Entwicklung und Umsetzung der integrierten Versorgung in der Schmerztherapie

Integrated care builds interdisciplinary networks across the different healthcare sectors. A conjoint effort toward clearly defined treatment goals is crucial for medically effective and economically efficient care. Allowing creativity in the implementation of integrated care triggers competition for more effective ideas and better solutions. Based on a summary of the development of integrated care and the example of the nationwide German headache treatment network, the successful organization and implementation of this cross-sectoral care within pain medicine is illustrated. An interdisciplinary nationwide network of pain therapists working hand in hand across the sectors, both in the outpatient and inpatient setting, and employing modern treatment regimens results in optimal pain relief. The treatment quality is assessed by continuous accompanying research and sustainable cost efficiency in all sectors of healthcare is confirmed through analysis of both direct and indirect costs. The project was started in May 2007. In the meantime, almost all large statutory health insurance providers in Germany have joined this healthcare project. The large treatment network confirms the significant clinical and economic efficiency of pain medicine. It demonstrates that coordinated modern therapy effectively relieves pain, lowers costs sustainably, and reduces sick leave. Patient satisfaction is very high. The healthcare providers may directly participate in treatment success through risk-sharing.     

Pharmakodynamische und pharmakokinetische Besonderheiten der Schmerztherapie bei Neugeborenen

The false assumption that neonates are less sensitive to pain than adults led to a long delay in the introduction of a reasonable pain therapy for children. Even if the basic principles of the development, transmission and perception of pain in premature infants and neonates are not completely understood, the results of studies have clearly shown that pain can be perceived from 22 weeks of gestation onwards. This knowledge results in the necessity to also administer an adequate pain therapy to premature and newly born infants. However, for the use of pharmaceuticals in neonates and infants the pharmacodynamic and pharmacokinetic characteristics must also be considered. The immaturity of the organs liver and kidneys limits the metabolism and also excretion processes. The different physical proportions also modify the dosing of pharmaceuticals. Children in the first year of life differ substantially from adults in physiology, pharmacodynamics and pharmacokinetics. The care of neonates and infants requires specialist knowledge which is described in this article.     

Schmerztherapie in der Lehre

Background

The subject of pain and pain therapy is not mandatory in medical curricula in Germany. Therefore, the German Society for the Study of Pain (DGSS) has developed a core-curriculum for pain and suggested its implementation for all medical faculties.

Method

At the University of Witten/Herdecke this DGSS core curriculum was extended in terms of a ??pain week??, which comprised 22?h of seminars and clinical teaching and started in 2009. The knowledge gained by the students regarding the intended learning issues was measured by a pre-post self-assessment questionnaire.

Results

In almost every category the students reported significant knowledge gain. The learning issues were rated as relevant for the professional career.

Conclusion

The ??pain week?? is intended to be a constant part of the medical curriculum at the University of Witten/Herdecke in the future. It will be integrated into the new cross-sectional subject of palliative care and be assessed by examinations.     

Schmerztherapie in der Onkologie

Background

Pain is one of the most prevalent and distressing symptoms of patients suffering from cancer. In the field of oncology comprehensive expertise is pursued not only with respect to the administration of anticancer treatment but to all fields that relate to the needs of cancer patients. However, the results of studies have revealed persisting and relevant deficits in pain therapy in the setting of oncology.

Materials and methods

An online survey was performed involving all members of the German Society for Hematology and Medical Oncology (DGHO) with respect to training and continuing education in pain therapy, the relevance for routine oncology and knowledge, to determine the level of expertise in pain therapy and the assessment of tumor-specific therapy.

Results

A total of 183 out of 1,962 questionnaires could be evaluated. Oncologists are often engaged in pain therapy and 80?% of the respondents perceived themselves as being primarily responsible for pain control. Education and assessment were identified as barriers to sufficient pain therapy. Case vignettes revealed only few relevant therapeutic misinterpretations.

Conclusion

This first survey of German oncologists exploring expertise in cancer pain therapy, showed similar problems in education and pain assessment as previous international studies. Despite the claimed responsibility for pain management, there were a small but relevant number of oncologists who showed serious therapeutic misinterpretations in case studies.     

Grenzen der Schmerztherapie

Medical principles of pain treatment are generally in line with the judicial principles. To relieve pain is one of the fundamentals of medicine and this has also been acknowledged by the Federal Court in Germany. It is criminal bodily harm, when a physician denies a possible pain treatment. Whereas courts clearly see an obligation to basic and continuing education in pain diagnosis and therapy, pain is still not represented in the German licensing regulations for physicians. Only palliative medicine has been added to the obligatory curriculum. Very similar pain is not mandatory in many clinical disciplines leaving physicians without the needed knowledge to treat pain. The need for interdisciplinary treatment is not yet acknowledged sufficiently, although meanwhile chronic pain is regarded as a bio-psycho-social illness. Since 2009 the advance directive is regulated by law. However, still many physicians are unaware that not only the position of the patient but also of the relatives have been strengthened. In 2010 the Federal Court has pronounced a judgment allowing ??passive euthanasia?? in certain conditions but prohibiting any active handling even in line with the patient??s will. This is also in line with the European Human Rights Convention. The judicial unpunished assisted suicide has provoked an ethical discussion within the medical profession. However, what is not illegal is not automatically accepted as ethical handling for physicians. Palliative medicine is at least one alternative in this discussion.     

