Clinical Challenge: Chronic Pain and COVID-19

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.”