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QUARTERLY BEAT / APRIL 2024

The CSU-FAPS is relatively easy to use and can help drive analgesic assessment and intervention but has not been fully validated in all settings and patient populations. It is somewhat subjective. Shipley et al. (2018) evaluated 68 female cats after OHE using the CSU-FAPS and found it to have moderate to good inter-rater reliability when used by veterinarians with advanced training in anesthesia; however, their conclusion was that the scale required further refinement before being widely applied in clinical practice. It is mentioned in the most current version of the AAHA/ AAFP pain management guidelines. The UNESP-Botucatu pain scale was originally developed in Brazilian Portuguese but has since been translated into and validated in English, Spanish, French, and Italian. It is easy to use but can be time-consuming to execute. The instrument is 3 pages long and uses three subscales encompassing 10 variables grouped around pain expression, psychomotor change, and physiologic variables. Pain expression variables include elements like vocalization, reaction to palpation, and other miscellaneous behaviors (tail movement, eye shape, limb movement, etc.). Psychomotor changes include activity, attitude, comfort, and posture. Physiologic variables include elements like appetite and blood pressure. The UNESP-Botucatu scale has been found to be discriminating, reliable, sensitive, specific, and valid in cats undergoing OHE when used by trained veterinary professionals (DVM and technician); however, it has not been applied to cats with chronic pain, other types of surgical pain, orthopedic pain, or trauma. Training materials, including a video tutorial, are available. Ketamine use may affect scoring of the psychomotor elements. Shy or fearful cats may score differently than extroverted, confident cats; scores should be interpreted carefully in these patients. The CMPS-Feline or Glasgow feline pain scale has been revised intensively since its creation; it has good validity and responsiveness but requires further evaluation for reliability. It is less time-consuming than the UNESP-Botucatu scale and has the advantage of being applicable to any type of acute pain, not just that associated with OHE; it also provides a score cut-off for rescue analgesia (≥5/20). It includes similar elements to the UNESP-Botucatu (activity, demeanor, facial expression, posture, vocalization, etc.). The CMPS-F is 2 pages long. Training materials including video tutorials are available. Fearful, introverted cats may score differently than extroverted, more interactive cats.

The FGS was first presented in 2019 after several years of development. Grimace scales have been in use for many years in laboratory animal medicine and have also been developed for horses, ferrets, piglets, and sheep; they are predicated on facial expressions that can be assessed using facial action coding systems, or FACS. FACS measure action units, or specific changes in the elements of expression (ears, eyes, whiskers, lips, etc.) and have been validated by thousands of measurements. Alterations in action units can be specific to individual species (for example, mice exhibit bulging cheeks when painful while horses show lip tightening). To develop and validate the FGS, photo analysis software was used to assess video stills of cats believed to be painful and those from a colony who had no documented health problems. Five action units were identified: ear position, orbital tightening, muzzle tension, whiskers change, and head position. Each action unit is graded on a scale of 0 (absent), 1 (moderately present), or 2 (markedly present) for a composite score of 0-10. Rescue analgesia is recommended if the score is ≥4. The FGS has demonstrated high correlation with the CMPS-F, internal consistency, and good to excellent intra-rater reliability. It has not been validated in brachycephalic cats or black cats. Further evaluation has shown that the FGS provides good agreement between scores assessed by DVMs and those assessed by veterinary technicians, pet owners, and veterinary students; it can also be used with reliability by untrained raters. There is a wide variety of safe analgesic drugs currently available for cats; many are injectable, and some are reversible. Multimodal analgesia is recommended (administration of a variety of drugs from different classes that will reduce the dose needed of all drugs while also addressing all potential pain pathways). Common classes of drugs used in multimodal feline analgesia include opioids, alpha-2 adrenergic agonists, nonsteroidal anti- inflammatory drugs (NSAIDs), and adjunctive medications such as local anesthetics, ketamine, or gabapentin. Loco-regional anesthetic techniques, such as epidurals, line blocks, or fascial plane blocks are also effective to provide analgesia in the immediate post-op period. If possible, analgesic drugs should be administered before a painful event occurs (such as a surgery). The ideal protocol is one that takes the patient’s comorbidities, temperament, pain score, vascular access device(s), hydration, and perfusion status into account. There is no “one size fits all” analgesic protocol for feline patients, and the best protocol is one that preserves normotension and cardiorespiratory function while also alleviating pain.

