What Can I Do When My Cat Is In Pain?

What Can I Do When My Cat Is In Pain?

Ron Hines DVM PhD

Solensia®?

Why Are There Less Pain Control Options For My Cat Than There Are For My Dog – Or For Me?

There are three main reason for that:

The first is that veterinarians have discovered over the years that cats are more sensitive to a number of pain-reducing drugs that dogs and us humans take with few, or no side effects. That’s because the liver of cats is naturally deficient in a number of enzyme systems (metabolic pathways) that allow their bodies to purge themselves of specific drugs to keep blood levels safe. One is their lesser capability of glucuronidation. Another, their lesser capabilities for drug hydroxylation. and demethylation. A third are differences in their P 450 detoxification pathways. (read here)

  The second  reason is that your cat can’t talk. It is very difficult for cat owners or veterinarians to determine if a cat is actually in pain. Dogs are non-verbal too; but they are considerably more likely than cats to limp or show postural or locomotion changes when they have bone, joint or tissue issues. Dogs in pain are also more adept at communicating with their owners through non-verbal means. Cats rarely change their facial expression, body language or beg for compassion the way dogs do when they face health issues. Cats are more stoic in those situations. Some attribute this to the fact that the ancestors of our house cats (unlike dogs and humans) were solitary creatures with no need to express their feeling to other members of their tribe. No one know how much of that is true, – but it is plausible.

  The third reason was until recently, economics.  Veterinary drug companies knew that the typical American dog owner was willing to spend more money on their dog’s health care than the typical cat owner was willing to spend on their cat’s. A not-too-long-ago survey of 250 dog owners found that they were willing spend an average of $10,725.46 to save their dogs life in an emergency, while the average for a cat owner was $3,454.22. Another survey about the same time found that the average yearly veterinary care expenditure for a dog was $257 – that for a cat $182. That has changed remarkably over the last few years with cat owners now willing to pay considerably more for their cat’s health care. That is why veterinary pharmaceutical companies have ramped up their research and pain relief drug offerings to felines.

Is There More Than One Type Of Pain?

Yes.

There are two – acute or sudden pain, and chronic or long-term pain. Pain can also be classified as neuropathic pain (pain due to damage to one or more nerves) or nociceptive pain (pain due to damage or inflammation of the tissue surrounding one or more nerves).  

Acute pain and chronic pain are also quite different in how they are relayed to the brain and how they are processed once they get there. They are also different in their long-term consequences to the quality of your cat’s life. Pain has been studied for centuries in humans and for decades in laboratory animals in an attempt to discover new human treatment options.  All of the pain-relieving medications available for you and for dogs grew out of that research. As I mentioned, cat are metabolically quite different from dogs and humans. Because of ethical concerns, the type of objective studies that would directly measure how cats respond to our current pain control medications and proposed new ones would never be allowed today. Today we are limited to subjective methods –  those not free from, optimism, motivation, personal feelings, personal tastes or pre-conceived opinions. 

Short Term Or Acute Pain

Animals, cats included, are probably better equipped to deal with short term pain than with long term pain. The natural sources of most short-term pain were things like minor traumatic injuries, bites, superficial punctures, thorns, infections etc. During healing time pain can be quite protective. It limits use increasing therapeutic rest and decreased activity. Pain increases the number of circulating white blood cells to better fight infection. It also increases blood volume which improves circulation at the point of damage. That gives wounds their best chance to fully heal. So attempts to eliminate short term pain can be overdone in certain situations. 

Long Term Or Chronic Pain

Some of the causes of short-term pain do not heal or resolve. With time, and continuing nerve stimulation the pain morphs into its chronic form. In those cases, brain circuits and spinal nerve pathways change. Pain is a perception made by the brain – not a concrete thing like blood pressure or heart rate. Those altered circuits change pain perception as time goes by. We know that from human studies. How time changes the perception of pain in cats is something we do not know. In humans, medications that worked well at first often loose their effectiveness as time goes by. At the same time, drugs that elevate mood sometimes become effective in lessening pain. That is thought to be due to changes in brain dopamine,   serotonin, and the brain’s internal pain control mechanism.

