EPISODE 23: Chronic Pain - Less Guesswork, Better Decisions
- Aug 2
- 12 min read
A practical GP approach to multimodal pain plans, anti-NGF conversations and meaningful rechecks with Matt Gurney of Zero Pain Philosophy
If you have ever opened an arthritic patient’s record and found an NSAID, gabapentin, paracetamol, a monthly injection and a hopeful little “seems brighter?” in the notes, this episode is for you.
If you have ever wondered whether the dog is deteriorating or simply sedated, whether the cat is painful or merely “getting old”, or whether the latest add-on actually changed anything, this one is definitely for you.
We sat down with Matt Gurney, specialist in anaesthesia and pain management and co-founder of Zero Pain Philosophy, for what was meant to be a broad pain chat. We made it approximately nowhere beyond chronic pain, because every answer opened another clinically useful door. Classic us.
What we took from the conversation was not a rigid ladder of drugs. It was a better way to think: define the pain problem, choose a treatment that has a plausible job, agree what success will look like and review it properly.
Chronic pain is not one problem with one prescription
Osteoarthritis is a disease, but “painful with osteoarthritis” is not a complete pain assessment. Two patients with similar radiographs can have very different movement, sensitivity, coping and home function. The longer pain persists, the more likely it is that several mechanisms and life factors are contributing.
A useful simplification from our conversation was to think in three broad pain categories: nociceptive pain arising from actual or threatened non-neural tissue damage; neuropathic pain caused by a lesion or disease of the somatosensory nervous system; and nociplastic pain, where altered nociception is present without clear evidence that ongoing tissue damage or a somatosensory lesion fully explains it. These are human definitions, and applying them to animals requires clinical inference, but the framework helps us ask better questions.
For us, the GP point is not to pin a perfect label on every patient. It is to notice when the story no longer sounds like a simple, local inflammatory ache.
Constant stiffness, reduced range of movement and predictable discomfort after rest may fit a predominantly musculoskeletal picture.
Sudden yelping, biting at a limb, episodic freezing or apparently electric, start-stop pain should make us consider a neuropathic component and revisit localisation.
Widespread sensitivity, sleep disruption, escalating reactions and function that seems disproportionate to a single lesion should prompt a broader reassessment rather than automatic polypharmacy.
And, of course, red flags still win: new paresis, proprioceptive deficits, pathological fracture concern, fever, focal swelling, severe night pain, rapidly changing function or a patient who is systemically unwell deserves diagnosis, not another layer added by reflex.
Measure the patient, not the optimism in the consult room
One of Matt’s most useful recurring points was to decide how we will know whether an intervention has worked before we start it. “Brighter” is lovely, but it is slippery. A small set of patient-specific activities is much harder to fool ourselves with.
Ask the owner to choose three to five things that matter and that can be observed consistently, such as:
settling comfortably overnight;
getting into the car without being lifted;
using stairs or steps, including steps into the garden;
grooming the lumbar area or climbing to a favourite cat perch;
keeping their usual pace on a familiar walk and recovering normally afterwards.
Record a baseline, agree a review interval and use the same questions next time. Validated tools such as the Canine Brief Pain Inventory, Liverpool Osteoarthritis in Dogs score, Client-Specific Outcome Measures and Feline Musculoskeletal Pain Index can add consistency. They do not replace examination; they rescue us from relying on memory alone.
The recheck question we are stealing: “What can they do now that they could not do before, and what still stops them?” |
Start with licensed foundations, then be deliberate
For canine and feline osteoarthritis, current licensed options and contraindications should anchor the plan. Which product is appropriate will depend on species, comorbidities, previous response, concurrent medication, owner priorities and the latest UK Summary of Product Characteristics, available through sources such as the NOAH Compendium. Weight management, appropriate exercise, rehabilitation, environmental adaptation and treatment of concurrent disease belong beside analgesia, not underneath it in tiny writing.
If the first option is ineffective or poorly tolerated, pause before piling on adjuncts. Was the diagnosis right? Was the trial long enough and the medicine given as intended? Is the patient receiving a dose within the authorised range for the actual current bodyweight? Is another licensed option more appropriate? Has a new clinical sign appeared?
That pause is not therapeutic hesitation. It is the bit that prevents a complicated medication list from concealing a missed problem.
Librela and Solensia: benefit, uncertainty and a proper safety conversation
We spent a good chunk of the episode on bedinvetmab (Librela) in dogs and frunevetmab (Solensia) in cats. Many of us have seen striking improvements in mobility and engagement. We have also had to navigate noisy online discussion, evolving pharmacovigilance and worried owners.
