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in humans. In dogs, bioavailability is poor and clinical efficacy is lacking.81 At this point in the manuscript, the Task Force wants to emphasize that many drugs and compounds enhance either monoamines or serotonin expression. Caution should be used when such analgesic agents are used in combination. Examples 74 JAAHA | 51:2 Mar/Apr 2015 include tramadol, TCAs (including amitriptyline and clomipramine), SS(N)RIs, amantadine, metoclopramide, selegiline, amitraz, mirtazapine, and trazodone. Acetaminophen Acetaminophen is contraindicated in cats. In dogs, several early studies revealed a pain-modifying effect in orthopedic surgery, and pharmacokinetic data has been reported.82–84 The literature does not appear to indicate that acetaminophen has a proclivity towards hepatotoxicity in dogs. Maropitant Maropitantc is a central antiemetic indicated for the treatment of acute canine and feline vomiting, which is often a postsurgical sequela and a contributor to the pain burden. Maropitant works through a blockade of substance-P binding to the neurokinin-1 receptor, which is involved in pain processing. The true painmodifying effect of maropitant in dogs remains uncertain despite canine studies revealing an anesthetic-sparing effect and a noninferior effect to morphine in an ovariohysterectomy model.85,86 Bisphosphonates Administered by IV infusion, this class of drug exerts antiosteoclast activity and can contribute to pain relief in dogs with bone cancer.87 Corticosteroids Corticosteroids are not primarily analgesic drugs, but may exert a pain-modifying effect by reducing inflammation. Their utility as an analgesic therapy in dogs and cats has not been reported.88–91 Polysulfated Glycosaminoglycans (PSGAGs) A parenterally administered PSGAG productd has regulatory approval for the control of signs associated with noninfectious degenerative and/or traumatic arthritis of canine synovial joints. Independent studies support PSGAGs as safe and effective chondroprotectants with possible disease-modifying effects.92–94 The bioavailability and distribution of PSGAGs to inflamed joints in cats has been demonstrated with extralabel subcutaneous administration.95 Nutraceuticals and Other Oral Supplements Oral nutritional supplements represent a wide spectrum of compounds either as single agents or in combinations. Anecdotal evidence for a pain-modifying effect of those products remains mixed If nutraceuticals and/or herbal supplements are made part of a treatment plan, the Task Force suggests mindfulness towards product quality control, potential drug interactions with other medications (e.g., some over-the-counter joint products and herbal mixtures contain aspirin and some may contain herbs such as St John’s Wort that interfere with serotonin release or reuptake), and avoidance of ingredients derived from endangered species. In the future, evidence for the pain-modifying effect of cannabinoids and/ or their commercial drug derivatives may become evident. Non-pharmacologic Modalities for Pain Management Weight Optimization for Pain Management Adipose tissue secretes a mixture of cytokines that circulate throughout the body, contributing to the pathology of many diseases, including DJD, and to the hypersensitization process in general. Either maintaining or regaining a lean body condition score is central to the treatment of chronic pain. Acupuncture for Pain Control 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.96 It is a minimally invasive treatment that, for most animals, is not uncomfortable, 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 an accepted treatment modality for painful animals.97–101 Physical Rehabilitation Combined modality therapy to decrease pain and restore function is now considered an essential approach for musculoskeletal injury and post-surgical recovery.102 In the treatment of chronic disease, such as DJD or conformational abnormalities, rehabilitation should be considered an important component of an overall long-term treatment strategy.103 The foundation of rehabilitation is therapeutic exercise that aims to restore musculoskeletal strength and function, endurance, proprioception, and the reduction of pain. Most commonly it involves exercise and manual therapy, including joint mobilizations, massage, and myofascial release. Energy-based modalities are also often employed, including neuromuscular electrical stimulation, transcutaneous electrical JAAHA.ORG 75 Pain Management Guidelines for Dogs and Cats nerve stimulation, cryotherapy with and without compression, therapeutic ultrasound, therapeutic laser, and extracorporeal shockwave therapy.104–108 Myofascial pain syndrome (MPS) is increasingly recognized as an important comorbidity in many chronic pain cases in animals. MPS is acknowledged for the important role it plays in the pathology of DJD, repetitive strain injuries in performance dogs, or as a sequela to orthopedic surgery. The pathophysiology of myofascial pain is a complex syndrome involving motor, sensory, and autonomic nerve components that are beyond the scope of these guidelines but is well described elsewhere.109 The treatment of MPS is often essential to regain full function of the affected limb regardless of the underlying cause.110 Nutrition Management for Pain Management In the overweight patient, the prime nutritional emphasis should be achieving a leaner body condition. Weight control diets fortified with omega-3 fatty acids have been shown to be effective at reducing signs associated with both canine and feline DJD.111–114 Thermal