Clinical Challenges and Considerations in Management of Chronic Pain Patients During a COVID-19 Pandemic

Abstract

Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions.Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.

Full text

September 2020, Vol. 49 No. 9
1 Division of Anaesthesiology, Department of Pain Medicine, Singapore General Hospital, Singapore
2 Division of Anaesthesiology, Department of Pain Medicine, Sengkang General Hospital, Singapore
Address for Correspondence: Dr Diana XH Chan, Department of Anaesthesiology, Academia, Level 5, Singapore General Hospital, Outram Road, Singapore 169608
Email: diana.chan.x.h@singhealth.com.sg
Clinical Challenges and Considerations in Management of Chronic Pain Patients
During a COVID-19 Pandemic
Diana XH Chan, 1,2MBBS, MMED (Anaes), MCI, Xu Feng Lin, 1,2MBBS, MMED (Anaes), Jane Mary George, 1,2MBBS, MMED (Anaes), FAMS,
Christopher W Liu, 1,2MBBS (Honors), MMED (Anaes)
Commentary
Introduction
In December 2019, a novel coronavirus was
identied as the cause of a cluster of severe pneumonia
cases in Wuhan, China. Since then, the coronavirus
has been named Severe Acute Respiratory Distress
Syndrome (SARS) Coronavirus (CoV) 2 (or SARS-
CoV-2) and the disease caused by the virus has been
named coronavirus disease 2019 (or COVID-19).
By March 2020, COVID-19 had become a global
pandemic of unprecedented scale, affecting >200
countries. At the time of writing, COVID-19 has infected
more than 10.2 million patients globally and has taken
the lives of at least 502,000 people. Singapore itself
recorded a total of 43,661 cases and 26 fatalities by 29
June 2020.
Pain physicians in Singapore are mostly anaesthetists
who may be deployed at the peak of the COVID-19
pandemic to run intensive care units, community and
swab facilities, and deliver anaesthesia for COVID-19
patients who may require emergent surgeries. In the
midst of our COVID-19 duties, there is still a need to
ensure continued support for our chronic pain patients
who may require urgent pain consultations, interventions
or medication titration and rells. Here we discuss
Abstract
Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March
2020, we have seen exponential increases in the number of cases and deaths worldwide.
The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer
non-essential clinical services to allocate scarce medical resources to the care of the
COVID-19 patient and reduce risk to healthcare workers.
Chronic pain patients require long-term multidisciplinary management even during
a pandemic. Fear of abandonment, anxiety and depression may increase during this
period of social isolation and aggravate pain conditions.Whilst physical consults for
chronic pain patients were reduced, considerations including continuity of support and
analgesia, telemedicine, allied health support and prioritising necessary pain services and
interventions, were also taken to ensure biopsychosocial care for them.
Chronic pain patients are mostly elderly with multiple comorbidities, and are more
susceptible to morbidity and mortality from COVID-19. It is imperative to review
pain management practices during the COVID-19 era with respect to infection control
measures, re-allocation of healthcare resources, community collaborations, and analgesic
use and pain interventions. The chronic pain patient faces a potential risk of functional
and emotional decline during a pandemic, increasing healthcare burden in the long term.
Clinical decisions on pain management strategies should be based on balancing the risks
and benets to the individual patient.
In this commentary, we aim to discuss the basis behind some of the decisions and
safeguards that were made at our tertiary pain centre over the last 6 months during the
COVID-19 outbreak.
Ann Acad Med Singap. 2020;49:669–73
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Copyright © 2020 Annals, Academy of Medicine, Singapore
Chronic Pain Management During COVID-19—Diana XH Chan et al
considerations for pain management strategies and
analgesic use in the midst of the threat of COVID-19,
and measures that have been put in place to continue to
provide support to our various pain populations.
Pain Interventions and Corticosteroid Use
A Joint Statement by American Society of Regional
Anaesthesia and Pain Medicine (ASRA) and European
Society of Regional Anaesthesia and Pain Therapy
(ESRA) recommended that no elective pain procedures,
except specic urgent and semi-urgent procedures, should
be performed during COVID-19 pandemic.1 However,
