Recommendations for Pain Management during the Covid-19 Pandemic
By August 7, 2020 11:13

Recommendations for Pain Management during the Covid-19 Pandemic

We are all aware of the current COVID-19 crisis. The question we need to ask as pain practitioners is whether this virus has any effect on pain and pain management.

Shanthanna H et al have published a statement on behalf of ESRA and ASRA. I believe it pertinent that we highlight some of the features relevant to our specialty so that we have some guidance in managing patient with COVID-19 and pain conditions. Included is a full list of references for anyone who wishes to further investigate the subject.

General Considerations in Chronic Pain Patients

  • Susceptibility of chronic pain patients could be higher as many are elderly with multiple comorbidities and potential immune suppression.4,5
  • Significant immune changes occur in a patient with COVID-19 disease.3,6Chronic pain exerts complex effects on the immune system, including immunosuppression in some individuals.7
  • Chronic opioid therapy may cause immune suppression in some patients, and individual opioids differ in their potential.8,9
  • Use of steroids in interventional pain procedures may induce immune suppression. Intraarticular corticosteroid injections have been associated with higher influenza risk.10

General Recommendations

No elective pain procedures, except specific semi-urgent procedures, should be performed.

The following are scenarios of “urgent” pain patient procedures during the COVID-19 pandemic

Intrathecal pump (ITP) refills and malfunction

  • ITP refills necessitate in-person meeting and evaluation.
  • End-of-life ITP battery requires urgent replacement to avoid withdrawal symptoms.

Neurostimulator infection and malfunction

  • If an implant infection is suspected, an in-person evaluation may be necessary. Depending on whether the infection is superficial or deep, device explant may be warranted and should be performed as soon as possible.13

“Semi-urgent” scenarios of pain patient procedures during the COVID-19 pandemic are as follows.  These cases should be evaluated on an individual basis, with shared decision making. Such procedural scenarios may include, but are not limited to, the following:

  • Intractable cancer pain
  • Acute herpes zoster or subacute, intractable post-herpetic neuralgia
  • Acute herniated disc and/or worsening lumbar radiculopathy
  • Intractable trigeminal neuralgia
  • Early complex regional pain syndrome
  • Acute cluster headaches and other intractable headache conditions

Opioids and COVID-19

Significant immune changes occur in patients with COVID-19 disease.3,6  Opioids are recognized as causing immune suppression, and individual opioids differ in their potential.8,9  Patients with COVID-19 who are receiving opioids can be more susceptible to respiratory depression, and the absorption of fentanyl during transdermal administration (fentanyl patch) may increase with fever.

  • We do not recommend any changes to ongoing opioid treatment regimens in the absence of documented changes in pain and/or function.

Opioid prescriptions and telemedicine

Considering the nature of the current COVID-19 health emergency, it is appropriate to make changes and/or continue prescriptions using telemedicine.

  • Use telemedicine to evaluate and continue opioid prescriptions.
  • Ensure adherence to the subscribed needs of telemedicine required by your country of practice.
  • Ensure all patients receive their appropriate prescription of opioids to avoid withdrawal.

Use of Anti-Inflammatories for Chronic Pain

  • It is recommended that all patients who have been prescribed or use non-steroidal anti-inflammatory drugs on a regular basis to continue using them.

Steroids in Chronic Pain and COVID-19

  • Patients on steroids have a potential for secondary adrenal insufficiency and altered immune response.23
  • Injections of corticosteroids into joints was shown to be associated with a higher risk of influenza.10
  • Consider evaluating the risks and benefits of steroid injections, and use a decreased dose, especially in high-risk patient populations.

I trust that these recommendations will aid us all in these trying times. Please be careful and stay safe.

Milton Raff


  1. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032. [Epub ahead of print].
  2. Baud D, Qi X, Nielsen-Saines K, Musso D, Pomar L, Favre G. Real estimates of mortality following COVID-19 infection. Lancet Infect Dis. 2020 Mar 12. pii: S1473-3099(20)30195-X. doi: 10.1016/S1473-3099(20)30195-X. [Epub ahead of print].
  3. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res. 2020 Mar 13;7(1):11. doi: 10.1186/s40779-020-00240-0.
  4. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2. Epub 2012May 10..
  5. Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019;123(2):e273-e83. doi: 10.1016/j.bja.2019.03.023. Epub 2019May 10..
  6. Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020 Mar 16. pii: S0140-6736(20)30628-0. doi: 10.1016/S0140-6736(20)30628-0. [Epub ahead of print].
  7. Ren K, Dubner R. Interactions between the immune and nervous systems in pain. Nat Med. 2010;16(11):1267-76.doi: 10.1038/nm.2234. Epub 2010Oct 14.
  8. Franchi S, Moschetti G, Amodeo G, Sacerdote P. Do all opioid drugs share the same immunomodulatory properties? a review from animal and human studies. Front Immuno. 2019;10:2914. doi: 10.3389/fimmu.2019.02914.
  9. Sacerdote P. Opioids and the immune system. Palliat Med. 2006;20 Suppl 1:s9-15.
  10. Sytsma TT, Greenlund LK, Greenlund LS. Joint corticosteroid injection associated with increased influenza risk. Mayo Clin Proc Innov Qual Outcomes. 2018;2(2):194-8. doi: 10.1016/j.mayocpiqo.2018.01.005.
  11. Luthi S. Surgeon general advises hospitals to cancel elective surgeries. Politico. 2020. March 14. Available at Accessed March 14, 2020.
  12. American College of Surgeons. COVID-19: guidance for triage of non-emergent surgical procedures. Available at Accessed March 17, 2020.
  13. Deer TR, Provenzano DA, Hanes M, et al. The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management. Neuromodulation. 2017;20(1):31-50. doi: 10.1111/ner.12565.
  14. Lippi G, Plebani M, Michael Henry B. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: a meta-analysis. Clin Chim Act. 2020Mar 13. pii: S0009-8981(20)30124-8. doi: 10.1016/j.cca.2020.03.022. [Epub ahead of print].
  15. Gomez-Flores R, Weber RJ. Differential effects of buprenorphine and morphine on immune and neuroendocrine functions following acute administration in the rat mesencephalon periaqueductal gray. Immunopharmacology. 2000;48(2):145-56.
  16. Plein LM, Rittner HL. Opioids and the immune system – friend or foe. Br J Pharmacol. 2018;175(14):2717-25.
  17. S. Department of Health and Human Services. Secretary Azar declares public health emergency for United States for 2019 novel coronavirus. 2020 Jan 31. Available at Accessed February 1, 2020.
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  19. Day M. COVID-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ 2020 2020;368:m1086. doi: 10.1136/bmj.m1086.
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  21. S. Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory 19. 2020 March 19, 2020. Available at Accessed March 19, 2020.
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  23. Liu MM, Reidy AB, Saatee S, Collard CD. Perioperative steroid management: approaches based on current evidence. Anesthesiology. 2017;127(1):166-72. doi: 10.1097/ALN.0000000000001659.
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By August 7, 2020 11:13

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