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In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: U. Kaiser, L. Schouten, G. Hoffmann, A. Preissler, F. Adler, L. Zinndorf, A. Kästner, B. Metz-Oster, E. Höfner, G. Lindena, T. Kohlmann, S. Meyer-Moock, D. Szczotkowski, C. Geber, F. Petzke, L. Milch und A. Gärtner geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2025. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Health services research looks at a form of care under contextual conditions. Often, and especially in the treatment of recurrent or chronic pain, these forms of care are complex interventions. Ensuring internal validity for subsequent interpretability of the results achieved as an essential requirement for studies in health services research therefore presents researchers with the challenge that they have to develop complex study protocols and implement and monitor them in clinical care. By its very nature, interdisciplinary multimodal pain therapy (IMST) involves multimodal interventions in an interdisciplinary care setting. In the reality of care, contextual factors for the effectiveness and feasibility of IMST are of great importance. On the one hand, health services research provides appropriate recommendations for the planning, implementation and evaluation of studies on complex interventions under contextual conditions, which can be of great importance for further research into the effectiveness of IMST. On the other hand, experience from interdisciplinary pain research can also help to successfully plan and conduct studies on complex interventions. This article introduces the understanding of interdisciplinarity (and interprofessionalism) in pain medicine and research, outlines possible key points for study planning and implementation using the example of two health services research studies and concludes by discussing gaps in research on interdisciplinary collaboration in pain medicine and research., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: Die Autorinnen L. Schouten und U. Kaiser erhalten für die Umsetzung der beiden vorgestellten Projekte Förderungen durch den Gemeinsamen Bundesausschuss (G-BA) in PAIN2020 (01NVF17049) sowie in PAIN 2.0 (01NVF20023). S. Berger, F. Mauz, F. Petzke und A. Kurz geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2025. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like., Competing Interests: Declarations. Conflict of interest: U. Kaiser, L. Schouten, G. Hoffmann, A. Preißler, F. Adler, L. Zinndorf, A. Kästner, B. Metz-Oster, E. Höffner, G. Lindena, T. Kohlmann, S. Meyer-Moock, D. Szczotkowski, C. Geber, F. Petzke, L. Milch and A. Gärtner declare that they have no competing interests. For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case. The supplement containing this article is not sponsored by industry., (© 2025. The Author(s).)

Background: The importance of opioids in the treatment of non-cancer pain is under debate. No current data are available from Germany on the prevalence of opioid treatment for non-cancer pain., Aim of the Study: Data on the prevalence of short- and long-term opioid prescriptions for patients without cancer, prescribed agents, co-medication, specialty of prescribing physicians, demographic and clinical characteristics of patients., Materials and Methods: Retrospective analysis of billing data of adult BARMER-insured persons without evidence of cancer (N = 6,771,075) in 2021 and for patients initiating opioid therapy in 2019 (n = 142,598)., Results: In total, 5.7% of the insured persons without a cancer diagnosis received at least one prescription for an opioid in 2021, while 1.9% received long-term therapy. Tilidine and tramadol were the most frequently prescribed opioids in short- and long-term therapy. Women received opioids more frequently than men. The frequency of prescriptions significantly increased with age. In 2021, 22.5% of insured persons with long-term opioid therapy received a co-medication with pregabalin and/or gabapentin, 37.5% with an antidepressant and 58.1% with metamizole and/or NSAIDs. A total of 59.5% of first prescriptions were issued by general practitioners. In the first year of therapy, an average of 2.1 practices were involved in prescribing analgetics for people on long-term opioid therapy and 13 different chronic diseases were documented., Discussion: Opioid therapy for non-cancer-related pain is predominantly carried out by general practitioners in older and multi-morbid patients. The indication for or against opioid therapy requires shared decision-making with patients and, if necessary, their relatives, as well as a review of possible drug interactions., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: V. Lappe und I. Schubert erhielten für die PMV forschungsgruppe (Uniklinik Köln) Drittmittel durch die BARMER, D. Grandt erhielt Honorare von der BARMER, U. Marschall ist Angestellte der BARMER, F. Petzke und W. Häuser haben keine materiellen Interessenkonflikte, sie sind Mitautoren der LONTS-Leitlinie. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s).)

