Georg Loick

Validation of the German version of the Brief Pain Inventory.

The Brief Pain Inventory is a comprehensive instrument for pain assessment and has been validated in several languages. A validated German version was not available until now. From March to May 1995 all outpatients of the pain clinic of the Department of Anesthesiology completed a questionnaire with the German versions of the Brief Pain Inventory (BPI) and the SF-36 quality-of-life questionnaire. The BPI was repeated after the consultation. The physician assessed the performance status score of the Eastern Cooperative Oncology Group (ECOG). The questionnaire was completed by 151 patients. Forty-two patients were excluded from evaluation for methodological reasons, so 109 patients were evaluated. As in the original version of the BPI, factor analysis showed a common factor for pain intensity and a second factor for pain-related interference with function. The comparative fit index of 0.86 confirmed this model. Responses before and after consultation correlated closely for the sum scores of the pain intensity items (Perarson correlation r = 0.976) as well as for the interference with function items (r = 0.974). Pain intensity in the BPI correlated with bodily pain in the SF-36 (r = 0.585). Sum scores of the pain interference items were higher in patients with deteriorated ECOG performance status, whereas sum scores of the intensity items were not changed. Validity and reliability of the German BPI were comparable to the original version. The BPI may be advantageous for palliative care patients, as it places only a small burden on the patient and offers easy criteria for evaluation. However, further research is needed to differentiate the impact of pain-related and disease-related interference with function on the BPI, and to find an algorithm for the evaluation of the BPI when values are missing.

Assessment and treatment of neuropathic cancer pain following WHO guidelines

Neuropathic pain syndromes are one of the major problems of cancer pain treatment. The present study surveys 593 cancer patients treated by a pain service following the WHO guidelines for relief of cancer pain. Of these, 380 presented with nociceptive, 32 with neuropathic and 181 with mixed (nociceptive and neuropathic) pain. In patients with nociceptive, mixed and neuropathic pain, the average duration of evaluated pain treatment was 51, 53 and 38 days, respectively. Non-opioid or opioid analgesics were given to 99%, 96% and 79%, antidepressants to 8%, 25% and 19%, anticonvulsants to 2%, 22% and 38% and corticosteroids to 26%, 35% and 22% of patients, respectively. Systemic analgesia was supported by palliative antineoplastic treatment (48%, 56% and 38% of patients), nerve blocks (3%, 6% and 6%), psychotherapy (3%, 7% and 3%), physiotherapy (6%, 12% and 13%) and transcutaneous electric nerve stimulation (1%, 6% and 6%). Analgesic treatment resulted in a significant pain relief in all groups of patients, as the mean pain intensity (NRS) decreased from 66 (nociceptive), 65 (mixed) and 70 (neuropathic) on admission to 26, 30 and 28 after 3 days and 18, 17 and 21 at the end of survey. The total outcome of pain treatment was not predicted by the designation to nociceptive, mixed or neuropathic pain. In conclusion, neuropathic cancer pain is not intractable and can be relieved in the majority of patients by treatment following the WHO guidelines.

Constipation and the use of laxatives: a comparison between transdermal fentanyl and oral morphine

Constipation and the use of laxatives were investigated in patients with chronic cancer pain treated with oral morphine and transdermal fentanyl in an open sequential trial. Forty-six patients were treated with slow-release morphine 30–1000 mg/day for 6 days and 39 of these patients were switched to transdermal fentanyl 0.6–9.6 mg/day with a conversion ratio of 100:1. Median fentanyl doses increased from 1.2 to 3.0 mg/day throughout the 30-day transdermal treatment period. Twenty-three patients completed the study. Two patients died from the basic disease while treated with transdermal fentanyl, 12 patients were excluded for various reasons, and not enough data for evaluation were available for two patients. Mean pain intensity decreased slightly after conversion although the number of patients with breakthrough pain or requiring immediate-release morphine as a rescue medication was higher with transdermal fentanyl. The number of patients with bowel movements did not change after the opioid switch but the number of patients taking laxatives was reduced significantly from 78–87% of the patients per treatment day (morphine) to 22–48% (fentanyl). Lactulose was used mainly and was reduced most drastically, but other laxatives were also used less frequently. In this study transdermal fentanyl was associated with a significantly lower use of laxatives compared to oral morphine. The difference in the degree of constipation between the two analgesic regimens should be confirmed in a randomized double-blind study that takes into account both constipation and use of laxatives.

