408 - Beyond Trazodone: When the "Chill Protocol" Isn’t Chilling

Summary

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The Cone of Shame Veterinary Podcast

Episode 408: Beyond Trazodone—When the "Chill Protocol" Isn’t Chilling

Host: Dr. Andy Roark
Guest: Dr. Chris Pachel, DACVB (Animal Behavior Clinic, Portland, OR)
Release Date: July 16, 2026

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Episode Overview

In this episode, Dr. Andy Roark welcomes board-certified veterinary behaviorist Dr. Chris Pachel to explore the evolving landscape of pre-visit anti-anxiety medications in veterinary medicine. As gabapentin and trazodone become staples in many clinics, Dr. Roark and Dr. Pachel discuss when these protocols fall short, the nuances of medication choice, and how clinics—and patient outcomes—can benefit from a more tailored approach. The conversation is rich with practical tips, medication insights, and discussion around client and patient experience.

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Key Discussion Points & Insights

Building a Better Veterinary Experience

• Practice Environment Matters (05:50-07:45):
  Dr. Pachel highlights the intentional design details of his new practice, such as glass doors and fully carpeted exam rooms, which contribute to patient comfort. He reports dogs and cats settling within minutes, often relaxing enough to lay down fully—a “proof of concept” for how environment shapes clinic visits.

  “Every single dog and cat that we brought into the space, completely comfortable, usually within about eight to 10 minutes…” – Dr. Chris Pachel (06:52)

• Client Experience Starts Early (08:15-09:30):
  Dr. Roark emphasizes that client perception of the clinic begins at appointment booking and extends post-visit. He draws a parallel with his daughter’s recent surgical experience, noting that pet owners’ anxiety about their pets mirrors human medicine concerns for family.

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Pre-Visit Pharmaceuticals: Beyond Gabapentin and Trazodone

• Rethinking First-Line Medications (11:21-12:39):
  Both gabapentin and trazodone are lauded for their safety and utility. However, Dr. Pachel urges practitioners not to stop there—“We have options rather than just saying, well, we can give more or we can give less, but we can absolutely give differently.” (12:21)

• When First-Line Fails: Assessment & Alternatives (13:13-15:06):
  Dr. Pachel’s approach:

  • Start with conservative dosing, assess tolerance.
  • Trial a “happy visit” at home to check for effect.
  • Increase dose incrementally if tolerated but not effective.
  • Key tipping point: If “excessive sedation without anxiety reduction” occurs, it’s time to switch classes.

  “If I start to see excessive sedation without anxiety reduction…we are now masking from a motor control standpoint, but I’m not actually making that animal feel better.” – Dr. Chris Pachel (14:34)

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Branching Out: Additional Medication Options

• Alpha-2 Agonists (16:45-17:39):
  Clonidine is Dr. Pachel’s go-to for patients with windup/heightened arousal states. It’s administered 90–120 minutes pre-visit and mitigates overactivation.

  "I love Alpha 2s for those patients...it helps to blunt that norepinephrine surge..." – Dr. Chris Pachel (16:53)

• Layering Medications or “Cocktailing” (17:39-18:44):
  Whether to stack drugs depends on individual patient need. Dr. Pachel tries single agents first, but may layer if different effects are desired (e.g., baseline calm + arousal reduction).

• Remote Dosing & At-Home Trials (19:18-21:33):
  To compensate for busy clinics, he encourages owners to trial medications at home in comparable, controllable stress situations (e.g., visitors, car rides). Feedback focuses on behavioral changes, not just sedation.

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Defining Success & Safe Protocols

• What Does a Well-managed Patient Look Like? (21:33-23:05):
  "Success" varies by veterinary need:

  • For mobility exams: minimal to no sedation.
  • For procedures (e.g., blood draws): more tolerable sedation may be desirable. Clinician must tailor protocol based on whether anxiolysis, sedation, or both are desired.

• Fourth-Line and Beyond (23:05-24:13):
  In specialty practice, Dr. Pachel often reaches for fourth/fifth options due to referral cases. General practitioners are encouraged to optimize dosing and consider combinations before escalating.

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Behavioral Risks and Cautions

• Disinhibition and Safety (24:13-26:54):
  Dr. Roark brings up concerns about anti-anxiety meds lowering bite thresholds. Dr. Pachel clarifies:

  • Benzodiazepines are the main class associated with “behavioral disinhibition” (loss of normal restraint), not gabapentin, fluoxetine, or trazodone.
  • Caregivers should observe closely during trials, use safety tools, and avoid introducing new stressors until response is confirmed.

