Veterinary anesthesia expert Tasha McNerney, CVT, CVPP, VTS (Anesthesia & Analgesia) joins The Cone of Shame Podcast with Dr. Andy Roark to break down the role of butorphanol (Torb) in veterinary practice today. They dive into its sedative vs. analgesic properties, when it shines, and when it falls short, especially in pain management. Tasha explains opioid receptor interactions, how to think critically about using butorphanol in different cases, and why it might still deserve a spot on your clinic’s shelf. Plus, they discuss Tasha’s new book, “Pain Management for Vet Techs and Nurses,” and the upcoming Veterinary Anesthesia Nerds Symposium. If you’ve ever wondered, “Do I still need Torb?” This episode is for you! Let’s get into it.
You can also listen to this episode on Apple Podcasts, Amazon Music, Spotify, YouTube or wherever you get your podcasts!
LINKS
Pain Management for Veterinary Technicians and Nurses
Dr. Andy Roark Charming the Angry Client Team Training Course
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.
Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.
In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!
Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.
EPISODE TRANSCRIPT
Dr. Andy Roark: Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one for you today. We’re talking about butorphanol, aka torb of torb and ace fame, if you’ve been in the profession for a little bit. You remember those days. Is it still, is it still worth having on our shelves?
That’s the question I put to Tasha McNerney and we break it down. She talks in detail. She talks in nuance about, yeah. I, she thinks it’s still worthwhile. She talks about why, she talks about when to use it, when we don’t use it. It’s a great refresher if you got Torb on your shelves and you’re thinking, Do I still need this?
This is the episode for you. Guys, check it out. I think you’re going to enjoy it. Let’s get into it.
Kelsey Beth Carpenter: This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark: Welcome to the podcast, the one and only, veterinary anesthesia nerd herself, Tasha McNerney. Thank you for being here my friend.
Tasha McNerney: Yeah, thanks for having me.
Dr. Andy Roark: I love having you on the podcast. For those who don’t know you, you are a CVT, CVPP, VTS, anesthesia, E I E I O you have, you have the alphabet soup behind your name because you’re amazing.
You are one of the administrators of the Veterinary Anesthesia Nerds. You are the founder of that organization. It is a group that I really love. I recommend to people. I just what you have done for anesthesia, I think people who love different specialties look to and admire, what you’ve built and how you have made this sort of beacon, this resource for people who want to learn more.
I just I just, the gift that you’ve given to our profession is, is pretty significant. And I just, I love that you do that. So that, that’s who you, that’s who you are. I, I wanted to come on and talk to you about I, we were, we were discussing your, your, some of your favorite topics and butorphanol came up.
And so I was raised in the old school, and butorphanol was a real go to back when I started. I mean, it was probably the number one most common control drug next to euthasol. That, that, That we use. And I have seen its popularity rise as it is used as a, you know, as a sedative and I have also seen its popularity fall.
I see people get excited when we talk about butorphanol and there’s some people who hate it and feel like it should not be in vet practices. And there’s other people who are still using it a lot for sedation and, and pain control. I wanted to just break it down with you today. Talk to me at a high level, and we’ll drill down, about butorphanol. How do you see this being used today in practice?
Tasha McNerney: Yeah, so, A, thank you for, let’s, like, talking about butorphanol because I like to say that I’m equal opportunity drug and as someone who loves anesthesia and loves receptor physiology, I think butorphanol and some of these drugs are really fascinating to talk about. So, We utilize butorphanol quite a bit especially if you’re working in practice that is utilizing it.
Maybe you are using it for its sedative properties. Maybe you’re using it for its analgesic properties. But most of the time, again, I’m working in surgery and anesthesia. So we do see use of a fair amount of butorphanol. And I have been working in veterinary medicine for quite a while now.
I’m going on my 19th year in veterinary medicine. And yes, when I first started almost every surgical patient the protocol that we use was TORB and ACE.
Dr. Andy Roark: That was it.
