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The Challenges of Pain Management in the Pandemic Era 

Dwi Pantja Wibowo, MD, PhD Anesthesiologist – Pain Consultant 

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Logo, company name

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Kapsul (10 Blister 10 Kap"A)
ALAXAN FR
Ibuprofen 200 mg
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SPASMAL
Hyoscine Butylbromide
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4 Tablet Tablets
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PARACETAMOL
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120 5 mL SIB,pnsion

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TROMETHAMINE
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DEXTOFEN@
Dexketoprofen Trometamol
25 mg/mL

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Problems Facing Chronic Pain Patients in the Covid-19 Era Telemedicine Strategies for Chronic Pain Clinics and  Inpatient Hospitals Pain Management During Covid-19 Management of Pain Associated with Covid-19 Infection 

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Since the outbreak of COVID-19 in China in late 2019,  followed by the wide and  rapid spread to other countries,  more than 122 million individuals have become  infected, resulting in more than 2,700,000 deaths as of March 2021. 

During this pandemic, health care providers have been  shown to be at a much higher risk of infection. Anesthesia and pain medicine physicians who perform  spinal interventions and  regional anesthetic blockades are  subjected to higher risk of infection compared  to many other medical specialties. 

WHO Novel Coronavirus 2019. Coronavirus Statistics. 2019. https://epidemic-stats.com/coronavirus/. 

Song XJ, Xiong DL, Wang ZY, Yang D, Zhou L, Li RC. Pain management during the COVID-19 pandemic in China: lessons learned. Pain Med. 2020. https://doi.org/10.1093/pm/pnaa143. 

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Pain is not just a response to an injury,  but a disruption of the body's homeostatic systems due to a multitude of factors leading  to increased stress responses. There is growing evidence that COVID-19 infection is  associated with myalgias,  referred pain, and widespread hyperalgesia. 

The importance of these associated  conditions cannot be understated , as while the pandemic continues  to affect every facet of our lives,  the treatment strategies for chronic pain during this time are  of vital importance. 

Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med.2020. https://doi.org/10.1056/NEJMoa2002032. 

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Chronic Pain vs. Acute Pain - Colorado Pain Care

PROBLEMS FACING CHRONIC PAIN PATIENTS IN THE COVID-19 ERA 

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Medical supply shortage: 64% of surgical staff hoard, waste or overuse |  Healthcare Finance News

Why Pharma Should Care About Patient Education | BlueNovius

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Significant increase in inactivity due to government lockdown and quarantine orders

Immunosuppression as a result of medication, whether chronic opioid therapy or the use of oral or injectable steroids

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The necessary medical services to patients with chronic pain during the COVID-19 epidemic.  

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Five factors need to be considered in treating pain patients with telemedicine:

The public health consequences of COVID-19 for patients with pain and the level of care.

The consequences of diminished and alternate/virtual treatments of chronic pain compared to the current in-person model.

Triaging patients in order to provide care to those with more urgent needs

Options for remote assessment and management.

Clinical evidence supporting remote therapies and modalities.

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STRATEGIES FOR CHRONIC PAIN CLINICS AND INPATIENT HOSPITALS 

To get benefits to both health care providers and  patients and to allow the pain clinics,  acute and chronic pain services to continue  and function during the epidemic. 

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RECOMMENDATIONS FOR THE OUTPATIENT PAIN CLINICS 

After initial screening for all patients using  strict control requirements. 

Patients with mild to moderate pain. Clear etiology, pathogenesis, & diagnosis. Had relatively well controlled comorbidities. This group of patients can receive  pain medication at home,  along with telemedicine/eHealth support.  

Level 1 patients who have been  exposed to COVID-19-positive individuals or Recently traveled to or from an epidemic area,  as determined by WHO. Have symptoms suggestive of COVID-19. These patients should self-quarantine at home and  should strongly consider getting tested for COVID-19. 

Those with severe pain,  and/or suspicion of emergency conditions To receive immediate treatment in the clinic or  should be admitted as inpatients for further testing and  treatment. Cases from levels 2 and  3 who need physical inspection are  immediately sent to an isolation area for further testing and  treatment. 

