Pain Management for Veterinary Technicians and Nurses

Stephen Niño Cital, RVT, RLAT, SRA, CVPP, VTS-LAM, is a Veterinary Technician Specialist in Research Anesthesia and Certified Veterinary Pain Practitioner. He is a Lab Manager for Howard Hughes Medical Institute at Stanford University and is an administrator for the Veterinary Anesthesia Nerds, LLC. Stephen is also a partner at Remedy Veterinary Specialists leading the pain service in the San Francisco Bay Area of California. Tasha McNerney, CVT, CVPP, VTS, is a Veterinary Technician Specialist in Anesthesia and Analgesia and a Certified Veterinary Pain Practitioner. She is a board member of the International Academy of Pain Management and founder of Veterinary Anesthesia Nerds. She is the Training Director at a large specialty referral hospital in the Philadelphia area. Darci Palmer, BS, LVT, VTS, is a Veterinary Technician Specialist in Anesthesia and Analgesia and a Clinical Teaching Specialist at Tuskegee University College of Veterinary Medicine. She is Executive Secretary for the Academy of Veterinary Technicians in Anesthesia and Analgesia and Administrator for Veterinary Anesthesia Nerds. She works as a private consultant, author, and lecturer in Auburn, AL.

• List of Contributors xxiiiForeword xxviiAcknowledgments xxixAbout the Companion Website xxxi1 Advancing Veterinary Pain Management into a New Era 1Mary Ellen Goldberg1.1 Introduction 11.2 Brief History of Human Pain Management 11.3 Veterinary Pain Management Through the Centuries 31.4 Animal Research Contributions 31.5 History of Animal Nursing Staff 41.5.1 National Association of Veterinary Technicians in America Recognized Veterinary Technician Specialty Academies 41.6 Eyewitness to 50 Years of Changes for Veterinary Technicians 51.7 Veterinary Technician Pioneers in Pain Management 61.8 Future Directions for Veterinary Technician Pain Management 71.9 Conclusion 7References 72 Careers in Animal Pain Management 9Tasha McNerney and Stephen Niño Cital2.1 Introduction 92.2 Pain Management Certifications Available for Veterinary Technicians/Nurses 92.2.1 Certified Veterinary Pain Practitioner (CVPP) 92.2.2 Veterinary Technician Specialist (Anesthesia and Analgesia), and Veterinary Technician Specialist (Laboratory Animal Medicine – Research Anesthetist) 102.2.3 Veterinary Technician Specialist (Physical Rehabilitation) 112.2.4 Surgical Research Anesthetist (SRA) 112.2.5 The University of Tennessee Companion Animal Pain Management Certificate Program 112.2.6 AAHA Pain Management Guidelines Certificate Course (AAHA Pain Management Champion) 112.2.7 WSAVA Certificate in Pain Management 122.2.8 Canine Rehabilitation Veterinary Technician Certifications 122.2.9 Equine Rehabilitation Veterinary Technician Certifications 122.2.10 Certified Equine Massage Therapist 122.2.11 Animal Acupressure and Massage 122.2.12 TCVM Veterinary Technician Programs Offered by the Chi Institute 122.2.13 Animal Acupuncture 132.2.14 Low- Stress Certifications 132.2.15 Veterinary Anaesthesia and Analgesia (MSc), (PgDip), (PgCert), or (PgProfDev) 132.2.16 Canine Arthritis Management Practitioner (CAMP) 142.2.17 Certified Companion Animal Rehabilitation Therapist (CCAT) 142.3 Leveraging Veterinary Technicians in Pain Management 142.4 Conclusion 153 Pain Physiology and Psychology 17Stephen Niño Cital, Tasha McNerney, and Robin Saar3.1 Introduction 173.2 What Is “Pain” 173.2.1 The Negative Effects of Pain 183.3 Breaking Down the Nociceptive Pathway 183.3.1 Transduction 183.3.2 Transmission 203.3.3 Modulation 203.3.4 Perception 203.3.5 The Dorsal Horn 213.3.6 Ventral Horn and Intermediate Zone 233.3.7 White Matter 233.3.8 Descending Pathways 233.3.9 Spinothalamic Tract 233.3.10 Spinoreticular Tract 243.3.11 Peripheral Sensitization 243.3.12 Central Sensitization 243.4 The Endocannabinoid System and Pain 273.5 The Gate Control Theory 283.6 Psychological Aspects of