Sterrett 1 Natalie Sterrett Marc Bousquet English 212-W 22 December 2014 Literature Review Performance horses often receive a variety of medications to allow them to compete comfortably and reduce pain or inflammation. The United States Equestrian Federation prohibits or regulates the use of several of these medications at horse shows, but many, including non-steroidal anti-inflammatories, are allowed in certain doses and used by most trainers before competition. There are always questions regarding the ethics of medicating horses, especially when they receive a cocktail of illegal drugs. Much of the research thus far has focused on the effects of commonly used drugs, hoping to clarify what types and quantities of medications are acceptable. One study examines the effects of Bute, Banamine, and ketoprofen in horses. It reveals that out of these NSAIDs, Bute has the most severe effects on the gastrointestinal tract (MacAllister, Morgan, Borne, and Pollet). Another study examines the simultaneous use of Bute and Banamine, finding that the combination of the two does not prove more effective than either drug used alone (Foreman and Ruemmler). Another review in in the Journal of Veterinary Pharmacology and Therapeutics reveals that though Bute is unlikely to cover up a serious injury, its use can still be controversial in many cases. It not only can lead to further injury, but it can also interfere with a pre-purchase exam or lead to gastric problems (Soma, Sterrett 2 Uboh, and Maylin). This type of research leads to literature such as an article in DVM newsmagazine, highlighting a recent USEF rule change that limits horses to one NSAID while at competition. Due to the danger of stacking NSAIDs, USEF modified its drug rules to prohibit trainers from using multiple non-steroidal antiinflammatories. There has also been acknowledgement of the potential abuse of medications in show horses. For example, an editorial in the Equine Veterinary Education Journal acknowledges that some trainers use excessive amounts of medications at shows and at home, whether to mask lameness or to make a horse easier to ride. The authors argue that the veterinarian should always be involved in medical decisions (White and Palmer). Much of the social research relates to the excessive use of medications in racehorses. One article finds that many racehorses are on NSAIDs daily (Kane). Another article investigates the role of the media in agenda setting. The authors argue that the New York Times coverage of medicating racehorses led to the public's exposure to the issue. It led to more media outlets covering the issue, and a greater awareness in the public (Denham). Finally, a 2012 article in the New York Times brings attention to the social issues present at USEF rated horse shows. Walt Bogdanich explains the tragic death of a show pony that happened to be on a long list of medications. However, there have been no further articles on the subject. Though there is scientific research regarding the use of medications in show horses, there is a lack of social research on the subject. It is clear how the drugs affect the horses, and which drugs are most commonly used, but there has not been focus on the inner workings of the industry as there has been in the racing industry. Sterrett 3 My research will focus on this part of the problem. How do trainers or owners decide what medications to give their horses, and what factors contribute to which medications? Do trainers and owners decide this together? These types of questions have been given little attention, but could reveal much about where the problem begins. Sterrett 4 Perfect Prep: The Use of Medication in Performance Horses Performance horses are used for a variety of disciplines, including dressage, reining, and show jumping. My interest surrounds the hunters, jumpers, and equitation horses competing on the USEF show circuit. Many of these horses show several times a month. They work hard, and they are treated like athletes. As athletes, they need a certain amount of maintenance to stay healthy. My research will investigate how show horses are maintained and prepped for competition. It will further examine the decisions and the decision-making process regarding horse show medications. Show horses' "prep" usually includes a list of nightly medications received at horse shows. The purpose of these drugs is most often to prevent pain or inflammation, or sometimes to make a horse quieter. USEF drug rules restrict and limit the use of certain medications, and they require random drug tests at every horse show. Although most trainers medicate their horses within the rules, there are those who attempt to work around them. In addition, it is unfortunately very easy to overuse several of the most commonly used medications. Today’s show horses face two common problems: they are naturally sore or injured from overwork, or they are unsuitable for their rider or for their job. The first group of horses is given drugs, most commonly non-steroidal antiinflammatories, in order to reduce pain or inflammation. Drugs such as Bute and Banamine are designed to work much like Advil does for humans. They are unlikely to cover