RESUMEN
On behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.
Asunto(s)
Dolor Crónico/clasificación , Dolor Crónico/terapia , Programas Nacionales de Salud/clasificación , Programas Nacionales de Salud/organización & administración , Clínicas de Dolor/clasificación , Clínicas de Dolor/organización & administración , Manejo del Dolor/clasificación , Garantía de la Calidad de Atención de Salud/clasificación , Garantía de la Calidad de Atención de Salud/organización & administración , Alemania , Humanos , Comunicación Interdisciplinaria , Colaboración IntersectorialRESUMEN
BACKGROUND: The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013. METHODS: The guidelines were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain. RESULTS: Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality). CONCLUSION: Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.
Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Cuidados a Largo Plazo , Adolescente , Adulto , Anciano , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/farmacología , Consenso , Ensayos Clínicos Controlados como Asunto , Medicina Basada en la Evidencia , Femenino , Alemania , Humanos , Prescripción Inadecuada , Masculino , Persona de Mediana Edad , Dimensión del Dolor/efectos de los fármacos , Guías de Práctica Clínica como Asunto , Adulto JovenRESUMEN
On behalf of the German chapter of the International Association for the Study of Pain (IASP) recommendations for German pain treatment services have been developed for the first time. The criteria were based on the IASP recommendations but adapted to the specific German situation. According to the structure and process criteria four different levels of pain treatment services can be distinguished. The aim of the recommendations is to serve as a guide for future development and implementation of pain therapy and quality assurance.
Asunto(s)
Dolor Crónico/terapia , Clínicas de Dolor/clasificación , Atención Ambulatoria/organización & administración , Dolor de Espalda/terapia , Dolor Crónico/clasificación , Alemania , Trastornos de Cefalalgia/terapia , Implementación de Plan de Salud/organización & administración , Necesidades y Demandas de Servicios de Salud/organización & administración , Investigación sobre Servicios de Salud/organización & administración , Humanos , Clínicas de Dolor/organización & administración , Garantía de la Calidad de Atención de Salud/organización & administración , Sociedades MédicasRESUMEN
BACKGROUND: The prevalence of chronic pain as related to the supply situation in primary care has been investigated insufficiently. PATIENTS AND METHODS: A questionnaire was used to collect data of 1,201 patients in 6 different specialists' practices (general medicine, surgery, internal medicine, neurology, oncology, orthopaedics). The questions posed related to socio-demographic facts, pain characteristics, psychosocial effects, previous therapies and their subjective effectiveness. RESULTS: Pain was the reason for consulting a doctor in nearly 50% of the patients; 40% of all respondents complained about chronic pain, defined as recurrent or constant pain lasting longer than 6 months. As many as 90% of these subjects reported psychosocial impairment due to chronic pain and 25% evaluated their therapies as ineffective. CONCLUSION: Chronic pain is a major problem in primary care. The high level of suffering and the enormous socioeconomic impact on public health demand consequences. Improvements in undergraduate and postgraduate training are urgently required for both an adequate pain treatment and the prevention of chronic pain.
Asunto(s)
Atención Ambulatoria/estadística & datos numéricos , Medicina/estadística & datos numéricos , Programas Nacionales de Salud/estadística & datos numéricos , Dolor/epidemiología , Adulto , Anciano , Enfermedad Crónica , Evaluación de la Discapacidad , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Dolor/psicología , Manejo del Dolor , Aceptación de la Atención de Salud/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Studies have provided no evidence that effective and stable long-term opioid treatment of pain necessarily impairs psychomotor abilities. Assessment of psychomotor abilities, especially of those involved in driving, can only be made in the individual case. Such abilities are affected especially by drug combination and such individual factors as age and driving experience.
