Markus Bleckwenn

Dependence on Prescription Opioids: Prevention, Diagnosis and Treatment

BACKGROUND The incidence of initial prescriptions of opioids for chronic non-cancer pain rose by 37% in Germany from 2000 to 2010. Prescribing practice does not always conform with the recommendations of current guidelines. In the USA, 8-12% of patients with chronic non-cancer pain are opioid-dependent. METHODS This review is based on publications retrieved by a selective PubMed search and on the German S3 guideline on the long-term use of opioids in non-cancer pain. RESULTS Patients must be informed and counseled about the effects and risks of opioids before these drugs are prescribed. All opioid prescriptions for patients with chronic non-cancer pain should be regularly reviewed. The risk of abuse is high in young adults (odds ratio [OR] = 6.74) and in those with a history of substance abuse (OR = 2.34). Any unusual medication-related behavior, e.g., loss of prescriptions or increasing the dose without prior discussion with the physician, calls for further assessment by the physician in conversation with the patient. Urine testing for drugs and their metabolites is helpful as well. The goal of treatment of opioid abuse is opioid abstinence by gradual reduction of the dose. If this is not possible on an outpatient basis, hospitalization for drug withdrawal or substitution-based addiction therapy can be offered. CONCLUSION Physicians who know the indications and risks of opioid therapy and the typical behavior of drug-dependent patients will be better able to identify patients at risk and to prevent dependence. Studies on the prevalence of opioid abuse and dependence in German patients with chronic pain can help provide better estimates of the current extent and implications of this problem in Germany.

Dringende Hausbesuche in Altenheimen – ein Status Quo aus hausärztlicher Sicht

AIM OF THE STUDY Due to demographic changes, home visits to nursing care facilities are increasing. Urgent home visits represent a challenge for general practitioners. There are no recommendations for the implementation of urgent home visits. Therefore, in this study, we investigated how GP practices deal with urgent home visits and what improvements can be made to the medical emergency care. METHODS A total of 15 teaching doctors of the Department of Family Medicine at the University of Bonn were interviewed using semi-structured interviews on the subject. We evaluated the interviews with the qualitative content analysis according to Mayring. RESULTS Urgent house visits were requested by telephone or fax. The home visits were carried out usually after the consultation hours during the lunch break of the doctors. General practitioners consider forwarding the request for a house visit to the rescue service as an absolute exception. At the nursing home, there were waiting times until the responsible nursing staff could do a joint emergency visit. In addition, there were clear differences in the qualifications of nurses and in dealing with emergencies. The physicians therefore saw improvements in their ability to provide further training to the nursing staff, to preventive house visits, and to assess the urgency of home visits. CONCLUSION To improve emergency care in elderly homes, the suggestions for improvement proposed by the family doctors should be tested in controlled studies. In addition, the cooperation between general practitioners and nursing homes could be strengthened by joint training in geriatric emergency care.

Treatment Options for Gout

BACKGROUND 1-2% of adults in Germany suffer from gout. Gout is one of the few rheumatological diseases that can be cured. It arises through the deposition of uric acid crystals in joints as a result of hyperuricemia. Painful redness and swelling of the affected joints are typical findings. Multiple pertinent guidelines and treatment recommendations have been published, but there is reason to believe that patients with gout are not always treated accordingly. METHODS This review is based on relevant publications from the years 2000-2016 that were retrieved by a selective search in the Cochrane and PubMed databases. RESULTS In a person with normal renal function, asymptomatic hyperuricemia is not an indication for treatment to lower the serum uric acid level. The drugs of first choice for acute gouty arthritis are nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and colchicine. Treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course; the target uric acid value is <6 mg/dL. Long-term treatment should be initiated only after resolution of the acute attack. For patients with refractory gout, lesinurad (approved in February 2016) in combination with XOI is a new treatment option that can be considered. Comprehensive patient education and counseling is an important component of the treatment of patients with gout. Regular laboratory follow-up is necessary as well. CONCLUSION The prevalence of gout is rising around the world. Patients with gout could benefit greatly from consistent implementation of the existing treatment guidelines and recommendations. In the future, controlled trials should be conducted to determine the best time to start treatment and the optimal target level for the serum uric acid concentration in terms of a risk/benefit analysis.

Hinterfragen Sie regelmäßig Indikation und Wirkung

Zusammenfassung„Und dann brauche ich noch ein neues Rezept für mein Schlaftablettchen!“ Sehr viele Patienten nehmen Schlaftabletten vom Benzodiazepintyp kritiklos, sozusagen aus Gewohnheit, über Jahre ein. Ob sie überhaupt noch wirken und ob eine eher kontraproduktive Abhängigkeit besteht — das wird viel zu selten überprüft.