up a severe injury, but they alleviate soreness and inflammation. However, often times, overuse of these medications can cover up a developing injury that Sterrett 5 requires rest and rehabilitation. This not only can further injure the horse, or cause gastric ulcers when several drugs are combined, but it also cheats the USEF rules that a horse must be sound in order to compete. Horses are also often given more targeted pain relievers, including muscle relaxants such as Robaxin. These types of drugs are useful in treating horses with back problems, but they can also be used to cover up injuries such as muscle strains. They are more commonly used in older horses, which often receive drugs such as Robaxin on top of a non-steroidal anti-inflammatory. Though it sounds like a lot, this kind of treatment is allowed under USEF rules. Trainers who over-medicate their horses are consistently using multiple NSAIDs plus combinations of other drugs that are prohibited under USEF rules. The horses who are deemed “too spooky” or “too fresh” or “too hard to ride” are often given drugs that function like sedatives, essentially helping them to perform better while making it easier for their riders. Though it’s more common in the hunter and equitation rings, where horses and riders are judged on their appearance and effortlessness, sedative type drugs can also be used in the jumpers when a horse is too much for its rider. Drugs such as Dexamethasone, a corticosteroid used to treat severe inflammation or allergic reactions, tend to make a horse quieter as a side effect. USEF rules allow the use of Dex for its intended purposes, and although they do not sanction its use as a sedative, it’s impossible to determine whether trainers are using it for the right reasons. Many riders and trainers argue that its use is unfair and unethical. Plus, many agree that it’s bad training. A horse will not get better if the rider does not address the problem. Sterrett 6 My research questioned trainers and riders competing at USEF rated horse shows regarding their horse show medications. Trainers and clients were given separate surveys of twelve questions each, in order to assess the ways in which different factors contribute to decisions regarding their horses' care. Questions were all multiple choice so as to avoid interpretation of different answers. I provided my own social analysis, as well as the statistical results. Though I believe my research has given me a strong basis to make some of these assumptions, the data is left up to different interpretations. Trainers were asked the following twelve questions with results from 82 respondents: 1. Do any of your horses show more than twice a month on average? (Yes or no) 2. Do all of your horses receive daily medications at horse shows? (Yes or no) 3. Do all of your horses receive the same medications? (Yes or no) 4. Do you frequently change a horse's medication? (Yes or no) 5. Do any of your horses receive more than one medication? (excluding those to prevent gastric ulcers) (Yes or no) 6. Do any of your horses receive more than one non-steroidal anti-inflammatory? (Yes or no) 7. Do any of your horses receive medications other than non-steroidal antiinflammatories? (excluding those to prevent gastric ulcers) (Yes or no) 8. Is your veterinarian involved in the medication plan for each horse? (Yes or no) 9. Is the owner or rider of the horse involved in the medication plan? (Yes or no) Sterrett 7 10. How willing would you be to discuss a horse's medication plan with its owner or rider? (Scale of 1 to 5, 1 being unwilling) 11. How willing would you be to comply with a client's wishes to alter their horse's medication? (Scale of 1 to 5, 1 being unwilling) 12. On average, how often do you receive a question from a client about their horse's medication? (Almost never, every few months, once a month, or once a week) From the survey results, I determined that I reached a population of trainers who have horses showing frequently and under a huge amount of stress. 62% have horses showing more than twice a month, with a 95% confidence interval of 52% to 73%. This type of schedule results in more weeks of showing than weeks off, which is obviously going to put stress on a horse. A horse on this type of schedule is undoubtedly going to need maintenance and show prep. 50% of trainers (confidence interval from 39% to 61%) responded saying that all of their horses receive daily medications at horse shows, while only 4%, with a confidence interval from 0% to 8%, give all their horses the same medications. This points to an individualized treatment plan. Only 16% of trainers (confidence interval from 8% to 24%) said that they frequently change a horse's medication. This could be for one of two reasons: either there is a lack of follow-up care (trainers do not frequently assess whether a horse's needs have changed) or most horses do not often need an increase (or decrease) in Sterrett 8 medication. Their maintenance is working. My guess is that it could probably be a combination of the two, but more so the second. Results also indicated that many trainers use multiple medications. 