High-Dose Tramadol in Comparison to Low-Dose Morphine for Cancer Pain Relief

Cancer pain treatment following the World Health Organization guidelines is effective and feasible. However, the evidence supporting the use of opioids for mild to moderate pain on the second step of the analgesic ladder is widely discussed. The present evaluation compares the efficacy and safety of high doses of oral tramadol (> or = 300 mg/d) with low doses of oral morphine (< or = 60 mg/d). Patients were included in this nonblinded and nonrandomized study if the combination of a nonopioid analgesic and up to 250 mg/d of oral tramadol was inadequate. 810 patients received oral tramadol for a total of 23,497 days, and 848 patients received oral morphine for a total of 24,695 days. The average dose of tramadol was 428 +/- 101 mg/d (range 300-600 mg/d); the average dose of morphine was 42 +/- 13 mg/d (range 10-60 mg/d). Additional nonopioid analgesics were given on more than 95% of days. Antiemetics, laxatives, neuroleptics, and steroids were prescribed significantly more frequently in the morphine group; the use of other adjuvants was similar in both groups. The mean pain intensity on a 0-100 numerical rating scale (NRS) was 27 +/- 21 (95% CI 26-29) in the tramadol and 26 +/- 20 (95% CI 24-27) in the morphine group (NS). The analgesic efficacy was good in 74% and 78%, satisfactory in 10% and 7%, and inadequate in 16% and 15% of patients receiving tramadol and morphine, respectively (NS). Constipation, neuropsychological symptoms, and pruritus were observed significantly more frequently with low-dose morphine; other symptoms had similar frequencies in both groups. These data suggest that tramadol can be used for the treatment of cancer pain, when nonopioids alone are not effective. High doses of tramadol are effective and safe.

Cognitive impairment and its influence on pain and symptom assessment in a palliative care unit: development of a Minimal Documentation System.

Symptom assessment in the palliative care unit must consider the reduced physical and mental status of the patients. Standardized instruments are often not completed by patients with cognitive impairment. We tried to combine minimal burden for patients and staff with sufficient information content in a Minimal Documentation System (MIDOS) for pain and symptom assessment in palliative care patients. From January to July 1998, 108 patients (123 consecutive admissions) with a mean age of 63 years (range 32–87 years) were admitted to the palliative care unit. Pain was reported as the reason for admission in 70% of the patients, and 71% were treated with opioids. Using a cut-off point of 20/21, 35% of the patients were impaired in the Mini Mental State Examination (MMSE). The number of missing values in the Brief Pain Inventory (BPI) and the quality-of-life questionnaire SF-12 correlated highly with each other and with the MMSE sum score, but not with the summary scores of BPI or SF-12. Only 31 patients completed the SF-12 quality-of-life questionnaire. Age was not correlated to MMSE scores, and neither were opioid doses for 26 patients with slow-release oral morphine or for 20 patients with transdermal fentanyl. Only a minority of patients was able to use the numerical scale for symptoms other than pain, though most patients were able to score symptom intensity on the verbal categorical scale. Pain and symptom assessments were performed by the physician for 17% of the patients at admission, and for 16% of the follow-up controls because self-assessment was not possible. In this study, cognitive impairment prevented symptom assessment with longer and more complicated instruments such as the SF-12 in a large number of the patients admitted to the palliative care unit. Assessment instruments for patients with advanced disease must provide simple categorical scales and the possibility of being administered by interview.

