Zero Pain Philosophy (Zero Pain Philosophy)

Earlier this year Matt joined the guys from The Vet Vault to chat all things chronic pain management. In this episode we chat about the use of ketamine subcutaneously for chronic pain. 

In this episode, Matt reviews the literature on gabapentin in cats. Does the science support our use of gabapentin as an analgesic. How does gabapentin work? To end, Matt reports a recent study he conducted examining the anxiolytic benefit of gabapentin in hyperthyroid cats. 

Find the show notes with all references on the Pain Updates page. 

Spoiler alert - you need to listen to this podcast to understand if there is a place for subcutaneous methadone in veterinary clinical practice!

In this edition, Matt reviews the first paper that investigated pharmacokinetics of subcutaneous methadone and first raised the question of using this route in dogs. Matt then chats to anaesthesia specialist Aoife Ryan about a study they performed together to attempt to enhance our understanding around this topic. With Carl, we then chat through a recent publication examining this route of administration in dogs.

For more on methadone, please see our pain update 'Methadone, the most versatile opioid' here

https://www.zeropainphilosophy.com/post/methadone-the-most-versatile-opioid

Need more detail? You can watch this webinar on methadone

https://www.zeropainphilosophy.com/members-webinars

References discussed in this podcast

Bini G, Vettorato E, De Gennaro C, Corletto F. A retrospective comparison of two analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs. Vet Anaesth Analg. 2018 Jul;45(4):557-565. doi: 10.1016/j.vaa.2017.11.005.

Ingvast-Larsson C, Holgersson A, Bondesson U, Lagerstedt AS, Olsson K. Clinical pharmacology of methadone in dogs. Vet Anaesth Analg. 2010 Jan;37(1):48-56. doi: 10.1111/j.1467-2995.2009.00476.x.

Ryan AC, Murrell JC, Gurney MA. Post-operative nausea and vomiting (PONV) observed in a clinical study designed to assess the analgesic effects of intravenous and subcutaneous methadone in dogs. Vet J. 2022 Sep;287:105876. doi: 10.1016/j.tvjl.2022.105876.

Upchurch D, Lin KTT, KuKanich B. Two doses of subcutaneous methadone for postoperative analgesia in dogs undergoing tibial plateau levelling osteotomies. J Small Anim Pract. 2024 Jun;65(6):368-375. doi: 10.1111/jsap.13728.

NMDA antagonists are excellent additions to chronic pain management. Why would you choose either? How do they work and what evidence do we have? In this edition of our member podcast, Matt reviews the use of these drugs and how they can help your patients. 

As a complementary supplement to Ian Self's webinar on CBD and our pain update, Matt has reviewed two of the papers on CBD in dogs. For people CBD comes with celebrity endorsement, but is this all there is to it? What does the evidence say? 

Recently Matt joined the team at Vet Vault to discuss analgesic management of Caesarean sections - amongst other things! You'll enjoy this lively discussion! 

What is ERAS? What are the principles and components of ERAS? In this podcast Carl will explore these questions, some of the medical and veterinary literature and explain how we can incorporate this into our everyday clinical practice and pain management protocols.

Your learning outcomes for this podcast are;

Understand what ERAS is

Learn how some published studies can be used to practice ERAS in your clinic

Your option for reflection

Consider how you can incorporate ERAS into your daily practice

References

The references and further information are all contained within our Pain Update, which you can read here.

https://www.zeropainphilosophy.com/post/enhanced-recovery-after-surgery

Matt joins Hugh and Gerardo from Vet Vault to discuss bedinvetmab, in one of three podcasts on OA management. 

In this Vet Vault chat, Matt talks to Hubert and Gerardo about our second line options in OA. We cover amantadine and discuss is there room for tramadol? 

In this podcast we will review a recent study examining the use of lumbosacral epidural injection in dogs undergoing caesarian section, exploring the pros and cons of this technique.

Always a popular topic, we decided to go back to the literature to guide your use of tramadol for post operative pain control. 

