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2022 AAHA Pain Management Guidelines-Critical Review & Questions (Transcript)
Narda G. Robinson, DO, DVM, MS, FAAMA
April 2022

Hi. This is Dr. Narda Robinson, founder and president and CEO of CuraCore MED and CuraCore VET. I want to talk to you today about the 2022 American Animal Hospital Association Pain Management Guidelines for Dogs and Cats. And I titled this talk Pain Practitioners We Have a Problem. Actually, several.

And you know when we first saw the last guidelines in 2015, it was like a celebration because there was so much good stuff in it. But this year, we have some issues and I want to educate you about them through this talk. So, as I said, it’s been seven years since the last group of authors which were different than these ones had published, you know, guidelines about how to assess pain, how they treat it, some new things that were on the horizon, things that worked and things that didn’t and what they recommended.

So, it was a real surprise to see what happened this time around, and I’m going to present to you my views about three salient aspects of what’s going on this time. In 2015 the section on acupuncture specifically said this, “The guidelines task force holds that acupuncture offers a compelling and safe method for pain management in veterinary patients and should be strongly considered as a part of multimodal pain management plans. It is a minimally invasive treatment that for most animals is not uncomfortable, and it’s often pleasant and can be used either alone or in addition to other pain treatment modalities. Acupuncture has been recognized by the National Institutes of Health since 1998, as having applications in human medicine, especially pain management, there is a solid and still growing body of evidence for the use of acupuncture for the treatment of pain in veterinary medicine, to the extent that it is now (2015) an accepted treatment modality for painful animals.” Yay, that was great.

The 2022 guidelines say this, “There is not an abundance of evidence guided studies supporting the use of acupuncture. However, a 1997 National Institutes of Health consensus statement indicated promising results for the use of acupuncture in humans postoperatively for treating chemotherapy nausea and vomiting and in cases of post operative dental pain. In the veterinary literature, acupuncture has been reported to be helpful as an adjunct treatment for post operative pain following ovariohysterectomies in cats and dogs, and for managing intervertebral disk disease, but it was not found to be beneficial for the treatment of pain associated with osteoarthritis in dogs. Further work is needed to fully define the role of acupuncture in pain control.”

So, what a difference. 2015 strongly recommended, evidence is good, we want to use it and it should be you know, front and center. And 2022– yeah, it’s just good for a few things. We’re reaching back still to 1997 talking about humans and using decades old literature. So, did the authors not know that abundant research exists in human and veterinary patients, which the guidelines seven years before were alluding to, but it seems like well, did that disappear? Of course not. Okay.

“Acupuncture demonstrates more safety and research evidence than do many of the medications, surgical procedures and physical medicine approaches that the 2022 authors do advocate for.” Number three, “The American College of Physicians recommends acupuncture as first line care for back pain instead of opioids.” Next, “Do US military and veterans administration provide acupuncture to their patients?” And finally, “Already a significant percentage of veterinarians practice acupuncture,” including several thousand that we alone have taught at CuraCore VET. Did they not know that? That’s baffling.

And then for pharmaceutical recommendations. In their Figure 3 of the 2022 guidelines where they have tiered recommendations for acute and chronic pain for dogs and cats for drug and non-drug approaches. For the top tier approach to chronic pain, they list a just approved medication that is still unavailable to veterinarians in the United States. It’s anti nerve growth factor, monoclonal antibodies, and there’s a dog version and a cat version. It’s made by Zoetis. For the third tier, so the bottom rung, they’re recommending an off label synthetic opioid called Tramadol. It’s poorly effective for pain in dogs. It tastes horrible, so even if you’re going to give it to cats, has a bad impact on their quality of life, and there’s a high potential for abuse and diversion.

So why are we giving synthetic opioids for use for the treatment of pain in animals when that could be going elsewhere than for the animal themselves? We should not be in that position. We should have other options, and acupuncture and related techniques are great options.

So back to these tiers that the authors wrote in the 2022 guidelines. They say, “The tiered or ranked approach is based upon review of evidence based veterinary medicine, incorporation of pertinent literature from human medicine, practical considerations and clinical experience of the advisory panel.”

