German Pain Society Research Articles

PAIN2.0: study protocol for a multicentre randomised controlled trial to evaluate the efficacy of a 10-week outpatient interdisciplinary multimodal pain therapy to manage recurrent pain for patients with risk factors of developing chronic pain in Germany.

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. 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 12months, implemented by 22 health care facilities nationwide). After 6months, 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. 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. The trial PAIN2.0 has been registered in the German Clinical Trials Register (DRKS) since 21/11/2022 with the ID DRKS00030773 .

Rasch analysis of the Depression, Anxiety, and Stress Scale in patients with chronic pain

ObjectiveQuestionnaires are commonly used to assess and screen pain-related, psychological symptoms in patients with chronic pain. In Germany, the “German pain questionnaire” provided by the German Pain Society used for this purpose includes the Depression, Anxiety, and Stress Scale (DASS). This study aims to analyze the DASS by fitting its data to the Rasch model to test the psychometric quality. Study design and settingIn this cross-sectional study, 932 patients with chronic pain answered the DASS. The 21-item short version was tested via Rasch analysis using the parameters threshold order, fit to the model, Differential Item Functioning, unidimensionality and reliability. ResultsThe Rasch analysis results showed a low reliability, misfitting items, Differential Item Functioning or multidimensionality. It was necessary to remove items from the subscales to improve fit to the Rasch model. A revised depression subscale of the DASS-21 was the only scale that achieved all the required psychometric parameters. The summation of all items to a total scale was not supported. ConclusionMore research is required on somatic free measurement of psychological symptoms in patients with chronic pain. The results demonstrate that the development of a new instrument or a revision of existing instruments for screening of psychological symptoms in chronic pain are needed.

Attitudes toward digital tools in pain medicine : Survey of German Pain Society health professional members and members of self-help groups

Digital medicine has increasing influence on the German healthcare system. In times of social distancing during the ongoing coronavirus disease 2019 (COVID-19) pandemic, digital tools enable health professionals to maintain medical care. Furthermore, digital elements have potential to provide effective guideline-oriented treatment to abroad range of patients independently from location and time. This survey was used to assess the attitudes of members of the German Pain Society (health professionals) and of associated self-help groups (patients) towards digital medicine. It was sent out as an online survey to health professionals in September 2020 and to patients in February 2021. The survey referred especially to present usage, attitude and potential concerns regarding particular digital elements. Furthermore, technical affinity was assessed. In total, 250health professionals and 154patients participated in the survey. The results show that-although digital elements are already known-asubstantial proportion of health professionals still lack broad transfer to regular treatment. The potential of digital tools seems to be recognized by both groups; interestingly, patients consider digital medicine as more useful than health professionals. Nevertheless, concerns about for example data security or digital competence remain in both groups. Taken together, our results indicate that disruptive changes, as the implementation of digital medicine in the healthcare system, have to be guided by intense education and channeled by political policies in order to successfully integrate digital elements into medicine on along-term basis. This would be in favor for all involved parties and is demanded especially by patients.

Updated S1guideline on long/post-COVID: relevant aspects for pain medicine

The S1guideline on long/post-COVID of the AWMF [German Association of the Medical Scientific Societies] registration number 020-027) was updated in August2022. Under the coordination of the German Society of Pneumology, the guideline was updated by 21scientific associations, two professional associations and clinical centers each and one institute and statutory accident insurance each. Each scientific association was responsible for its own chapter. The German Pain Society prepared the chapter "Pain". The coordinators of each chapter performed aselective literature search and also received approval for the chapter within their scientific association. During an internal period of comments, all representatives of the participating institutions could comment on all chapters. The AWMF task force commented on the draft of the guideline, which was then finally approved by the boards of all participating institutions. Coronavirus disease 2019 (COVID-19) increases the risk of persistent headache and musculoskeletal pain. Long/Post-COVID pain is frequently associated with fatigue and cognitive problems. Aspecialist assessment might be considered if symptoms with limitations of daily activities persist 3months after the infection. The diagnostic workup of long/post-COVID-associated pain should be performed according to the standards of pain medicine. Management should follow the pain guidelines of the AWMF. The updated S1guideline on long/post-COVID is aclinical manual which offers orientation for diagnostics and treatment despite limited data.

One year of digital health applications (DiGA) in Germany - Rheumatologists' perspectives.

