The drug resistant client - understanding why clients would refuse medications

Advances in animal behavior has helped veterinarians provide less stressful care to many patients, both large and small. The ability to correctly read the body language of stress before it reaches aggression, and then respond to this by changing the exam room, treatment and hospitalization areas has helped keep staff safe and prevent aggression1. There are some cases though, where reducing the stress of the environment is not enough to produce a non -anxious or aggressive animal.

Back to School Blues - Foote and Friends
Clients worry about older pets and medications. Enlist the owner's help to create a low stress handling exam experience.

Specific handling techniques to reduce patient stress can also create a calm care experience. Staff training for correct towel wrapping, limit patient movement and correct technique for rewarding greatly reduces patient stress and aggression during care. Higher skills in low stress handling skills will provide a less stressful exam on an unmedicated animal.

When you are presented with a patient that is increasing in anxiety to the point of aggressing despite a less stimulating environment and high rewards, appropriate anxiety reducing medication is needed for improved patient welfare.(2) The advancing knowledge of both animal behavior and pain management has provided veterinarians a broad base of medications to use in these cases. Pre visit pharmaceuticals (PVP) are given to create a less anxious and easier to handle animal. These medications must be given a few hours before the veterinary exam. Medication does not reduce the need for less stressful handling or providing a less stressful environment. Medications are tools to prevent the damaging effects of stress – increased heart rate, struggle that can lead to injury, and retaining a memory of fear associated with the veterinary practice.

Prior to the advancement of less stressful veterinary care, the use of pre-visit medications was limited to strong oral sedatives such as Acepromazine. Acepromazine is one of the few oral sedatives approved for veterinary use.  Currently, recommendations advise for more anxiolytic  medications such as Trazadone, Gabapentin, Alprazolam, and Clonidine. An important point is that these medications are not veterinary approved and are off label use(3) There is little if any documented studies of how any of these drugs affect behavior(4).  The majority of speakers are recommending on personal use experience.

Client resistance to pre visit medications can come from different points of view. Many clients have been prescribed the same drugs we are prescribing for their pet. If the client did not like how the medication made themselves feel, they will naturally be concerned that their pet will have the same experience. Asking a client to sign a waiver for off label drug is concerning.   Some clients do not want their pet to be affected for hours, when the need for the medication is for a 15-minute appointment.

Take the time to ask the client why they are not agreeing to the needed medication. Listen more than you speak.  Many of the client's concerns are valid, and this creates an opportunity for you to creatively work with your client.   It think of this like " let's make a deal.  You don't want drugs, We need calm and safety.  Here is what we need you to do to help us"  and then you demonstrate muzzle for rewards for dogs who will flip to bite, 12 hour fast before the appointment, the yummiest food used when handling and the most difficult part of the exam, happy visits to the clinic on a regular basis, and scheduling exams  when it is best for the pet not the owner.

As my friend Dr Esther Ling of Cresthill cat and dog clinic says " the owner is always part of the equation."   For my drug resistant clients, a typical exam would be scheduled the first one in the morning, on a Wednesday when we were quiet, escorted to the exam room immediately from the car,  Adaptil or Feliway bandana 30 minutes before travel ,and the most awesome food to feed through a muzzle or under a blanket cover.   Our cats were examined in the carrier base, using the cowl technique with minimal handling.  The deal was 3 short sweet appointments per year not just one  big appointment, so we could keep it low stress.  With each visit, the animal was less stressed and drug free.