Background: Pain medicine is an interdisciplinary and interprofessional field of specialisation. Due to concerns about new recruits and an aging workforce, especially among physicians, it is important to better understand professional and career pathways in pain medicine., Objectives: The aim of this study was to record the occupational routes of people working in an institution specialised in pain medicine/pain management as well as their motivation and job satisfaction., Materials and Methods: A standardised online questionnaire was used to survey members via cooperating scientific societies and organisations., Results: Data from 398 physicians, 78 psychologists, 62 physiotherapists, three occupational therapists and 23 nursing professionals were included in the analysis. The age distribution skewed towards higher age groups, with the majority of respondents aged between 51 and 60 years. The respondents usually first came into clinical contact with pain medicine after many years of work. In the case of physicians in particular, there was a delay of almost a decade after their licence to practise. With regard to motivational factors, intrinsic aspects were rated higher than monetary ones. Work-life balance issues tended to be in the middle of the ranking. Regarding job satisfaction in pain medicine, the overall satisfaction of the respondents was high, with the lowest satisfaction ratings being given in the categories "opportunities for further career development", "additional income options" and "recognition by superiors". A significant proportion of respondents (1/3) stated that career changes were forthcoming-changes outside a pain medicine setting or in particular retirement., Conclusions: The results emphasise the critical perspectives regarding the future provision of care for people with chronic pain. The results provide, for the first time, an insight into the career routes of staff in the field of pain medicine and their motivations and job satisfaction, which should be considered in the discussion about ensuring personnel resources in the future., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: J. Erlenwein: Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V., Nürnberg (Mitglied engeres Präsidium, Sektionssprecher Schmerzmedizin, 1. Sprecher Wiss. AK Schmerzmedizin), Deutsche Schmerzgesellschaft e. V., Berlin (Mitglied des ständigen Beirats, 2. Sprecher AK Akutschmerz, Ad-hoc-Kommission Kongressfortbildung); Konsortialpartner G‑BA Innovationsfonds Projekt POET-Pain. D. Boujong: Vorsitzender Arbeitsgemeinschaft schmerztherapeutischer Einrichtungen in Bayern e. V. (ASTiB). J. Nadstawek: Vorsitzender Berufsverband der Ärzte und Psychologischen Psychotherapeuten in der Schmerz- und Palliativmedizin in Deutschland e. V. (BVSD). M. Hüppe: Mitglied des ständigen Beirats der Deutschen Schmerzgesellschaft e. V., Geschäftsführer der Akademie für Schmerzpsychotherapie der DGPSF. T.P. Jürgens: Vizepräsident der Deutschen Migräne- und Kopfschmerzgesellschaft e. V., Sprecher Ad-hoc-Kommission Kongressfortbildung, Deutsche Schmerzgesellschaft e. V. und Deutsche Migräne- und Kopfschmerzgesellschaft e. V. W. Meißner: Vorstandsmitglied der Deutschen Schmerzgesellschaft e. V., Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V., Nürnberg (Mitglied Wiss. AK Schmerzmedizin). F. Petzke: Vorstandsmitglied der Deutschen Schmerzgesellschaft e. V., Tätigkeiten in Arbeitskreisen und Kommissionen, z. B. Ad-hoc-Kommission KEDOQ-Schmerz, Cannabis in der Medizin, Konsortialpartner G‑BA Innovationsfonds Projekt PAIN2020, PAIN 2.0; BMBF-Projekt WorkHealth; Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V., Nürnberg (Mitglied Wiss. AK Schmerzmedizin). B. Kube gibt an, dass kein Interessenkonflikt besteht. Entsprechend der Thematik und den kooperierenden Verbandspartnern ist ein Interessenkonflikt bzgl. der berufspolitischen Vertretung und Förderung der Schmerzmedizin unvermeidlich. Der Studiencharakter machte eine genehmigende Beratung einer Ethikkommission nicht erforderlich (Ethik-Kommission Göttingen Nr. 111024)., (© 2024. The Author(s).)

Background and Objective: Chronic pain requires graduated and staged levels of care. The aim of this study is to provide a regional overview regarding the accessibility of specialized outpatient and (partial) inpatient pain medicine care from the patient's perspective in Germany., Material and Methods: For 1000 model patients randomly generated from German postal code location combinations, the travelling time by car (individual transport, IT) and available public transport connections (PTC) to the nearest specialized outpatient and inpatient pain medicine clinics and units were assessed using a route planner., Results: Outpatient facilities (in a practice setting) were mostly realistically accessible depending on the proportion of pain treatment and the networking structure. University pain outpatient clinics were at a critically reachable distance with IT for 70% of the patients (80% with PTC) and had unrealistic accessibility for 49% of the patients with IT (68% with PTC). Interdisciplinary multimodal pain programs in day clinics were at a critically reachable distance for 68% of patients with IT (83% with PTC) and in 49% (75% PTC) at an unrealistic travelling time distance considering the more intense treatment requiring frequent travel. Full inpatient interdisciplinary multimodal treatment was more realistically reachable (IT 39% critical, 14% unrealistic, PTC 61% critical, 48% unrealistic)., Conclusion: The results show relevant nationwide differences in the accessibility of facilities for specialized pain treatment depending on the place of residence. Considering the treatment of a chronic condition with long-term therapeutic goals and the need for graduated care (outpatient and inpatient treatment), the results reveal a partly critical situation from the patient's perspective., (© 2024. The Author(s).)

