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Research
Research EDITORIAL
Veterinarians’ attitudes towards chronic pain Jackie Brearley A paper summarised on p 428 of this issue of Veterinary Record on the attitudes of veterinary surgeons to chronic pain in dogs (Bell and others 2014) poses some interesting questions when viewed in the light of other research. In this paper and others (for example, Yeates and Main 2011), it is apparent that veterinarians in practice perceive that chronic pain is a welfare issue that requires the attention of the profession. Bell and colleagues’ paper reports the results of a survey of general veterinary practitioners and veterinary anaesthesia and oncology specialists who, it was felt, dealt with patients suffering from chronic pain conditions. Included in the survey was a list of conditions which, according to the literature and in the authors’ opinions, were associated with chronic pain. These were remarkably similar to model conditions used to study sustained pain states in experimental animals with a view to understanding chronic pain in people and
Jackie Brearley, MA, VetMB, PhD, DipECVAA, DVA, MRCVS, Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK e-mail: [email protected]
426 | Veterinary Record | November 1, 2014
animals in more depth. These models and, more importantly, the behaviours that they trigger, have been described by the US National Research Council Committee on the Recognition and Alleviation of Pain in Laboratory Animals (2009.) In the paper by Bell and others, the assessment of chronic pain is reported to be a significant barrier to the treatment of chronic pain. This seems unfortunate, in that there are well-recognised behaviours associated with persistent pain in laboratory animals and, while the species may differ, this would at least be a starting point for the detection of pain. A similar number of respondents indicated that the expense of long-term analgesic treatment is a significant barrier to treatment. This is understandable as the conditions described are often incurable, for example, osteoarthritis, and an animal may require treatment for the rest of its life. It does beg the question, however, as to whether this perceived barrier results in a lack of treatment and therefore presents a welfare issue, or whether dogs’ lives are prematurely terminated due to financial considerations. In a survey conducted by Huxley and Whay (2007), financial considerations among UK cattle farmers
Downloaded from http://veterinaryrecord.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Research were felt to be less of a barrier to treatment than was the case among previously surveyed veterinary surgeons (Huxley and Whay 2006). Perhaps the same is true in the case of the treatment of chronic pain in dogs, that is, that the veterinary surgeons who took part in the survey by Bell and others made incorrect assumptions about the opinions of their clients. Interestingly, owner compliance is thought to be a major barrier to treatment but, as Bell and others indicate, this may be based on compliance with the administration of drugs that do not alter behaviour, for example, antibiotics, rather than analgesics, which, if effective, should positively alter pain behaviour in pets. As this was a survey of veterinarians’ attitudes rather than what actually happens, there may be a discrepancy here as well. The veterinarians surveyed did not cite lack of knowledge as a major barrier to treatment. This either indicates that veterinary surgeons have a good knowledge of pain physiology and the treatment of pain, or that the respondents were not aware how much or how little knowledge was available (and therefore how much or how little knowledge they actually had). Cox (2010) wrote that veterinary surgeons receive more training in pain relief education than student nurses; this either indicates that vets are well trained in pain treatment or nurses are badly trained. Plaisance and Logan (2006) drew the conclusion that nurses had an inadequate knowledge of pain management. However, increasingly, pain and analgesia education forms a part of undergraduate veterinary curricula and so the perception that knowledge is not a barrier to treatment may be correct. The perception that certain conditions are common causes of chronic pain (for example, osteoarthritis, neoplasia, dental disease, ear disease and vertebral and spinal conditions) requires further investigation. It is unclear whether these
