INDICATIONS

FOR USING
PAIN KILLERS
Drh. Listriani Wistawan

Indonesia International Cat Conference & Exhibition

11-12 May 2024
Smesco Convention Center, Jakarta
Contents
Understanding Pain
Acute Pain Assessment
Chronic Pain Assessment
Acute Pain Management
Chronic Pain Management
Understanding Pain
Definition of Pain?
• Unpleasant sensory and emotional experience
associated with actual or potential tissue
damage (International Association For study
of Pain )
• Component : sensory, emotional, cognitive
and social
Understanding Pain
Pain?
• Difficult to recognize in cat due to their
unique behavior
• Pain are suffering condition
• Vet have medical & ethical duty for
minimize suffering from pain
• Vet know how to recognize & manage pain
Acute Or Chronic Pain?
Acute Chronic
• Adaptive pain characterized by • Maladaptive pain characterizes by
nociception and inflammation pain functional and neuropathic pain
• Associated with potential & actual • Persists beyond the expected course
tissue damage of healing/ acute disease
• Usually self limiting • Not associated with healing
• Surgical procedures, trauma & • Osteoarthritis, cancer, periodontal &
acute onset disease oral diseases
Mechanisms of Pain
• Mechanism of modulation in tissues
(transduction)
• Mechanism of modulation in peripheral nerves
(transmission)
• Mechanism of modulation in the spinal cord
(modulation)
• Mechanism of modulation in the brain
(Perception)
Mechanisms of Pain
• Transduction occurs via activation of peripheral
nociceptors (skin, muscle, joint & viscera)
• Transmission occurs this impulse travels from the
primary afferent fiber to dorsal horn of the spinal cord
• Modulation occurs at the level dorsal horn of the spinal
cord
• Perception occurs when the is translation of the
stimulus into perceived pain in the brain (insular cortex)
Principles Of Pain Assessment

• Feline friendly handling techniques

• Understanding of feline behaviors
• The hospital environment : cat friendly clinic
• Clinical pain assessment incorporates : behavioral
changes, posture changes, palpation of wound, facial
expressions, demeanor
Acute pain Assessment
• If you cannot measure it, you cannot improve
it (Lord Kelvin)
• The key in treating pain is identify pain in the
patient
• Evaluation pain after the treatment
• Communication between veterinary and owner
• Pain assessment should be considered the
fourth vital sign after TPR assessment
Acute pain Assessment
• Pain assessment tools : Physiological &
behavioral indicator
• Physiological is not sensitive to
measurement pain
• Several scoring methods developed for
pain assessment
• Clinical metrology instrument : tools or
scale to scoring the degree of pain
Clinical metrology Instrument

Acute Pain Scoring Scale:

• The Colorado State University Acute Pain
Scale
• Glasgow Composite Measure Pain Scale
• UNESP Composite Pain Scale
• Feline Grimace Scale
Clinical metrology Instrument

Chronic Pain Scoring Scale :

• Feline musculoskeletal pain index
• Musculoskeletal pain screening
check list
• Montreal instrument for cat arthritis
testing
3 key points when assessing pain in cat
1. Cat demonstrating normal behavior?
2. Cat lost normal behavior after injury or
surgery ?
3. Cat develop new behavior after surgery or
injury?
Facial expression is an important indicator of
pain
Clinical Sign of Acute Pain in Cats
Behavioral Changes:
1. Licking lip and /or salivating
2. Hiding and/or at back of the cages
3. Not comfortable
4. Licking the wound
5. Growling & vocalizations
6. Aggressive
Clinical Sign of Acute Pain
• Postural Changes: tense, stiff, rigid,
hunched, arched back, head down
• Palpation of the wound: quick
turning, flinching, biting, aggression
vocalization
• Demeanor: ovoid people, avoid
petting
Clinical Sign of Acute Pain
Facial expressions:
• Orbital tightening ( narrowing of the orbital
area)
• Altered ear position ( tips of ears pulled apart
& rotated outward)
• Muzzle tension (flattening and stretching of
the muzzle)
• Tightly closed or squinted eyes
• Whisker pulled back
Pain or not pain?
Pain or not pain?
Pain or not pain?
Pain or not pain?
Feline Grimace scale (FGS)
• University of Montreal
• Download Phone App : Google play &
App store
• Download FGS Factsheet & the training
manual
• Based on changes in facial expressions
• Valid, fast, reliable & easy to use
• The scale for veterinarian & cat owners
Feline Grimace scale (FGS)
• FGS composed of 5 action : Ear position,
Orbital tightening , Muzzle tension, Whiskers
change & Head position
• Rate each action unit from 0 until 2
• 0 = absent
• 1 = moderately present
• 2 = markedly present
• Analgesic/pain killer when the score => 4
Colorado pain Scale
• Colorado State University
• Pain Score from 0 (no pain) until 4 (pain)
• Physiological & behavioral, response to
palpation and body tension
• Clinic /veterinarian : appetite, hair coat,
posture, vocalization, facial expressions,
response to palpation & body tension
• Owner : change in normal routine
Glasgow Composite Measure Pain Scale

