Common Painkiller Proven Ineffective for Both Acute and Chronic Pain

August 01, 2018 • 14,528 views

Edition: English

Story at-a-glance

A recent study published in the Journal of the American Veterinary Medical Association concludes that the painkilling drug tramadol is ineffective in dogs with arthritis
The lead study author believes the risks of the drug outweigh any benefits it may provide
Despite the study results, many veterinarians feel tramadol is a useful medication for certain patients, including those receiving end-of-life care, as well as pets who are suffering emotionally because they’re in pain
Many arthritic dogs can be well managed without drugs using a customized, nontoxic, multimodal approach that includes physical therapy, weight management, exercise, the right diet and natural remedies that help support and repair degenerating joints

By Dr. Karen Shaw Becker

All of you who read here regularly and watch my videos know I’m not a big fan of pharmaceuticals. However, as a proactive integrative veterinarian, I do use them in certain situations, such as when a drug is needed to save an animal’s life, or with a pet who has intractable pain that can’t be effectively managed by other means. I also often recommend drugs for patients at the end of life who are receiving palliative or hospice care.

As a general rule, in nonemergency situations, I always try safer, nontoxic approaches first. Drugs have their place, but in my opinion they’re overused to the point of abuse in conventional human and veterinary medicine. Pharmaceutical companies have a vested interest in developing and selling their products.

Sadly, most doctors and veterinarians are all too happy to help them out by prescribing drugs without addressing the root cause of a patient’s condition or, in the case of antibiotics, without even confirming the presence of a bacterial infection. Another wildly overprescribed drug in Western medicine is prednisone and other types of corticosteroids. Steroid therapy, especially when it’s given repeatedly or long-term, carries an extensive list of very serious side effects, some of them life-threatening.

Study Shows Tramadol Isn’t Effective in Relieving Arthritis Pain in Dogs

Thanks to Western medicine’s love affair with pharmaceuticals, it’s rare to see an established drug come under the kind of scrutiny recently given to tramadol, a medication used to alleviate pain, by researchers at the University of Georgia College of Veterinary Medicine.

For the study, which was funded by the Morris Animal Foundation, veterinary researchers evaluated the drug’s ability to alleviate signs of arthritis pain in dogs, and found it ineffective. The team published their results in the Journal of the American Veterinary Medical Association.1 Study leader Dr. Steven Budsberg, professor of surgery and director of clinical research, pulls no punches when discussing the results:

“The data shows conclusively that tramadol is not an effective drug in treating the pain associated with arthritis in the dog, despite its common recommendation. This use of tramadol is a classic example of failing to acknowledge and control for bias when evaluating a potential treatment.”2

The study compared tramadol with both a placebo and the nonsteroidal anti-inflammatory drug (NSAID) carprofen in 40 pet dogs with arthritis of the elbow or knee. The dogs received each of the three treatments in random order, with each treatment lasting 10 days. They were evaluated using vertical impulse, peak vertical force and Canine Brief Pain Inventory scores to assess their mobility and pain. The results showed no improvement when the tramadol was given.

A Veterinary Pain Specialist, Hospice Practitioner and Anesthesiologist Weigh in on Tramadol

Veterinary industry publication dvm360 asked three conventional veterinarians for their thoughts on the study, and their answers were revealing.

The first, Dr. Michael Petty, a vet who is a pain and canine rehabilitation specialist, told the magazine that veterinary pain experts have long known oral tramadol doesn’t work well to address or prevent acute pain. He and his fellow pain specialists have also suspected for years the drug doesn’t work in cases of chronic pain, either. According to Petty:

“You have a drug that is a controlled substance, has the potential for human abuse, has no studies showing it works in either acute or chronic pain, and might kill your patient. Everyone who wants to prescribe it to a patient needs to imagine the courtroom scenario where you’re trying to defend your decision to use it on an animal that came to harm.”3

Petty added that tramadol can also cause serotonin syndrome, even at small doses, and even the first time it’s given to a pet. Dr. Dani McVety is the founder and CEO of the Lap of Love Veterinary Hospice network, and like Petty, wasn’t surprised by the study results.

However, in treating pets in hospice, McVety and her colleagues “… occasionally need to push the boundaries on medical comfort measures,” and she plans to continue to use tramadol as a calming agent to treat the emotional wind-up that comes with painful conditions.

“When I prescribe tramadol,” McVety explains, “I tell my clients that it’s not used directly for pain reduction, but more like a glass of wine. Sometimes you need one; sometimes you need two or three to get calmed down a bit. But if we’re leaning on a very high dose for more than one to two nights, we have a quality of life issue and need to have a separate conversation.”

The third veterinarian interviewed was Dr. Ralph Harvey, associate professor of anesthesiology at the University of Tennessee College of Veterinary Medicine. Harvey says the jury’s still out on whether tramadol is effective in relieving pain in veterinary patients, and believes part of the problem is in viewing the drug as a painkiller.

