Chronic pain patients may be more susceptible to COVID-19, and if
infected with the virus, may face different consequences than others.
“There is a
complex relationship between chronic pain and the immune system,” said Samer Narouze, MD, PhD, of Western Reserve Hospital in Cuyahoga Falls, Ohio.
“Generally speaking, chronic pain patients can be considered
immunocompromised, mainly because so many are elderly and have multiple
comorbidities,” he noted. “Many also are on long-term opioid therapy,
and this is known to
interact with the immune system. Some are on steroids, which also may induce immunosuppression.”
A number of resources are available to guide chronic pain treatment during the COVID-19 outbreak, including
guidelines
published jointly by the American Society of Regional Anesthesia and
Pain Medicine and the European Society of Regional Anesthesia and Pain
Therapy.
Pain management during COVID-19 is particularly important to prevent
emergency room visits, Narouze said. “Our role is to keep the patient
safe at home, minimizing face-to-face interactions,” he noted. “Keep the
patient comfortable and safe, so they don’t have to see you or go to
the ER.”
Opioids and COVID-19
Patients who use opioids to manage pain need to be especially careful
during COVID-19, Narouze observed. “I don’t want to say this is the
time to tell pain patients to stop opioid therapy, because they want it
for a good reason,” he said. “But they should be mindful that the more
you take it, the more you lose respiratory reserves, and you may not be
able to fight this infection. We’re not sure — we don’t have data yet —
but this makes sense.”
As with many virus-related diseases, COVID-19 can present with
extensive muscle aches and pains, noted Jeffrey Fudin, PharmD, of the
Stratton VA Medical Center in Albany, New York. “This can aggravate
various pain syndromes, particularly those involving muscle and bone,”
Fudin pointed out. If a patient has chronic back, neck, or orofacial
pain, excessive coughing may worsen it.
“Since this virus affects respiration, there is no doubt that
patients on opioids are at an elevated risk of sedation, opioid-induced
respiratory depression, and increased mortality,” Fudin said. “Although
there have been no specific studies about COVID-19 patients, I’m
confident that for persons on one or more sedating drugs in addition to
opioids, the risk is even higher,” he added. These drugs include most
antidepressants, skeletal muscle relaxants — especially cyclobenzaprine
(Flexeril and others) and carisoprodol (Soma) — and anticonvulsants.
“Moreover, for drugs delivered by transdermal routes, such as
fentanyl and buprenorphine, elevated body temperature can increase
medication absorption,” he added.
Pain patients on opioids should be prescribed emergency naloxone,
Narouze emphasized. “Naloxone saves lives, and patients don’t have to go
to the ER if they have overdosed,” he said. “We need to do more
education here. We need to educate our patients and their partners how
to use naloxone if needed.”
During the COVID-19 public health emergency period, the Drug Enforcement Administration has
waived federal requirements for in-person visits before prescribing controlled substances and has issued
prescribing guidelines.
“An individual practitioner may issue multiple prescriptions
authorizing the patient to receive a total of up to a 90-day supply of a
schedule II controlled substance, subject to specific conditions,”
Fudin explained. “These conditions include, among other things, that the
practitioner must sign and date the multiple prescriptions as of the
date issued and write on each separate prescription the earliest date on
which the prescription can be filled. But some states have stricter
laws that require shorter supplies.”
Beyond Opioids
Chronic pain patients may be on oral steroids or may have received a
recent steroid intervention, and thus may have an altered immune
response, Narouze noted. Steroids, for example, have been associated
with a
higher risk of influenza,
“so we try to avoid steroid injections,” he said. If steroids are
needed, the duration of immune suppression may be less with drugs like
dexamethasone, he added.
A
clinician in France suggested ibuprofen and other NSAIDs may increase the COVID-19 disease severity, but “there is currently
no scientific evidence establishing a link between ibuprofen and worsening of COVID-19,” the European Medicines Agency said in a statement.
During the pandemic, many patients may not be able to attend regular
physical therapy sessions to help manage pain, but a number of online
tools can teach them how to perform exercises at home. “We need to
encourage continued movement and adaptive exercise options,” said Beth
Darnall, PhD, of Stanford University in Palo Alto, California. The
American Chronic Pain Association linked to resources to
help patients stay active during the pandemic, she noted.
Clinical video visits are key to promoting patient health and safety,
Darnall emphasized. This holds for medical, psychology, and social work
consultations, she said: “More than ever, patients need access to all
three.” Online support groups also can help pain patients remain
connected at a time when people are more isolated.
Importantly, pain patients need to know how to get help if they need
it during COVID-19. “Allay patient concerns,” Darnall advised. “If
possible, send out messages to patients alerting them to steps being
taken to ensure their access to care during COVID-19 and help them
prepare for delays in certain services.”
https://www.medpagetoday.com/clinical-challenges/pain-management/85857
