Gabapentin in der Therapie chronischer therapieresistenter Schmerzen

INTRODUCTION: Gabapentin has been shown to reduce pain associated with diabetic neuropathia and postherpetic neuralgia. To date it is not known, whether gabapentin is generally effective in other types of pain. It was therefore the aim to study gabapentin in patients suffering from intractable pain with respect to efficacy, predictive factors and side effects. METHODS: Retrospective analysis of the data sheet of pretreated patients suffering from intractable pain and treated with gabapentin as a third line drug at a university pain clinic. Pain intensity (visual analogue scale, VAS 0 -10 cm), pain characteristics, diagnosis, pre- and co-treatment, and side effects were assessed. Response to treatment was defined as a 50% reduction in pain or a pain intensity of VAS 相似文献   

Tetrahydrocannabinol zur Therapie chronischer Schmerzen

INTRODUCTION: Even in the last century cannabis was used in the treatment of chronic pain. The main active component of cannabis Delta-9-Tetrahydrocannabinol (THC) has been increasingly used in the treatment of nausea, vomiting, loss of appetite and depression. It is also recommended in the treatment of chronic pain. We present our first experiences with THC in the treatment of patients with chronic pain. METHODS: All patients treated with THC in the period from February 1998 until January 2000 were evaluated. Pain relief and side effects of THC were examined retrospectively. RESULTS: In the period of investigation 6 patients had been treated with THC because of chronic pain. Dosages between 5 and 20 mg/d had been used. A sufficient pain relief had been achieved in three patients. The other three suffered from intolerable side effects such as nausea, dizziness and sedation without a reduction of pain intensity. In these cases the treatment was continued with other analgesics. CONCLUSION: This retrospective evaluation of 6 case reports of patients treated with THC showed large individual differences in the effectiveness of THC in pain management. Prospective studies are necessary to evaluate the importance THC in the treatment of chronic pain.     

Therapie chronischer Schmerzen mit oralem retardiertem Oxycodon

Oral controlled-release oxycodone has been available for the treatment of chronic pain in Germany since 1998. Controlled trials have shown good clinical efficacy and tolerability. This survey reports results from six open prospective multicenter trials. In these trials 4196 patients suffering from cancer pain and non-cancer-related pain with inadequate pain relief were treated with oral controlled-release oxycodone for 3-4 weeks. Only a few participating physicians were pain specialists. A total of 356 patients suffering from pain of the musculoskeletal system and receiving oxycodone therapy were monitored for 6 months. Exclusion from the studies was due mainly to inadequate analgesia, side effects, and noncompliance. The efficacy of oxycodone was rated to be better than moderate by most of the patients, quality of life parameters increased significantly, and patient satisfaction was high. The treatment with oral controlled-release oxycodone was a safe and effective option even when used by nonspecialized physicians.     

Zur Integration psychologischer Diagnostik und Therapie bei der Behandlung chronischer Schmerzen

A multidisciplinary approach, acknowledged as being the best treatment strategy for a wide range of chronic pain patients, requires cooperation at least between trained professionals in the medical and the psychological disciplines. Psychological criteria are formulated to bridge persisting gaps in the interdisciplinary implementation of pain treatment strategies.     

Therapie bei Schmerzen der Kaumuskulatur

Zusammenfassung Myalgien der Kiefermuskulatur sind die häufigsten nichtinfektiösen Beschwerden in der Kiefer-Gesichts-Region. Nach Zusammenfassung des aktuellen Kenntnisstands zur Physiologie, Ätiologie, Pathophysiologie, Diagnostik und Differenzialdiagnostik wird anhand einer Literaturrecherche der aktuelle Stand der therapeutischen Möglichkeiten dargestellt. Die Ergebnisse zeigen, dass bei der Mehrzahl der Patienten mit nichtinvasiven reversiblen Maßnahmen Schmerzlinderung bzw. -freiheit erreicht werden kann. Im Kurz- und Langzeitvergleich ergeben verschiedene Behandlungsverfahren vergleichbar gute Resultate. Bei chronischen Verläufen mit ausgeprägter psychosozialer Beeinträchtigung ist neben der Standardtherapie die Betreuung durch einen Psychotherapeuten conditio sine qua non.Die Autoren schreiben im Namen des Interdisziplinären Arbeitskreises für Mund- und Gesichtsschmerzen der Deutschen Gesellschaft zum Studium des Schmerzes     

