Beyond Gabapentin and Trazodone, Smarter Pre-Visit Anxiety Meds with Dr. Chris Pachel Dr. Chris Pachel, DVM, DACVB, joins Dr. Andy Roark to tackle a problem every clinic knows too well, stressed pets, stressed owners, and appointments that start going sideways before the car even leaves the driveway. They dig into pre-visit pharmaceuticals beyond the usual gabapentin and trazodone, including when to increase doses, when sedation is masking anxiety (not fixing it), and how options like clonidine, benzodiazepines, and even dexmedetomidine can fit the patient in front of you. Chris also shares how his new Animal Behavior Clinic space in Portland is reducing stress fast, plus practical tips for at-home trial runs, safety planning, and cautions around acepromazine and “chill protocol” variations. Gang, let’s get into this episode. Dr. Chris Pachel is a board-certified veterinary behaviorist and is the owner and lead clinician at the Animal Behavior Clinic in Portland, Oregon. Dr. Pachel lectures extensively worldwide, teaches courses at multiple veterinary schools in the United States, and has authored numerous articles and book chapters for veterinarians and pet owners. He is a sought-after expert witness for legal cases and serves on the Editorial Advisory Board for dvm360. He is also a Vice-president of Veterinary Behavior for Instinct Dog Behavior and Training, as well as co-owner of Instinct Portland, which opened in the fall of 2020.

Woo.

2

Welcome everybody to the Code

of Shame Veterinary podcast.

3

I am your host, Dr.

4

Indy York.

5

Guys, I got a great one for you today.

6

My friend Dr.

7

Chris Pockle is here.

8

He is so fun.

9

He is just absolutely got the best energy

and he is so insightful and charismatic

10

and just interesting and we're talking

about pre-visit, anti-anxiety medications.

11

Guys, I'm a big fan.

12

I, this is not a hard sell.

13

The pet owners are generally

very excited about this.

14

They don't want their pets to be

stressed out coming in the clinic.

15

They can.

16

See that their pet is nervous, tail

down, ears down, pacing, trying

17

to, you know, escape from the room.

18

They see that stuff

and they don't want it.

19

And if you say, Hey, next time can I have

you pick something up, before you come in,

20

I, I, I, that's such an easy, easy, yes.

21

For the vast majority of cases.

22

I know there's some people who, who

are not on board, but it's, it's.

23

Rare.

24

And I really, I see gratitude in the

eyes of the pet owners when they're

25

like, oh yes, please, I would love to

have something to make this trip easier.

26

And so I, I, you know, I've been using

Gabapentin and Trazodone and I'm sure

27

the, probably the majority of you, who

are in practice who are listening to

28

this, that's probably your go-to as well.

29

That seems to have corner the market.

30

But is that all we should be using?

31

Is there more nuance to this?

32

I feel like maybe we should have a little

bit more flexibility in the tools that

33

we're using to bring pets into the clinic.

34

And like, I just think that

there's an area for expansion

35

here and, we can, we can do.

36

Better for our patients and

for our clients and make our

37

jobs easier at the same time.

38

Let's look into this.

39

And so anyway, that's what Chris

is talking about with me today.

40

Really great stuff.

41

You are going to deepen your knowledge

and understanding around, pre-visit

42

pharmaceuticals and I hope, hope

you're gonna find some nice little

43

pearls that you can put to use.

44

Let's get into it.

45

Kelsey Beth Carpenter: This is your show.

46

We're glad you're here.

47

We want to help you in

your veterinary career.

48

Welcome to the Cone of Shame with Dr.

49

Andy Roark.

50

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

51

Dr.

52

Chris Pockle.

53

How are you my friend?

54

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

55

I am doing fantastic, sir.

56

I appreciate the opportunity

to have this chat with you.

57

You know, I always look forward to 'em.

58

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

59

I am always happy when I can

get you to come on the podcast.

60

I just, I think the world of you.

61

I love your energy, I love your insight.

62

and honestly, right now, I'm

specifically excited to talk to you

63

because you are on a new adventure.

64

So for those who don't know you,

you are a board certified veterinary

65

behaviorist, and you are the owner

and the lead clinician at the Animal

66

Behavior Clinic in Portland, Oregon.

67

This is your new baby.

68

You're in a new facility, like

I'm looking at it behind you.

