strategy including lifestyle change, weight loss, exercise programmes, regular monitoring and support networks. Similarly, drugs may form the heart of a pain relief strategy, but shouldn’t be used as an excuse to avoid other measures that can help – and there are even times when non-drug pain control is good enough that painkillers are not needed. Whatever the non-drug modality used, the decision on when not to use painkillers is a simple one:
  1. The pain is being completely controlled by non-drug methods.
  2. That’s it.
Remember that phrase – pain is not acceptable in our patients. If nothing else, these blogs should have explained both why pain is a bad thing in the long run, and the sheer number of drugs that fight pain. Treating pain completely without drugs is a brilliant solution, but simply taking the edge off the pain is not enough. Equally, though, finding a number of ways to help with the pain will almost certainly mean that your pet gets more relief and is happier. Treatment modalities which can help in chronically painful conditions include:
  • Acupuncture – there’s a reasonable body of evidence for the physical effects of acupuncture and theories of how it may ‘close the gate’ on pain. It’s now widely available around the country, but must be performed by or under the direction of a vet.
  • Supplements – for joint problems, there are a number of supplements containing combinations of glucosamine, chondroitin and green-lipped mussel extract, which protect the cartilage and may even get rid of the need for painkillers in early arthritis. Additionally, essential fatty acid supplements and vitamin E are both mooted as aids to tissue repair and free-radical scavenging.
  • Herbal remedies containing Devil’s Claw are widely available, but be warned that the supplement can cause side effects and that clinical trials have produced highly variable results.
  • Weight loss – whilst it’s obvious that in arthritis, every excess ounce is another ounce of pain, recent work has suggested that body fat has a chemical pro-inflammatory effect which may exacerbate pain generally. Reducing body fat may reduce the body’s pain responses, particularly in chronic conditions.
  • Surgery – for many painful conditions, surgery is the obvious treatment to permanently remove the pain at source.
  • Physiotherapy – hydrotherapy, mobilisation, massage and PROM are all very useful in promoting recovery and dealing with chronically painful conditions. Access to these services is usually by referral from your vet, and animal physios are highly qualified professionals.
  • Mood enhancement – pain is depressing, so elevating mood helps patients to cope, and also makes new pain easier to deal with. A number of products are available, from pills (including zylkene, a natural extract, and amitryptilline) to pheromone sprays and diffusers (feliway, DAP), but equally, promotion of routine and enjoyable activities can be very successful.
  • Prevention –as the best pain relief is prevention, a word should be said about how we avoid seeing dogs with arthritis or cats with pancreas issues in the first place. Also perhaps timely, as the Animal Health Trust, in conjunction with Edinburgh Vet School, have just announced a project into genetic testing for hip and elbow dysplasias in Labradors. Being able to breed the conditions out of our patients will have a major impact on the wellbeing of future generations (so, if your Lab is KC registered and hip scored, the AHT might just want to hear from you).
  • Magnet therapy – to this day, I still don’t know if this really works, but plenty of my clients are convinced – including a large proportion of horse owners, who are about the most hard-bitten, unpersuadable people out there.
There are, of course, countless other integrated therapies, like Reiki or Homeopathy, and each will have their champions and detractors. The important factors with any of these are choice and inclusivity – it’s fine to explore all of the possibilities, but not to the detriment of the patient. As a general rule, the vet who prescribes you meloxicam won’t demand that you stay off the Reiki during treatment, and this should work both ways. The mainstay of pain relief will always be drug therapy, but its effectiveness can be massively enhanced by looking at integrated treatments. Pain is such a debilitating problem that anything which can help to remove it has got to be worth exploring. If you feel that your pet may be in pain, especially if you’re already giving treatment, then speak to your vet about what you can do - there are so many ways to target pain that there’s bound to be something to help. And do remember that phrase: pain is not acceptable in our patients. If you are worried about your pet's health, talk to your vet or use our Interactive Symptom Guide to help assess how urgent the problem may be.
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Pain in animals part 1: what is pain?