  "Behavioral disinhibition is something that is specifically tied to benzodiazepines." – Dr. Chris Pachel (26:01)

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Underused Tools & The “Chill Protocol”

• Advocating for Benzodiazepines (27:19-28:06):
  While GPs are cautious (due to control status and side effects), Dr. Pachel notes that for panic and extreme situational distress, benzos can be much more effective than gabapentin/trazodone and can be used judiciously, alone or in combination.

  "Don’t forget that [benzos are] there as a potential option...they do a much better job than gabapentin or trazodone tend to do." – Dr. Chris Pachel (27:33)

• Cautions with Acepromazine (28:39-30:26):
  Dr. Pachel sees increased use of acepromazine with the “chill protocol.” He reminds listeners:

  • Ace can blunt motor activity but isn’t truly anxiolytic.
  • Risk: Masking distress rather than alleviating it.
  • Caution against increasing ace dose just for apparent “easy handling.”

  “Be really mindful that for the vast majority of patients, acepromazine doesn’t have any significant anxiolytic effects.” – Dr. Chris Pachel (29:12)

• What IS the Chill Protocol? (30:33-31:37):

  • Classic: Gabapentin, acepromazine, and melatonin.
  • In reality, “chill protocol” is often a catch-all for various cocktail preps.

  “Now when people say ‘I’m using the chill protocol,’ I kind of have to go, ‘What do you mean by that?’” – Dr. Chris Pachel (31:03)

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Notable Quotes & Memorable Moments

• “If what we’re doing isn’t working...we can absolutely give differently. And being curious about that is super helpful.” — Dr. Chris Pachel (12:21)
• “I tell you what, in the four weeks that we’ve been operational here, without exception, every single dog and cat that we brought into the space, completely comfortable, usually within about eight to ten minutes...” — Dr. Chris Pachel (06:52)
• “That’s kind of what we achieved: the dog is really, really tired and they're having a panic attack and they're exhausted at the same time.” – Dr. Andy Roark (15:06)
• “Call it blueberry for all I care... if it's working for you, and you're mindful of what you're using and why, great.” — Dr. Chris Pachel on naming protocols (31:51)

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Important Timestamps

• 05:50 – Designing a low-stress clinic environment
• 11:21 – Beyond gabapentin and trazodone: medication options
• 13:13 – Criteria and process for adjusting or changing medications
• 16:45 – Introduction of Alpha-2 agonists (e.g., clonidine)
• 19:18 – Setting up at-home medication trials
• 22:14 – What a “well-managed” patient looks like on meds
• 24:52 – Discussing behavioral disinhibition and benzodiazepines
• 28:39 – Acepromazine and the risks of masking anxiety
• 30:33 – Origins and shifting definitions of the “chill protocol”

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Practical Pearls for Practice

• Optimal protocols are customized, not one-size-fits-all.
• Sedation ≠ Anxiety relief: Monitor for “masked” patients.
• Alpha-2 agonists and benzodiazepines are valuable but underused tools—know when and how to use them.
• Be cautious with acepromazine; don’t conflate calm handling with true emotional comfort.
• Establish clear communication with pet owners about medication trials, side effects, and safety protocols at home.

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Connect with Dr. Chris Pachel:

• Animal Behavior Clinic Website
• @drpachel on social media
• Drpachel.com for podcast/media archives

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This episode is an essential listen for veterinarians seeking to improve patient welfare, decrease stress for clients and animals alike, and expand their pharmacologic toolbox for behavioral cases. Dr. Roark and Dr. Pachel combine actionable advice with engaging storytelling and clinical wisdom.

Transcript

[A]

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[B]

Welcome everybody to the Code of Shame veterinary podcast. I am your host, Dr. Andrew. Guys, I got a great one for you today. My friend Dr. Chris Pockle is here. He is so fun. He's just absolutely got the best energy and he is so insightful and charismatic and just interesting. And we're talking about pre visit anti anxiety medications. Guys, I'm a big fan. I this is not a hard sell. The pet owners are generally very excited about this. They don't want their pets to be stressed out. Coming in the clinic, they can see that their pet is nervous, tail down, ears down, pacing, trying to, you know, escape from the room. They see that stuff and they don't want it. And if you say, hey, next time can I have you pick something up before you come in? I, I, that's such an easy, easy yes for the vast majority of cases. I know there's some people who, who are not on board but it's, it's rare. And I really, I see gratitude in the eyes of the pet owners when they're like, oh yes, please, I would love to have something to make this trip easier. And so I, you know, I've been using gabapentin and trazodone and I'm sure that probably the majority of you who are in practice who are listening to this, that's probably your go to as well, that seems to have cornered the market. But is that all we should be using? Is there more nuance to this? I feel like maybe we should have a little bit more flexibility in the tools that we're using to bring pets into the clinic. And like, I just think that there's an area for expansion here and we can, we can do better for our patients and for our clients and make our jobs easier at the same time. Let's look into this. And so anyway, that's what Chris is talking about with me today. Really great stuff. You are going to deepen your knowledge and understanding around pre visit pharmaceuticals and I hope you're gonna find some nice little pearls that you can put to use. Let's get into it.