Objective: This study investigated the efficacy of combining at-home anodal transcranial direct current stimulation (tDCS) of the left primary motor cortex (M1) with mindfulness meditation (MM) in fibromyalgia patients trained in mindfulness., Methods: Thirty-seven patients were allocated to receive ten daily sessions of MM paired with either anodal or sham tDCS over the primary motor cortex. Primary outcomes were pain intensity and quality of life. Secondary outcomes were psychological impairment, sleep quality, mood, affective pain, mindfulness level, and transcranial magnetic stimulation (TMS) measures of cortical excitability. Outcomes were analyzed pre- and post-treatment, with a one-month follow-up., Results: We found post-tDCS improvement in all clinical outcomes, including mindfulness level, except for positive affect and stress, in both groups without significant difference between active and sham conditions. No significant group*time interaction was found for all clinical and TMS outcomes., Conclusions: Our findings demonstrate no synergistic or add-on efffect of anodal tDCS of the left M1 compared to the proper effect of MM in patients with fibromyalgia., Significance: Our findings challenge the potential of combining anodal tDCS of the left M1 and MM in fibromyalgia., (Copyright © 2024 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Secondary preventive outpatient diagnostic services for patients with pain and risk factors for chronification have not yet been sufficiently established. In the PAIN2020 project (Innovation Fund, 01NVF17049) an outpatient interdisciplinary multimodal assessment (IMA) was introduced for the first time early in the course of the disease., Objective: For the implementation of the IMA procedures for team cooperation and decision criteria were developed, which were implemented by a team of medical, physiotherapeutic and psychological therapists. These procedures and decision criteria are to be discussed against the background of clinical experience and examined with respect to their feasibility (qualitative)., Methods: In PAIN2020 a workshop on IMA was held in September 2021 to jointly reflect on the findings and experiences gained in the process so far through monitoring and structuring documentation in the implementation with staff or teams of PAIN2020 centers on the feasibility of implementing a structured interdisciplinary multimodal assessment. In three work phases, occupational group-specific and cross-occupational group topics were addressed., Results: In the decision-making processes of the occupational groups, in addition to profession-specific focal points within the framework of the assessment of findings (somatic, functional or psychosocial core criteria), overarching core criteria within the professions as well as complementary patient-related aspects are evident, which are included in the integrative team process. With respect to team collaboration, the implementation of the team meeting and the final discussion can be used to identify structural and process parameters that promote or inhibit implementation, which are also accompanied by interactional factors., Discussion: For the implementation of the IMA, there were (1) adaptations of the IMA, which is currently implemented as A‑IMA in the selective agreement with BARMER and (2) new dimensions or task fields and ideas for evidence-based concepts for the content design of integrative diagnostics as well as for the feedback of the results to the patients, which should be discussed in the future., (© 2024. The Author(s).)

In the endeavor to advance our understanding of interindividual differences in dealing with chronic pain, numerous motivational theories have been invoked in the past decade. As they focus on relevant, yet different aspects of the dynamic, multilevel processes involved in human voluntary action control, research findings seem fragmented and inconsistent. Here we present Personality Systems Interactions theory as an integrative meta-framework elucidating how different motivational and volitional processes work in concert under varying contextual conditions. PSI theory explains experience and behavior by the relative activation of four cognitive systems that take over different psychological functions during goal pursuit. In this way, it may complement existing content-related explanations of clinical phenomena by introducing a functional, third-person perspective on flexible goal management, pain acceptance and goal maintenance despite pain. In line with emerging evidence on the central role of emotion regulation in chronic pain, PSI theory delineates how the self-regulation of positive and negative affect impacts whether behavior is determined by rigid stimulus-response associations (i.e., habits) or by more abstract motives and values which afford more behavioral flexibility. Along with testable hypotheses, multimodal interventions expected to address intuitive emotion regulation as a central process mediating successful adaptation to chronic pain are discussed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Kästner and Petzke.)

Background: In PAIN2020 (Innovation Fund, 01NVF17049), an outpatient interdisciplinary multimodal assessment (IMA) was introduced early in the course of the disease. The central quality feature is the close interdisciplinary collaboration of pain medicine, physiotherapy and psychology, which requires a complex organizational and coordination process, especially in team meetings and final discussions., Objectives: The (different) views of the professional groups involved are brought together in the team process as a common consensus. The process of shaping the interaction of the professional groups among each other in the team meeting and final discussion as well as with the patients is examined (qualitatively) and discussed., Methods: In PAIN2020, a workshop on IMA was held to jointly reflect on the insights and experiences gained in the process so far through monitoring with staff or teams of the PAIN2020 centers. In one of three work phases, interprofessionally composed groups gathered statements from participants on the design of the interaction in team meeting and final discussion in three rotating rounds within the framework of a World Café., Results: It was possible to identify conducive and obstructive factors for the design of interdisciplinary collaboration in team meetings and final discussions, which were brought together in a superordinate framework model., Discussion: The provision of the new care service as an interdisciplinary task in a team goes beyond existing structural and process parameters in the definition of framework conditions in interdisciplinary multimodal pain therapy and should therefore also take personal competencies and professional competencies into account. Therefore, new dimensions arise for the implementation of the IMA, which should be discussed in the future., (© 2023. The Author(s).)

