Pain Management

TBVH’s uncompromising approach to the recognition, prevention, and treatment of pain is clearly articulated in our Position Statement. Understanding the negative ethical and physiological consequences of undermanaged pain, TBVH is dedicated to remaining on the forefront of the developments in the field and applying the most contemporary and comprehensive, pharmacologic and non-pharmacologic methodologies available in our daily practice. These methodologies will be evidence-based whenever possible, and otherwise reflect a consensus of expert opinion. As this is a rapidly growing field of knowledge, doctors and all team members are advised to dedicate themselves in a continual process of self-improvement.

TBVH’s pain management systems and protocols will stand on the following 3 pillars:

  1. Multi-modal
  2. Pre-emptive / Preventive
  3. Measured / Recorded

1. Multi-Modal: for most moderate-to-severely painful conditions, clinicians typically will apply the combination of at least 4 pharmacologic +/- non-pharmacologic interventions. These interventions may include but are not limited to the following:

  • Pharmacologic
    • NSAIDs
    • Opioids
    • Alpha2 agonist
    • Local/Regional blocks
    • Dorsal horn spinal modulators including:
      • NMDA antagonists
      • Calcium channel blocker
      • NE reuptake inhibitors
      • Serotonin agonists
    • Adjunct agents e.g. sedatives/anxiolytics
    • DMOAA’s

Routes of delivery may include:

    • Oral
    • IV, SQ, IM
    • Intra-articular
    • Transdermal
    • Transmucosal
    • Epidural


  • Non Pharmacologic
    • Low-stress handling, pheromone therapy
    • Cold compression
    • Coaptation (bandaging/splint)
    • Massage and passive range of motion
    • Physical rehabilitation
    • Environmental modification
    • Human contact and warmth
    • Laser Therapy
    • Acupuncture

2. Pre-emptive & Preventive: Pharmacologic interventions shall, whenever possible, be administered prior to any procedure which can be predicted to elicit pain

3. Measuring/Scoring: Pain shall be considered the “4th Vital Sign” and may accompany the temperature, pulse, and respiration evaluation of patients and recorded in the medical record.




Pain in animals is both under-recognized and too often, under-managed. This is largely due to the challenge they present as non-verbal patients, as well as an under-appreciation of the consequences of undermanaged pain. However, pain has been clearly demonstrated to cause:

  • worsening and lengthening of illness as a result of the body’s stress response (and in extreme cases can contribute to a cause of death)
  • in early life experiences, heightened sensitivity to pain even years later
  • diminished memory and cognitive skills in chronic pain patients

…and of course in animals, undermanaged pain can be, sadly, a criteria for euthanasia. Fortunately, the emerging field of animal pain management is experiencing exciting advances in the understanding of pain neurophysiology and treatment. We are uniquely focused on those changes, and leveraging them on behalf of your pet.


TBVH hospitals and Carolinas Animal Pain Management (CAPM) are designed to provide resources for, and the treatment of, pets for whom a prime consideration is the control of discomfort and the restoration and/or improvement of mobility and abilities. The eligible patient population spans the entire continuum of acute and chronic pain circumstances and syndromes.

We utilize an integrated, balanced, flexible approach to pain management, taking advantage of many non-pharmacologic (non-drug) modalities as well as traditional and novel pain-relieving medications. Each pet and pet owner is treated as an individual with its own history and circumstances. Our staff will devote the time and attention necessary for education, characterizing your pet’s condition, and formulating and then helping to implement a plan to meet the needs of your beloved friend and companion, and as importantly, your own.

CAPM operates within TotalBond Veterinary Hospital at Forestbrook in Gastonia, N.C., but the culture of pain management permeates throughout all of our TBVH facilities.

The Veterinary Team is led by:
Mark E. Epstein, DVM, Dipl. ABVP (Canine and Feline), dAAPM, CVPP

Dr. Epstein is a nationally recognized expert in the recognition, prevention, and treatment of pain in animals. He is a Board-certified specialist in Canine/Feline practice, has been certified by a leading human pain organization (American Academy of Pain Management), and is recognized as a Certified Veterinary Pain Practitioner by the International Veterinary Academy of Pain Management. He is a past-president of IVAPM, has authored articles and book chapters in the veterinary literature, and is a sought-after speaker at veterinary conferences. He is the lead author of the 2015 AAHA-AAFP Pain Management Guidelines.

Complementing Dr. Epstein and the other doctors of TBVH is an experienced, compassionate, highly-skilled corps of support staff. They are highly trained in the concepts, tools, and services that will be leveraged on behalf of your pet, and they are a valuable resource for support and guidance as you continue treatments at home.


What is Pain?

The International Association for the Study of Pain defines pain as:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

However, an important addition was made in recent years, because it reflects the reality of non-verbal patients…including animals!

“The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment.”

The important point is that pain is a conceptual sense, always subjective to the individual, always unpleasant, always elicits a cascade of stress chemicals and hormones, and is always both an emotional and physiologic experience. . .and that in animals, it can be sometime very difficult to know with certainty how much pain is being experienced.