Okay, so we want to look at evidence. We want to look at human medicine and is it practical to give it, and what’s the clinical experience? Well, so this anti nerve growth factor monoclonal antibody, they put as tier 1 for chronic pain. It’s called Solensia for the cat version, and Librela for dogs. Well, so let’s see it was just approved in January 2022. So, three months before the recording of this talk, for cats, and Librela is not even approved yet in the US. It was approved in the European Union last year, but not yet here. So, if we’re going to say that tier one treatments are those that are considered the mainstay of pain management in the respective categories, and that’s written in the guidelines then how can an unavailable drug be a mainstay? It’s not even out there yet.

And so, the folks that wrote this, I mean, I don’t know all of them, but you know, they’re good people. I think veterinarians are some of the best people and best hearted people on the planet. So, this is nothing against them. This is nothing specifically against AAHA or the drug companies, you know, Zoetis and whatever, that are supporting this whole process. But I think that it’s worthwhile to just take a deeper look at what’s going on here.

So, the guidelines authors you see here listed the top two are who are put forth by the guidelines written in there as the ones that you communicate with. And so, when this was brought to my attention by students of mine that were alarmed by how acupuncture was being portrayed in the 2020 guidelines, so I took a look at it and then we have a summary on our website that I’ll link to at the end of the talk. But I really start to scrutinize what was written and what was omitted. And that’s where this talk came from as well as a letter to the editor that we’ve compiled. So, for me and many of our graduates and the list keeps getting longer. So, we’ve already sent that in, as instructed by the people at AAHA, as far as how to dialogue about this.

So anyway, just taking a look at okay, here are the two authors that you’re supposed to communicate with, Margaret Gruen and Duncan Lascelles, and then we have other people on that list as well. So is it reasonable as we might for any author I mean, I’ve authored papers, I’ve had to fill out conflict of interest disclosures. I have to do that whenever I’m giving a talk. So, it is really a standard thing that you pretty much expect to complete whenever you’re going to represent yourself as an authority. So, is it reasonable to ask if any of the authors with this paper have potential conflicts of interest that they need to disclose?

All right, well, let’s look at some of the research that has been done with this monoclonal antibody because within the guidelines, there was nothing pertaining to the authors. So, looking around a little bit more, okay. What’s the research that was done on this you know, top tier medication that’s being recommended for cats and dogs with chronic pain. And were these authors part of that?

So, here’s one article in the Journal of Veterinary Internal Medicine that was done with cats. Well, the authors there were two of the same authors that wrote in the guidelines as well as some others. And so, in the conflict of interest declaration for this Journal of Veterinary Internal Medicine paper, we do see yes, the same authors that wrote the guidelines. It says, “Margaret Gruen and Duncan Lascelles have received honoraria for continuing education lectures sponsored by Zoetis.” I mean, that’s fine. Just write it down there. And they’re also both paid consultants for Zoetis.

So, and, you know, the thing is that with the perpetual cutbacks that have been at least over the past five years or so, in federal research funding, I mean, but you know, I think it’s always been like too little. So, what happens is, especially for in academia, I mean, I’ve taught at Colorado State University for 20 years. I know how hard it is to get research funding. And it’s even being more and more talked about, through different information services and scholarly journals, things about this crossover, this infiltration or integration of industry, into academia because if you want to do research, and it’s really, really hard to get federal funding, especially under certain administrations, and so remember, elections have consequences and so, you know, the more that a certain administration might want to just kowtow to pharmaceutical companies, then that’s going to grease the wheels for having a more of a presence in academia. And in some ways that works because where else are you going to get the money if you are a researcher or an institution.

On the other hand, it compels us even further to adhere to recognized rules of transparency that anyone would expect. And so why should the AAHA pain management guidelines be any different than any other publication, where it’s helpful as the reader to know that the authors that are advocating for, and researching a top tier medication that is not even available, that they are actually paid by the drug company that runs the studies.

Now, interestingly, the study that was written up in Journal of Internal Veterinary Medicine, the funding did come from Zoetis. So, the same company that is paying the authors, the same company that contributes to AAHA, the same company you know, where the guidelines are promoting this product. We always need an institutional review board and okay, this study was reviewed by the Zoetis ethical review board.