categorising pain procedures as elective, urgent or
emergent is subjective in many cases. It is important to
note that the pain patients at risk (e.g. elderly, multiple
comorbidities) of COVID-19 and its complications are
also the same at-risk population who is susceptible to
complications of immobility and functional deterioration
from severe distressing and debilitating pain such as deep
vein thrombosis and pulmonary embolism, urinary tract
infections, muscle atrophy and stiffness, bed sores and
more infections, major depression and other sequelae. As
such, individualised assessments of benets and risks of
pain interventions must be exercised.
Corticosteroids were advocated for the treatment
of SARS-CoV as well as MERS-CoV because it was
thought that corticosteroids could blunt the host immune
response and therefore suppress pulmonary inammation.2
However, studies performed during these outbreaks not
only failed to show a mortality benet from the use of
corticosteroids but also demonstrated possible harm.3-7
Consequently, the World Health Organization (WHO)
recommends against the use of corticosteroids for
the treatment of COVID-19 outside of a clinical trial
setting.8 A statement by the Faculty of the Pain Medicine
of Royal College of Anaesthetists also addressed the
potential harm of steroid injection to individuals who
might be incubating or later develop COVID-19.9
Although steroid injections for certain pain conditions
are given locoregionally to the affected tissues, there is
still systemic uptake of the medication. A recent
randomised controlled trial found that the use of
particulate steroids in a single short epidural injection
led to a signicant decrease in morning cortisol levels
at 3 months, suggesting that corticosteroid injection
can lead to short-term adrenal suppression.10 There
is also weak evidence suggesting that short term
use of oral corticosteroids can result in a signicant
immunosuppression.11 This may have potential
implications of delayed COVID-19 presentation and
reduced immune response to the virus. Patients should
be counselled of these potential implications during
informed consent taking should they require steroid
injections for pain control. The use of non-particulate
steroids (such as dexamethasone) over particulate
steroids may also be considered as a risk mitigation
strategy if the efficacy of the injection is not
compromised. This is based on limited evidence that
dexamethasone causes a shorter and unsustained
duration of adrenal suppression which is likely to be
secondary to its lack of depot effect.10, 12 In addition,
there is also emerging preliminary evidence that
dexamethasone use in COVID-19 patients reduced
28-day mortality among those receiving invasive
mechanical ventilation or oxygen in an ongoing
randomised controlled trial.13
It is important to note that steroid usage is only one
component of interventional pain management. If pain
is severe and function is significantly impaired,
advanced pain management techniques and steroid-
sparing alternatives such as nucleoplasty, annuloplasty,
radiofrequency (RF) neurotomy and other neurolytic
techniques should be considered whenever possible
and in a timely manner.14 Withholding pain
interventions might potentially lead to significant
morbidity, functional deterioration and over-reliance on
opioid therapy. As the COVID-19 situation continues to
evolve, it is best to make a balanced decision based on
the individual patient’s needs and medical condition.
Non-Steroidal Anti-Inammatory Drugs (NSAIDS)
NSAIDS are commonly used for pain management—
either prescribed by physicians or self-medicated by
patients. Use of NSAIDs in the conrmed or suspected
COVID-19 patient has been controversial. Given that
ibuprofen may upregulate angiotensin-converting
enzyme 2 (ACE2) and that SARS-CoV-2 binds to their
target cells by binding to ACE2, it has been questioned
if ibuprofen use can facilitate COVID-19 infections.15
The use of NSAIDs has also been found to be associated
with higher rates of complications in patients with
community acquired pneumonia.16 The National
Agency for the Safety of Medicines and Health
Products (ANSM) of France thus issued a warning in
April 2019 that NSAID use may worsen the severity of
existing infections.17
Despite these warnings, there is currently no clear
evidence linking the use of NSAIDS to poorer outcomes
following COVID-19. There are also contrary opinions
that anti-inammatories may help to reduce pulmonary
inflammation and several studies are underway to
look at whether anti-inflammatories (such as IL-1