[C]

This is your show.

[D]

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[C]

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[D]

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[C]

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[D]

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[B]

Dr. Chris Packle. How are you, my friend?

[C]

I am doing fantastic, sir. I appreciate the opportunity to have this chat with you. You know, I always look forward to them.

[B]

I am always happy when I can get you to come on the podcast. I just, I think the world of you. I love your energy, I love your insight. Honestly, right now I'm specifically excited to talk to you because you are on a new adventure. So for those who don't know you, you are a board certified veterinary behaviorist and you are the owner and the lead clinician at the Animal Behavior Clinic in Portland, Oregon. The. This is your new baby. You're in a new facility. Like, I'm looking at it behind you. I said, tell me about, tell me about the Animal Behavior Clinic. How's it going? Like, what have you, what are you excited about?

[C]

I. Yeah, we were about a month in as of the recording today. We're about a month into this new space and I feel like it's been this Goldilocks story for me. When I, when I moved to Portland in 2010 and I kind of took over the office from, from my, my mentor at the time, Dr. Jackie Nielsen. I took over the office and we just had this little tiny space in a GP clinic and it worked great. And we were there for about 12 years and then I moved into this ginormous facility. That was fantastic. And we had all these opportunities, but it was too big. It was too big, structurally, functionally, logistically, responsibility, like all of it. And so now we're in the just right version.

[B]

Okay.

[C]

And it's about a 2500 square foot office. I've got three consultation rooms, two dedicated for dogs, one exclusively for cats. I've got a Space that my team can really mix and mingle in. We've got a space for continuing education events and networking, and we get the opportunity to completely customize it. Color choices, artwork, all of the things. And it is. It has been just an epic adventure to really take all that we've learned over, gosh, at this point. 25 years in my career.

[B]

Yeah.

[C]

And, hey, what do I want to do? Let's do it.

[B]

Yeah. That's one of the things that always excited me the most about veterinary medicine in general is it's still this place where you can come in a clinician and decide what your vision is. And you can make this thing and you can make it the way you want it to be. And, like, I can just get all kinds of romantic about that. Like, I just. I love it. It's. It's so awesome. It's one of the things that I just love the most about this profession. We were talking before I hit record here, and we were talking about pets coming into your. Into your practice and just sort of the vibe and the way that they respond to the environment. Talk to me a little bit more. I want to bring that back up because that's really kind of where I want to go today. Talk to me about what that's like when animals sort of come in and the experience that they seem to have.

[C]

Yeah, it's been really, really cool in that. You know, there's little elements that I'm recognizing, some of them by design and some of them almost by accident, that.

[B]

Yeah.

[C]

As our clients and our patients are coming to the front door, we do have a glass front. So it. I think for many of them, it's not as though there's this solid wall with the door opening and they're kind of figuring out what's on the other side. They're already starting to gather information even before they step inside. Our lobby is really spacious. It's got a double door entry at the front. So if we needed to, we can give them a full 6, 7ft of clearance. They can walk into the lobby. Nobody needs to be within, you know, any significant space proximity for them. So for those patients who need a little bit more of a special handling, we can do that. We can prop the doors open, they can come on in. We've got three exam rooms that are, you know, including the one that I'm in right now, they are fully carpeted, which is an interesting choice for a veterinary space.

[B]

Yeah.

[C]

It completely changes the sound, it changes the reverberation. It changes the energy of this Space in a way that doesn't make it feel clinical. And I tell you what, in the four weeks that we've been operational here, without exception, every single dog and cat that we brought into the space, completely comfortable, usually within about eight to 10 minutes, I've got dogs who are ordinarily pacing, exit seeking, interacting with the owners, barking, panting, all of it, full lateral sleeping.

[B]

Wow.

[C]

It's such a proof of concept for me that when we set them up for success, what that does both for them and their ability to engage with us, and also for the pet parents and the caregivers to see sort of a glimpse of what's possible.

