Pain therapy, drug therapy

Author:Prof. Dr. med. Peter Altmeyer

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Last updated on: 20.05.2022

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DefinitionThis section has been translated automatically.

I.A. complex sensory perception (with a strong emotional component = pain experience) caused by excitation of pain receptors, often involving other senses (pressure-temperature sense). See also Table 1.

General definitionThis section has been translated automatically.

General guidelines for pain therapy:
  • Build up drug therapy step by step (do not "shoot the powder" immediately).
  • Observe intake intervals exactly.
  • Treat tumour patients adequately (quality of life should be significantly improved by pain therapy).
  • Before drug therapy, make full use of curative or palliative treatment options.
  • Avoid combination preparations.
  • Consider concomitant medication (e.g. laxatives in opioid therapy).
  • If necessary, consider necessary check-ups and mirror examinations (e.g. carbamazepine).
  • Do not use opiates as needed but according to the clock. Continuously monitored levels should prevent the pain from reoccurring. This pain-relieving therapy requires lower doses because the pain is not always treated.

ImplementationThis section has been translated automatically.

Step therapy depending on the underlying disease, see table 2

. Do not shy away from higher-dose therapy if the patient is in severe pain. 50-80% of tumor patients are insufficiently treated!

  • Opioids: Btm prescription for the prescription of opioids required. Apply for prescriptions at the Federal Institute for Drugs and Medical Devices Kurt-Georg-Kiesinger-Allee 3, 53175 Bonn, Germany (enclose certificate of approval). Enter drug name, dosage form and weight, number of units and prescription. Exceeding the permitted maximum quantity/day or the prescription periods (> 30 days) is possible, but mark prescription with "A" and report to the responsible district president.

    Remember! When using opioids always prescribe laxatives (e.g. Laxoberal Trp.)!

  • Adjuvant analgesics
    :Primary non-analgesic substances which, however, in combination with other analgesics, have an adjuvant analgesic effect, in particular:
    • Antidepressants, e.g. Amitriptyline (Sarotene) 25 mg/day p.o.
    • Anticonvulsants, e.g. carbamazepine (Tegretal) 400-800 mg/day p.o.
    • Neuroleptics, e.g. haloperidol (Haldol) 1-5 mg/day p.o.
  • Special measure: PCA (patient controlled anaesthesia) pump. The patient can control the administration of analgesics by himself depending on pain. Prior detailed instruction by pain therapists is necessary.
From a naturopathic point of view, St. John's wort (Hypericum) is a suitable antidepressant; the preparation "Jarsin" is particularly well known. Pain can be treated with willow bark (Assalix). Pain, especially muscle and bone pain, responds to devil's claw (Harpagophytum).

TablesThis section has been translated automatically.

Skin diseases and pain

Pain type by etiology

Associated diseases

Comments

Zoster pain

Nerve pain (e.g. as postzosteric pain)

Sudden, "electrifying" pain in the diseased area; also occurring as almost unbearable dull continuous pain.

Wound pain

Pain, postoperative

Bright, sometimes throbbing wound pain, limited to the surgical area.

Pain with ulcus cruris

Knocking, but also burning or stabbing continuous pain, limited to the wound area.

E.g. bullous pemphigoid, pemphigus, erythema exsudativum multiforme, Lyell syndrome.

Pain in wound areas due to epidermolytic processes.

Ischemic pain in AVK

Ulcus cruris arteriosum

Dull deep pain due to deficiency of blood supply (ischemia) intensified by movement and heat, diminished by rest and cold.

Infectious pain

E.g. erysipelas, boils, phlegmonous processes

Pain of varying intensity, limited to the area of inflammation, rarely referred, usually bright to the touch or pulsating continuous pain.

Burn pain

E.g. dermatitis solaris

Burning pain of varying intensity, limited to the area of inflammation, usually bright, persistent, intensified by touch.

Tumor pain

In metastatic tumors (e.g. malignant melanoma)

Bone pain: Circumscribed pain; often unbearable and lancinating. Initially movement-dependent, later also at rest.

Visceral pain: Diffuse, not exactly localizable pain, pressing, possibly crampy, often intolerable. Often hyperalgesia of skin areas.

Soft tissue pain: Dull, movement-dependent constant pain, often intolerable.

In benign skin tumors (e.g., amputation neuromas, leiomyomas, glomus tumor).

Circumscribed, bright, stabbing pain usually occurring only when pressure is applied specifically.

Pain associated with actinic keratosis

Keratosis actinica

Bright, stabbing touch pain sharply limited to the lesional area.

Pain in dermatitis herpetiformis

Dermatitis herpetiformis

Burning or stabbing, very bright interval pain limited to the efflorescence.

Pain in collagenoses

SLE, PSS

Rheumatic joint pain: movement-dependent, later also at rest (onset pain). Soft tissue pain: Dull, movement-dependent constant pain, often unbearable.

CDLE

Bright, stabbing touch pain sharply limited to the lesional area.

Pain in granulomatous inflammations

e.g. erythema nodosum

Bright, also stabbing, pressure and touch pain limited to the lesional area.

Pain in vasculitides, also in vasculitic ulcers

Vasculitis, leukocytoclastic (non-IgA-associated); polyarteritis nodosa

Bright, but also stabbing, lesional continuous or touch pain.

WHO grading scheme for severe pain

Active ingredient

Trade names

Daily dosage

[mg]

Duration of action

[hrs]

Important adverse effects

Step I

Paracetamol

Benuron

4-6 times 500-1000

4-6

pseudoallergic reactions

Acetylsalicylic acid

Aspirin

4-6 times 500-1000

4-6

pseudoallergic reactions, gastrointestinal ulcers

Ibuprofen retard

Exneural 800 retard

2 times 800

12

s. Acetylsalicylic acid

Naproxen

Proxen

2 times 500

12

s. Acetylsalicylic acid

Diclofenac retard

Voltaren retard

2 times 50-150

12

s. Acetylsalicylic acid

Metamizole

Novalgin (tbl., lsg., trp., injection lsg.)

4-6 times 500-1000

4-6

RR drop, leucopenia, agranulocytosis, anaphylatic shock

Stage II

Codeine

Codipront (caps., trp., juice)

6 times 50-100

4

Constipation, nausea, sedation, respiratory depression.

Dihydrocodeine retard

Paracodin N (syrup, trp., cps.)

2-3 times 60-180

8-12

s. Codeine

Tramadol retard

Tramal (Trp., Kps., Tbl., Injection-Lsg.)

23 times 100300

8-12

Nausea, vomiting, fatigue, sweating

Stage III

Morphine

MST (tbl.)

6 times 5-500

4

Constipation, urinary retention, nausea, vomiting, sedation, respiratory depression.

Levomethadone

L-polamidone

0.1-0.2 mg/kg bw

Initial: 4; after 2-3 doses: 6-12.

s. Morphine

Buprenorphine

Temgesic (tbl., injection solution)

3-4 times 0.2-1.2

6-8

s. Morphine

Fentanyl

Fentanyl TTS transdermal patch

0.6-12 (transdermal)

48-72

s. Morphine

Analgesic

Antiphlogistic

Antipyretic

Acetylsalicylic acid

+++

+

+++

Diclofenac

++

+++

+

Ibuprofen

++

+++

+

Paracetamol

+

-

+++

Metamizole

+++

+

+++

Celecoxib

++

+++

+

Flupirtine

++

-

-

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Last updated on: 20.05.2022