Therapie bei Schmerzen der Kaumuskulatur

Besides the different forms of odontalgia, myalgias of the masticatory muscles are the most frequent noninfectious complaints in the orofacial region. After summarizing the recommendations set forth by the Interdisciplinary Working Group of Orofacial Pain within the German Chapter of the IASP (German Pain Society), we present the current state of knowledge regarding the etiology, diagnosis, and therapeutic options, based on an extensive literature search. A systematic literature search was carried out in PubMed, the Cochrane Library, and the database of the Deutsche Zahnärztliche Zeitschrift. The results corroborate our previous recommendations that for the majority of patients pain reduction or pain relief can be achieved with noninvasive, reversible methods. Short- and long-term trials have added more evidence to the fact that different therapeutic measures have similar efficacy. In patients with chronic myalgias of the jaw muscles, involvement of a psychotherapist is crucial. Patient education, oral appliances, physiotherapeutic exercises, and acupuncture are recommended therapeutic measures, while physical therapy, pharmacotherapy, and psychological therapy received a limited recommendation.     

Psychobiologische Mechanismen bei der Pathophysiologie chronischer viszeraler Schmerzen

Although visceral pain is of high clinical relevance, it remains poorly understood especially when compared to somatic pain. Nevertheless, interdisciplinary research approaches bridging psychophysiology and neurogastroenterology have contributed to a more refined knowledge about the complex peripheral and central mechanisms of the bidirectional brain-gut axis in recent years. This review summarizes current knowledge regarding psychobiological mechanisms in the pathophysiology of chronic visceral pain in functional gastrointestinal disorders with a focus on irritable bowel syndrome (IBS). Special attention is paid to the role of affective disturbances and emotions, particularly psychological stress as well as to influences of cognition and learning on gastrointestinal motor and sensory functions in healthy individuals and patients with IBS. In this emerging field of research, new evidence from the fields of placebo research and pain-related fear conditioning provide new insights into the psychological and neurobiological mechanisms involved in the transition from acute to chronic pain and the maintenance of pain. This opens up new perspectives for innovative treatment approaches for IBS and other functional gastrointestinal disorders.     

Versorgung chronischer Schmerzen

From the point of view of healthcare policies, improvement in pain care has been required for years; however, there is a great discrepancy between the current need for pain care and the actual provision by healthcare services. This article seeks to demonstrate that while healthcare policies are one of the critical factors involved, a variety of conceptual, diagnostic and therapeutic causes should also be taken into account. Firstly, considering that pain care is primarily concerned with the suffering of pain by patients, the focus lies with their conscious experience in order to define the patients’ understanding of pain. Additionally, in this article current biomedical and psychosocial comprehension concerning chronic pain will be illustrated and why it is necessary to broaden our horizons in order to do justice to patients with chronic pain.     

Intrathekale und epidurale Applikation von Nichtopioidanalgetika zur Therapie akuter und chronischer Schmerzen