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Contacts between the patient and health care providers should be minimized by scheduling a minimal number of necessary pain patients.

Discharged patients can have follow-up appointments via telemedicine/eHealth aids unless they fall under level 3.

Patients with severe pain, or with complex conditions that require urgent treatment, there will be a need to be seen as inpatient and practitioners will need to arrange for the necessary pain treatment, including interventions or surgery as required.

Arm and blood pressure machine reading scale

Recommendations for the inpatient setting

The inpatient chronic pain service brings other concerns in regards to consistent patient exposure in a hospital setting.

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With the rise of telehealth and  other methods of healthcare delivery growing  during the pandemic, multimodal analgesia may play  an increased role in the post-COVID era,  and is therefore important to review  

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The medication should be  considered alone or in combination with non-steroidal anti-inflammatory drugs (NSAIDs) in the management of mild-to-moderate pain as part of multimodal analgesia. Paracetamol can also be used safely to alleviate  symptoms of COVID-19 such as fever,  headache, and acute or chronic pain. However, caution must be  observed due to liver toxicity at high doses of paracetamol.  

Schug SA, Palmer GM, Scott DA,  Halliwell R, Trinca J. Acute pain management:  scientific evidence fourth edition, 2015. Med. J Aust. 2016;204(8): 315–17. 

Dong E, Du H, Gardner L. An interactive web-based  dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020. https://doi.org/10.1016/S1473- 3099(20)30120-1/. 

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Prolonged use of non-selective NSAIDs is associated with a higher risk of adverse effects including gastrointestinal disease, renal toxicity, inhibition of platelet function, and respiratory bronchospasm in some patients with asthma. Specific concerns related to COVID-19 and the use of NSAIDs have hypothesized that NSAIDs may upregulate entry through the angiotensin-converting enzyme (ACE) 2 receptors, thereby increasing susceptibility to the virus. These data are still inconclusive

Schug  SA, Palmer GM, Scott DA, Halliwell R,  Trinca  J. Acute pain management: scientific evidence fourth edition, 2015. Med. J Aust. 2016;204(8): 315–17.

Lim YJ, Yang CH. Non-steroidal anti-inflammatory drug-induced enteropathy. Clin  Endosc . 2012;45(2):138–44.

DarpVaria
KETOROLAC
TROMETHAMINE
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Selective COX-2 inhibitors (e.g.,  etoricoxib and celecoxib) specifically target  prostaglandins that mediate  pain and inflammation and  have less gastric side effects compared  to their non-specific NSAID counterparts.  COX-2 inhibitors are as effective as classical NSAIDs for the treatment of mild-to-moderate pain,  but have been associated  with an increased cardiovascular risk. 

Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33:160–71. 

Chou R, Gordon DB, de Leon-Casasola OA,  et al. Guidelines on the management of postoperative pain management of postoperative pain:  a clinical practice guideline from the American Pain Society,  the American Society of Regional Anesthesia and  Pain Medicine, and the American Society of Anesthesiologists. J Pain. 2016;17(2):131–57. 

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NSAIDs and COVID-19 Cytokine storm is  a poorly understood exaggerated response involving  an uncontrolled release of proinflammatory cytokines. Adverse outcomes of COVID-19 have been  linked to this exaggerated inflammatory response . Anti-inflammatories ranging  from NSAIDs to glucocorticoids to hydroxychloroquine and  others may be beneficial to reduce  inflammation before it overwhelms the body's systems. An anti-inflammatory can reduce  inflammation but it may have  a limited or poorly understood  effect on cytokine storm. An anti-inflammatory agent may affect  certain cytokines but not others. 

Pergolizzi J, Varrassi G, Magnusson P, LeQuang JA,  Paladini A, Taylor R, Wollmuth C,  Breve F, Christo 464 Pain Ther (2020) 9: 453–466 P. COVID-19 and  NSAIDS: a narrative review of knowns and unknowns. Pain Ther. 2020. https://doi.org/10.1007/s40122-020-00173-5. 

Zhang W, Zhao Y, Zhang F, et al. The use of antiinflammatory  drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19):  the perspectives of clinical immunologists from China. Clin Immunol. 2020;214:108393. 

