[Cancer pain therapy in palliative care patients: knowledge of prehospital emergency physicians in training. Prospective questionnaire-based investigation]. / Kenntnisse angehender Notfallmediziner über die Tumorschmerztherapie bei Palliativpatienten. Prospektive fragebogenbasierte Untersuchung.

BACKGROUND: Cancer diseases are often associated with acute and chronic pain. Therefore, cancer pain is a symptom frequently reported by palliative care patients with cancer diseases. Prehospital emergency physicians may be confronted with exacerbation of pain in cancer patients. The aim of this study was to evaluate the knowledge of prehospital emergency physicians in training concerning cancer pain therapy. METHODS: A total of 471 prehospital emergency physicians received a questionnaire (period of time: 2007-2009). The questionnaire was prepared for the study ("mixed methods design"). Twenty-four questions concerning cancer pain therapy (response options: scaling, open) were designed. The evaluation was done descriptively according to professional experience, field name and experience in treating patients with cancer as well. RESULTS: A total of 469 participants completed the questionnaire (response rate 99%). On average, 10.8 (SD +5.7, range 2-24) questions were answered correctly. Resident physicians answered statistically significantly more questions correctly than consultants (p=0.02). Only physicians working in internal medicine achieved statistically significantly better results than other disciplines (e.g., surgery; p=0.01). Physicians with professional experience of less than 5 years answered statistically significantly more questions correctly (p=0.004). CONCLUSIONS: The results of this study verify that emergency physicians in training have insufficient knowledge of pain therapy and end-of-life decisions. The data of this investigation suggest that more attention should be paid to education on pain therapy and end-of-life care in medical curricula. Prehospital emergency physicians may thus be better prepared to provide quality care for palliative patients.

[Influence of opioids on the psychomotor ability of patients in chronic pain]. / Einfluss von Opioiden auf die psychophysische Leistungsfähigkeit von chronischen Schmerzpatienten.

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.

[Pain therapy in addicted patients]. / Schmerztherapie bei suchtmittelabhängigen Patienten.

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

[Safety-relevant performance of patients on chronic opioid therapy]. / Sicherheitsrelevante Leistungsfähigkeit von Schmerzpatienten unter Langzeitopioidtherapie.

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.

[Novel potential uses of thalidomide in the management of pain? A review of the literature]. / Neue Indikation für Thalidomid in der Schmerztherapie. Eine Literaturübersicht.

Thalidomide was introduced as a sedative and antiemetic agent to the European market in the late 1950s. However, it soon became clear that a hitherto unheard-of incidence of severe birth defects was due to the maternal use of thalidomide and the drug was withdrawn from the market. Despite its teratogenesis, thalidomide is currently being rediscovered because of its known spectrum of anticachectic, antiemetic, mildly hypnotic, anxiolytic, anti-inflammatory, antiangiogenic, and analgesic properties. The mechanism of action of thalidomide is probably based on its immunomodulatory effect, namely the suppression of production of tumor necrosis factor alpha and the modulation of interleukins. A striking but not well-known finding is the effectiveness of thalidomide as an analgesic or analgesic adjuvant. During the early era of thalidomide use, the drug was shown to enhance the analgesic efficacy of a combined treatment with acetylsalicylic acid, phenacetin, and caffeine (APC) by testing "normal volunteers, using electrical stimulation of teeth." The combination of thalidomide and APC was superior to other combinations (APC alone, APC and codeine) with respect to both the total analgesic effect and the duration of this analgesic effect. In 1965 thalidomide was found to be effective in treating the painful subcutaneous manifestations of the leprosy-associated erythema nodosum leprosum, a condition for which it eventually was approved by the United States Food and Drug Administration in 1998. In an animal model of neuropathic pain (chronic constriction injury), thalidomide was shown to reduce both mechanical allodynia and thermal hyperalgesia. Recent studies documented the analgesic efficacy of thalidomide in treating painful mucocutaneous aphthous ulcers associated with HIV syndrome and Behcet's disease.However, to date there are no recent clinical trials that are specifically designed to explore the analgesic potential of thalidomide. In view of the current basic research and clinical findings,we suggest to investigate the potential benefits of thalidomide in severe pain conditions that respond poorly to common pain management approaches such as neuropathic pain, postherpetic neuralgia, or central pain phenomena. Because its mechanism of action is distinct from that of other drugs such as steroids, thalidomide offers the possibility of a combined treatment with other agents with nonoverlapping toxicities. We conclude that thalidomide, when used properly,may enrich the therapeutic regimen in the management of some pain-related conditions.

[Delayed negative pressure pulmonary edema]. / Verzögert auftretendes, postobstruktives Lungenödem.