Veterinarians today believe that common causes of chronic pain in cats might be arthritis and cancer. But veterinarians have little scientific proof of that. Nor can veterinarians separate the signs of pain from the signs of depression or the many organ decline issues that affect cats in their golden years. A study of 101 cats found that the x-rays of most older cats show some evidence of joint arthritis (74.26% – most often in the elbow). X-rays of their spines had evidence of arthritic changes 40.59% of the time. However only two cat owners had noticed that their cats were lame. The veterinarians could not detect any obvious pain when the joints of the cats with x-ray evidence of arthritis were palpated.  Spinal manipulation caused pain in  7 of the cats. (read here)  A North Carolina study came up with considerably larger number, based on x-ray examination. But they had no objective way to specifically measure pain. (read here

Age and joint wear go hand in hand. About 70% of people over the age of 60 have similar joint changes to what is seen radiographically in cats. In people the amount of joint pain reported relates quite poorly to the changes doctors see on x-rays.  (read here here , here & here) I know of no reason why cats would be any different. Joints and spines that have substantial x-ray evidence of arthritis often cause us humans little or no pain; while some people with very little x-ray evidence of arthritis have joints that are quite painful.  The same mismatch situation occurs in cats. (read here)  So x-rays are a good way for your veterinarian to confirm arthritis and joint wear – but a very unreliable way to confirm that these age-related changes ae causing your cat discomfort or causing behavioral changes that need medication. 

What Are Some Signs That My Cat Might Be In Pain?

First of all I believe that the most accurate determination that your cat might be in pain should be done by you, the cat’s owner – not your cat’s veterinarian and not by your cat’s score on standardized tests, metrology or questionnaires. Since cats can’t talk, one can only come to general conclusions based on hints – similar to situations that occur in non-verbal people. You know that cats act quite differently with strangers and in unfamiliar situations. So an animal hospital, even a “cat friendly one”,  is not a good environment for attempts to accurately judge a cat’s pain level.

Here are some signs of an uncomfortable cat. Keep in mind that for every  sign, there are many alternative health and psychological explanations. However taken together, particularly in the absence of other exam findings that would explain them, these signs are things that would make me suspicious that pain is involved:

 Does your cat appear uncomfortable to you? Is it less active? Is it more reluctant to move? Is its playtime running jumping and climbing reduced? That can be just Father Time knocking. But in cats under the age of 11, a general health exam is indicated. 

 Has your cat become more temperamental, irritable or grumpy – particularly when handled, petted or interacting with its feline housemates?

  Is your cat less inclined to jump up on your bed than it used to be ? Is it grooming itself less or has it begun to concentrate on just one or two areas? Has its hair become matted – particularly over its rump? 

 Cats are creatures of habit. Your cat has favorite sitting positions. Have they changed? Is your cat lying on its side more or less? Are its legs more extended and tense than they used to be? Does your cat seem more restless?

 Does your cat move about attempting to find a more comfortable position ? Is Your cat limping or stiff? Does that limping and stiffness decrease with continued activity?

 Has your cat lost its normal interest in its surroundings? Is your cat less playful than it used to be?

If you touch or press various areas of your cat’s body or flex its joints, does it flinch, growl, meow, claw or bite? Has it become inclined to defecate next to its litter box rather than climb into it?

Do you need to trim your cat’s claws more frequently? Are your cat’s claws growing longer these days due to inactivity?

Is your cat having more potty accidents next to the litter box than it used to?

 Does your cat still purr when you stroke it? Does your cat hide more than it used to?

I let the owners of a cat make the decision. But there are plenty of veterinarians who take a more authoritarian, less passive, position than I do. Other than pompous bluster, they give no evidence that they have a clue as to which cat needs what, how much and when. (read here)  

What Medications Are Options For Post-Surgical Pain In My Cat?