Pain. Everybody knows what it feels like, and – apart from a few determined individuals – we tend to avoid it. But what is it? The International Association for the Study of Pain (IASP) defines it as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Or, in other words, when you damage yourself it hurts. And if you’re feeling down already, it hurts more. And if you’re not feeling down already, then pain may make you feel down. And then it will hurt more. The IASP mainly looks at pain in humans, but it’s a long time since we stopped trying to pretend that animals either don’t feel pain like we do, or else don’t get upset about it. They do, and their inability to communicate pain effectively (or else our inability to properly listen) means that for a lot of animals, pain is a chronic, miserable constant in their lives, despite help being close to hand. There are tiny pain receptors all over the body, inside and out, attached to nerve fibres. When a tissue is damaged, they’re triggered to send impulses up to the brain, which senses them and registers the feeling we call pain. Hard to describe, but we all understand what it is and we’ve all got experience of it. Pain receptors are usually well embedded in tissues, and usually need a fair bit of triggering – otherwise, any form of touch would be painful. When we describe pain in ourselves, we often use terms like sharp, jabbing, dull or throbbing, and they can give an indication of how bad it is. But in a more fundamental sense, we differentiate into two types: physiologic and pathologic. Physiologic pain is ‘protective’ – it’s the pain we get when picking up a hot pan. Very quickly, the body registers the ‘ouch’ and the pan is dropped, hopefully before too much damage is done. Without this kind of reflexive response, we’d just keep on holding the pan until our hands were badly damaged. Physiologic pain, more or less, is our friend. Pathologic pain, on the other hand, is the pain that comes from existing damage, such as a broken leg or a arthritis. Whilst it can initially be useful to draw our attention to the condition, it becomes debilitating quite quickly and can be a problem in its own right. It’s this kind of pain that we need to deal with in our patients: the pain that is ever-present or recurrent, at whatever level. If we don’t, the pain becomes responsible for stress, depression and a reduced quality of life. For example, the pain of arthritis can actually make the condition worse:
  1. being unwilling to move around makes the joints stiffen up through lack of use
  2. lack of exercise piles on the weight, putting more pressure on the joints
  3. increased pressure on the joints means more pain, so less movement, more stiffening and more weight gain
A vicious cycle is created where the problem becomes worse and worse under its own steam – and pain is as the root of it. Whilst we can’t cure the arthritis itself, by removing pain and getting our patients moving we can reverse the stiffness and get some weight off. Pathologic pain can have its uses, but isn’t always our friend. How do we recognise pain? Domino sleepingIn order to be able to keep our pets out of pain, we must be able to recognise the signs of pain. Remember, though, that absence of signs doesn’t guarantee that there’s no pain – if in doubt, assume it’s there. Understanding how a pet feels depends on a number of things:
  • Empathy
  • Understanding of normal behaviour
  • Observation
Some owners are just better at spotting pain. Some patients are better at showing it. But unless we look for it, we’re never going to find it. Dogs tend to be the easiest patients in which to spot pain: their outward responses to pain are more similar to ours than for most species. They’re designed for pack-living, and their conditioning in our homes makes them more likely to be willing to show pain to us, and even to seek help with it. I have, over the years, seen a small number of ‘malingerers’ who were hopping lame at home, but completely normal when away from their owners - generally because being hopping lame at home meant cuddles and treats and all things good. Do beware, though, of behavioural changes as the only signs of chronic pain in dogs. When our collie, Juno, was a younger dog, a combination of being overweight (yes, shame on me), hip dysplasia and the appearance of screaming toddlers with grabby hands made her mildly aggressive – which, for Spoony, was so out of character that it was immediately apparent. Early recognition of the central issue, along with pain control measures (weight loss, acupuncture, educating the kids) sorted it all out quickly. Cats are different, very different. When in pain, they tend to isolate and may just become distant and/or grumpy. There may be aggression towards inanimate objects, or self-directed as overgrooming to the point of self-harm, and accidentally touching the sore spot will usually lead to bloodshed, none of which will be the cat’s. But cats are relatively worse at expressing pain in other ways which are immediately recognisable. Drop in food intake is, though, a classic sign of pain in cats. Rabbits and other herbivores (traditionally, the prey animals) can be very difficult to recognise as being in pain. Their entire survival in the wild depends on not looking weak – predators will tend to go after the stragglers first, to reduce energy expenditure and risk in obtaining food. Survival in the wild depends on being invisible as a target, so hiding signs of pain is standard in these patients. Sometimes, you have to look very hard to find it, which doesn’t mean that the pain isn’t significant. It’s entirely connected that these are the species whose general welfare gives us the most worry. General signs of pain in animals include:
  • Reduced mobility or abnormal movement – if it hurts to move, pain is reduced by not moving. Equally, if a pet is moving in an odd way, then it’s because moving in a normal way hurts. A major, major problem that we encounter is the attitude that reduced mobility is a normal part of ageing – so pain is often not recognised in older patients. It’s amazing what a trial on painkillers can do to change minds.
  • Guarding and defence – hiding away or trying to protect the bit that hurts. A common entry on clinical notes is ‘guarding the abdomen’ which usually relates to a tenseness in the belly when we’re trying to palpate.
  • Inappetance – most animals will either eat less or stop eating altogether when in pain. When the pain is settled, we often see rebound eating, where intake is increased for a while. This can be a cardinal sign for assessing response to treatment.