72% of trainers (confidence interval from 62% to 82%) have horses receiving more than one medication (excluding omeprazole or the like) and 83% (confidence interval from 75 to 91%) have horses receiving medications other than a NSAID. The most interesting result is the 16% of trainers (confidence interval from 8% to 24%) who reported having horses receiving more than one non-steroidal anti-inflammatory. USEF banned the use of multiple NSAIDs several years ago. I’m unsure whether there was a misinterpretation of the question, or whether a good proportion of trainers are disregarding or unaware of the rules. I believe that further research could clarify this. The survey results also suggest that veterinarians and clients are fairly involved in horse show medications. 59% of trainers (confidence interval from 48% to 69%) involve their veterinarian in the horses' medication plans. 71% of trainers, with a confidence interval from 61% to 81%, involve their clients in the horses’ medication plans. In response to question ten, no trainers said they were unwilling to discuss a horse's medication with its owner, while 65% said they were extremely willing. This leaves some hesitation (even a slight hesitation) on the trainer's part. I believe that even though 65% is a good proportion, the 35% should still be investigated. In order to ensure that horse owners are involved in their horse's care, it's important to know why trainers would hesitate in consulting them. Sterrett 9 In response to question eleven, no trainers were completely unwilling to comply with a client's wishes to alter medication, while 21% were extremely willing. The value of 4 on this scale had the highest proportion, where 33% of trainers felt they were comfortable. This distribution seems to agree with the rest of my survey. Not all owners are, or want, to be involved, so a decision coming from them might not be as knowledgeable, and I believe that this is where hesitation comes from. However, I think owners and trainers need to be knowledgeable and educated enough to make the decision together, and something needs to be done to bridge the slight gap that exists. In response to question twelve, 50% of trainers reported almost never receiving a question from a client about a horse's medication. This seems like a fairly high proportion and could either be because clients do not wish to be involved in their horse's medication plan, or because clients never doubt or question their trainer’s judgment, and they are always aware of their horse's prep. I believe that there needs to be a push toward educating owners and riders, and encouraging them to become involved in their horse's care. Conditional proportions were also evaluated. Of the 51 trainers who have horses showing more than twice a month, 39 of them, or 76% have horses receiving more than one medication and 80% reported having horses who receive medications other than a non-steroidal anti-inflammatory. This indicates that though there is a correlation between the statistics, there are still a significant number of trainers giving more than one medication that do not show more than twice a month. Sterrett 10 Of the 48 trainers who involve their veterinarians in their horses’ medication plans, 35 (73%) have horses receiving more than one medication. I note this because I would like to point out that in most cases, more medication could be necessary. Conditional proportions also revealed that of the trainers who are less willing to discuss medication with clients, a majority do not involve owners in the horse’s medication plan. In addition, of the trainers who do not involve clients in their horse's medication plan, a majority have horses receiving more than one medication. I think this may indicate that owners and riders are sometimes left out of the decision-making process, but they do play an important role in their horse's care, and they will make a difference if they ever do feel the need to voice their opinions. Clients were asked 12 very similar questions with the following results from 226 respondents: 1. Does your horse show more than twice a month on average? (Yes or no) 2. Does your horse receive daily medications at horse shows? (Yes, no, or I’m not sure) 3. Do you know what medications your horse receives? (Yes or no) 4. Does your horse's medication frequently change from show to show? (Yes, no, or I’m not sure) 5. Does your horse receive more than one medication? (excluding those to prevent gastric ulcers) (Yes, no, or I’m not sure) Sterrett 11 6. Does your horse receive more than one non-steroidal anti-inflammatory? (Yes, no, or I’m not sure) 7. Does your horse receive medications other than a non-steroidal antiinflammatory? (excluding those to prevent gastric ulcers) (Yes, no, or I’m not sure) 8. Is your veterinarian involved in the medication plan for your horse? (Yes, no, or I’m not sure) 9. Are you involved in your horse's medication plan? (Yes or no) 10. Do you want to be involved in your horse's medication plan? (Yes or no) 11. Who makes the ultimate decision regarding your horse's medication? (Me, my trainer, or my veterinarian) 12. How comfortable would you feel discussing your horse's medication with your trainer? (Scale of 1 to 5, 1 being uncomfortable) Fewer clients than trainers had horses showing more than twice a month. Only 30% responded “Yes,” with a confidence interval from 24% to 36%. However, this still indicates that many clients have horses on extremely strenuous schedules. 