Episode 23 - Bonus Episode! Chronic pain management part II - Zero Pain Philosophy with SPECIAL GUEST MATT GURNEY!

1.The GP hook

Chronic pain isn’t “one drug and done”. Matt Gurney joins Brendan and Charlotte to share what’s working in UK practice right now – from calmer admissions and NMDA antagonists to paracetamol know-how and making sense of Librela/Solensia.

Chronic pain isn’t “one drug and done”. In this bonus Chatty Vets episode Matt Gurney (Zero Pain Philosophy) walks through what’s working in UK practice now — calmer admissions, when to think NMDA antagonists, pragmatic paracetamol use, how to make sense of Librela/Solensia, and where subcutaneous ketamine fits. Below are the practical bits that GP teams actually use, with clear prompts for conversations and governance.

NOTE: doses and routes mentioned below reflect Matt Gurney’s clinical practice as discussed in the interview. Treat them as experiential guidance — always verify against product datasheets, local governance (VDS/VMD) and your hospital policy before prescribing or administering.

2.Start with the outcome: calmer admissions beat chasing “sedation”

Common Trap

Expecting trazodone or gabapentin to sedate a wound‑up dog. They’re anxiolytics. If your goal is “safe IM and forget”, plan for IM sedation quickly and in a calm, prepared space.

Admission prompt

Book anxious patients first or last, pre‑authorise IM sedation, prepare a quiet room and brief the team: “We’re going straight to IM once the muzzle’s on — no repeated attempts.”

• Define the goal before you press the buzzer: do you need anxiolysis so you can safely give an IM injection, or true sedation for anaesthesia?
• Trazodone and gabapentin are primarily anxiolytics, not full sedatives. Combine them and plan timing (night before + morning of admission can help) when extra calm is needed.
• Melatonin features in some international “chill” protocols but is not widely available in the UK — don’t waste time chasing it.
• Once you can safely handle the patient, IM sedation (alpha‑2 agonist + opioid) is fast and reliable if the team is ready to move straight to it.
• Benzodiazepines can be useful — but timing matters. In fit, healthy dogs, giving midazolam too early can cause disinhibition/twitchiness. Many teams get smoother results by giving benzodiazepine after the alpha‑2/opioid effect is established, or using it as co‑induction only in already‑settled patients.

3.Subcutaneous ketamine: “small dose, big difference” for selected chronic cases

Clinical caveat

SC ketamine protocols below reflect one clinician’s practice. Verify governance and monitoring requirements locally before adopting.

• Where it fits: Matt uses subcutaneous ketamine for chronic pain where central sensitisation is suspected — osteoarthritis and lumbosacral/neuropathic presentations.
• How he uses it (clinical practice): a low SC dose given on a repeat schedule (monthly is his starting point), and frequency adjusted by caregiver‑reported outcomes. If benefit shortens, move to fortnightly then weekly — when you’re needing twice‑weekly it often means the case has reached the limits of benefit from this approach.
• Practical measure: pick 3–5 caregiver‑reported behaviours (stairs, sleep interruptions, sudden “nibble” episodes, garden hesitations). Reassess exactly those after each injection to decide benefit.
• Evidence: current use is largely experiential; a clinical study in arthritic dogs has ethical approval and is underway.

4.Is it neuropathic pain? Listen for the paroxysms

• Nociceptive (inflammatory): dull, constant pain — typical of arthritis.
• Neuropathic: caused by lesion/dysfunction in the somatosensory system. In people it’s burning/shooting/stabbing; in animals think sudden onset/offset behaviours: whirl‑and‑nibble episodes, jumping from rest, freezing in the garden.
• History is gold — use it to separate patterns and guide whether neuropathic‑directed therapies (NMDA antagonists, ketamine, gabapentin in some cases) are needed.

5.Rethinking gabapentin in osteoarthritis

Day‑5 “off‑legs” calls after starting gabapentin are frequent — think drug‑related sedation/ataxia before assuming OA has worsened.

• Matt’s big message: we’re often too aggressive with gabapentin for OA. Overuse can cause sedation/ataxia that owners interpret as disease progression.
• Practical plan: start low and titrate. In the interview Matt described starting at a low twice‑daily dose and titrating as needed; if you find yourself pushing very high three‑times‑daily doses to achieve effect, reconsider strategy and look for alternative/additional targets.
• Common trap

6.Target central sensitisation early: think NMDA antagonists

Cats

Caveat

Use NMDA antagonists in accordance with available evidence, product licences and after discussing off‑licence use where relevant.

