NHG-Richtlijnen
NHG-Standaard
M106
2.5
juni 2018
september 2024
A. Algemeen

Richtlijnen diagnostiek

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Anamnese

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Lichamelijk onderzoek

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Aanvullend onderzoek

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Evaluatie

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Richtlijnen beleid

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Beleid bij acute nociceptieve pijn

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Voorlichting en advies

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Niet-medicamenteuze behandeling

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Medicamenteuze behandeling

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Controles

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Consultatie en verwijzing

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Beleid bij chronische pijn

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Aanpak algemeen

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Voorlichting (educatie)

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Niet-medicamenteuze behandeling

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Medicamenteuze behandeling

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Controles

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Consultatie en verwijzing

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Beleid bij neuropathische pijn

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Beleid bij pijn in de palliatieve en terminale fase

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Beleid bij afbouwen na langdurig gebruik opioïden

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Controles

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Samenwerking, consultatie en verwijzing

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Belangrijkste wijzigingen

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Kernboodschappen

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Inleiding

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Scope

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Buiten de scope

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Samenwerking en afstemming

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Achtergronden

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Pijn

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Acute nociceptieve pijn

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Epidemiologie

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Pathofysiologie

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Symptomatologie en beloop

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(Dreigende) chronische pijn

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Epidemiologie

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Pathofysiologie

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Centrale sensitisatie
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Symptomatologie en beloop

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Risicofactoren chronisch beloop
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Neuropathische pijn

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Epidemiologie

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Pathofysiologie

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Symptomatologie en beloop

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Richtlijnen diagnostiek

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Anamnese

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Klachtexploratie middels SCEGS

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Diagnostiek depressie/angst bij aanhoudende pijn

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Heteroanamnese

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Pijnschalen

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Neuropathische pijn

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Arbeid

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Aanvullingen op de anamnese bij pijn in de terminale fase

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Lichamelijk onderzoek

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Aanvullend onderzoek

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Evaluatie

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Richtlijnen beleid

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Beleid bij acute nociceptieve pijn

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Voorlichting en advies

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Thuisarts
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Bedrijfsarts
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Niet-medicamenteuze behandeling

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Medicamenteus stappenplan

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Stappenplan
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Specifieke aandoeningen
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Algemene uitgangspunten
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Stap 1: paracetamol

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Dosering paracetamol
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Stap 2a: dermaal NSAID

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Stap 2b: oraal (of intramusculair of rectaal) NSAID

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Aandachtspunten veiligheid NSAID’s
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Preventie van maagcomplicaties door NSAID’s
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Voorkeursmiddelen en doseringen NSAID’s
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NSAID’s bij kinderen
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Controles bij NSAID’s
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Stap 3: zwakwerkend opioïd

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Stap 4: sterkwerkend opioïd

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Risicofactoren voor problematisch opioïdgebruik
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Screeningsinstrument
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Praktische toepassing bij indicatie voor een sterkwerkend opioïd
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Keuze preparaat en toedieningsvorm
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Dosering
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Preventie van obstipatie bij opioïdgebruik
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Behandeling van misselijkheid en braken bij opioïdgebruik
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Opioïdrotatie bij onvoldoende effect sterkwerkend opioïd bij acute pijn
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Afbouwen sterkwerkende opioïden na kortdurend gebruik
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Aanvullingen beleid bij gebruik van sterkwerkende opioïden bij chronische pijn
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Stap 5: subcutane of intraveneuze toediening van sterkwerkende opioïden

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Controles

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Aanpak controles
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Consultatie en verwijzing

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Beleid bij chronische pijn

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Aanpak algemeen

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Voorlichting (educatie)

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Thuisarts
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Bedrijfsarts
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Niet-medicamenteuze behandeling

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Maatschappelijk werk
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Psychologische interventies
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Behandeling comorbide angst en/of depressie
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Beweeg- en oefenprogramma’s
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Medicamenteuze behandeling

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Voorlichting en advies over pijnmedicatie
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Gebruik van vrij verkrijgbare NSAID’s
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Cannabis
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Specifieke aandoeningen
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Controles

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Aanpak controles bij gebruik pijnmedicatie
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Consultatie en verwijzing

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Monodisciplinair werkende medisch specialisten
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Fysiotherapeut/oefentherapeut
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Maatschappelijk werk
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Psycholoog
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Bedrijfsarts
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Specialist ouderengeneeskunde of klinisch geriater
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Pijnbehandelcentrum
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Pijnrevalidatieteam
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Samenwerking

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Beleid bij neuropathische pijn

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Voorlichting

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Niet-medicamenteuze behandeling

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Medicamenteuze behandeling

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Medicatie bij neuropathische pijn
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Orale medicatie
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Cannabis bij chronische neuropathische pijn
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Dermale medicatie
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Capsaïcine
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Lidocaïne
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Consultatie en verwijzing

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Beleid bij pijn in de palliatieve en terminale fase

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Niet-medicamenteuze behandeling

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Medicamenteuze behandeling

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Beleid bij doorbraakpijn in de palliatieve/teminale fase
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Methadon in de palliatieve/terminale fase
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Cannabis in de palliatieve/terminale fase
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Controles

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Beleid bij afbouwen na langdurig gebruik opioïden

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Indicaties

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Voorlichting

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Aanpak afbouw van opioïden

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Adviezen bij afbouwen van opioïden
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Controles

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Samenwerking, consultatie en verwijzing

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Referenties

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MAD intranasale verstuiver
Cassettepomp
Subcutane vleugelnaald inbrengen
NHG-werkgroep:
Keizer D, Luiten WE, Schouten F, Van den Donk M, Veldhoven CMM, Verbree-Willemsen L, Vossenberg PCTJ. (September 2023)

Damen Z, Kadir-Klevering F, Keizer D, Luiten WE, Van den Donk M, Van ’t Klooster S, Van Walraven A, Veldhoven CMM, Vossenberg PCTJ. (November 2021)
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