The sensible middle ground is neither automatic enthusiasm nor automatic rejection. Use the current product information, explain expected benefits and known risks in plain language, document the baseline neurological and musculoskeletal examination, and give owners specific changes to report. Product safety information can change as post-authorisation data accumulate, so yesterday’s consent script should not become clinic folklore.
A practical anti-NGF check-in can include:
mobility and weight-bearing compared with baseline;
new weakness, ataxia, altered gait, collapse or loss of function;
urination, drinking, appetite and general demeanour;
new skin lesions, pruritus or overgrooming, particularly in cats;
whether pain relief is lasting to the planned review point.
Suspected adverse events should be treated clinically, recorded and reported through the VMD’s pharmacovigilance route, even when causality is uncertain. Reporting is how rare signals become interpretable; it is not a declaration that the medicine definitely caused the event.
Adjuncts need a job description
This was probably our biggest “write that down” moment. An adjunct should not be added because it is the next familiar name on the list. It should have a target, a tolerability plan and a stop rule.
Gabapentinoids: watch the patient standing up
Gabapentin is widely used in veterinary practice, but evidence for routine osteoarthritis pain relief is limited and mixed. Sedation and ataxia can look remarkably like disease progression, particularly in an older dog already struggling with strength. If it is used for a plausible neuropathic component or another specific indication, start cautiously, review function as well as comfort, and reassess if mobility worsens after introduction or escalation.
The consult-room pearl is wonderfully unglamorous: ask when the wobbliness started and line it up against the medication timeline.
When neuropathic pain looks like scratching: CM-P and syringomyelia
We were delighted that Matt brought up Professor Clare Rusbridge’s work on Chiari-like malformation-associated pain (CM-P) and syringomyelia. We are enormous Clare fans (wondrous is the word), and her treatment algorithm is a genuinely useful bridge between recognising a neuropathic pattern and planning what happens next.
These patients do not all arrive performing the textbook “phantom scratch”. The history may include spontaneous vocalisation, facial or ear rubbing, sudden start-stop pain, reluctance to jump or climb, disturbed sleep, sensitivity to exercise, excitement, touch or weather, cervical sensitivity, altered gait or weakness. Dermatological disease, otitis and other painful disorders can mimic parts of that story, while the severity of imaging findings does not automatically tell us how much pain an individual dog is experiencing.
For the GP team, good video and a careful neurological and orthopaedic examination are hugely valuable. Record the frequency and triggers of episodes, look for progressive neurological deficits, and discuss referral and MRI when the presentation or progression warrants it. Treatment should follow the clinical phenotype, comorbidities, severity and response, rather than becoming “gabapentin because Cavalier”.
Clare’s free CM-P and syringomyelia treatment algorithm organises medical options and escalation for individual cases, including difficult neuropathic-pain presentations. It is specialist decision support, not a substitute for diagnosis or case-specific judgement; ketamine’s appearance in difficult cases should not turn it into a first-line tick box.
Amantadine and other NMDA strategies: plausible, but not magic
Amantadine has a small canine trial supporting its use as an adjunct to an NSAID in refractory osteoarthritis pain. That is useful evidence, but it is not a vast evidence base, and feline data are also limited. Ketamine and memantine entered our discussion through their NMDA-antagonist rationale and specialist experience.
Subcutaneous ketamine for chronic pain was one of the episode’s most memorable ideas. Matt described using 0.5 mg/kg initially at monthly intervals, then judging frequency against patient-specific outcomes. That figure reflects specialist experience discussed in the episode; it is not a licensed regimen or a chronic-pain protocol established by robust clinical trials. We would direct teams to current Zero Pain Philosophy guidance rather than lift the number into a practice SOP. Any case being considered for it needs an individual risk-benefit assessment, informed consent, suitable monitoring, Cascade compliance and a clear method for deciding whether it helped.
Paracetamol: absence of obvious drama is not evidence
The episode also explored paracetamol in dogs. There is more veterinary discussion around acute perioperative use than good evidence for long-term canine osteoarthritis management. Licensed combination products have specific indications and treatment durations; extending use or changing formulation moves the decision into a different prescribing context. Cats are a separate and crucial safety issue: paracetamol is highly toxic and must never be treated as a casual cross-species option.
Pardale-V, the authorised canine paracetamol-codeine product discussed in the episode, is labelled for use for up to five days; its current SPC should also be checked for contraindications, including hepatic dysfunction. Longer use, a different dose or another formulation needs a fresh decision under the UK prescribing Cascade rather than becoming an automatic repeat. We discussed figures around 20 mg/kg every eight hours and the lower 10–15 mg/kg ranges many clinicians have traditionally used, but the evidence does not turn either into a universal long-term osteoarthritis protocol.