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Chronic Pain Management During COVID-19—Diana XH Chan et al
and IL-6 inhibitors) can benefit patients stricken
with COVID-19.18
In response to this issue, several organisations
including the WHO, Food and Drug Administration
(FDA) and the Ministry of Health in Singapore
(MOH) have recommended that there is no need to
avoid NSAIDS. Notably, as compared to corticosteroids,
NSAIDS have a short duration of action. Hence, if
new evidence emerges, the cessation of NSAIDS will
rapidly revert the risk level of patients back to baseline.
As such, until further clarity is obtained, NSAIDs can
be used as indicated during the COVID-19 pandemic,
keeping the duration of therapy to the minimum and using
the lowest possible doses.
Opioid Prescription
Although opioids are commonly prescribed in pain
clinics, there is now emerging evidence that opioid
therapy may not result in sustained pain relief when used
long-term.19 Furthermore, it is recognised that chronic
opioid therapy may cause immunosuppression, with
heterogeneous effects observed in different opioids.20,21
In the context of COVID-19, this immunosuppression
can affect patients negatively by increasing the risk
of infection or reducing their ability to mount an
appropriate immune response.
For these reasons, opioid therapy should be used
only after an adequate trial of non-opioid therapy. An
opioid with minimal immunosuppressive effect should
be prescribed if possible, starting at the lowest dose
possible and titrated according to its efcacy and side
effects.21 It must be noted that in initiating opioids,
regular repeat consultations are often needed to monitor
for dose titration, adherence, aberrant use and adverse
effects.22 Containment measures during the pandemic
may pose difculties in monitoring of opioid use.
Face-to-face consultations may be postponed or
cancelled, opioid prescriptions may not be lled in time
due to stay home notices (SHN) or quarantine, and
telemedicine has legal and safety limitations in
monitoring opioid consumption. For patients who are
already on long-term opioid therapy, there is a need to
ensure that they continue to receive these medications
to avoid withdrawal symptoms, and there should be
regular follow-ups to gradually wean them to the lowest
effective dose possible.
Continuing Essential Pain Services
Cancer Pain Management
Cancer patients may experience a considerable amount
of pain as a result of the tumour pathology and cancer
treatment. Management of cancer-related pain is an
ethical responsibility of healthcare professionals to
relieve unnecessary suffering and hence all treatment
for cancer pain should be continued in spite of
pandemic containment measures.23 The joint statement
by ESRA and ASRA have also classied cancer-related
pain procedures such as intrathecal pump insertions
and refills as urgent pain procedures during the
pandemic.1 Neurolytic procedures should also be
considered to help increase the duration and efcacy
of pain relief.24 Telemedicine should be considered for
palliative care and cancer pain patients in view of their
lowered immune system and increased susceptibility
to infection. Even though clinic visits are limited,
continued vigilance should be practised by both the
pain and palliative care physicians, as well as the
oncological teams to monitor disease progression
and recurrence.
Pain Management and the Elderly
The incidence and prevalence of chronic pain
increases with age, however pain can often be
underreported in the geriatric population as many of
the elderly patients may believe that pain is a normal
process of aging.25 Safe distancing measures during
the COVID-19 outbreak can be a particularly socially
isolating period for them when household visits from
families are restricted, hence the increasing the risk of
worsening anxiety, depression, and functional decline
from pain and immobility. Multidisciplinary involvement
is paramount, and these should include efforts in
collaborations with other specialties and community
nursing teams, galvanising support from next of kins,
easy access to help hotline numbers and ensuring that
there is regular monitoring of patients who are at risk.
Role of Primary Care
Patients with stable pain conditions may be discharged
to the care of their primary care physician with proper
correspondences on their treatment regime. Primary care
physicians have an important role to play in managing
patients with chronic pain, working in tandem with pain
specialists through monitoring of the pain conditions,
providing medication rells when needed and aiding
to reduce visits to emergency care units. At the start
of COVID-19 in Singapore, many primary care clinics
were converted to public health preparedness clinics
(PHPCs) to consolidate the primary care clinic response to
national emergencies.26 With the growing numbers of
COVID-19 positive patients, more general practitioners
(GP) are involved in the war against the virus, be it in
PHPCs or in swab and community care facilities, and
they inadvertently have less time to devote to pain