A young athletic male adult (smoker) developed a pulmonary edema 30 min after the end of anaesthesia. Extubation was complicated by a laryngospasm. After artificial ventilation for 12 h the patient recovered completely.A negative pressure pulmonary edema (NPPE) develops after deep inspiratory efforts with an occluded airway. Such a maneuver leads to negative intrapleural pressures of -50 to -100 mmHg. This pressure gradient causes damage to the pulmonary capillaries, a transcapillary volume shift into the interstitium,and hemodynamic changes that increase the intrapulmonary blood volume. As a NPPE may occur with a delay of up to 1 h it is crucial to provide adequate monitoring for patients at risk. Symptomatic therapy usually leads to complete recovery within several hours.

[Treatment of low back pain--significance, principles and danger]. / Medikamentöse Therapie bei Rückenschmerzen - Bedeutung, Prinzipien und Gefahren.

Today, a wide range of efficient analgesic and non-analgesic drugs for the treatment of back pain are available. However, drugs should never be the only mainstay of a back pain treatment program. Non-steroidal antiinflammatory drugs (NSAID) are widely used in acute back pain. NSAIDs prescribed at regular intervals are effective to reduce simple back pain. The different NSAIDs are effective for the reduction of this pain. They have serious adverse effects, particularly at high doses, in the elderly, and on long-term administration. The new cyclooxygenase II-inhibitors have less gastrointestinal complications. But the long-term experiences are limited up to now. Considerable controversy exists about the use of opioid analgesics in chronic noncancer pain. Many physicians are concerned about the effectiveness and adverse effects of opioids. Other clinicians argue that there is a role for opioid therapy in chronic noncancer pain, e. g. especially in chronic low back pain. There is a low incidence of organ toxicity in patients who respond to opioids. The incidence of abuse and addiction is likewise relatively low. The potential for increased function and improved quality of life seems to outweigh the risks. However, there is a lack of randomised controlled trials (RCT) on opioid therapy in a multimodal pain treatment approach. Clinical experience and some studies suggest administration of sustained release opioids because of better comfort for the patient and less risks for addiction. The opioids should be selected due to the specific side effects of the different drugs. For patients with pre-existing constipation transdermal fentanyl should be preferred. Antidepressant medications have been used for the treatment of chronic back pain, though there is only little scientific evidence for their effectiveness. There is no evidence for the use of antidepressants in acute low back pain. Trials of muscle relaxants for patients with acute back pain have used a wide range of agents, e. g. benzodiazepines. They mostly reduce acute back pain, but they have significant adverse effects including drowsiness and psychological and physical dependence even after relatively short treatment. Benzodiazepines are not indicated in the treatment of chronic back pain. Drugs are sometimes necessary for the patients to begin and persevere a multimodal treatment program. Drug therapy should be terminated as soon as other treatment strategies succeed. Unfortunately, no studies exist evaluating the place of analgesics within a multimodal treatment program.

[Posttraumatic pain. Causes and therapeutic possibilities]. / Posttraumatische Schmerzen. Ursachen und Therapiemöglichkeiten.

Each patient has the right of a dedicated pain therapy according to the state of the art. However an efficient pain therapy is not possible without knowing the cause of pain. In most posttraumatic pain situations peripheral nociceptors are activated and normal afferences are conducted via an intact nociceptive system. In contrast, neuropathic pain pain is caused by lesions of the nervous system itself. Mechanisms of central sensibilization and involvement of the sympathetic nervous system may lead to chronification of such pain conditions. The therapeutic regime of nociceptive and neuropathic pain is demonstrated by algorithms of treatment modalities. Apart from classic non-opioid analgesics, co-analgesics and opioids have an important status in chronic pain management as well. Prescription of these substances has to follow strictly defined standards of pain therapy. Blockades with local anaesthetics as mono-therapy of chronic pain are obsolete. In posttraumatic pain, however, a certain number of adjuvant blockades or infiltrations of triggerpoints may be helpful. The exceptional place of sympathetic blockades are in diagnosis and therapy of sympathetic maintained pain (SMP).

Post-traumatic pain. Causes and therapeutic concepts.

Each patient has the right of a dedicated pain therapy according to the state of the art. However an efficient pain therapy is not possible without knowing the cause of pain. In most posttraumatic pain situations peripheral nociceptors are activated and normal afferences are conducted via an intact nociceptive system. In contrast, neuropathic pain pain is caused by lesions of the nervous system itself. Mechanisms of central sensibilization and involvement of the sympathetic nervous system may lead to chronification of such pain conditions. The therapeutic regime of nociceptive and neuropathic pain is demonstrated by algorithms of treatment modalities. Apart from classic non-opioid analgesics, co-analgesics and opioids have an important status in chronic pain management as well. Prescription of these substances has to follow strictly defined standards of pain therapy. Blockades with local anaesthetics as mono-therapy of chronic pain are obsolete. In posttraumatic pain, however, a certain number of adjuvant blockades or infiltrations of triggerpoints may be helpful. The exeptional place of sympathetic blockades are in diagnosis and therapy of sympathetic maintained pain (SMP).

[Postdural puncture headache: diagnosis, prevention and therapy]. / Postpunktioneller Kopfschmerz.Diagnose, Prophylaxe und Therapie.