Tasha McNerney: Right? Every surgery, whether it was a neuter or a small lumpectomy or a major abdominal surgery, it was torb and ace. And it kind of, as we got to know more about how these receptors work and as we started to utilize other opioids for pain management, we started to kind of hone in on where should we really be utilizing butorphanol and when should we when we choose our opioids, when should we actually maybe be choosing butorphanol, right? So, let’s get into it really quickly and hopefully we can talk about, if you’re okay with me going into the receptors a little bit.
Dr. Andy Roark: Receptors.
Tasha McNerney: Dude, but it’s so interesting.
Dr. Andy Roark: It’s you so I’m gonna go along with this.
Tasha McNerney: So, it’s, butorphanol in itself and just some of these opioids are a little bit complicated, right? So there’s different types of receptors within our nervous system that respond to opioids.
Most often we talk about mu opioid receptors. Those are the ones that are going to change and modulate pain signals going through. Those are giving, you know, you the feelings of euphoria and those mu opioid receptors and mu agonists are drugs like hydromorphone, fentanyl, kind of like the kind of potent heavy hitters when we talk about analgesia.
However, butorphanol works a little bit different in that butorphanol is actually an agonist antagonist opioids, which means it goes over to the kappa receptor and it stimulates that. It actually goes over to the mu receptor and it blocks it, right? So that’s why I do think butorphanol has kind of a cool and interesting place when it comes to analgesia and sedation.
And I don’t like the blanket statement then like, oh, butorphanol is worthless when it comes to anesthesia and pain management. I don’t think that’s true, but I do think we need to be careful about how and when we’re utilizing it. So, let’s say you have a patient that you need that kappa receptor activation.
Why would we need kappa receptor activation? Well, because the kappa receptor, don’t forget about the kappa receptor, right? I know the mu receptor gets all of the accolades, right? Because it’s so cool. But the kappa receptor is actually responsible for some mild visceral analgesia. Important, right? When we have a patient that we might be like going in and our surgeons are in there touching and feeling and pulling on all those guts and initiating some visceral pain, right?
So the kappa receptor is important there, but also the kappa receptor is really responsible for sedation. And that is where butorphanol is going to shine. So if I have a patient in front of me that I think, you know what, we don’t necessarily need to do something super painful for this patient. However, this patient is a brachycephalic and they’re really freaking out and I have to put them on their back for an ultrasound.
Butorphanol is probably going to shine here, right, because, again, let’s say I have a patient that maybe has some pancreatitis that we’re dealing with. Right? Kappa receptor needs to be activated. So what’s going to do that? That’s going to be our butorphanol. And in some of these patients, we look at utilizing maybe a butorphanol CRI when the pain is mainly visceral.
Okay? Now, why am I mentioning when the pain is mainly visceral? Because sometimes we extrapolate that information and we say, well, but if we’re doing a spay procedure, that pain is mainly visceral, right?
Dr. Andy Roark: Well, yeah. Right. So, I mean, we’ve, it’s interesting. I was gonna, I was gonna dig into this exactly. When we talk about visceral pain, what does that mean, Tasha? Like, we’re doing a spay, we’re doing a midline incision, and you know, we’re, we’re, I don’t know. I mean, visceral pain is part of it, but, you know, it’s a fairly, when we really think about it, especially like a dog spay, like a big dog spay, it’s a pretty significant abdominal surgery.
Are we gonna call that? There’s, it’s certainly part of his visceral pain. Like, I don’t know. Talk to me a little bit about, about where you draw those lines of, like, what constitutes visceral pain as opposed to you know, just generalized surgical pain.
Tasha McNerney: Yeah, so we have probably all experienced visceral pain. Well, maybe not some of you, but for some of us who grew up in the Midwest and then, you know, experienced Taco Bell for the first time, you have experienced some visceral pain. It’s that deep pain in your guts, right? It comes along with that stretching and movement, that kind of deep visceral,
guttural pain. Now, the thing is, just as you brought up, Andy, when we do a large dog spay, there are going to be some components of visceral pain. However, the most painful part of this is going to be the cutting through the muscle and the skin, etc. And the healing of that, at least in people, that’s what they report to be the most painful part.
