Abstract
Background and purpose
Treatment of acute pain is an essential part of emergency and rescue medicine. In Germany, there has been an increasing number of patients undergoing opiate substitution therapy. Managing acute pain in these patients is a great challenge. Knowledge of current substitution therapies, the effects of opioid-induced hyperalgesia, and opioid tolerance is helpful for the treating staff. The stigma (need for pain medication as an expression of addiction) of this patient group and fears of induced relapse often make adequate analgesia difficult. The importance of handovers at the interfaces between prehospital, emergency department, and in-hospital is high, as they pave the way for adequate pain control and the establishment of an early multimodal pain concept. This study aimed to enhance the knowledge about current opiate substitution therapies, including opiate-induced hyperalgesia and opiate tolerance, within the context of pain management. To facilitate this, a list of potentially available pain medications will be provided as a working tool to physicians who are inexperienced in pain management for an early multimodal therapy concept.
Methods
We reviewed and analyzed the currently available data on opioid-based substitution therapy and pain management in patients receiving long-term opioid therapy by searching relevant databases, including PubMed, UptoDate, TripPro, and the Cochrane Library. A classic patient casuistry was presented and discussed.
Results
Knowledge of substitution therapies and their impact on pain management help in the care of this special patient population
Conclusion
With the increasing number of patients receiving opiate substitution therapy, the knowledge of substitution therapy and possible treatment strategies would facilitate the provision of acute care for these patients and enable the initiation of adequate pain management in preclinical settings.
Zusammenfassung
Hintergrund und Ziel
Die akute Schmerzbehandlung ist ein wesentlicher Bestandteil der Notfall- und Rettungsmedizin. In Deutschland ist eine steigende Anzahl opiatsubstituierter Patienten zu verzeichnen. Die Behandlung akuter Schmerzen in diesem Patientenkollektiv stellt eine große Herausforderung dar. Hilfreich für das behandelnde Personal sind Kenntnisse der gängigen Substitutionstherapien, der Auswirkungen von opioidinduzierter Hyperalgesie und Opioidtoleranz. Die Stigmatisierung (Bedarf an Schmerzmedikation als Ausdruck der Sucht) dieser Patientengruppe und Ängste vor einem induzierten Rückfall erschweren häufig eine adäquate Analgesie. Der Stellenwert von Übergaben an den Schnittstellen zwischen Präklinik, Notaufnahme und innerklinisch ist hoch, da sie den Weg ebnen für eine ausreichende Schmerzkontrolle und die Etablierung eines frühzeitigen multimodalen Schmerzkonzepts. Ziel ist es, Kenntnisse zu den heute gängigen Substitutionstherapien zu vermitteln und die opioidinduzierte Hyperalgesie und Opioidtoleranz in die Überlegungen zur Schmerzbehandlung miteinzubeziehen. Mithilfe einer Auflistung potenziell verfügbarer Schmerzmedikamente wird auch den in der Schmerztherapie unerfahrenen Ärzten ein Arbeitswerkzeug für ein frühzeitig multimodales Therapiekonzept an die Hand gegeben.
Material und Methoden
Die medizinischen Literaturdatenbanken PubMed, TripPro, Cochrane Library und UpToDate wurden nach relevanter Literatur zum Thema opiatbasierter Substitutionstherapie und Schmerztherapie bei Patienten mit Opioiddauertherapie durchsucht und zusammengefasst. Außerdem erfolgte die Darstellung und Diskussion einer klassischen Patientenkasuistik.
Ergebnisse
Das Wissen um Substitutionstherapien und deren Auswirkungen auf eine Schmerzbehandlung helfen bei der Versorgung dieser besonderen Patientengruppe.
Schlussfolgerung
Bei einer zunehmenden Zahl von Patienten mit Opioidsubstitution erleichtern Kenntnisse der Substitutionstherapie und möglichen Behandlungsstrategien die akute Versorgung dieser Patienten und ermöglichen es, mit einer adäquaten Schmerztherapie schon präklinisch zu beginnen.
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Acknowledgements
We thank the patient for his cooperation and the permission to publish this case report. We would also like to thank Editage for proofreading and English language editing.
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Authors and Affiliations
Contributions
Nadja Spitznagel conceived the presented idea, structured the article and carried out the literature search in the field of substitution therapy. Fabian Heuser was responsible for the treatment algorithm due to this expertise in pain therapy. Flora Seeliger was responsible for the literature search in the field of emergency pain relief medication. Dominik Hinzmann was responsible for the supervision of the individual sub-steps as well as for the overall content. Presentation of the results was decided in the author team. The article was written by all the authors. All the authors read and approved the final manuscript.
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Conflict of interest
N. Spitznagel, F. Heuser, F. Seeliger and D. Hinzmann declare that they have no competing interests.
All studies mentioned were in accordance with the ethical standards indicated in each case.
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Spitznagel, N., Heuser, F., Seeliger, F. et al. Acute pain therapy in opiate-substituted patients. Notfall Rettungsmed (2024). https://doi.org/10.1007/s10049-024-01313-6
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DOI: https://doi.org/10.1007/s10049-024-01313-6
Keywords
- Acute pain therapy
- Prehospital care
- Opiate addiction
- Emergency medicine
- Pain therapy for opiate-substituted patients