  • Adipsia or polydipsia – most animals will also drink less, although some, often as a response to stress, will drink too much. Patients with abdominal pain will often swallow great bowlfuls of water, possibly because of a temporary soothing effect.
  • Altered interaction – many animals will hide away and reduce their interactions with other members of the household; others, particularly dogs, will become more needy and seek more interaction. Normally friendly relationships may explode into world war three and, rarely, vice-versa. It’s not so much how the interactions change, but that they change in the first place.
  • General distress – other signs of distress include increased breathing rate, increased pulse rate, abnormal breathing (cats DON’T pant as a normal behaviour), vocalisation (howling, mewing, whimpering), a certain glassiness of the eyes, hunched body position, bubbling at the mouth (reptiles), fluffing of the feathers or over-stimulation and anxiety from normal noises and events.
Harvey hidingEven allowing for all of these symptoms, pain can be a vague and difficult thing to spot. One of our classic presentations in the consult room is ‘S/he’s just not right’, where a patient just isn’t him- or herself. It’s astonishing how many of these patients have some kind of pain complex, and full marks from me to any owner who can spot when their pet is just not happy, however subtle. Nothing ever happens for no reason, and absence of any particular symptom in a depressed patient should always trigger suspicion of pain as a cause. What factors make pain worse? Inflammation is a big one. Inflammation is the swelling you get around, say, a cut or a sprain. It’s also the reason why a sprained ankle tends to hurt more the next day than it does at the time of injury. Inflammation is the body’s reaction to detecting damage and is its way of drawing the immune system in to start repairing things. Once damage is detected, a sequence of events is triggered called the inflammatory cascade, which goes a bit like a line of dominoes – once started, it takes on a life of its own. The end result is the release of a lot of chemicals which promote blood flow into the area and, importantly here, an increased sensitivity of the local pain receptors so that almost any pressure sets them off. A good illustration of this is to imagine someone poking you lightly in the arm. For most of us, it’s not painful, just annoying (and strangely familiar for those with brothers and sisters). However, if you’d been to the doctors for a jab earlier in the day, suddenly the touch is extremely painful. The inflammation around the injection site has switched all the pain receptors on to the point where even light pressure sets them off. This phenomenon is at the heart of much of the chronic pain that our patients suffer from, with conditions like arthritis. Drugs which try to stop the inflammatory cascade are called anti-inflammatories. Other things that make pain feel worse are:
  • The amount of time that it’s been going on for - most of us are fairly stoic, at least at first, but sooner or later an inability to get comfortable, to sleep, to do the things we want to, all start to get us down. It’s the same for our pets.
  • Having more than one painful bit – two plus two in this case tends to make five.
  • Previous experience of pain. Our pets have a phenomenal memory for pain, which translates to a fear of repeating the experience. Pain at the vets can put a patient off us for life, which is why we try to make the first couple of visits as stress-free as possible.
  • Being in a bad mood already. If you walk down the street on a happy day and stub your toe, it hurts. If you’re already in a bad mood, the world seems to cave in. This is where the vicious cycle of pain and depression starts to bite: being in pain causes stress and depression, and stress and depression make pain feel worse.
Pain control is one of the most progressive aspects of veterinary medicine, which means that pain in our pets is no longer acceptable. It might not always be possible to get right on top of it, but that doesn’t mean we should ever be happy about it - and there are now so many available treatments that giving up is simply not a reasonable option. In the next instalment, I want to discuss the various drugs that we can use in dealing with pain in animals, and how they might fit together. After that, we’ll briefly go on to integrated (non-drug) treatments and how they can make all the difference to some patients. If you are worried about any symptoms in your pet, please talk to your vet or use our Interacitve Symptom Guide for advice on how urgent the problem may be.