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To date, there is no strong evidence that NSAIDs must be  avoided in all patients diagnosed with COVID-19.  Clinicians must weigh these choices on an individual basis.  It is not yet clear which anti-inflammatory therapies provide  the most benefit,   at which point during the disease,  at what doses, and for what duration should be  used is still unknown. Insufficient evidence exists  to establish a link between the use of some NSAIDs and  susceptibility to contracting  COVID-19 or the worsening of its symptoms . 

U.S. Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fdaadvises-patients-use-nonsteroidal-antiinflammatory-drugs-nsaids-covid-19. Accessed 22 Mar 2020. 

Day M. Covid-19: European drugs agency to review  safety of ibuprofen. BMJ. 2020;368:m1168. 

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Paracetamol/acetaminophen can be  used instead of NSAIDs. Caution must be observed  due to liver toxicity at high doses of paracetamol. However, the antipyretic effect of both  paracetamol and NSAIDs may mask  the symptoms associated with COVID-19 such as a rising  fever and thus may delay  the diagnosis and rapid management of the infection.  

Favalli EG, Ingegnoli F, De Lucia O, Cincinelli G,  Cimaz R, Caporali R. COVID-19 infection and  rheumatoid arthritis: faraway, so close! Autoimmun Rev. 2020;19(5):102523. 

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PRACTICAL TIPS FOR THE USE OF NSAIDS DURING THE COVID-19 PANDEMIC: 

Newly prescribed oral NSAIDs might only be  used intermittently over a very short period of time for patients with Covid-19. Must consider a patient's whole picture with the addition of any new medication.  Discontinuation of prescribed NSAIDs for chronic pain conditions is  not recommended at this time. No reason to fear it might increase  their risk of contracting COVID-19 or exacerbate  symptoms if previously on treatment. Acetaminophen has been proposed  as an alternative to NSAID use,  but there are also issues with toxicity in high doses. 

FitzGerald GA. Misguided drug advice for COVID19. Science. 2020;367(6485):1434. 

Larson AM, Polson J, Fontana RJ,  et al. Acetaminophen- induced  acute liver failure: results of a United States multicenter,  prospective study. Hepatology. 2005;42(6):1364–72. 

Little P. Non-steroidal anti-inflammatory drugs and  covid-19. Brit Med J. 2020;368:m1185. 

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Opioids may be use in the treatment of chronic cancer pain but  long-term opioid use for chronic non-malignant pain is  controversial. Opioids used as only part of a treatment plan,  which includes physical therapy,  pain psychology, interventional procedures,  and other ancillary therapies. Most of the opioids have  a similar spectrum of adverse effects,  e.g., respiratory depression,  sedation, nausea/vomiting,  constipation, physical dependence,  and opioid use disorder.  There is also evidence suggestive that chronic opioid use can produce  a chronic pain state. 

Reuben DB, Alvanzo AAH,  Ashikaga T, Bogat GA, Callahan CM,  Ruffing V, Steffens DC.  National institutes of health pathways to prevention workshop:  the role of opioids in the treatment of chronic  pain. Ann Intern Med. 2015;162(4):295–300. 

Vallejo R, Barkin RL, Wang VC. Pharmacology of opioids in the treatment of chronic pain syndromes. Pain Phys. 2011;14(4):E343–E360360 

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In opioid-tolerant patients,  opioids are linked to infections like pneumonia. Pain may have an immunosuppressive effect so that it is  possible that the use of opioids to relieve  acute and chronic pain may actually enhance  the immune response. Providing adequate analgesia should be  achieved without significant adverse events,  and opioids with minimal immunosuppressive characteristics may be  reasonable options in such situations. Buprenorphine is highly recommended , tramadol and oxycodone can be  used as a second option,  while morphine and fentanyl are  not recommended due to side effects and  addiction potential. 

Plein LM, Rittner HL. Opioids and the immune system—friend or foe. Br J Pharmacol. 2018;175: 2717–25. 

Dublin S, Walker RL, Jackson ML, et al. Use of opioids or  benzodiazepines and risk of pneumonia in older adults:  a population-based case-control study. J Am Geriatr Soc. 2011;59:1899–907. 