Sometimes, pain is good; it protects us from further tissue damage (no one keeps their hand on the hot stove!). This would be considered “normal” or “adaptive” pain. But depending on its type, intensity, and duration,, pain can become bad, dangerous, harmful, debilitating, and self-perpetuating. . . not only to one’s state of mind but to the body itself; we call this “maladaptive” pain.

Treating, and preventing, maladaptive pain is our primary focus.

Acute Pain

You are trying to attach a leash to the collar, and instead, the latch pinches your finger. Hard. The crushing effect destroys some tissue cells, which release chemicals that stimulate nerve endings. The impulse shoots up nerve cells (“neurons”) in your arm to the spinal cord. There they connect (“synapse”) onto other neurons there which then shoot an electrical impulse up to the brain. There, in the thalamus, you perceive the pain, but you cannot yet localize it; another synapse occurs and a third neuron carries the impulse to the cerebral cortex, where you can then tell where the pain is occurring and consider whether or not to swear an oath. Lastly, an inhibitory neuron travels back down the spinal cord to synapse in the spinal cord where the first neuron is connecting to the second; it releases chemicals that blunt some of the original impulse, causing some of the most intense immediate pain to quickly abate. All this happens in a nano-second.

Chronic Pain

The equation changes.

Someone applies a vise to your finger, and it is tightened. The initial tissue damage occurs, as described above, but the vise stays attached. It never lets go. It continues to send impulses up the spinal cord, bombarding the second neuron with chemicals (“neurotransmitters”). This constant bombardment of pain impulses causes a new fiesta of neurotransmitters to be secreted, which in turns opens other receptors, allowing more and more impulses to travel up the spinal cord, even though the vise hasn’t changed. Same stimulation → more pain. A chemical caused Nerve Growth Factor is secreted, which brings other neurons to make connections to this pain pathway. Now, what was once just a “touch” neuron is now transmitting pain impulses. Neurons coming from other parts of the body begin to make connections here. Now, the pain seems to be coming from everyone at once…you can’t localize it just to your finger. The inhibitory neurons begin to lose their function. Abnormal electrical impulses begin to go back down the neuron in your arm, which then causes the release of more inflammatory chemicals which then cause even more impulses to back up to the spinal cord, continuing the cycle and worsening it. The pain becomes more intractable, more refractory to medications.

Replace “vise on the finger” with “arthritis in the hips” or “disc in the back” and you have an idea of what is happening with many of our pets, especially older ones. Furthermore, their adaptive mechanisms delude us into thinking that they are not nearly as uncomfortable as they really are. However, even though they can’t verbally report the pain that they are living with, we can intervene. The goal is not only to improve things in obvious ways for the immediate future, but to take a long view, interrupt where we can the otherwise inevitable chemical and biochemical chronic pain changes in the spinal cord. In this way we can dramatically improve quality of life, not only next week but years from now.



The neurophysiology of pain – the study of nerves, nerve function, chemical transmitters, and receptors – is experiencing an explosion of information and understanding, with new developments appearing at a rapid pace. This permits the availability of a large arsenal of medications that can target pain through a variety of different mechanisms and locations. And, we have many different types and ways of using them: orally of course, but also topically on and through the skin, IV and subcutaneously (under the skin), local and regional nerve blocks, and so on. All medications in the treatment plan are prescribed with flexibility and careful attention to avoiding potential adverse effects while still achieving the positive result desired.





These techniques and modalities are a complement any pain management program, and sometimes are central to it. The evidence of benefit for physiotherapy is well-established in both humans and animals to improve strength and mobility. Science is also beginning to illuminate the underlying mechanisms in acupuncture and demonstrate effectiveness in a number of pain conditions. We are equipped to incorporate basic aspects of this modality into an integrated pain management program at our practices. When determined that a pet might benefit from a more comprehensive application of these modalities, a recommendation for referral may be made to certified practitioners of the discipline.



Undermanaged pain from surgery is a leading cause of long-term pain in humans…and we can only assume the same must be true for pets. Anesthesia (being asleep) is not the same thing as analgesia (not feeling pain)! Part of a comprehensive anesthetic and operative episode that places an emphasis on both safety and comfort must include multiple layers (types) of pain control that impede pain impulses at several different levels and through different mechanisms. These include, but are not limited to: local and regional nerve blockade (including epidurals), opioids, non-steroidal anti-inflammatories, spinal cord modulating medication, and unique instrumentations such as surgical laser (for feline declaws and other procedures), and availability of minimally invasive (laparascopic) surgery.


Pets with life-limiting conditions present a very special set of patients and circumstances. Cancer especially is unique in its ability to have a negative impact on quality of life, but on the other hand pet owners are often surprised to learn of our ability to combat it. Palliative care, however, uses the tools and resources at our disposal to minimize pain and discomfort without attempting to achieve cure of disease. Through a combination of in-hospital treatments, phone consults, and at-home visits, including for humane euthanasia when the need exists, we are uncompromising in our desire to help pet owners and allow their pet to live, and encounter death, with the greatest of grace and dignity.

For pet owners wishing a Pain Management Consult, feel free to contact TBVH @ Forestbrook, 704-867-8318 for an appointment with Dr. Epstein.