In an effort to combat the opioid epidemic, the DEA decreased opioid production by 25% in 2017, and plans to continue to decrease production in 2018. As many of the more commonly used full mu agonists such as morphine, hydromorphone, and fentanyl become harder to acquire (and remaining supplies are diverted to human hospitals), veterinarians will be challenged to provide adequate pain management to their patients.
At this time, we expect the opioid drug shortages will grow worse before they get better. It is likely that veterinarians will need to alter their current pain management protocols. We’ve compiled some tips and dosages below.
If you have additional questions regarding alternative pain management therapies in your patients, please contact Dr. Ashley Mitek at firstname.lastname@example.org, or call the Veterinary Teaching Hospital referral coordinator at (217) 333-5311 to speak with the anesthesiologist on duty.
- Consider loco-regional anesthesia whenever possible
- Non-opioid injectable medications such as dexmedetomidine, ketamine, and lidocaine can be analgesic and used as constant rate infusions for painful patients
- Non-opioid oral medications such as NSAIDs, amantadine, and gabapentin can be beneficial
- Multi-modal analgesia is the practice of administering several different medications that have differing mechanisms of action, but, taken as a whole, provide analgesia superior to that of one drug alone. Multi-modal analgesia protocols are recommended whenever possible.
- Remember that acepromazine, trazadone, butorphanol, midazolam, diazepam, propofol, and alfaxalone have minimal to no analgesic properties, though other properties of these medications may be beneficial in painful animals
- Tramadol has limited efficacy
- Although intravenous fentanyl is efficacious in dogs and cats, fentanyl patches have been shown to have variable absorption rates
|Local Anesthetics||Dosage||Duration of Action||Comments|
|Lidocaine||2 mg/kg||1-2 hrs|
|Bupivacaine||1 mg/kg||4-6 hrs||Do not inject IV|
|Adding Dexmedetomidine to local anesthetic mixture|
1 mcg/mL of local anesthetic
|Extends duration of action|
|Nocita (liposome-encapsulated bupivacaine)||5.3 mg/kg||May provide up to 72 hours duration||One-time use vial|
- Ring blocks for distal limb procedures (declaws, paw pad laceration, etc.), mass removals, etc.
- Lidocaine or bupivacaine splash blocks for enucleations or ovariohysterectomies
- Line blocks for laparotomy incisions
|Intravenous Agents||Dosage||Duration of Action||Comments|
|Dexmedetomidine (one-time dose)||1 mcg/kg IV, 4 mcg/kg IM (dogs), 8 mcg/kg IM (cats)||<45 minutes||Cardiovascular effects may prevent use in many patients; use as an adjunctive analgesic agent only|
|Dexmedetomidine CRI||1 mcg/kg loading dose, then 1 mcg/kg/hr|
2 mg/kg loading dose IV, then 2-4 mg/kg/hr
|Do not administer IV in cats|
|Ketamine||0.5 mg/kg loading dose, then 0.2-0.5 mg/kg/hr|
|Buprenorphine||0.02 mg/kg IV or IM||6 hours||Appropriate for mild to moderate pain|
|Extended-release buprenorphine (Simbadol)||0.24 mg/kg IV or IM||24 hours||Cats only; appropriate for mild to moderate pain|
Lidocaine/Ketamine CRI for fracture repair, limb amputation
|Other Medications||Dosage||Dosing Frequency||Comments|
|Gabapentin||5-10 mg/kg||8 hours|
|Amantadine||3-5 mg/kg||24 hours|
|12 hours (alternatively 4.4 mg/kg every 24 hours)||Dogs only|
|Meloxicam||0.1 mg/kg SQ or PO (dogs)||24 hours|
|Deracoxib||3-4 mg/kg||Every 24 hours for 7 days, then decrease to 1-2 mg/kg daily||Dogs only|
|Robenacoxib (Onsior)||2 mg/kg||Daily for up to 3 days||Cats only|
|Maropitant||1-2 mg/kg IV, IM or PO||Every 12-24 hours||Has analgesic properties with few cardiovascular effects; ideal as an analgesic adjunct|
—Dr. Stephanie Keating and Dr. Ashley Mitek, with contributions from ISVMA