[Feasibility of the interdisciplinary multimodal assessment-The team perspective]. / Umsetzbarkeit des interdisziplinären multimodalen Assessments ­ die Teamperspektive.

BACKGROUND: Secondary preventive outpatient diagnostic services for patients with pain and risk factors for chronification have not yet been sufficiently established. In the PAIN2020 project (Innovation Fund, 01NVF17049) an outpatient interdisciplinary multimodal assessment (IMA) was introduced for the first time early in the course of the disease. OBJECTIVE: For the implementation of the IMA procedures for team cooperation and decision criteria were developed, which were implemented by a team of medical, physiotherapeutic and psychological therapists. These procedures and decision criteria are to be discussed against the background of clinical experience and examined with respect to their feasibility (qualitative). METHODS: In PAIN2020 a workshop on IMA was held in September 2021 to jointly reflect on the findings and experiences gained in the process so far through monitoring and structuring documentation in the implementation with staff or teams of PAIN2020 centers on the feasibility of implementing a structured interdisciplinary multimodal assessment. In three work phases, occupational group-specific and cross-occupational group topics were addressed. RESULTS: In the decision-making processes of the occupational groups, in addition to profession-specific focal points within the framework of the assessment of findings (somatic, functional or psychosocial core criteria), overarching core criteria within the professions as well as complementary patient-related aspects are evident, which are included in the integrative team process. With respect to team collaboration, the implementation of the team meeting and the final discussion can be used to identify structural and process parameters that promote or inhibit implementation, which are also accompanied by interactional factors. DISCUSSION: For the implementation of the IMA, there were (1) adaptations of the IMA, which is currently implemented as A­IMA in the selective agreement with BARMER and (2) new dimensions or task fields and ideas for evidence-based concepts for the content design of integrative diagnostics as well as for the feedback of the results to the patients, which should be discussed in the future.

PAIN2.0: study protocol for a multicentre randomised controlled trial to evaluate the efficacy of a 10-week outpatient interdisciplinary multimodal pain therapy to manage recurrent pain for patients with risk factors of developing chronic pain in Germany.

BACKGROUND: Up to 27% of the German population suffers from recurrent or persistent pain (lasting more than three months). Therefore, prevention of chronic pain is one major object of pain management interventions. The aim of this nationwide, multicentre, randomised controlled trial is to evaluate the efficacy of a 10-week ambulatory (outpatient) interdisciplinary multimodal pain therapy (A-IMPT) for patients with recurrent pain and at risk of developing chronic pain. This project was initiated by the German Pain Society (Deutsche Schmerzgesellschaft e.V.) and the public health insurance provider BARMER. It is currently funded by the German Innovation Fund (01NVF20023). The study PAIN2.0 focuses on reducing pain intensity and pain-related disability and investigates whether this intervention can improve physical activity, psychological well-being, and health literacy. METHODS: PAIN2.0 is designed as a multicentre 1:1 randomised controlled trial with two parallel groups (randomisation at the patient level, planned N = 1094, duration of study participation 12 months, implemented by 22 health care facilities nationwide). After 6 months, patients within the control group also receive the intervention. The primary outcomes are pain intensity and pain-related impairment, measured as Characteristic Pain Intensity (PI) and Disability Score (DS) (Von Korff), as well as patient-related satisfaction with the intervention. Secondary outcomes are the number of sick leave days, sickness allowance, treatment costs, psychological distress, health-related quality of life, and catastrophizing. The effects of the intervention will be analysed by a parallel-group comparison between the intervention and control groups. In addition, the long-term effects within the intervention group will be observed and a pre-post comparison of the control group before and after the intervention will be performed. DISCUSSION: Recurrent or persistent pain is common in the German population and causes high costs for patients and society. The A-IMPT aims to improve pain and pain-related impairments in pain patients at risk of chronification, thereby reducing the risk of developing chronic pain with its high socioeconomic burden. This new therapy could easily be integrated into existing therapy programs if positively evaluated. TRIAL REGISTRATION: The trial PAIN2.0 has been registered in the German Clinical Trials Register (DRKS) since 21/11/2022 with the ID DRKS00030773 .

[Interdisciplinary multimodal assessment : Interprofessional interaction in team meetings and final talks]. / Interdisziplinäres Multimodales Assessment : Interprofessionelle Interaktion in Teamsitzung und Abschlussgespräch.

BACKGROUND: In PAIN2020 (Innovation Fund, 01NVF17049), an outpatient interdisciplinary multimodal assessment (IMA) was introduced early in the course of the disease. The central quality feature is the close interdisciplinary collaboration of pain medicine, physiotherapy and psychology, which requires a complex organizational and coordination process, especially in team meetings and final discussions. OBJECTIVES: The (different) views of the professional groups involved are brought together in the team process as a common consensus. The process of shaping the interaction of the professional groups among each other in the team meeting and final discussion as well as with the patients is examined (qualitatively) and discussed. METHODS: In PAIN2020, a workshop on IMA was held to jointly reflect on the insights and experiences gained in the process so far through monitoring with staff or teams of the PAIN2020 centers. In one of three work phases, interprofessionally composed groups gathered statements from participants on the design of the interaction in team meeting and final discussion in three rotating rounds within the framework of a World Café. RESULTS: It was possible to identify conducive and obstructive factors for the design of interdisciplinary collaboration in team meetings and final discussions, which were brought together in a superordinate framework model. DISCUSSION: The provision of the new care service as an interdisciplinary task in a team goes beyond existing structural and process parameters in the definition of framework conditions in interdisciplinary multimodal pain therapy and should therefore also take personal competencies and professional competencies into account. Therefore, new dimensions arise for the implementation of the IMA, which should be discussed in the future.