69

Um, so tell, tell me about.

70

Tell me about the Animal Behavior Clinic.

71

How's it going?

72

like what have you, what

are you excited about?

73

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

74

I, yeah, we we're about a month in as

of the recording today, we're about a

75

month into this new space, and I feel

like it's been this Goldilocks story for

76

me when I, when I moved to Portland in

77

from, from my, my mentor at the time, Dr.

78

Jackie Nielsen.

79

I took over the office and we, we

just had this little tiny space in

80

a GP clinic and it worked great and

we were there for about 12 years.

81

And then I moved into this ginormous

facility that was fantastic and we had all

82

these opportunities, but it was too big.

83

It was too big.

84

Structurally, functionally, logistically,

responsibility, like all of it.

85

And so now we're in

the just right version.

86

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

87

Okay.

88

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

89

And it's, it's about a

2,500 square foot office.

90

I've got three consultation

rooms, two dedicated for dogs,

91

one exclusively for cats.

92

I've got a space that my team

can really mix and mingle in.

93

We've got a space for continuing

education events and networking, and

94

we get the opportunity to completely

customize it, color choices, artwork,

95

all of the things, and it is.

96

It has been just an epic adventure to

really take all that we've learned over,

97

gosh, at this point, 25 years in my

career and say, what do I want to do?

98

Let's do it.

99

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

100

Yeah.

101

Oh, I, that's, that's one of the things

that's always excited me the most about

102

veterinary medicine in general is it's

still this place where you can come in as

103

a clinician and decide what your vision

is, and you can make this thing and you

104

can make it the way you want it to be.

105

And like, I can just get all

kinds of romantic about that.

106

Like, I just, I love it.

107

It's, it's so awesome.

108

It's one of the things that I just

love the most about this profession.

109

We, we were talking before I hit

record here, and we were talking

110

about pets coming into your, into

your practice and just sort of the,

111

the vibe and the way that they were.

112

Respond to the environment.

113

Uht, talk to me a little bit more.

114

I wanna bring that back up

and, because that's really kind

115

of where I want to go today.

116

Talk to me about what that's like when

animals sort of come in and, and, and

117

the experience that they seem to have.

118

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

119

Yeah, it's, it's been

really, really cool in that.

120

You know, there's, there's little

elements that I'm recognizing some of

121

them by design and some of them almost

by accident, that as, as our, our clients

122

and our, our, our patients are coming to

the front door, we do have a glass front.

123

So it, I think for many of them it's not

as though there's this solid wall with

124

the door opening and they're kind of

figuring out what's on the other side.

125

They're already starting to gather

information even before they step inside.

126

Our lobby is really spacious.

127

It's got a double door entry at the front.

128

So if we needed to, we can give them

a full six, seven feet of clearance.

129

They can walk into the lobby.

130

Nobody needs to be within, you know, any

significant space, proximity for them.

131

So for those patients who need a

little bit more of a, a special

132

handling, we can do that.

133

We can prop the doors

open, they can come on in.

134

We've got three exam rooms

that are, you know, including

135

the one that I'm in right now.

136

They are fully carpeted, which is an

interesting choice for a veterinary space.

137

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

138

Yeah.

139

Yeah.

140

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

141

completely, it completely

changes the sound.

142

It changes the reverberation, it

changes the energy of this space in a

143

way that doesn't make it feel clinical.

144

And I tell you what, in the, the, the four

weeks that we've been operational here,

145

without exception, every single dog and

cat that we've brought into this space.

146

Completely comfortable.

147

Usually within about eight to 10

minutes, I've got dogs who are ordinarily

148

pacing, exit seeking, interacting

with the owners, barking, panting,

149

all of it, full lateral sleeping.

150

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

151

Wow.

152

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

153

It's, it's such a proof of concept for

me that when we set them up for success,

154

what that does both for them and their

ability to engage with us, and also for

155

the pet parents and the caregivers, to see

sort of a glimpse of what's possible, that

156

when we change the environment, when we

change the conversation, even their pets.

157

The ones that they have significant

concerns about, have the potential

158

to be somewhat flexible, and that it,

it gives, it's giving me this lovely

159

inroad to having the conversations

and we say, well, maybe this isn't

160

what's replicable or necessary in

your home, but we're getting a glimpse

161

into your own dog or cat's flexibility

in how they show up in the world.

