Therapeutische Umschau. Revue thérapeutique
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The diagnosis and therapy of pain is routine in common practice of almost all clinical fields. Whilst acute pain may be controlled fairly easily, the treatment of chronic pain patients may be frustrating if conventional approaches for analgesia are chosen. Only a specialized and multidisciplinary procedure is beneficial for advanced stages of pain chronification. Precisely, an adequate treatment program has to consider biological, psychological and social aspects of chronic pain.
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Opioids do not yield adequate analgesic effects in at least one-third of all patients suffering from chronic pain. Nonetheless, in contrast to former opinion there is no type of pain that is principally resistant to opioids, which means that the individual patient's response to opioid administration has to be investigated to determine adequate treatment. Opioids fail most frequently in cases of neuropathic, osseous or sympathetically maintained pain. ⋯ A differential indication of the large number of possible coanalgesics should be determined with the help of a detailed pain history focussing on the pain quality. Similar to the WHO analgesic ladder used in (tumor) pain therapy, co-analgesic therapy should only be supplemented by invasive therapeutic procedures after various combinations and alternative substances have proven fruitless. Experience shows that this is necessary only for a small number of patients.
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Adequate control of postoperative pain does not only improve patient satisfaction, but is also indicated from a medical point of view. Besides conventional non-opioid analgesics and opioids, more sophisticated analgesia concepts like intravenous patient-controlled analgesia (PCA) and epidural analgesia may be indicated. ⋯ In conclusion, there is good evidence of improved analgesia from PCA and epidural analgesia. Data on outcome improvement by analgesia is still contradictory, but improvement of patient satisfaction is without doubt.
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Approximately 80% of all patients with chronic pain report current or past psychological impairment. That is why psychologists or psychosomatic specialists necessarily have to play a role in pain management. ⋯ A lot of different therapeutic approaches are used in clinical practice. Today the best evidence exists for relaxation techniques, behavioural therapy and analytical psychotherapy.
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Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. A painful stimulus elicits an activation of receptors in the periphery which transduce the stimulus into an electrical impulse. This electrical impulse is transmitted to the dorsal horn of the spinal cord and subsequently to the brain. ⋯ In parallel, endogenous control mechanisms, in which predominantly the opioid but also other systems are involved, counteract these pathological changes. Both the initiation of pain and its control can be regarded as the body's response to prevent further injury, to support wound healing, and to return to a normal function as quickly as possible. The transition from acute to chronic pain may critically depend on disturbances of the intrinsic pain control mechanisms as well as on effective therapeutic measures, initiated at the earliest possible time.