Dtsch Med Wochenschr 2018; 143(19): 1372-1380
DOI: 10.1055/a-0587-0274
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© Georg Thieme Verlag KG Stuttgart · New York

Therapierefraktäre Schmerzen

Treatment-Refractory Pain
Jens Keßler*
,
Marcus Geist*
,
Hubert Bardenheuer
Further Information

Publication History

Publication Date:
19 September 2018 (online)

Abstract

Pain therapy concepts should be based on a biopsychosocial model. A prerequisite for adequate pain therapy is the detailed medical history. The questions about the intensity of pain and especially about the quality of pain are crucial for the selection of drug therapy. In addition to the questioning, targeted physical examination is essential. This should be repeated in case of therapy-refractory pain in the course. The transfer of clinically relevant knowledge about the emergence and the development of pain occurs in the new cross-sectional area ​​14 “pain medicine” and has been anchored in the licensing regulations. Treatment-refractory pain, despite adequate pharmacological therapy, may be the result of individual metabolism. For tumor-related pain, opioid rotation is a suitable symptom control procedure. To avoid treatment-refractory pain peaks, the medication for the need for basic medication should be adjusted in the dose. Non-drug treatment should be targeted for treatment-refractory pain to promote patient’s ownership. Physiotherapeutic measures have the goal of increasing the self-efficacy of pain and regaining confidence in one’s own bodily functions.

Schmerz ist einer der häufigsten Gründe für Arztbesuche und oft wird er fachübergreifend behandelt. Meist kann der Behandler mithilfe einfacher Therapiealgorithmen in kurzer Zeit eine Linderung gewährleisten. Manchmal aber ist der empfundene Schmerz therapierefraktär, er eskaliert oder chronifiziert. Warum das so ist, erläutert dieser Beitrag. Zudem stellt er praxisorientierte Lösungswege vor – auch für den Umgang mit „schwierigen“ Patienten.

* Geteilte Erstautorenschaft.


 
  • Literatur

  • 1 Williams AC, Craig KD. Updating the definition of pain. Pain 2016; 157: 2420-2423 . doi:10.1097/j.pain.0000000000000613
  • 2 Cohen M, Quintner J, van Rysewyk S. Reconsidering the International Association for the Study of Pain definition of pain. Pain reports 2018; 3: e634 . doi:10.1097/pr9.0000000000000634
  • 3 Ott J, Aust S, Nouri K. et al. An everyday phrase may harm your patients: the influence of negative words on pain during venous blood sampling. Clin J Pain 2012; 28: 324-328 . doi:10.1097/AJP.0b013e3182321cc3
  • 4 Angelini E, Wijk H, Brisby H. et al. Patients’ Experiences of Pain Have an Impact on Their Pain Management Attitudes and Strategies. Pain Manag Nurs DOI: 10.1016/j.pmn.2018.02.067.
  • 5 Neustadt K, Deckert S, Kopkow C. et al. Was bedeutet Schmerzintensität aus Sicht der Patienten? Eine qualitative Studie zur Patientenperspektive auf Schmerzstärke als Konstrukt in der Therapieevaluation und die Interpretierbarkeit der Schmerzstärkemessung. Schmerz 2017; 31: 580-593 . doi:10.1007/s00482-017-0234-x
  • 6 Kirsch J. Schmerz lass’ nach! Eine Einführung in die Grundbegriffe der Schmerzmedizin. 1. Aufl. Heidelberg: Springer; 2018
  • 7 Deutsche Schmerzgesellschaft e. V. (Hrsg). Deutscher Schmerzfragebogen (DSF). Im Internet: https://www.dgss.org/deutscher-schmerzfragebogen/ . Stand: 21.08.2018
  • 8 Nikendei C, Ganschow P, Groener JB. et al. „Heidelberg standard examination“ and „Heidelberg standard procedures“ – Development of faculty-wide standards for physical examination techniques and clinical procedures in undergraduate medical education. GMS J Med Educ 2016; 33: Doc54 . doi:10.3205/zma001053
  • 9 Oliveira CB, Franco MR, Maher CG. et al. The efficacy of a multimodal physical activity intervention with supervised exercises, health coaching and an activity monitor on physical activity levels of patients with chronic, nonspecific low back pain (Physical Activity for Back Pain (PAyBACK) trial): study protocol for a randomised controlled trial. Trials 2018; 19: 40 . doi:10.1186/s13063-017-2436-z
  • 10 Grobe TG, Steinmann S, Szecsenyi J. (BARMER Hrsg.). Arztreport 2017. Schriftenreihe zur Gesundheitsanalyse. Siegburg: Asgard; 2017
  • 11 Quandt C, Ruschulte H, Friedrich L. et al. Das longitudinale Modul Schmerzmedizin (LoMoS). Bedarfsanalyse und Lernzielformulierung. Schmerz 2013; 27: 475-486 . doi:10.1007/s00482-013-1354-6
  • 12 Frankenhauser S, Boker-Blum T, Busch C. et al. Etablierung des neuen Querschnittsbereichs Schmerzmedizin: Ein Anwendungsbeispiel der Medizinischen Fakultät Heidelberg. Schmerz 2017; 31: 391-398 . doi:10.1007/s00482-017-0188-z
  • 13 Manworren RC. Multimodal pain management and the future of a personalized medicine approach to pain. AORN J 2015; 101: 308-314 ; quiz 315-308. doi:10.1016/j.aorn.2014.12.009
  • 14 Gabriel RA, Ehrenfeld JM, Urman RD. Preoperative Genetic Testing and Personalized Medicine: Changing the Care Paradigm. J Med Syst 2017; 41: 185 . doi:10.1007/s10916-017-0835-z
  • 15 Branford R, Droney J, Ross JR. Opioid genetics: the key to personalized pain control?. Clin Genet 2012; 82: 301-310 . doi:10.1111/j.1399-0004.2012.01923.x
  • 16 Solhaug V, Molden E. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics. Scand J Pain 2017; 17: 193-200 . doi:10.1016/j.sjpain.2017.09.009
  • 17 Doleys DM. Philosophical Issues and Psychological Variables that Influence the Determination of Opioid Effectiveness: A Narrative Review. Pain physician 2017; 20: 1091-1105
  • 18 Meuser T, Pietruck C, Radbruch L. et al. Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 2001; 93: 247-257
  • 19 Afsharimani B, Kindl K, Good P. et al. Pharmacological options for the management of refractory cancer pain-what is the evidence?. Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer 2015; 23: 1473-1481 . doi:10.1007/s00520-015-2678-9
  • 20 Schuster M, Bayer O, Heid F. et al. Opioid Rotation in Cancer Pain Treatment. Dtsch Arztebl Int 2018; 115: 135-142 . doi:10.3238/arztebl.2018.0135