162

So what do we want to do?

163

Where do we go next?

164

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

165

so I've been thinking a lot about

the client experience coming into vet

166

practices and, you know, I, I, I think

a lot about patient care, but this

167

is kind of a little bit different in

that I'm really a big believer that,

168

you know, the clients today are really

kind of deciding how they feel about

169

their vet and about going to the vet

before they even leave their house.

170

And I, I think, I think that we like to

think the experience that we're measured

171

in starts when they walk into our door and

it leaves when they walk out of our door.

172

And I don't think that that's true at all.

173

I think it starts when they, when

they book the appointment, whether

174

it's online or by text or by calling

or what's required to, to do that

175

and how much friction is there.

176

And then it rolls from the moment they

make the appointment until they're back in

177

home and, and totally settled and probably

until treatment has been provided.

178

And I really think it's a much longer.

179

Experiential window than we,

than we give it credit for.

180

And so, so I've been thinking a lot about

that and sort of the client experience.

181

And then I think about, about moving

effectively in the exam rooms and being

182

efficient while also still doing a

really good job with the pets and making

183

sure that we're, that we're creating

the experience that, that, that we

184

want for them and that we're being,

and that we're able to do a good job.

185

And so I've been thinking a lot about

our protocols for, helping pets come in.

186

In the most sort of relaxed way

possible to, to make the transport

187

of pets more, I don't know, more

enjoyable for, for the pet owners.

188

So I, I mean, I'll tell you this.

189

So this morning my youngest daughter

got her wisdom teeth taken out,

190

and and my wife took her to the

orthodontist, to get this done.

191

And my wife was more anxious

than my daughter was.

192

And she was like, oh my gosh,

they're gonna sit, they're, you

193

know, they're gonna sedate my baby

and she's gonna have surgery and

194

then she's gonna be uncomfortable

when, you know, when she went.

195

Accept and, and, my daughter did

great and I think my wife needs a nap.

196

it was.

197

It was, it was, it was a big thing,

but, but just, the experience and, and

198

how comfortable my daughter was going

in that really mattered a lot to, to

199

my wife and then also the way that my

daughter recovered from the procedure and

200

how comfortable she seemed coming out.

201

Like those things, obviously they

were important to my daughter.

202

They were obviously, and they're important

to me, don't get me wrong, but, but

203

they, but they were really important.

204

But I'm watching my wife, you know, go,

go through this and sort of, and handle

205

this in the way that she's feeling.

206

And I think that there's a lot of

parallels there around controlling

207

stress and anxiety in our pets and

our patients and bringing people in.

208

And so, you know, I am really

happy to see the rise of sort of

209

pre-visit anti-anxiety medications.

210

And you know, the go-tos I see

are Gabapentin and Trazodone

211

and I, that's what I keep sort

of seeing again and again.

212

But Chris, I've got this idea that

I'm sure that we're, that we're just

213

scratching the surface of what's possible.

214

In terms of pre-visit medications

and anxiety control and stress

215

management and things like that.

216

And so that's really one of what

I wanna talk to you about today.

217

I'm just gonna start, stop there.

218

Am I right on this?

219

Is there more nuance than

we tend to see in practice?

220

Or are you're like, Nope, just Trazodone.

221

It is.

222

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

223

There definitely is, and I, I think

back to the early days when, you

224

know, we had acepromazine and a benzo

and that was pretty much it before

225

Trazodone was sort of unleashed in

our world and kind of took over all of

226

our, all of our prescribing patterns.

227

But you know, we have

Gabapentin, we have Trazodone.

228

They're both great drugs.

229

For a lot of dogs.

230

I love them because neither of them has

a significant cardiovascular effect.

231

And so from a safety standpoint,

especially if we've not done a

232

comprehensive evaluation yet,

I love being able to onboard

233

those to an individual patient.

234

And yet if they're not hitting the

nail on the head for that particular

235

patient, we have other options.

236

We've got clonidine and guanine and taine

and we've got, propanolol and we've got

237

half a dozen benzos and we've got oral

transmucosal, DMed, Toine options that

238

can allow us to truly sedate patients

without having to poke them with a needle.

239

Like we have all of these

options available to us.

240

And so.

