Basiswissen zur medikamentösen Schmerztherapie in der Palliativsituation

Dieser Übersichtsartikel bietet einen Überblick zum Basiswissen in medikamentöser Schmerztherapie in der Palliativsituation. Schmerz ist eines der führenden Symptome bei 60–90% aller Krebspatienten. Schmerzen entstehen auch bei neurologischen oder anderen Krankheiten, die am Lebensende auftreten. Um dieses Symptom zu behandeln, ist eine ganzheitliche Strategie vonnöten, die alle körperlichen, psychologischen, sozialen und spirituellen Aspekte der multidimensionalen Schmerzerfahrung (gemäß dem „Total-Pain“-Konzept) umfasst.

Abstract

This review provides an overview of the basic knowledge of drug pain therapy in the palliative situation. Pain is one of the main symptoms in 60 to 90% of cancer patients. Pain also develops with neurological and other diseases that occur in end-of-life situations. To address this symptom, a holistic strategy is required that encompasses all physical, psychological, social, and spiritual aspects of the multi-dimensional pain experience (“total pain” concept).

Drug treatment for cancer pain has been based on a stepwise approach for many years, starting with non-opioid analgesics, followed by moderate and strong opioids. In contrast, today’s pain management is determined more by the actual intensity of this aversive event.

The pain assessment should be tailored to identify a nociceptive vs. a neuropathic pain component that needs to be challenged by the most appropriate drug therapies. Non-opioid analgesics are ideal substances for relieving nociceptive pain. Antidepressants and anticonvulsants reduce the intensity of new neuropathic pain. Opioids are suitable for all types of pain, but are restricted to a second-line choice. Among all opioids are Tilidine and Tramadol prodrugs, which only relieve pain after activation in the liver. Drug-drug interactions may also block this activation. Rapid release opioids should be used for break-through cancer pain. Transdermal opioid applications are recommended in case of swallowing disorders, but usually not to initiate pain control. An opioid change can be performed if side effects such as hallucinations for the selected opioid are more pronounced than the pain reduction.

Kernaussagen

• Schmerz ist in 60–90% der Fälle eines der führenden Symptome bei Patienten mit fortgeschrittenen Tumor-Erkrankungen.

• Opioide sind nicht nur gegen Tumorschmerzen, sondern auch gegen eine neuropathische Schmerzkomponente wirksam.

• Das „Total-Pain“-Konzept ermöglicht eine mehrdimensionale Betrachtungsweise des Tumorschmerzes.

• Komorbide Angst und depressive Störungen bedürfen einer differenzialdiagnostischen Abklärung und Mitbehandlung.

• Transdermale, subkutane und intravenöse Applikationswege können eine Alternative bei Schluckstörungen sein.

• Die Opioide Tilidin und Tramadol sind Prodrugs, die erst nach Aktivierung in der Leber schmerzlindernd wirken.

• Tumor-Durchbruchschmerzen werden mit schnellwirksamen Opioiden behandelt.

• Ein Opioid-Wechsel wird bei weiterhin relevanten Schmerzen und/oder unerwünschten Wirkungen wie z.B. Halluzinationen empfohlen.

Schlüsselwörter

Palliativmedizin - Schmerztherapie - Opioide - Total Pain

Keywords

palliative care - pain therapy - drug therapy - opioids - total pain

Publication History

Article published online:
25 June 2025

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