Not necessarily the deep visceral pain, but the actual somatic pain that comes along with the healing of the muscle and the skin, etc. Now remember, the kappa receptors, that’s not really going to get into somatic pain. That’s why when we look at whether or not butorphanol is an appropriate choice for these patients, we need to look at what type of pain is this patient going to be experiencing during the procedure and in the postoperative part, right?
So that’s why I think I don’t want to poo on butorphanol and say like it has no place because butorphanol, if I have a patient that maybe has some mild pancreatitis, we need to be pushing on their abdomen with an ultrasound or we need to be putting them on their side or they are having some respiratory difficulty, right, because remember the kappa receptor is also going to be nice for cough suppression there, so if they’re having some difficulty respiratory wise, butorphanol is a really nice drug to activate the kappa receptor, provide some sedation, and provide some mild visceral analgesia.
But when we talk about procedures that are going to have multiple different components, somatic pain, visceral pain, neuropathic pain, butorphanol is just not enough, right, to get to where we need to go analgesia wise.
Dr. Andy Roark: I agree with, I agree with that.
Dr. Andy Roark: Okay. correct me if I’m wrong, once we go down the buprenorphine roll path, we’ve really closed a lot of doors, right? Like, because we’ve got a mu agonist, I can’t be like, ooh, this is more in depth than I thought it was, because my, my hands are really tied. So, one of the things in my life that has both held me back and saved my bacon is my tendency to catastrophize and just be like what if this goes badly?
What if what if I get in there? And it is the worst possible scenario it could possibly be and that has kept me alive many times in my life but also it makes me very wary of taking paths that will close doors I’m like, ah, it’s gonna be fine. I don’t tend to think I am definitely more on the It, what, it could go wrong.
If it could go wrong, it probably will. I’m much more on that side than the, that’ll be fine. So, talk to me a little bit. Do you have those concerns about, about Torb? Like, are there times when, when you’re looking and you say, this should probably be fine, but I don’t know if we want to commit to this agonist antagonist? It’s, how do you, how do you make those sorts of choices?
Tasha McNerney: Yeah, and this happens quite a lot, right? Because sometimes we just need to get a patient sedated so we can get some diagnostics. We get some diagnostics and we go, oh, like this actually is a foreign body and now we got to go to surgery and now we have butorphanol on board. So are we completely like, you know, in the red here?
And the truth is a little bit, but not completely. So remember what I said about those receptors, right? So we think about those receptors as basically your Walmart parking lot and some of the parking spaces are going to be taking up with the butorphanol, right? Because they go over to that mu receptor and they like they take up the space so it can’t be activated. But it doesn’t necessarily mean that it’s going the butorphanol dose is going to take up all of the mu receptors, so if you got yourself into a situation that you think man, I gave this this animal butorphanol Now it is a foreign body.
It is going to be going to surgery in an hour. How can I provide additional analgesia? You can still top off with something like a fentanyl or a hydromorphone or a methadone. It’s going to go to those open receptors and it’s going to take those over, right? So it will go to the open spots in the parking lot and you’re going to get some efficacy and some analgesia.
Not going to be as good because, again, your parking spots are all taken up. However, it’s still going to be decent. And again, when we think about these procedures, we got to think about how can we get multimodal because we don’t want to risk, we don’t want to rely on only the opioid to do the heavy lifting for analgesia.
So if we get ourselves into a situation where we’ve given butorphanol, but now we’re going to go to surgery and it’s going to be a major abdominal surgery. Go ahead and give the dose of whatever stronger opioid you have, whether it be buprenorphine, whether it be hydromorphone, et cetera, right? And then talk to your technicians about how can we add in some additional analgesia, analgesic adjuncts to this protocol to make it multimodal to supplement the fact that some of those receptors are going to be taken up by our butorphanol.
Another thing to remember though is butorphanol is shorter acting so it’s not like we’re getting six to eight hours on those receptors with the butorphanol. You really only get like, you know, two to four hours max. So that is going to save you a little bit as well. Timing does come into play here.