Nociceptive stimuli are modulated at the dorsal horn of the spinal cord. This modulation is performed by various systems working independently complementarily, additively or supra-additively. Non-opioid analgesics relieve pain without a motor blockade. In contrast to spinal opioids a reduced risk of respiratory depression is expected. In the therapy of chronic pain non-opioid analgesics may be an alternative, given alone or in combination with an opioid. Clinically relevant dosages for antinociception mediated by the alphaadrenoceptoragonistclonidine are >/=150 mug epidurally. Clonidine is effective in reducing acute and chronic pain. In combination with opioids the action of the opioids is intensified. Clonidine intensifies and prolongs the action of local anesthetics. If opioid tolerance occurs, epidural clonidine alone or in combination with an opioid has good antinociceptive action.Midazolam, a water-soluble benzodiazepine, was injected spinally for the reduction of pain for various indications (postoperative, malignancy, chronic back pain, spinal spasticity). Spinal benzodiazepine should not be injected into the spine in patients until it has been proven that there are no neurotoxic effects. Intrathecally injectedbaclofen is a well-known means of reducing spinal spasticity. Used in this way, it may have a secondary analgesic effect. No significant direct analgesic effect has so far been demonstrated. Spinalcalcitonin often leads to insufficient pain relief when given alone. Combination with an opioid may reduce the dosage of the opioid. Nausea and vomiting are frequent side effects of spinal calcitonin. Intrathecalsomatostatin produces antinociception. However, in animal studies neurotoxic action has been observed. Administration in man has not yet been proved to be safe. Spinalketamine has procluted controversial results in clinical studies, and has not yet been excluded that the substance is not neurotoxic.Lysine acetylsalicylic acid (L-ASA) has been given intrathecally for the therapy of severe cancer pain and chronic back pain. In most patients good analgesia was observed up to 2 months after a single injection. If neurotoxity can be excluded, L-ASA may be an alternative in the therapy of cancer pain before neurodestructive therapy is done.     

Kontinuierliche subkutane Buprenorphinapplikation in der Therapie karzinombedingter Schmerzen

Introduction Buprenorphine is well known in cancer pain therapy because of the long duration of its action and high analgesic potency. Many studies exist about the intravenous and sublingual application form; however, few data are available on its use by the continuous subcutaneous route. Methods Twenty-five patients were analysed retrospectively over 956 days who has been treated with continuous subcutaneous buprenorphine for cancer-related pain. In 7 of these 25 patients plasma analyses were performed. Due to a modified sensitive HPLC method with electrochemical detection for the analysis of buprenorphine in plasma, a detection limit of 40 pg/ml could be obtained. The other analytical methods for plasma concentration have detection limits between 150 and 500 pg/ml. Results During the treatment with continuous subcutaneous buprenorphine it was necessary to increase the initial average daily dose of 1.07 (+/-0.41) mg to 1.58 (+/-0.58) mg. The initially high pain intensity (rated from 0 to 100%) of 67% could be reduced to a moderate pain of 26% on average. Only 2 patients had to be switched over to morphine because of insufficient analgesia. In no case did complications occur that required intervention or would have made it necessary to change the pain therapy. Eighty percent of the patients judged this kind of treatment as effective and comfortable. Most often patients complained about drowsiness, low appetite and constipation. Because of the progress of the cancer disease these effects could not clearly be related to treatment side effects. With 7 of 25 patients the median daily dose of 1.2 (minimum 0.9-maximum 2.3) mg buprenorphine was related to the median plasma concentration of 438 (minimum 64-maximum 3374) pg/ml. In one case with progressive liver dysfunction, the potential risk of cumulation with buprenorphine could be controlled with this method. Conclusions Continuous subcutaneous buprenorphine with external infusors is a safe and efficient cancer pain therapy without severe side effects. Because of its ceiling effect, it is not as effective as morphine, but can be discussed as an alternative if other opioids cause incompatibility reactions.     

Empfehlungen der Weltgesundheitsorganisation zur Therapie tumorbedingter Schmerzen

Ohne Zusammenfassung     

Opioidtherapie chronischer Schmerzen bei Kindern

Based on 4 case reports we focus on the peculiarities of long-term pediatric opioid based pain control. Case report #1, emphasizing the importance of adequate opioid dosing with reference to body weight, illustrates that with adequate management oral sustained-release opioid therapy is safe even in infants less than one year old. Case report #2 is the first report on the usage of buccal fentanyl citrate for pediatric break-through pain control. Case report #3 focuses on the adverse effects of opioid pain control in an infant with neurological impairment. Case report #4 reports on the successful tumor pain control using transdermal buprenorphine. We conclude that proven therapeutic strategies for opioid pain control as applied in adults may be adopted for the usage on children in pediatrics. However, it is mandatory to take into account both the pharmacokinetic and pharmacodynamic peculiarities of childhood.     