58%, with a confidence interval from 51% to 64%, give their horses daily medications at horse shows. Only 2% of clients said that they did not know whether their horse receives daily medications. In fact, 94%, with a confidence interval from 91% to 97%, indicated that they knew exactly what medications their horse receives. It seems that owners are relatively knowledgeable in regard to show meds. 5% of clients said that their horses' medications frequently change from show to show (confidence interval from 2% to 8%). As with the trainer responses, Sterrett 12 this either indicates a lack of individualized treatment, or horses who are maintained well and do not need progressively more medications. Another 5% of clients indicated they were unsure of whether their horses' medications frequently change. Client results also pointed to horses who receive a decent amount of show prep, but not as much as trainers indicated. 31% of clients (confidence interval from 25% to 37%) have a horse who receives more than one medication, excluding those such as omeprazole, while 4% were unsure. Using one medication as the average, or what it seems that most people would see as the go to prep for any horse, it seems that less than 50% receive more than this norm. Only 4%, with a confidence interval from 1% to 6%, have a horse receiving more than one NSAID, while 36% of client horses (confidence interval from 30% to 42%) receive a medication other than a non-steroidal anti-inflammatory (excluding those to prevent gastric ulcers). 5% of clients were unsure, which is consistent with the analysis that the vast majority of owners do have some idea of their horses' care. Survey results also indicated that a good amount of horse owners involve the veterinarian in the medication plan. 66% of clients (confidence interval from 59% to 72%) indicated that their veterinarian is involved, while only 7% were unsure. My analysis also suggests that clients are very much involved in their horses’ medication plans. 90% of clients (confidence interval from 86% to 94%) responded “Yes” to this question. This, again, is a surprisingly high statistic relative to the most popular conceptions of show horse owners. However, 94% of clients (confidence interval from 91% to 97%) want to be involved in their horse's medication plan. Sterrett 13 This statistic is very slightly higher than the proportion who are involved, which indicates that it's possible there are clients who want to be involved, but are unable. This would point to clients being uncomfortable talking to their trainers, or trainers who are unwilling to involve their clients. In response to question eleven, 71% of clients believe that they are the ultimate decision maker, 19% believe that their trainer is, and 10% believe that their veterinarian is. A good proportion of clients are transferring their decisionmaking role to the trainer. The most logical explanation is that they do not feel comfortable making the final decision, and they feel the trainer is more qualified. In response to question twelve, 68% of clients feel very comfortable (value of 5) talking to their trainers about medication, while 32% indicated a 4 or less. Only 1% felt uncomfortable discussing medication with their trainer. I think that it's important to discover why some owners may not feel entirely comfortable, and whether that deters them from voicing their opinion and participating in the decision-making process. Conditional proportions regarding client responses also had some interesting results. It seems that a large proportion of horses showing more than twice a month do not receive daily medications. Of the 67 clients who indicated their horses show more than twice a month, only 57% said their horses receive show meds. It would be interesting to get further information from these types of clients because a horse that doesn't need any prep is the kind of horse everyone wants. It's an easy keeper. There also does not seem to be a strong correlation between show schedule and amount or type of meds. Only 24 of the same 67 clients, or 36%, give their Sterrett 14 horses more than one medication and only 45% indicated that their horse receives a medication other than a non-steroidal anti-inflammatory. In addition, of the 81 clients whose horses receive a medication other than a NSAID, 62, or 77%, said their horses receive more than one medication. I believe that this is entirely expected, as most people think of a NSAID as standard, and anything else is most likely given on top of the non-steroidal anti-inflammatory. Of course, this is not always the case, but it confirms my hypothesis that this is what happens quite frequently. There was a small proportion of clients who indicated they want to be, but are not, involved in their horse’s medication plan. Of the 212 respondents who said that they want to be involved in their horse's medication plan, 5% admitted that they are