Purpose: Substance use disorders (SUD) are a challenging comorbidity in patients with chronic non-cancer pain (CNCP) as they complicate diagnosis and therapy, especially when opioids are part of the therapeutic regimen. A definite diagnosis of opioid use disorder (OUD) in patients with CNCP on long-term opioid therapy (LTOT) is a prerequisite for effective and targeted therapy but may be complicated as some criteria of OUD might be attributed to the desire of the patient to relieve the pain. For instance, the desire to increase the dose can be based on both a SUD as well as inadequate pain therapy. Many scientific studies use standardized questions. Therefore, potential misunderstandings due to possible diagnostic overlaps often cannot be clarified., Methods: 14 qualitative guided interviews were conducted and analyzed (Kuckartz content analysis), with the intention to verify if patient's initial response to simple questions based on the wording of the DSM-5, as commonly used in research and practice, were consistent with the results of a more in-depth inquiry., Results: The results suggest that without in-depth investigation, there is a particular risk of false-positive assessment of the DSM-5 criteria for OUD when opioids are prescribed, especially when the questions are considered independently of chronic pain. The risk of a false-negative assessment has also been shown in isolated cases., Conclusion: Only after asking for and describing specific situations it was possible to determine whether the patient's positive or negative answers were based on a misunderstanding of the question. To avoid misdiagnosis, staff conducting DSM-5 interviews should be trained in pain-specific follow-up questions that may help to uncover diagnostic confounding., Competing Interests: W. Häuser and F. Petzke collaborated on the German S3 guidelines on long-term opioid therapy for chronic non-cancer pain. W. Häuser has received a lecture fee from Janssen-Cilag and the Falk Foundation. N. Scherbaum has received honoraria for several activities (eg, advisory board membership, lecture, manuscripts) from AbbVie, Camurus, Hexal, Janssen-Cilag, MSD, Medice, Mundipharma, Reckitt-Benckiser/Indivior, and Sanofi-Aventis. During the last three years he has participated in clinical trials financed by the pharmaceutical industry. The other authors declare no conflicts with regard to the manuscript., (© 2024 Kufeld et al.)

Background: Up to 27% of the German population suffers from recurrent or persistent pain (lasting more than three months). Therefore, prevention of chronic pain is one major object of pain management interventions. The aim of this nationwide, multicentre, randomised controlled trial is to evaluate the efficacy of a 10-week ambulatory (outpatient) interdisciplinary multimodal pain therapy (A-IMPT) for patients with recurrent pain and at risk of developing chronic pain. This project was initiated by the German Pain Society (Deutsche Schmerzgesellschaft e.V.) and the public health insurance provider BARMER. It is currently funded by the German Innovation Fund (01NVF20023). The study PAIN2.0 focuses on reducing pain intensity and pain-related disability and investigates whether this intervention can improve physical activity, psychological well-being, and health literacy., Methods: PAIN2.0 is designed as a multicentre 1:1 randomised controlled trial with two parallel groups (randomisation at the patient level, planned N = 1094, duration of study participation 12 months, implemented by 22 health care facilities nationwide). After 6 months, patients within the control group also receive the intervention. The primary outcomes are pain intensity and pain-related impairment, measured as Characteristic Pain Intensity (PI) and Disability Score (DS) (Von Korff), as well as patient-related satisfaction with the intervention. Secondary outcomes are the number of sick leave days, sickness allowance, treatment costs, psychological distress, health-related quality of life, and catastrophizing. The effects of the intervention will be analysed by a parallel-group comparison between the intervention and control groups. In addition, the long-term effects within the intervention group will be observed and a pre-post comparison of the control group before and after the intervention will be performed., Discussion: Recurrent or persistent pain is common in the German population and causes high costs for patients and society. The A-IMPT aims to improve pain and pain-related impairments in pain patients at risk of chronification, thereby reducing the risk of developing chronic pain with its high socioeconomic burden. This new therapy could easily be integrated into existing therapy programs if positively evaluated., Trial Registration: The trial PAIN2.0 has been registered in the German Clinical Trials Register (DRKS) since 21/11/2022 with the ID DRKS00030773 ., (© 2024. The Author(s).)