Based on given legislation the German approach to digital health applications (DiGA) allows reimbursed prescription of approved therapeutic software products since October 2020. For the first time, we evaluated DiGA-related acceptance, usage, and level of knowledge among members of the German Society for Rheumatology (DGRh) 1 year after its legal implementation. An anonymous cross-sectional online survey, initially designed by the health innovation hub (think tank and sparring partner of the German Federal Ministry of Health) and the German Pain Society was adapted to the field of rheumatology. The survey was promoted by DGRh newsletters and Twitter-posts. Ethical approval was obtained. In total, 75 valid response-sets. 80% reported to care ≥ 70% of their working time for patients with rheumatic diseases. Most were working in outpatient clinics/offices (54%) and older than 40 years (84%). Gender distribution was balanced (50%). 70% knew the possibility to prescribe DiGA. Most were informed of this for the first time via trade press (63%), and only 8% via the scientific/professional society. 46% expect information on DiGA from the scientific societies/medical chambers (35%) but rarely from the manufacturer (10%) and the responsible ministry (4%). Respondents would like to be informed about DiGA via continuing education events (face-to-face 76%, online 84%), trade press (86%), and manufacturers' test-accounts (64%). Only 7% have already prescribed a DiGA, 46% planned to do so, and 47% did not intend DiGA prescriptions. Relevant aspects for prescription are provided. 86% believe that using DiGA/medical apps would at least partially be feasible and understandable to their patients. 83% thought that data collected by the patients using DiGA or other digital solutions could at least partially influence health care positively. 51% appreciated to get DiGA data directly into their patient documentation system/electronic health record (EHR) and 29% into patient-owned EHR. Digital health applications awareness was high whereas prescription rate was low. Mostly, physician-desired aspects for DiGA prescriptions were proven efficacy and efficiency for physicians and patients, risk of adverse effects and health care costs were less important. Evaluation of patients' barriers and needs is warranted. Our results might contribute to the implementation and dissemination of DiGA.

Psychosocial factors in pain and pain management : A statement

Although psychosocial factors have aprofound impact on the experience of pain and pain recovery, the transfer to clinical application has so far been insufficient. With this article, atask force of the special interest group "Psychosocial Aspects of Pain" of the German Pain Society (Deutsche Schmerzgesellschaft e. V.) would like to draw attention to the considerable discrepancy between existing scientific evidence on the importance of psychosocial factors in the development of chronic pain disorders and the translation of these findings into the care of pain patients. Our objective is astronger integration of psychological and psychosomatic expertise in pain treatment and research, as well as the improvement of structural and institutional conditions, to achieve an increased consideration of psychosocial aspects. In this way, modern, integrative and complex pain concepts can reach the patient. Based on these fundamental findings on the importance of psychosocial factors in pain and pain treatment, implications for the transfer to clinic and further research will be shown.

Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics. An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within aformal, structured consensus process. The panel agreed that nonopioid analgesics shall be part of amultimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for alimited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs. The use of nonopioid analgesics as part of aperioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

Medical pain care for children and adolescents with chronic pain in Germany : An inventory

Chronic pain in children and adolescents is increasing in prevalence, affects the quality of life, predisposes to pain in adulthood and causes numerous contacts to the healthcare system. In contrast, the number of therapeutic offers tailored to the special needs of this age group is insufficient and confusing. The working group on pain in children and adolescents of the German Pain Society therefore documented appropriate facilities in aquestionnaire survey carried out using asnowball system. The response rate of 27/109 questionnaires was low. Thus, the results may not be entirely representative. Nevertheless, the heterogeneity of the offers and in total an undersupply became very clear. In order to improve the care situation, joint efforts by the various pediatric subdisciplines dealing with pain, an increase in the number of child pain treatment centers and a better networking are necessary.