Dr. Andy Roark: Okay, so, if, if I said to you, Tasha, a level of caution of between one, which is zero caution, which is, ah, we just sedate him, we just, we just use butorphanol, and then we just, we’ll sort it out later on, and ten is maximum caution, I almost never use this because it gets in the way of other things I might want to do.
I’m getting the impression you’re somewhere around a three or a four, do you think that that’s right?
Tasha McNerney: I think that’s right. I was gonna say four or five, but yes. Yeah, because I think that you guys also have to use, you know, your clinical judgment if they come in for, you know, If it’s a Great Dane and it’s coming in for unproductive vomiting and we think, hmm, maybe here, that might not be the one I’m giving butorphanol to.
If I think there’s a high likelihood just walking in the door, it may end up in the surgery suite.
Dr. Andy Roark: Yeah. Tell me I’m gonna, I’m gonna sort of shift courses here a little bit, because this has been really helpful. I like this a lot. It makes me feel good about the sort of choices that I make with butorphanol. I’m glad it’s still on my shelf. You know, I’ve kind of looked at it a couple times recently and been like, do I still, do I still want to have that?
I mean, do I need it? Is that worth the shelf space? And it, I, you’re, you’re, you’re validating a lot of the choices that I’ve made recently, which is good. It makes me, it makes me really happy.
Tasha McNerney: Yeah, Let me just tell you this one cool thing only because when you have patients that are maybe not as amenable and you can’t get the drugs in IV and you have to look at other routes of administration, right? I know that I’ve talked about this before in some of my lectures but butorphanol is one of those drugs that it can be given intramuscularly and subcutaneous, and it also has really good bioavailability when given intranasally or oral transmucosally.
Dr. Andy Roark: Yeah. Makes sense. Switching, I want to switch gears here. You have a new book out. It’s called Pain Management for Vet Techs and Nurses. What made you decide that, that, that this was the book that you wanted to write? I mean, it’s very specific. It’s not a pain management textbook. It’s very specifically techs nurses in the title.
Tell me, tell me a little bit about what sort of what inspired you to start working on that.
Tasha McNerney: Yeah. Well, so full disclosure, it’s a second edition and the three of us who are the administrators of the veterinary anesthesia nerds were approached to take over as editors for the second edition. Now, I’ll tell you, Andy I’ve written book chapters before, but to be an editor on a second edition, also a second edition where,
about seven, eight years have gone by since the first one. So talk about the amount of research and changes that you’ve seen just in those eight, nine years in pain management. We did almost a complete overhaul of this book and kind of started from scratch. We really, really wanted to make sure that the veterinary technicians and nurses out there understood what a key critical role they play in the pain management team, right?
Not only are they usually the ones who are doing that first assessment of a patient in the morning, or even that first triage of a patient that comes in on ER, they are often the ones that are doing the multiple checks post op and in recovery of those patients. They’re the ones doing the follow up phone calls.
So, from just a perspective of the people in the veterinary hospital who have kind of the most hands on time with these animals and are really experts at pain recognition. It’s the veterinary technicians and the nurses and we wanted to give them a really comprehensive way to, you know, all the way from preoperative to post op recovery to dealing with chronic pain issues, a way for them to see all of the different things that are out there, not only from a new research perspective, but also just maybe from a career perspective.
I think that maybe some technicians don’t know that they can become certified veterinary pain practitioners, that they can get their technician specialty in analgesia, that if they wanted to hone in on it, they could become rehab specialists. They can go work with an acupuncturist. So pain management doesn’t always just revolve right around the immediate time of surgery. I mean, pain management is kind of a lifelong thing and veterinary technicians and nurses are the key to that.
Dr. Andy Roark: That, yeah, I think that’s fantastic. I, I love, I love education for technicians. I just think they’re so important. Vet medicine is a team game and becoming more and more of a team game, which I think is wonderful. I just, I love that you put this out. It’s funny, when you first said, you know, it’s been eight years since the first edition.
I’m like, that doesn’t sound like that much to me. But when, but when you think about, when you think about the amount of research that’s come out and how fast we have moved in the field of pain management and analgesia, it’s it’s, it’s pretty, it’s a pretty daunting task. So anyway, I’m, I, I am glad you took this on.