The quality of postoperative pain management is still considered insufficient in many cases, also in surgical ophthalmology. Complex constellations and comorbidities, such as pre-existing chronic pain, opioid consumption and opioid use disorders represent a special challenge due to psychosocial influencing factors and sometimes psychological and psychiatric comorbidities but also due to pharmacological effects, such as the development of opioid tolerance, the opioid-induced hyperalgesia. This review article aims to impart knowledge on aspects of these comorbidities and the perioperative management to improve the treatment skills of ophthalmologists in the management of pain in these complex patients., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Numerous conditions in the field of ophthalmology are associated with pain in or around the eye. Chronic pain associated with the eye is a common finding in the daily routine of ophthalmologists and can be associated with primary ocular or extraocular diseases as well as with other conditions. Appropriate diagnostic assessment and management of people with chronic pain requires an understanding of the condition based on the biopsychosocial model in which the interactions of biological/somatic, psychological and social factors are determining pain and suffering. Beyond the ophthalmological findings,  close interdisciplinary cooperation and assessment are required. Therefore, if eye pain is insufficiently responsive to treatment or if symptoms of chronic pain are evident, pain medicine expertise should be involved. The management of chronic ocular pain is based on interdisciplinary multimodal approaches, in addition to the ophthalmologist-specific approaches. These focus on self-efficacy, patient competence and acceptance of pain as central goals of treatment rather than pain relief. Patient information, education and the development of a suitable concept by the interdisciplinary team are essential therapeutic aspects in this context., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: Previous neuroimaging studies have shown that patients with chronic pain display altered functional connectivity across distributed brain areas involved in the processing of nociceptive stimuli. The aim of the present study was to investigate how pain chronification modulates whole-brain functional connectivity during evoked clinical and tonic pain., Methods: Patients with osteoarthritis of the hip (n = 87) were classified into 3 stages of pain chronification (Grades I-III, Mainz Pain Staging System). Electroencephalograms were recorded during 3 conditions: baseline, evoked clinical hip pain, and tonic cold pain (cold pressor test). The effects of both factors (recording condition and pain chronification stage) on the phase-lag index, as a measure of neuronal connectivity, were examined for different frequency bands., Results: In women, we found increasing functional connectivity in the low-frequency range (delta, 0.5-4 Hz) across pain chronification stages during evoked clinical hip pain and tonic cold pain stimulation. In men, elevated functional connectivity in the delta frequency range was observed in only the tonic cold pain condition., Conclusions: Across pain chronification stages, we found that widespread cortical networks increase their synchronization of delta oscillations in response to clinical and experimental nociceptive stimuli. In view of previous studies relating delta oscillations to salience detection and other basic motivational processes, our results hint at these mechanisms playing an important role in pain chronification, mainly in women., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objective: An early treatment of patients who suffer from pain and show risk factors for chronification is meaningful as these patients can benefit from an early interdisciplinary multimodal pain treatment (IMST). In view of the insufficient treatment, two outpatient treatment modules for the secondary prevention of pain chronification are developed within the framework of PAIN2020: the educative and accompanying IMST (E‑IMST and B‑IMST)., Material and Methods: The developmental process of both IMSTs is presented. In this context two target groups of patients were defined for which 1 session (E‑IMST) or 10 intervention appointments (B‑IMST) were planned, depending on the chronification, impairment and complexity of the disorder. The conception was carried out in five steps: development of the objectives, development of the main contents, workshop on the content and conceptional design (contents, mediation, exercises), preparation of a time schedule and processing of the results (manual, presentations, worksheets, handbook). The B‑IMST was initially developed from which the contents for the E‑IMST were subsequently extracted. Additionally, a concept for testing the feasibility and a working model for a pilot study were developed., Results: The objectives for both forms of IMST are improvement of the understanding of pain and contributing factors, the increase of the experience of control and self-efficacy and the increase in self-responsibility with respect to strategies to reduce pain. Differences between the two treatment modules arise from the needs and framework conditions. Medical, physiotherapeutic and psychotherapeutic contents and schedules were organized for both IMST modules. The B‑IMST consists of five modules each with two sessions as group interventions (biopsychosocial model, activation planning, regulation of needs, sleep and medication, routine transfer). The 3‑h E‑IMST group intervention mainly intends to mediate knowledge on pain and the biopsychosocial pain model. Theoretical and practical interventions, empirical knowledge and experience-oriented methods are employed., Conclusion: There are now two interdisciplinary structured manuals for the secondary preventive treatment of patients with recurrent pain and a risk profile for chronification. These approaches must now prove themselves with respect to feasibility and effectiveness., (© 2023. The Author(s).)

Background: Low intensity transcranial electrical stimulation (tES) and meditation are two promising, yet variable, non-pharmacological interventions. Growing research is investigating combined effects of both techniques on one's cognitive, emotional, and physical health., Objective: This article reviews the current research that combines tES and meditation interventions in healthy and diseased participants. The review considers the intervention parameters and their effects in a well-organized manner., Method: A systematic search for clinical and experimental published studies was conducted in the PubMed, Cochrane, and transcranial direct current stimulation (tDCS) databases using common keywords for tES and for meditation techniques well defined by previous studies. Unpublished ongoing studies were identified with the ClinicalTrials.gov and DRKS.de clinical trial websites., Results: 20 published studies and 13 ongoing studies were included for qualitative analysis. 13 published articles studied patients with chronic pain, psychological disorders, cognitive impairment, and movement disorders. Anodal tDCS was the only tES technique while mindfulness meditation was the most common meditation type. Eight studies had a main group effect, with outcome improvement in the active combined intervention. However, most published studies showed improvements after at least one combined intervention with variable effects., Conclusion: Pairing anodal tDCS with meditation shows promising improvements of the physical, mental, and emotional aspects of daily life. Further studies are required to confirm the relevance of this combination in the clinic., (© 2023 The Authors.)

