European journal of pain : EJP
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The use of opioids has long been accepted as the standard of care in patients with cancer and acute pain. Opioids can further be used effectively in specific subgroups of patients with chronic nonmalignant pain states. While the development of tolerance and physical dependence are known effects of opioids in cancer and noncancer pain populations, these patients can not be regarded as addicted. ⋯ Recent research has confirmed the important role of psychopathologic and psychosocial conditions as predictors of failed opioid effectiveness in a significant number of noncancer pain subgroups. The clinical picture of failed therapy may be complicated by noncompliance, concealed consumption of psychotropic substances, and diversion of prescribed opioids for various purposes as, e.g., selling for profit, or sharing excess opioids with others. This article discusses the effects of opioid therapy, including tolerance, physical dependence, drug-aberrant behavior, drug history, psychopathology, and somatization.
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Opioid effectiveness can be improved by individualizing dosing, route of administration and the drug. Particularly in the treatment of chronic non-cancer pain, careful patient selection is essential. ⋯ These pharmacological "oipioid adjuvants" include e.g. alpha(2)-adrenergic agonists, non-steroidal anti-flammatory analgesics, NMDA-receptor antagonists, CCK-antagonists, gabapentinoids and NK-1 receptor antagonists. The theoretical background and the clinical evidence of these combinations will be discussed.
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The use of opioid analgesics for long term management of chronic non-cancer pain is now an accepted, although still a controversial medical practice. In some well selected patients with long-lasting or recurrent pain, severe enough to markedly reduce their quality of life, and for whom no other more effective and less risky therapy is available, opioid analgesics may reduce intensity of pain, increase functioning and improve quality of life for prolonged periods. The type of pain and pain history of the patients do not predict reliably the chance of long term success or risk of complications from opioid therapy. ⋯ When a patient is managed by a multidisciplinary team, the compliance is better and risk of loss of control and complications are less than when a single doctor is managing the patient. The evidence base for this type of pain management is meagre because the needed randomized controlled trials, which ideally should last for several years, have not been performed. Therefore a number of national and international guidelines are being published, recommending experts' opinion on appropriate use and responsible follow-up of long term treatment with opioids for chronic non-cancer pain.
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Pain, the cardinal feature of irritable bowel syndrome (IBS), is a multidimensional phenomenon with sensory and affective dimensions. Price's pain processing model was used to delineate four a priori sequentially related stages (pain sensation intensity, immediate pain unpleasantness, long-term suffering, and pain-related behavior). Although prior research with both healthy individuals and somatic pain patients supports the model in general, its applicability to IBS is unclear. ⋯ Age was related to pain sensation and illness behaviors but not pain affect. Gender tended to be more strongly associated with more distal pain stages (e.g., pain affect) vis-a-vis its effects on pain sensation. These data are generally supportive of a four-stage pain processing model.
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The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) differentiates between a biomedical versus a biopsychosocial treatment orientation with regard to common low back pain. This study re-examined the factor structure and psychometric properties of the PABS-PT, along with the relationship between PABS-PT scores and the perceived harmfulness of physical activities and treatment recommendations for common low back pain. ⋯ Furthermore, scores on both factors of the PABS-PT were related to measures of related concepts (statistically significant Pearson correlation coefficients between 0.30 and 0.65) such as the HC-PAIRS and a therapist version of the TSK. Regression analyses revealed that both factors were consistent predictors of judgements of the harmfulness of physical activities (PHODA) and of recommendations for return to work and normal activity.