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
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.
- 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].
- 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].
- 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.
- 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..
- 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..
- 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].
- 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.
- 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.
- Sacerdote P. Opioids and the immune system. Palliat Med. 2006;20 Suppl 1:s9-15.
- 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.
- Luthi S. Surgeon general advises hospitals to cancel elective surgeries. Politico. 2020. March 14. Available at https://www.politico.com/news/2020/03/14/surgeon-general-elective-surgeries-coronavirus-129405. Accessed March 14, 2020.
- American College of Surgeons. COVID-19: guidance for triage of non-emergent surgical procedures. Available at https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage. Accessed March 17, 2020.
- 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.
- 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].
- 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.
- Plein LM, Rittner HL. Opioids and the immune system – friend or foe. Br J Pharmacol. 2018;175(14):2717-25.
- 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 https://www.hhs.gov/about/news/2020/01/31/secretary-azar-declares-public-health-emergency-us-2019-novel-coronavirus.html. Accessed February 1, 2020.
- Diversion Control Division, Drug Enforcement Administration. COVID-19 information page. Available at deadiversion.usdoj.gov/coronavirus.html. Accessed February 17, 2020.
- 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.
- BMJ Best Practice. Coronavirus disease 2019 (COVID-19) Available at https://bestpractice.bmj.com/topics/en-gb/3000168/treatment-algorithm#referencePop126. Accessed March 17, 2020.
- S. Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory 19. 2020 March 19, 2020. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19. Accessed March 19, 2020.
- European Medicines Agency. EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19. 2020 March 13. Available at https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19. Accesed March 18, 2020.
- 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.
- Friedly JL, Comstock BA, Heagerty PJ, et al. Systemic effects of epidural steroid injections for spinal stenosis. Pain. 2018;159(5):876-83. doi: 10.1097/j.pain.0000000000001158.
- Van Boxem K, Rijsdijk M, Hans G, et al. Safe use of epidural corticosteroid injections: recommendations of the WIP Benelux Work Group. Pain Pract. 2019;19(1):61-92. doi: 10.1111/papr.12709.
- van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020 Mar 17. doi: 10.1056/NEJMc2004973. [Epub ahead of prin