Narcotics:

Traditionally, veterinarians did not believe that cats were good candidates for receiving narcotic pain killers. They appeared to suffer a number of side effects uncommon to people or dogs that received the same medications. Cats receiving these older narcotics (opiates) had a high incidence of depression, muscle weakness,  vocalization, tremors, twitching, vomiting, body temperate control issues and agitation. (read here  &  here

Buprenorphine  (Buprenex®/ Zorbium®)

However, more recent studies have found that cats tolerate a newer narcotic pain-relieving medication called buprenorphine considerably better that the older, traditional opiate narcotics when a moderate doses are given. How effective those lower doses are in relieving pain is still in question. (read here) Although study results are inconsistent, it shows promise in blocking acute post-surgical pain. There is a great deal of variation in its pain-blocking effectiveness and the drug dose required to achieve it. (read here)  Veterinarians know little about its possible effectiveness in relieving chronic pain in cats. If the drug conforms to the pattern of other narcotics used in humans, its effectiveness countering pain would tend to decrease over time requiring the dose to be increased. Until recently, veterinarians used human buprenorphine products “off label” to lessen pain in cats and dogs. It is sold as Buprenex® and a number of other trade names. It is also available with your veterinarian’s prescription from compounding pharmacies such as Wedgwood. 

In 2022, the FDA approved a topical buprenorphine solution designed specifically for post-surgical pain in cats, Elanco’s Zorbium™ buprenorphine transdermal solution. The directions are to apply the correct amount to the skin of your cat’s dorsal neck (its nape). Elanco states that up to 4 days of pain relief can be obtained from a single application. 

In 2014 the FDA approved another buprenorphine medication, Simbadol® for post-operative pain in cats. That drug is administered daily by subcutaneous injection for up to three days starting with the first dose one hour before to surgery. 

Butorphanol (Torbugesic®/ Torbutrol®)

Butorphanol is also a narcotic. The primary use of butorphanol in people was as a nasal spray for the relief of migraine headache pain. The trade name was Stadol® NS.  Butorphanol is also available for humans in injectable form and tablets. The tablets effectively control moderate to severe pain. The injectable liquid form can be a  component of general anesthesia “cocktails” given to humans.  In humans the injectable form has been linked to a rise in liver enzymes that indicate possible liver damage. The spray has not. The spray is less commonly prescribed these days because butorphanol is highly addictive. 

For veterinarians, butorphanol is sold under the trade name Torbugesic® and Torbutrol®.  Those product are FDA-approved for use in horses to treat cough and to relieve the acute pain of intestinal colic. When given “off label” by injection to cats, butorphanol appeared to be as effective as buprenorphine in reducing surgical pain. (read here) But unlike buprenorphine, butorphanol did not appear to be effective in relieving pain when applied topically to cats. (read here)

Fentanyl Patch (Duragesic® patch) 

Fentanyl is a very powerful narcotic pain-relieving medication. It can be administered in many ways. It is most commonly used in cats as a portion of a human-size fentanyl patch (Duragesic® patch) folded over and placed on shaven skin. (read here  & here)   Fentanyl has a proven acute pain and hospice prolonged pain track record in humans. However the drug is susceptible to diversion and misuse. Because of that the DEA places many obstacles to it use in veterinary medicine. Many veterinarians –  dreading the complicated record keeping involved and the severe penalties possible when records do not meet DEA inspection – avoid or refuse to prescribe fentanyl patches. They do so even when these patches would probably be the most effective pain-relieving option available  

Tramadol (Ultram®)