Temporal Presentation of Chronic Cancer Pain: Transitory Pains on Admission to a Multidisciplinary Pain Clinic

Transitory flares of pain are well-recognized events in both untreated and treated patients suffering from chronic cancer pain. For the purpose of this survey, we refer to transitory pain (TP) as any event subjectively characterized by transience and pain intensity over a baseline pain. In Part I, TP was reported by 243 (39%) of 613 consecutive cancer pain patients. Gender, age, tumor site, stage, and therapy were not related to the presence of TP. Neuropathic baseline pain was associated with a higher prevalence of TP (P < 0.0001). TP was somatic in 39%, visceral in 22%, and neuropathic in 36% of patients. TP intensity was severe or worse in 92% of patients. Neuropathic TP was briefer and occurred more frequently than nociceptive TP. In Part II, further features of TP were surveyed in 55 patients. Patients reported spontaneous occurrence of TP (40%), a relationship to movement (36%), to the analgesic regimen (35%), to coughing (11%), and to various other factors (18%). Only half of the movement-related TP were predictable. Rescue medication was at least partially effective in 75% of patients. Change in position, rest, diversion, and physiotherapy were commonly employed to alleviate TP. This survey outlined a framework to characterize TP that may prove useful to clarify the definition, pathophysiology, and prevalence of these pains.

Intravenous titration with morphine for severe cancer pain: report of 28 cases.

BACKGROUND In a multicenter study, 28 patients with cancer pain and insufficient pain relief with analgesic treatment according to step II of the guidelines of the World Health Organization (WHO) were switched to oral slow-release morphine. METHODS Patients received intravenous morphine through a patient-controlled pump (PCA) for the first 24 hours (bolus = 1 mg, lockout interval = 5 minutes, maximum dose = 12 mg/hour). From day 2 patients were treated with oral slow-release morphine. Daily doses were calculated from the requirements of the day before. Breakthrough pain was treated with PCA until stable doses were reached (<2 boluses/day) and then with oral immediate-release morphine solution. Pain intensity was reported in a diary four times a day, in addition to mood, activity, and quality of sleep once daily. RESULTS Mean duration until adequate pain relief reported (<30 on a 101-step numerical scale; NRS) was 5 hours (range = 80-620 minutes). Mean pain intensity was reduced from 67 NRS to 22 NRS. Mean doses of oral morphine were 133 mg/day initially and then 154 mg/day on day 14. Serious adverse events such as respiratory depression were not observed. Two patients terminated the study due to progressive symptoms of gastrointestinal obstruction. Seventy-five percent of the patients evaluated the effectiveness of the analgesic regime as good. CONCLUSIONS Dose finding with intravenous PCA may be appropriate for a small minority of patients with severe pain. Higher treatment costs and the risk of complications are drawbacks of this method compared with conventional oral titration.

Entwicklung und Stand der stationären palliativmedizinischen Einrichtungen in Deutschland

