Chronic Pain and COVID-19: A Case with Recommendations

by Micheal T. Murphy, MD

Photo by Karolina Grabowska, link here.

A 54-year-old male with a history of alcohol abuse, A.Fib on AC, CKD III, and hypertrophic nonobstructive cardiomyopathy s/p orthotopic heart transplant on chronic immunosuppression presents with centralized low back pain of one year duration. Pain is constant, deep, and achy with intermittent sharp, stabbing, burning sensation down the left leg. Back pain is worse than leg pain. Pain is worse with prolonged sitting/standing and improved with rest. Patient has failed conservative measures. Exam is significant for 4/5 weakness at left S1 myotome, + lumbar facet loading, and + left Slump. Plain films demonstrated moderate L4-L5 and L5-S1 facet osteoarthritis. An MRI of the lumbar spine ruled out osteomyelitis/discitis and demonstrated left lateral recess stenosis at L5-S1 in addition to multilevel central spinal stenosis, most pronounced at L4-L5. Patient was subsequently scheduled for and received bilateral L4-L5 and L5-S1 facet injections. Shortly thereafter, a national emergency was declared for COVID-19 and policy changes began to be implemented.

The CDC released mitigation recommendations which included limiting unnecessary visits and canceling elective and non-urgent procedures. Additionally, the CDC released consensus medical conditions thought to increase the risk for serious COVID-19 infection including but not limited to heart disease, CKD, and immunosuppression [1]. In accordance with CDC guidelines, the patient was scheduled for follow-up via TeleHealth at which time no pain relief was reported from prior facet injections. The decision was made to prescribe Norco 10/325mg and schedule the patient for an L4-L5 interlaminar epidural steroid injection once elective procedures resumed.

Chronic pain is a prevalent condition worldwide and causes suffering, limitation of daily activities and reduced quality of life. According to the United States 2012 National Health Interview Survey, 126.1 million adults reported some pain in the previous 3 months, with 25.3 million adults (11.2%) suffering from daily chronic pain and 14.4 million (6.3%) reporting “a lot” of pain most days or every day [2]. Until recently, there was no document or guidelines for the management of chronic pain patients, either during the current crisis or at the time of previous epidemic or pandemic outbreaks. Shanthanna et al compiled an expert panel of pain physicians, psychologists and researchers from North America and Europe to address this specific deficiency in the literature.

Their recommendations are based on the best available evidence and expert opinion, and can be summarized as follows: temporarily suspend all elective in-person visits and pain procedures; use TeleMedicine as a first approach; monitor and provide resources for psychological health, social circumstances, and ongoing pain; opioid prescribing without direct in-person medical evaluation is permissible; NSAIDs may be prescribed without associated increased risk for infection; prescribe steroids with caution due to potential for immune suppression; do not perform new pump/stimulator trials or implants; exercise clinical judgement on a case-by-case basis for semi-urgent procedures [3].

The American Society of Regional Anesthesia and Pain Medicine subsequently endorsed these recommendations in addition to highlighting the distinction between urgent vs semi-urgent procedures and what procedural precautions need to be taken. Comprising the urgent category were intrathecal pump (ITP) refills/malfunction and neurostimulator infection/malfunction. While new trials and implants are to be avoided, patients who recently underwent an implant procedure should have access to medical care. Procedure related complications are to initially be evaluated over telemedicine with subsequent in-person evaluation if implant infection is suspected. ITP refills and end-of-life battery replacements should be performed to avoid withdrawal symptoms. Comprising the semi-urgent category were intractable cancer pain, acute herpes zoster or intractable post-herpetic neuralgia, acute herniated disc and/or worsening lumbar radiculopathy, intractable trigeminal neuralgia, early complex regional pain syndrome, acute cluster headaches or other intractable headache condition, and other intractable medically resistant pain syndromes [3]. These cases need to be evaluated on an individual basis with shared decision making based on factors such as: the acuteness of the condition, potential for significant morbidity without intervention, the need for additional resources, the likelihood of benefit, and the potential for the patient to use emergency services [3, 6].

If a patient is determined to need an in-person meeting or procedure, ASRA recommends screening these individuals for the possibility of COVID-19. Patients can then be triaged into two groups: COVID-19 negative or low-risk patient and COVID-19 positive or high-risk patient. For both groups, following the CDC prevention and control recommendations is strongly recommended [4–5]. For the former group, the following recommendations apply: minimize patient movement within the hospital, use a clean room with no prior COVID-19 positive patients, use sterile technique when handling medication, utilize appropriate PPE for provider and patient, don and doff equipment carefully, protect equipment and minimize contact with patient as able, minimize personnel present during the procedure, and follow routine aseptic technique. For the latter group, in addition to the above recommendations, the following apply: limit these patients to urgent procedures, perform procedures in a designated COVID-19 room, and monitor these patients in an isolation room post procedure [6].

Given the fluidity of the COVID-19 pandemic, it is essential that practioners and organizations alike continue to adapt as more information and guidelines become available. Overall, the goal in our chronic pain population must be to avoid deterioration of function, reliance on opioids, and use of emergency services that would otherwise increase the risk of exposure.

Micheal is a PGY-2 resident in Physical Medicine and Rehabilitation at the University of Kansas Medical Center.

References:

1. Centers for Disease Control and Prevention. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf. Accessed May 19, 2020.
2. Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. Journal of Pain 2015; 16: 769–80.
3. Shanthanna H, Strand NH, Provenzano DA, et al. Caring for patients with pain during the COVID-19 pandemic: Consensus recommendations from an international expert panel. Anaesthesia. 2020 Apr 7.
4. Centers for Disease Control and Prevention. Environmental Cleaning and Disinfection Recommendations. https://www.cdc.gov/coronavirus/2019ncov/community/organizations/cleaning-disinfection.html. Published March 6, 2020. Accessed May 19, 2020
5. Centers for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-riskassesmenthcp.html?fbclid=IwAR24sPRluyXo7abdKY4WfUwg4TtckmlqV9AZdMHpC80ZgDyEtqqwxb0baBo. Published March 7, 2020. Accessed May 19.
6. Shanthanna, Harsha, et al. “Recommendations on Chronic Pain Practice during the COVID-19 Pandemic.” American Society of Regional Anesthesia and Pain Medicine, 27 Mar. 2020, www.asra.com/page/2903/recommendations-on-chronic-pain-practice-during-the-covid-19-pandemic.