• Universities of Glasgow &

Edinburgh Napier
• 28 descriptors options within
6 behavioral categories
Glasgow Composite Measure Pain Scale
• Vocalization
• Posture/activity
• Attention to wound or painful area
(surgical site)
• Facial expressions ( ear & muzzle)
• Response to touch
• Demeanor
Glasgow Composite Measure Pain Scale
• Maximal score is 20
• Useful indicator of analgesic
requirement
• Recommended analgesic/pain killer
in level 5/20
Frequency of pain Assessment
• Patient status
• Type of surgery and medical status
• Pain severity
• Hospitalization
• Individual response to analgesic
• Age
• Temperament
• Illness and residual anesthetic effects
Management of Acute Pain
Concept of Treatment of Acute Pain
• Preemptive analgesia : analgesic drugs before tissue damage
• Preventive analgesia : analgesic drug pre, intra and post surgery
(in the clinic & at home)
• Multi-modal analgesia : pharmacological & non-pharmacological
(integrative approach)
Pharmacological
• NSAIDs
• Local anesthesia
• Opioids
• Agonists alfa adrenergic
receptors
• Ketamine
• Gabapentin
Non-Pharmacological
• Cold therapy
• Warm, clean & comfortable
bedding
• Quite environment
• Gentle stroking & positive
interaction
• Providing hiding space &
elevated surface
Drugs à Treatment Acute Pain
NSAIDs: Opioids:
1. Carprofen 4 mg/kg, q 24 hours SC 1. Morphine 0,2-0,5mg/kg q 4-6 hours
2. Robenacoxib 2 mg SC followed 1mg/kg IM, IV, epidural
for 3-6 days PO, q 24 hours 2. Methadone 0,3-0,5 mg/kg q 4 hours
3. Meloxicam 0,2 mg SC followed 0,05 IM, IV
mg/kg PO q 24 hours for 3-5 days 3. Tramadol ec2-6 mg/kg q 6-8 hours
4. Tolfenamic acid 4mg/kg SC/PO q 24 IM/IV/PO
hours for 3-5 days 4. Fentanyl inject Bolus 1-3 ug/kg + CRI
5. Ketoprofen 2mg/kg once SC, followed 5-15 ug/kg/hour IV
PO 1mg/kg q 24 hours 5 days 5. Butorphanol 0,2-0,4 mg/kg q 1-2
hours IM/IV
Drugs à Treatment Acute Pain
Agonists alfa adrenergic receptors: Local Anesthetics :
1. Medetomidine 6-40 ug/kg IM, IV 1. Bupivacaine not exceed 2mg/kg
2. Xylazine 02 -1mg/kg IM, IV (4-6 hours)
Ketamine bolus 0,5 mg/kg followed CRI 10-30 2. Lidocaine not exceed 5-10 mg/kg
ug/kg/minute IV (1-2 hours)
Gabapentin àpremedication at home , anxiety &
stress during transportation
Note : Attention for adverse effect of each
analgesic
Assessment Chronic Pain
• No full validated pain scoring to assess
chronic pain
• Based on owner reported sign
• Client communication is important in
diagnosis
• The cat shows no chronic pain-induced
behavior changes in the examination
room
Assessment Chronic Pain
• Clinical chronic pain mixture of different types
of pain : inflammatory, neuropathic &
functional pain
• Degenerative joint disease, (DJD) &
osteoarthritis, dental & oral disease, neoplasia,
CKD, IBD etc
• Challenging : differences in pain mechanisms
with underlaying primary disease
Clinical sign & behavior Changes of Chronic pain

