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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).Critical discussion of new study results on the prevalence of opioid use disorder in CNCP patients in Germany.Selective literature search and multiprofessional classification of results by an expert panel (pain therapy, neurology, psychiatry, palliative medicine, general medicine and addiction therapy).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.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.HINTERGRUND: Es gibt keine Opioidkrise in Deutschland. Neue Studien mit Nichttumorpatienten mit chronischen Schmerzen (CNTS) in Deutschland zeigen jedoch eine unerwartet hohe Prävalenz von Opioidgebrauchsstörungen nach Diagnostic and Statistical Manual for Psychiatric Diseases 5 (DSM-5).Kritische Diskussion neuer Studienergebnisse zur Prävalenz von Opioidgebrauchsstörungen bei Schmerzpatienten in Deutschland.Selektive Literaturrecherche und multiprofessionelle Einordnung der Ergebnisse durch Expertenrunde (Schmerztherapie, Neurologie, Psychiatrie, Palliativmedizin, Allgemeinmedizin und Suchttherapie).Die Kriterien für die Diagnose „Opioidgebrauchsstörung“ des DSM‑5 sind auf Patienten mit CNTS nur eingeschränkt anwendbar, können aber für problematisches Verhalten sensibilisieren. Hierbei ist die Diagnose Opioidgebrauchsstörung nicht mit der Diagnose einer Substanzabhängigkeit nach ICD-10 gleichzusetzen, da die Diagnose nach DSM‑5 ein deutlich breiteres Spektrum abdeckt (mild, moderat, schwer). Risikofaktoren für eine Opioidgebrauchsstörung sind jüngeres Alter, depressive Störungen, somatoforme Störungen und hohe Opioidtagesdosen. Die interdisziplinäre Leitlinie zur Langzeitanwendung von Opioiden bei chronischen nichttumorbedingten Schmerzen (LONTS) enthält Empfehlungen, welche das Risiko für eine Opioidgebrauchsstörung reduzieren sollen.Eine Anpassung der DSM-5-Diagnosekriterien der Opioidgebrauchsstörung an die besondere Situation von Patienten mit CNTS und eine Validierung dieser Kriterien könnte helfen, in der Zukunft genauere Daten zu Opioidgebrauchsstörungen von Patienten mit chronischen Schmerzen in Deutschland zu erheben. Verordner sollten für diese Problematik sensibilisiert werden, ohne die Patienten zu pathologisieren oder gar zu stigmatisieren. Weitere Forschung zur Einordnung dieses bisher unterschätzten Phänomens ist notwendig.

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 rDer Veterans RAND 12-Item Health Survey (VR-12) wurde als Selbstbeurteilungsverfahren zur Erfassung gesundheitsbezogener Lebensqualität 2016 in den Deutschen Schmerzfragebogen (DSF) aufgenommen und ersetzt den bis dahin verwendeten lizenzpflichtigen SF-12. Beide Verfahren haben 12 Items und führen zu einer körperlichen und einer psychischen Summenskala. Auswertungen der deutschen Version mit größerer Stichprobe zu Kennwerten und zur teststatistischen Güte des VR-12 bei Patienten mit chronischem Schmerz fehlen bislang.Daten zum VR-12 und weiterer Verfahren des DSF wurden von 11.644 Patienten aus 31 an KEDOQ-Schmerz beteiligten Zentren ausgewertet. Die Patienten hatten den DSF vor Beginn einer angestrebten schmerztherapeutischen Behandlung ausgefüllt. Die Bestimmung der Änderungssensitivität erfolgte für 565 Patienten, für die der VR-12 aus einem Verlaufsfragebogen des DSF mehrere Monate nach der Ersterhebung vorlag.Die Reliabilität (Cronbachs Alpha) der körperlichen Summenskala war r

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.The aim was to identify and grade the risk of critical incidents in the context of acute pain management.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.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.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.HINTERGRUND: Tätigkeitsgebiete mit vielen Schnittstellen, wie die Akutschmerztherapie, gelten per se als Bereiche, in denen ein erhöhtes Risiko für Fehler und Zwischenfälle besteht.Ziele waren die Risikoidentifikation und Graduierung des Risikos von gemeldeten Zwischenfällen im Kontext der Akutschmerztherapie.Aus 5365 Fällen des bundesweiten Meldesystems CIRSmedical Anästhesiologie wurden 508 Berichte mit dem Selektionskriterium „Schmerz“ identifiziert und 281 Berichte (55 %) analysiert und anhand einer Risikomatrix graduiert.Diese eingeschlossenen Fälle standen im Kontext parenteraler Analgetikaapplikationen (40 %) und rückenmarknaher (40 %) bzw. peripherer Regionalanästhesieverfahren (23 %) sowie der patientenkontrollierten Analgesie in 13 % der Meldungen (Mehrfachnennung möglich). Die meisten Ereignisse waren anhand der Schilderungen auf fachliche Fehler, Kommunikationsdefizite und ein Abweichen von der Routine zurückzuführen. Sie basierten meist auf Zugangs‑, Dosis- oder Wirkstoffverwechslungen. Etwa ein Drittel der Fehlerquellen war organisatorischer Art. Ein mögliches vitales Risiko war anhand der Berichte in 59 % der Fälle anzunehmen; 16 % der Fälle gingen mit tatsächlichen vitalen Komplikationen einher. Die Risikograduierung ergab zusammengefasst in Risikoklassen in 7 % ein „extrem hohes“, in 62 % ein „hohes“, in 25 % ein „moderates“ und in 6 % ein „niedriges“ Risiko.Insgesamt stellte sich ein relevantes Risikopotenzial für die Patienten dar. Gerade Zwischenfälle mit menschlichen Fehlern, Abweichen von der Routine und organisatorischen Aspekten gehen mit hohem Risiko einher.