Longitudinal Analysis of Outpatient Physician Visits in the Oldest Old: Results of the Agequalide Prospective Cohort Study

ObjectivesThe aim of this study was to identify determinants of outpatient health care utilization among the oldest old in Germany longitudinally.DesignMulticenter prospective cohort “Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe).SettingIndividuals in very old age were recruited via GP offices at six study centers in Germany. The course of outpatient health care was observed over 10 months (two waves).ParticipantsPrimary care patients aged 85 years and over (at baseline: n=861, with mean age of 89.0 years±2.9 years; 85–100 years).MeasurementsSelf-reported numbers of outpatient visits to general practitioners (GP) and specialists in the past three months were used as dependent variables. Widely used scales were used to quantify explanatory variables (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale, or Global Deterioration Scale).ResultsFixed effects regressions showed that increases in GP visits were associated with increases in cognitive impairment, whereas they were not associated with changes in marital status, functional decline, increasing number of chronic conditions, increasing age, and changes in social network. Increases in specialist visits were not associated with changes in the explanatory variables.ConclusionOur findings underline the importance of cognitive impairment for GP visits. Creating strategies to postpone cognitive decline might be beneficial for the health care system.

Misuse of Substitution Drugs in the Substitution-Based Therapy.

Background: The reasons for, and the extent of, misuse of prescribed substitution medication as well as parallel consumption of other drugs during substitution-based therapy have still not been adequately researched in Germany. Methods: This study examines the use of substitution medication in German substitution clinics utilizing a nationwide survey with anonymised questionnaires. Results: The analysis of the 605 questionnaires showed a 30-day consumption prevalence of 8.8% with regard to misuse of substitution substances. The lack of available heroin (38%) and the lack of open spots in treatment programs (21%) were quoted as being the main reasons for the misuse of substitution medication. Conclusion: Although the misuse of substitution medications is considered an important problem, our study showed that the current misuse was prevalent only among a minority of the patients. German regulations focused on the avoidance of misuse might be partially contributing to the problem.

Behandlung einer stillen Sucht

Mit großer Wahrscheinlichkeit haben Sie heute in Ihrer Praxis einen Patienten mit Medikamentenabhängigkeit gesehen. Haben Sie ihn als solchen erkannt? Wenn ja, wie haben Sie mit ihm über das Problem gesprochen? Hinterfragen Sie jedes neu ausgestellte Rezept? Der nachfolgende Beitrag gibt Tipps, wie Sie die oft „stille“ Medikamentensucht verhindern und behandeln können.

Eine der tödlichsten Suchterkrankungen

Horrorbilder von verfaulten Zähnen, Krebsgeschwüren und schwarzen Lungen sowie motivierende Sprüchen: All diese in den vergangenen Jahren in Deutschland ergriffenen Maßnahmen, die die Bevölkerung vom Griff zum Glimmstängel abhalten sollten, hatten nur mäßigen Erfolg. Was also hilft Rauchern tatsächlich, ihr Laster zu bewältigen?

Mild Depressive Symptoms Predict Mortality from Heart Failure in Elderly Men but Not Women

aged 60 and older, interrater reliability of the method was not assessed. Experience with the clinical vignette template and the CFS significantly improved interrater reliability ratings in the current study, so it is recommended that research teams interested in applying the CFS to retrospective chart data pilot the scale with 20 clinical vignettes and engage in discussions with seasoned geriatricians to determine potential sources of interrater variability before embarking on frailty research using medical records.

Prävention von Infekten der oberen Atemwege

Because of its high prevalence acute respiratory diseases have a significant impact on the population. The focus of this review was the current state of knowledge for the prophylactic efficacy of: zinc, vitamin C, Echinacea preparations, garlic and carrying out physical measures. Furthermore, the benefits of pneumococcal and influenza vaccine were elicited. In the synopsis, the physical measures proved to be the most effective, cost-effective method to prevent infections. The intake of zinc, Echinacea preparations (for example: E. purpurea), vitamin C and garlic showed moderate success in the prevention of infection and must be elicited individually. Pneumococcal and annual influenza vaccines in family practice should be given furthermore accordingly topical STIKO-recommendation. Nevertheless, the prophylactic effect from influenza vaccines on usual cold illnesses is unsettled.