[B]

Yeah.

[C]

That when we change the environment, when we change the conversation, even their pets, the ones that they have significant concerns about, have the potential to be somewhat flexible and that it gives. It's giving me this lovely inroad to. To having the conversations. And we say, well, maybe this isn't what's replicable or necessary in your home, but we're getting a glimpse into your own dog or cat's flexibility in how they show up in the world. So what do we want to do? Where do we go next?

[B]

So I've been thinking a lot about the client experience coming into vet practices, and, you know, I think a lot about patient care, but this is kind of a little bit different in that I'm really a big believer that, you know, the clients today are really kind of deciding how they feel about their vet and about going to the vet before they even leave their house. And I think that we like to think the experience that we're measured in starts when they walk into our door and it leaves when they walk out of our door. I don't think that that's true at all. I think it starts when they book the appointment, whether it's online or by text or by calling or what's required to do that and how much friction is there. And then it rolls from the moment they make the appointment until they're back in home and totally settled and probably until treatment has been provided. And I really think it's a much longer experiential window than we. Than we give it credit for. And so I've been thinking a lot about that and sort of the client experience. And then I think about moving effectively in the exam rooms and being efficient while also still doing a really good job with the pets and making sure that we're. That we're creating the experience that we want for them and that we're being. And that we're able to Do a good job. And, and so I've been thinking a lot about our protocols for helping pets come in, in the most sort of relaxed way possible to, to make the transport of pets more, I don't know, more enjoyable for, for the pet owners. So I, I mean, I'll tell you this. So this morning my youngest daughter got her wisdom teeth taken out and, and my wife took her to the, or the Donna to get this done. And my wife was more anxious than my daughter was. And she was like, oh my gosh, they're gonna, they're, you know, they're gonna sedate my baby and she's gonna have surgery and then she's gonna be uncomfortable when, you know, when she wakes up. And, and my daughter did great. I think my wife needs a nap. It was, it was, it was, it was a big thing. But, but just the experience and, and how comfortable my daughter was going in, that really mattered a lot to, to my wife. And then also the way that my daughter recovered from the procedure and how comfortable she seemed coming out. Like those things, obviously they were important to my daughter. They were obviously. And they're important to me, don't get me wrong. But, but they're, but they were really important. But I'm watching my wife, you know, go, go through this and sort of, and handle this in the way that she's feeling. And I think that there's a lot of parallels there around controlling stress and anxiety in our pets and our patients and bringing people in. And so, you know, I am really happy to see the rise of sort of pre visit anti anxiety medications. And you know, the go tos I see are gabapentin and Trazodone and I, that's what I keep sort of seeing again and again. But Chris, I've got this idea that I'm sure that we're, that we're just scratching the surface of what's possible in terms of pre visit medications and anxiety control and stress management and things like that. And so that's really what I, what I want to talk to you about today. I'm just going to stop there. Am I right on this? Is there more nuance than we tend to see in practice or are you like, nope, just Trazodone.

[C]

It is there definitely is. And I think back to the early days when, you know, we had Ace Promising and a Benzo and that was pretty much it before Trazodone was sort of unleashed in our world and kind of took over all of our, all of our prescribing patterns. But you know, we have gabapentin, we have trazodone. They're both great drugs for a lot of dogs. I love them because neither of them has a significant cardiovascular effect. And so from a safety standpoint, especially if you've not done a comprehensive, comprehensive evaluation yet, I love being able to onboard those to an individual patient. And yet if they're not hitting the nail on the head for that particular patient, we have other options. We've got clonidine and guanfacine and tacitimidine and we've got propranolol and we've got half a dozen benzos and we've got oral transmucosal dexmedetomidine options that can allow us to truly sedate patients without having to poke them with a needle. Like we have all of these options available to us. And so I love that we're seeing a rise of the use of those pre visit pharmaceuticals. And also if what we're doing isn't working, by all means we have options rather than just saying, well, we can give more or we can give less, but we can absolutely give differently. And being curious about that is super helpful.

[B]

Great. So. So let's start to dig into that a little bit. It sounds like you're kind of on board with gabapentin and trazodone kind of being first line. Let's, let's try this first. It sounds like it's probably the things that people are most likely to have on their shelves. Chris, when do you start to look at other options? So let me just ask. Let's start at the beginning. Walk me through that. Let's say that we start with this. At what point do you start to adjust doses? Are there flags for you that say we need to go up or down? And then what are the sort of the switch lights that make you think maybe this isn't the right medication for us?