Pain 293.6.1 Personality and the Pain Experience 293.6.2 Stress and Anxiety on Pain 293.6.3 Pain Catastrophizing 293.6.4 Boredom and Pain 303.6.5 Neuroplasticity and the Memory of Pain 313.6.6 Caregiver Placebo 313.7 Types of Pain 323.7.1 Somatic, Visceral, and Referred Pain 323.7.2 Physiological/Adaptive/Acute Pain 323.7.3 Pathological/Maladaptive/Chronic Pain 333.7.4 Neuropathic Pain 333.7.5 Radicular Pain 343.7.6 Chronic/Persistent Postsurgical Pain 343.7.7 Complex Regional Pain Syndrome 353.7.8 Social Resilience and Pain 353.8 The Microbiome and Pain Pathophysiology 353.8.1 What Is a Microbiome? 363.8.2 Determining “Healthy” in a Microbiome 373.8.3 Gut Microbiome Imbalance or Dysbiosis 373.8.4 The Gut- Brain Axis 383.8.5 Microbial Derived Mediators 383.8.6 Pathogen- Associated Molecular Patterns (PAMPs) 383.8.7 Microbial- Derived Metabolites 393.8.8 Neurotransmitters or Neuromodulators 393.8.9 Endocannabinoid Axis 413.8.10 Pain Medication and the Microbiome 42References 424 Integrating Pain Recognition and Scoring in Companion, Equine, Food and Fiber Species, and Exotic/Lab Animal Species 47Stephen Niño Cital, Ian Kanda, Taly Reyes, Jessica Birdwell, and Mary Ellen Goldberg4.1 Introduction 474.2 Pain Domains 484.2.1 Pain Intensity and Affect 484.2.2 Temporal Dimensions 484.2.3 Location and Bodily Distribution of Pain 484.3 Disposition and Personality 484.4 Breed or Species Bias 504.5 Dysphoria, Emergence Agitation, and Emergence Delirium 514.6 Placebo, Caregiver Placebo, and Placebo- by- Proxy 524.7 Non–species- specific Assessments 524.7.1 Quantitative Sensory Testing (QST) 524.7.2 Temporal Summation (TS) 534.7.3 Nociceptive Withdrawal Reflex (NWR) 534.7.4 Gait Analysis 534.7.5 Pain Biomarkers 534.7.6 Machine Learning and Artificial Intelligence (AI) 544.7.7 Activity Monitors (AMs) 544.7.8 Facial Expression or Grimace Scales 554.8 Clinical Pain Scoring Tools (Canine and Feline) 554.8.1 Canine Acute Pain Scoring 564.8.1.1 Glasgow Composite Measure Pain Scale – Short and Long Forms (CMPS) (Validated) 564.8.1.2 French Association for Animal Anesthesia and Analgesia Pain Scoring System (4A- Vet) (Validated) 584.8.1.3 University of Melbourne Pain Scale (UMPS) (Validated) 584.8.2 Canine Chronic Pain Scoring 584.8.2.1 Canine Brief Pain Inventory (CBPI) (Validated) 584.8.2.2 Helsinki Chronic Pain Index (HCPI) (Validated) 594.8.2.3 Liverpool Osteoarthritis in Dogs (LOAD) (Validated) 594.8.3 Feline Acute Pain Scoring 594.8.3.1 Glasgow Composite Measure Pain Scale- Short- Form (CMPS- SF) (Validated) 594.8.3.2 Feline Grimace Scale (FGS) (Validated) 604.8.4 Feline Chronic Pain Scoring 604.8.4.1 Client- specific Outcome Measures – Feline (CSOMf) (Validated) 604.8.4.2 Montreal Instrument for Cat Arthritis Testing- caretaker (MI- CAT-(c)) (Validated) 604.8.4.3 Feline Musculoskeletal Pain Index (FMPI) (Not Validated) 604.8.4.4 Oral Pain Scale – Canine/Feline (COPS–C/F) (Validated) 624.8.4.5 Cincinnati Orthopedic Disability Index (CODI) (Not Validated) 624.8.4.6 HHHHHMM Scale (Not Validated) 624.8.4.7 VetMetrica™ Health- related Quality of Life (HRQoL) (Validated) 624.8.4.8 Food and Fiber Species Pain Recognition and Scoring 634.9 Bovids 634.9.1 Indications of Pain in Cattle 714.10 Small Ruminants and Camelids 714.11 Swine 734.11.1 Normal Behavioral Observations in Swine 734.12 Equid Pain Recognition and Scoring 734.12.1 Horses 744.12.1.1 Appearance of the Normal Horse 744.12.1.2 Somatic Pain Indicators 754.12.1.3 Signs of Laminitis Pain Vary with the Progression of the Disease 754.12.1.4 Visceral Pain Indicators 754.12.1.5 Horse Grimace Scale 754.12.2 Donkeys 774.13 Exotic Species Pain Recognition and Scoring 774.13.1 Birds 774.13.2 Appearance of a Non- painful Bird 784.13.3 Appearance of a Painful Bird 784.13.4 Developing a Pain Score in Birds 814.14 Reptiles 824.14.1 Appearance of a Nonpainful Reptile 824.14.2 Appearance of a Reptile in Pain 824.14.3 Developing