Editorial introductions

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Claudia SommerClaudia SommerClaudia Sommer is a Professor of Neurology at the University of Würzburg, Germany. Her research interests are immune neuropathies and the pathophysiology of pain and of antibody-mediated diseases. She has written more than 250 original research papers and more than 100 reviews and book-chapters and edited several books. She is a longstanding member of the Peripheral Nerve Society (PNS) and a Board Member of the Inflammatory Neuropathy Consortium (INC), as well as Chair of the Teaching Course Subcommittee of the European Academy of Neurology (EAN). Dr Sommer is active in the development of national and international guidelines on immune neuropathies, diagnosis and treatment of peripheral neuropathies, on nerve and skin biopsies, and on neuropathic and primary pain syndromes. She is currently president of the German Pain Society and president elect of the International Association for the Study of Pain (IASP). John VissingJohn VissingJohn Vissing is professor of Neurology at the University of Copenhagen, Denmark, and the Director of the Copenhagen Neuromuscular Center at the National Hospital, Rigshospitalet, in Copenhagen, with 38 dedicated neuromuscular employees. He obtained his MD in 1986 and was then a research fellow at University of Copenhagen and UT, Southwestern Medical Center in Dallas, USA. His research focuses on hereditary muscle diseases. Main research interests are treatment and pathophysiology of metabolic myopathies myasthenia gravis and channelopathies, discovery of new neuromuscular diseases, rehabilitation of muscle disease including exercise training, MR imaging of muscle, defining outcome measures for natural history and trials and unraveling genotype-phenotype relations in muscle disease. He has authored more than 400 scientific papers on neuromuscular diseases. Jinsy A. AndrewsJinsy A. AndrewsJinsy A. Andrews, MD, MSc, FAAN is an Associate Professor of Neurology, in the Division of Neuromuscular Medicine and serves as the Director of Neuromuscular Clinical Trials at Columbia University Irving Medical Center, USA. She currently oversees neuromuscular clinical trials at the medical center and cares for patients with neuromuscular disease, primarily with Amyotrophic Lateral Sclerosis (ALS) at the Eleanor and Lou Gehrig ALS Center. Dr Andrews has extensive experience in all phases of human clinical trials and drug development in both the academic and industry settings. Dr Andrews is the elected co-chair of the Northeastern ALS (NEALS) Consortium, which is a network of over 100 ALS clinical research centers internationally. She is also elected to the National Board of Trustees of the ALS Association and is a Fellow of the American Academy of Neurology (FAAN) in the United States. She has also received the Diamond Award for ALS clinical research from Wings Over Wall Street and the Muscular Dystrophy Association. Dr Andrews received her B.S. from Union College, USA, M.Sc. in Biostatistics (Patient-Oriented Research) from Columbia University's Mailman School of Public Health, USA, and M.D. from Albany Medical College, USA. She completed her residency training in Neurology at the University of Connecticut, USA, and served as the Chief Neurology Resident in her final year. Dr Andrews completed fellowship training in Neuromuscular Disease/ALS and Clinical Neurophysiology at Columbia University. She is board certified in Neurology, Neuromuscular Disease, and Electrodiagnostic Medicine.

Pain therapy care in Germany-Do patients receiving day care differ from those receiving outpatient or inpatient care at the start of treatment? : Afurther evaluation based on the KEDOQ-pain data set

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 acontinuation 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 25centers with atotal 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 ahigher level of education, were more frequently employed, reported higher impairment values and showed ahigher severity index according to von Korff than inpatients and outpatients treated for pain. In addition, they described ashorter 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 aspecial 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.

Recommendations of the second update of the LONTS guidelines : Long-term opioid therapy for chronic noncancer pain

The second scheduled update of the German S3guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the LONTS (AWMF registration number 145/003), was started in December 2018. The guidelines were developed by 28scientific societies and 2 patient self-help organizations under the coordination of the German Pain Society. Asystematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Scopus databases (up until December 2018) was performed. The systematic reviews with meta-analyses of randomized controlled trials with opioids for CNCP from the previous versions of the guideline were updated. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by formal multistep procedures in order to reach aconsensus according to the Association of the Medical Scientific Societies in Germany (AWMF) regulations. The guidelines were reviewed by four external pain physicians. Public comments were possible for 4weeks. Opioid-based analgesics are a drug-based treatment option for short-term (4-12weeks), intermediate-term (13-25weeks) and long-term (≥26weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. Based on a clinical consensus the guidelines list other medical conditions for which atherapy with opioids can be considered on an individual basis. Long-term therapy of CNCP with opioids is associated with relevant risks. A responsible administration of opioids requires consideration of possible indications and contraindications as well as regular assessment of efficacy and adverse effects. Opioids remain atreatment option for CNCP if nonpharmacological therapies are not effective and/or other drugs are not effective, are not tolerated or are contraindicated.