241

I love that we're seeing a rise of the

use of those pre-visit pharmaceuticals

242

and also if what we're doing isn't

working, by all means we have options

243

rather than just saying, well, we can

give more or we can give less, but

244

we can absolutely give differently.

245

And being curious about

that is super helpful.

246

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

247

Great.

248

So, so let's start to dig

into that a little bit.

249

It sounds like you are kind of

on board with gabapentin and

250

trazodone kind of being first line.

251

Let's, let's, let's try this first.

252

It sounds like it's probably the,

the, the things that, that people are

253

most likely to have on their shelves.

254

Chris, when do you start

to look at other options?

255

So lemme just ask like,

lemme start at the beginning.

256

W walk me through that.

257

Let's say that, let's say

that we start with this.

258

At what point do you

start to adjust doses?

259

Are there flags for you that

say we need to go up or down?

260

And then what are, what are the, what

are the sort of the switch lights

261

that make you think maybe this isn't

the right, the right medication

262

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

263

Yeah, so first things first, when we're

starting out at a, you know, mid-range

264

or even maybe conservative dosing, I'm

first looking for tolerance number one.

265

There are some patients.

266

I will tell you my bias here.

267

I think a lot of my patients who are

herding breed dogs with anxiety issues.

268

I think a lot of them don't like how

they feel on some of these medications

269

and it, there's often the perception

that they could actually be kind of

270

fighting the effect a little bit.

271

So first things first,

I'm looking for tolerance.

272

Does it look like it's tolerated?

273

And obviously looking at those signs

as well as any gastrointestinal upset

274

or excessive sedation, of course.

275

If it is tolerated, then we try

out what we think is an appropriate

276

dose for that particular animal.

277

Maybe it's a, a happy visit or a a,

a trial run, if you will, just to see

278

what magnitude of effect we're getting.

279

If there's no effect whatsoever,

but it's tolerated, by all means,

280

I'll try a dose increase to see

if more is more helpful than less.

281

And if we're getting an incremental

improvement in whatever the parameters are

282

for that particular animal that we think

is kind of their struggle point, then by

283

all means I'm willing to do a couple of

trials, even doing some at home trials

284

to kind of find the edge of sedation.

285

The tipping point for me though, in

the, you know, kind of the, oops,

286

let's maybe go in another direction,

is if I start to see excessive

287

sedation without anxiety reduction.

288

That's, that's a huge piece for me

that if I'm seeing sedation, but I can

289

still get a read on that animal and

the emotional response is still there,

290

I worry that we are now masking from a

motor control standpoint, but I'm not

291

actually making that animal feel better.

292

And in that case I'm gonna say,

wait a minute, is there a different

293

mechanism that might be more specific

to this particular animal's needs

294

that will allow us to get through

to them more, more effectively?

295

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

296

Okay.

297

I I like that, that, that speaks to me.

298

So I, I definitely understand that.

299

'cause we've definitely had the

experience of like, this might as

300

well be Ace Promazine, this dog is,

is really, really tired and, and

301

they're having a panic attack and

they're exhausted, at the same time.

302

And that's kind of what we achieved.

303

Okay.

304

I'm gonna be honest, like my, my game

gets really weak outside of these,

305

it gets, it gets really weak outside

of Gabapentin and Trazodone here.

306

They're just the ones that I've,

I've been most comfortable with.

307

what does changing

medications look like, Chris?

308

So when you say, Hey, you know, we're

trying these, and, and, and I'm not

309

getting the response I want, I'm,

I've, I'm, I don't think that we're

310

actually reducing anxiety here.

311

What, what factors into your choice

to change medications and, and what

312

are you most likely to reach for?

313

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

314

Yeah, so it kind of depends

on how that patient shows up.

315

And what I mean by that is if I have a

patient who's reasonably comfortable,

316

but when we start to work with

them, they really start to wind up.

317

And once they've hit that heightened

arousal level and we're seeing, you

318

know, tachycardia or tachypnea and

you know, they're just really, really

319

activated and they can't come back down.

320

I love Alpha Twos for those

patients as a next choice.

321

And the one that we use

most commonly is Clon.

322

You know, that's, you know, again,

it's the alpha two category.

323

It's something that can be administered 90

to 120 minutes before the stress starts,

324

and it helps to blunt that norepinephrine

surge that happens during those periods

325

of sympathetic nervous system activation.