a Pain Score in Reptiles 834.15 Amphibians and Fish 844.15.1 Appearance of a Nonpainful Fish and Amphibian 844.15.2 Appearance of a Painful Fish and Amphibian 844.15.3 Developing a Pain Scoring Assessments in Fish and Amphibians 844.16 Small Exotic Mammals 854.16.1 Appearance of Nonpainful Small Exotic Mammals 854.16.2 Appearance of Painful Small Exotic Mammals 854.16.3 Developing a Pain Score in Small Exotic Mammals 85References 895 Analgesia Pharmacology 95Darci Palmer and Stephen Niño Cital5.1 Introduction 955.2 Definitions 955.3 Analgesic Drugs 965.4 Opioids 975.4.1 Full Opioid Agonists 975.4.2 Individual Drug Facts 995.4.2.1 Morphine 995.4.2.2 Meperidine (Pethidine) 995.4.2.3 Methadone 995.4.2.4 Hydromorphone 1005.4.2.5 Oxymorphone 1005.4.2.6 Fentanyl, Remifentanil, Sufentanil, Alfentanil, Carfentanil 1005.4.2.7 Fentanyl Patches 1005.4.2.8 Codeine 1015.4.2.9 Hydrocodone and Oxycodone 1015.4.2.10 Tramadol 1015.4.2.11 Tapentadol 1025.4.3 Partial Agonist Opioids 1025.4.3.1 Buprenorphine 1025.4.3.2 Simbadol 1045.4.3.3 Zorbium 1045.4.3.4 Sustained or Extended Release (SR or ER) Buprenorphine 1045.4.3.5 Buprenorphine Patches 1055.4.4 Agonist/Antagonist Opiods: Butorphanol and Nalbuphine 1055.4.5 Opioid Antagonists: Naloxone, Nalmefene, Naltrexone 1055.4.6 Mixing Opioids 1065.5 Non- steroidal Anti- inflammatory Drugs (NSAIDs) 1065.5.1 Washout 1085.5.2 Piprant Class 1085.6 Corticosteroids 1095.7 Cannabinoids 1095.8 Local Anesthetics 1105.8.1 Nocita 1105.8.2 Systemic Toxicity 1105.8.3 Lidocaine as a CRI 1115.9 Gabapeninoids 1115.9.1 Gabapentin 1115.9.2 Pregabalin 1125.10 Alpha- 2 Agonists 1125.10.1 Xylazine, Medetomidine, Dexmedetomidine, Romifidine, Detomidine 1125.10.2 Zenalpha® (Medetomidine and Vatinoxan) 1135.11 N- Methyl- D- Aspartate (NMDA) Antagonists 1145.11.1 Ketamine and Tiletamine 1145.11.2 Precautions/Contraindications 1155.11.3 Amantadine and Memantine 1155.12 Neurokinin- 1 Inhibitors 1155.13 Bisphosphonates 1165.14 Acetaminophen (Paracetamol) 1165.15 Frunevetmab (Solensia®) and Bedinvetmab (Librela®) 1175.16 Polysulfated Glycosaminoglycans (PSGAGs) 1175.17 Dipyrone (Metamizole) 1175.18 Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin– Norepinephrine Reuptake Inhibitors (SNRIs) 1185.19 Acepromazine 1195.20 Trazodone 119References 1196 Regional Anesthesia and Local Blocks 127Imeldo Laurel, Jeanette M. Eliason, Amy Dowling, Tasha McNerney, and Stephen Niño Cital6.1 Introduction 1276.2 Current Drug Options for Regional Anesthesia and Nerve Blocks 1286.2.1 Mixing Local Anesthetics 1296.2.2 Adjunctive Agents 1296.2.3 Volume Expansion, Onset Time, and Buffering 1296.2.4 Maximum Recommended Dose (MRD) 1306.2.5 Equipment Selection 1316.3 Dental and Facial Regional/Local Anesthesia 1336.4 Dentistry and Facial Blocking Techniques 1336.4.1 Inferior (Caudal) Alveolar Nerve Block (Extraoral/Intraoral) 1336.4.2 Middle Mental Foramen Nerve Block 1356.4.3 Infraorbital Nerve Block 1366.4.4 Major Palatine Block: Small Animal 1376.4.5 Caudal Maxillary Block 1386.4.6 Auriculopalpebral Nerve Block: Motor Blockade of the Eyelid 1386.4.7 Retrobulbar Block 1406.4.8 Frontal Nerve (Supraorbital Foramen) Block 1406.4.9 Auriculotemporal Block + Greater Auricular Block 1426.5 Common Regional and Local Anesthetic Techniques: Less Specified 1436.5.1 Intraperitoneal Lavage Technique for Dogs and Cats 1436.5.2 Incisional Line Block 1436.5.3 Circumferential Block 1446.6 Regional and Local Blocks of the Thorax and Abdomen 1446.6.1 Intercostal Blocks 1446.6.2 Interpleural Block 1466.6.3 Intratesticular and Spermatic Cord Block 1476.6.4 Sacrococcygeal Block 1476.6.5 Epidural 1496.6.6 Spinal Anesthesia 1536.6.7 Epidural Catheter 1536.6.8 Erector Spinae Plane Block (ESP) 1566.6.9 Thoracic Paravertebral Block 1576.6.10 Transverus Abdominis Plane (TAP) Block 1586.7 Blocks of the Limbs 1606.7.1 Femoral- Saphenous Nerve Complex Block 1606.7.2 Sciatic Nerve Block 1626.7.3 