The Ouch Factor
Pain management is great medicine and good business. It gets even better when the client is an informed partner.
Not that long ago, I went to the ER with my dad, who had heart-related symptoms: weakness, shortness of breath, lightheadedness. As he was being admitted, after his temperature, pulse, respiration and blood pressure were noted, the admitting nurse asked: “On a scale of 0 to 5, please rate your pain.” The medical record had a big red box in which to note the score. Pain had become the fifth vital sign for people.
As veterinarians, we need to ask a similar question during our collection of patient data: “On a scale of 0 to 5, please rate your pet’s pain.” And to go one step further, we must anticipate the pain based on the condition or procedure and treat it accordingly.
Pain management is great for your patients, expected by their owners and good for business.
The Standard Of Care
The management, prevention and treatment of pain should be a written, documented and adhered-to standard in your practice. Consider the following statement:
“At ABC Animal Hospital, we believe that no animal should suffer from pain. To that end, we will assess pain upon presentation of all cases, pre-emptively treat pain prior to any procedure, maintain pain management during any procedure, and determine short- and long-term treatment plans for pain in all cases.
“A minimum standard will be accepted by all clinicians; however, the level of care may be escalated based upon the patient’s needs and the nature of the condition under treatment.
“All treatment plans will include pain management at an appropriate level.
“All pain management plans will be completely and thoroughly communicated to clients with explanations of which medications have been chosen and why.”
A similar statement should be posted on your website, shared with clients and committed to by all team members. It serves as an expectation of your practice and possibly of both your practice act and state veterinary medical board.
A Quick Overview
Practitioners have a plethora of pain management options:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Alternative painkillers such as gabapentin and trazodone
- Local injections of pain medications
- Alternative modalities
Here are two rules of thumb:
- Make sure all your treatment estimates include pain management.
- Make sure all your desexing procedures include pain management.
Think about pain management from a breed and species standpoint. Which breeds seem more sensitive to pain? Consider hunting dogs versus toy breeds. Does one have a different pain threshold? Is one more stoic? Be careful not to overestimate the pain in a small breed or underestimate the pain in a large breed.
Also, think about pain management from a diagnosis standpoint. How painful would you consider any of these conditions?
- A hot spot
- Fractured carnassials
- A broken toenail
With a diagnosis in mind, plan a minimal pain management program. And of course, clearly and transparently communicate your plan to the pet owner and explain why.
Long-Term Pain Management
With some conditions or procedures, pain is relatively short term. But with conditions such as osteoarthritis or intervertebral disc disease, the pain might be chronic and long term.
As you determine short- and long-term treatment plans, you need to understand both the short- and long-term side effects. This means setting standards for how you follow up on prolonged pain management cases. Most of the current medications for pain attenuation have few side effects, but anything can happen in a given case. As the clinician in charge, you need to know about a medication’s possible effects on a pet’s liver and kidneys. You must plan the monitoring of side effects and explain your approach to the client.
Questions to ask yourself when determining a long-term pain management standard of care include:
- What side effects have been reported with the medication?
- Which breeds, if any, have shown a greater predilection to suffer side effects?
- How can I monitor the side effects using routine testing?
- When do I want to run monitoring tests? How long after starting the drug?
- How do I communicate the plan to the client?
- How do I charge the client for the tests and visits?
A long-term medication plan is good for the patient, client and practice, but it must be communicated from the start to prevent a frustrated or disgruntled client.
Remember the pain score I mentioned at the start? It needs to be updated routinely and can be done through follow-up communication with the client, either by phone call, email, text or telemedicine. A client who sees improvement might be tempted to take a pet off of a medication without consulting you. By staying in touch with the client, you can ensure that the pet is doing well and that the medication is being given.
With pain being another vital sign, you wouldn’t expect client compliance to be an issue. However, since pets don’t take medications on their own — accidental ingestion is the exception — the owner is responsible for purchasing and administering the drugs. Thus, you need to make sure the pet owner is actually administering the meds.
Make Refills Easy
Client compliance is easier if getting the medications is easier. Assuming that follow-up tests and examinations are being performed, how can you help get medications into the pet owner’s hands? Here are six ways.
- Make notes in the medical records that a medication may be refilled “X” number of times over a finite period. For example: “OK to refill 60 pills per month for six months, after which an exam and a full profile are needed.” Doing this allows your staff to refill a medication without having to get the doctor’s approval. (Refer to your state practice act and hospital policy for more on this.)
- Automatically send refills at the appropriate time. Have a credit card on file to do so, and call or email or text before sending the refill.
- Use your online pharmacy to allow for periodic refills.
- If administering medication is problematic, consider having it compounded, especially with feline patients.
- Have a dedicated phone number or email address for refill requests along with a dedicated staff member who understands your policies.
- Clearly communicate the treatment plan from Day One when a chronic medication is involved. Handouts and website resources are useful.
Pain management should be considered a profit center at your practice. Alternative treatments should be considered, too. They include:
- Cold laser therapy
- Physical therapy and rehabilitation
- Cannabinoids, glucosamine and chondroitin
Do your due diligence on all the options. Learn about the pros and cons, the side effects, and any additional education you might need to provide alternative pain management.
Considering pain management from a multimodal, multifaceted angle can expand the choices for pet owners and your practice.
Dr. Peter Weinstein owns PAW Consulting and is the executive director of the Southern California Veterinary Medical Association. He serves as chair of the American Veterinary Medical Association’s Veterinary Economics Strategy Committee. The podcast “Peter & Phil’s Courageous Conversations,” a dialog between Dr. Weinstein and Dr. Phillip Nelson, is available through all major podcast providers.
BE THE NO. 1 CHOICE
Your clients would love to have you fill their pets’ prescriptions. Frequently, however, they find somebody who is easier to deal with. How do you get the love back? By establishing an online store to fill and refill prescriptions and provide the convenience of home delivery.
An online pharmacy often has lower labor and overhead costs compared with an on-site pharmacy. The savings will allow you to reduce prices and net the same income. With an online store, you can schedule auto-refills so that prescriptions are sent automatically. And, of course, your store is open when your clinic isn’t.
Make sure the medical records clearly define the refill parameters — how often and how much medication before a doctor needs to reauthorize the prescription.
Keep it easy. Make it convenient. Work on affordability. You can easily be the No. 1 choice if you meet the needs of your clients.
PLAYING DOCTOR COMES WITH RISKS
The internet, friends and a lack of common sense frequently lead pet owners into trouble. When veterinarians aren’t the go-to health care provider for a pet, an owner might seek shortcuts for the treatment of an animal’s pain and discomfort. If the drug works for the person, it works for Garfield, right? If I’m 150 pounds and Garfield is 15, I can give him one-tenth of my pill and he’ll feel better, right? We all know such logic can be dead wrong.
Pet owners must be taught that their medications are not the pet’s. It’s best to teach clients proactively. Consider posting a notice on your website about the risks of playing pet doctor and how different medications can harm a pet. Also, outline which drugs a pet owner can safely administer and how much to give.
What’s interesting is that clients might personally use the antibiotics you prescribed for their cats but can’t give Tylenol to the cats.
When pet owners call, warn about the risks of self-medicating cats. The question you usually get is, “Is there anything I have at home that I can give
for his pain?” Your team needs to read from a script that warns of the adverse side effects when the wrong medication or wrong dosage is given. And for pet owners who ask,
“Is it OK that I gave him Tylenol?” you need a second script about immediately bringing the pet to your clinic or an emergency hospital.