Zusammenfassung. Im April 1999 gab es in Deutschland insgesamt 114 stationäre palliativmedizinische Einrichtungen (50 Palliativstationen, 64 Hospize). Verglichen mit 1993 bedeutet dies einen Anstieg von 256%, gegenüber dem Stand von 1997 immerhin noch 60%. Die Bettenkapazität wurde seit 1997 um 58% auf 989 Betten gesteigert. Dies entspricht einem Bettenangebot von 12 Betten/1 Mio. Einwohner. Doch trotz der deutlichen Zunahme an stationären Einrichtungen besteht weiterhin ein erhebliches Defizit; die Verteilung der Stationen über die einzelnen Bundesländer ist äußerst inhomogen, der geschätzte Bettenbedarf von 50 Betten/1 Mio. Einwohner wird noch immer nicht annähernd erreicht. Zusätzlich bestehen hinsichtlich einiger Qualitätsmerkmale (Personalschlüssel, interdisziplinäre Zusammenarbeit, Dokumentation, Fortbildung) deutliche Defizite und auch erhebliche Unterschiede zwischen Hospizen und Palliativstationen. Der von der Deutschen Gesellschaft für Palliativmedizin für Palliativstationen geforderte Personalschlüssel von mindestens 1,4 Pflegestellen/Bett wird nur von 18% der Stationen erfüllt. Nur wenige Hospize und die Hälfte der Palliativstationen kooperieren mit einer Schmerzambulanz.Abstract. In April 1999 altogether 114 inpatient units providing palliative care (50 palliative care units, 64 inpatient-hospices) offered a total of 989 beds. Compared to 1993 this has been an increase of 256%, compared to 1997 of 60%. The number of available beds, compared to 1997, increased markedly (58%), with a availability of 12 beds per one million residents. However, there are still major deficits: the distribution of the units is very irregular and the number of available beds is still to low, compared to the estimated need of 50 inpatient beds per one million residents. The quality of palliative care shows significant deficits (e. g. the availability of nursing staff, cooperation with pain clinics, standardised documentation, education). Differences between palliative care wards and hospices were huge. According to the definition of the German Society for Palliative Care, a palliative care ward should provide a ratio of at least 1.4 nursing staff per bed, however, only 18% of the palliative care units fulfil this definition. Only few hospices and half of the palliative care units worked in close cooperation with pain clinics. Despite a significant increase in units and inpatient beds providing palliative care, there still is a major deficit in the overall number of beds and the quality of palliative care.

Opioidwechsel auf transdermales Fentanyl im klinischen Alltag

ZusammenfassungEinleitung: Transdermales Fentanyl gewinnt in der Tumorschmerztherapie zunehmend an Bedeutung. Wir beschreiben die Gründe für eine Umstellung einer Opioidtherapie auf transdermales Fentanyl in einer universitären Schmerzambulanz. Material und Methode: Retrospektiv wurden die Krankenakten der Patienten untersucht, die in unserer Schmerzambulanz mit transdermalem Fentanyl behandelt worden waren. Die Umrechnungsfaktoren wurden aus den Opioiddosierungen vor und nach dem Wechsel ermittelt. Die Schmerzstärke wurde anhand der Numerischen Ratingskala (NRS 0: kein Schmerz, 10: nicht stärker vorstellbarer Schmerz) gemessen. Ergebnisse: Von Oktober 1995 bis Dezember 1997 wurden 101 Patienten mit transdermalem Fentanyl behandelt. 36 dieser Patienten waren schon zum Aufnahmezeitpunkt auf transdermales Fentanyl eingestellt. Von einem weiteren Patienten lagen nur unvollständige Unterlagen vor, so daß die Umstellung auf transdermales Fentanyl bei 64 Patienten ausgewertet werden konnte. Von diesen wurden 53 stationär und 11 ambulant auf transdermales Fentanyl umgestellt. 48% der Patienten waren mit retardiertem Morphin, 17% mit nicht-retardiertem Morphin, 11% mit Buprenorphin, 11% mit Tramadol, 5% mit Levomethadon, 5% mit Tilidin/Naloxon und 3% mit Piritramid vorbehandelt. Gründe für die Umstellung auf transdermales Fentanyl waren die unzureichende Schmerzreduktion (33%), der Wunsch des Patienten nach oraler Medikamentenreduktion (20%), gastrointestinale Nebenwirkungen wie Übelkeit (31%), Erbrechen (13%) und Obstipation (19%), Schluckbeschwerden (27%) oder andere. Eine Reduktion der Nebenwirkungen gaben 10 von 19 Patienten mit dokumentierten Nebenwirkungen an. 12 von 21 Patienten, die wegen unzureichender Schmerzreduktion umgestellt worden waren, berichteten nach Umstellung auf transdermales Fentanyl eine Abnahme der Schmerzintensität. Diskussion: Die Umstellung einer Opioidtherapie auf transdermales Fentanyl führte bei der Hälfte der Patienten entweder zu einer besseren Schmerzreduktion oder zu einer Verminderung der Nebenwirkungen. In der Literatur sind Umrechnungsfaktoren von oralem retardierten Morphin zu transdermalem Fentanyl von 70:1–100:1 beschrieben, was durch unsere Auswertungen bestätigt wird. Umrechnungsfaktoren von anderen Opioiden auf transdermales Fentanyl werden vorgeschlagen.AbstractIntroduction: The use of transdermal fentanyl is gaining in importance in the management of cancer pain. We describe the reasons for switching opioid medication to transdermal fentanyl in a pain management unit. Methods: Case records of patients treated with transdermal fentanyl in our pain clinic were evaluated retrospectively. Conversion ratios were calculated from the opioid dosage before and after conversion. Pain intensities were assessed on a numeric rating scale (NRS 0: no pain, 10: worst pain imaginable). Results: From October 1995 to December 1997 101 patients received transdermal fentanyl. Thirty-six patients had been treated with transdermal fentanyl before admission to our pain clinic, and relevant information was missing for one patient, so 64 patients were evaluated. Opioid therapy was switched to transdermal fentanyl during in-patient treatment for 53 patients and during out-patient treatment for 11 patients. Before conversion patients were treated with slow-release morphine (48%), immediate-release morphine (17%), buprenorphine (11%), tramadol (11%), levomethadone (5%), tilidine/naloxone (5%) and piritramid (3%). Reasons for opioid rotation were inadequate pain relief ( 33%), the patients’ wish to reduce oral medication (20%), gastrointestinal side effects such as nausea (31%), vomiting (13%) and constipation (19%), dysphagia (27%) or others. Reduction of side effects was reported by 10 of 19 patients . In 12 of 21 patients, in whom the medication was switched because of inadequate pain relief, a reduction in pain intensity was reported. Discussion: Conversion to transdermal therapy may readjust the balance between opioid analgesia and side effects. The opioid switch resulted in more pain relief or fewer side effects in half of the patients. A proposed equianalgesic conversion ratio between 70:1 and 100:1 from oral slow-release morphine to transdermal fentanyl can be confirmed by our data. Conversion rates from other opioids to transdermal fentanyl are suggested.