Brachial Plexus Block 1646.7.4 Radial, Ulnar, Median, and Musculocutaneous (RUMM) Nerve Blocks 1666.8 Common Equine Techniques 1676.8.1 Local Analgesia for Horse Castration 1676.8.2 Caudal Epidural in the Horse 1676.9 Common Production Animal Techniques 1686.9.1 Analgesia for Castration 1686.9.2 Cornual Nerve Block 1706.9.3 Analgesia for Livestock Epidural 1716.9.4 Local Anesthetic Blocks for Exotics and Laboratory Animals 174References 1757 Analgesia for Acute Pain 179Tasha McNerney, Melissa Streicher, and Karen Maloa Roach7.1 Introduction 1797.2 Fear, Anxiety, and Stress in the Acute Pain Response 1807.3 Multimodal Therapies 1807.4 Types of Acute Pain 1817.4.1 Surgical Pain 1817.4.1.1 Premedication 1827.4.1.2 Induction 1837.4.1.3 Maintenance 1837.4.1.4 Postoperative Analgesic Medications 1837.4.1.5 Pain Vacation 1847.4.1.6 Take- home Analgesics 1847.4.1.7 Local Anesthesia Techniques 1857.5 Creating an Effective Acute Pain Analgesic Plan 1857.5.1 Continuous Rate Infusions 1857.6 Analgesia Plans for Painful Procedures 1867.6.1 Reproductive Tract Surgery 1867.6.1.1 Premedication 1877.6.1.2 Regional Anesthesia 1877.6.1.3 Maintenance 1877.6.1.4 Postoperative Analgesic Plan 1877.6.1.5 Home Medications 1877.6.2 Analgesia for Surgery Involving the Eye 1887.6.2.1 Premedication 1887.6.2.2 Regional Anesthesia 1887.6.2.3 Maintenance 1887.6.2.4 Postoperative Analgesic Plan 1887.6.2.5 Home Medications 1887.6.3 Analgesia Techniques for Surgery Involving the Ear 1897.6.3.1 Premedication 1897.6.3.2 Regional Anesthesia 1897.6.3.3 Maintenance 1897.6.3.4 Postoperative Analgesic Plan 1897.6.3.5 Home Medications 1897.6.4 Gastrointestinal Procedures or Acute Abdominal Pain 1907.6.4.1 Premedication 1907.6.4.2 Maintenance 1907.6.4.3 Regional Anesthesia 1907.6.4.4 Postoperative Analgesic Plan 1917.6.4.5 Home Medications 1917.6.5 Thoracic Procedures 1917.6.5.1 Premedication 1917.6.5.2 Maintenance 1927.6.5.3 Regional Anesthesia 1927.6.5.4 Postoperative Analgesic Plan 1927.6.5.5 Home Medications 1927.6.6 Protocols for Patients with Cranial Disease, Injury, or Neurosurgery 1937.6.6.1 Premedication 1947.6.6.2 Maintenance 1947.6.6.3 Regional Anesthesia 1947.6.6.4 Postoperative Analgesic Plan 1947.6.6.5 Home Medications 1947.6.7 Analgesia Protocols for the Patient with Urinary Disease 1947.6.7.1 Premedication 1947.6.7.2 Regional Anesthesia 1957.6.7.3 Maintenance 1957.6.7.4 Postoperative Analgesic Plan 1957.6.7.5 Home Medications 1957.6.8 Minimally Invasive Procedures 1957.6.8.1 Premedication 1957.6.8.2 Regional Analgesia 1967.6.8.3 Maintenance 1967.6.8.4 Postoperative Analgesic Plan 1967.6.8.5 Home Medications 1967.7 Orthopedic Procedures 1967.7.1 Orthopedic Procedures of the Forelimb 1967.7.1.1 Premedication 1967.7.1.2 Maintenance 1967.7.1.3 Regional Anesthesia 1967.7.1.4 Postoperative Analgesic Plan 1977.7.1.5 Home Medications 1977.7.2 Hindlimb Amputation, Spinal Disease, Spinal Surgery, and Pelvic Fracture Repair 1977.7.2.1 Premedication 1987.7.2.2 Maintenance 1987.7.2.3 Regional Anesthesia 1987.7.2.4 Postoperative Analgesic Plan 1987.7.2.5 Home Medications 1987.7.3 Surgery of the Tail 1987.7.4 Mandibulectomy/Maxillectomy 2007.7.4.1 Inferior Alveolar (Mandibular) Blocks 2007.7.4.2 Maxillary Blocks 2007.8 Postoperative Patient Evaluation 2017.9 Management of Painful Dermatologic Conditions 2017.9.1 Sensory Perception in the Skin 2027.9.2 Recognizing Cutaneous Discomfort 2027.9.3 Painful and Pruritic Cutaneous Conditions 2037.9.3.1 Allergic Skin Disease 2047.9.3.2 Skin Infections 2047.9.3.3 Autoimmune and Immune- mediated Dermatopathies 2067.9.3.4 Cutaneous Burns 2077.9.4 Treatment of Cutaneous Pain and Pruritus 2117.10 Conclusion 212References 2128 Analgesia for the Pregnant, Neonatal, and Pediatric Patient 217Darci Palmer and Natalie Pedraja8.1 Introduction 2178.1.1 Pain Management During Pregnancy 2178.1.2 Analgesic Drugs Used During Pregnancy and C- Sections 2188.1.2.1 