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18. Schalm OW: Phenylbutazone toxicity in two dogs. Can Pract 6:47-50, 1979 19. Spyridakis LK, Bacia JJ, Barsanti JA, Brown SA: Ibuprofen toxicosis in a dog. J Am Vet Med Assoc 188:918-919 20. Tandy J, Thorpe E: A fatal syndrome in a dog following administration of phenylbutazone. Vet Rec 81:398-399, 1967 21. Watson ADJ, Wilson JT, Wilson DM, eta!: Phenylbutazone-induced blood dyscrasias suspected in three dogs. Vet Rec 107:239-241, 1980 22. Wells PG, Ramji P, Ku MSW: Delayed enhancement of acetaminophen hepatotoxicity by general anesthesia using diethyl ether or halothane. Fundam Appl Toxicol 6:299306, 1986

Acupuncture Analgesia Alan M. Klide, VMD From the Section of Small Animal Anesthesia, Department of Clinical StudiesPhiladelphia, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania

Acupuncture has been used to produce surgical analgesia, to produce postoperative analgesia, to treat chronic pain, and to treat disease states. BASIC ACUPUNCTURE Traditional Chinese Medicine

According to traditional Chinese concepts, energy, called Chi, flows through channels in the body called meridians. Along these channels are points at which one is able to influence the flow of energy through the meridians, like dams control the flow of water. Disease is caused by an imbalance in the amount of energy in the diseased organ. The treatment is to reestablish the normal amount of energy. I am not implying that these traditional concepts are the literal mechanism of action for acupuncture. In fact, I think that we can explain all of the things produced with acupuncture in modern neurophysiologic terms. Points

In traditional Chinese medicine, it is thought that when an organ is diseased, a painful point will appear on the surface of the body and

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that treating that point with acupuncture will help the organ become normal. Charts

Charts for humans and for farm animals (horses, cattle, and pigs), which evolved from the Oriental literature, are very common. There were no such charts for dogs, cats or laboratory animals. In these species, anatomic transposition was used to decide where the points might be. This is done by anatomically locating a point on a person that is useful in treating a specific condition and then anatomically locating the same site in the animal. This method of point location has many difficulties. Acupuncture Point Stimulation

Acupuncture points can be stimulated in many different ways. The most common was traditional needling with a solid needle that is placed and left for a length of time, often 20 minutes, or intermittently twirled. Other more commonly used methods at the present time are low powered lasers; injection of substances, such as isotonic saline, at the site of the acupuncture points; electrical stimulation; or implant metal at the site of the acupuncture points. PHYSIOLOGY AND ACUPUNCTURE ANALGESIA

It has been shown that many types of "stimulation" or "stress" can produce analgesia, including acupuncture. 1A' 9' 17 These various stimuli seem to cause activation of descending pathways from the brain to the spinal cord, where there is inhibition of incoming pain information in various layers of the Lamina of Rexed in the dorsal horn of the spinal cord. The most commonly implicated neurotransmitters are serotonin, endogenous opiates, and norepinephrine. Activation of nociceptive afferents increases the rate of glucose utilization in the dorsal horn. Pretreatment with morphine diminishes the increase in glucose utilization in the dorsal horn produced by a noxious stimulus. Nonnoxious low frequency electrical stimulation of the sciatic nerve ipsilateral to the subsequent nociceptive stimuli likewise produced a relative decrease in the rate of glucose utilization in the most superficial part of the dorsal horn. 11 Electro-acupuncture has been shown to reduce minimum alveolar concentration (MAC) for halothane anesthesia approximately 11% to 17%. 15 This is virtually the same reduction that has been shown in dogs for the various opiate agonist-antagonist analgesics such as pentazocine, butorphanol, and nalbuphine.

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It has also been shown that the administration of an opiate antagonist, naltrexone IV or intrathecally, does not reverse the acupuncture-induced decrease in halothane MAC in the dog; therefore, it appears that an opiate pathway is not involved in the mechanism by which acupuncture causes the decrease in halothane MAC. 14 ACUPUNCTURE-PRODUCED SURGICAL ANALGESIA

Acupuncture has been used to produce surgical analgesia without the use of any drugs. In some circumstances it has great advantages over analgesia produced with drugs. This is especially true for the extremely ill animal and the animal undergoing cesarean section or when it is important to avoid postanesthetic depression. Techniques Restraint

For some patients just gentle reassurance may be all that is necessary; others will require varying degrees of chemical restraint. Technique

The only practical technique is electrical stimulation of acupuncture needles. In all the examples discussed, an alternating current, electrostimulator was connected to preplaced stainless steel acupuncture needles. Examples of Acupuncture-Produced Surgical Analgesia

Review of the literature shows that it is possible to produce surgical analgesia with acupuncture fairly reliably. Surgical analgesia has been produced and used clinically in many species, including horses, mules, donkeys, cattle, sheep, pigs, dogs, and cats. 2, 3, ?, 10 , 12, B, 16 The author has used acupuncture to produce surgical analgesia in dogs, horses, and sheep. Excellent analgesia was obtained without the use of drugs. The horses responded somewhat (movement) to suturing the skin. This is common and predictable. The reason is not that pain is felt but that the sensation of touch still remains during acupuncture analgesia. When the horse's skin was held with a forceps for suturing, the horse felt the "touch" of the forceps and began to twitch its skin. 6 Contraindications

It is thought that the concomitant or recent administration of systemic corticosteroids may interfere with the positive effects of acupuncture.