Patient-controlled intravenous analgesia (PCIA) is a well-established technique in acute pain management and available in most German hospitals. Despite its widespread use, information on current clinical practice is limited. This investigation evaluated clinical practice and monitoring as well as PCIA-associated adverse events and critical incidents in German hospitals.An invitation to participate in this online-survey was sent to 995 heads of anesthesiology departments belonging to the "German Society of Anaesthesiology and Intensive Care Medicine".Of the departments receiving the link, 244 took part (response rate 25%). PCIA was used in 193 of these hospitals (79%). All the following statements relate to the hospitals in which PCIA was used. Piritramide was the most frequently used opioid. In parallel with PCIA, additional nonopioid analgesics were used in 94% of the hospitals, and in 38%, additional slow-release oral opioids were used. Parenteral opioids were administered by the ward staff in 4% of the hospitals. In 75% of hospitals, there were standardized indications for PCIA therapy, with almost two thirds of respondents stating that PCIA was the technique of second choice if regional procedures were contraindicated or failed. In all, 76% of the hospitals had an acute pain service. Twenty-four percent of the hospitals regularly used PCIA in non-surgical patients. In pediatric patients, PCIA was used in 62 hospitals (32%). Only 31% of the hospitals reported the use of standardized protocols for the specific monitoring of patients' vital signs on general wards, exceeding general care. Of the department, 158 (82%) reported adverse events in connection with the use of PCIA within the six-month period preceding the survey (most frequently due to patients' noncompliance [52%], dislocated intravenous lines [41%], communication errors [16%], administration of additional analgesics [16%] and/ or sedatives [14%], problems with the pump [16%], programming errors [9%], incorrect opioid concentration in the reservoir [8%], non-observance of contraindications [7%], incorrect dosing [6%] and self-dosing by the patient [4%] or by third parties [3%], filling the reservoir with thewrong medication [2%]; and other problems [5%]). Only 35 of the hospitals (18%) reported no problems associated with PCIA therapy. Seventy-five of the 193 respondents (39%) stated that at least one critical incident had occurred in the context of the use of PCIA. This resulted in a total of 335 cases out of an estimate of 50.000 patients treated with PCIA. The respondents classified these as follows: I) 273 incidents requiring a prolonged stay in the recovery room, but without further complications, II) 58 requiring transfer to the intensive care unit, but without further complications, III) three resulting in permanent harm to the patient and IV) one resulting in the death of the patient. A comparison of the monitoring standards for PCIA showed that critical incidents were reported less frequently in hospitals with less intensive monitoring, and more frequently in hospitals with higher monitoring standards.PCIA is a frequently used analgesic technique in German hospitals. There were many differences in how PCIA therapy was applied and monitored on general wards. Adverse events occurred to a significant extent, with a considerable part of them, which might be preventable. Critical incidents were perceived more often when standards for monitoring on general wards were higher. Consented current recommendations regarding treatment and monitoring standards as well as the systematic recording of complications when using PCIA are pending.HINTERGRUND: Die patientenkontrollierte intravenöse Analgesie („patient controlled intravenous analgesia“, PCIA) ist als Verfahren in der Akutschmerztherapie etabliert. Ziel dieser Untersuchung war es, Anwendungspraxis, Überwachung, unerwünschte Vorkommnisse und Komplikationen unter einer PCIA-Therapie an deutschen Krankenhäusern zu erfassen.Alle 995 bei der Deutschen Gesellschaft für Anästhesie und Intensivmedizin e. V. registrierten Chefärzte wurden zur Teilnahme an der elektronischen Umfrage eingeladen.Aus 244 Kliniken wurden Antworten zurückgesandt. In 193 (79 %) dieser Kliniken kam die PCIA zum Einsatz. Alle folgenden Angaben beziehen sich auf diese Krankenhäuser. Das am häufigsten genutzte Opioid war Piritramid. Bei Patienten mit PCIA setzten 94 % der Kliniken zusätzlich Nichtopioidanalgetika ein, 38 % retardierte orale Opioide sowie 4 % parenterale Opioide. Bei Anwendung der PCIA auf Normalstation lag lediglich in 31 % der Kliniken ein standardisiertes Überwachungskonzept vor, das über die Routineversorgung der Stationen hinausging. Insgesamt 82 % der befragten Kliniken berichteten von unerwünschten Vorkommnissen im Zusammenhang mit der PCIA. In 39 % der Kliniken war in den vorangegangenen 6 Monaten mindestens eine potenziell vital bedrohliche Komplikation aufgetreten, insgesamt wurden 335 Einzelfälle berichtet (bei ca. 50.000 durchgeführten PCIAs). Kliniken, die über Komplikationen berichteten, hatten einen höheren Überwachungsstandard als Kliniken, die über keine Komplikationen berichteten.Die PCIA ist ein verbreitetes, aber durchaus mit Risiken verbundenes Analgesieverfahren. Anwendungs- und Überwachungspraxis sind heterogen. Konsentierte, aktuelle Empfehlungen hinsichtlich Behandlungs- und Überwachungsstandards sowie der systematischen Erfassung von Komplikationen bei Anwendung der PCIA stehen aus.

The direct comparison of day care pain patients with patients from other treatment sectors with respect to sociodemographic, pain-related and psychological characteristics has not yet been the subject of systematic analyses. The project core documentation and quality assurance in pain therapy (KEDOQ-pain) of the German Pain Society (Deutsche Schmerzgesellschaft e.V.) makes this comparison possible. This second analysis of the available KEDOQ data was intended to show how patients receiving day care treatment can be characterized using the core data set and whether and to what extent they differ from patients receiving outpatient or inpatient treatment. This is a continuation of the first publication, which showed remarkably small differences between outpatients and inpatients but did not include day care patients.The KEDOQ-pain data from 25 centers with a total of 8953 patients were evaluated. Patients had completed the German pain questionnaire (DSF) between January 2012 and March 2017 and received day care (n = 1264), outpatient (n = 4082) or inpatient (n = 3607) pain therapy treatment. Sociodemographic, pain-related and psychometric data of the DSF reported by patients were evaluated as well as physician information on the pain chronification stage and pain localization. The evaluation was descriptive and compared groups using univariate and multivariate procedures.Day care treated patients were significantly younger, had a higher level of education, were more frequently employed, reported higher impairment values and showed a higher severity index according to von Korff than inpatients and outpatients treated for pain. In addition, they described a shorter pain duration as well as worse habitual well-being (Marburg questionnaire on habitual well-being, MFHW). These predictors explained roughly half of the variance in the prediction of the day care treatment setting. The comparison of outpatients and inpatients showed significant group differences for some variables; however, the effects were very small.The evaluations suggest that pain therapy day care facilities treat a special group of pain patients that significantly differ from patients in other treatment sectors. Cautious conclusions are drawn regarding the systematic allocation of patients to care appropriate to their treatment needs.

Chronic pain is a frequent comorbidity of patients in hospitals and has an influence on the clinical course and the duration of hospitalization. There is a need to have a better understanding of chronic pain as a comorbidity and it should be considered to a greater extent in understanding diseases, in treatment concepts and hospital structures to ensure a resource-oriented and high-quality care. This begins on admission by identifying pre-existing pain and related risk factors with the medical history and taking these into account in the treatment regimen. A multimodal treatment approach that involves medicinal, educational, psychological and physiotherapeutic expertise is required in these patients. A unimodal approach in the treatment is not effective. A pain physician should be involved in the treatment team as early as possible. Furthermore, psychological joint supervision should be available for these patients as several studies have demonstrated positive perioperative effects of psychological approaches on the treatment in this patient group.

Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.Obwohl Schmerzdienste als Versorgungsmodell etabliert sind, besteht eine erhebliche Heterogenität bezüglich Organisation, personeller Besetzung und Qualifikation sowie zum Behandlungsspektrum. Mit der vorliegenden Empfehlung definiert die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin personelle und organisatorische Voraussetzungen für Schmerzdienste, um in Ergänzung zur allgemeinen Schmerzbehandlung der primär bettenführenden Abteilungen eine qualitativ hochwertige, spezialisierte, innerklinische schmerzmedizinische Versorgung in allen Versorgungseinheiten des Krankenhauses zu gewährleisten.Schmerzdienste sollen die Betreuung spezieller anästhesiologischer Analgesieverfahren sowie die Konsil- und Liaison-Betreuung fachlich und organisatorisch in einer Dienststruktur abdecken. Sie sollen 24 h/7 Tage die Woche über einen einheitlichen Kontakt erreichbar sein. Der Ärztliche Leiter soll die Zusatzbezeichnung Spezielle Schmerztherapie innehaben, zusätzlich möglichst eine Weiterbildung in psychosomatischer Grundversorgung. Weitere ärztliche Mitarbeiter sollen den Facharztstandard erfüllen, nicht-ärztliche Mitarbeiter schmerzspezifische Weiterbildungen nachweisen. Als zeitliche Richtwerte für die Personalkalkulation wurden Mindestzeiten definiert für die Betreuung spezieller Analgesieverfahren (Erstkontakt 20 min, Folgekontakte 10 min) und für Konsil- und Liaison-Betreuung (Erstkontakt 45 min, Folgekontakt 20 min), zuzüglich Wege- und Rüstzeiten, Schulung und Qualitätssicherung. Neben der Definition der räumlichen Ressourcen und Ausstattung wird betont, dass die Sicherstellung der spezialisierten Versorgung fach- und abteilungsübergeordnet eine hohe Priorität hat und ein ausreichendes und planbares eigenes Budget zur Verfügung stehen soll. Klinikinterne schriftliche Vereinbarungen zwischen den beteiligten Fachabteilungen werden zur Sicherung der Versorgungsqualität empfohlen, ebenso eine für alle Beteiligten transparente Dokumentation und die regelmäßige Erfassung der Ergebnisqualität aus Patientensicht.

The long-term use of opioids for chronic pain can be problematic in many respects. Besides potentially harmful and considerable undesired side effects and possible drug abuse, the indications for prescription, efficacy and safety in the long run have to be considered. The recently updated S3 guidelines on long-term opioid treatment in non-cancer pain (LONTS) provide recommendations with the highest currently available evidence. This article summarizes the most relevant contents for the clinical rheumatologist.

Acute pain management is an interprofessional and interdisciplinary task and requires a good and trustful cooperation between stakeholders. Despite provisions in Germany according to which medical treatment can only be rendered by a formally qualified physician ("Arztvorbehalt"), a physician does not have to carry out every medical activity in person. Under certain conditions, some medical activities can be delegated to medical auxiliary personnel but they need to be (1) instructed, (2) supervised and (3) checked by the physician himself; however, medical history, diagnostic assessment and evaluation, indications, therapy planning (e.g. selection, dosage), therapeutic decisions (e. g. modification or termination of therapy) and obtaining informed consent cannot be delegated. With respect to drug therapy, monitoring of the therapy remains the personal responsibility of the physician, while the actual application of medication can be delegated. From a legal perspective, the current practice needs to be stressed about what is within the mandatory requirements and what is not when medical activities are delegated to non-medical staff. The use of standards of care improves treatment quality but like any medical treatment it must be based on the physician's individual assessment and indications for each patient and requires personal contact between physician and patient. Delegation on the ward and in acute pain therapy requires the authorization of the delegator to give instructions in the respective setting. The transfer of non-delegable duties to non-medical personnel is regarded as medical malpractice.

A comparison of chronic pain patients in outpatient and inpatient treatment settings regarding pain-related and psychological characteristics, has not yet been systematically analyzed. The core documentation and quality assurance in pain therapy (KEDOQ-Schmerz) is a quality assurance system for documentation and quality management of pain therapy in different treatment settings. The system was initiated by the German Pain Society. We used KEDOQ-Schmerz data to describe differences between patients being treated in outpatient and inpatient settings with respect to social, pain-related and psychological factors. In total, the set of KEDOQ-Schmerz data analyzed included information from 4705 patients (from 13 clinics) collected between January 2012 and April 2016. Patients received either outpatient (n = 2682) or inpatient (n = 2023) treatment. The data analyzed comprised sociodemographic, pain-related and psychological data collected through the German Pain Questionnaire (DSF) at the beginning of treatment as well as information about pain chronification and pain localization provided by practitioners. The statistical analysis was carried out by descriptive and comparative data analysis using univariate and multivariate statistical methods. Patients with inpatient treatment were significantly older, more often female and more often had multiple pain localizations. They described stronger pain intensity and more frequently had a higher Mainz Pain Staging System (MPSS) score of pain chronification. They described a significantly poorer physical and mental health-related quality of life in the short form (SF-12) health survey, had significantly higher depression, anxiety and stress values (DASS) and a poorer habitual well-being in the Marburg questionnaire on habitual well-being (MFHW). Significant group differences had only small effect sizes. Even though most predictors for the inpatient treatment setting in multivariate analysis were significant, in total they explained less than 5% of the variance. The results indicate that pain therapy in specialized pain settings more and more has to manage patients with higher pain chronification, higher pain-related stress and previous therapy experience. The differences in patient characteristics between treatment settings are mostly clinically unimportant. Differences in clinical features do not declare the allocation to one treatment setting or the other.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A search of the literature for systematic reviews on randomized, controlled trials on patient education and shared decision-making from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences, clinical and practical applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.The diagnosis of fibromyalgia syndrome should be explicitly communicated to the affected individual. Shared decision-making with the patient on the therapeutic options based on individual preferences of the patient, comorbidities and the success of previous treatment is recommended. A step-wise treatment approach depending on the severity of fibromyalgia syndrome and the response to therapeutic measures is recommended.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A literature search for systematic reviews of randomized controlled drug trials from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.Amitriptyline and duloxetine are recommended in the case of comorbid depressive disorders or generalized anxiety disorder and pregabalin in the case of generalized anxiety disorder. Off-label use of duloxetine and pregabalin can be considered if there are no comorbid mental disorders or no generalized anxiety disorder. Strong opioids are not recommended.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n = 8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A search of the literature for systematic reviews on randomized controlled trials of multimodal therapy from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.The use of multimodal therapy (combination of aerobic exercise with at least one psychological therapy) with a duration of at least 24 h is strongly recommended for patients with severe forms of fibromyalgia.

The impact of conflicts of interest (COI) in general and of academic COI in particular on guideline recommendations in pain medicine has not yet been studied. Whether the inclusion of patients and of representatives of all relevant healthcare professions into a guidelines group is protective against a systematic bias of decisions of a guidelines group is currently unknown.All members of the guidelines group declared their COI before the consensus conferences by a standard form according to the rules and standards of the Association of the German Medical and Scientific Societies. The acceptance or rejection and the strength of consensus of recommendations of the second update of the interdisciplinary guidelines on fibromyalgia syndrome was analyzed twice by first including and then excluding the votes of the guideline group members with COI related to a recommendation from the results of anonymous voting via an internet platform.A total of 42 persons from different healthcare professions and patients participated in the online voting on recommendations. Of the participants 29% had no COI according to the predefined criteria, 53% met the criteria of academic and 33% the criteria of financial COI. In the case of exclusion of participants with a COI related to a specific recommendation, 2 out of 23 recommendations (homeopathy, tramadol) were not accepted. In all votes, there were more participants without COI than with COI.Academic COI were more frequent than financial COI in the second update of the German interdisciplinary guidelines group on fibromyalgia syndrome. The impact of COI on guideline recommendations was low. The inclusion of patients and of all relevant healthcare professionals into a guidelines group is a protective factor against the influence of COI on guideline recommendations.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A systematic search of the literature from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.The clinical diagnosis of fibromyalgia syndrome can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with examination of tender points) or without the examination of tender points by the modified preliminary diagnostic ACR 2010 or 2011 criteria.

