Cuyahoga Falls, OH, April 8, 2020 - 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.
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