There will be times that a medication is needed for patient welfare and safety.  The speed of aggression or panic may make this animal unsafe to examine, and the adrenaline/ cortisone stress is harmful to the patient's health.  If your client is resistant to pre -exam pharmaceuticals, start with pheromone application before arrival at the clinic.  This gives a baseline anxiolytic effect and is often accepted by clients.  Give oral transmucosal Buprenorphine to relieve any possible pain at history taking.   Emphasize the pain relief requirement to provide a kind and accurate exam.  Buprenorphine does not sedate, and be sure to inform you client of this as it reduces the client resistance and will begin to show clinical benefit in a few minutes.  Apply topical anesthetic to injection sites ahead of time and inform the client you are doing this to reduce pain and anxiety from pain.  With every touch, and approach tell the client  what you see in the animal’s response.  This is how you educate your client about both your efforts to reduce stress and to recognize the body language of stress in our patients.  Following these steps, 85% of my patients would reduce  their anxiety and aggression  without medication. The remaining 15% needed medication or supplements to provide mental calm. The verbalization of what we saw, and the client witnessing our adaptation to the patient to reduce the stress, helped our clients understand why medication or supplements were needed for care.

Many of my clients were drug resistant. Why? It may be the rural, small town conservative approach to life here in Tuscola Il where I live. Many farmers had toughed out injuries – so why can’t my animal tough it out?  I found supplements were accepted by clients and  were  effective  to reduce anxiety and mild aggression when combined with a Low Stress Handling plan specific for this patient.  The supplement did not have the potential side effects such as aggression dysinhibition, and were more acceptable in general as compared to prescription drugs.   I never had a "back" and did the majority of blood draw, care and treatment in the exam room with the client present for my 30 years of practice ownership.  This approach kept care transparent so if the pet was resisting, or rising to panic or aggression it was more clear to the client that drugs were needed and were then accepted.

Where would I draw the line on the drug resistant client? When either patient safety or staff safety was at risk. If a dog or cat was struggling, urinating, or cowering despite the less stressful veterinary care, I would stop and required my staff  to do the same.  I would point out how this experience was harming the heart, the joints and creating a firm memory to panic or aggress. If the client would not accept the need for medication, then I would refuse care. I often quoted the $350,000.00 average educational cost to create a DVM,(5) or $50,000.00 cost to create a licensed tech, and that my practice could not afford to lose either. At this point, many clients agreed to use the medications. For those who did not, I referred to a house call veterinarian and then informed that veterinarian of this patient's triggers to stress and behavior.

We cannot force our clients to take our recommendations. We can ask why they are resistant and listen. Think of ways to address the fears. If the client is afraid of how the medication will affect the pet, offer day care give the trial dose at the clinic. You can observe the response, take a video to show the client and you may be able to provide the care that day as well. Know your drugs and how effective they are for modifying specific behaviors. Trazadone is a popular drug to reduce physical activity, yet it is not a sedative. It will not be enough as a solo agent to prevent a dog from lunging up to bite you. Alprazolam will help reduce fear but may disinhibit aggression. Tell the client why you have chosen a certain medication, and what to expect as the response. Empathize with clients that worry their pet will feel as weird as they did on a med. Discuss the differences in animal metabolism as compared to human. In the end, my negotiation was the less medication, the more I needed the client to co operate by bringing a prepared patient, scheduling when it was best for the pet not the human, and follow all the steps of  the plan we created for care.  We should not use medications to replace expansion of our low stress handing knowledge. Creative, empathetic use of both less stressful care and appropriate medications can help reduce client drug resistance.

1. Foote, S. Job stress of veterinary staff in small animal practice. JAVTE Summer 2019. Pg4-9.
2. Lloyd,J. Minimising Stress for Patients in the Veterinary Hospital: Why It Is Important and What Can Be Done about It. Vet Sci. 2017 Jun; 4(2): 22.
Published online 2017 Apr 13. doi: 10.3390/vetsci4020022

3., Approved animal drug products. accessed Sept 12, 2019
4. Shell,L. Psychotropic Agents. Accessed Sept 12, 2019.
5. AAVMC cost comparison tool. Accessed Sept 12, 2019.
6.Albrecht, B. Staiger,P. Hall,K. Benzodiazepine use and aggressive behaviour: A systematic review Accessed Sept 12, 2019.

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