Introduction: Most patients with amputation (up to 80 %) suffer from phantom limb pain postsurgery. These are often multimorbid patients who also have multiple risk factors for the development of chronic pain from a pain medicine perspective. Surgical removal of the body part and sectioning of peripheral nerves result in a lack of afferent feedback, followed by neuroplastic changes in the sensorimotor cortex. The experience of severe pain, peripheral, spinal, and cortical sensitization mechanisms, and changes in the body scheme contribute to chronic phantom limb pain. Psychosocial factors may also affect the course and the severity of the pain. Modern amputation medicine is an interdisciplinary responsibility., Methods: This review aims to provide an interdisciplinary overview of recent evidence-based and clinical knowledge., Results: The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme., Discussion: Consequent prevention and treatment of severe postoperative pain and early integration of pharmacological and nonpharmacological interventions are required to reduce severe phantom limb pain. To obtain or restore body function, foresighted surgical planning and technique as well as an appropriate interdisciplinary management is needed., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background and Objective: A major concern with cannabis-based medicines (CbM) and medical cannabis (MC) is the risk of abuse and dependence. The face validity of the International Classification of Diseases (ICD-10) criteria for cannabis dependence in patients prescribed CbM for chronic pain has not been assessed., Databases and Data Treatment: Physicians from Canada, Germany and Israel were recruited via the mailing lists of national pain societies. To be eligible, physicians had to have prescribed CbM for chronic pain treatment in the past 12 months. Participants were asked to rate the appropriateness of items adapted from the substance use module of the Composite International Diagnostic Interview Version 3.0 to assess dependence in the context of chronic pain treatment with CbM and the appropriateness of two additional items. In case of disagreement, participants were asked to give reasons. Furthermore, they were asked to suggest potential additional criteria., Results: On average 69.0% of 178 participating physicians indicated agreement with the appropriateness of the ICD-10 criteria, while 20.6% indicated disagreement. The highest disagreement rate was observed for the item on repeated use despite legal problems (35.4% disagreement or strong disagreement). Reasons for disagreement were summarized into six content categories using qualitative methods of analysis. Additional criteria suggested by participants were summarized into 10 content categories., Conclusions: A collaboration of psychiatrists and pain physicians is required to define criteria and develop instruments to capture abuse and dependence of CbM in chronic pain patients., Significance: Sixty-nine per cent of 178 pain medicine physicians in Canada, Germany and Israel who participated in a survey on the appropriateness of the ICD-10 criteria for cannabis abuse and dependence for patients prescribed cannabis-derived products for chronic pain assessed the criteria as appropriate, whereas 20.6% deemed the criteria as not appropriate., (© 2023 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®.)

Background: This double-blinded, randomized and sham-controlled pilot clinical trial aimed to investigate the preliminary clinical efficacy and feasibility of combining mindfulness meditation (MM) and transcranial direct current stimulation (tDCS) for pain and associated symptoms in patients with fibromyalgia syndrome (FMS)., Methods: Included FMS patients (age: 33 to 70) were randomized to three different groups to receive either ten daily sessions of anodal tDCS over the left primary motor cortex paired with MM for 20 min (active + MM, n = 10), sham tDCS combined with MM (sham + MM, n = 10) or no intervention (NoT, n = 10). Patients in the bimodal therapy groups received a week of training in MM prior to the stimulation. Participants reported pain intensity, the primary outcome, by filling in a pain diary daily throughout the whole study. They were also evaluated for quality of life, pressure pain sensitivity, psychological wellbeing, sleep quality and sleep quantity. Assessments were performed at three time points (baseline, immediately after treatment and one-month follow-up)., Results: Participants in the active + MM group did not exhibit reduced pain intensity following the bimodal therapy compared to controls. Patients in active group demonstrated clinically meaningful and significantly higher quality of life following the therapeutic intervention than other groups. There was no significant difference among groups regarding pressure pain sensitivity, sleep parameters and psychological scales. The combined treatment was well tolerated among participants, with no serious adverse effects., Conclusion: This study was the first to pair these two effective non-pharmacological therapies for pain management in FMS. In the light of an underpowered sample size, repetitive anodal tDCS combined with MM did not improve pain or FMS-associated symptoms. However, patients in the active + MM group reported higher quality of life than the control groups. Studies with more participants and longer follow-ups are required to confirm our findings., Clinical Trial Registration: [www.drks.de], identifier [DRKS00023490]., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ramasawmy, Khalid, Petzke and Antal.)