Asunto(s)
Analgésicos Opioides/efectos adversos , Conducción de Automóvil , Dolor/tratamiento farmacológico , Desempeño Psicomotor/efectos de los fármacos , Adulto , Factores de Edad , Anciano , Analgésicos Opioides/uso terapéutico , Examen de Aptitud para la Conducción de Vehículos , Medicina Basada en la Evidencia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/fisiopatología , Dolor/psicología , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
The German Society for the Study of Pain has formed an interdisciplinary committee to answer urgent ethical questions on the diagnosis and treatment of pain and to give an ethical orientation on the care of pain and palliative patients. The treatment of pain is a fundamental objective of medicine. Competent and adequate relief of pain in all stages of life is a basic characteristic of a humane medicine oriented to the quality and meaning of life for people. However, there are substantial deficits in all areas, especially in the knowledge of physicians and patients, in training and further education, diagnosis and therapy. Freedom from pain is a substantial element of quality of life. A central duty of all physicians is an adequate diagnosis and treatment of acute pain and thereby the prophylaxis of chronic pain. If pain persists over a longer period of time, it loses the warning function and becomes taken for granted. Alterations, disabilities and limitations of the physical, psychic and social levels are the consequences. For these patients an interdisciplinary approach is necessary by which various medical disciplines, psychologists and physiotherapists are involved and all collaborate on the diagnosis and therapy of pain. All patients have the right to sufficient and individually tailored treatment of pain. Special attention must be paid to vulnerable patient groups, such as newborns, children and adolescents, as well as aged and mentally retarded patients. For cancer patients pain relief of their tumor pain is totally in the forefront. Indications of "unbearable pain" must not lead to resignation or even be seen as an argument for legalization of "death on request". The nursing of terminally ill patients necessitates a special measure not only of clinical, but also ethical competence, communication and multiprofessional collaboration. The modern options for palliative care are real alternatives to demands for legalization of "death on request". Physician-assisted suicide does not belong to the scope of functions of palliative medicine. The basic constitutional law makes an appropriate treatment of pain obligatory. Neglect of pain treatment fulfils the elements of criminal bodily harm. As a consequence, there is a legal right to a comprehensive pain diagnosis and a pain treatment corresponding to the appropriate standard. The state is obliged to provide the legal, social and financial prerequisites for an adequate treatment of pain. Continuous efforts in research are necessary to fill the existing gaps in our knowledge. The transfer between basic research and clinical application of pain therapy must be urgently improved. Of central importance for the German Pain Society are therefore: Improvement of training and further education in pain therapy. Chronic pain must be accepted and coded as an autonomous sickness. Graded structures for care of pain patients must be realized. Interdisciplinary structures of care must be made available to patients with chronic pain. Palliative medical care is a basic right of all terminally ill patients. Politics and health care providers must establish prerequisites for adequate pain diagnosis, pain therapy and palliative medicine.
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Códigos de Ética , Ética Médica , Dolor , Sociedades Médicas/ética , Alemania , Humanos , Cuidados Paliativos/ética , Cuidado Terminal/éticaRESUMEN
UNLABELLED: A total of 121 patients with at least a 3-year history of opioid use were evaluated by a standardized interview during a clinical visit or telephone call. Assessed items were the present and former drug medication, daily doses, withdrawals, contentment with the treatment, positive/negative treatment effects, average/maximum pain and others. STATISTICS: chi(2), ANCOVA and survival analysis. Of 121 patients (frequency of withdrawal 14.8% mainly due to lack of efficacy) with an average treatment time of 66 months (37-105 months; 80,264 days; 87% more than 5 years), 103 (85%) still took an opioid step II or III according to the WHO analgesic ladder. Patients further treated in the pain clinic stopped significantly less frequently than patients treated by GPs or other non-specialised physicians (5 versus 23%). Patients with long-term opioid intake revealed significantly lower pain intensity and higher contentment with the pain management and achieved improvement (global, quality of life and physical state). Changes of opioid dosages during the 5 years were inconsistent (no change 33%, decrease 16%, slight increase 27%, high increase 19%). However, the number of patients with high dose increased from 6 to 23 due to significant loss of efficacy (proved in the morphine subgroup, p<0.05). The survey demonstrates a very low frequency of withdrawal in patients with long-term opioid medication after initial response without evidence for tolerance development, especially if their treatment is controlled in a pain centre.