Schmerztherapie in der Geburtshilfe

Labor pains can be stronger than pain caused by fractures and as a result of fear and stress can even have a negative effect on the course of parturition. A proportion of 75% of all women in labor use one or more supportive forms of analgesia to relieve labor pains. The procedures used range from supportive non-pharmacological measures, single intramuscular or intravenous analgesics and a prolonged inhalative analgesia up to highly efficient neuraxial blocks. Non-pharmacological interventions are considered to be generally safe but poorly effective. In contrast, pharmacological and invasive interventions are proven to be effective for analgesia but associated with potential side effects.     

Schmerztherapie der akuten Nierenkolik

The severe pain of a renal colic is an emergency and requires a fast and sufficient analgesic therapy with few side-effects. The release of the ureteral obstruction is secondary to this initial treatment. Inhibition of prostaglandin synthesis directly interferes with the mechanism of renal colic pain. Dipyrone, indomethacin and diclofenac are the drugs of choice. They should be administered intravenously if possible. Narcotic agents and their derivatives are the second choice. Spasmolytic agents are unnecessary in the treatment of renal colic.     

Elektrophysiologische Messverfahren in der Schmerztherapie

Elektrophysiological methods provide objective data about the function of the somatosensory system. Broadly established methods like neurography, myography, sensory evoked potentials and electrically evoked reflexes are in contrast to less well known techniques as laser-evoked potentials and microneurography. It is important to keep in mind that neurography and sensory evoked potentials comprise the function of myelinated nerve fibers with big axonal diameters. Unlike, laser-evoked potentials and microneurography describe the functionality of nonmyelinated, small diameter nerve fibers, which transmit pain and temperatures as sensory signals. Investigation of the sympathetic sudomotoric system can provide evidence for lesions within sympathetic nerves.     

Ultraschall in der interventionellen Schmerztherapie

Peripheral nerve blocks are currently performed relatively blind even in the most complex anatomical structures and physicians mostly rely on palpable anatomical landmarks on the surface. Ultrasound has become an indispensable part of the modern medical world and has long since found its way into almost all medical professions. More and more this trend also reaches interventional pain physicians as it is possible to accurately target structures, to track the needle course during the intervention and to visualize the spread of the local anesthetic. Another advantage compared to other radiological techniques is the profound radiation safety for patients as well as for personnel performing the intervention. A deep understanding of anatomy and its correlate in ultrasound images is one of the most important requirements for the successful use of these interventional techniques. Moreover, the safe performance of the procedure depends on the simultaneous hand-eye coordination. Nevertheless, despite the euphoria ultrasound technology should only be used in pain management with sufficient indications.     

Integrierte Versorgung in der Schmerztherapie

Sectorally segregated healthcare structures are seen as a major reason for deficits in quality and efficiency. With the introduction of §§ 140 a ff. SGB V, the sectoral splitting into outpatient, inpatient and rehabilitative services will be eliminated. This is especially true for the requirements of state-of-the-art multidisciplinary and comprehensive pain therapy. Through this form of contract competition and competition for the best idea, incentives shall be created for economic behaviour of market participants, above all the efficient use of limited resources and allocation of healthcare resources based on need. Selective contracts are essential competition parameters for continued innovative development of the healthcare system. They enable statutory healthcare providers to offer their insurants innovative treatments which are not available in standard care. Agreements can be made concerning higher levels of quality and healthcare services, incentives for economical behaviour and success-based payment models. The key idea is the orientation on the needs of the insurant. The successful realisation of innovation in pain therapy is described using a practical example. Professional contractual partners, high quality information and communication, the taking over of responsibility for treatment and cost effectiveness are factors essential the success of innovative treatment concepts.     

Transkranielle Magnetstimulation und Motorkortexstimulation bei neuropathischen Schmerzen

Non-invasive and invasive cortical stimulation allows the modulation of therapy-refractory neuropathic pain. High-frequency repetitive transcranial magnetic stimulation (rTMS) of the contralateral motor cortex yields therapeutic effects at short-term and predicts the benefits of epidural motor cortex stimulation (MCS). The present article summarizes the findings on application, mechanisms and therapeutic effects of cortical stimulation in neuropathic pain.