Identifying the objective stiffness of the neck muscles facilitates the early and specific diagnosis of neck pain and targeted therapy. However, individual variation in the muscle shear modulus obscures differences between healthy and diseased individuals. Normalization may improve the comparability between individuals. The shear modulus at different functional tasks served as a reference for normalizing the neck muscles' shear modulus of 38 women, 20 with chronic neck pain and 18 asymptomatic. Reference tasks were maximal voluntary contraction , relaxed sitting , prone head lift , balancing 1 kg on the head, and neck extension at 48 N . The effects of normalization on within-group variation and between-group differences were compared. Normalization with maximal voluntary contraction was discarded due to imaging problems. Normalization with relaxed sitting , prone head lift , balancing 1 kg , and neck extension at 48 N reduced within-group variation, by 23.2%, 26.8%, 11.6%, and 33.6%, respectively. All four normalization approaches reduced the p -values when testing for between-group differences. For the pain group, normalization with relaxed sitting and head lift indicated less normalized muscle stiffness, while normalization with balancing 1 kg and extension at 48 N indicated higher stiffness. The contradictory results are explainable by non-significant group differences in the reference tasks. Normalization of the muscle shear modulus is effective to reduce within-group variation, but a trustworthy normalization approach for group comparisons has yet to be identified.

Background: Areas of activity with many intersections pose an increased risk for errors and critical incidents. Therefore, procedures for acute pain therapy are potentially associated with an increased risk for adverse patient outcomes., Objective: The aim was to identify and grade the risk of critical incidents in the context of acute pain management., Material and Methods: The register of the nationwide reporting system critical incident reporting system of the Professional Association of German Anesthesiologists, the German Society for Anesthesiology and Intensive Care Medicine and the Medical Center for Quality in Medicine (CIRSmedical Anesthesiology) was screened for incidents concerning pain management. Out of 5365 cases reported nationwide up to 24 March 2020, 508 reports with the selection criterion "pain" could be identified and reviewed and 281 reports (55%) were included in a systematic analysis., Results: Of the 281 reports most came from anesthesiology departments (94%; 3% from surgery departments and 3% from other departments). The reported cases occurred most frequently on normal wards but a relevant proportion of the reports concerned intermediate and intensive care units or areas covered by a pain service (PS). Based on the description of the incident in the report, an involvement of the PS could be assumed for 42% of the cases. In terms of time, most of the events could be assigned to normal working hours (90%) and working days (84%; weekends 16%). The analyzed reports related to parenteral administration of analgesics (40%) and central (40%) or peripheral regional anesthesia procedures (23%) and 13% of the reports related to patient-controlled intravenous analgesia (PCIA; multiple answers possible). Most of the events were caused by technical errors, communication deficits and deviations from routine protocols. A relevant number of the cases were based on mix-ups in the administration route, the dosage, or the active agent. About one third of the sources of error were of an organizational nature, 59% of the cases posed a possible vital risk and in 16% of cases patients had vital complications. The risk grading by risk matrix resulted in an extremely high risk in 7%, a high risk in 62%, a moderate risk in 25% and a low risk in 6% of the cases. Comparing risk assessment of events with involvement of different analgesic methods, multiple medication, combination of analgesic methods or involvement of PS showed no significant differences. Likewise, no differences could be identified between the risk assessments of events at different superordinate cause levels. If more than one overriding cause of error had an impact, initially no higher risk profile was found., Conclusion: Incidents in the context of acute pain management can pose high risks for patients. Incidents or near-incidents are mostly related to mistakes and lack of skills of the staff, often due to time pressure and workload as well as to inadequate organization., (© 2021. The Author(s).)

Background: The pressure on physicians when a patient seeks pain relief and their own desire to be self-effective may lead to the prescription of strong opioids for chronic noncancer pain (CNCP). This study, via physician self-reporting, aims to identify and measure (i) physician adherence to national opioid prescribing guidelines and (ii) physician emotions when a patient seeks a dosage increase of the opioid. Methods: Within a cross-sectional survey—conducted as part of a randomized controlled online intervention trial (ERONA)—600 German physicians were queried on their opioid prescribing behavior (choice and formulation of opioid, indications) for CNCP patients and their emotions to a case vignette describing a patient seeking an opioid dosage increase without signs of objective deterioration. Results: The prescription of strong opioids in this study was not always in accordance with current guidelines. When presented with a scenario in which a patient sought to have their opioid dose increased, some physicians reported negative feelings, such as either pressure (25%), helplessness (25%), anger (23%) or a combination. The risk of non-guideline-compliant prescribing behavior using the example of ultrafast-acting fentanyl for CNCP was increased when negative emotions were present (OR: 1.7; 95%-CI: 1.2−2.6; p = 0.007) or when sublingual buprenorphine was prescribed (OR: 15.4; 95%-CI: 10.1−23.3; p < 0.001). Conclusions: Physicians’ emotional self-awareness represents the first step to identify such direct reactions to patient requests and to ensure a responsible, guideline-based opioid prescription approach for the long-term well-being of the patient.