In our latest podcast, Modifying the Microbiome to Minimise Pain, Matt talks to Dr Siobhain O’Mahony, a leading academic in microbiome research. Dr O’Mahony has published work within human medicine, examining the link between the microbiome and pain outcomes after surgery. And we ask, ‘How could this translate into our field of veterinary pain management?’ 

We also touch upon what we should eat ourselves and ask whether we are feeding our pets correctly.

References for shownotes

The gut microbiota as a key regulator of visceral pain (2017)

The gut microbiota in persistent post-operative pain following breast cancer surgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11137075/

Stevens, Christina et al. “Gut Microbiome and Osteoarthritis: Insights From the Naturally Occurring Canine Model of Osteoarthritis.” Arthritis & rheumatology (Hoboken, N.J.), 10.1002/art.42956. 19 Jul. 2024, doi:10.1002/art.42956

Stewart, H L et al. “Differences in the equine faecal microbiota between horses presenting to a tertiary referral hospital for colic compared with an elective surgical procedure.” Equine veterinary journal vol. 51,3 (2019): 336-342. doi:10.1111/evj.13010

Stewart, Holly L et al. “Changes in the faecal bacterial microbiota during hospitalisation of horses with colic and the effect of different causes of colic.” Equine veterinary journal vol. 53,6 (2021): 1119-1131. doi:10.1111/evj.13389

Jan S Suchodolski

https://pubmed.ncbi.nlm.nih.gov/34514619/

The Dysbiosis Index (DI) is a validated quantitative PCR assay for canine fecal samples that measures the abundance of seven important bacterial taxa and summarizes the results as one single number. 

The DI can be used to assess the microbiome in clinical patients over time and in response to therapy (eg, fecal microbiota transplantation).

Our December podcast presents the results of our latest Zero Pain Insight looking at grapiprant prescribing considerations. 

Meet Prof Paulo Steagall. Hear about his career, where the feline grimace scale developed from, and what the future of the FGS is.

In this episode, Matt & Carl chat through all things relating to feline pain scoring with Paulo and explore a number of questions. Where does AI fit with the future of the feline grimace scale? Can pet owners use the feline grimace scale?

Are cats difficult to pain score?

The podcast takes a look at how pain scoring is just one part of the picture of enabling us to give optimal care to our feline patients.

Listen to Paulo’s reflections on burprenorphine and how the use of the FGS has enhanced our understanding

Show notes below are the papers that we refer to within the podcast and you can link to the mentioned pain scale resource here

Steagall PV, Robertson S, Simon B, Warne LN, Shilo-Benjamini Y, Taylor S. 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats. J Feline Med Surg. 2022 Jan;24(1):4-30. doi: 10.1177/1098612X211066268. PMID: 34937455.

Steagall PV, Monteiro BP. Acute pain in cats: Recent advances in clinical assessment. J Feline Med Surg. 2019 Jan;21(1):25-34. doi: 10.1177/1098612X18808103. Epub 2018 Oct 15. PMID: 30320529.

Marangoni S, Beatty J, Steagall PV. An ethogram of acute pain behaviors in cats based on expert consensus. PLoS One. 2023 Sep 28;18(9):e0292224. doi: 10.1371/journal.pone.0292224. PMID: 37768967; PMCID: PMC10538801.

Evangelista MC, Watanabe R, Leung VSY, Monteiro BP, O'Toole E, Pang DSJ, Steagall PV. Facial expressions of pain in cats: the development and validation of a Feline Grimace Scale. Sci Rep. 2019 Dec 13;9(1):19128. doi: 10.1038/s41598-019-55693-8. PMID: 31836868; PMCID: PMC6911058.

Steagall PV, Monteiro-Steagall BP, Taylor PM. A review of the studies using buprenorphine in cats. J Vet Intern Med. 2014 May-Jun;28(3):762-70. doi: 10.1111/jvim.12346. Epub 2014 Mar 21. PMID: 24655078; PMCID: PMC4895465.