Method report of the second update of the guidelines on long-term opioid therapy for chronic noncancer pain

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 February 2020 due to the expiry of the validity period. The guidelines were updated by 28scientific societies and 2 patient self-help organizations under the coordination of the German Pain Society and the Association of the Scientific Medical Societies in Germany (AWMF). Asystematic literature search was performed in the CENTRAL, MEDLINE and Scopus databases from October 2013 to December 2018. The previous meta-analyses of randomized controlled trials (RCT) of opioids in CNPC syndromes with a study duration of ≥4weeks were updated. 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 amultistep formalized consensus procedure, in accordance with AWMF rules and standards. The guidelines were reviewed by four experts not involved in the development of the guidelines. The public was given the opportunity to comment on the guidelines. The guidelines 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.

Is interdisciplinary multimodal pain therapy threatened? : Increasing controversy on the necessity for inpatient treatment

Interdisciplinary multimodal pain therapy (IMST) is recognized as a scientifically founded form of therapy for inpatient treatment of chronic pain conditions. The indications are assessed by private practitioners and must be confirmed by physicians at the inpatient institution. The health insurance companies are obliged to remunerate this treatment but are allowed to test the conditions in individual cases. Recently, reports from members of the German Pain Society on a drastic increase in testing and rejection quotas have become more frequent. Therefore, this article discusses the legal foundations of the treatment of patients with chronic pain in the inpatient sector. Hard criteria for treatment in a certain sector could not be established. A decision in individual cases will depend on the complexity of the disease in the individual patient. A treatment in hospital is principally only necessary when the treatment corresponds to the generally recognized state of medical knowledge and treatment options in daycase unitshave not been successful. Important guidance can be found in the treatment guidelines of the medical specialist societies. The transfer to a more intensive treatment sector must be made dependent on the severity and complexity of the symptoms and the insufficient effectiveness of the treatment in the previous sector. Simple ICD-10 diagnoses are not suitable as decision-making criteria and therefore, also not as testing criteria for the indications for inpatient treatment. Decompensated and acutely exacerbated chronic pain conditions must as a rule be treated in hospital, also due to the mental component of the pain disease.

Do doctors treat themselves differently than their patients? Study on the self-treatment of migraine among German neurologists and pain specialists.

To investigate whether the self-treatment of migraine among neurologists and pain specialists corresponds to national medical guidelines and treatment of patients. An email cross-sectional survey was sent to members of the German Society for Neurology, German Pain Society and German Migraine and Headache Society containing questions on demographics, professional experience and specialization and - in case participants suffered from migraine - questions about their migraine and its treatment. 175/418 (41.9%) participants suffered from migraine (m: 29.3%; f: 55.2%, 45.9 ± 10.7 years). For acute migraine attacks, 96.6 % of them use a first-line treatment according to the medical guidelines. Seventeen (9.7%) are currently taking a migraine prophylaxis, 52.9% of these use a recommended first-line prophylaxis. In all, 21.7% are not taking a prophylactic treatment despite an indication (based on number of monthly migraine days) for it, due to fear of side-effects, low intensity of migraine attacks and a sufficient effect of acute medication. This group of participants was younger, less experienced and specialized and was mainly employed (vs. self-employed) compared to those taking a prophylaxis. A total of 96.6% reported treating their patients in line with current guidelines; 14.3% would treat themselves differently when they were their own patients. The self-treatment of acute migraine attacks for the most part complies with the guidelines but, regarding the indication for a prophylaxis, a more divergent treatment approach was observed among younger, less experienced physicians. For the majority of physicians there is no difference between self-treatment and treatment of migraine patients.

Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug

Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After aformal, structured consensus process, the recommendations were approved by the involved medical societies. The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has arelatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug

Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After aformal, structured consensus process, the recommendations were approved by the involved medical societies. The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has arelatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

Perioperative use of metamizole and other nonopioid analgesics in children : Results of a survey