not. This is a very small proportion, but I believe that it should, by definition of what it means to be a horse owner, be zero. I think it's important to discover why some owners may not be able to participate in the decision making process even though they want and are prepared to do so. However, relatively few of the clients who felt less comfortable (value of 1, 2, or 3) discussing meds with their trainer indicated that they are not involved in their horse’s medication plan. Only 23% indicated that they are not involved. This suggests that though clients may feel uncomfortable, it does not always deter them from being involved and making decisions. What is more surprising than some of the individual survey results is the discrepancy when comparing trainer and client responses. Trainers and clients Sterrett 15 seem to have vastly different horse show experiences just based off of my initial run through of the data. Some of this can be explained with a more detailed analysis. The first issue is the huge difference in response form trainers and clients to question one. While 52% to 73% of trainers have horses showing more than twice a month, only 24% to 36% of client horses show more than twice a month. I am fairly confident that I reached the same population: a group of trainers and owner/riders that frequently attend USEF rated horse shows. My surveys were directed specifically at this group, and they were shared on the Chronicle of the Horse forums, where they could most easily reach this group of people. I claim that I have, in fact, reached exactly the same population with accurate responses, but the clients are distributed among trainers so that a higher proportion can respond “Yes.” Trainers are asked if they have at least one horse showing more than twice a month, while clients are asked if their personal horse shows more than twice a month. The same distribution occurs in questions five and seven. While trainers are asked if they have "at least one," clients are asked about their one specific horse. For each question, the proportion of clients responding "Yes" is significantly lower than trainers responding "Yes." A smaller proportion of clients have horses receiving more than one medication or something other than a NSAID, while more trainers have at least one horse on this type of medication plan. Another difference in the survey results is the response to question nine. Trainers were asked if owners are involved in the medication plans for their horses, and I generated a confidence interval from 61% to 81%. Clients were asked if they are involved in their horse's medication plan, and I generated a confidence interval Sterrett 16 from 86% to 94%. Unfortunately, I don't think that it's possible to determine if this difference is significant without doing further research. It is entirely possible that the high proportion of involved clients could be distributed to a smaller portion of trainers who involve their clients. However, it is also possible that horses are distributed more evenly, and trainers and clients aren't completely honest with themselves, indicating that they are more or less involved than they really are. I believe that further research in this area could clarify the results. In summary, the majority of owners are somewhat involved, or at least aware, of their horse’s medications. Though not all clients feel entirely comfortable discussing the topic with their trainer, and not all trainers with their clients, it seems that most have some level of communication. There are high proportions of trainers who use multiple and targeted medications, but it seems to be individualized to the horse. I believe that further research should address the correlation of trainer/owner communication and involvement in the horse’s care, the discrepancy in trainer and owner responses to involvement, and the effect that this result has on NSAID use. Sterrett 17 Works Cited Bogdanich, Walt. "Sudden Death of Show Pony Clouds Image of Elite Pursuit." The New York Times. The New York Times, 27 Dec. 2012. Web. 19 Dec. 2014. Denham, Bryan E. "Intermedia Attribute Agenda Setting in the New York Times: The Case of Animal Abuse in U.S. Horse Racing." Journalism & Mass Communication Quarterly 17-37 91.1 (2014): n. pag. Web. Foreman, J. H., and R. Ruemmler. "Phenylbutazone and Flunixin Meglumine Used Singly or in Combination in Experimental Lameness in Horses." Equine Veterinary Journal 43 (2011): 12-17. Web. Kane, Ed. "Panel Questions Drugs in Horse Racing." DVM Newsmagazine (n.d.): n. pag. Web. MacAllister, CG, SJ Morgan, AT Borne, and RA Pollet. "Comparison of Adverse Effects of Phenylbutazone, Flunixin Meglumine, and Ketoprofen in Horses." Journal of the American Veterinary Medical Association 71-7 202.1 (1993): n. pag. Web. Soma, L. R., C. E. Uboh, and G. M. Maylin. "The Use of Phenylbutazone in the Horse." Journal of Veterinary Pharmacology and Therapeutics 35.1 (2012): 1-12. Web. White, N. A., and S. E. Palmer. "Therapeutics in Sport Horse Competition: Searching for Definition." Equine Veterinary Education 339-340 26 (n.d.): n. pag. Web. "U.S. Equestrian Federation Modifies NSAID Rules." DVM Newsmagazine (n.d.): n. pag. Web.