326

So I love it as an alternative if

that sort of overall baseline calming

327

effect of Gabapentin and Trazodone just

wasn't, wasn't ticking the box for us.

328

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

329

Do you, do you layer that in

with gabapentin and trazodone?

330

You said, you know, it's, it kind

of seems like it has a specific,

331

this specific value in the windup.

332

Are we making cocktails now, or are,

or are we just switching to Exactly.

333

So are we, are we just

switching to clonidine, straight

334

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

335

So it depends again, as

everything in a behavior world.

336

It depends.

337

I don't have any problem

using them together.

338

With that being said, I'm usually trialing

them as independent options more from

339

the standpoint of if one drug will do

it, I don't need to make a cocktail.

340

Right, so I can, I can do that.

341

With that being said, if an owner tells

me, oh, it felt like Gabapentin did this

342

and it felt like Trazodone did this and

Clonidine is doing this, and all three

343

things are relevant, then there are

those animals that I may end up using a

344

cocktail to say, what's the, what's the

right balance between these influences?

345

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

346

Yeah.

347

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

348

me what I'm looking for, and in

some cases it's more sedation.

349

In some cases it's more arousal reduction.

350

In other cases, you know, it

may be something completely

351

and totally different.

352

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

353

So talk to me a little bit

about kind of how you get this

354

right when you are not there.

355

This is happening at the client's house.

356

And you are seeing sort of the fallout

of this, you know, two hours later and

357

think like, and again, also, I, I suspect

that you are not having a dry run the

358

day they're coming in to the clinic.

359

And so what, walk me through, like

what does that protocol look like?

360

How do you get them to, to, to start

to try working with this at home?

361

What feedback do they give to

you to help you understand where

362

they are and make adjustments?

363

Walk, walk me through that part.

364

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

365

it's such an important part of this

process and I think at the heart of

366

this is the fact that clinics are busy.

367

You know, we don't have the time.

368

And as much as we would love

to say, no, no, no, by all

369

means, let's do 17 trial runs.

370

Stop by, we'll do a mock exam.

371

Like nobody got time for that in the

real world, even as much as we want to.

372

And so I really think it's important

when I'm, when I'm having that

373

conversation first and foremost with

my client, I'm looking at the dog

374

or the cat in front of me saying,

listen, when I see signs of stress in

375

your animal, this is what I'm seeing.

376

Do you see that with me?

377

And I'm kind of looking shoulder

to shoulder with the client to make

378

sure that they're getting this.

379

Same observational window that I have

so that they're able to see those

380

same patterns and they're able to

report back on whether those things

381

got better, worse, or no different.

382

So that's part of it.

383

What I also try to do in the at-home

experience is identify one or two

384

scenarios that the client can set up

on their own without having to involve

385

the clinic to say, you know, maybe

this is a scenario where the animal

386

gets really stressed in a similar way

when visitors come over to the house.

387

Or maybe this is a dog that when we take

them for a ride in the car, we see a

388

similar level of stress or anxiety, or

maybe it's a dog that we walk them in a

389

novel environment, whatever it happens

to be, I try to identify that and say,

390

okay, once we've confirmed tolerance with

this medication, could you actually do

391

a, a trial run in this other scenario to

try to get the sense of, you know, maybe,

392

maybe it's actually gonna be different

and something would work differently

393

in those, those various scenarios.

394

But if we do get an improvement in a

comparable situation, it gives me a

395

lot more confidence to be able to do

some dose adjustments or additional

396

trials to then say, cool, I think we've

got a cocktail or an individual drug

397

that has been shown to be efficacious.

398

Now it's time to do our

trial run in the clinic.

399

Let's give it a try knowing that we're

gonna do our best to set that animal and

400

everybody on the team up for success.

401

And I'm always leaving myself that

ripcord that if we thought that it's

402

just not going well and we need to

make a different, different course

403

of action, of course we will do that.

404

But I don't want to have to do that

more times than is absolutely necessary.

405

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

406

Yeah.

407

So if I've got a highly anxious dog,

and we, we'll do a dog and a cat.

408

So, but, but dog, we'll

do put the dog and a cat.

409

So I've got a patient coming in

and they, they are highly anxious.