[C]

Yeah. So first things first, when we're starting out at a mid range or even maybe conservative dosing, I'm first looking for tolerance. Number one. There are some patients, I will tell you my bias here. I think a lot of my patients who are herding breed dogs with anxiety issues. I think a lot of them don't like how they feel on some of these medications. And there's often the perception that they could actually be kind of fighting the effect a little bit. So first things first, I'm looking for tolerance. Does it look like it's tolerated? And obviously looking at those signs as well as any gastrointestinal upset or Excessive sedation, of course. Course, if it's tolerated, then we try out what we think is an appropriate dose for that particular animal. Maybe it's a happy visit or a trial run, if you will, just to see what magnitude of effect we're getting. If there's no effect whatsoever but it's tolerated, by all means, I'll try a dose increase to see if more is more helpful than less. And if we're getting an incremental improvement in whatever the parameters are for that particular animal that we think is kind of their struggle point, then by all means, I'm willing to do a couple of trials, even doing some at home trials to kind of find the edge of sedation. The tipping point for me though, in the, you know, kind of the, oops, let's maybe go in another direction is if I start to see excessive sedation without anxiety reduction, that, that's a huge piece for me, that if I'm seeing sedation but I can still get a read on that animal and the emotional response is still there, I worry that we are now masking from a motor control standpoint, but I'm not actually making that animal feel better. And in that case, I'm going to say, wait a minute, is there a different mechanism that might be more specific to this particular animal's needs that will allow us to get through them more, more effectively?

[B]

Okay, I like that that, that speaks to me. So I definitely understand that because we've definitely had the experience of like, this might as well be acepromazine. This dog is really, really tired and they're having a pan attack and they're exhausted at the same time. And that's kind of what we achieved. The uncharted veterinary conference Medical Director Summit is coming up. It is happening on September 15, 2026. It is a virtual event. It is meant to minimize your time off the floor if you're a medical director and maximize your skill growth and your ability to implement what you're learning into your practices. I love to be a supporter of medical directors. I've gotten to work with medical directors all over the world and I am thrilled to be hosting this year's Medical Director Summit. Registration is Open right now, $199 to register and you can use the code medical to get 20% off on your registration. That is medical as your promo code. I would love to see you there. I love this event. That's September 15th. Medical directors head over to unchartedvet.com to get signed up today. Okay. I'm going to be honest like, my. My game gets really weak outside of these. It gets. It gets really weak outside of gabapentin and trazodone here. They're just the ones that I've been most comfortable with. What does changing medications look like, Chris? So when you say, hey, you know, we're trying these and I'm not getting the response I want, I don't think that we're actually reducing anxiety here. What. What factors into your choice to change medications and what are you most likely to reach for?

[C]

Yeah, so it kind of depends on how that patient shows up. And what I mean by that is if I have a patient who's reasonably comfortable. But when we start to work with them, they really start to wind up. And once they hit that heightened arousal level and we're seeing, you know, tachycardia or tachypnea, and, you know, they're just really, really activated and they can't come back down. I love Alpha 2s for those patients as a next choice. And the one that we use most commonly is clonidine. You know, that's, you know, Again, it's the Alpha 2 category. It's something that can be administered 90 to 120 minutes before the stress starts, and it helps to blunt that norepinephrine surge that happens during those periods of sympathetic nervous system activation. So I love it. As an alternative, if that sort of overall baseline calming effect of gabapentin and trazodone just wasn't. Wasn't ticking the box for us.

[B]

Do you. Do you layer that in with gabapentin and trazodone? You said, you know, it kind of seems like it has a specific. This specific value in the wind up. Are we making cocktails now or are we just switching to. Exactly. Are we just switching to clonidine just straight away?

[C]

So it depends. Again, as with everything in a behavior world, it depends. I don't have any problem using them together. With that being said, I'm usually trialing them as independent options. More from the standpoint of if one drug will do it, I don't need to make a cocktail, so I can. I can do that. With that being said, if an owner tells me, oh, it felt like gabapentin did this, and it felt like trazodone did this and clonidine is doing this, and all three things are relevant, then there are those animals that I may end up using a cocktail to say, what's the. What's the right balance between these influences? Yeah, to give me what I'm looking for and in some cases it's more sedation. In some cases it's more arousal reduction. In other cases, you know, it may be something completely and totally different.

[B]

So talk to me a little bit about kind of how you get this right when you're not there. This is happening at the client's house and you're seeing sort of the fallout of this, you know, two hours later and things like. And again, also, I suspect that you're not having a dry run the day they're coming in to the clinic. So walk me through, like, what does that protocol look like? How do you get them to start to try working with this at home? What feedback do they give to you to help you understand where they are and make adjustments? Walk me through that part.