Opioid drugs, such as buprenorphine, fentanyl, hydromorphone, and methadone are an excellent choice for moderate-to-severe and acute pain. They can be titrated to effect, combined with other drugs, given as an intermittent bolus, or delivered as a constant rate infusion and are reversible with naloxone or partially reversible with butorphanol, which halts the objectionable effects of opioids while preserving their pain-relieving properties better than naloxone. Documented side effects of opioids in cats include euphoria, mydriasis (eye dilation), nausea/vomiting/ ptyalism, and hyperthermia. Opioid drugs that are well-studied in cats include methadone, buprenorphine, butorphanol, morphine, hydromorphone, oxymorphone, fentanyl, and fentanyl analogues. Not all are considered 100% safe (e.g., morphine may cause histamine release when administered IV). Butorphanol is best reserved as a sedative since it has weak analgesic properties. Nonsteroidal anti-inflammatory drugs such as robenacoxib can be added once hypovolemia is corrected and kidney function has been evaluated. Robenacoxib is labeled specifically for feline patients and has good analgesic and anti-inflammatory effects. It can be administered orally or subcutaneously. Other drugs

• Simon BT, Scallan EM, Carroll G et all. The lack of analgesic use (oligoanalgesia) in small animal practice. Journal of Small Animal Practice. 2017;58:543-554. • Simon BT, Steagall PV. Feline procedural sedation and analgesia: when, why, and how. J Fel Med Surg. 2020;22:1029-1045. • Shipley H, Guedes A, Graham L et al. Preliminary appraisal of the reliability and validity of the Colorado State University Feline Acute Pain Scale. J Fel Med Surg. 2019;21(4):335-339. • Steagall PVM, Monteiro-Steagall BP, Taylor PM. A review of the studies using buprenorphine in cats. J Vet Intern Med. 2014;28:762-770. • Steagall PV, Benito J, Monteiro BP et al. Analgesic effects of gabapentin and buprenorphine in cats undergoing ovariohysterectomy using two pain-scoring systems: a randomized clinical trial. J Fel Med Surg. 2018;20(8):741-748. • Wiese AJ. Canine and feline pain scales. Vet Team Brief. October 2018;28-32. • World Small Animal Veterinary Association Guidelines for Recognition, Assessment, and Treatment of Pain. WSAVA. Wsava.org/WSAVA/media/PDF_old/jsap_0.pdf such as ketamine or gabapentin also have a role in multi-modal pain relief. Gabapentin has also been shown to improve stress behaviors in hospitalized cats and may be a good adjunct for cats who require extended hospitalization and associate handling with pain. If surgery is required, soaker catheters and regional blocks provide additional analgesic coverage. Specific dosing information is available elsewhere. The understanding and recognition of feline pain have grown by leaps and bounds in the past 30-40 years. Multiple multimodal, validated pain scoring instruments are available for use in cats and many provide comprehensive training in the use of the instrument (e.g., interactive practice scoring scenarios are available for the FGS). Regardless of which instrument is selected, veterinary technicians have the unique ability to drive practice improvements in feline analgesia by advocating for their patients, educating themselves and their peers, staying current on new research, using analgesic medications with confidence, and being a bridge between the patient, the client, and the DVM.

REFERENCES

• Adrian D, Papich M, Baynes R et al. Chronic maladaptive pain in cats: a review of current and future drug treatment options. The Veterinary Journal. 207;230:52-61. • Belli M, De Oliveira AR, de Lima MT et al. Clinical validation of the short and long UNESP-Botucatu scales for feline pain assessment. Peer J. 2021;1-21. • Bortolami E, Love EJ. Practical use of opioids in cats: a state-of- the-art, evidence-based review. J Fel Med Surg. 2015;17(4):283- 311. • Brondani JT, Mama KR, Luna STL et al. Validation of the English version of the UNESP-Botucatu multidimensional composite pain scale for assessing postoperative pain in cats. BMC Veterinary Research. 2013;9(143):1-15. • Buisman M, Wagner MC, Hasiuk MMM et al. Effects of ketamine and alfaxalone on application of a feline pain assessment scale. J Fel Med Surg. 2016;18(8):643-651.

• Court MH. Feline drug metabolism and disposition:

pharmacokinetic evidence for species differences and molecular mechanisms. Vet Clin North Am Small Anim Pract. 2013;43(5):1-8. • Evangelista MC, Watanabe R, Leung VSY et al. Facial expressions of pain in cats: the development and validation a feline grimace scale. Scientific Reports. 2019;9(19128):1-11. • Monteiro BP, Steagall PV. Chronic pain in cats recent advances in clinical assessment. J Fel Med Surg. 2019;21:601-614.

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