Okay, in another study, let’s see, more research on the same anti nerve growth factor, monoclonal antibody for cats. Okay, we see here again, Gruen, Meyers and Lascelles, this was Frontiers in Veterinary Science, 2021, open access. And again, conflict of interest declaration is just standard fare. Okay. They’re paid consultants and have conducted sponsored CE and then the third person Meyers is an employee of Zoetis. And the authors declare that “This study received funding from NexVet,” which is now Zoetis. “The funder was involved in the study design, the execution and data analysis and publication decision. Data interpretation and writing of the article was performed in part by Zoetis employee.” really good to know. Let’s just be transparent. Let the reader decide. About ethics statement, this one too, “The animal study was reviewed and approved by the Zoetis ethical review board.” Whether that’s good or not good or whatever, it’s just important to know. Right? And so, my question arose about where were the conflict-of-interest declarations for these guidelines?

Now AAHA does say, “These guidelines are supported by generous educational grants from Arthrex Vet Systems, Boehringer Ingelheim Animal Health USA Incorporated, Elanco, and Zoetis.” So that’s nice. We don’t know how much, but it helps build a picture that those that are interested can use about, okay if a drug is recommended in the guidelines by the authors. These guidelines are put out for veterinarians to use when they make their own decisions, or an organization that is also receiving money from maybe some of the drug makers like Zoetis that are there.

I think it’s just good policy for publication, especially in light of the history in human medicine, of opioids, Purdue Pharma, federation for state medical boards, and pain experts that were hired to promote opioid friendly guidelines. So that’s not what’s happening here necessarily. This is not about opioids and monoclonal antibodies aren’t there, but with the backdrop of there being decades of real cozy relationships between companies that make the drugs, pain medicine practitioners that promote use of the drugs, and companies or organizations that are involved with creating standards or policy or guidelines for prescriptions. You know, that was then, and this is now and it’s different, but still, I think it’s just a good, good way to move forward.

So how would I know why this is? Because in the instructions for authors in that same journal, where the guidelines appear, it says, “All manuscript submissions to the Journal of the American Animal Hospital Association must include a submission fee, signed copyright agreement, and signed consent to the conflict of interest and animal care and use guidelines.” This is not unusual. They also said, “Authors also should disclose all financial interests that they may have in companies that manufacture products cited in the study, or in companies that manufacture competing products. Such financial interests include employment, consultant positions, shareholding, ownership, or officer advisory board membership in the company.”

So, is it wrong to expect transparency? Because actually, when I first asked someone at AAHA, I got a really like, agitated response about why I should be asking this question. So, is it wrong to expect transparency? Well, here’s the committee on publication ethics from their guidelines on good publication practice. This was 2003. A long time ago. They say. “Conflicts of interest arise when authors, reviewers, or editors have interests that are not fully apparent, and that may influence their judgments on what is published. They have been described as those which when revealed later would make a reasonable reader feel misled or deceived.”

So, we have lingering questions. Why doesn’t JAAHA provide disclosure about potential conflicts of interest for their pain management guidelines, when they do for submitted manuscripts? Why do the 2022 guidelines on pain recommend a medication as top tier that isn’t even available for veterinarians to use? Why do they include surgery, particularly salvage surgery or de innervation procedures for chronic pain, and not even mentioned acupuncture by name? And finally, why did the 2022 guidelines authors fail to cite up to date evidence on the safety and effectiveness of acupuncture and contradict the strong emphasis that was given about its value in 2015?

So, if you’d like to read more, I do have a summary and cited evidence and links to evidence on our website. Just go to this link here  where we have a downloadable PDF, or you can just search in the search bar for this page. And so, it’s in a blog format and a PDF and includes the emails of people that you can write your own letter to and voice your concerns or your praise or whatever you want to do.

If you’d like to contact us, write to info at curacore.org And again, the website is curacore.org That will take you to the med side and the vet side. So, this is all on the vet side. So, thanks for listening. I hope you’re going to act if you feel agitated like I do. Thanks.