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Analgésicos Opioides/uso terapéutico , Dolor/tratamiento farmacológico , Analgésicos Opioides/normas , Enfermedad Crónica/mortalidad , Enfermedad Crónica/terapia , Estudios de Seguimiento , Humanos , Entrevistas como Asunto , Neoplasias/fisiopatología , Análisis de SupervivenciaRESUMEN
Opioids are valuable analgesics, capable of providing pain relief and functional improvement not only in patients with cancer-related pain, but also in chronic noncancer-related pain patients. However, recent data have shown that the increasing prescription of opioids is associated with a rise in aberrant drug-related behaviour. The causes of this behaviour are multifactorial. Some pharmacotherapeutic, but in particular psychosocial risk and etiologic pain factors have been identified. The indication for the prescription of opioids must be very carefully weighed in the presence of any risk factors. In these cases the integration into a multimodal, interdisciplinary therapy programme is mandatory. A contractual agreement on the opioid therapy including goals, side effects, controls including urine drug testing and criteria to finish the opioid therapy are advisable. Assessment of the progress of therapy is based on the following factors: analgesic efficacy, adverse side effects, functional status and aberrant drug-related behaviour. In the absence of a successful opioid therapy, the treatment must be discontinued to avoid iatrogenic damage, substance abuse and illegal diversion. After discontinuation of the therapy, a comprehensive interdisciplinary re-evaluation is required.
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Analgésicos Opioides/efectos adversos , Dolor/tratamiento farmacológico , Trastornos Relacionados con Sustancias/prevención & control , Enfermedad Crónica , Humanos , Dolor/psicología , Factores de RiesgoRESUMEN
AIM: Is there a difference in performance and psychomotor function between patients on chronic opioid therapy and healthy controls and which factors influence the performance of the patients? METHODS: A total of 80 patients and 243 healthy controls were investigated with computer-based tests concerning concentration, coordination, reaction time, vigilance, and perception. RESULTS: The patients' results were worse in the test for concentration and better in the test for coordination than the results of the healthy controls. The results in the tests for reaction time, vigilance, and perception did not significantly differ between the two groups. Patients receiving an antidepressant in addition to the opioid were worse in the test for concentration than patients without antidepressant. Patients older than 50 years were impaired in four of five tests, and patients driving a car within the last 12 months had better results than patients without driving experience. Pain intensity, dose of opioid, mental feeling and side effects did not influence the results of the patients. CONCLUSION: Psychomotor function and performance are not inevitably impaired in patients receiving opioids for pain therapy, but the ranges in the results prevent general conclusions. Performance and driving ability must be evaluated individually.
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Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Dolor/tratamiento farmacológico , Nivel de Alerta , Enfermedad Crónica , Humanos , Percepción , Tiempo de Reacción , SeguridadRESUMEN
QUESTION: Do comorbid psychological disorders, dysfunctional pain processing, and psychosocial pain coping occur with complex regional pain syndrome (CRPS) and is a connection between clinical and psychological manifestations apparent? METHODS: In addition to securing information on case histories and performing clinical neurological examinations of chronic CRPS patients, the structured clinical interview (SCID), pain perception scale, and the Kiel Pain Inventory were employed. RESULTS: The structured clinical interview revealed evidence of a depressive episode in 65% of CRPS patients. Pain perception is similar to neuropathic pain syndromes and patient history revealed a slightly increased frequency of anxiety and affective disorders. Depressive syndrome occurred significantly more often in right-sided CRPS; otherwise, there were no significant correlations between medical history, clinical examination, and frequency of psychological disorders. However, CRPS patients with allodynia manifest clinical signs of special psychological distress. CONCLUSION: In chronic CRPS depressive syndrome frequently develops and psychological treatment can be recommended.
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Depresión/etiología , Trastornos Mentales/etiología , Distrofia Simpática Refleja/psicología , Comorbilidad , Humanos , Dolor/fisiopatología , Dolor/psicología , Dimensión del Dolor , PercepciónRESUMEN
BACKGROUND AND METHODS: The aim of this study was to get more information about the prevalence of chronic pain in different practices of home physicians. 900 patients of five different specialists (general medicine, internal medicine, neurology, orthopaedics, surgery) in the german town Bochum were investigated with a questionnaire about chronic pain. Chronic pain was defined as a continuous or intermittend pain of longer duration than six months. RESULTS: 36% (328 patients) of all investigated patients had chronic pain due to this definition, twice more women than men. The four most frequent localisations of chronic pain were the back, the head, the joints and the legs. 15% of the patients with chronic pain were retired or going to retire due to their chronic pain. Orthopaedics were the most frequent physicians visited in the past. Only 5% of the patients had a psychological therapy and only 1% were treated in a pain clinic. The primary treatment strategies of the chronic pain were physiotherapy and drug therapy. 30% of the patients did not have any pain relieve by the past treatment strategies. CONCLUSION: Patients with chronic pain are a frequent and important problem in practices of home physicians. The high frequency of patients with chronic pain in practices of specialists demonstrates the necessity of a special qualification also on this level of our medical system.