The aim of this analysis was to describe the role of anesthesiology departments in pain medicine and palliative care services in German hospitals.In the year 2012, all heads of departments of anesthesiology registered with the German Society of Anesthesiology and Intensive Care Medicine were surveyed about structures of pain medicine and palliative care services in their hospitals using a standardized postal questionnaire.Out of 408 returned questionnaires (response rate 47%) 403 could be evaluated. Of the hospitals 58% had a designated pain medicine service, in 36 (9%) of the hospitals this was organized as an independent department and in 195 (57%) as part of another department, mostly the department of anesthesiology. The "pain clinic" as an outpatient service was the most common form of structure for pain medicine services (41%). Inpatient pain medicine units were available in 77 (19%) of the hospitals and a partial inpatient unit in the form of a day hospital in 26 (7%) of the hospitals. For the care of inpatients from other departments, there was an intrahospital pain consultation service in 166 of the hospitals, which was the only structure for pain medicine in 32 of the 231 hospitals that reported having a designated pain medicine service. In 160 pain medicine services anesthesiologists were the only medical practitioners and in a further 18 both anesthesiologists and other specialists were available (orthopedist/orthopedic surgeons n = 6, internal medicine n = 4, psychiatrist n = 2, general practitioner = 1 and neurologist n = 1). Only two hospitals had no anesthesiologist in the pain medicine team and for the remaining 51 hospitals no information was provided. In 189 of the 231 hospitals with pain medicine services, there was at least 1 physician with special qualifications in pain management. In 97 (44%) of the hospitals psychologists were part of the team with 53 having at least 1 psychologist with a special qualification in chronic pain management. Of the hospitals, 16% had a specialized department for palliative care, in 32% a specialized palliative care service was part of another department, which was the department of anesthesiology in 30%. Of the hospitals 56% had a palliative care consultation service, 41% had a specialized inpatient palliative care unit, 6% an outpatient clinic, 4% a day hospital and in 16% a specialized outpatient palliative care (SOPC) serving the community was incorporated. Inpatient consultation services and the SOPC were more common when the department of anesthesiology was involved in the palliative care services.In German hospitals, the departments of anesthesiology make a significant contribution to the provision of both pain medicine and palliative care services. Nevertheless, the respective structures of care are often incomplete or even lacking. There were shortcomings in terms of organization and qualification of the team in pain medicine services (e.g. no doctor with special qualifications in pain management or no psychologist). Palliative care services are more often organized as independent departments than as pain medicine services. Engagement of the anesthesiology department in palliative care is linked to a broader scope of the services provided, which might reflect the capacity of many anesthesiologists to work in an interdisciplinary manner and across interfaces.

Objective The causes for the disabling condition of phantom limb pain (PLP), affecting 85% of amputees, are so far unknown, with few effective treatments available. Sensory feedback based strategies to normalize the motor commands to control the phantom limb offer important targets for new effective treatments as the correlation between phantom limb motor control and sensory feedback from the motor intention has been identified as a possible mechanism for PLP development. Approach Ten upper-limb amputees, suffering from chronic PLP, underwent 16 days of intensive training on phantom-limb movement control. Visual and tactile feedback, driven by muscular activity at the stump, was provided with the aim of reducing PLP intensity. Main results A 32.1% reduction of PLP intensity was obtained at the follow-up (6 weeks after the end of the training, with an initial 21.6% reduction immediately at the end of the training) reaching clinical effectiveness for chronic pain reduction. Multimodal sensory-motor training on phantom-limb movements with visual and tactile feedback is a new method for PLP reduction. Significance The study results revealed a substantial reduction in phantom limb pain intensity, obtained with a new training protocol focused on improving phantom limb motor output using visual and tactile feedback from the stump muscular activity executed to move the phantom limb.

Funktionelle Schmerzsyndrome sind in der Regel gekennzeichnet durch eine erhohte lokale oder generalisierte Schmerzempfindlichkeit, spontane Schmerzen und eine Vielzahl variabler begleitender Symptome. Die Einteilung oder Zuordnung der Syndrome bezieht sich meist auf den Ort der Hauptbeschwerden oder das Hauptsymptom, eine Uberlappung der Symptomatik findet sich jedoch haufig. Weitere Hinweise fur eine mogliche Beteiligung des zentralen Nervensystems (ZNS) sind haufige komorbide affektive Storungen, Beeintrachtigungen der Kognition, Veranderungen der neuroendokrinen Funktion und eine Dysregulation des autonomen Nervensystems, wobei diese Storungen immer nur bei einem Teil der Betroffenen vorliegen. Ergebnisse der funktionellen Bildgebung liefern weitestgehend plausible Korrelate fur die geklagten subjektiven Beschwerden und weisen auf eine zentrale Augmentation in der Schmerzverarbeitung und anderen sensorischen Systemen einschlieslich des postulierten Systems der interozeptiven Regulation hin. In der pathophysiologischen Zuordnung dieser Augmentation gibt es keinen einheitlichen Befund, die Bedeutung peripherer Faktoren bleibt unklar, ebenso wie die genaue Rolle spinaler und supraspinaler Mechanismen. Kognitive und affektive Faktoren beeinflussen die Schmerzverarbeitung, erklaren aber die beschriebene Augmentation nicht. Beim Fibromyalgiesyndrom (FMS), beim chronischen Ruckenschmerz und dem Reizdarmsyndrom gibt es Hinweise auf eine Dysfunktion der deszendierenden Hemmung. Longitudinale Studien sind notwendig, um die Kausalitat der beschriebenen Zusammenhange und eine primare Storung im ZNS zu sichern. Aktuelle Methoden (VBM, H-MRS) haben strukturelle und lokale metabolische Veranderungen des ZNS bei vielen der Syndrome nachgewiesen, die Konsequenz und klinische Relevanz bleiben derzeit noch offen. Neue theoretische Konzepte bieten einen Rahmen, um interdisziplinare, prospektive und hypothesengetriebene Forschungsansatze zu entwickeln, um das ganze Potenzial der Methoden der funktionellen Bildgebung zu nutzen.