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Another contraindication may be pregnancy. There are some points that are used to induce labor or cause abortion in women. There is no literature demonstrating that acupuncture is either safe or dangerous in any species of pregnant animal. We have treated one horse through three pregnancies with no abortion, fetal death, or fetal abnormalities. Limitations

There are many circumstances in which acupuncture-produced surgical analgesia could be useful; however, there are three main problems with the use of acupuncture produced surgical analgesia: lack of restraint, occasionally inadequate analgesia, and lack of information on points to use for analgesia for a particular surgical site. Use of Acupuncture for Postoperative Analgesia

Another use for acupuncture-produced analgesia is to treat or prevent postoperative pain. This may be obtained with various drugs; however, one might want to avoid these drugs for various reasons. The choice of points and techniques would be the same as that for surgery of the site in question. An alternative technique for producing postoperative analgesia is to place a long needle subcutaneously on either side of the incision and parallel to the incision and electrically stimulate them. USE OF ACUPUNCTURE FOR THE TREATMENT OF CHRONIC PAIN

Acupuncture is a treatment form that should be considered for the treatment of chronic pain/ It is not a quick treatment and involves repeated treatments (usually eight) over a period of tim~. The duration of effectiveness has varied from a few hours to a number of years. Most commonly the duration of effect, at least in our horses, has been 1 to 3 months, and this period is quite consistent for each individual animal. Retreatment usually involves fewer treatments than the initial series, i.e., usually one or two. Two examples of the use of acupuncture to treat chronic pain are the treatment of laminitis and chronic back pain in horses. Laminitis in Horses

Laminitis5 is often a devastating disease leaving the horse with varying degrees of chronic disability and pain. Seven horses were treated with electro-acupuncture applied to the surface of the skin and

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to one needle in each foreleg. There were six horses that improved and one horse did not. Chronic Back Pain in Horses

Many horses develop chronic back pain just as many humans do. Two hundred horses were treated for chronic back pain with acupuncture.8 None of the horses could train or perform at an acceptable level because of primary back pain. Of the 200 horses treated, 171 had alleviation of clinical signs and could train and compete.

SUMMARY Acupuncture-produced surgical analgesia has been demonstrated in a wide variety of species under experimental and clinical circumstances. The main advantage is that no depressant drugs need to be used. The disadvantages of its use are unfamiliarity, the need for special equipment, inconsistent effects, and lack of restraint. References 1. Ca() XD: Acupuncture activates pain modulating system resulting in acupuncture analgesia. In Abstracts of the Fifth International Symposium on Acupuncture and Electro-therapeutics, New York, 1989, pp 281-282 2. Gonzales MV, Sumano HL, Ocampo LC: Induction of surgical analgesia of the abdomen in dogs using electro-acupuncture. Vet Med 6:157-162, 1985 3. Haragopal V, Lakshmipathi GV, Ramakrishna 0: Caesarean section in an ewe under acupuncture anesthesia. Am J Acupuncture Vol 12, 1984 4. James LW, Terman GW, S)1avit Y, eta!: Neural, neurochemical, and hormonal bases of stress-induced analgesia. In Kruger L, Liebeskind JC, eds: Advances in Pain Research and Therapy. New York, Raven Press, 1984, pp 277-288 5. Klide AM: Acupuncture for the treatment ()f chronic laminitis in the horse. In Proceedings of the 16th IVAS Congress on Veterinary Acupuncture, Noordwivk aan Zee, The Netherlands, 1990, pp 16/1-16/3 6. Klide AM: Use of acupuncture for the control of chronic pain and for surgical analgesia. In Short CE, ed: Animal Pain. New York, Churchill Livingstone, 1992, pp 249-258 7. Klide AM, Kung SH: Veterinary Acupuncture. Philadelphia, University of Pennsylvania Press, 1977 8. Klide AM, Martin Jr. BB: Acupuncture for the treatment of chronic back pain in the horse. In 16th IVAS Congress on Veterinary Acupuncture, 1990, p 32/1 9. Mayer DJ, Watkins LR: Multiple endogenous opiate and nonopiate analgesia systems. In Kruger L, Liebeskind JC, eds: Advances in Pain Research and Therapy. New York, Raven Press, 1984, pp 253-276 10. O'Boyle M, Vajda GK: Acupuncture anesthesia for abdominal surgery. Mod Vet Pract 56:705-707, 1975 11. Sjolund BH, Schouenborg J: Site of action of anti-nociceptive acupuncture-like nerve stimulation in the spinal rat as visualized by the 14C-2 deoxyglucose method. In Bonica JJ, et a!, eds: Advances in Pain Research and Therapy. New York, Raven Press, 1983, pp 535~541

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12. Still J: Acupuncture analgesia for laparotomy in dogs and cats: An experimental study. Am J Acupuncture 15:155-165, 1987 13. Still J, Still V, Merta J, Jahn P: Experimental ear acupuncture analgesia in the dog. Vlaams Diergeneeskindig Tijdschrift 55:407-415, 1986 14. Tay AL, Tseng CK, Pace NL, et a!: Failure of narcotic antagonist to alter electroacupuncture modification of halothane anaesthesia in the dog. Can Anaesth Soc J 29:231-235, 1982 15. Tseng CK, Tay AL, Pace NL, et a!: Electro-acupuncture modification of halothane anaesthesia in the dog. Can Anaesth Soc J 28:125-128, 1981 16. Wright M, McGrath CJ: Physiologic and analgesic effects of acupuncture in the dog. JAm Vet Med Assoc 178:502-507, 1981 17. Yaksh TL: Multiple spinal opiate receptor systems in analgesia. In Kruger L, Liebeskind JC, eds: Advances in Pain Research and Therapy. New York, Raven Press, 1984, pp 197-215

Address reprint requests for this section to Steve C. Haskins, DVM, MS Department of Surgery University of California, Davis, School of Veterinary Medicine Davis, California 95616