I hope that a lot of people get to see you the book and and will benefit from it. I think the services you do for educating the profession as a whole are just, are just wonderful. And so, anyway, I love that you’re doing it. I love that you’re here. I’ll put a link to the book in the show notes. It’s up for sale.
It’s a pre-sale. It may even by the time this episode comes out, we’re probably gonna be getting close to it actually launching. And so yeah, guys. I hope you guys will take a look at it and check it out. Tasha, where can people find you besides the book?
Tasha McNerney: Sure. So you can check us out on the Veterinary Anesthesia Nerds website. We have a bunch of educational blogs on the website. We have links to our symposium where we do anesthesia and pain management. A conference that we do each year, and then we also just launched our YouTube channel and there’s a link to that on our website.
And some merch just in case you want to, you know, rep some Anesthesia Nerds coffee mugs in the morning.
Dr. Andy Roark: I love, I love an anesthesia nerd coffee mug in the morning. Tell me about the live event. Are you guys doing your conference?
Tasha McNerney: Yeah, we are doing our Alright, cool. Tell me a little bit about that. We are going to do our conference this year. It’s the Veterinary Anesthesia Nerds Symposium, and it will be in Virginia Beach, Virginia this year because we got an overwhelming amount of people asking for an East Coast event. So East Coasters, this one’s for you.
Dr. Andy Roark: That’s fantastic.
Tasha McNerney: We are gonna have– it’s a three day event.
We are gonna have 16 hours of CE on some pretty advanced and cool anesthesia and pain management topics with VTS in anesthesia, VTS in lab animal medicine, and two really fantastic anesthesiologists, kind of like my favorite speakers. We are also going to be offering wet labs in addition, and we are going to be offering two wet labs this coming time around and the first wet lab is going to be local block basics.
So let’s say you are in a GP and you just want to get started doing some more local blocks. Maybe you want to try your hand at sacred coccidial blocks or you want to learn retro bulbar blocks or dentistry blocks or something like that, not the ones that require an ultrasound or the more advanced.
We have a wet lab for you where it’s going to be basic local blocks that you can start using next day in your clinic. And then for you guys who are into the more advanced blocks and want to get trained on some of those in depth ultrasound guided blocks, we’re also going to have an advanced nerve block wet lab for those individuals as well.
So we really want to make sure that people walk away from this event feeling confident and utilizing regional anesthesia and pain management protocols in their practice.
Dr. Andy Roark: When is that happening?
Tasha McNerney: That is happening in June of this year, June, 2025
Dr. Andy Roark: Registration open now?
Tasha McNerney: Yeah registration is open now.
Dr. Andy Roark: Get on it! Outstanding! That’s amazing! Awesome! Guys, check it out! You should, as you can tell, Tasha’s amazing. If you get a chance to work with her and learn from her, you should totally do it. Tasha, thanks so much for being here. Gang, thanks for tuning in and listening. I hope you guys had a great time.
Take care of yourselves, everybody!
Tasha McNerney: Thanks.
Dr. Andy Roark: And that’s what I got. Guys, thanks so much for being here. Thanks to Tasha for being here. I am super excited about her new book that is coming out, Pain Management for Vet Techs and Nurses. She is the editor.
I don’t want to take away anything from the people who wrote the chapters. This is going to be a great collection. I, I, I talked about in the episode. I love what she’s doing. Guys, I really love talking about the Vet Anesthesia Nerds Conference. Boy, we talked about some more after we stopped recording.
They’ve got a great thing going on over there. Really interesting. As someone who loves active, engaged learning and new types of teaching styles, boy, they’re pushing the envelope. They’re doing some really cool stuff at that conference So if you’re an anesthesia nerd you you got you got to jump on it, too they are they are three quarters sold out at the time of this recording I suspect they’re probably gonna sell up pretty darn fast So if you’re like, oh man, I need to be there you you need to jump on it right now. So anyway gang take care of yourselves everybody.
I’ll talk to you later. Bye