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 2198.1.2.2 Opioids 2198.1.2.3 Alpha- 2 Agonists 2218.1.2.4 Dissociative Agents 2228.1.2.5 Local and Regional Blocks 2228.2 Postoperative Analgesia 2248.3 Anesthesia and Analgesia Case Management for a Cesarean Section 2248.4 Pain Management for Neonates and Pediatrics 2278.4.1 Insulting the Neonatal Pain Pathways 2278.4.1.1 NMDA Receptors 2288.4.1.2 Cutaneous Receptors 2288.4.2 Treatment of Pain in Neonatal and Pediatric Patients 2288.4.2.1 Opioids 2288.4.2.2 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 2298.4.2.3 Alpha- 2 Agonists 2298.4.2.4 Local and Regional Blocks 229References 2299 Analgesia in the Emergency and Critical Care Setting 233Heather Ann Scott and Rachel Stauffer9.1 Introduction 2339.2 Treating Pain in the Emergency and Critical Care Veterinary Patient 2339.3 Evaluating Pain in ER and ICU Patients 2349.4 Nursing Care and the Role of Pain Management in Kirby’s Rule of 20 2399.5 Pain and the Physiological Stress Response: A Summary 2409.6 Sleep Deprivation 2419.7 Windup Pain in the ER 2429.8 Techniques and Nuances for Analgesic Delivery in the Emergency Room 2429.8.1 Pain Vacations (Acute Pain) 2439.8.2 Lidocaine Use in ECC 2439.8.3 Opioid Analgesia for Emergency and Critical Care Patients 2449.8.4 Local/Regional Analgesia in ECC 2449.8.5 Nsaids 2459.8.6 Maropitant 2459.8.7 Physical Rehabilitation Methods in ECC 2459.9 Common Painful Conditions in the ER/ICU Setting 2469.9.1 Fractures 2469.9.2 Acute Soft Tissue Injuries 2479.9.3 Feline Lower Urinary Tract Obstruction 2479.9.4 Trauma Patients 2479.9.5 Abdominal Pain in ECC Patients 2479.9.6 Acute Swelling and Edema 2489.10 Conclusion 248References 24910 Chronic Pain Management for the Companion Animal 253Taly Reyes, Jessica Birdwell, and Stephen Niño Cital10.1 Introduction 25310.2 The Complexity of Chronic Pain 25310.3 Neuropathic Pain 25510.4 Common Chronic Pain Conditions 25510.4.1 Chronic Joint Pain- Osteoarthritis (OA) 25510.4.2 Oncologic/Malignant Pain 25710.4.3 Chiari Malformation Pain 25710.4.4 Headaches and Migraines in Animals 25910.4.5 Meningitis 25910.4.6 Chronic Wounds 26010.5 Assessing Chronic Pain 26110.6 Goals and Modalities for Treating Chronic Pain 26110.7 Pharmacological Interventions 26110.7.1 Pain Vacation (Chronic Pain) 26210.7.2 Mesotherapy 26210.7.3 Transdermal Medications 26310.7.4 Non- steroidal Anti- Inflammatory Drugs (NSAIDs) 26410.7.5 Acetaminophen 26510.7.6 Corticosteroids 26510.7.7 Opioids 26610.7.8 Atypical Opioids: Tramadol and Tapentadol 26610.7.9 Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs) 26710.7.10 Gabapentinoids: Gabapentin and Pregabalin 26810.7.11 N- Methyl- D- Aspartate Antagonists 26910.7.12 Neurokinin- 1 Inhibitors 26910.7.13 Bisphosphonates 27010.7.14 Anti- NGF, Monoclonal Antibodies 27010.7.15 Nutraceuticals and Animal Health Supplements 27010.8 Lifestyle Modifications 27110.8.1 Weight Loss and Appropriate Nutrition 27110.8.2 Routine Exercise and Physical Therapy 27110.8.3 Thinking “Out of the Box” through Environment Modifications 27110.9 Conclusion 271References 27211 Analgesia for Shelter Medicine and Trap–Neuter–Return Programs 277Anne Marie McPartlin and Erin Spencer11.1 Introduction 27711.2 Multimodal Analgesia 27711.2.1 Opioids 27911.2.2 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 27911.2.3 NMDA Antagonists 28111.2.4 Alpha- 2 Adrenoceptor Agonists 28211.2.5 Local Anesthetics 28211.2.6 Adjunct Therapies 28311.3 HQHVSN and TNR Programs 28311.4 Rabbits 28511.5 Conclusion 286References 28612 Pain Management in Equids 289Molly Cripe Birt, Rebecca Johnston, Rachael Hall, and Janel Holden12.1 Introduction 28912.2 Pain Assessment in Horses 28912.3 Common Analgesics and Strategies in Horses 28912.3.1 Butorphanol 29012.3.2 Buprenorphine 29112.3.3 Meperidine 29112.3.4 Tramadol 29112.3.5 Pure Opioid Agonists 29112.3.6 Non- steroidal Anti- inflammatories 29212.3.7 