410

They, they vocalize,

they seem very stressed.

411

We're gonna work with the pet owner.

412

We're gonna kind of come up with, a

protocol that works well for this pet.

413

Chris, for dogs and cats.

414

What does a well sort of managed

patient look like coming in the door?

415

What, how, is there a level

of sedation that you want?

416

Is there.

417

Too much, I'm assuming there's

too much sedation, right?

418

If they're a limp noodle

coming in, that's not good.

419

but, but so like, what does, what

does success look like for you when

420

you're using these medications?

421

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

422

It really depends on what needs

to happen within that assessment

423

or within that appointment.

424

You know, if I've got a dog that is

coming in for a lameness evaluation, I

425

really need to be mindful of how much

sedation I'm putting on ahead of time.

426

Because if they are literally that limp

noodle, unless the owner's got really good

427

video footage, I'm gonna be flying blind.

428

So, you know, that depends.

429

Versus if I had a dog where

we're saying, you know what?

430

We've done the exam, we need blood work.

431

I may be tolerating or even looking for a

greater level of sedation for that patient

432

because that may facilitate a calmer state

during venipuncture or other procedures.

433

So I want, as a clinician, I'm

really thinking, what do I need?

434

What's my goal?

435

Is it anxiolytic effects?

436

Is it sedation?

437

Is it both?

438

How do I prioritize that?

439

And that really allows me to customize

what I'm doing to achieve that goal.

440

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

441

Yeah.

442

How often do you go beyond

the alpha two agonists?

443

Like how, how often do you

get down to your fourth level

444

medication, things like that.

445

Is that, is that common?

446

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

447

It's for my patient population, it's

pretty common, but I think that's

448

partially because I would say almost

every patient that comes through my

449

door has already been on Gabapentin,

has already been on Trazodone.

450

They may have already

trialed clonidine as well.

451

I've got an amazing group

of practitioners, especially

452

here locally in Portland.

453

They're really well educated

when it comes to this.

454

You know, we've had boarded behaviorists

in Portland for 30 years now, so I mean,

455

I get spoiled with my practitioners.

456

They're brilliant.

457

So I'm, I would say, yeah, I'm

looking at fourth and fifth

458

line treatments pretty commonly.

459

When I'm doing vet to vet calls with

practitioners around the country where

460

perhaps that access has been a little

bit more limited, I would say we're

461

more often in the, the first 1, 2,

3, and we're doing dose optimizations

462

and we're saying, Hey, let's, let's

try some of these things together.

463

Or maybe we're going down the chill

protocol route and we're doing a

464

little bit of gabapentin with a,

you know, touch of ace promazine

465

and some melatonin thrown in there.

466

We can look at all of these protocols

to see what, what's working best.

467

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

468

Chris, I saw a patient yesterday who has

a, is an anxious dog, um, and has a bad

469

habit of trying to bite the grandkids.

470

and so we, we talked about some,

some, you know, event specific

471

anti-anxiety medications for this dog.

472

But I, but I wanted to go ahead and

caution the owner and, you know, when I

473

was, I was trained, you know, with these

anti anti-anxiety medicines, you have to

474

be a little bit careful about reducing

inhibition and we might even increase the.

475

Answers of, of events, like

biting or things like that.

476

Is that still sort of the, the advice

that, that you, that you give and how,

477

how do you talk to pet owners about that?

478

How much, how much, how much emphasis,

I guess, do you put on that possibility?

479

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

480

Yeah, I think it's a very real

possibility, especially with certain

481

categories of medications and especially,

you know, no matter what we're trying,

482

whether it's gabapentin, trazodone, a

benzodiazepine, an Alpha two, we never

483

know exactly what effect that's going to

have on a particular animal in a given

484

set of circumstances until we're there.

485

So for me, anytime I'm doing those

trials, I do wanna make sure that to

486

the best of my ability, I'm working with

caregivers who are able to spot some

487

of the early warning signs where we've

talked about, you know, safety tools

488

like baby gates and leashes, and perhaps

basket muzzles or maintaining distance.

489

Maybe this is the dog that we.

490

As one of my clients said yesterday,

put them up for safekeeping and we

491

put them in a great in the bedroom

with the door closed and it's locked.