• Decreased mobility • Mood alteration decreased

• Decreases ability to perform activity or increased grooming
• Isolation • Appetite alteration
• Depression • Sensitivity to touch
• Irritation
Degenerative Joint Disease & Osteoarthritis
Clinical sign :
1. Decrease mobility
2. Altered movement
3. Less grooming
4. Hiding & decreased or
altered socialization
5. Changes in litter box use
Assessment Chronic pain: DJD & OA
Feline musculoskeletal pain index
• 17 questions (jumping, up & down, playing with toys, grooming)
• Owner & clinical practice
Assessment Chronic pain: DJD & OA
Client Specific Outcome Measures
No item to be scored, 3 activities observed in home environment:
1. Jumping onto the kitchen counter for the food without bench
2. Playing with the string at night in the living room without losing
interest after 2 minutes
3. Using litter box in the basement in the morning
Cancer
• Acute (inflammation pain) & chronic pain (neuropathic pain)
• Inflammatory pain caused by tissue growth & destruction of
adjacent tissue & structure
• Neuropathic pain caused nerve compression or primary
tumor in nerve system
• Assessment acute pain scale (Colorado, Glasgow)
• Multiple method : observation, (vet & owner), physical
examination (palpation the wound), physiological variable
Management of Chronic Pain
• Chronic pain causes suffering & reduces quality of life
• Improving the patient quality of life
• Multimodal approach : pharmacological and non pharmacological
• Appropriate assessment, identification primary cause, diagnosis &
treatment
• Client communication
• Prevent acute pain become chronic pain: preemptive analgesia &
continue provide analgesia for sufficient length of time
Pharmacological
• DJD/OA related pain: NSAIDs, tramadol, gabapentin, antidepressant
• Cancer related pain: NSAIDs as needed, gabapentin if neuropathic pain,
anti depressant, amantadine, buprenorphine
• Periodontal disease: NSAIDs as needed, gabapentin if there is nerve
involvement
• Chronic otitis: NSAIDs, gabapentin if there is nerve involvement
Pharmacological
• NSAIDs : meloxicam & robinacoxib, piroxicam
• Piroxicam : 1mg/cat (0,3 mg/kg) q 24 hours
PO (analgesic and anti cancer with other
therapies)
• Pamidronate : 1-2 mg/kg q 21-28 days IV
(analgesic and anti cancer with other
therapies)
• Gabapentin : 5-10mg/kg q 6-12 hours PO
Non Pharmacological
• DJD/OA related pain : physical activity & weight control, implement
environmental enrichment, chondroprotective agent, physical therapy,
rehabilitation, acupuncture, laser
• Cancer related pain : cold therapy, acupuncture, rehabilitation, surgery for
pain management, nutrition, hygiene, happiness, mobility
• Periodontal disease : dental extraction, provide soft food, add water in the
kibble, laser, acupuncture
• Chronic otitis : ear cleaning, surgery
Summary
• Pain is an illness that can be recognized and effectively managed in most cases
• Pain is the fourth vital sign and should be incorporated into the TPR (temperature, pulse,
respiration) assessment of every patient
• Preventive and multi-modal analgesia should always be considered
• Principles of pain management include preventive analgesia, multimodal analgesia
• Treatment of pain should always include pharmacological and non-pharmacological
therapies
• The use of cat friendly handling techniques, anxiolysis and nursing care are central to
appropriate pain management
THANK YOU