NMDA Receptor Antagonists 29312.3.8 Alpha- 2 Agonists 29312.3.9 N- butylscopolammonium Bromide (NBB) 29412.3.10 Dimethylsulfoxide (DMSO) 29412.3.11 Prokinetics and Antispasmodics 29412.3.12 Locoregional Anesthetics and Techniques 29412.4 Lidocaine Use in Horses 29512.4.1 Postoperative Period Lidocaine Use 29512.5 Common Painful Conditions and Procedures in Horses 29612.5.1 Surgical Pain 29612.5.2 Gastrointestinal (Colic and Ulcers) Pain 29612.5.3 Lameness 29712.5.3.1 Acute Lameness 29712.5.3.2 Chronic Lameness 29812.5.4 Osteoarthritis 29812.5.5 Laminitis 29912.5.6 Pleuropneumonia 30012.5.7 Dystocia 30112.6 Analgesia in Foals 30212.7 Pain Management in the Donkey 30412.7.1 Common Painful Conditions 30412.7.2 Pain Scoring and Behaviors 30412.7.3 Anatomic and Physiologic Distinctions from the Horse 30612.7.4 Analgesics in Donkeys 30612.7.4.1 Nonsteroidal Anti- inflammatory Agents 30612.7.4.2 Alpha- 2 Adrenoceptor Agonists 30712.7.4.3 Opioids 30712.7.4.4 Local Anesthesia/Analgesia Methods 30712.8 Nonpharmacologic Approaches to Pain 30812.9 Conclusion 308References 30813 Food and Fiber Species 315Janel Holden, Rachael Hall, MegAnn Harrington, and Mary Ellen Goldberg13.1 Introduction 31513.2 Cattle 31813.2.1 Bovine or Cattle Medications 31813.2.1.1 Opioids 31813.2.1.2 Nsaids 31813.2.1.3 Alpha- 2- Adrenergic Agonists 31913.2.1.4 NMDA Antagonists 31913.2.2 Regional Anesthesia and Analgesia 31913.2.2.1 Local Anesthetic Agents 31913.2.2.2 Intravenous Regional Anesthesia 32013.2.2.3 Teat Block 32113.2.2.4 Infusion of the Teat Cistern 32113.2.2.5 Epidural Analgesia 32113.2.2.6 Analgesia for Dehorning 32213.2.2.7 Spermatic Cord Block 32213.2.3 Analgesic Adjuvants 32213.2.3.1 Gabapentin 32213.2.3.2 Continuous Infusion Analgesia 32213.2.4 Withdrawal Period 32413.3 Sheep (Ovine) and Goat (Caprine) Medications 32613.3.1.1 Opioids 32613.3.1.2 NSAIDs 32713.3.1.3 Alpha- 2- Adrenergic Agonists 32713.3.1.4 NMDA Antagonists 32713.3.2 Regional and Local Anesthesia 32713.3.2.1 Cornual Block 32713.3.2.2 The Inverted L- Block or 7- Block 32813.3.2.3 Paravertebral Nerve Block 32813.3.2.4 Caudal Epidural 32913.3.3 Intravenous Regional Anesthesia 32913.3.3.1 Bier Block 32913.3.3.2 Intratesticular Block 33013.3.3.3 Continuous Rate Infusions 33013.3.4 Pain Management for Pigs (Swine) 33013.3.4.1 Opioids 33213.3.4.2 NSAIDs 33213.3.4.3 Alpha- 2 Adrenergic Agonists 33413.3.4.4 NMDA Antagonists 33413.3.4.5 Lumbosacral Epidural Block 33413.3.4.6 Continuous Rate Infusions 33513.4 Pain Management for Camelids 33513.4.1 Camelid Medications 33713.4.1.1 Opioids 33713.4.1.2 Nsaids 33813.4.1.3 Alpha- 2 Agonists 33913.4.1.4 Local Anesthetics 33913.4.1.5 NMDA Antagonists 34013.4.1.6 CRI Techniques 34013.4.1.7 Tramadol 34213.4.1.8 Gabapentin 34213.5 Conclusion 342References 34214 Exotic Companion Animals 347Katrina Lafferty, Elizabeth Vetrano, Mary Ellen Goldberg, and Stephen Niño Cital14.1 Introduction 34714.2 Why Treat Pain? 34814.3 Rabbits 34914.3.1 Painful Behaviors: Rabbits 34914.3.2 Pain Scoring: Rabbits 35014.3.3 Nursing Care and Environmental Management: Rabbits 35014.3.4 Common Analgesics in Rabbits 35114.3.4.1 Opioids 35214.3.4.2 NSAIDs 35214.3.4.3 Regional and Local Anesthesia 35214.3.4.4 Continuous Rate Infusions 35314.4 Rodents and Ferrets 35314.4.1 Mice 35414.4.1.1 Pain Scoring: Mice 35414.4.2 Rats and Ferrets 35514.4.2.1 Pain Scoring: Rats and Ferrets 35514.4.3 Gerbils 35514.4.4 Hamsters 35514.4.5 Guinea Pigs 35614.4.5.1 Pain Scoring: Gerbils, Hamsters, Guinea Pigs, and Ferrets 35614.4.5.2 Common Analgesics in Rodents 35614.4.5.3 Opioids 35614.4.5.4 NSAIDs 35814.4.5.5 Regional and Local Anesthesia 35814.5 Multimodal Analgesia: All Species 35914.6 Avian Analgesia 35914.6.1 Recognizing Relevant Behaviors for Each Species 36014.6.2 Avian Pain Scoring and Management 36114.6.3 Avian Drug Delivery 36214.6.4 Common Analgesics in Birds 36514.6.4.1 Nsaids 36514.6.4.2 Opioids 36514.6.4.3 