are common conditions that cause chronic pain or if animals that display chronic pain behaviours commonly have one of these conditions. Because the paper looks at veterinary surgeons’ attitudes towards pain rather than the incidence of chronic pain, each individual’s own previous experience could have influenced their responses, resulting in extrapolation to their animal patients. In people, back pain and arthritis appear to be the most common causes of chronic pain (Elliot and others 1999), while pain has been reported in over 50 per cent of human cancer patients, with many of these indicating that they felt that their pain was not adequately managed (Breivik and others 2009). The major difference in the perceived causes of chronic pain in animals and in people is the presence of dental disease as the second most common cause of pain in animals. In people, dental pain generally results in rapid treatment at a dental clinic and dental disease is generally viewed as an acute, rather than a chronic, source of pain. Dental disease is undoubtedly a major cause of pain in cats and dogs. In one study, 97 per cent of dogs showed some degree of periodontal disease (Gad 1968). In addition, dental trauma with cracked teeth or worn teeth and undiagnosed tooth decay are common in dogs. It would appear that veterinary surgeons, whatever their specialty status, feel that pain associated with cancer is underdiagnosed. This could be because in people a very high proportion of cancer patients report pain as one of their symptoms (van den Beuken and others 2007) and veterinary surgeons extrapolate this to their patients. If we feel that pain is underdiagnosed, we should be making more efforts at diagnosis and, if this is felt to be too difficult, then test treating with analgesics may be a way forward. According to the participants of the Bell and others (2014) study, nonsteroidal anti-inflammatory drugs were the most
popular class of drugs administered, along with opioids. More novel treatment options (for example, tricyclic antidepressant or nondrug therapies) are likely to be used rarely or never. Studies assessing the efficacy of these treatments need to be undertaken, not least because these may make up some of the less expensive options in the long run. This paper is a long overdue start at looking at how, as a profession, we regard chronic pain and the welfare issues that result from ignoring it.
References
Bell, A., Helm, J. & Reid, J. (2014) Veterinarians’ attitudes to chronic pain in dogs. Veterinary Record doi: 10.1136/vr.102352 Breivik, H., Cherny, N., Collett, B., De Conno, F., Filbet, M., Foubert, A. J. & Dow, L. (2009) Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Annals of Oncology 20, 1420-1433 Cox, F. (2010) Veterinary surgeons receive more pain relief education than nurses. Nursing Times 106, 4 Elliott, A. M., Smith, B. H., Penny, K. I., Smith, W. C. & Chambers, W. A. (1999) The epidemiology of chronic pain in the community. Lancet 354, 1248-1252 Gad, T. (1968) Periodontal disease in dogs. Journal of Periodontal Research 3, 268-272 Huxley, J. N. & Whay, J. R. (2006) Current attitudes of cattle practioners to pain and the use of analgesics in cattle. Veterinary Record 159, 662-668 Huxley, J. N. & Whay, H. R. (2007) Attitudes of UK veterinary surgeons and cattle farmers to pain and the use of analgesics in cattle. Cattle Practice 15, 189-193 Plaisance, L. & Logan, C. (2006) Nursing students’ knowledge and attitudes regarding pain. Pain Management Nursing 7, 167-175 National Research Council (US) Committee on Recognition and Alleviation of Pain in Laboratory Animals (2009) Recognition and Alleviation of Pain in Laboratory Animals A: Models of Pain. National Academies Press van den Beuken-van Everdingen, M. H. J., de Rijke, J. M., Kessels, A. G., Schouten, H. C., van Kleef, M. & Patijn, J. (2007) Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology 18, 1437-1449 Yeates, J. W. & Main, D. C. (2011) Veterinary surgeons’ opinions on dog welfare issues. Journal of Small Animal Practice 52, 464-468
doi: 10.1136/vr.g6404
November 1, 2014 | Veterinary Record | 427
Downloaded from http://veterinaryrecord.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Veterinarians' attitudes towards chronic pain Jackie Brearley Veterinary Record 2014 175: 426-427
doi: 10.1136/vr.g6404 Updated information and services can be found at: http://veterinaryrecord.bmj.com/content/175/17/426
These include:
References Email alerting service
This article cites 9 articles, 3 of which you can access for free at: http://veterinaryrecord.bmj.com/content/175/17/426#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Research