“We do better to think of it as an emotion-modifying drug — at least in those animals that produce the right metabolite,” he says. “Dogs are extremely variable in their ability to produce that mu-receptor-binding metabolite. Some dogs do; others don’t.”

Harvey explains there are two types of pain: the pain itself, and the suffering or emotional component of being in pain, which can compromise quality of life. He also points out that since tramadol is often used in conjunction with other drugs, including painkillers, it’s difficult to know which drug is causing which effect.

“But absence of evidence is not evidence of absence,” Harvey says. “Our greatest limitation in evaluating pain is our ability to recognize and quantify it, especially when it comes to validated models for the suffering aspect of pain. This is a new frontier we are only just beginning to explore.”

Harvey says that while he has respect for the Budsberg study, “… the metric is limited to the sensory rather than the emotional component of pain.” For the record, I have tramadol in my veterinary toolbox and use it with certain patients, in conjunction with other therapies, to alleviate mild pain and emotional wind-up. But as with all drugs, I use it only when it’s absolutely necessary and beneficial to the animal.

Lifestyle Suggestions for Arthritic Dogs

The University of Georgia study looked specifically at tramadol for dogs with arthritis, and concluded that carprofen (the NSAID) was more effective. Again, we have conventional medicine practitioners recommending pharmaceuticals, when in many cases, dogs withdegenerative joint disease can be well managed with a natural, nontoxic protocol. In my experience, a multimodal approach to managing arthritis is critical for slowing its progression, including:

Physical therapy. Physical therapy is an absolute must for arthritic pets and should be designed to maintain and increase joint strength, muscle tone and range of motion. This can be accomplished with therapeutic exercises, swimming and massage.
Weight management. Keeping your pet at a lean, healthy weight is also absolutely crucial in preventing or alleviating arthritis symptoms. An overweight dog with arthritis can have noticeable improvement in symptoms after losing just a small amount of body weight.
Exercise. Pets need to move their bodies more, not less, as they age. Although the intensity, duration and type of exercise will change, daily activity is still crucial to prevent profound musculoskeletal weakness with age. Muscles maintain your pet's frame, so preserving muscle tone will also slow the amount of joint laxity (which causes arthritis) as well.

Other crucial factors in maintaining the health of an arthritic pet include feeding a nutritionally balanced, species-appropriate diet, and avoiding unnecessary re-vaccinations (titer test instead).

In addition to therapies such as laser treatments and the Assisi loop, I’ve found that incorporating maintenance chiropractic, acupuncture, daily stretching and mild exercise along with an oral protocol to manage pain and inflammation will yield the best results possible for an arthritic dog.

Oral Protocol Recommendations

Chondroprotective agents (CPAs) that protect the joints, including glucosamine sulfate, MSM, eggshell membrane, perna mussel (green-lipped clam), Adequan and cetyl myristoleate are essential for dogs with arthritis. CPAs slow the rate of cartilage degeneration, which is critical.

The form, dose and type of CPA your veterinarian prescribes should be based on a careful assessment of your dog's individual needs. CPAs should be blended with pain control options as necessary.

There are many natural remedies for arthritis that can reduce or eliminate the need for painkillers, including a high-quality omega-3 supplement (krill oil), ubiquinol, turmeric, supergreen foods (spirulina, astaxanthin), natural anti-inflammatory formulas (herbs, proteolytic enzymes, nutraceuticals, TCM formulas), homeopathic remedies (Rhus tox, Arnica) and Esterified Fatty Acid Complex (EFAC). I have found CBD oil can be one of the safest long-term management strategies for chronic pain.

There are also ayurvedic and Chinese herbs and nutraceuticals that can be very beneficial for dogs with arthritis, depending on their individual symptoms. It's important to monitor your pet's symptoms on an ongoing basis, because arthritis progresses over time. Your dog's body is constantly changing, and her treatment protocol will need to evolve as well.

In the vast majority of mild to moderate joint pain cases, if CPAs and natural pain control options are initiated early, the need for intermittent NSAID therapy can be minimized to those occasional “bad days” when the weather or the day’s activities temporarily exacerbated the dog’s discomfort. Moderate to severe joint pain cases (requiring consistent NSAID drug administration to maintain quality of life) can rely on lower drug doses by using an integrative protocol.

I definitely recommend finding an integrative or holistic veterinarian to work with you to customize a comprehensive protocol for your pet. Practitioners who’ve gone beyond their traditional veterinary school training to learn and incorporate complimentary therapies into their practice will have many more options to offer your arthritic dog or kitty.

I also recommend bringing your pet for a wellness checkup with your veterinarian at least twice a year to review the status of her health, and to check the range of motion in her joints, the muscle mass she’s either gaining or losing, and to make adjustments to her protocol as necessary to ensure her quality of life is optimal.

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Wednesday, August 1, 2018