Recently published systematic reviews came to different conclusions with respect to the efficacy, tolerability and safety of cannabinoids for treatment of chronic neuropathic pain.A systematic search of the literature was carried out in MEDLINE, the Cochrane central register of controlled trials (CENTRAL) and clinicaltrials.gov up until November 2015. We included double-blind randomized placebo-controlled studies (RCT) of at least 2 weeks duration and with at least 9 patients per treatment arm comparing medicinal cannabis, plant-based or synthetic cannabinoids with placebo or any other active drug treatment in patients with chronic neuropathic pain. Clinical endpoints of the analyses were efficacy (more than 30 % or 50 % reduction of pain, average pain intensity, global improvement and health-related quality of life), tolerability (drop-out rate due to side effects, central nervous system and psychiatric side effects) and safety (severe side effects). Using a random effects model absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. The methodological quality of RCTs was rated by the Cochrane risk of bias tool.We included 15 RCTs with 1619 participants. Study duration ranged between 2 and 15 weeks. Of the studies 10 used a plant-derived oromucosal spray with tetrahydrocannabinol/cannabidiol, 3 studies used a synthetic cannabinoid (2 with nabilone and 1 with dronabinol) and 2 studies used medicinal cannabis. The 13 studies with parallel or cross-over design yielded the following results with 95 % confidence intervals (CI): cannabinoids were superior to placebo in the reduction of mean pain intensity with SMD - 0.10 (95 % CI - 0.20- - 0.00, p = 0.05, 13 studies with 1565 participants), in the frequency of at least a 30 % reduction in pain with an RD of 0.10 [95 % CI 0.03-0.16, p = 0.004, 9 studies with 1346 participants, number needed to treat for additional benefit (NNTB) 14, 95 % CI 8-45] and in the frequency of a large or very large global improvement with an RD of 0.09 (95 % CI 0.01-0.17, p = 0.009, 7 studies with 1092 participants). There were no statistically significant differences between cannabinoids and placebo in the frequency of at least a 50 % reduction in pain, in improvement of health-related quality of life and in the frequency of serious adverse events. Patients treated with cannabinoids dropped out more frequently due to adverse events with an RD of 0.04 [95 % CI 0.01-0.07, p = 0.009, 11 studies with 1572 participants, number needed to treat for additional harm (NNTH) 19, 95 % CI 13-37], reported central nervous system side effects more frequently with an RD of 0.38 (95 % CI 0.18-0.58, p = 0.0003, 9 studies with 1304 participants, NNTH 3, 95 % CI 2-4) and psychiatric side effects with an RD of 0.11 (95 % CI 0.06-0.16, p 0.0001, 9 studies with 1304 participants, NNTH 8, 95 % CI 7-12).Cannabinoids were marginally superior to placebo in terms of efficacy and inferior in terms of tolerability. Cannabinoids and placebo did not differ in terms of safety during the study period. Short-term and intermediate-term therapy with cannabinoids can be considered in selected patients with chronic neuropathic pain after failure of first-line and second-line therapies.

Within the last ten years healthcare services research has developed into an independent interdisciplinary field of research. A selective search of the literature was conducted in the database Google Scholar and the database on healthcare services research in Germany (http://versorgungsforschung-deutschland.de) for healthcare services research projects on pain in Germany. Healthcare services research projects were conducted by pharmaceutical companies, patient self-help organizations, scientific societies, statutory health insurance companies and university departments on acute and chronic pain. Valid data on the epidemiology, grading and treatment of chronic pain are available. There was an overuse of opioids and invasive procedures in patients with chronic low back pain, fibromyalgia syndrome and somatoform pain disorders. Databases for patients with chronic pain are currently constructed by pain societies. The fragmentation of data from health insurance companies, old age pension insurances, clinical institutions and population surveys and inconsistencies in diagnosing or encoding chronic pain impede the carrying out of significant longitudinal studies. Based on the data available, the needs of care for patients with chronic pain and the necessary care services cannot be derived. Important topics of future healthcare services research on pain are longitudinal studies on the cost efficacy and risks of inpatient and outpatient pain therapy based on routine data of health insurance companies, old age pension insurances and pain registries, longitudinal studies on "patient careers" (i.e. sequences of healthcare) and the identification of potential starting points for control of healthcare.

Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management.A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin).For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI.In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

Background: Functional magnetic resonance imaging (fMRI) using blood-oxygen-level-dependent (BOLD) contrasts is a common method for studying sensory or cognitive brain functions. The aim of the present study was to assess the effect of the intravenous anaesthetic propofol on auditory-induced brain activation using BOLD contrast fMRI. Methods: In eight neurosurgical patients, musical stimuli were presented binaurally in a block design. Imaging was performed under five conditions: no propofol (or wakefulness) and propofol plasma target concentrations of 0.5, 1.0, 1.5, and 2.0 µg ml−1. Results: During wakefulness we found activations in the superior temporal gyrus (STG) corresponding to the primary and secondary auditory cortex as well as in regions of higher functions of auditory information processing. The BOLD response decreased with increasing concentrations of propofol but remained partially preserved in areas of basic auditory processing in the STG during propofol 2.0 µg ml−1. Conclusions: Our results suggest a dose-dependent impairment of central processing of auditory information after propofol administration. These results are consistent with electrophysiological findings measuring neuronal activity directly, thus suggesting a dose-dependent impairment of central processing of auditory information after propofol administration. However, propofol did not totally blunt primary cortical responses to acoustic stimulation, indicating that patients may process auditory information under general anaesthesia.

Standardized treatment approaches can improve the quality of the management of acute postoperative pain.The purpose of this study was to describe the content and structure of currently implemented standards for the management of acute postoperative pain in German hospitals and to better define the concept of a treatment standard for acute pain.Written standardized treatment protocols from 68 hospitals for the management of acute postoperative pain were analyzed. The evaluation was based on the layout of processes, the baseline and rescue or on-demand analgesic medication and safety mechanisms.A treatment standard per hospital separated for adults (68 standards) and children (27 standards) was identified and analyzed. A baseline medication was provided in all standards for adults and in 89% for children. Of the 95 standards 68% routinely combined opioids and non-opioids as a basis (78% for adults and 42% for children). A way to adapt the baseline medication was described more often in standards for adults. Of the standards for adults 91% (85% for children) contained provisions for rescue or on-demand analgesia and half of them (both adults and children) included an immediate-release opioid formulation, which was readily available. For adults the availability was regulated by a predefined process in 29% of the standards (8% for children). In cases of persisting pain, repetition of the rescue medication was generally possible in 63% of adult standards (54% for children) but within 1 h after the first dose in only 43% (30% for children). Intervention limitations for application of the rescue medication (e.g., a defined score on the numeric rating scale) were set in 63% of adult standards (54% for children). A follow-up assessment of the pain intensity after a rescue medication was only required in approximately half of the standards and safety information or mechanisms were only rarely included.Content, structure and type of the evaluated treatment standards showed a considerable heterogeneity with respect to the availability of rescue and baseline medication. Safety aspects were not addressed in many cases. These findings show that despite the requirements of the German guidelines for treatment of perioperative and posttraumatic pain for treatment standards, there are still no practical recommendations with respect to contents and structure of such standards.