Regional and Local Analgesia 36614.6.4.4 Adjunctive Analgesics 36614.7 Reptile Analgesia 36714.7.1 Causes of Pain in Reptiles 36814.7.2 Analgesic Medications 36814.7.2.1 Opioids 36914.7.2.2 NSAIDs 36914.7.2.3 Local Anesthetics 36914.7.2.4 Adjunctive Analgesics in Reptiles 37114.8 Analgesia in Fish and Amphibians 37114.8.1 Fish and Amphibian Treatment Strategies 37214.9 Analgesia in Invertebrates 37214.9.1 Invertebrate Analgesia Strategies 37514.10 Conclusion 375References 37515 Analgesia in Zoo Animals 381Lindsay Wesselmann, Mark Romanoski, Alison Mott, and Margot Monti15.1 Veterinary Technicians in a Zoological Setting 38115.1.1 Types of Questions to Ask Keepers Include 38115.2 Recognizing Pain in Non- domestic Animals 38215.2.1 Scoring Pain and Discomfort 38415.3 Treatment 38515.4 Medication Administration 38515.5 Adjunctive Therapies 38815.6 Choosing a Pain Regimen 38915.7 Taxon- specific Considerations 38915.7.1 Elephants 38915.7.1.1 Pain Interpretation 39415.7.1.2 Treatment 39515.7.2 Great Apes 39815.7.3 Old World and New World Non- human Primates (NHP) 39915.7.3.1 Signs of Pain or Distress in Nonhuman Primates 40115.7.3.2 Local and Regional Anesthetics 40115.7.4 Exotic Ungulates 40215.7.4.1 Nonruminant Ungulates 40315.7.4.2 Ruminant Ungulates 40415.7.5 Swine 40515.7.6 Wildlife 40615.8 Conclusion 407References 40716 Physical Rehabilitation 411Kristen Hagler, Wendy Davies, and Lis Conarton16.1 Scope of Training for the Team 41116.1.1 Team Approach to Care 41316.1.2 Applications in Veterinary Medicine 41316.2 The Veterinary Technician and Physical Rehabilitation 41316.2.1 Common Conditions and Therapeutic Modalities 41316.2.2 General Wound Healing 41516.2.3 Bone 41516.2.4 Muscle 41516.2.5 Tendons and Ligaments 41616.2.6 Articular Cartilage 41716.3 Client Communication and Activity Modification 41716.4 Patient Assessment 41816.4.1 Veterinary Diagnosis – The Rehabilitation Team 41816.4.2 Objective Outcomes: Goniometry and Muscle Girth 41916.4.3 Pain and Disability Scoring – Methodology in Pain Scoring and Assessment 42016.4.4 The Musculoskeletal System 42216.4.5 Structural and Postural Evaluation 42416.4.6 Gait Analysis and Movement 42516.4.7 Lameness 42516.4.8 The Aging Patient 42716.5 Patient Management 42716.5.1 Assistive Devices: Mobility Wheelchairs, Harnesses, and Footwear 42716.5.2 Bracing, Splinting, and Prosthesis 42916.5.3 Kinesio Taping 43016.5.4 Environmental Modifications 43016.6 Therapeutic Modalities and Emerging Treatments 43116.6.1 Superficial Thermal Therapies 43116.6.2 Photobiomodulation (Therapeutic Laser) 43316.6.3 Electrical Stimulation 43416.6.4 Extracorporeal Shock Wave Therapy (ESWT) 43516.6.5 Therapeutic Ultrasound (ThUS) 43516.6.6 Electro- Magnetic Therapy 43616.7 Manual Therapy and Myofascial Trigger Points 43616.7.1 Myofascial Trigger Points 43616.7.2 Joint Mobilizations and Chiropractic 43716.7.3 Joint Range of Motion – Passive 43816.7.4 Therapeutic Massage 43816.8 Emerging Therapeutic Medical Interventions 43916.8.1 Regenerative Medicine and Biological Treatments 43916.8.2 Corticosteroids and Hyaluronic Acid 44016.8.3 Stem Cells 44016.8.4 Platelet Rich Plasma (PRP) 44016.8.5 Interleukin- 1 Receptor Antagonist Protein (IRAP) 44016.8.6 Prolotherapy 44116.8.7 Emerging Technologies: Radiosynoviorthesis (Conversion Electron Therapy) 44116.8.8 Emerging Technologies: Viscoelastic Therapies – Injectable Hydrogel Microparticles and Polyacrylamide Gels 44116.9 Therapeutic Exercise and Aquatic Therapy 44216.9.1 Therapeutic Exercise Principles and Application 44216.9.2 Land Treadmills 44316.9.3 Hydrotherapy or Aquatic Therapy 444Appendix 16.A Obtaining Goniometric Measurements in the Canine Patient 446Appendix 16.B Limb Circumference 447Appendix 16.C Postural Compensations and Associated Medical Conditions 447Appendix 16.D Photobiomodulation Example Protocols Adapted from (Monici et al. 2019) 448Appendix 16.E Electrical