Tramadol is also a narcotic – but one that has, in addition to its pain-relieving quality, a mood elevating effect similar to human SSRI antidepressants. Based on cat-owner perception, tramadol appeared to lessen arthritic pain in a group of older cats. (read here) That is encouraging. But pet-owner reports are the least accurate method of judging your cat’s medication’s worth because hope and love factor in. Because of its antidepressant activity, tramadol has on rare occasion in cats been associated with a problem called serotonin syndrome.  There were only two earlier studies that attempted to determine how effective tramadol might be in combating acute or chronic pain in cats. One thought it might have some use in combating chronic pain – although they did note that it is extremely bitter and that it has a very short persistence in the blood stream. (read here) The other, using toe pinch and hotplate withdrawal tests concluded that it was not effective in blocking acute pain (at the doses given).  (read here) Tramadol is rarely prescribed for severe pain. Fentanyl, for example, is 1000 times as potent than tramadol (1 μg/kg of fentanyl=1000μg/kg of tramadol ) in its pain-relieving ability. 

Local Anesthetics

Bupivacaine (Nocita™)

If you have been to a dentist, you are acquainted with the lidocaine/Xylocaine®/Novocaine® used to numb your gums. It is very effective. However its effect wears off in 3-5 hours.  The effect of bupivacaine (Marcaine®), a similar drug, lasts for up to 8 hours. bupivacaine has been used extensively for post-surgical pain relief in humans. (read here)

Bupivacaine appears to lessen post-surgical pain in cats as well. (read here)   It is a moderately priced drug, and since the DEA does not consider bupivacaine to have addiction potential, they do not hassle us veterinarians about administering it. As I mentioned earlier, judging the effect of all pain control medications in cats is a challenge. When bupivacaine is coated with a fatty layer (a liposomal suspension) its pain-relieving ability lasts even longer (up to 72 hours). That product, FDA-approved for cats and dogs, is marketed by Elanco as Nocita™  to reduce post-surgical pain. It is called . It can also be used to block specific nerves as well. (read here) The drug is unlikely to be a treatment option for chronic pain. 

NSAIDs / Non-Steroidal Anti-inflammatory Drugs

Meloxicam (Metacam®/Meloxidyl®)

Meloxicam (Metacam®/Meloxidyl®)is the most common NSAID given to cats to relieve pain.  Although it can be given to humans and dogs long term to combat the pain of arthritis, repeated injections of meloxicam to cats are thought to be able to produce kidney damage. (read here) That black box warning still appears on the 2022 Metacam® instructions. see here:   and on the FDA website. Others disagree that kidney damage from repeated meloxicam doses is a danger. (read here   & here) Many veterinarians give cats a single subcutaneous injection of this medication prior to surgery. (read here   & here)  Meloxicam is also available as an oral liquid that cat owners can give to their cat ONE TIME after surgery.  However the European Medicines Agency (EMA)  approved meloxicam’s for long-term use in cats suffering from arthritis. 

Robenacoxib (Onsior®)

Robenacoxib is the second NSAID that has been successfully used to treat post-surgical pain in cats. The drug is marketed in injectable and tablet form by Elanco as Onsior®. It carries the same FDA label warning as meloxicam regarding the potential for kidney damage. However the European Medicines Agency (EMA) approved robenacoxib for the long-term treatment of arthritis in cats. 

When given by injection, robenacoxib might cause less pain and swelling at your cat’s injection site than meloxicam.  In that study, robenacoxib’s pain-relieving ability appears to be greater than meloxicam.  (read here) Another study in dogs reached the opposite conclusion. (read here)  I believe the two are probably identical or close to it in their ability to reduce pain in cats and in their potential for side effects. Quantifying the degree of pain in cats is exceptionally difficult and prone to error. Drug companies will always quote the studies that show their product in the most favorable light. 

What Medications Are Best For My Cat When Chronic Joint Pain, Arthritis Or Other Long Term Pain Are The Issues?

The two products I mentioned above, meloxicam/Metacam® and robenacoxib/Onsior® are also options for treating chronic pain in cats.  If either of them effectively control  the pain of arthritis at their label suggested doses or if those doses are low enough to avoid the possibility of kidney decline  over time has yet to be fully determined. Kidney functional decline is quite common in the older cats that are most likely to suffer from arthritis. It will be very hard to judge the effect of these drugs on their rate of their kidney decline. Any cat receiving either meloxicam or robenacoxib needs pre-drug-administration baseline BUN and creatinine level determinations and frequent repeat tests thereafter, run at approximately the same time after their last meal. 