492

Like maybe that's what we need to do to

be able to manage that, but I wanna make

493

sure that we've got safety parameters

and we can, you know, reliably evaluate

494

is this better, worse, or no different?

495

Versus saying let's just meet at

the door and it's a free for all

496

and we'll find out on the backside.

497

So with that being said, it goes, you

know, it goes across the board and also.

498

Behavioral disinhibition is something that

is specifically tied to benzodiazepines.

499

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

500

Okay.

501

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

502

Everything else can have adverse effects.

503

It could increase baseline irritability.

504

It could change thresholds for reaction,

whether that's touch sensitivity, whether

505

it's sensory perceptions in other ways,

there are all of these different impacts

506

that could be there, but specifically

disin inhibition is not fluoxetine.

507

It's not Trazodone, it's not gabapentin.

508

It's our alprazolam, diazepam,

clonazepam, lorazepam, da da, da.

509

All of the PAMs basically is, is where

we're seeing that specific behavioral

510

disinhibition, not unlike what you or

I might experience, if we had a couple

511

of literal cocktails and we have some

alcohol on board, that's essentially

512

that same gaba specific inhibition

that goes away and the filter gets

513

a little well less filtered and.

514

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

515

Yeah.

516

Right.

517

And, and that's when karaoke happens.

518

Yeah, I got it.

519

Okay.

520

Okay.

521

I know how that goes.

522

Alright, so yeah.

523

Alright, so this, this is,

this is really helpful.

524

Are there tools that you don't see in the

GP toolbox that you think should be there?

525

So we talked about clonidine a bit.

526

beyond that, are there other things

that you would like to see more

527

in the GP practices that you don't

see there or you don't see being

528

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

529

I, I think that as we've gotten

really comfortable with medications

530

like Gabapentin and Trazodone,

I see fewer and fewer patients

531

coming in, having trialed benzos.

532

And I think there's a lot

of good reasons for that.

533

You know, they're controlled medications.

534

We do have risks of, of

disinhibition, like I think

535

there's valid concerns for that.

536

And also when we're dealing with

panic, when we're dealing with intense

537

situational emotional responses.

538

Benzos are often fabulous when it comes to

actually doing, they do a much better job

539

than Gabapentin or Trazodone tend to do.

540

I urge everybody.

541

Maybe you're not gonna use

benzos as your first line.

542

I certainly don't, but don't

forget that they're there.

543

As a potential option.

544

And you know, again, a cocktail may

be really well indicated here that a

545

little bit of calming baseline from

Trazodone or Gabapentin with a touch

546

of alprazolam may be just exactly that

synergistic effect that a patient needs.

547

So I, I think benzos are, are kind of a,

don't, don't forget that they're there.

548

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

549

Gotcha.

550

Alright.

551

Is there any words of caution you

would give here as we kind of wrap up?

552

Are there mistakes that you see people,

people make or you say like, I see, I see

553

you trying, but, but maybe, maybe this,

maybe this was the wrong way to try.

554

What?

555

Anything I should look out for?

556

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

557

Yeah, I think there's something that I'm

seeing much more frequently now that gives

558

me a little bit of a, a moment of caution.

559

And that is, it's Ace Promazine.

560

Now I've been around long enough

that I've seen multiple evolutions.

561

Back in the day, ACE Promazine

was all we had, right?

562

We're like, well, let's try

that and see what happens.

563

And then we're like, wait a minute.

564

That's kind of like a chemical

Rait jacket, and I don't know that

565

that's the greatest thing to do.

566

And then it was like, ACE Promazine is

the devil and we should never use it.

567

It's a terrible drug.

568

We should.

569

I don't think either of those

two are completely accurate.

570

And as I'm seeing the chill protocol

getting more and more visibility

571

and traction in the community, I'm

getting more veterinarians now,

572

especially younger veterinarians who

haven't perhaps been around for all

573

of those e evolutions, across time.

574

And I'm getting these questions like, Hey,

when I bumped the ACE dose just a little

575

bit in the chill protocol, everything

felt like it got a whole lot easier.

576

Can I just do that?

577

And so I'm, I'm, I'm really having

to have those conversations more

578

frequently now than I needed to

three or five years ago to say yes.

579

And.

580

Be really mindful that for the vast

majority of patients, acepromazine doesn't

581

have any significant anxiolytic effects.