Nonopioid analgesics are frequently used for perioperative pain management in children. In many countries, the nonopioid metamizole (dipyrone) is administered as an alternative to paracetamol and traditional NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen and diclofenac; however, concerns over possible life-threatening adverse events (agranulocytosis) have prompted a debate over the use of metamizole. To investigate current practice and use of nonopioid analgesics, particularly of metamizole in children younger than 14years, in the perioperative setting. Furthermore, metamizole-related side effects, safety and approaches used to inform patients were addressed. Alink to an online questionnaire on the perioperative use of nonopioid analgesics in children, with a specific focus on dipyrone, was sent by e‑mail to members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and to members of the German Pain Society. Atotal of 2284 anesthesiologists filled out the questionnaire. Of these, 1476 were involved in the perioperative care of children younger than 14years. The majority of respondents worked in German hospitals (90.5%) but Austria, Switzerland and the Netherlands were also among the countries represented. Of the respondents, 99.1% reported using nonopioid analgesics in the perioperative setting. The NSAID, metamizole, paracetamol and COX-2 inhibitors were administered by 83.9%, 68.6%, 67.5% and 2% of the respondents, respectively. Intravenous metamizole was the preferred nonopioid analgesic during surgical procedures, but following surgery, NSAID, metamizole and paracetamol were given with the same frequency by anesthesiologists. Of the respondents, 49.3% reported using metamizole in combination with another nonopioid analgesic in cases of severe pain, 14.8% used it as the sole nonopioid analgesic, and 23.2% never used it at all. Nearly half of the respondents administered metamizole i.v. in doses of 15 mg/kg body weight or lower, whereas 26% administered doses of at least 16 mg/kg up to more than 20 mg/kg. Of the physicians, 298 (20.2%) restricted the duration of metamizole use, varying between one single administration (4.7%), administration for 1 day (27.5%), or for 1-2 weeks (29.2%). Of the anesthesiologists, 65.6% reported no metamizole-related adverse effects. Allergic reactions/anaphylaxis and adrop in blood pressure requiring intervention were observed by 3-4% of the respondents. No change in blood cell counts within the last 2 years was reported by 73.1% of the respondents, whereas 17anesthesiologists (1.3%) had observed children with altered blood cell counts, with 2 (0.14%) reporting agranulocytosis. In most cases these were incidental findings. No severe sequelae or deaths were reported. Few respondents (5.5%) performed routine blood cell counts to monitor metamizole therapy. Furthermore, only aminority always (3.5%) or sometimes (6.1%) informed achild's parents of possible side effects of treatment with metamizole. The survey confirmed that metamizole is frequently used in children in the perioperative setting. Intravenous metamizole is the preferred nonopioid analgesic administered intraoperatively for pain prophylaxis. Clinical symptoms of agranulocytosis should be monitored and patients should be better informed about metamizole-related side effects.

Editorial introductions

Editorial introductions

Assessment of initial differences between inpatient and outpatient patients receiving pain therapy in Germany: the KEDOQ-Pain quality assurance system

KEDOQ-Pain is a quality assurance system for documentation and quality management of pain therapy under different treatment settings initiated by the German Pain Society. We used KEDOQ-Pain data to describe initial differences in sociodemographic, pain-related and psychological factors between pain patients receiving pain therapy in inpatient or outpatient treatment settings. Our data, collected by the German Pain Questionnaire (DSF), comprised information on pain patients receiving out- and inpatient therapy (n=4,705). Statistical analysis was carried out by descriptive and comparative data analysis using uni- and multivariate statistical methods. Patients receiving inpatient pain therapy were significantly older, more often female and had more often multiple pain localizations. They reported greater pain intensity, had a higher stage of pain chronification and higher pain-related disabilities. They showed higher levels of anxiety, depression and stress and had a lower quality of life. Significant group differences, however, had only small effect sizes. Even though multivariate analysis revealed most predictors of treatment in an inpatient setting to be significant, taken as a whole they explained less than 5% of the observed variance. Criteria underlying the current practice of allocation of patients to inpatient or outpatient pain therapy remain unclear. Our analysis suggests that highly chronified pain will increasingly be the challenge of future pain management, requiring professional competence from a multidisciplinary specialist team.

Etiology and pathophysiology of fibromyalgia syndrome : Updated guidelines 2017, overview of systematic review articles and overview of studies on small fiber neuropathy in FMS subgroups

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was planned 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 atotal of 42members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. Asystematic search of the literature from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Prospective population-based studies and systematic reviews with meta-analyses of case control studies were taken into consideration for the statements. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The statements were generated by multiple step formalized procedures. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. Current data do not enable identification of distinct factors in the etiology and pathophysiology of fibromyalgia syndrome. Fibromyalgia syndrome can be associated with inflammatory rheumatic diseases, gene polymorphisms, life style factors (e.g. smoking, obesity and lack of physical activity), depressive disorders as well as physical and sexual abuse in childhood and adulthood. Fibromyalgia syndrome is most probably the end result of various pathogenetic factors and pathophysiological mechanisms.