Page GG. Immunologic effects of opioids in the presence or  absence of pain. J Pain Symptom Manage. 2005;29:S25–31. 

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Many services and guidelines have permitted  opioid prescriptions via telemedicine visit or  E-health to facilitate  delivery and reduce the risk of opioid withdrawal. Patients at risk of opioid withdrawal should be  scheduled for an in-patient visit. Non-opioid strategies to prevent  withdrawal (e.g., using  clonidine) are alternative options when there is  difficulty in getting the opioids. Emphasis must be placed  on the appropriate prescription of opioid medications,  as the quarantine and social distancing with the current pandemic has been  postulated to lead to worsening  of disorders like alcohol dependence and  opioid use disorders. 

Ahmadi J, Jahromi MS.  Anxiety treatment of opioid dependent patients with buprenorphine:  a randomized, double-blind. Clin Trial Indian J Psychol Med. 2017;39:445–9. 

Cheatle MD, Webster LR. Opioid therapy and sleep disorders:  risks and mitigation strategies. Pain Med. 2015;16(Suppl 1):S22–26. 

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Opioid use via telemedicine must be  used sparingly and only when absolutely indicated.  Current recommendations for non-malignant acute pain recommend  a maximum of 7 days. Red flags associated with COVID-19 including  lethargy, nausea and gastrointestinal symptoms must be  excluded before prescription. If patients need opioids for longer durations or  to be continued, an inpatient visit is  recommended to identify  patients who might be candidates for opioid prescription or  other interventions for pain managements. 

Shanthanna H, Strand NH, Provenzano DA, Lobo CA,  Eldabe S, Bhatia A, et al. Caring for patients with pain during the COVID-19 pandemic:  consensus recommendations from an international expert panel. Anaesthesia. 2020;75:935–44. 

Franklin G, Sabel JC, Jones CM,  Mai J, Baumgartner C, Banta-Green CJ,  Neven D, Tauben D. A comprehensive approach to address  the prescription opioid epidemic in Washington State –  milestones and lessons learned. Am J Pub Health. 2015;105(3): 463–9. 

Dey S, Usmani H, Hussain A. Pain practice during the COVID-19 pandemic:  transitioning to a new normal. Indian J Pain. 2020;34:61. 

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The fevers and elevated temperature associated  with symptomatic COVID-19 may increase  absorption from transdermal opioid patches (e.g.,  fentanyl and buprenorphine) and  could increase opioid side-effects. Patients who are prescribed  transdermal opioids with increased  side effects who become increasingly drowsy or  somnolent may require patch strength to be  reduced, or alternatively replaced , with short-acting opioid formulations. This should continue until symptomatic infection is  resolved and the fever is lowered. 

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PRACTICAL TIPS  FOR  OPIOIDS WITH COVID-19 PANDEMI 

Long-term opioid recipients should be  evaluated every 2-3 months.  Differentiate between disease progression from other opioid drawbacks,  e.g., tolerance and hyperalgesia before increasing  the dose of chronic opioids. Opioids should be used for pain relief only. Opioids are also cough suppressants that may mask  or delay the initial presenting  symptoms of COVID-19 infection.  Lethargy, nausea, and gastrointestinal symptoms could be  worsened by prescribed opioids. 

Cohen S, Baber Z, Buvanendran A,  et al. Pain management best practices from multispecialty organizations during the COVID-19 pandemic and  public health crises. Pain Med. 2020;21(7):1331–46. 

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Photo by National Cancer Institute on Unsplash

Elective: not time-sensitive;  a patient normally could wait  greater than 4 weeks to undergo  the procedure based on the unique circumstances and  no significant harm to the patient is  anticipated with postponement of the procedure. Urgent elective: time sensitive;  a patient normally could not wait  months to undergo the procedure,  for unique circumstances,  where a delay of the procedure for more than a few weeks could potentially lead  to a worsening of a patient's condition. Urgent: time-sensitive;  a delay in proceeding with a procedure would result  in significant exacerbation and  worsening of the condition such as emergency visit,  inpatient hospitalization,  or unintended consequence of analgesics. 

