Pain Management in Racing Greyhounds
Pain
Pain is a syndrome consisting of multiple organ system responses, and if left untreated will
contribute to patient morbidity and mortality. Greyhounds incur a wide variety of injuries during
races, ranging from minor lacerations to catastrophic long bone and joint fractures.
Severe soft tissue injuries and traumatic fractures cause moderate to severe pain requiring rapid,
potent analgesia. The drug and dose for initial management are determined by the severity and
instability of the injury and any concurrent haemodynamic instability or organ dysfunction.
On Track Veterinarians (OTVs) are faced with the task of providing, rapid, effective and safe
analgesia to dogs which are hypertensive or hypotensive, tachycardic, possibly dehydrated and
distressed by injury.
OTVs are also frequently required to undertake procedures on injured greyhounds (for example,
bandaging or suturing) requiring a combination of sedation and analgesia to perform competently
and humanely.
Management protocols will vary with the severity of the injury but will generally involve:
• combining opioids with sedatives
• combining opioids with NSAID's
• combining opioids with alpha2agonists
• NSAID's only
Remember: Injury and associated anxiety and fear induce a”stress response” which is
counterproductive or even deleterious, and prolongs recovery.
PAIN = STRESS = POOR AND PROLONGED RECOVERY
Opioids - overview
Opioids are primarily used to provide profound analgesia and a degree of sedation in animals with
pre existing pain and can reduce the anxiety and fear that contribute to pain and suffering (by
blocking noxious stimuli).
Opioids are also frequently used as part of safe and effective sedation protocols
(neuroleptanalgesia).
Opioids can act at mu (u) receptor sites and kappa (k) receptor sites located throughout the central
and peripheral nervous system. Drugs can be
• pure agonists (inducing a maximal response once bound to the receptor)
• partial agonists (inducing a submaximal response once bound to the receptor
• antagonists (inducing no response once bound to the receptor
Opioids with a high affinity for the receptor (eg buprenorpine) have a relatively long duration of
action which is unrelated to the plasma half life.
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mu agonists kappa agonists Partial mu agonist mu antagonists
Morphine Butorphanol Buprenorphine Butorphanol
Methadone Naloxone
Fentanyl
Pethidine
The desirable effects of opioids are ANALGESIA and SEDATION
The potential undesirable side effects are cns excitation, bradycardia, hypotension, respiratory
depression, vomiting/nausea and gastrointestinal stasis.
ANALGESIA is most predictably produced at mu receptor sites with mu receptor selective
agonists being the most effective analgesics. SEDATION can be considered a side effect when
using opioids primarily as analgesics. The most effective SEDATIVES are reported to be
BUTORPHANOL and MORPHINE .
CNS excitation can be an uncommon undesirable side effect, but despite this potential, use of mu
agonists in animals that are in pain will result in calming of the animal.
Opioids – commonly used
Morphine
• mu selective agonist
• excellent analgesic and effective sedative
• duration of action 4-6 hours
• dose rate 0.2-1.0mg/kg I/M, S/C, or SLOW I/V
• will not generally induce vomiting in animals already in pain (compared to use as a
premedicant)
• may cause excitement in greyhounds?
• GOOD ANALGESIA, GOOD SEDATION-THE GOLD STANDARD OPIOID
ANALGESIC FOR SEVERE PAIN IN DOGS
Methadone
• mu selective agonist
• equipotent to morphine but less effective sedative
• combined with acepromazine, diazepam or midazolam, it provides effective sedation.
• dose rate 0.1-0.5mg/kg I/M or S/C, can be given I/V for more rapid onset of action
• duration of action 4-6 hours
• GOOD ANALGESIA, MODERATE SEDATION
Pethidine
• selective mu agonist
• does not cause bradycardia
• half as potent as morphine
• rapid onset of action
• short duration of action (30-60 minutes). The need for frequent dosing makes it a poor
choice for ongoing pain management
• useful as a premedicant
• dose rate 3-5mg/kg I/M only.
• MILD ANALGESIA, MILD SEDATION
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Fentanyl
• potent mu agonist
• rapid onset of action (2-5 minutes)
• short duration of action (5-20 minutes) dose rate 0.005-0.02mg/kg I/M , S/C or I/V
• can be used as transdermal patches but take approximately 18-24 hours to achieve optimum
plasma concentration. Effective for 72 hours.
• GOOD ANALGESIA, MODERATE SEDATION
Buprenorphine
• mu selective partial agonist
• slow onset of action (30-60 minutes for peak effect regardless of route of administration).
• S/C injection does not result in fast enough uptake so must be given I/M or I/V
• moderate duration of action (4-8 hours)
• dose rate 0.01-0.03mg/kg I/M or I/V
• binds very strongly and dissociates from receptor sites slowly making reversal or concurrent
use of other opioids difficult.
• MODERATE ANALGESIA, MODERATE SEDATION
Butorphanol
• kappa selective agonist and mu selective weak antagonist (can be used to partially reverse
the respiratory depressant effects of pure mu agonists ( morphine, methadone )
• effective sedative
• rapid onset of action
• duration of action 1-2 hours
• dose rate 0.2-0.4mg/kg I/M, I/V or S/C
• poor analgesic for somatic pain, traumatic injuries
• MILD ANALGESIA, MODERATE SEDATION
Tramadol
Tramadol is a synthetic opioid agonist which is an analogue of codeine. It is not a controlled
substance. There is diversity among specialist surgeons as to its effectiveness with a “ best of the
rest” opinion prevailing. Its effects are attributed to both the direct opioid effect (mu receptors only)
and the inhibition of re-uptake of serotonin and noradrenaline. Its analgesic
potency is one-fifth to one-tenth that of morphine. Hepatic metabolism of tramadol produces o-
desmethyl tramadol which possesses 200-300 times the affinity for mu receptors than tramadol
itself and this metabolite is largely responsible for the analgesia attributed to tramadol. There is a
rapid and effective production of this first metabolite following intravenous injection. Equipotent
doses of tramadol (2mg/kg I/V) and morphine (0.2mg/kg I/V) resulted in similar post operative pain
scores in dogs undergoing ovariohysterectomy, while anecdotal evidence suggests similar analgesia
can be obtained with equipotent doses of tramadol and morphine for mild to moderate pain.