The efficacy and safety of opioid therapy in chronic low back pain (CLBP) is under debate. We updated a recent systematic review on the efficacy and safety of opioids in CLBP.We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CLBP. We included double-blind randomized placebo-controlled studies of at least 4 weeks duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables.We included 12 RCTs with 17 treatment arms and 4375 participants. Median study duration was 12 (4-16) weeks. Of the 17 treatment arms, seven (41.2 %) used oxycodone; four (23.6 %) tramadol; buprenorphine and oxymorphone were each used in two (11.8 %) and hydromorphone and tapentadol each in one (5.8 %). The results for studies with parallel/cross-over design were as follows (with 95 % confidence interval, CI): opioids were superior to placebo in reducing pain intensity (SMD - 0.29 [- 0.37, - 0.21], p 0.0001; six studies with 2896 participants). Opioids were superior to placebo in 50 % pain reduction (RD 0.05 [0.01, 0.10], p = 0.01; two studies with 1492 participants; number needed to benefit (NNTB) 19 [95 % CI 10-107]). Opioids were not superior to placebo in reports of much or very much improved pain (RD 0.16 [- 0.01, 0.34], p = 0.07; two studies with 1153 participants). Opioids were superior to placebo in improving physical functioning (SMD - 0.22 [- 0.31, - 0.12], p 0.0001; four studies with 1895 participants). Patients dropped out less frequently with opioids than with placebo due to lack of efficacy (RD - 0.10 [- 0.16, - 0.04], p = 0.001; five studies with 3168 participants; NNTB 10 [8-13]). Patients dropped out more frequently with opioids than with placebo due to adverse events (RD 0.12 [0.05, 0.19], p = 0.0007; six studies with 2910 participants; number needed to harm (NNTH) 7 [95 % CI 6-8]). There was no significant difference between opioids and placebo in terms of the frequency of serious adverse events or deaths.Opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. Opioids and placebo did not differ in terms of safety during the study period. The conclusion on the safety of opioids compared to placebo is limited by the low number of serious adverse events and deaths. Short-term and intermediate-term opioid therapy may be considered in selected CLBP patients. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").

The update of the German S3 guidelines on long-term opioid therapy of chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003) was scheduled for May 2014.The guidelines were developed by 25 scientific societies and two patient self-help organizations under the coordination of the German Pain Society and the Association of the Scientific Medical Societies in Germany (AWMF).A systematic literature search was performed in the CENTRAL, MEDLINE and Scopus databases from October 2008 to October 2013. Meta-analyses of randomized controlled trials (RCT) of opioids in CNPC of study duration ≥ 4 weeks were conducted. Levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine version 2009 classification system. The formulation and strength of recommendations was established in a multistep formalized consensus procedure, in accordance with AWFM rules and standards. The guidelines were reviewed by three scientific societies not involved in their development and were approved by the executive boards of the societies that were engaged in development of the guidelines.The guidelines will be published in several forms: complete and short scientific versions, as well as clinical practice and patient versions.

The efficacy and safety of opioid therapy in chronic neuropathic pain (CNP) is under debate. We updated a recent Cochrane systematic review on the efficacy, tolerability and safety of opioids in CNP.We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CNP. We included double-blind randomized placebo-controlled studies of at least 4 weeks duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables.We included 12 RCTs with 1192 participants. The included diagnostic entities were painful diabetic neuropathy (four studies), postherpetic neuralgia (three studies), mixed polyneuropathic pain (two studies), and lumbar root, spinal cord injury and postamputation pain (one study each). Mean study duration was 6 (4-12) weeks. Four studies tested morphine, three studies tramadol, two studies oxycodone and one study tapentadol. These are the pooled results of studies with a parallel or cross-over design: opioids were superior to placebo in reducing pain intensity (SMD - 0.64 [95 % confidence interval, CI - 0.81, - 0.46], p 0.0001; 11 studies with 1040 participants). Opioids were not superior to placebo in 50 % pain reduction (RD 0.16 [95 % CI - 0.04, 0.35], p = 0.11; one study with 93 participants). Opioids were not superior to placebo in reports of much or very much improved pain (RD 0.17 [95 % CI - 0.01, 0.36], p = 0.07; one study with 53 participants). Opioids were superior to placebo in improving physical functioning (SMD - 0.28 [95 % CI - 0.43, - 0.13], p 0.0001; seven studies with 680 participants). Patients dropped out less frequently due to lack of efficacy with opioids than with placebo (RD - 0.07 [95 % CI - 0.13, - 0.02], p = 0.008; six studies with 656 participants). Patients dropped out due to adverse events more frequently with opioids than with placebo (RD 0.08 [95 % CI 0.05, 0.12], p 0.0001; ten studies with 1018 participants; number needed to harm 11 [95 % CI 8-17]). There was no significant difference between opioids and placebo in terms of the frequency of serious adverse events (SAE) or deaths.In short-term studies (4-12 weeks) in CNP, opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. Opioids and placebo did not differ in terms of safety. The conclusion relating to the safety of opioids compared to placebo in CNP is limited by the low number of SAE and deaths. Short-term opioid therapy may be considered in selected CNP patients. The English full-text version of this article is freely available at SpringerLink (under "Supplementary Material").

The efficacy, tolerability and safety of opioid therapy in chronic osteoarthritis (OA) pain is under debate. We updated a Cochrane systematic review on the efficacy and safety of opioids in chronic OA pain published in 2009.We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in chronic osteoarthritis (OA) pain. We included double-blind randomized placebo-controlled studies lasting ≥ 4 weeks. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables.We included 20 RCTs with 33 treatment arms and 8545 participants. Median study duration was 12 (4-24) weeks. Oxycodone and tramadol were each tested in six studies; buprenorphine, hydromorphone, morphine and tapentadol each in two studies and codeine, fentanyl and oxymorphone in one study each. Results are reported with 95 % confidence intervals (CIs). Opioids were superior to placebo in reducing pain intensity (SMD - 0.22 [- 0.28, - 0.17], p 0.00001; 16 studies with 6743 participants). Opioids were not superior to placebo in 50 % pain reduction (RD - 0.00 [- 0.07, 0.07], p = 0.96; two studies with 2684 participants). Opioids were superior to placebo in terms of reports of much or very much global improvement (RD 0.13 [0.05, 0.21], p = 0.002; three studies with 2251 participants). Opioids were superior to placebo in improving physical functioning (SMD - 0.22 [- 0.28, - 0.17], p 0.00001; 14 studies with 5887 participants). Patients dropped out more frequently with opioids than with placebo (RD 0.17 [0.14, 0.21], p 0.00001; 15 studies with 6834 participants; number needed to harm 5 [4-6]. There was no significant difference between opioids and placebo in the frequency of serious adverse events (SAE) or deaths over the respective observation periods.Opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. The effect sizes of average reduction in pain intensity and physical disability were small. Opioids and placebo did not differ in terms of safety. The conclusion on the safety of opioids compared to placebo is limited by the low number of SAE and deaths. Short-term opioid therapy may be considered in selected chronic OA pain patients. No current evidence-based guideline recommends opioids as first-line treatment option for chronic OA pain. To provide superior evidence for future treatment guidelines, RCTs must directly compare existing pharmacological and nonpharmacological therapies and administer these in various combinations and sequences. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").