Frunevetmab (Solensia®) 

Frunevetmab, sold by Zoetis as Solensia® is the newest addition to long-term pain control in cats. It gained FDA and EMA approval in 2022. Frunevetmab/(Solensia®) is an artificially produced (bio-engineered) antibody specifically designed to neutralize feline nerve growth factor (NGF). It is a monoclonal antibody or mAb. Feline nerve growth factor (NGF) has many known functions – and probably some as yet to be discovered. In fetal and immature animals, it guides the development of the nervous system. Later in life, it is important to maintain nerve health. NGF is also involved in the transmission of pain signal along nerve pathways and it is known that monoclonal antibodies that reduce the amount of NGF relieve the pain of arthritis. (read here) Because cats tolerate so many other pain-relieving drugs poorly, Zoetis offers Solensia® as perhaps a safer option. Read about Solensia® in detail here

Less Proven And Unproven Products:

Glucosamine And Chondroitin

Veterinarians, trying to avoid the potential side effects of non-steroidal anti-inflammatory drugs (NSAIDs) and narcotics and cat owners unable to afford those more expensive medications often gravitate to “nutraceutical” products in an attempt to relieve chronic pain in their cats. They provide oral products such as Dasuquin® or Cosequin®  or have their veterinarians inject glycosaminoglycan products such as Adequan™.  Since no high quality studies in cats or dogs exist we really have no solid evidence that those and similar products are helpful in relieving pain or encouraging healing. Experimental studies did not show them to have significant healing or pain-relieving abilities. (read here,   here  &  here) The oral products are  natural components of food, the injectable ones are natural constituents of joint cartilage. I tent to rely on the Cochrane data base conclusions. This is what they have to say These products are harmless when given to pets as directed. We can always be hopeful that  they will help.  That is why 3 out of 5 people experiencing the pain of joint arthritis elect to take them. (read here

Gabapentin (Neurontin®)

Gabapentin is a drug that was initially developed to treat human epilepsy. It is considered one of the safest anti-epileptic medications to date. But it has gradually been replaced by levetiracetam (Keppra®), phenytoin (Dilantin®)  and other medications. One reason is that gabapentin doses must be given three times a day to be effective. Gabapentin also appears to be effective in reducing neuropathic pain. That is pain caused by damage or inflamed nerves themselves. It is much less likely to be effective against the pain of damaged tissues surrounding it such as bone or muscle. So gabapentin is not likely to be a good candidate drug for bruises, surgery after care, bone fractures or arthritis. The effectiveness of gabapentin in cats to lessening the chronic pain of arthritis or the acute pain of surgery remains unknown. However because the drug is inexpensive, has few if any side effects at the doses suggested and is not a controlled narcotic, it is often dispensed by veterinarians. Usually the oral form is dispensed. However injectable forms exist and even transdermal gabapentin patches have been tried on cats with mixed results.

Gabapentin appears to be both a sedative and an appetite stimulant in cats. Its sedative quality have led some to suggest that a dose be given to nervous cats 2 hours before their scheduled veterinary appointment. You can read more about gabapentin in cats  here,  here  &  here.  Having a daughter that took gabapentin for many years and having taken it myself, I have little faith in this drug’s value in reducing pain. 

Amitriptyline (Elavil®)

Amitriptyline is an antidepressant (a tricyclic antidepressant) that is helpful in treating fibromyalgia, migraines and herpes-related nerve pain in humans. There is moderately strong evidence that it is helpful in reducing pain in about 20% of the people who take it for those conditions.  Amitriptyline has been used for a long time in cats. It is usually dispensed to treat behavioral problems like peeing outside their litter box – with mixed results. There are veterinarians who suggest amitriptyline it for cats with chronic pain. There is no scientific evidence one way or the other as to its effectiveness in feline pain control. 