Lumbar puncture (LP) is a routine technique performed for a variety of procedures, e.g. diagnosis, administration of drugs, myelography and spinal anaesthesia. Postdural puncture headache is a common complication (30-40% in diagnostic LP). Prevention can be accomplished by using small-gauge needles (< or = 25 G) or pencil-point needles (22 G). Therapy should be carried out in a stepwise approach. The first step is bedrest, use of analgetics, i.v. fluids and an adequate guidance of the patient. The second step comprises special drug therapy. Several methods of pharmacologic management have been presented in the literature, but most of these are case reports. There is a lack of large double-blind placebo-controlled studies. Theophylline, caffeine, ACTH and sumatriptan are potentially promising agents for the treatment of postdural puncture headache. The efficacy of theophylline has been proven in a double-blind and placebo-controlled study. There are a few studies and case reports reporting that caffeine p.o. and i.v. is effective in the treatment of postdural puncture headache, but recurrence of headache after caffeine therapy is frequent. ACTH acts on a complex hormonal system. The treatment with sumatriptan has been reported in only a few case reports. The third step, and one of the most effective treatments of postdural puncture headache, is the epidural blood patch. The success rate ranges between 80 and 97%.

[Coenesthesia--an important differential diagnosis in chronic pain syndromes]. / Zönästhesie. Wichtige Differentialdiagnose bei chronischen Schmerzerkrankungen.

BACKGROUND: Coenesthesias can be defined as disorders of body perception or body hallucinations, projected in different parts of the body. Patients complain of intractable pain or dysesthesia. These symptoms are reported even from organs where we usually have no perception. Coenesthesia must be regarded as a symptom that can be observed in various psychiatric diseases, e.g., schizophrenia. However, in rare cases coenesthesias can be documented in neurological diseases, e.g., intracranial tumors or infections. Therefore, accurate assessment of possible differential diagnoses is important. In late stages, coenesthesias can easily be recognized because of their "bizarre" character. In early stages, however, patients often complain of intractable, unlocalizable burning pain. They frequently undergo operations because of their great suffering. The drug treatment of first choice is neuroleptics, but the results are unpredictable. CASES AND THERAPY: The case studies of three patients are presented and discussed (patient 1 with coenaesthetic schizophrenia, patient 2 with coenesthesia in the course of a delusional (paranoid) disorder; patient 3 with coenesthesia caused by carcinomatous meningitis).

[Pharmacist's attitudes towards opioid prescription]. / Betäubungsmittelverschreibungsordnung. Einstellung der Apotheker.

UNLABELLED: The prescription of strong opioids underlies a special legislation. The attitude of the pharmacists towards the long-term treatment with these analgesics and their opinion about the legislation is unknown in Germany and other European countries. METHODS: A questionnaire was included in the Journal "Mitteilungsblatt der Apothekerkammer Westfalen-Lippe" and send to all 2300 pharmacists of the region Westfalen-Lippe in December 1997. RESULTS: 797 (35%) questionnaires were returned. In 82.4% of the pharmacies strong opioids are kept in stock. However, 140 pharmacists do not have opioids in stock due to too many different preparations or low prescription rate. 54% of the pharmacists warn their patients about endangering by the medication. The fear of psychological addiction (48.1%) is the main argument, also in patients with regular intake of the opioids (20.1%) and related to long acting opioids (10.8%). Nevertheless, 73% of the pharmacists advocate for a liberalization and 10.7% for an abolishment of the actual prescription laws. DISCUSSION: The importance of the therapy with strong opioids is well accepted by the pharmacists. An ease of the prescription is demanded to improve the situation of the patients with chronic pain. However, the majority of the pharmacists warns the patients about this medication. Contact between prescribing doctors and pharmacists and an intensified education concerning the therapy with opioids are needed in addition to the education of the medical staff and the liberalization of the prescription laws.

[Staged analgesic therapy in tumor pain]. / Analgetische Stufentherapie bei Tumorschmerz.

Overall, pain is one of the most common symptoms associated with cancer and often produces greater anticipatory distress than other features of the disease. Drug selection depends on the intensity of pain rather than on the specific pathophysiology. Mild to moderate pain can often be treated effectively by so-called "weak" opioids. Non-opioid analgesics, like acetyl-salicylic acid or paracetamol can be added according to the "analgesic ladder" proposed by the World Health Organization (WHO). Opioids should be given on a fixed time schedule thereby, preventing pain from recurring. Additional rescue doses (approximately 50 degrees, of baseline single dose) are given for breakthrough pain. Noninvasive (oral, rectal, sublingual, transdermal and intranasal) routes of application should be maintained as long as possible to preserve independence and mobility. When treatment by infusion therapy (subcutaneous, intravenous, epidural) has been elected, the addition of patient controlled analgesia (PCA), which permits patients to administer a preset amount of narcotic at preset intervals, is an effective means to manage breakthrough and incident pain in selected patients. Antidepressants, anticonvulsants and some antiarrhytmics are used as co-analgesics. Oral medication alone can guarantee pain relief in about 95% of the patients. The WHO analgesic ladder has proven effective in all settings of patients care.