Der Schmerz
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Four multidimensional inventories used as instruments for the assessment of pain are examined: "Fragebogen zur Erfassung der Schmerzverarbeitung' [Questionnaire for Assessment of Level of Coping with Pain], "Kieler Schmerzverarbeitungs-Inventar' [Kiel Inventory of Coping with Pain], "Fragebogen zur Schmerzregulation' [Questionnaire on Pain Regulation], and the German version of the "Multidimensional Pain Inventory'. None of these questionnaires assesses all domains that are important in chronic pain. The recommended standardized assessment routine for pain centres includes the use of a diary, the rating of actual, average and maximum pain intensity, the application of the PDI, a measure of disability, and the FESV, which records cognitive processing and coping. As measures of general psychological dysfunction the ADS for the assessment of depression and the B-L, a symptom checklist, are suggested as instruments suitable for routine use in diagnosis and evaluation.
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The effects of combined spinal administration of alpha(2)-adrenoceptor agonists, local anaesthetics, and opioids have been extensively studied. The motor and the sensory block of spinal and epidural anaesthesia is enhanced and prolonged by the combination of clonidine with the local anaesthetics lidocaine, tetracaine and bupivacaine. Because higher plasma levels of local anaesthetics were measured when clonidine was injected epidurally, the enhancement of the local anaesthetic's effect by clonidine is not due to slowed resorption, but rather to direct spinal and supraspinal effects of clonidine. ⋯ Despite the sedative properties of clonidine, there is no increased risk of respiratory depression when clonidine is given in combination with opioids. The inhibiting effect on the sympathetic nervous system activity regularly observed during spinal administration of clonidine supports the value of this therapy and will support its use in the future. Therefore, the combination of alpha(2)-adrenoceptor agonists with local anaesthetics or opioids is reasonable and may improve anaesthetic practice.
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Long-term administration of morphine for the treatment of chronic pain produces constipation; this requires the use of laxatives, which impair water absorption and upset the electrolyte balance. Morphine-induced constipation is mainly due to inhibition of the propulsive movement of the gastrointestinal tract combined with spastic contraction of smooth circular muscles as a result of drug binding to opioid receptors in the tract. Since papaverine lacks affinity for opioid receptors but relaxes smooth muscle, it seemed possible that oral papaverine might be capable of diminishing constipation without impairing the analgesia achieved with morphine. ⋯ Since in former experiments on nociceptive activity evoked in thalamus neurones it has been found that the ED(50) of i. v. morphine is 0.05 mg/kg, it is very likely that the presystemic elimination of orally administered morphine is very high and, in addition, that the efficiency of its active metabolite, morphine-6-glucuronide, is rather poor. When morphine 2.5 mg/kg was given together with papaverine 0.5 mg/kg, and morphine 5 mg/kg was administered in combination with papaverine 2 mg/kg, there was no significant reduction in the depressant effect of morphine on nociceptive activity evoked in thalamus neurons (Figs. 6, 7). The results suggest that papaverine given by the oral route may reduce morphine-induced constipation without impairment of the analgesic action of morphine in patients suffering from pain.