Omega 3 Supplements (PUFAs)

Omega-3 fatty acid supplements are thought by many to reduce inflammation. But I cannot tell you for sure if they will be helpful to your arthritic cat. You never know what is actually in commercial omega, krill or fish oil capsules. Particularly the ones marketed for pets. Freshly cooked herring, salmon and mackerel are much safer sources of omega-3s. You can offer them to your cat in moderate amounts and see if they appear to make your cat more motile or just happier. Don’t overdo the use of these omega 3 products. (read here)

What About Hemp Oils And CBD Oil?

Both are among the snake oils  of today. (read here) Something  within the realm of alternative medicine and psychics. That doesn’t mean you or your cat should not try them.  Most are harmless. New ones pop up every day and always will.   But my  articles on medication and procedure effectiveness rely on science-based, evidence based evaluation. Once you leave science behind your options are limitless. Acupuncture,   laser therapy,   homeopathy,   chiropractic,    holistic therapies,    dubious stem cell treatments,    myofascial trigger points,   reiki,   energy transfer, channeling, Laying on of Hands  by the gifted, and applied kinesiology  practitioners would all be delighted to assist you.  When us humans are in pain, placebos like these often have powerful positive effects. read hereIf your cat senses your hope and feels better too I cannot say.

Your Other Options In Dealing With Feline Pain

Warmth is beneficial in relieving the chronic pain of arthritis and inflamed joints. Warmth also speeds recovery from acute muscle pain and surgery. My favorite source of heat for cats are the specially designed, rigid, waterproof heating mats with soft washable covers. They should have a maximum temperature of no more than 105 F/40.6 C.  Be sure your cat has the capacity to leave the mat if it becomes too warm. Pain control medications, severe arthritis or joint injuries can make cats hesitant or unable to do so. Hot water bottles are equally safe and effective, but they are labor intensive. We do not know why moderate heat is so therapeutic. It causes blood vesicles to dilate as local tissue temperatures rise. That speeds many biochemical and cellular processes. But I know from personal experience that heat must also have unidentified properties that block pain sensation in or to the brain.  

If your cat is overweight, begin it on a slow weight reduction diet. Buy a scale and keep a diary. Your cat’s weight loss needs to be gradual. Its not only that excess weight is hard on your cat’s joints and spine, fat is also pro-inflammatory. Read about weight loss programs in cats here

Have easily-accessible drinking water sources available to your cat at multiple locations. Cats easily become dehydrated. – particularly those fed dry kibble.  Dehydration is thought to increase the chances of bad reactions to NSAIDs and other medications. Dehydration also puts extra stress on your cat’s kidneys’ ability to remove toxins from the body and overly-concentrated urine is more likely to form urinary tract crystals. (read here   & here)

Modifying your cat litter boxes to lower their height and adding additional low profile containers make toiletry chores easier for cats facing chronic pain.

Buy a comfortable and soft cat bed with very low sides. Placed it in a draft-free location. If your cat prefers an igloo bed, modify it so that it does not have to step up to enter. Add ramps to make your cat’s favorite resting places more accessible.

Mind diversions, distraction toys and puzzle feeders might shift your cat’s focus away from pain. So might the nepetalactone in catnip. (read here)  We know that diversions and mindfulness seem to help humans divert their thoughts from pain.  Open your drapes for window views. If your cat can no longer jump to the window ledge, construct a cat ramp to help it along. Many small snacks throughout the day shift focus as well. So does lap time and stroking massages. Diversion techniques are limited only by your imagination. 

Disabled cats have trouble grooming themselves. Comb and brush them frequently. Keep their claws from overgrowing. Pay particular attention to its front 5th inner front claw.

You are on the Vetspace animal health website

Visiting the products that you see displayed on this website help pay the cost of keeping these articles on the Internet.