The Veterans RAND 12-Item Health Survey (VR-12) was added to the German Pain Questionnaire (DSF) as a self-report measure of health-related quality of life in 2016, replacing the previously used SF-12, which required a license. Both measures have 12 items and include a physical component summary (PCS) and a mental component summary (MCS). Evaluations with a larger sample on characteristic values and on the test-statistical goodness of the VR-12 in patients with chronic pain are so far missing. Data on the VR-12 and other procedures of the DSF were evaluated from 11,644 patients from 31 centers participating in KEDOQ pain. The patients filled out the DSF before starting a pain therapy treatment. Change sensitivity was determined for 565 patients for whom the VR-12 was available from a follow-up questionnaire of the DSF several months after the initial survey.The reliability (Cronbach's alpha) of the PCS was r tt  = 0.78 and for the MCS r tt  = 0.84. The MCS had significant relationships with the depression, anxiety and stress scales (r = -0.51 to r = -0.72), and the PCS correlated more highly with areas of pain-related impairment (r = -0.48 to r = -0.52). Patients with higher pain chronicity, those with higher pain severity, and those with evidence of high psychological distress described significantly lower health-related quality of life in PCS and MCS. The effect size (ES) of change in terms of improvement in health-related quality of life was ES = 0.33 in the MCS and ES = 0.51 in the PCS.The results are in agreement with the findings of the SF-36 and SF-12 in patient collectives with chronic pain. In summary, they show that the VR-12 is an adequate substitute for the SF-12 in the German pain questionnaire., (© 2021. The Author(s).)

Background: There is no opioid crisis in Germany. However, new studies involving patients with chronic noncancer pain (CNCP) in Germany show an unexpectedly high prevalence of opioid use disorder according to DSM‑5 (Diagnostic and Statistical Manual for Psychiatric Diseases)., Objectives: Critical discussion of new study results on the prevalence of opioid use disorder in CNCP patients in Germany., Materials and Methods: Selective literature search and multiprofessional classification of results by an expert panel (pain therapy, neurology, psychiatry, palliative medicine, general medicine and addiction therapy)., Results: The DSM‑5 criteria for the diagnosis of "opioid use disorder" have limited applicability to patients with CNCP, but may raise awareness of problematic behavior. The diagnosis of opioid use disorder is not the same as the diagnosis of substance dependence according to ICD-10, as the DSM‑5 diagnosis covers a much broader spectrum (mild, moderate, severe). Risk factors for opioid use disorder include younger age, depressive disorders, somatoform disorders, and high daily opioid doses. The interdisciplinary guideline on long-term opioid use for CNCP (LONTS) includes recommendations intended to reduce the risk for opioid use disorder., Conclusion: An adaptation of the DSM‑5 diagnostic criteria of opioid use disorder to the specific situation of CNCP patients and a validation of these criteria could help to collect more accurate data on opioid use disorders of patients with chronic pain in Germany in the future. Prescribers should be sensitized to this problem without pathologizing or even stigmatizing patients. Further research is needed to classify this previously underestimated phenomenon., (© 2021. The Author(s).)

Background: Strong opioids can have unintended effects. Clinical studies of strong opioids mainly report physical side effects, psychiatric or opioid use disorders. To date, too little attention has been paid to the psychological effects of opioids to treat patients with chronic noncancer pain (CNCP). This study aims to identify and measure (i) the nature and frequency of physical and psychological effects and (ii) the degree of physician counseling of patients with CNCP taking strong opioids., Methods: Within a cross-sectional survey-conducted as part of a randomised controlled online intervention trial (ERONA [Experiencing the risk of overusing opioids among patients with chronic non-cancer pain in ambulatory care])-300 German CNCP patients were surveyed via patient-reported outcome measures regarding on both the side effects from their use of strong opioids as well as their counselling experience., Results: Among the patients' reported effects, the psychological outcomes of the opioids in CNCP were: feeling relaxed (84%), fatigue (76%), dizziness (57%), listlessness (37%), difficulty with mental activities (23%), dulled emotions (17%) and poor memory (17%). Ninety-two per cent of the patients reported having received information about opioid effects, and 46% had discussed cessation of the opioid medication with their physicians before commencing the prescription., Conclusions: In addition to the well-known physical side effects, patients with CNCP taking strong opioids experience significant psychological effects. In view of these effects, discontinuation of opioid therapy should be discussed early to ensure their benefits do not outweigh their harm., Significance: In this study, patients with non-cancer pain notice that opioids they have taken do not only cause physical side effects but also may have an impact on their psyche and their emotions and, thus, may also affect quality of life substantially. Clinical trial number: DRKS00020358., (© 2021 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®.)