Schmerz最新文献

Background: The importance of opioids in the treatment of non-cancer pain is under debate. No current data are available from Germany on the prevalence of opioid treatment for non-cancer pain.

Aim of the study: Data on the prevalence of short- and long-term opioid prescriptions for patients without cancer, prescribed agents, co-medication, specialty of prescribing physicians, demographic and clinical characteristics of patients.

Materials and methods: Retrospective analysis of billing data of adult BARMER-insured persons without evidence of cancer (N = 6,771,075) in 2021 and for patients initiating opioid therapy in 2019 (n = 142,598).

Results: In total, 5.7% of the insured persons without a cancer diagnosis received at least one prescription for an opioid in 2021, while 1.9% received long-term therapy. Tilidine and tramadol were the most frequently prescribed opioids in short- and long-term therapy. Women received opioids more frequently than men. The frequency of prescriptions significantly increased with age. In 2021, 22.5% of insured persons with long-term opioid therapy received a co-medication with pregabalin and/or gabapentin, 37.5% with an antidepressant and 58.1% with metamizole and/or NSAIDs. A total of 59.5% of first prescriptions were issued by general practitioners. In the first year of therapy, an average of 2.1 practices were involved in prescribing analgetics for people on long-term opioid therapy and 13 different chronic diseases were documented.

Discussion: Opioid therapy for non-cancer-related pain is predominantly carried out by general practitioners in older and multi-morbid patients. The indication for or against opioid therapy requires shared decision-making with patients and, if necessary, their relatives, as well as a review of possible drug interactions.

Background: The importance of dysfunctional coping strategies in the chronification of pain is well documented. The avoidance endurance model (AEM) has proven to be well-suited which, according to initial clinical experiences, is also well-suited to depicting dysfunctional illness behavior in post-COVID syndrome (PCS, COVID coronavirus disease). The aim of this study is to demonstrate which patterns occur and how frequently in PCS patients and whether they change in the context of multimodal rehabilitation.

Method: As part of the PoCoRe multicenter study, N = 481 PCS rehabilitation patients were examined with respect to illness behavior according to the AEM at the start and end of rehabilitation. Frequency analyses, χ²-tests and Sankey diagrams were used.

Results: At the start of rehabilitation around 81.8% of PCS patients exhibited dysfunctional illness behavior, of which 57.7% were dysfunctional endurers (distress endurance response), in 24.1% fear avoidance was present, in 10.0% eustress endurance and in 8.2% an adaptive response. Over the course of rehabilitation the behavioral patterns shifted by 8.8% towards adaptive response and by 12.7% to eustress endurance, which mainly comes from the former distress endurance types (-6.7%). Fear avoidance decreased by approx. 4.8%. Within the individual AEM reaction patterns, dysfunctional patterns can change in favor of functional patterns as well as functional patterns in favor of dysfunctional patterns.

Conclusion: The clear predominance of dysfunctional patterns in this highly chronified sample suggests that the avoidance endurance concept is also relevant in the chronification of fatigue in PCS. In contrast to chronic pain patients, however, the endurance patterns clearly predominate here. There was a clear shift towards the functional pattern during rehabilitation, which speaks in favor of modifiability; however, around 10-15% of patients developed in an unfavorable direction, which should be taken into account in treatment planning and investigated further.

Migraine is the most frequent neurological disorder and has a prevalence of 10-14% of the population. In addition to the frequency and the fact that it is usually manifested in adolescence, the frequent comorbid illnesses are also the cause of the high burden associated with migraine. Diseases from very different functional areas are associated with the presence of migraine. In general, this increased risk is more pronounced in the presence of migraine with aura and in women. For example, migraine is associated with a higher risk of developing stroke, heart attack, arterial hypertension, depression, anxiety disorder and probably dementia syndromes. The article presents the most important epidemiological studies on a number of these comorbid diseases. It is unclear what the neurobiological basis is for this accumulation of comorbid diseases in migraine. In addition to the purely coincidental cooccurrence in individual cases, other factors can be responsible for the increased risk: a shared genetic background, e.g. in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) or epileptic seizures, or treatment of a primary independent chronic disease (e.g. treatment with phosphodiesterase inhibitors, hormone substitution therapy or beta-interferon therapy). Another cause, which is discussed more broadly here, is inflammatory mechanisms, which are found in both the triggering of migraine and in a variety of comorbid diseases. This applies primarily to all chronic inflammatory diseases such as rheumatoid arthritis but also to depression and cardiovascular diseases. So far, these findings have not had any influence on the treatment of migraine but this may change in the future with a better understanding of the molecular mechanisms (e.g. activation of microglia).