Epidemiologie und Kosten chronischer Schmerzen

Low back pain is one of the most common factors leading to longtime disability. Unspecific low back pain is predominant, i. e. low back pain without an anatomic or neurophysiological correlate. The socioeconomic impact of back pain is huge. In Germany 4% of all work force is lost only due to low back pain. Psychosocial factors are essential for the chronification and must be take into account in therapy. Conventional therapy has shown low efficacy, especially once chronification has started.     

Beeinflussung von Schmerzen durch physikalische Therapie

The new orientation concerning the therapy of chronic pain has brought about essential progress during recent years. However, physical therapy is often disregarded. Therefore, various possible ways of influencing pain by physical therapy are presented. In contrast to pharmacotherapy, physical therapy is often able to abolish the causes of pain. By means of respiratory control or relaxation it is possible to reduce increased muscular oder vascular reactivity. The unfavourable influences of increased tone of the sympathatic nervous system on the development of chronic pain may be reduced by several methods of physical therapy. The possibility of influencing the nociceptor and the surrounding tissue by electrotherapy is still a hypothesis, but a promising one. Central pain control by physical therapy is investigated most frequently and is of essential importance. It is also of value to take into consideration the psychotherapeutic effects of physical therapy. The integration of physical therapy into a complex treatment schedule may lead to further progress in the treatment of patients with pain.     

Risikofaktoren für Missbrauch und Abhängigkeit bei der Opioidtherapie chronischer nicht-tumorbedingter Schmerzen

Zusammenfassung Opioide sind wertvolle Analgetika, die nicht nur bei tumorbedingten, sondern auch chronischen nicht-tumorbedingten Schmerzen zu Schmerzlinderung und funktioneller Verbesserung führen können. Aktuelle Daten zeigen jedoch, dass die zunehmende Verschreibung von Opioiden mit ansteigenden Zahlen missbräuchlichen Verhaltens verbunden ist. Dessen Ursache ist multifaktoriell. Pharmakotherapeutische Faktoren sind bekannt.Besonderes Gewicht aber haben psychosoziale und ätiologische Risikofaktoren. Zunehmend spielen iatrogene Faktoren eine Rolle, so mangelndes Wissen über psychische Einflussfaktoren auf Schmerzen und fehlende Bereitschaft zur interdisziplinären Therapie. Liegen Risikofaktoren vor, ist die Indikation zur Opioidgabe nur nach interdisziplinärer Diagnostik im Konsens zu stellen. Die Integration in eine multimodale interdisziplinäre Therapie ist nötig, das Abfassen eines Behandlungsvertrages ist ratsam.Zur Therapiekontrolle gehören analgetische Wirksamkeit, Nebenwirkungskontrolle, funktioneller Zustand und missbräuchliches Verhalten, gegebenenfalls einschließlich gelegentlicher Urinkontrollen. Bei mangelndem Therapieerfolg muss die Therapie beendet werden, andernfalls sind iatrogene Schädigung, Missbrauch und illegale Weitergabe des erfolglos verabreichten Opioids an Dritte möglich.     

Physikalisch-medizinische Therapie bei akuten und chronischen Schmerzen

For almost all pain syndromes, whether caused by tumours or not, physicomedical therapies are used as primary or accompanying measures to treat chronic and acute pain. The selection of suitable treatments is, however, often challenging, as there are clear discrepancies between the results of controlled studies on the one hand and the positive results based on individual observations on the other. This article presents an overview of those methods, therapeutic agents, and techniques within the broad range of physicomedical treatments that show a pain-modulating effect and have proven their efficiency for treating acute and chronic pain.