582

It is going to do a much better job

than some of our other medications

583

are controlling motor patterns,

and if we are controlling anxiety

584

and mitigating that effect in other

ways, it's not inappropriate to use

585

Ace, but really be cautious with Ace

and with some of our other sedative

586

medications like Trazodone or perhaps

even Gabapentin that we're not masking.

587

That we're not just blunting

everything but still having an

588

animal who may be still sensitizing

from an emotional experience.

589

perhaps we could be making the

problem worse, even though it

590

looks better in the moment.

591

So just be cautious.

592

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

593

Yeah.

594

Yeah.

595

I, I like, I I like that, that,

that's, that's good advice.

596

Run me through the chill protocol

as you kind of use it and teach it.

597

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

598

So the classic chill protocol,

as I learned it, is Gabapentin,

599

ace, promazine, and melatonin.

600

It's a pretty benign protocol

for a lot of patients.

601

Again, there's that ace piece in there,

which I do think works synergistically

602

with the other options, and so

that's the classic chill protocol.

603

What I'm seeing now, and, and this

isn't a problem, it's just something

604

that I have to tease, tease out, is

that when, now when people say, I'm

605

using the chill protocol, I kind of

have to go, what do you mean by that?

606

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

607

That's, well, that's

why, that's why I asked.

608

It gets thrown, it gets sort of

thrown around a lot, and I, I just

609

wanna know what, what the crisp bale

version of the Chill protocol is.

610

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

611

I will say that I don't even have

a version that I use reliably.

612

It's sort of like,

okay, what am I getting?

613

What am I trying to piece together?

614

I will say that some people use that

chill protocol label in a way that

615

includes those baseline meds, but

they're also throwing Trazodone in, or

616

maybe they drop the ace out or maybe

they forgot to give the melatonin.

617

And so there's often different versions

that I think it's now, it's a kind of a

618

label that's being thrown around as a,

it's a cocktail to give before visits.

619

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

620

Oh yeah, the people get creative.

621

Like I, I've already run into

the Carolina Chill Protocol and

622

I'm like, that's not a thing.

623

That's not a thing.

624

You just made that, like, you guys

made that up and they just smile.

625

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

626

Like, yep, yep.

627

But it works for us.

628

And

629

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

630

But it's not a thing.

631

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

632

that's the lovely thing about it, is like,

if it's working for you and you're mindful

633

of what you're using and why, great.

634

Call it blueberry for all I care.

635

I don't, I, I don't care.

636

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

637

A blueberry chill.

638

All right.

639

I can

640

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

641

There we go.

642

Right.

643

Lots of options.

644

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

645

There's people who are getting

way too excited about this.

646

Yeah.

647

Okay.

648

No, I, I like where your head's at, Dr.

649

Chris Pockle.

650

Where can people find you online?

651

Where they, where can

they keep up with you?

652

cloudRecording_Dr. Chris Pachel _Take_1_audio-mp3:

653

So they can find me in a

lot of different places.

654

they can track what we're doing at the

Animal Behavior Clinic, either on our

655

website, animal behavior clinic.net,

656

or through Facebook and

Instagram for the practice.

657

You can also check me [email protected],

658

where all podcasts and media appearances

get archived for viewing pleasure.

659

You'll find this one there as

soon as it gets launched, and

660

it's ready to be to be uploaded.

661

cloudRecording_Dr. Andy Roark _Take_1_audio-mp3:

662

Thanks so much for being here guys.

663

Thanks for tuning everybody.

664

Take care of yourselves, gang.

665

I'll talk to you later.

666

And that's what I got guys.

667

Thanks for being here.

668

Thanks to Dr.

669

Chris Bockel again for being

here and sharing his wisdom.

670

king, I hope you enjoyed it.

671

I hope you got something out of it.

672

If you did, please share

this, episode far and wide.

673

Let's get the word out.

674

This is a great little episode

for people as a refresher.

675

on stress management for

patients coming into the clinic.

676

This is, this is a great one

for pet owners to even have and

677

listen to and, and have good

questions for their veterinarian.

678

So anyway, guys, hope, help me spread

the word, like share, subscribe,

679

do all the positive things if

you enjoyed, the podcast and I

680

hope to talk to you next week.

681

Take care, gang.

682

I'll talk to you later on.

683

Bye.