The aim of this study was to analyze the degree of organization of different standard protocols for acute pain management, as well as the derivation and definition of typical but structurally different models.A total of 85 hospitals provided their written standardized protocols for analysis. Protocols for defined target processes from 76 hospitals and another protocol used by more than one hospital were included into the analysis. The suggested courses of action were theoretically simulated to identify and characterize process types in a multistage evaluation process.The analysis included 148 standards. Four differentiated process types were defined ("standardized order", "analgesic ladder", "algorithm", "therapy path"), each with an increasing level of organization. These four types had the following distribution: 27 % (n = 40) "standardized order", 47 % (n = 70) "analgesic ladder", 22 % (n = 33) "algorithm", 4 % (n = 5) "therapy path". Models with a higher degree of organization included more control elements, such as action and intervention triggers or safety and supervisory elements, and were also associated with a formally better access to medication. For models with a lower degree of organization, immediate courses of action were more dependent on individual decisions. Although not quantifiable, this was particularly evident when simulating downstream courses of action. Interfaces between areas of hospital activity and a cross-departmental-boundary validity were only considered in a fraction of the protocols. Concepts from clinics with a certificate in (acute) pain management were more strongly process-oriented. For children, there were proportionately more simple concepts with a lower degree of organization and less controlling elements.This is the first analysis of a large sample of standardized protocols for acute pain management focusing on the degree of organization and the possible influence on courses of action. The analysis shows how different the structures and presumably the practical objectives of the various concepts are. The analyzed protocols with a lower degree of organization can manage only the assignment of a particular medication to the corresponding patient group, with a presumably high requirement for considerable implicit knowledge of the responsible employees. Accordingly, a requirement for such protocols should be that they not only describe the preferred standard therapy, but also define the interactions between the staff members involved. It remains questionable whether a protocol with a low level of organization and a comparably high requirement for implicit knowledge and individual action--also from nonmedical personnel--is able to ensure efficient pain therapy, particularly in view changing staff and dynamic responses to changing pain situations.

Unrelieved pain is a substantial public health concern owing in part to deficits in clinical expertise among physicians. In most medical faculties worldwide, teaching on pain and pain management is either nonexistent or limited to a small number of students attending voluntary courses. In light of the fact that pain is the most frequent reason to seek medical advice, the lack of formal training of pain medicine is considered the leading reason for inadequate pain management. Therefore, the patients' unmet needs for adequate diagnosis and therapy call for action.Pain assessment and effective pain management should be a priority in the health care system. The limited number of pain specialists available in hospitals and primary care and CME (continuous medical education) activities focusing on pain are not sufficient to solve the problem. Every practicing physician should, therefore, have basic knowledge of the most prominent painful conditions and management strategies. To achieve this goal, pain medicine should become an integral part of the undergraduate curriculum for medical students. In Germany, pain medicine became a mandatory subject in undergraduate medical studies in 2012.The introduction of pain medicine into the undergraduate curriculum in Germany is a major challenge regarding the development and implementation processes. This article describes current instruments and implementation strategies for pain medicine as a new cross-sectional subject in Germany.

In 2007, the German national guidelines on "Treatment of acute perioperative and post-traumatic pain" were published. The aim of this study was to describe current structure and process data for acute pain management in German hospitals and to compare how the guidelines and other initiatives such as benchmarking or certification changed the healthcare landscape in the last decade.All directors of German departments of anesthesiology according to the DGAI ("Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin", German Society for Anesthesiology and Intensive Care) were mailed a standardized questionnaire on structures and processes of acute pain management in their hospitals.A total of 403 completed questionnaires (46 %) could be evaluated. Of hospitals, 81 % had an acute pain service (ASD), whereby only 45 % met defined quality criteria. Written standards for acute pain management were available in 97 % of the hospitals on surgical wards and 51 % on nonsurgical wards. In 96 %, perioperative pain was regularly recorded (generally pain at rest and/or movement, pain-related functional impairment in 16 % only). Beside these routine measurements, only 38 % of hospitals monitored pain for effectiveness after acute medications. Often interdisciplinary working groups and/or pain managers are established for hospital-wide control. As specific therapy, the patient-controlled analgesia and epidural analgesia are largely prevalent ( 90 % of all hospitals). In the last decade, intravenous and oral opioid administration of opioids (including slow release preparations) has become established in acute pain management.The survey was representative by evaluating 20 % of all German hospitals. The organizational requirements for appropriate pain management recommended by the German guidelines for acute pain recommended have been established in the hospital sector in recent years. However, the organizational enforcement for acute pain management in nonsurgical areas is not adequate yet, compared to the perioperative care. In all hospitals modern medication and invasive techniques are widely available.

In recent decades, the focus of pain management in hospitals was the organization and quality of control of postoperative pain, although there is a similar demand in nonsurgical departments. The aim of this study was to assess the employees' perspective on problems and corresponding solutions in pain management in a university hospital and to further clarify whether the implementation of concepts and tools of pain management across disciplines is feasible.Physicians and nursing staff of all inpatient departments of the University Hospital Göttingen were asked about problems in pain management and the importance of various established instruments using a standardized questionnaire. Ratings were recorded on a numeric rating scale (0-10). The analysis was primarily descriptive, the Kruskal-Wallis and Mann-Whitney U test were used when appropriate.In all, 149 medical and 501 nursing employees were included. The quality of pain management was perceived as better in surgical departments than in the conservative and pediatric departments. In all areas, the lack of an adequate order for baseline- and rescue-analgesic, and accordingly the nursing staff's limited ability to act was rated as problematic. In contrast to the conservative and pediatric departments, the predominant problem of surgical departments was the lack of availability of physicians on the ward. As a solution, the advice provided by pain consultation services was rated highly by the staff in all areas. The importance of implementation of standardized analgesic concepts was also supported equally in all areas. The evaluation of the quality of pain management was related to the employee's estimation of their ability to actively treat pain. Physicians rated problems in quality and organization lower compared to nursing stuff.The results demonstrate that from the employee's perspective problems in pain management in surgical and nonsurgical departments are very similar. Transferring concepts and structures of surgical pain management, such as standardized concepts and advice and or care through pain services, would meet high levels of acceptance. The results also indicate that the nursing staff's ability to treat should be increased by the provision of adequate rescue-analgesics. To close deficits in the management of care, established concepts of pain management could be extended to all departments of a hospital. Similarities outweigh differences in the employee's assessment.

Although exercise can be effective for relief of neck pain, little is known about the effect of exercise on the neural control of neck muscles.A randomized controlled trial was conducted on 46 women with chronic neck pain to investigate the immediate effectiveness of an 8-week exercise programme on pain and directional specificity of neck muscle activity. At baseline, the patients completed questionnaires including the neck disability index (NDI) and performed a circular contraction of their head in the horizontal plane at 15 N force, with continuous change in force direction in the range 0-360°. Electromyography (EMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SCap) muscles. Tuning curves of the EMG amplitude were computed, which depicts muscle activity over a range of force directions. The mean point of the tuning curves defined a directional vector, which determined the specificity of muscle activity. Patients were randomly assigned either to a training or control group.A significant between-group difference in the change in NDI was observed. A reduction in NDI was observed following training (pre: 18.2 ± 7.4; post: 14.1 ± 6.5; p 0.01) but not for the control group (pre: 17.5 ± 6.3; post: 16.6 ± 7.4). The training group showed higher specificity of muscle activity post-intervention (pre: 18.6 ± 9.8%, post: 24.7 ± 14.3%; p 0.05), whereas no change occurred for the control group (pre: 19.4 ± 11.9%, post: 18.2 ± 10.1%).An exercise programme that aims to enhance motor control of the cervical spine improves the specificity of neck muscle activity and reduces pain and disability in patients with neck pain.

