Abstract
Chronic pain management during the coronavirus disease 2019 (COVID-19) pandemic is a challenging process, especially with growing evidence that COVID-19 infection is associated with myalgias, referred pain, and widespread hyperalgesia.
Understanding both the general problems facing chronic pain patients as well as specific problems in the COVID-19 era including deconditioning, increased mental health concerns, financial burdens, and potential for medication-induced immune suppression is vital in the appropriate management of patients.
Telemedicine, the practice of caring for patients remotely when the provider and patient are not physically present with each other, is becoming increasingly used and recognized as a valuable tool to both health care providers and patients.
As a result, delaying, or stopping, treatment for chronic pain patients will have negative consequences, and strong pain evaluations must be administered to triage patients appropriately. Recent recommendations for the safe use of non-opioid analgesics, opioid analgesics, and interventional pain management procedures are vital to know and understand specifically during the pandemic era
Introduction
Chronic pain is a significant medical and socioeconomic problem that affects 13.5–47% of the general population and can carry a significant financial burden, more than 600 billion dollars annually in the US alone.
From a societal perspective, chronic pain not only increases suffering, but impairs daily activities, increases illicit drug consumption, and results in a high frequency of sick leave and disability pensions, leading to high downstream societal cost. Also, it poses a major problem of public health, creates substantial costs for healthcare systems, and disability insurance.
Anesthesia and pain medicine physicians who perform spinal interventions and regional anesthetic blockades are subjected to a higher risk of infection compared to many other medical specialties. (https://daradia.com/headache-in-covid/)
There is growing evidence that COVID-19 infection is associated with myalgias, referred pain, and widespread hyperalgesia.
Epidemiology
The patterns of chronic pain problems vary greatly by age and sex, e.g., knee pain from osteoarthritis affects over one-third of persons over the age of 60, and fibromyalgia tends to affect middle-aged women more. Pain conditions are, however, more common in the elderly. In fact, > 60% of individuals greater than 60 years old have been found to have at least one chronic pain condition, commonly at multiple sites. Pain is also associated with arthritis, bone, and joint disorders, myofascial disorders, cancers, neurological disorders, and other chronic disorders. While the prevalence of pain is about 1.5–2 times more common in women than in men and the ratio can be as high as over 4 to 1 for specific pain conditions such as fibromyalgia.
Problems Facing Chronic Pain Patients in the COVID-19 Era
While chronic pain patients and pain management have been highlighted in recent years due to issues with the opioid epidemic, the COVID-19 pandemic has brought new problems to already struggling patients
Chronic opioid therapy with a monitoring program that mitigates the risk. There is a correlation between increasing opioid use and an ‘epidemic’ of prescription opioid-related harm. (https://daradia.com/pain-management-in-covid/)
Lack of education is a poor outcome marker and contributes to poor outcomes associated with chronic pain.
Immunosuppression as a result of medication, whether chronic opioid therapy or the use of oral or injectable steroids (e.g., in interventional pain procedures), is especially concerning during a time of the global pandemic.
Telemedicine
Telemedicine allows providing instructions and guidance for pain relief through real-time two-way audiovisual communication Telemedicine has become an effective way of providing necessary medical services to patients with chronic pain during the COVID-19 epidemic. While allowing patients to remain at home while maintaining continuity of care, telemedicine has allowed for follow-up of chronic conditions.
- Plan and use complementary resources
- Problem-solve and integrate self-help activities.
- Use experiential learning.
- Explore your patients’ living and socio-economic environment.
Strategies for Chronic Pain Clinics and Inpatient Hospitals
Level 1:
Patients with mild to moderate pain. (Clear etiology, pathogenesis, and diagnosis. Had relatively well-controlled comorbidities. This group of patients can receive pain medication at home, along with telemedicine/eHealth support.)
Level 2:
COVID-19-suspected patients (Have symptoms suggestive of COVID-19, including fever, night sweats, respiratory symptoms, and others. These patients should self-quarantine at home and should strongly consider getting tested for COVID-19.)
Level 3:
Those with severe pain, and/or suspicion of emergency conditions (i.e., spinal fracture, cauda equina syndrome). These patients are to receive immediate treatment in the clinic or should be admitted as inpatients for further testing and treatment.
Patients with COVID-19 usually complain of fever, headache, and mild-to-moderate body pain suggesting viral-induced myalgias [5]. Associated pain that was present before COVID-19 and may be exaggerated by a superimposed viral infection.
Mild pain symptoms associated with COVID-19 can be relieved with simple analgesics such as acetaminophen and NSAIDs. Acetaminophen is an alternative to NSAIDs where its use for COVID-19 patients has been linked to a worsening of symptoms. For moderate-to-severe chronic malignant pain, however, opioids with minimal effects on the immunosuppression (like buprenorphine) are recommended compared to others. It is vital for the practitioner to avoid corticosteroids if a patient has a COVID-19 infection, even if asymptomatic at the time of presentation.
Summary
COVID-19 is having a profound effect on health care and patients with pain. Delaying, or stopping, treatment for patients who are suffering from severe chronic pain will have negative consequences for patients including increases in pain, disability, and depression [13]. This can have significant downstream effects including worsening mental health and addiction disorders, as well as increased future healthcare spending.