[C]

It's such an important part of this process. And I think at the heart of this is the fact that clinics are busy. You know, we don't have the time. And as much as we would love to say no, no, no, by all means, let's do 17 trial runs, stop by, we'll do a mock exam. Like, nobody got time for that in the real world, even as much as we want to. And so I really think it's important when I'm, when I'm having that conversation first and foremost with my client, I'm looking at the dog or the cat in front of me saying, listen, when I see signs of stress in your animal, this is what I'm seeing. Do you see that with me? And I'm kind of looking shoulder to shoulder with the client to make sure that they're getting the same observational window that I have so that they're able to see those same patterns and they're able to report back on whether those things got better, worse, or no different. So that's part of it. What I also try to do in the at home experience is identify one or two scenarios that the client can set up on their own without having to involve the clinic to say, you know, maybe this is a scenario where the animal gets really stressed in a similar way when visitors come over to the house. Or maybe this is a dog that when we take them for a ride in the car, we see a similar level of stress or anxiety. Or maybe it's a dog that we walk them in a novel environment, whatever it happens to be, I try to identify that and say, okay, once we've confirmed tolerance with this medication, could you actually do a trial run in this other scenario to try to get the sense of, you know, maybe, maybe it's actually going to be different and something would work differently in those. Those various scenarios. But if we do get an improvement in a comparable situation, it gives me a lot more confidence to be able to do some dose adjustments or additional trials to then say, cool, I think we've got a cocktail or an individual drug that has been shown to be efficacious. Now it's time to do our trial run in the clinic. Let's give it a try. Knowing that we're going to do our best to set that animal and everybody on the team up for success. And I'm always leaving myself that rip cord, that if we thought that it's just not going well and we need to make a different, different course of action, of course we will do that, but I don't want to have to do that more times than is absolutely necessary.

[B]

Yeah. So if I've got a highly anxious dog and we can do a dog and a cat. Both a dog and a cat. So I've got a patient coming in and they are highly anxious. They. They vocalize, they seem very stressed. We're going to work with the pet owner. We're going to kind of come up with a protocol that works well for this pet. Chris, for dogs and cats, what does a well, sort of managed patient look like coming in the door? What. How is there a level of sedation that you want? Is there too much. I'm assuming there's too much sedation. Right. If they're a limp noodle coming in, that's not good. But. But, like, what is. What does success look like for you when you're using these medications?

[C]

It really depends on what needs to happen within that assessment or within that appointment.

[B]

Okay.

[C]

You know, if I've got a dog that is coming in for a lameness evaluation, I really need to be mindful of how much sedation I'm putting on ahead of time. Because if they are literally that limp noodle, unless the owner's got really good video footage, I'm going to be flying blind. So, you know, that depends versus if I had a dog, where we're saying, you know what, we've done the exam, we, we need blood work. I may be tolerating or even looking for a greater level of sedation for that patient because that may facilitate a calmer state during venipuncture or other procedures. So I want, as a clinician, I'm really thinking, what do I need? What's my goal? Is it anxiolytic effects? Is it sedation? Is it both? How do I prioritize that and that really allows me to customize what I'm doing to achieve that goal.

[B]

Yeah. How often do you go beyond the alpha 2 agonists? Like how, how often do you get down to your fourth level medication, things like that? Is that, is that common?

[C]

For my patient population it's pretty common. But I think that's partially because I would say almost every patient that comes through my door has already been on gabapentin, has already been on trazodone. They may have already trialed clonidine as well. I've got an amazing group of practitioners, especially here locally in Portland. They're really well educated when it comes to this. You know, we've had boarded behaviorists in Portland for 30 years now. So I mean I get spoiled with my practitioners. They're brilliant. So I'm, I would say yeah, I'm looking at fourth and fifth line treatments pretty commonly when I'm doing vet to vet calls with practitioners around the country where perhaps that access has been a little bit more limited. I would say we're more often in the, the first one, two, three and we're doing dose optimizations and we're saying, hey, let's, let's try some of these things together. Or maybe we're going down the chill protocol route and we're doing a little bit of gabapentin with a, you know, touch of Ace promising and some melatonin thrown in there. We can look at all of these protocols to see what, what's working best.

