Pain therapy, drug therapy

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 20.05.2022

Definition
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I.A. complex sensory perception (with a strong emotional component = pain experience) caused by excitation of pain receptors, often involving other senses (pressure-temperature sense). See also Table 1.

General definition
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General guidelines for pain therapy:

Build up drug therapy step by step (do not "shoot the powder" immediately).
Observe intake intervals exactly.
Treat tumour patients adequately (quality of life should be significantly improved by pain therapy).
Before drug therapy, make full use of curative or palliative treatment options.
Avoid combination preparations.
Consider concomitant medication (e.g. laxatives in opioid therapy).
If necessary, consider necessary check-ups and mirror examinations (e.g. carbamazepine).
Do not use opiates as needed but according to the clock. Continuously monitored levels should prevent the pain from reoccurring. This pain-relieving therapy requires lower doses because the pain is not always treated.

Implementation
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Step therapy depending on the underlying disease, see table 2

. Do not shy away from higher-dose therapy if the patient is in severe pain. 50-80% of tumor patients are insufficiently treated!

Opioids: Btm prescription for the prescription of opioids required. Apply for prescriptions at the Federal Institute for Drugs and Medical Devices Kurt-Georg-Kiesinger-Allee 3, 53175 Bonn, Germany (enclose certificate of approval). Enter drug name, dosage form and weight, number of units and prescription. Exceeding the permitted maximum quantity/day or the prescription periods (> 30 days) is possible, but mark prescription with "A" and report to the responsible district president.
Remember! When using opioids always prescribe laxatives (e.g. Laxoberal Trp.)!
Adjuvant analgesics
:Primary non-analgesic substances which, however, in combination with other analgesics, have an adjuvant analgesic effect, in particular:

Antidepressants, e.g. Amitriptyline (Sarotene) 25 mg/day p.o.
Anticonvulsants, e.g. carbamazepine (Tegretal) 400-800 mg/day p.o.
Neuroleptics, e.g. haloperidol (Haldol) 1-5 mg/day p.o.

Special measure: PCA (patient controlled anaesthesia) pump. The patient can control the administration of analgesics by himself depending on pain. Prior detailed instruction by pain therapists is necessary.

From a naturopathic point of view, St. John's wort (Hypericum) is a suitable antidepressant; the preparation "Jarsin" is particularly well known. Pain can be treated with willow bark (Assalix). Pain, especially muscle and bone pain, responds to devil's claw (Harpagophytum).

Tables
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Skin diseases and pain

Pain type by etiology	Associated diseases	Comments
Zoster pain	Nerve pain (e.g. as postzosteric pain)	Sudden, "electrifying" pain in the diseased area; also occurring as almost unbearable dull continuous pain.
Wound pain	Pain, postoperative	Bright, sometimes throbbing wound pain, limited to the surgical area.
	Pain with ulcus cruris	Knocking, but also burning or stabbing continuous pain, limited to the wound area.
	E.g. bullous pemphigoid, pemphigus, erythema exsudativum multiforme, Lyell syndrome.	Pain in wound areas due to epidermolytic processes.
Ischemic pain in AVK	Ulcus cruris arteriosum	Dull deep pain due to deficiency of blood supply (ischemia) intensified by movement and heat, diminished by rest and cold.
Infectious pain	E.g. erysipelas, boils, phlegmonous processes	Pain of varying intensity, limited to the area of inflammation, rarely referred, usually bright to the touch or pulsating continuous pain.
Burn pain	E.g. dermatitis solaris	Burning pain of varying intensity, limited to the area of inflammation, usually bright, persistent, intensified by touch.
Tumor pain	In metastatic tumors (e.g. malignant melanoma)	Bone pain: Circumscribed pain; often unbearable and lancinating. Initially movement-dependent, later also at rest.
		Visceral pain: Diffuse, not exactly localizable pain, pressing, possibly crampy, often intolerable. Often hyperalgesia of skin areas.
		Soft tissue pain: Dull, movement-dependent constant pain, often intolerable.
	In benign skin tumors (e.g., amputation neuromas, leiomyomas, glomus tumor).	Circumscribed, bright, stabbing pain usually occurring only when pressure is applied specifically.
Pain associated with actinic keratosis	Keratosis actinica	Bright, stabbing touch pain sharply limited to the lesional area.
Pain in dermatitis herpetiformis	Dermatitis herpetiformis	Burning or stabbing, very bright interval pain limited to the efflorescence.
Pain in collagenoses	SLE, PSS	Rheumatic joint pain: movement-dependent, later also at rest (onset pain). Soft tissue pain: Dull, movement-dependent constant pain, often unbearable.
Pain in collagenoses	CDLE	Bright, stabbing touch pain sharply limited to the lesional area.
Pain in granulomatous inflammations	e.g. erythema nodosum	Bright, also stabbing, pressure and touch pain limited to the lesional area.
Pain in vasculitides, also in vasculitic ulcers	Vasculitis, leukocytoclastic (non-IgA-associated); polyarteritis nodosa	Bright, but also stabbing, lesional continuous or touch pain.

WHO grading scheme for severe pain

Active ingredient	Trade names	Daily dosage [mg]	Duration of action [hrs]	Important adverse effects
Step I
Paracetamol	Benuron	4-6 times 500-1000	4-6	pseudoallergic reactions
Acetylsalicylic acid	Aspirin	4-6 times 500-1000	4-6	pseudoallergic reactions, gastrointestinal ulcers
Ibuprofen retard	Exneural 800 retard	2 times 800	12	s. Acetylsalicylic acid
Naproxen	Proxen	2 times 500	12	s. Acetylsalicylic acid
Diclofenac retard	Voltaren retard	2 times 50-150	12	s. Acetylsalicylic acid
Metamizole	Novalgin (tbl., lsg., trp., injection lsg.)	4-6 times 500-1000	4-6	RR drop, leucopenia, agranulocytosis, anaphylatic shock
Stage II
Codeine	Codipront (caps., trp., juice)	6 times 50-100	4	Constipation, nausea, sedation, respiratory depression.
Dihydrocodeine retard	Paracodin N (syrup, trp., cps.)	2-3 times 60-180	8-12	s. Codeine
Tramadol retard	Tramal (Trp., Kps., Tbl., Injection-Lsg.)	23 times 100300	8-12	Nausea, vomiting, fatigue, sweating
Stage III
Morphine	MST (tbl.)	6 times 5-500	4	Constipation, urinary retention, nausea, vomiting, sedation, respiratory depression.
Levomethadone	L-polamidone	0.1-0.2 mg/kg bw	Initial: 4; after 2-3 doses: 6-12.	s. Morphine
Buprenorphine	Temgesic (tbl., injection solution)	3-4 times 0.2-1.2	6-8	s. Morphine
Fentanyl	Fentanyl TTS transdermal patch	0.6-12 (transdermal)	48-72	s. Morphine

	Analgesic	Antiphlogistic	Antipyretic
Acetylsalicylic acid	+++	+	+++
Diclofenac	++	+++	+
Ibuprofen	++	+++	+
Paracetamol	+	-	+++
Metamizole	+++	+	+++
Celecoxib	++	+++	+
Flupirtine	++	-	-