RESUMEN
Psychologic strategies for the treatment of chronic pain are an important component of the necessary multidimensional treatment for patients in chronic pain. These techniques including relaxation training, biofeedback, hypnosis and cognitive-behavioral therapy have demonstrated efficacy. The impact of these techniques is on the sensory aspect of pain and the psychologic distress and on the maladaptive coping mechanism people develop in response to pain. In Germany there are still several impediments for the consequent application of psychologic strategies for patients with chronic pain. These impediments and possible solutions are discussed.
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Dolor/psicología , Grupo de Atención al Paciente , Psicoterapia , Adaptación Psicológica , Enfermedad Crónica , Terapia Combinada , Humanos , Manejo del Dolor , Rol del Enfermo , Resultado del TratamientoRESUMEN
Chronic pain has an economic impact for the society and the patients suffering from chronic pain. The indirect costs of chronic pain (loss of productivity, social security payments) are higher than the direct costs (prevention, diagnosis and therapy). The indirect costs in the family are often underestimated. It is proven that in-patient and out-patient treatment in multidisciplinary pain centers are effective. In-patient treatment is more expensive. Multidisciplinary pain programmes increase the return-to-work-rate significantly. Further investigations are requested to uncover costs and outcome of different pain treatment methods.
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Costo de Enfermedad , Dolor/economía , Grupo de Atención al Paciente/economía , Enfermedad Crónica , Análisis Costo-Beneficio , Humanos , Dolor/etiología , Manejo del DolorRESUMEN
INTRODUCTION: Clinical observations of patients under oral opioid treatment suggest that the initially appearing central side effects such as sedation, dizziness or drowsiness decrease after a few weeks of treatment. However, it is still unclear whether long-term treatment with opioids impairs complex psychomotor functions such as driving a car. METHODS: Twenty patients on stable dosages of oral opioids were examined using a driving simulator. The patients were regular car drivers and not older than 70 years. Additionally, every patient had to complete a questionnaire for mental condition and vigilance and the "d II" letter cancellation task. Control groups tested in the same way were: patients before an elective operation after taking benzodiazepines for sedation, volunteers after alcohol consumption (0.80 per thousand ), physicians on call with less than 4 h of sleep and healthy volunteers without any medication. RESULTS: Some of the patients treated with opioids reacted as fast as medication-free volunteers. There were no significant differences between the reaction times of older patients (>50 years) receiving opioids in comparison to the group of older healthy volunteers. The same result was obtained in the letter cancellation task. No differences could be seen between medication-free volunteers and patients receiving opioids with regard to tasks of visual or motor control skills. The volunteers under influence of alcohol and the patients under benzodiazepines had a considerable decrease in performance. CONCLUSIONS: Long-term therapy with opioids does not inevitably impair complex skills, but the decision to permit driving a car can only be made in the individual case. PRACTICAL RECOMMENDATIONS: At the beginning of therapy with opioids the physician has to fulfil his duty to inform the patient of any possible dangers of treatment. From the medical point of view, driving must be prohibited until a stable opioid dosage is reached. Any changes in dosage (increase, reduction), change of the opioid and poor general condition independent of the opioid therapy must result in prohibition of car driving. Continuous control of the therapy with documentation is a duty of the physician. The written documentation should include the patients' physical and mental condition, side effects and the therapeutic result. From the medical point of view, driving can be possible when dosage treatment and general condition remain stable. In any case, the doctor has to remind the patient of the responsibility of critical self-examination. In doubt, special performance investigation should be taken into consideration.