[B]

Chris, I saw a patient yesterday who has, is an anxious dog and has a bad habit of trying to bite the grandkids. And so we, we talked about some, some, you know, event specific anti anxiety medications for this dog. But, but I wanted to go ahead and caution the owner and you know, when I was, I was trained, you know, with these anti anxiety medicines, you have to be a little bit careful about reducing inhibition and we might even increase the chances of, of events like biting or things like that. Is that still sort of the advice that, that you, that you give and how, how do you talk to pet owners about that? How much, how much, how much emphasis I guess do you put on that possibility?

[C]

Yeah, I think it's a very real possibility, especially with certain categories of medications and especially, you know, no matter what we're trying, whether it's gabapentin, trazodone, a benzodiazepine, an alpha 2, we never know exactly what effect that's going to have on a particular animal in a given set of circumstances until we're there. So for me, anytime I'm doing those trials, I do want to make sure that, to the best of my ability, I'm working with caregivers who are able to spot some of the early warning signs where we've talked about, you know, safety tools like baby gates and leashes and perhaps basket muzzles or maintaining distance. Maybe this is the dog that we, as one of my clients said yesterday, put them up for safekeeping, and we put them in the bedroom with the door closed, and it's locked. Like, maybe that's what we need to do to be able to manage that. But I want to make sure that we've got safety parameters and we can, you know, reliably evaluate is this better, worse, or no different versus saying, let's just meet at the door and it's a free for all, and, yeah, we'll find out on the backside. So with that being said, it goes, you know, it goes across the board. And also, behavioral disinhibition is something that is specifically tied to benzodiazepines.

[B]

Okay.

[C]

Everything else can have adverse effects. It could increase baseline irritability. It could change thresholds for reaction, whether that's touch sensitivity, whether it's sensory perceptions in other ways. So there are all of these different impacts that could be there. But specifically, disinhibition is not fluoxetine. It's not trazodone. It's not gabapentin. It's our alprazolam, diazepam, clonazepam, lorazepam. All of the PAMs basically is. Is where we're seeing that specific behavioral disinhibition, not unlike what you or I might experience. If we had a couple of literal cocktails and we have some alcohol on board, that's essentially that same GABA specific inhibition that goes away, and the filter gets a little less filtered.

[B]

Yeah, right. That's when karaoke happens. Yeah, I got it. Okay. I get it. I know how that goes. All right. So. Yeah. All right. So this is really helpful. Are there tools that you don't see in the GP toolbox that you think should be there? So we talked about clonidine. A bit beyond that. Are there other things that you would like to see more in the GP practices that you don't see there or you don't see being used?

[C]

I. I think that as we've gotten really comfortable with medications like gabapentin and trazodone, I see fewer and fewer patients coming in having trialed benzos, and I Think there's a lot of good reasons for that. You know, they're controlled medications. We do have risks of disinhibition. I think there's valid concerns for that. And also, when we're dealing with panic, when we're dealing with intense situational emotional responses, benzos are often fabulous when it comes to actually doing. They do a much better job than gabapentin or trazodone tend to do. I urge everybody. Maybe you're not going to use benzos as your first line. I certainly don't. But don't forget that they're there as a potential option. And, you know, again, a cocktail may be really well indicated here that a little bit of calming baseline from trazodone or gabapentin with a touch of alprazolam may be just exactly that synergistic effect that a patient needs. So I think benzos are kind of a.

[B]

Don't.

[C]

Don't forget that they're there.

[B]

Gotcha. All right. Is there any words of caution you would give here as we kind of wrap up? Are there mistakes that you see people. People make, or you say, like, I see. I see you trying, but. But maybe. Maybe this. Maybe this was the wrong way to try anything. I should look out.

[C]

Yeah, I think there's something that I'm seeing much more frequently now that gives me a little bit of a moment of caution. And that is. It's ace promising. Now, I've been around long enough that I've seen multiple evolutions. Back in the day, ace promising was all we had.

[B]

Right.

[C]

We're like, let's try and see what happens. And then we're like, wait a minute. That's kind of like a chemical straightjack. And I don't know that that's the greatest thing to do. And then it was like, ace promising is the devil, and we should never use it. It's a terrible drug. We should. I don't think either of those two are completely accurate.

[B]

Right.

