Articles: chronic.
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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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Treatment of chronic cancer pain with strong opioids is indicated in about 60-70 % of patients. Surprisingly, these very potent analgesics are prescribed with great reservations in many countries, including Germany. The aim of our investigation was to analyse the supply of opioid analgesics to outpatients with cancer pain in the region of Hannover, which has about 1.1 million inhabitants. ⋯ Our data indicate a significant undertreatment of outpatients suffering from cancer pain. Taking into account the estimated total number of patients suffering from cancer, only 14.5 % (1988) and 19.0 % (1991) of all outpatients in need of strong opioids were supplied sufficiently with those analgesics. Comparing the results from the observation period in 1988 with the results from 1991 it becomes obvious that the situation has not changed. There are different reasons for the insufficiency of opioid treatment: many physicians as well as their patients are still afraid of the side effects of strong opioids. Therefore, it is necessary to improve education concerning this issue. The legal restrictions on the use of narcotics and their complexity are another important reason for doctors not to prescribe strong opioids. In 1993 the regulations were simplified; nevertheless, this has not led to a profound change in the attitude of the prescribing practitioners. Thus, further changes in legislation seem to be necessary so that the requirements for the prescription of strong opioids do not differ from other drugs.
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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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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.
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There is a great need to expand current knowledge of the various functional capacity measurements used in the rehabilitation of chronic low back pain (CLBP) patients. The literature on these patients reports that mobility, endurance, trunk strength and lifting capacity decrease during the process of chronicity. Chronically disabled patients appear to have lower functional capacity than asymptomatic persons. ⋯ Study results showed that physical capacity in disabled patients with low back pain is substantially reduced in comparison to persons who do not suffer from back pain. The only exception was in trunk flexor strength and endurance, in which measurements did not differ between the patients and the control group. However, even CLBP- patients with long-term pain and severe physical illness can successfully improve their physical condition by participating in an active treatment program. Back extensor muscle training has to be included in physical therapy. Because of loss of condition during the time after treatment, regular monitoring of patients and their home training programs is necessary. Overall, treatment of CLBP has to include physical training and psychosocial treatment to achieve satisfactory results.