Tramadol is available for injection as a 50mg/ml solution and can be given I/V, I/M or S/C. It is also
available in capsules, slow release tablets and liquid. Used I/V or I/M it may be a useful pain
relieving medication for those On Track Veterinarians reluctant to carry controlled substances on
racetracks, however it is not suitable for management of fractures or severe injury. It is extremely
safe and can be combined with benzodiazepines, acepromazine and medetomidine for sedation.
The severity of the injury will determine the choice of opioid and sedative to be used.
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Mild pain Moderate to severe pain
(lacerations) (fractures, severe soft tissue injury)
Butorphanol Morphine
Buprenorphine Methadone
Pethidine Fentanyl
Tramadol
Alpha-2 agonists
Alpha 2 agonist drugs such as xylazine, medetomidine and the newer dexmedetomidine
are reliable and predictable sedative agents. They are often combined with opioids to enhance their
sedative effects. They are powerful analgesics as well. The analgesic effect of alpha 2 agonists is
believed to be mediated by similar pathways to opioids, inhibiting the passage of painful stimuli
through the central nervous system.
The major disadvantage associated with using alpha 2 agonists for analgesia is their potent
cardiovascular side effects. Recommended sedative doses result in a hypotensive, vasoconstricted
and bradycardic patient often with an arrhythmia. Most specialist anesthetists discourage the use of
xylazine in dogs, citing incidents of sudden death up to 24 hours after use.
Microdoses of medetomidine (1-5ug/kg equating to 0.03-0.15ml for a 30kg dog) given I/V or I/M
will give mild sedation but will provide short term analgesia. These micro doses may reduce the
cardiovascular effects allowing use in a wider range of patients. If difficulties arise the drug can be
quickly reversed using Atipamerzole
Dexmedetomidine is the new generation alpha 2 agonist . Literature suggests it has fewer
cardiovascular effects but comparable sedative and analgesic properties given at half the dose for
medetomidine.
Use of medetomidine should be restricted to young healthy, normotensive, normovolemic dogs if
used at all. Xylazine is not an appropriate choice of medication for dogs.
Sedatives
Sedatives will potentiate the analgesia produced by analgesic drugs but on their own they have NO
analgesic properties.
Diazepam and Midazolam
Benzodiazepines are the safest supplements to opiate sedation. I/M absorption of midazolam
(Hypnovel) is better than that of diazepam and is preferred for the I/M route. Either is
suitable for I/V administration.
• dose rate 0.2-0.3mg/kg I/V (preferred), I/M
• duration of action 2-5 hours.
Acepromazine
Acepromazine can be combined with morphine and methadone for severe pain and with
butorphanol for milder pain to provide additional sedation.
• dose rate 0.01-0.05mg/kg I/V, 0.02-0.1mg/kg I/M,S/C
• duration of action 4-6 hours.
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Sedative/opioid combinations and dose rates
Medication Dose rate (mg/kg) Route of Comments
Combinations administration
Acepromazine + 0.01 – 0.03 IV, IM, SC
Methadone 0.1-0.3mg/kg IV, IM, SC OR morphine
Diazepam + 0.2 IV OR midazolam
Methadone 0.3 IM, IV OR morphine
Acepromazine + 0.02 IV, IM, SC
Butorphanol 0.2 IV, IM, SC Slow onset IM or SC (20-
30 minutes)
Diazepam + 0.1 – 0.2 IV OR midazolam
Fentanyl 0.01 IV Rapid onset/short
duration of action
Medetomidine + 0.005- 0.01 IV, IM Rapid onset of action
Butorphanol 0.1 IV, IM resulting in recumbency
for 1 hour
Diazepam + 0.2 IV OR Midazolam
Tramadol 1 -2 IV, IM OR Acepromazine
0.03mg/kg
Non steroidal anti-inflammatories (nsaids)
• NSAIDS are generally less analgesic than opioids (except perhaps pethidine)
• provide analgesia without sedation
• effective for inflammatory pain (musculoskeletal or wound pain) not visceral pain
• delayed onset of action (2-4 hours)make them unsuitable for pain management in the acutely
traumatised patient
• POTENTIALLY NEPHROTOXIC IN DEHYDRATED, HYPOVOLEMIC AND
HYPOTENSIVE PATIENTS
• potential to cause gastric ulceration.
Administration of NSAID's should be carefully approached and monitored in patients with possible
dehydration. The maintenance of blood supply to the kidneys is mediated by prostaglandin E2,
which may be inhibited by the use NSAID's
NSAID's are most useful
• in the treatment of mild pain
• combined with opioid analgesia in moderate to severe injuries
• as continuing analgesia after discontinuation of opioids.
• in patients with no potential for concurrent haemodynamic instability (for example in
dehydration or blood loss)
Conclusion
The best welfare outcome for injured Greyhounds will be achieved by prompt administration of
analgesic medications which will prevent or limit pain as much as possible and avoid long term
side-effects.