Research EDITORIAL
Veterinarians’ attitudes towards chronic pain Jackie Brearley A paper summarised on p 428 of this issue of Veterinary Record on the attitudes of veterinary surgeons to chronic pain in dogs (Bell and others 2014) poses some interesting questions when viewed in the light of other research. In this paper and others (for example, Yeates and Main 2011), it is apparent that veterinarians in practice perceive that chronic pain is a welfare issue that requires the attention of the profession. Bell and colleagues’ paper reports the results of a survey of general veterinary practitioners and veterinary anaesthesia and oncology specialists who, it was felt, dealt with patients suffering from chronic pain conditions. Included in the survey was a list of conditions which, according to the literature and in the authors’ opinions, were associated with chronic pain. These were remarkably similar to model conditions used to study sustained pain states in experimental animals with a view to understanding chronic pain in people and
Jackie Brearley, MA, VetMB, PhD, DipECVAA, DVA, MRCVS, Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK e-mail: [email protected]
426 | Veterinary Record | November 1, 2014
animals in more depth. These models and, more importantly, the behaviours that they trigger, have been described by the US National Research Council Committee on the Recognition and Alleviation of Pain in Laboratory Animals (2009.) In the paper by Bell and others, the assessment of chronic pain is reported to be a significant barrier to the treatment of chronic pain. This seems unfortunate, in that there are well-recognised behaviours associated with persistent pain in laboratory animals and, while the species may differ, this would at least be a starting point for the detection of pain. A similar number of respondents indicated that the expense of long-term analgesic treatment is a significant barrier to treatment. This is understandable as the conditions described are often incurable, for example, osteoarthritis, and an animal may require treatment for the rest of its life. It does beg the question, however, as to whether this perceived barrier results in a lack of treatment and therefore presents a welfare issue, or whether dogs’ lives are prematurely terminated due to financial considerations. In a survey conducted by Huxley and Whay (2007), financial considerations among UK cattle farmers
Downloaded from http://veterinaryrecord.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Research were felt to be less of a barrier to treatment than was the case among previously surveyed veterinary surgeons (Huxley and Whay 2006). Perhaps the same is true in the case of the treatment of chronic pain in dogs, that is, that the veterinary surgeons who took part in the survey by Bell and others made incorrect assumptions about the opinions of their clients. Interestingly, owner compliance is thought to be a major barrier to treatment but, as Bell and others indicate, this may be based on compliance with the administration of drugs that do not alter behaviour, for example, antibiotics, rather than analgesics, which, if effective, should positively alter pain behaviour in pets. As this was a survey of veterinarians’ attitudes rather than what actually happens, there may be a discrepancy here as well. The veterinarians surveyed did not cite lack of knowledge as a major barrier to treatment. This either indicates that veterinary surgeons have a good knowledge of pain physiology and the treatment of pain, or that the respondents were not aware how much or how little knowledge was available (and therefore how much or how little knowledge they actually had). Cox (2010) wrote that veterinary surgeons receive more training in pain relief education than student nurses; this either indicates that vets are well trained in pain treatment or nurses are badly trained. Plaisance and Logan (2006) drew the conclusion that nurses had an inadequate knowledge of pain management. However, increasingly, pain and analgesia education forms a part of undergraduate veterinary curricula and so the perception that knowledge is not a barrier to treatment may be correct. The perception that certain conditions are common causes of chronic pain (for example, osteoarthritis, neoplasia, dental disease, ear disease and vertebral and spinal conditions) requires further investigation. It is unclear whether these