Watanabe R, Frank D, Steagall PV. Pain behaviors before and after treatment of oral disease in cats using video assessment: a prospective, blinded, randomized clinical trial. BMC Vet Res. 2020 Apr 10;16(1):100. doi: 10.1186/s12917-020-02302-w. PMID: 32272922; PMCID: PMC7146962.

Watanabe R, Doodnaught G, Proulx C, Auger JP, Monteiro B, Dumais Y, Beauchamp G, Segura M, Steagall P. A multidisciplinary study of pain in cats undergoing dental extractions: A prospective, blinded, clinical trial. PLoS One. 2019 Mar 1;14(3):e0213195. doi: 10.1371/journal.pone.0213195. PMID: 30822336; PMCID: PMC6396900.

Monteiro BP, Lee NH, Steagall PV. Can cat caregivers reliably assess acute pain in cats using the Feline Grimace Scale? A large bilingual global survey. J Feline Med Surg. 2023 Jan;25(1):1098612X221145499. doi: 10.1177/1098612X221145499. PMID: 36649089.

Belli M, de Oliveira AR, de Lima MT, Trindade PHE, Steagall PV, Luna SPL. Clinical validation of the short and long UNESP-Botucatu scales for feline pain assessment. PeerJ. 2021 Apr 12;9:e11225. doi: 10.7717/peerj.11225. PMID: 33954046; PMCID: PMC8048399.

Zero Pain Philosophy is an educational resource for vet professionals. If you are a pet owner, please encourage for vet to connect with us. We are unable to offer advice direct to pet owners.

In this month’s members podcast we will be talking about the use of lidocaine as an intravenous infusion and its impact on survival following septic peritonitis in dogs. In this episode Carl will review a 2016 study on survival of dogs with septic peritonitis.

Our November podcast explores the use of fentanyl transdermal patches in dogs and cats. 

If you are thinking about intra-articular therapies, where do you start? In this episode Matt chats to the Vet Vault team about where he sees IA therapies fit with Oa management

Professor Clare Rusbridge is a global thought leader in the management of syringomyelia, Chiari malformation and phantom scratching. To assist vets in treatment of these conditions, Clare has recently updated and released her 2024 treatment algorithms. In this episode, Matt discusses the new algorithms with Clare, as well as ensuring we have our diagnosis correct and also looking to the future with these diseases.

You can read the treatment algorithms here:

https://veterinary-neurologist.co.uk/cmsm-new-treatment-algorithm-2024/

This is the link to the symptom checker:

https://veterinary-neurologist.co.uk/chiari-checker/

Find Clare's YouTube channel here:

https://www.youtube.com/@clare-neurovet

Link to Head Space project:

https://www.surrey.ac.uk/research-projects/head-space-project-canine-chiari-group

This month we review two studies comparing different methods to confirm correct epidural injection placement in dogs in sternal and lateral recumbency.

Understand how to incorporate pre visit sedation protocols with your cat or dog friendly approach

This podcast complements the pre-visit medication protocols that we have on Zero Pain Philosophy

Learn how to interpret some of the behaviours that anxious dogs are showing in the hospital and how our interactions with those pets are 90% of the solution

Review the pre-visit and hospital sedation protocols created by Dr Matt Gurney & Dr Sarah Heath first, as you listen to this podcast

Find the sedation protocols at www.zeropainphilosophy.com. Please note access is limited to veterinary professionals and we are unable to answer advice queries from pet owners. Please contact your vet. 

For information on behavioural medicine support from Behaviour Referrals Veterinary Practice please visit https://behaviouralreferrals.co.uk/

References

Mills, Daniel S et al. “Pain and Problem Behavior in Cats and Dogs.” Animals : an open access journal from MDPI vol. 10,2 318. 18 Feb. 2020, doi:10.3390/ani10020318

Tooley, Carrie, and Sarah E Heath. “Emotional Arousal Impacts Physical Health in Dogs: A Review of Factors Influencing Arousal, with Exemplary Case and Framework.” Animals : an open access journal from MDPI vol. 13,3 465. 28 Jan. 2023, doi:10.3390/ani13030465

Continuing our OA series, the Zero Pain & Vet Vault teams chat about the role of NSAIDs and grapiprant in management of your OA cases. 