There is a close bidirectional relationship between chronic pain and psychological trauma disorders, which frequently results in more intense suffering and greater impairment for those affected. This article elucidates the intricate interrelationships between chronic pain, early childhood stress, and traumatic experiences as well as the underlying neurobiological, neuroimmunological and psychosocial mechanisms. Early childhood trauma, such as abuse or neglect, has a significant impact on individuals during particularly vulnerable phases of development, leading to long-lasting changes at various levels. The influence of trauma on pain perception is twofold: it increases the prevalence of chronic pain and intensifies pain and suffering. Therapeutically, interventions that target the hyperactive threat system and strengthen the hypoactive soothing system are essential. The article discusses evidence-based models of pain-trauma interaction and presents therapeutic approaches such as Eye Movement Desensitization Reprocessing (EMDR), Emotional Awareness and Expression Therapy (EAET), and psychodynamic interventions that are promising in the treatment of trauma-associated chronic pain.

Background: Antibodies against CGRP or its receptor (eptinezumab, erenumab, fremanezumab, galcanezumab, from here on: "CGRP(R) antibodies") are modern migraine preventives. German statutory health insurance covers CGRP(R) antibodies only for patients refractory to other preventive therapies. Thus, the effect of this regulation on patient selection was investigated, as well as the effect of a change of insurance coverage for erenumab in October 2022.

Methods: In total, 759 patients with CGRP(R) antibody treatment were compared with 961 patients prescribed nonspecific oral migraine preventive medicines (amitriptyline, betablocker, flunarizine, topiramate) from the DMKG Headache Registry.

Results: Patients with CGRP(R) antibodies had more prior preventive therapies that were insufficiently effective or tolerated compared to patients prescribed nonspecific oral preventive medicines (p < 0.001). Moreover, they had longer disease duration (p < 0.001), more often suffered from chronic migraine (p = 0.002), had more severe headache days (p = 0.004) and acute medication days (p = 0.04), lower quality of life (p < 0.05), more comorbidities (p = 0.001), and fewer of them were working (p < 0.001). After change of insurance coverage, treatment with erenumab shifted towards less refractory patients (p < 0.001) with shorter disease duration (p < 0.001), who were less severely affected compared to patients with other CGRP(R) antibodies (e.g., headache days p = 0.01; disability p = 0.005).

Conclusion: CGRP(R) antibodies are prescribed for to patients affected by exceedingly severe migraine. Insurance coverage has a significant effect on use of medicines for migraine prevention.

Background: Persistent pain, one of the most common reasons for suffering and health care seeking, often co-occurs with emotional problems such as depression and anxiety. Within the Center for Health and Medical Psychology at Örebro University, Sweden, we have developed a new treatment aimed at addressing co-occurring persistent pain and emotional problems: hybrid emotion-focused exposure treatment. The overarching idea behind the treatment is that patients who struggle with comorbid pain and emotional problems need to develop skills in dealing with emotions as well as pain. With better skills in tolerating and soothing difficult emotions, patients will be more able to approach previously avoided stimuli and situations, such as movements, activities and social interaction.

Objectives: This review aims to delineate the development of the hybrid emotion-focused exposure treatment. It begins by outlining the theoretical background, then proceeds to describe the techniques, discuss the evidence and conclude with an illustrative case example.

Results: Thus far, the treatment has been tested in a single-case study and a randomized controlled trial with promising outcomes. Overall, the hybrid treatment seems to have a good effect on patients' depressive symptoms and pain interference. The treatment is currently being implemented, and the implementation process evaluated, in primary and specialist care across Sweden.

Conclusions: The hybrid emotion-focused exposure treatment seems to be a well-suited treatment for people with a high burden of persistent pain and emotional difficulties. There is good reason to implement the treatment in clinical practice and continue evaluating treatment effects across different contexts.

Background: Chronic pain affects millions of people worldwide. Nociplastic pain in particular, characterized by central sensitization and a dysfunctional alarm system, requires innovative therapeutic approaches.

Objective: This review introduces pain reprocessing therapy (PRT) as a promising psychotherapeutic approach to specifically disrupt the pain-fear-pain cycle. The theoretical background, practical implementation, and effectiveness, evidence, and feasibility of this new therapeutic method for treating nociplastic conditions are described and discussed.

Results: PRT enables patients to develop a new understanding of pain and break the pain-fear-pain cycle. Studies and clinical experience demonstrate that this method can achieve a significant reduction in pain intensity.

Discussion: PRT provides an innovative framework for treating chronic pain by combining evidence-based methods and enhancing patient self-efficacy. It has the potential to integrate the biopsychosocial model more effectively into practice and transform the paradigm of pain therapy. Challenges include the diagnostic differentiation of nociplastic pain, the required paradigm shift, and the need for training and time resources. However, studies show promising results for sustainable, patient-centered pain therapy.