Articles: treatment.
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The prescription of strong opioid by general practitioners was studied, particularly for the treatment of chronic pain. In a medium-sized town (around 250 000 inhabitants) 17,839 prescriptions of strong opioids were issued by 455 doctors over 5 years (1 January 1990 until 31 December 1994) to 1,939 patients. Of these patients 37.8-48.3 % of them received only one prescription for 6 months, 60.5-75.8 % received between 1 and 4 prescriptions for 6 months, and only 20.9-35.7 % of all patients received 5 or more prescriptions for 6 months. ⋯ In order to safeguard the quality of medical care for pain treatment by strong opioid analgesics, unbiased training of physicians and a clear definition of narcotics is required. It is suggested that the expression "narcotic prescription" be changed related to the legislative terminology in the pharmacology-related expression "analgesic prescription". The prescribing regulations should not constrain medical treatment, but create a basic rule for the prescription of strong opioids.
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According to WHO guidelines, morphine is the first choice for the treatment of chronic cancer pain, preferably as a controlled-release preparation administered orally. The WHO classifies the quality of pain management of a particular country by its morphine consumption for medical reasons. For this article, data from clinical and market research were collected. ⋯ The report also focuses on physicians' subjective viewpoints and prejudices. When strong opioids are only rarely prescribed, a general practitioner then has difficulties in assessing pain and possible side effects and treatment evaluation. Clinical research, too, is hampered by special regulations concerning controlled opioid administration.
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The present legal requirements for the prescription of controlled drugs remains an impediment to adequate therapy for chronic pain because of an abundance of legal regulations. The physician prescribing opioids must consider the permitted maximum amount per prescription, the period of time the drug is prescribed for, numerous cross references, and other special regulations, and he still cannot be sure that he does not violate certain legal requirements. Often these difficulties result in withholding necessary pain treatment. ⋯ It is important that the use of the narcotic be justified in the sense of paragraph 13 Abs. 1 of the drug control regulation, as judged by the responsible prescriber of the drug, and that any offence be punished. The use of triplicate prescriptions guarantees sufficient proof. Legislation is requested that will substitute for the present drug control regulations, which are difficult to handle.
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In spite of the fact that the treatment of pain is highly developed, outpatient care of patients suffering from chronic pain is frequently insufficient. In particular general practitioners often refrain from prescribing the necessary pain therapy with opioids. Because of the contract regarding medical treatment, however, the patient has a legal claim to adequate pain treatment, if necessary by administration of opioids. ⋯ Now that the legal and administrative conditions for prescribing opioids have been consolidated, the main objective is to exhaust the possibilities of prescription for the benefit of patients suffering from pain in a better way. This is first and foremost, an organizational and technical task of the medical professional group. In particular, training and continuing education in the field of pain therapy must be further developed without delay.
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The majority of authors agree today that psychosocial factors have more influence on a successful treatment of chronic back pain than other variables, in particular medical findings. Therefore treatments aim to integrate psychotherapeutic intervention in order to lessen emotional impairment, to change behavioral patterns (which advocate rest and the avoidance of physical activity), and to change cognitive attitudes and fears concerning exercise and work ability. Nevertheless, the interplay of cognitive measures and disability in treatment programs still remains an unclear issue. ⋯ An analysis of coping dimensions demonstrated that current cognitive measures might be too general to explain low back disability adequately. In addition, the results indicate that the use of the 'catastrophizing' factor as a separate variable is questionable, since it may simply be a symptom of depression. The relevance of coping as a sensitive parameter for change is also addressed. It is suggested that an alteration in coping strategies may be an important treatment effect, but is subject to individual prerequisites to maximize treatment response. Thus, future research must focus on the complex interactions between personality variables, environmental factors, and the coping demands posed by the specific nature of pain problems. A more lengthy evaluation of so-called 'fear-avoidance beliefs' in combination with 'disability' and coping dimensions could possibly lead to further treatment on the development of chronicity in chronic low back pain patients.