It's been two years since bedinvetmab was launched as a treatment for the pain associated with osteoarthritis - quickly followed by frunevetmab. During that time Matt has lectured around the world on the topic. This podcast brings together a number of questions that have been raised as part of those lectures - and we always say that if someone has a question, then 10 are people are thinking the same thing!

After this podcast you will have a better understanding of the anti nerve growth factor agents. If you have questions, we would love to help. Please use the contact box to send us a message.

Don't forget that we offer a telemedicine service - so for case advice, please ask for our help!

Reflective learning

What further questions does this podcast content raise for you?

How will this understanding impact the management of your current and future patients?

Learning actions

Revise the mechanism of action of anti nerve growth factor agents (both references below)

Review the data sheet (summary of product characteristics) for bedinvetmab (Librela/Beransa) and frunevetmab (Solensia).

Practice discussion

As a practice team do we feel that anti-NGF agents are a first line treatment for OA in dogs and cats?

References

Enomoto M, Mantyh PW, Murrell J, Innes JF, Lascelles BDX. Anti-nerve growth factor monoclonal antibodies for the control of pain in dogs and cats. Vet Rec. 2019 Jan 5;184(1):23. doi: 10.1136/vr.104590. Epub 2018 Oct 27. PMID: 30368458; PMCID: PMC6326241.

Schmelz M, Mantyh P, Malfait AM, Farrar J, Yaksh T, Tive L, Viktrup L. Nerve growth factor antibody for the treatment of osteoarthritis pain and chronic low-back pain: mechanism of action in the context of efficacy and safety. Pain. 2019 Oct;160(10):2210-2220. doi: 10.1097/j.pain.0000000000001625. PMID: 31145219; PMCID: PMC6756297.

Join Matt & Carl as we discuss the two papers here that document the difference between using pregabalin and gabapentin after spinal surgery in dogs.

Reflective learning

After listening to this podcast do you see a place for gabapentinoids in the management of pain following spinal surgery?

How will this understanding impact the management of your current and future patients? 

Learning actions

Watch Gwen Covey Crump's webinar on gabapentinoids.

Watch Matt's webinar on descending modulation which explores the mechanism of action of gabapentinoids.

Practice discussion 

As a practice team discuss your use of gabapentinoids.

References

Aghighi SA, Tipold A, Piechotta M, Lewczuk P, Kästner SB. Assessment of the effects of adjunctive gabapentin on postoperative pain after intervertebral disc surgery in dogs. Vet Anaesth Analg. 2012 Nov;39(6):636-46. doi: 10.1111/j.1467-2995.2012.00769.x. Epub 2012 Aug 10. PMID: 22882632.

Almeida et al (2023) Evaluation of Gabapentin in the Treatment of Postoperative Pain after a Tibial Plateau Levelling Osteotomy in Dogs DOI https://doi.org/

10.1055/s-0042-1751069.

Crociolli GC, Cassu RN, Barbero RC, Rocha TL, Gomes DR, Nicácio GM. Gabapentin as an adjuvant for postoperative pain management in dogs undergoing mastectomy. J Vet Med Sci. 2015 Aug;77(8):1011-5. doi: 10.1292/jvms.14-0602. Epub 2015 Mar 29. PMID: 25816802; PMCID: PMC4565804.

Schmierer, P. A., Tünsmeyer, J., Tipold, A., Hartnack-Wilhelm, S., Lesczuk, P., & Kästner, S. B. R. (2020). Randomized controlled trial of pregabalin for analgesia after surgical treatment of intervertebral disc disease in dogs. Veterinary Surgery, 49(5), 905–913. https://doi.org/10.1111/vsu.13411