For us, the practical point is to document why paracetamol is being considered, the formulation and total daily exposure, what the owner will measure, the patient-specific risks and the planned review or withdrawal trial. Apparent tolerability in everyday practice is reassuring for an individual patient, but it cannot establish long-term safety. Hepatic disease, concurrent medicines and any clinical or laboratory concern should materially change that risk-benefit assessment.
Cats turn feasibility into pharmacology
A theoretically elegant plan that cannot be administered is not an elegant plan. Feline chronic pain asks us to balance evidence, palatability, handling stress, comorbidity and the owner’s ability to deliver treatment without damaging the relationship with the cat.
Look for home changes that owners may have normalised: hesitation before jumping, using an intermediate surface, reduced grooming, altered litter-tray posture, sleeping in easier-to-reach places, irritability on handling or a shrinking territory. Video is gold. So are simple environmental changes: low-entry trays, non-slip routes, warm accessible beds and steps to important resources.
When trialling an adjunct, a short initial supply and an early tolerability check can be more useful than issuing a month and hoping. Sedation, dysphoria, gastrointestinal effects, skin change and the practical battle of administration all count as outcomes.
In our own feline cases, the options we reach for most often include meloxicam when it is appropriate for the individual cat and monthly frunevetmab. Oral-transmucosal buprenorphine can also be useful in selected situations, particularly when a short-term or breakthrough-pain plan is needed, but this route is generally off-label in UK practice and formulation, duration and Cascade requirements matter. Concurrent treatment should never be inferred from a list: check the current product information and make the combination decision case by case.
Pain begins before the examination table
Our detour into anxious patients was not really a detour. Fear can amplify pain behaviour, handling can create pain and distress, and a failed first attempt can make every subsequent attempt harder. Matt’s question was simple: what are we trying to achieve?
For some patients, the aim of pre-visit medication is not to produce a deeply sedated animal at home. It is to reduce anxiety enough for safe arrival and a calm, effective in-clinic plan. Environment matters alongside medication: quieter timing, direct entry to a room, non-slip flooring, familiar bedding, minimal repeated restraint and a team that knows the plan before touching the patient.
Benzodiazepines and co-induction also came up, including the possibility of disinhibition in some fit, healthy patients and respiratory depression when sedative or anaesthetic combinations stack up. The practical point is to judge the whole protocol, not a drug in isolation, and ensure the monitoring team is prepared for the predictable physiology of that protocol.
Early recognition is valuable; disease modification is not yet a promise
We finished with regenerative medicine, including platelet-rich plasma and cell-based therapies, and the hope of intervening earlier in osteoarthritis. Earlier recognition is absolutely worth chasing. The COAST staging concept is helpful because it makes room for dogs at risk or with preclinical disease, not only the profoundly lame patient at the far end of the journey.
The uncertainty belongs in the same sentence. Study methods, products, patient selection and outcomes for regenerative interventions are heterogeneous, and symptom improvement is not the same as proven slowing of structural disease. These options may form part of an individual plan or referral discussion, but “disease modifying” should not become a promise before the evidence can carry it.
A chronic-pain review that fits a GP day
What we took from Matt’s approach can be turned into a six-part review:
Reconfirm the diagnosis and ask what has changed since the last examination.
Describe the likely pain mechanisms and check for neurological or systemic red flags.
Choose three to five owner-observable outcomes and record the baseline.
Optimise licensed treatment and the non-drug plan before adding complexity.
Give every adjunct a target, tolerability check, review date and stop rule.
At recheck, keep, change or remove treatments according to measured benefit and harm.
Chronic pain management will always contain uncertainty. The goal is not to eliminate it with a heroic medication list. It is to make each decision visible, testable and kind to the patient in front of us.
🩺 Quick Clinical Takeaways
Define what success looks like before changing treatment; use three to five specific home activities rather than “seems better”.
Reassess localisation, pain phenotype and red flags when a plan stops working instead of automatically adding another drug.
Optimise appropriate licensed options, bodyweight, exercise, environment and rehabilitation as one coordinated plan.
Sedation and ataxia from an adjunct can masquerade as worsening osteoarthritis; always check the medication timeline.
For suspected CM-P or syringomyelia, collect owner video, characterise triggers and neurological change, and use Clare Rusbridge’s algorithm alongside referral and case-specific judgement.
Use the current Librela or Solensia product information, document baseline function and invite prompt reporting of new neurological, urinary, skin or mobility changes.
Treat subcutaneous ketamine for chronic pain as an off-label, evidence-limited specialist-style option, not a standard monthly add-on.
