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Oral medication is the simplest way in treatment of chronic pain. For cancer pain oral analgesics are efficacious in more than 90% of the patients. When a causal therapy of pain (e.g. chemotherapy, operation) fails an analgesic ladder with oral analgesics is instituted. This ladder starts with a non-narcotic analgesic in a sufficient dose. The regular dose of acetylsalicylic acid or paracetamol is 4 g daily. When this dose does not work sufficiently, a weak opioid (e.g. dihydrocodeine) is given concomitantly at an individual dose. When the weak opioid fails, strong opioids are given (e.g. morphine). The drugs should be given by mouth whenever possible. The most important point is the regular application according to a time-schedule. This time-schedule is related to the action time of the drug. Patients with severe vomiting or dysphagia can receive a continuous subcutaneous infusion. These measures are based on recommendations of the WHO.The same medications can be employed in patients with chronic non-malignant pain, provided that all other conventional measures in pain treatment fail. However, many states of pain are not opioid-responsive. Pain related to the sympathetic nervous system is more responsive to antidepressants than to opioids or NSAID. Neuropathic pain as in trigeminal neuralgia responds to anticonvulsants. Pain from muscle spasm is better controlled by muscle relaxants than by analgesics. Bone pain is more sensitive to NSAID than to any other drug.In any state of pain the response to the different groups of drugs should be evaluated first. Then a stepwise pharmacological approach should be performed. In most cases pain can be treated effectively by oral drugs.
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Klinik für Anaesthesiologie, Intensiv- und Schmerztherapie, Universitätsklinik Bergmannsheil, Gilsingstr. 14, 4630, Bochum 1.