Stimulation Example Protocols (Armitage 2019) 448Appendix 16.F Myofascial Trigger Point (MTrP) and Myofascial Pain Syndrome (MPS) Terminology 449Appendix 16.G Myofascial Trigger Point Examination Techniques 449Appendix 16.H Techniques Addressing Myofascial Trigger Points 450Appendix 16.I Joint Mobilizations 450Appendix 16.J Passive Range of Motion 451Appendix 16.K Therapeutic Massage Techniques 452Appendix 16.L Therapeutic Exercises for Early Rehabilitation 453Appendix 16.M Sample Guidelines 454References 45917 Nutrition and Integrative Medicine 465Robin Saar, Jaime Brassard, and Stephen Niño Cital17.1 Nutrition – The 5th Vital Assessment 46517.1.1 Components of a Nutrition Assessment 46617.1.1.1 Pet- Related Components 46617.1.1.2 Diet- Related Components 46617.1.1.3 Feeding Management 46617.1.2 Nutrition Plan 46717.1.3 Complete and Balanced Nutrition 46717.1.4 Obesity’s Role in Inflammation and Pain 46817.1.5 Key Nutritional Factors 46817.1.6 Macronutrients and Micronutrients 47017.1.7 Antioxidants 47117.1.8 Nutrient- Focused Diets 47117.2 Microbiota Health 47117.2.1 Prebiotics 47117.2.2 Probiotics 47117.2.3 Fecal Microbial Transplant (FMT) 47217.2.4 Postbiotics 47217.3 Cannabinoid Medicine 47317.3.1 History of Cannabis 47317.3.2 Cannabis Potential in Veterinary Medicine 47417.4 The Endocannabinoid System (ECS) and Endocannabinoidome (eCBome) 47517.4.1 Primary Cannabinoid Receptors 47517.4.2 Endocannabinoids 47617.4.3 Retrograde Signaling 47717.4.4 Exogenous Cannabinoids 47717.4.5 Major Cannabinoids 47817.4.6 Minor Cannabinoids 47817.4.7 Terpenoids and Flavonoids 47917.4.8 Entourage Effect and Synergy 48017.5 Cannabinoid Role in Pain Management 48017.5.1 Acute Pain 48017.5.2 Chronic Pain 48117.5.3 G- Coupled Protein Receptors (GPR) 48117.5.4 Glycine Receptors (GlyR) 48117.5.5 N- Methyl- d- Aspartate (NMDA) Receptor 48117.5.6 Peroxisome Proliferator- activated Receptors (PPAR) 48217.5.7 Serotonin Receptors (5- HT) 48217.5.8 Transient Receptor Potential (TRP) Cation Channel Superfamily 48217.5.9 Opioids and Opioid Receptors (OPD1, OPK1, OPM1) 48217.5.10 Acetaminophen and the ECS 48317.5.11 Gabapentinoids 48317.6 Cannabis Safety and the Veterinary Technicians Role in Client Education 48317.7 Harm Reduction Education (HRE) 48517.7.1 THC Intoxication 48517.7.2 Cognitive Perception Modulation 48617.7.3 Product Guidance 48617.7.4 Dosing 48717.7.5 Monitoring 48817.8 Acupuncture 48817.9 Supplements for Pain Management 48917.9.1 Omega- 3 Fatty Acids 48917.9.2 Palmitoylethanolamide (PEA) 49017.9.3 Turmeric (Curcumin) 49017.9.4 Glucosamine/Chondroitin and Undenatured Collagen- based Supplements 49117.9.5 Kratum 49117.9.6 Magnesium 49117.9.7 Green Lipped Mussel Extract 49217.9.8 Passion Fruit Peel Extract 49217.9.9 Avocado/Soybean Unsaponifiables (ASU) 49217.9.10 Yucca Schidigera 49317.9.11 Melatonin 49317.10 Conclusion 493References 49418 Pain Management for End- of- Life Care 507Brooke Quesnell and Danielle DeCormier18.1 Hospice and Palliative Care 50718.1.1 Veterinary Staff in the Hospice and Palliative Care Environment 50818.1.2 Work Areas 50818.2 Technicians’ Roles in a Hospice and Palliative Care Practice 50918.2.1 Patient Presentation and Evaluation 50918.2.2 Planning of Care 50918.2.3 Delivery of Care 50918.2.4 Caregiver Education and Training 51018.2.5 Setting Up the Physical Environment 51018.2.6 Social Environment 51018.2.7 Support for the Family 51018.2.8 Pain Recognition and Management 51118.2.8.1 Neoplasia 51118.2.8.2 Osteoarthritis 51118.2.8.3 Analgesia for Specific Procedures and Special Problems 51118.2.9 Advocacy 51218.3 Euthanasia and Analgesia for the Dying Patient 51218.3.1 Euthanasia 51318.3.2 Natural Death 51418.3.3 Pain Management for the Dying Animal 51418.4 Support for the Family of the Dying Patient 51518.5 Conclusion 515References 51619 Selected Case Studies in Analgesia 517Tasha McNerney, Darci Palmer, and Stephen Niño CitalIndex 529