• When first‑line analgesia fails and you find widespread sensitivity and sore muscles, suspect central sensitisation.
• NMDA antagonists (amantadine, memantine, ketamine) are the second‑line tools Matt reaches for. There is published canine evidence for amantadine (usually used with an NSAID); memantine has strong clinical experience behind it but less published veterinary trial data; ketamine (SC) is another option.
• Practical signpost: muscles that feel less tense at re‑check after starting an NMDA antagonist are a good procedural clue that you’re on the right track.
• Small, short studies exist: amantadine and gabapentin have shown some benefit in tiny trials (sedation reported). Tramadol has limited evidence and palatability issues; some clinicians use palatable tablet options when appropriate. SC ketamine has been used in selected feline cases at low doses with perceived benefit.

7.Paracetamol in chronic pain: cautious, practical, sometimes helpful

“We’ll start with the licensed short course. If your dog benefits and we consider longer‑term use, that will be off‑licence; we’ll supply it from the practice and monitor appetite, thirst and behaviour.”

• Evidence for chronic use is limited; acute evidence is stronger. Clinically some dogs clearly benefit.
• Licensed UK approach: start with the licensed short course as per the product datasheet (five days was discussed). Longer‑term use is off‑licence clinical practice for some vets.
• Governance and supply: don’t advise clients to buy OTC paracetamol — prescribing and supplying from the practice is the advised route (VDS guidance). If continuing off‑licence, explain monitoring and the reasons for practice supply.
• Practical conversation

8.Librela / Solensia: keep perspective and document consent

Consent prompt

Update consent forms for anti‑NGF injections: explain expected benefits, common adverse events (polydipsia, ataxia, lack of effect) and that rare musculoskeletal events have been reported.

• These anti‑NGF monoclonal antibodies have been transformational for some patients and not helpful for others.
• Adverse events: musculoskeletal adverse events have been reported in a very small proportion of dogs; more common reports include polydipsia, ataxia and lack of effect. Descriptions and causality are still developing — “rapidly progressive OA” (RPOA) is a human term and not a settled veterinary diagnosis.
• Practical check: if effect seems to wane mid‑cycle, confirm the actual mg/kg dose and consider whether the animal should be on the next vial size to reach the higher end of the licensed mg/kg range — but always verify against the current product datasheet and local policy before changing dose strategy.
• Cats on Solensia: dermatological reactions have been reported in some cats; mechanisms are not clear. Re‑challenge in some cases produced no recurrence, but monitoring and informed consent are required.

9.Regenerative medicine: earlier may be better

• OA is often diagnosed late. For mild disease, regenerative approaches (stem cells, PRP) may offer potential to slow progression and preserve function longer.
• Practical move: spot mild OA early (COAST staging helps), set a pathway to discuss regenerative options with owners, and consider local referral pathways for cases where slowing progression is realistic.

10.Ketamine and benzodiazepines around anaesthesia: use them intentionally

Clinical pearl

After an IV ketamine rescue you may see a climb in ETCO2 and slowed rate — be ready to bag/ventilate briefly and communicate with your monitor.

• IM ketamine (as part of a multimodal approach or as an IM surgical analgesic) is a commonly used tool in theatre prep.
• IV ketamine as intra‑operative rescue can be effective but can depress respiration — capnograph rises, respiration slows and brief apnoea is possible. Forewarn your anaesthesia nurse and be ready to ventilate.
• Co‑induction with ketamine/benzodiazepines has trade‑offs (apnoea risk). Matt’s pragmatic approach: include ketamine where it benefits the patient, prefer IM dosing for routine cases, and use IV rescue doses with monitoring and team readiness.

11.Build your “zero‑pain” habit stack

Useful resources mentioned on the episode (searchable)

Takeaway

Chronic pain management is a sequence of small, well‑judged moves: pick the outcome for today (calm the visit, give safe IM, reduce central sensitisation), track the behaviours that matter to the owner, and adjust stepwise. When OA breaks through, think NMDA antagonists and targeted options (including SC ketamine in select cases) rather than automatically increasing gabapentin. Keep consent and governance front and centre, supply paracetamol via the practice if you’re continuing it long term, and always check product datasheets and local policy before changing doses or licensing status.

• Always define and track 3–5 owner‑observed behaviours and re‑check the same list.
• Review meds systematically: ask “what changed when we added X?”
• Allow time: many first‑line options take several weeks for full effect as the pain system re‑balances.
• Plan handling: calm handling, planned IM sedation when needed, and sensible pre‑visit anxiolysis matter as much as the drugs.
• When OA breaks through, consider NMDA antagonists before reflexively escalating gabapentin.
• Be transparent with owners about licence status and monitoring, and supply paracetamol from the clinic if you plan longer courses.
• Zero Pain Philosophy — pain news, podcasts, webinars, and Zero Pain Practice accreditation
• Clare Rusbridge — neuropathic pain resources and syringomyelia/Chiari treatment algorithm (neuro resources/YouTube)
• COAST — Canine Osteoarthritis Staging Tool
• Regenerative medicine resources (various clinical groups and specialists)