Akute und chronische Schmerzen und insbesondere neuropathische Schmerzen erfordern eine unterschiedliche Herangehensweise und Auswahl der medikamentösen Schmerztherapie. Als pharmakotherapeutische Angriffspunkte haben sich insbesondere die unspezifische Hemmung der schmerzauslösenden inflammatorischen Mediatoren, wie z. B. Prostaglandin E2 durch COX-Inhibitoren, und die Inhibition der Schmerzweiterleitung sowie die zentrale Dämpfung durch Opioide etabliert. Für neuropathische Schmerzen sind dagegen weitere Angriffspunkte, wie die Aktivierung deszendierender inhibitorischer Neurone z. B. durch trizyklische Antidepressiva, eine therapeutische Option. Weitere therapeutische Targets sind derzeit in der klinischen Entwicklung.

Dieses Taschenbuch gibt Allgemeinmedizinern und allen schmerztherapeutisch tätigen Ärzten einen Überblick über die Vielzahl von Analgetika: Dosierungen, Pharmakokinetik, mögliche Nebenwirkungen und Wechselwirkungen können im Buch oder im ebook rasch nachgeschlagen werden.

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.

35 patients with severe cancer pain received oral retard morphine. Pain reduction was achieved in each case; duration of effectiveness was between 8 and 12 hours. Mean daily dose was 230 mg morphine, but in individual cases the maximal daily dose had to be over 800 mg. The Karnofsky index of physical capacity was increased in all patients. The main side effect was constipation, which actually increased in the course of treatment. On the other hand, nausea and vomiting decreased after a few weeks. No dependence developed in any of the patients. This form of morphine medication thus was effective over long periods and it has become an important part in the range of strongly effective analgesics.

A number of studies suggest that physicians are not adequately addressing patients' expectations, resulting in widespread dissatisfaction with the quality of care. Patients complain that providers fail to appreciate the impact of symptoms on function and neglect discussion of diagnosis and prognosis. Physician-patient communication appears to be central to patients' perceptions of quality of care. Specifically, addressing patients' expectations may influence satisfaction as much, or more than, the outcome of treatment itself. The gap between patient expectations and physician response is cited commonly in studies conducted in patients with painful conditions. This review describes factors that contribute to the expectation gap, with emphasis on studies conducted in this patient subset.

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.

Der Einsatz von Opioiden ist in der Tumorschmerztherapie seit langem etabliert. Grundlage der Schmerztherapie ist das WHO-Stufenschema. Auch bei nicht tumorbedingten Schmerzen werden Opioide zunehmend verwendet, allerdings mit geringerer Effektivität. Verschiedene zentrale und gastrointestinale Nebenwirkungen können die Therapie limitieren. Eine sorgfältige Patientenauswahl sowie die Beachtung von Indikationen und Kontraindikationen verbessern die Effektivität bei einer Langzeittherapie. Die Leistungsfähigkeit ist unter einer Schmerztherapie mit Opioiden nicht zwangsläufig eingeschränkt, muss aber individuell überprüft werden. Unter Beachtung von Therapieregeln und einer regelmäßigen Therapiekontrolle können Opioide bei chronischen Schmerzen als ein Baustein eines interdisziplinären Therapiekonzepts sicher eingesetzt werden.

Der ethische und juristische Konsens gebietet das Recht eines jeden Menschen auf eine adäquate und effektive Schmerztherapie. Jedoch untersuchten nur wenige Studien die Besonderheiten derselben bei suchtmittelabhängigen bzw. abstinenten abhängigen Patienten. Suchtmittelabhängigkeit ist eine ungünstige Diagnose für eine erfolgreiche Schmerztherapie, da u. U. Medikamente verordnet werden, die eine gleichartige Abhängigkeit erzeugen können. Außerdem ergeben sich häufig Toleranzprobleme. Schließlich besteht die Gefahr einer iatrogenen Schmerzchronifizierung durch Nichtbeachtung bekannter Risikofaktoren und Komorbiditäten. Jedoch darf eine Suchterkrankung eine suffiziente Schmerztherapie nicht behindern, denn sie macht, wenn sie adäquat zur Pathophysiologie erfolgt, fast nie abhängig. Patienten mit einer Suchterkrankung können eine adäquate Schmerztherapie erhalten. Größte Erfolgsaussichten bestehen bei Beachtung der physiologischen und psychischen Besonderheiten von Suchterkrankten mit der Ausschöpfung verschiedenster multimodaler Therapieansätze sowie einer interdisziplinären Herangehensweise.

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.

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.