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PRACTICAL TIPS FOR INTERVENTIONAL PAIN THERAPY WITH COVID-19: 

Patients should be informed  of the possible risk of infection before intervention,  should done face coverings,  and those with respiratory symptoms or  fever should follow up with their primary physician,  all surfaces should be clean and disinfected. Procedures should be limited  to urgent or emergent cases. The procedure should be  conducted in a room designated for such purposes. After the procedure, the patient should be  monitored in the same room. 

Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators:  Crisis/alternate strategies. 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternatestrategies.html. Accessed 2 Apr 2020. 

American Society of Anesthesiologists. UPDATE: The use of personal protective equipment by anesthesia professionals during the COVID-19 pandemic. 2020. https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/update-the-useofpersonal- protective-equipment-by anesthesiaprofessionals- during-the-covid-19pandemic. Accessed 3 Apr 2020 

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Use the surgical facemasks,  eye shields, and gloves during patient care. N95 masks should be used for emergent procedures or  high-risk patients. During the procedures, sterile attire must be  donned  and this attire should be  carefully discarded after. Patients shower before receiving  injections in high-risk situations. Procedures with the potential for aerosolization,  N95 masks should be used as recommended. Deep sedation that  may require  airway support should be avoided. Minimize ''unnecessary' ' exposure of hospital staff to patients,  and to themselves. One physician to perform  all procedures during the same session. 

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Physicians may continue to perform  epidurals and other injections for selected  patients when indicated.  No clear evidence of a causative effect between spinal procedures without steroids and  the increased risk of infection,  suggesting an increased  risk of infection with corticosteroid use. Clinical trials showed no difference between 40 and  80 mg of triamcinolone for knee injections. It is important to note  that many simple procedures such as trigger point injection,  steroids has no additional benefit compared to saline. 

Popescu A, Patel J, Smith CC,  Spine Intervention Society's Patient Safety C. Spinal injections in immunosuppressed patients and  the risks associated with procedural care:  to inject or not to inject? Pain Med. 2019;20:1248–49 

Popma JW, Snel FW, Haagsma CJ,  et al. Comparison of 2 dosages of intraarticular triamcinolone for the treatment of knee arthritis:  results of a 12-week randomized  controlled clinical trial. J Rheumatology. 2015;42:1865–8. 

Cummings TM, White AR.  Needling therapies in the management of myofascial trigger point pain:  a systematic review. Arch Phys Med Rehabil. 2001;82: 986–92. 

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MANAGEMENT OF PAIN ASSOCIATED  WITH COVID-19 INFECTION 

Pain may be related to COVID-19 infection in a variety of forms:  an early sign of infection, a return of infection,  and iatrogenic effects such as prolonged bed rest,  immobility, psychological stress, and others. Patients usually complain of fever, headache, and  mild-to-moderate body pain suggesting  viral-induced myalgias. Pain that was present before COVID- 19 may exaggerated  by a superimposed viral infection. Mild pain symptoms can be  relieved with simple analgesics such as acetaminophen and  NSAIDs.  Opioids are recommended for moderate to severe malignant pain compared  to others. Avoid corticosteroids even if a symptomatic. 

Song XJ, Xiong DL, Wang ZY, Yang D, Zhou L, Li RC. Pain management during the COVID-19 pandemic in China:  lessons learned. Pain Med. 2020. https://doi.org/10.1093/pm/pnaa143. 

Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020. https://www. fda.gov/drugs/drug-safety-and-availability/fdaadvises-patients-use-nonsteroidal-antiinflammatory-drugs-nsaids-covid-19. Accessed 22 Mar 2020 

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Shelter in place and social distancing are  two of the best ways to limit  the spread of infectious respiratory diseases. Protecting oneself means  protecting others, because one's own safety depends  on the safety of the whole community. Telemedicine can help to provide  ongoing services to patients; assessments, treatment,  and follow-up. 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 (increases in pain,  disability, and depression) and  can worsening mental health and  addiction disorders, as well as increased  future healthcare spending 

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The Challenges of Pain Management in the Pandemic Era

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