Pre-existing or chronic pain is a relevant risk factor for severe postoperative pain. The prevalence of pre-existing and chronic pain in hospital depends on the time definition used and is approximately 44 % and 33%, at 3 or 6 months, respectively. The aim of this study was to determine the prevalence and importance of pre-existing pain in patients treated by a postoperative acute pain service (APS) and to evaluate the requirements for treatment and resources as well as its quality in this context.This study involved an evaluation of all visits by the APS of the University Hospital in Göttingen over an 8-week period including patient subjective quality assessment on the basis of the quality improvement in postoperative pain therapy (QUIPS) questionnaire. Pre-existing pain (12 weeks) was assessed by recording patients history of pain by members of the APS. The results from patients with and without pre-existing pain were compared.A total of 128 patients (38% female, 62% male, aged 15-88 years old, mean age 59.8 ± 14.4 years) were seen by the APS on 633 occasions. Of these patients 91% had been admitted to hospital for surgery (66% for tumor surgery, 8% joint replacement, 9% other joint surgery and 16% other interventions), 50% had acute postoperative pain without pre-existing pain, 50% had had pre-existing pain for at least 12 weeks, 31% had chronic non-cancer pain and 19% pain possibly related to cancer. Patients with pre-existing pain showed no significant differences in the treatment requirements (e.g. adjustment of medication), use of resources (e.g. number of visits to the APS and time spent in hospital) and quality of care (e.g. pain intensity, functional aspects, side effects and complications) in the setting of the APS. However, there was an additional subsequent support by chronic pain and palliative care services.Pre-existing pain is a common comorbidity in surgery patients treated by the APS. There were no significant differences in treatment requirements and quality of care between the patients. This is in contrast to other studies of postoperative pain management which showed that patients with pre-existing postoperative pain had higher pain intensity. This indicates indirectly that the presence of pre-existing pain should be further evaluated as a potentially useful indication for the support by an APS. However there is an urgent need for further studies to clarify whether this indirect effect can be replicated at other hospitals or in other patient collectives. Also it has to be clarified what benefits pain patients have from this kind of treatment: if they benefit from the APS in general or from the special technique, if there is a long-term effect lasting beyond treatment in the APS or if this group of patients would benefit in general from multiprofessional and non-invasive concepts of acute pain treatment.

For most (aerobic) animal organisms, oxygen is a mandatory and global substrate. The accurate measurement of oxygen is therefore of importance in the fields of medicine, biology, environmental research and biotechnology. The fact that oxygen is not readily soluble in aqueous media makes its detection more difficult. In contrast to the technique of polarography, the use of luminescence quenching by paramagnetic oxygen, does not consume the oxygen. Another problem of oxygen detection in connection with respiration is the need for very short response times. A third problem, which is associated with luminescence itself, is the fading of the dyes, which results in long-term signal instability. The last two problems can be optimally resolved by adsorbing the luminescence dye onto chromatographic materials--in particular hydrophobic material--having a very large internal surface area, and using the decay time in accordance with the Stern-Volmer equation as oxygen signal. For this, continuous evaluation of the signal is necessary. The carrier material doped with dye is incorporated in a single-grain layer. For measurements in liquids, the detector layer is protected by a black silicone membrane. Two designs are possible for the oxygen detector: (I) a special form using glass fibres, and (II) a miniature detector utilizing optoelectronic solid state technology. Both fluorescence and phosphorescence can be employed, the dye used being excited by light, obviating the need for quartz. The detector layers may be either of high sensitivity for small oxygen concentrations, or have equal sensitivity over the entire oxygen concentration range. There is an optimal figure for the specific amount of adsorbed dye. Application examples are given for respiration and for the determination of oxygen uptake by suspended cells.

The aim of this investigation was to describe the effects of standardization and central control of the processes involved in postoperative pain management from patient and employee perspectives.Patients (n = 282/307) and respective hospital staff (n = 149/119) evaluated the processes, the quality of postoperative pain management and result parameters 3 months before and 12 months after the introduction of standardization of the postoperative pain therapy process using a set of standardized questionnaires.Pain level and the waiting period for an analgesic partially decreased and a higher subjective effectiveness of medication was achieved in patients after the standardization. Patients felt that the pain was taken more seriously and contacted the staff for additional medication more frequently. From an employee viewpoint the quality of care and individual competence and ability to treat pain increased after the introduction of standardization. Pain assessment was improved and employees rated their knowledge and education level as higher than before the intervention. Patients with pre-existing chronic pain and patients with special regional therapy benefited only partially after the introduction and an increase in pain intensity was even observed.The quality of care was improved by standardization of the postoperative pain management. The legal and practical ability of the nursing stuff to administer pain medication within well-defined margins reduced the dependence on the ward doctor and at the same time patient pain levels. Patients received analgesics more quickly and experienced increased effectiveness. These results should be an incentive to reconsider the importance of the organization of postoperative pain management, because the quality of care with all potential medical and economic advantages, can be easily optimized by such simple mechanisms. They also show that the quality assessment of acute pain and the selection of appropriate indicators need further development.

The aim of this investigation was to describe the performance profile and the requirements for the management of complex pain patients for the structures of a consultation service.The content and number of all inpatient consultations of the pain department (as an independent service in addition to acute pain and palliative care services) were evaluated for the period from 2008-2010.During the study, 1,391 contacts were made in 882 patients; in approx. 50% of the consultations diagnostic or specific (interventional) procedures were requested. Beside additional diagnostic tests, physiotherapy (19.2%), psychological and psychiatric care (11.1%), and other therapeutic approaches (e.g., mirror therapy, transcutaneous electrical nerve stimulation, progressive muscle relaxation) or the long-term follow-up in specialized pain service (20.5%) were recommended.Within the scope of the pain consultation, a wide spectrum of pain diagnoses and difficult patients are examined. Mixed forms of acute, chronic, and tumor-related pain are often present. Therapeutically, optimization of only the pharmacological regimen is often not sufficient. Similar requirements for a multimodal diagnosis and therapeutic concept as established in ambulatory and/or specialist care are ultimately needed.

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.Amitriptyline and-in case of comorbid depressive disorder or generalized anxiety disorder-duloxetine are recommended. Off-label use of duloxetine and pregabalin can be considered in case of no comorbid mental disorder. Strong opioids are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.The clinical diagnosis of FMS can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with tender point examination), by the modified preliminary diagnostic ACR 2010 criteria or by the diagnostic criteria of the German interdisciplinary guideline (AWMF) on FMS. The English full-text version of this article is available at SpringerLink (under "Supplemental").

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine.Current data do not identify distinct etiologic or pathophysiological factors mediating development of FMS. The development of FMS is associated with inflammatory rheumatic diseases (EL2b), with gene polymorphisms of the 5-hydroxytryptamine (HT)(2) receptor (EL3a), lifestyle factors (smoking, obesity, lack of physical activity; EL2b), physical and sexual abuse in childhood and adulthood (EL3a).FMS is most likely the result of various pathogenetic factors and pathophysiological mechanisms. The English full-text version of this article is available at SpringerLink (under "Supplemental").