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Chronic Pain Management During COVID-19—Diana XH Chan et al
management and other chronic illnesses. Coupled with
the population’s general reluctance to visit primary care
clinics unless they are acutely unwell, chronic pain
patients may not have as quick or often access to
primary care for pain consultations or medication rells.
Should the pandemic worsen, resources will be even
more limited. Community collaborations have thus been
put in place to optimise the role of primary care even
during a lockdown situation, to provide accessibility to
clinical care and support for the chronic pain patient.
Community Collaborations for Chronic Pain Patients
The deferment of specialist pain clinic consultations
and limited access to primary care can increase
morbidity and mortality.27–29 It is imperative to have
a plan in place for the continued support of pain
patients who may otherwise run out of essential pain
management medications leading to worsening pain,
functional decline and adverse psychological sequelae,
prompting multiple emergency department (ED)
attendances and untoward hospital admissions.
Collaboration is fundamental for pandemic
preparedness with integration across health care sectors.30
In Singapore, coordination of care for our pain patients
was done through collaboration with community
healthcare teams, primary care physicians, hospital
pharmacists and social service to provide for timely
and effective responses to cater to the needs of the
elderly and vulnerable, help reduce ED visits and hospital
admissions. Palliative home-care teams supported
terminal cancer patients in the community. In addition,
community teams also provided education and
guidance needed for patients and carers to participate in
their own care.
Community team referrals were made on physician
request for vulnerable patients who were elderly, had
impaired mobility and/or multiple comorbidities,
needing closer monitoring for pain and medication
reconciliation. Categorisation of patients was done
through telephone interviews and review of medical
records. Stable patients were offered deferment of clinic
appointments and home delivery of medication rells.
Patients on regulatory authority-controlled drugs like
opioids had medication rells via a strict verication
protocol, with close monitoring of opioid effects. Pain
clinic visits with appropriate screening for COVID-19
were continued for those who required consultation.
Essential home or hospital consultations were restricted
to a maximum of 30 minutes, with personal protection
aids. Reviews by community teams and hospital teams
were documented on a common electronic medical
records portal for seamless access of information.
Use of Telemedicine in Pain Management
Telemedicine has been encouraged as an alternative
to clinic consultations to comply with safe distancing
and stay home measures. The use of telemedicine and
appropriate triaging through telehealth were reported
to be useful in managing pain services during
COVID-19.31 At the time of writing, tele and video
consultation platforms with enhanced security features
are vigorously being set up and encouraging buy-ins
from physicians and patients to reduce the number of
physical clinic consults. Psychiatry and allied health
teams can also make use of these platforms to conduct
cognitive behavioural therapy sessions and exercise
sessions for chronic pain patients respectively.
Challenges in video consultations include poor access
to and unfamiliarity with the technology especially in
the elderly and less educated. Hence, there is a need for
careful patient selection. The extremely infectious and
insidious nature of the SARS-CoV-2 virus, however,
means that this may become the new normal in view of a
likely prolonged COVID-19 period. It is also important
to realise that the medicolegal implications of
telemedicine use are largely unknown. Like in all clinical
disciplines, pain management assessment necessitates a
detailed clinical examination to rule out any evolving
diagnoses which will affect management strategies. At
present, telemedicine is limited only to follow-up patients
with stable pain conditions. New case consults, patients
on opioid medications and patients with worsening pain
conditions not responsive to treatment regime will still
require face-to-face consults for detailed assessments.
Conclusion
This is a difcult period for all healthcare workers
and patients. The chronic pain patient is especially
vulnerable during a pandemic crisis and their needs are
likely to be neglected or even deemed non-essential.
However, it is important to realise that severe chronic
pain is often debilitating and there is a need to ensure
continuity of care for suffering patients through
teleconsultations and community-based multidisciplinary
care when physical face-to-face consults are not
possible. At the same time there is a need to consider the
risks and benets of current pain management therapies,
medications and interventions in the context of the
COVID-19 pandemic—weighing the risks of potentially
worsening outcomes should the pain patient contract
COVID-19 and the benet of pain improvement through
the prescribed care plans. The authors hope that the
above recommendations and experience will help
to guide decision making in the care of the chronic
pain patient.

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