Das Kölner Internet-Schmerzmanual

ZusammenfassungZiel. Die Verbesserung der Versorgung von ambulanten Patienten, die unter chronischen Kopf- oder Tumorschmerzen leiden. Methodik. Verbreitung anerkannter Leitlinien und Standards über das Internet, um diese im niedergelassenen Bereich bekannter zu machen und zudem Patienten den Zugriff auf diese Informationen zu erleichtern. Ergebnisse. Es entstand ein Internet-Schmerzmanual, auf das in einem Zeitraum von 33 Monaten ca.9100 Leser zugegriffen haben.Das Manual wurde 279-mal komplett heruntergeladen.Ärzte und Patienten auf der Suche nach Informationen über Kopfschmerz benutzten besonders häufig Suchmaschinen. Die am meisten nachgefragten Begriffe waren “Migräne” und “Spannungskopfschmerz”. Schlussfolgerung. Es lohnt sich, medizinische Informationen für das Internet aufzubereiten und dort der Allgemeinheit zur Verfügung zu stellen.AbstractObjective. The improvement of ambulant treatment for patients with chronic headache or cancer pain. Methods. Distribution of accepted guidelines and standards by means of the internet in order to make this knowledge known among general practitioners and to give patients better access to this information. Results We have built an internet manual about the treatment of chronic headache and cancer pain.About 9100 readers accessed the manual during a period of 33 month.The manual has been completely downloaded 279 times.Physicians and patients very often used search engines to access the manual in their search for information about headache.The terms “migraine” and “tension type headache” were looked up the most. Conclusions. It is worthwhile editing medical information for use on the internet and thus making it available to the public.