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What is health? Putting the Principles of Holistic Care into Veterinary Practice

Are you and your pet healthy? dog walkIt’s an odd question, which you’ll probably answer depending on how you feel, especially if you’re suffering with, say, a cold or a broken leg. And if your pet is currently having treatment, it’s easy to say that he or she isn’t healthy, but would that automatically be the case? Is a contented cat with well-controlled hyperthyroidism any worse off than a depressed horse? Is a puppy with a rash any healthier than a very old dog without any obvious issues? Defining health is like trying to catch fog in a net. To start, there are lots of different viewpoints of what it actually means, and it soon becomes apparent that perfect health is an impossible ideal, faced as we are by so many challenges every second of our lives. Unless you’re holding your breath, you’ll have breathed in a lot of germs just since you started reading this, one of which may make you ill next Tuesday. How depressing – unless, of course, you were hoping to avoid that work meeting next Tuesday, in which case the world is suddenly a brighter place. Context matters with these things: a gut full of bacteria is normal; a lung full of bacteria isn’t. Worms aren’t something you’d want to have, but it’s not that long since diet pills for ladies contained tapeworm eggs, in order to maintain that ‘healthy’ figure. We spend more time, effort and money on polyfilla to mask signs of ageing than we do on exercise and decent diet, because we think that a wrinkle-free face on an unfit body is healthier-looking than someone who looks their age only from the neck up. So what might it mean to be healthy? Is there one theory which brings it all together? Can it be defined without a blood test? More to the point, how does your vet define it, and can he or she explain it to you? I’d like to discuss three theories of health which could really alter your perception of what it means, for you and your pet. They might seem complicated to look at, but in reality they’re very simple, like all the best ideas:
  • Biomedical Health
  • Activities of Living
  • Self-Care Deficit
Biomedical refers to the presence of disease: imagine if I had a Star Trek type scanner, which I could wave at you and it would tell me if you were biomedically healthy in terms of infection or organ function. But I wouldn’t have a clue about how happy you were, how many friends you had and whether you played sport last Saturday. Aren’t these important as part of a healthy life? So three very clever people called Roper, Logan and Tierney came up with the Activities of Living. These are twelve basic activities (since expanded by other theorists), ranging from eating, drinking and breathing, through social interactions and sexual expression, to dying, as normal parts of a healthy life. It’s not enough to be free of disease: in order to be truly healthy, one has to be able to take part in all of the activities (even dying, but hopefully only at the end of a long and fruitful life). JunoDorothea Orem produced the wonderful Self-Care Deficit Theory, which simply means that anything you can’t do to look after yourself is called a self-care deficit: so if you can’t put your own socks on, that would be a deficit. Orem considered that where a deficit was identified, enough help should be given to overcome it, but no more. So, when my collie Juno was recently struggling with getting out of her basket after a vestibular attack, she got just enough support to make it happen, but that was all. She had to make some effort herself, and that meant that she overcame the problem more quickly. These are brilliant theories, but what really made them great was combining them and incorporating them into medical care. You often hear the term holistic applied to alternative therapies and lifestyles, but its true definition has its roots in this kind of care: veterinary medicine shouldn’t just be about curing disease, but about enabling patients to live as full a life as possible. The veterinary profession has identified with this ideology since it first evolved, but the recent introduction of these theories into the education of young vet nurses and vets has cemented their importance. So, there’s now a very good chance that your local vet practice is already putting the principles of holistic care into practice:
  1. We do, of course, look at your pet’s health from a biomedical point of view
  2. Then we may go further and look at how they get on with the Activities of Living.
  3. If there are any that they can’t manage (apart, usually, from sexual expression), we may look at their inability to do it – or self-care deficit – and work out how we can help to put it right.
In this way, health is about more than just a negative lab test, and the common presentation of “he’s just not right” can be looked at more fully. Ginger catIf Tiger, the car-chasing cat, is hospitalised with a broken pelvis, his care won’t just be about pain relief: it’s possible to put food into a cat even against his will, but the real trick is to make him happy enough to want to eat it. So the team will look at what activities would make him a whole, happy cat again, and what his self-care deficits for each activity are. And they’ll give him the help to bridge those gaps: so if he can’t self-groom all over, they’ll do the bits he can’t reach; if he can’t wee, they’ll take care of that. When the gaps between what he can do and what he needs to be able to do have dwindled to nothing, he’ll be healthy again. A lot of that work can be done at home, so when Tiger is discharged, there should be a good chat about what can be done to carry on the process. Labrador crop If Tess, the old Labrador with arthritis, has lost her spark even with painkillers, the practice may have ways to get that spark back – finding new ways to play and to interact, stimulating (as though a Lab would ever need it) interest in food and people. We should look at her expectations out of life – and she won’t want to run for ten miles in the rain each day – and make sure that she’s not being limited by her routine. Curious bunnyAnd for concepts designed for a rabbit, look no further. Rabbit welfare in terms of general lifestyle and care is one of the most pressing problems we face in veterinary medicine: the lives of some (but by no means all) of these creatures are simply miserable. So if you’ve got a rabbit stuck in a small hutch all day, dig out a copy of the Activities of Living and see how you score as an owner. We’re pretty good at keeping our pets free of disease. Where we might need some work is in making sure they’re truly healthy. Dogs can’t tell the difference between a cheap collar and an expensive one, but they do know all about quality time and the importance of a good play session. So it might be that looking at our pets’ health helps us to look at our own, and who knows where that could lead? If you are worried about any aspect of your pet's health, talk to your vet or use our Interactive Symptom Guide to help assess the urgency of the problem.
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