are common conditions that cause chronic pain or if animals that display chronic pain behaviours commonly have one of these conditions. Because the paper looks at veterinary surgeons’ attitudes towards pain rather than the incidence of chronic pain, each individual’s own previous experience could have influenced their responses, resulting in extrapolation to their animal patients. In people, back pain and arthritis appear to be the most common causes of chronic pain (Elliot and others 1999), while pain has been reported in over 50 per cent of human cancer patients, with many of these indicating that they felt that their pain was not adequately managed (Breivik and others 2009). The major difference in the perceived causes of chronic pain in animals and in people is the presence of dental disease as the second most common cause of pain in animals. In people, dental pain generally results in rapid treatment at a dental clinic and dental disease is generally viewed as an acute, rather than a chronic, source of pain. Dental disease is undoubtedly a major cause of pain in cats and dogs. In one study, 97 per cent of dogs showed some degree of periodontal disease (Gad 1968). In addition, dental trauma with cracked teeth or worn teeth and undiagnosed tooth decay are common in dogs. It would appear that veterinary surgeons, whatever their specialty status, feel that pain associated with cancer is underdiagnosed. This could be because in people a very high proportion of cancer patients report pain as one of their symptoms (van den Beuken and others 2007) and veterinary surgeons extrapolate this to their patients. If we feel that pain is underdiagnosed, we should be making more efforts at diagnosis and, if this is felt to be too difficult, then test treating with analgesics may be a way forward. According to the participants of the Bell and others (2014) study, nonsteroidal anti-inflammatory drugs were the most
popular class of drugs administered, along with opioids. More novel treatment options (for example, tricyclic antidepressant or nondrug therapies) are likely to be used rarely or never. Studies assessing the efficacy of these treatments need to be undertaken, not least because these may make up some of the less expensive options in the long run. This paper is a long overdue start at looking at how, as a profession, we regard chronic pain and the welfare issues that result from ignoring it.
References
Bell, A., Helm, J. & Reid, J. (2014) Veterinarians’ attitudes to chronic pain in dogs. Veterinary Record doi: 10.1136/vr.102352 Breivik, H., Cherny, N., Collett, B., De Conno, F., Filbet, M., Foubert, A. J. & Dow, L. (2009) Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Annals of Oncology 20, 1420-1433 Cox, F. (2010) Veterinary surgeons receive more pain relief education than nurses. Nursing Times 106, 4 Elliott, A. M., Smith, B. H., Penny, K. I., Smith, W. C. & Chambers, W. A. (1999) The epidemiology of chronic pain in the community. Lancet 354, 1248-1252 Gad, T. (1968) Periodontal disease in dogs. Journal of Periodontal Research 3, 268-272 Huxley, J. N. & Whay, J. R. (2006) Current attitudes of cattle practioners to pain and the use of analgesics in cattle. Veterinary Record 159, 662-668 Huxley, J. N. & Whay, H. R. (2007) Attitudes of UK veterinary surgeons and cattle farmers to pain and the use of analgesics in cattle. Cattle Practice 15, 189-193 Plaisance, L. & Logan, C. (2006) Nursing students’ knowledge and attitudes regarding pain. Pain Management Nursing 7, 167-175 National Research Council (US) Committee on Recognition and Alleviation of Pain in Laboratory Animals (2009) Recognition and Alleviation of Pain in Laboratory Animals A: Models of Pain. National Academies Press van den Beuken-van Everdingen, M. H. J., de Rijke, J. M., Kessels, A. G., Schouten, H. C., van Kleef, M. & Patijn, J. (2007) Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology 18, 1437-1449 Yeates, J. W. & Main, D. C. (2011) Veterinary surgeons’ opinions on dog welfare issues. Journal of Small Animal Practice 52, 464-468
doi: 10.1136/vr.g6404
November 1, 2014 | Veterinary Record | 427
Downloaded from http://veterinaryrecord.bmj.com/ on June 29, 2015 - Published by group.bmj.com
Veterinarians' attitudes towards chronic pain Jackie Brearley Veterinary Record 2014 175: 426-427
doi: 10.1136/vr.g6404 Updated information and services can be found at: http://veterinaryrecord.bmj.com/content/175/17/426
These include:
References Email alerting service
This article cites 9 articles, 3 of which you can access for free at: http://veterinaryrecord.bmj.com/content/175/17/426#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