[Development of two outpatient interdisciplinary group modules in the treatment of patients with pain and risk of chronification]. / Entwicklung zweier ambulanter gruppentherapeutischer interdisziplinärer Therapiemodule in der Behandlung von Patienten mit Schmerzen und Chronifizierungsrisiko.

BACKGROUND AND OBJECTIVE: An early treatment of patients who suffer from pain and show risk factors for chronification is meaningful as these patients can benefit from an early interdisciplinary multimodal pain treatment (IMST). In view of the insufficient treatment, two outpatient treatment modules for the secondary prevention of pain chronification are developed within the framework of PAIN2020: the educative and accompanying IMST (E­IMST and B­IMST). MATERIAL AND METHODS: The developmental process of both IMSTs is presented. In this context two target groups of patients were defined for which 1 session (E­IMST) or 10 intervention appointments (B­IMST) were planned, depending on the chronification, impairment and complexity of the disorder. The conception was carried out in five steps: development of the objectives, development of the main contents, workshop on the content and conceptional design (contents, mediation, exercises), preparation of a time schedule and processing of the results (manual, presentations, worksheets, handbook). The B­IMST was initially developed from which the contents for the E­IMST were subsequently extracted. Additionally, a concept for testing the feasibility and a working model for a pilot study were developed. RESULTS: The objectives for both forms of IMST are improvement of the understanding of pain and contributing factors, the increase of the experience of control and self-efficacy and the increase in self-responsibility with respect to strategies to reduce pain. Differences between the two treatment modules arise from the needs and framework conditions. Medical, physiotherapeutic and psychotherapeutic contents and schedules were organized for both IMST modules. The B­IMST consists of five modules each with two sessions as group interventions (biopsychosocial model, activation planning, regulation of needs, sleep and medication, routine transfer). The 3­h E­IMST group intervention mainly intends to mediate knowledge on pain and the biopsychosocial pain model. Theoretical and practical interventions, empirical knowledge and experience-oriented methods are employed. CONCLUSION: There are now two interdisciplinary structured manuals for the secondary preventive treatment of patients with recurrent pain and a risk profile for chronification. These approaches must now prove themselves with respect to feasibility and effectiveness.

Face validity of the ICD-10 criteria of substance abuse and dependence for patients prescribed cannabis-based medicines for chronic pain-A survey of pain medicine physicians in Canada, Germany and Israel.

BACKGROUND AND OBJECTIVE: A major concern with cannabis-based medicines (CbM) and medical cannabis (MC) is the risk of abuse and dependence. The face validity of the International Classification of Diseases (ICD-10) criteria for cannabis dependence in patients prescribed CbM for chronic pain has not been assessed. DATABASES AND DATA TREATMENT: Physicians from Canada, Germany and Israel were recruited via the mailing lists of national pain societies. To be eligible, physicians had to have prescribed CbM for chronic pain treatment in the past 12 months. Participants were asked to rate the appropriateness of items adapted from the substance use module of the Composite International Diagnostic Interview Version 3.0 to assess dependence in the context of chronic pain treatment with CbM and the appropriateness of two additional items. In case of disagreement, participants were asked to give reasons. Furthermore, they were asked to suggest potential additional criteria. RESULTS: On average 69.0% of 178 participating physicians indicated agreement with the appropriateness of the ICD-10 criteria, while 20.6% indicated disagreement. The highest disagreement rate was observed for the item on repeated use despite legal problems (35.4% disagreement or strong disagreement). Reasons for disagreement were summarized into six content categories using qualitative methods of analysis. Additional criteria suggested by participants were summarized into 10 content categories. CONCLUSIONS: A collaboration of psychiatrists and pain physicians is required to define criteria and develop instruments to capture abuse and dependence of CbM in chronic pain patients. SIGNIFICANCE: Sixty-nine per cent of 178 pain medicine physicians in Canada, Germany and Israel who participated in a survey on the appropriateness of the ICD-10 criteria for cannabis abuse and dependence for patients prescribed cannabis-derived products for chronic pain assessed the criteria as appropriate, whereas 20.6% deemed the criteria as not appropriate.

A simple and sensitive fully validated HPLC-UV method for the determination of 5-fluorouracil and its metabolite 5,6-dihydrofluorouracil in plasma.

The authors developed a simple and sensitive, fully validated HPLC-UV method for the determination of both 5-FU and its metabolite DHFU in small-volume plasma samples. The analytes were separated on a 4.6 x 250 mm ID Atlantis dC18 5-microm column with isocratic elution at room temperature. Chlorouracil was used as internal standard. The analytes were detected with an UV diode array detector. DHFU was detected at 205 nm, 5-FU at 266 nm, and chlorouracil at both wavelengths. The limits of quantification in plasma were 0.040 mug /mL for 5-FU and 0.075 microg/mL for DHFU. Linearity, accuracy, precision, recovery, dilution, freeze-thaw stability, and stability in the sample compartment were evaluated. The method appeared linear over a range from 0.04 to 15.90 microg/mL for 5-FU and from 0.075 to 3.84 microg/mL for DHFU. The method appeared very suitable for therapeutic drug monitoring and pharmacokinetic studies of 5-FU because of its simple extraction and small sample volume. Problems in earlier published methods with interfering peaks and variable retention times were overcome. The method appeared also to be suitable for detection of uracil and its metabolite dihydrouracil in plasma.