[C]

And as I'm seeing the chill protocol getting more and more visibility and traction in the community, I'm getting more veterinarians now, especially younger veterinarians who haven't perhaps been around for all of those evolutions across time. And I'm getting these questions like, hey, when I bumped the ACE dose just a little bit in the chill protocol, everything felt like it got a whole lot easier. Can I just do that? And so I'm really having to have those conversations more frequently now than I needed to three or five years ago to say yes. And Be really mindful that for the vast majority of patients, ACE Promising doesn't have any significant anxiolytic effects. It is going to do a much better job than some of our other medications at controlling motor patterns. And if we are controlling anxiety and mitigating that effect in other ways, it's not inappropriate to use ace. But really be cautious with ACE and with some of our other sedative medications like trazodone or perhaps even gabapentin, that we're not masking, that we're not just blunting everything, but still having an animal who may be still sensitizing from an emotional experience, and perhaps we could be making the problem worse, even though it looks better in the moment. So just be cautious.

[B]

Yeah, Yeah, I like. I like that. That's. That's good advice. Run me through the chill protocol as you kind of use it and teach it.

[C]

So the classic chill protocol, as I learned it, is gabapentin, ACE fromazine, and melatonin. It's a pretty benign protocol for a lot of patients. Again, there's that ace piece in there, which I do think works synergistically with the other options. And so that's the classic chill protocol. What I'm seeing now, and this isn't a problem, it's just something that I have to tease out, is that when. Now when people say I'm using the chill protocol, I kind of have to go. What do you mean by that? Because that's.

[B]

Well, that's why I asked. It gets sort of thrown around a lot, and I just want to know what the ChrisBuckle version of the chill protocol. Yeah.

[C]

I will say that I don't even have the version that I use reliably. It's sort of like, okay, what am I getting? What am I trying to piece together? Together? I will say that some people use that chill protocol label in a way that includes those baseline meds, but they're also throwing trazodone in, or maybe they dropped the ace out, or maybe they forgot to give the melatonin. And so there's often different versions. And I think it's. Now it's a kind of a label that's being thrown around as a. It's a cocktail to give before visits.

[B]

Oh, yeah. The people get creative.

[C]

Right?

[B]

Like, I've already run into the Carolina chill protocol. I'm like, that's not a thing. That's not a thing. You just made that. Like, you guys made that up. And they just smile like, yep, yep.

[C]

But it works for us. And That's.

[B]

But it's another thing.

[C]

That's the lovely thing about it is, like, if it's working for you and you're mindful of what you're using and why, great. Call it blueberry for all I care.

[B]

I don't.

[C]

I don't.

[B]

A blueberry chill I could see.

[C]

There we go.

[B]

Right?

[C]

Lots of options.

[B]

There's people who are getting way too excited about this. Yeah, okay. No, I. I like where Your head's at. Dr. Chris Packle. Where can people find you online? Where they. Where can they keep up with you?

[C]

So they can find me in a lot of different places. They can track what we're doing at the Animal Behavior Clinic, either on our website, animalbehaviorclinic.net or through Facebook and Instagram for the practice. You can also check me [e-mail] where all podcasts and media appearances get archived for viewing pleasure. You'll find this one there as soon as it gets launched and it's ready to be uploaded.

[B]

Thanks so much for being here, guys. Thanks for tuning in, everybody. Take care of yourselves, gang. I'll talk to you later. And that's what I got, guys. Thanks for being here. Thanks to Dr. Chris Spockel again for being here and sharing his wisdom. Gang, I hope you enjoyed it. I hope you got something out of it. If you did, please share this episode far and wide. Let's get the word out. This is a great little episode for people as a refresher on stress management for patients coming into the clinic. This is. This is a great one for pet owners to even have and listen to and have good questions for their veterinarian. So anyway, guys, I hope you help me spread the word, like, share, subscribe, do all the positive things if you enjoyed the podcast and I hope to talk to you next week. Take care, gang. I'll talk to you later on. Bye. Are you an early career veterinarian, a new graduate, or a vet Student? This is Dr. Andy Rourke and guys, I wanted to put something together just for you. I've got a brand new, totally free newsletter. It only comes out once a quarter. It's definitely not meant to fill up your inbox, but I wanted to go ahead and just consolidate all of the information that me and the Uncharted Veterinary Conference are doing for early career veterinarians into one place. I'm going to be writing especially for this newsletter. We're going to have podcast episodes that are in here specifically for early career vets, new grads, vet students. We're going to have training resources, we're going to have certificate courses, we're going to have special discount codes that are just for you guys. And so if you're in this boat and you want some content, that's going to help you have an easier career, enjoy your time in practice, be more effective and happier as a veterinarian. Guys, this is for you. It's totally free. I'm happy to give it to you. Head over to Dr. Andy Roark.comcareervets. that's Drandy Rourke.comcareervets or you can find the link in the show notes. I hope this is really valuable for you. I hope that you'll check it out.