In cats, administration stress and palatability are clinical outcomes; a theoretically good drug may still be the wrong plan.
Earlier OA recognition creates more options, but regenerative treatments should not be presented as proven disease modification.
📚 Episode Resources
Zero Pain Philosophy — Veterinary Professionals (commercial educational resource; no sponsorship stated in the transcript)
Matt Gurney and Carl Bradbrook’s education platform brings together pain news, podcasts, webinars and veterinary professional learning; some content is free and membership or individual paid learning is also offered.
WSAVA Global Pain Council Guidelines
A broad, practical reference for recognising, assessing and treating acute and chronic pain in dogs and cats, including multimodal care and team-based implementation.
Link: WSAVA pain guidelines
Clare Rusbridge — CM-P and Syringomyelia Treatment Algorithm
Professor Clare Rusbridge’s free clinical decision-support resource for individualising treatment of Chiari-like malformation-associated pain and syringomyelia, including difficult neuropathic-pain presentations and escalation.
Canine OsteoArthritis Staging Tool (COAST)
A downloadable staging framework that includes dogs at risk and those with preclinical, mild, moderate or severe osteoarthritis. This copy is hosted by Elanco; no episode sponsorship was stated.
NOAH Compendium
A practical route to current UK veterinary medicine Summaries of Product Characteristics, including authorised indications, contraindications, interactions, dosing and adverse-event information.
Link: NOAH Compendium
VMD: Report a suspected adverse event
The UK reporting route for suspected adverse reactions, lack of expected efficacy, human reactions and environmental incidents involving veterinary medicines.
💬 Chatty Challenge
Which one patient-specific outcome will you start recording at your next chronic-pain consult, and what treatment decision could it help you make at the recheck?
Podcast Links
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Clinical source notes
1. 2022 WSAVA Global Pain Council guidelines. Monteiro BP et al. Journal of Small Animal Practice, 2023;64:177–254. Multimodal pain assessment and management across dogs and cats. [Free to access] Open source
2. 2022 AAHA Pain Management Guidelines for Dogs and Cats. Gruen ME et al. Journal of the American Animal Hospital Association, 2022;58:55–76. Practical framework for assessment, multimodal care and reassessment. [Free to access] Open source
3. IASP terminology. International Association for the Study of Pain. Current definitions for nociceptive, neuropathic and nociplastic pain; veterinary use requires clinical interpretation. [Free to access] Open source
4. Librela product information. European Medicines Agency. Current authorised product information for bedinvetmab, including indications and adverse-event information. Check the latest UK-authorised SPC before prescribing. [Free to access] Open source
5. Solensia product information. European Medicines Agency. Current authorised product information for frunevetmab, including indications and adverse-event information. Check the latest UK-authorised SPC before prescribing. [Free to access] Open source
6. Amantadine in a multimodal analgesic regimen for alleviation of refractory osteoarthritis pain in dogs. Lascelles BDX et al. Journal of Veterinary Internal Medicine, 2008;22:53–59. Small randomised trial of amantadine added to meloxicam. [Abstract/free bibliographic record; article access may vary] Open source
7. Effects of gabapentin on activity and owner-perceived mobility in osteoarthritic geriatric cats. Guedes AGP et al. Journal of the American Veterinary Medical Association, 2018;253:579–585. Small placebo-controlled crossover study; sedation and ataxia affected tolerability. [Abstract/free bibliographic record; article may be paywalled] Open source
8. Report a veterinary medicine problem. Veterinary Medicines Directorate. UK pharmacovigilance route for suspected adverse events and lack of efficacy. [Free to access] Open source
9. The prescribing Cascade. Veterinary Medicines Directorate. UK legal framework for prescribing an unauthorised medicine when no suitable authorised veterinary medicine is available. [Free to access] Open source
10. NOAH Compendium. Current UK veterinary medicine Summaries of Product Characteristics supplied by participating animal-health companies; confirm the live SPC at the point of prescribing. [Free to access] Open source
11. CM-P and syringomyelia treatment algorithm. Rusbridge C. Free clinician-facing decision-support resource for individualising management of Chiari-like malformation-associated pain and syringomyelia; use alongside diagnosis and specialist judgement. [Free to access] Open source
12. Canine OsteoArthritis Staging Tool (COAST). Downloadable staging tool for canine osteoarthritis, including at-risk and preclinical dogs. The supplied PDF is hosted by Elanco. [Free to access] Open source
In the BSAVA formulary it states that amantadine is restricted to human use only in the EU due to its use as an anti viral agent, so should we be using memantadine instead?