key: cord-0793345-akcop8il authors: Shanthanna, H.; Strand, N. H.; Provenzano, D. A.; Lobo, C. A.; Eldabe, S.; Bhatia, A.; Wegener, J.; Curtis, K.; Cohen, S. P.; Narouze, S. title: Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel date: 2020-04-26 journal: Anaesthesia DOI: 10.1111/anae.15076 sha: 9821569e338224cbee84c915ff50b631148725ca doc_id: 793345 cord_uid: akcop8il Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID‐19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID‐19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti‐inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID‐19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies. Chronic pain is a prevalent condition worldwide and causes suffering, limitation of daily activities and reduced quality of life [1] [2] [3] . 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 [4] . In Europe, almost one in five individuals report having moderate or severe chronic pain and in the UK, the prevalence of moderate to severely disabling chronic pain is estimated to range between 10.4% and 14.3% [5, 6] . Most chronic pain conditions occur in the elderly and are musculoskeletal in nature, such as low back, neck and joint pain. These contribute to the largest number of years lived with disability [7, 8] . In the UK, over 50% of the elderly population reported that chronic pain was the most important factor affecting their quality of life [9] . Chronic pain patients often suffer with co-existing comorbidities [5, 6] . In a large cross-sectional database study involving 1,751,841 people, pain was the most common co-existing condition among four common disease states: coronary artery disease; diabetes; cancer; and chronic obstructive pulmonary disease [10] . Adequate management of chronic pain is not only a moral and ethical imperative, but also mitigates against subsequent physical and psychological complications [7, 11, 12] . [13, 14] . We performed a literature search that did not identify any 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, including SARS-2003 . In response to the urgent need, an expert panel consisting of healthcare providers and pain researchers from North America and Europe were brought together to formulate practice recommendations to help physicians and health providers continue to care for their chronic pain patients [15] . The first and senior authors (HS, SN) The immune response and opioid therapy Pain and the immune system have a close relationship. Chronic pain exerts complex effects on the immune system, including immunosuppression in some individuals [17] . Immune cells and their products have a role in both inflammatory and neuropathic pain [18] . Significant immune system changes occur in patients with COVID-19, with a higher risk of mortality observed in the elderly alongside individuals who have hypertension; diabetes; coronary artery disease; and chronic lung disease [19, 20] . Although the mortality risk in cancer patients is unclear, early reports suggest a higher risk [21] . The association of comorbidities, old age and chronic pain increases the risk of immune suppression and subsequent COVID-19 infection. Opioids can have serious adverse effects including endocrine changes and the potential to suppress the immune system [22] [23] [24] ; however, some suggest there could be beneficial effects [25] . Opioids can interfere with the innate and acquired immune response, act on the hypothalamicpituitary-adrenal axis and the autonomic nervous system [23, 25, 26] . Higher doses and longer duration of therapy are associated with greater endocrine abnormalities [26] . Individual opioids differ in their effect on the immune system [27, 28] , however, morphine and fentanyl have been observed to be the most immunosuppressive [23, 29] . Based on available data, buprenorphine appears to be the safest to use in immunocompromised or elderly patients susceptible to infection [24] . The clinical relevance of these observations for individual opioids is unclear; however, observational studies indicate the potential for an increase in incidence and severity of infections in patients on opioids [30, 31] . It is, therefore, appropriate to consider that chronic pain patients on opioids could potentially be more susceptible to COVID-19 and other secondary infections. Furthermore, the potential for respiratory depression is higher in patients using fentanyl patches, as fever enhances absorption [32, 33] . Chronic pain patients may take oral steroids or receive steroid injections for a wide variety of musculoskeletal conditions [34] . Patients who receive steroids have the potential for secondary adrenal insufficiency and an altered immune response [35] , along with several other adverse effects including myopathy and osteoporosis [36] . Among available steroids, the depot form of methylprednisolone is most frequently used for chronic pain. Secondary adrenal insufficiency with 80 mg methylprednisolone can last up to 4 weeks; however, for a small proportion it could be up to 2 months [37] . Also, a recent trial evaluating epidural steroid injections noted that the duration of immune suppression could be less when using dexamethasone and betamethasone [38] . In a large retrospective study, the injection of corticosteroids into joints was shown to be associated with a higher risk of influenza [39] . Although the pathophysiology of COVID-19 infection suggests an exaggerated immune response, steroid use in COVID-19 patients is only recommended in those with refractory shock and this is based on low quality evidence [40] . During the 2003 SARS pandemic, arthralgias involving large joints were commonly observed during the recovery phase and many patients were treated with steroid therapy [41] . Those patients receiving higher doses and for longer treatment durations were more likely to develop osteonecrosis [42] . In view of these considerations, we feel that any new therapy that may influence the COVID-19 disease course should be discussed with the treating infectious disease physician. It should also be recognised that steroids are routinely used in many procedures despite an absence of evidence supporting the practice [43, 44] . Anaesthetists' position statement urges caution on the safety of steroids injected during the current COVID-19 pandemic [45] . The pain neuromatrix model integrates multiple inputs inclusive of: genetically informed synaptic architecture; sensory and/or afferent processing; cognitive; affective; motivational; immunoendocrine; and autonomic nervous system [46] . Chronic pain patients have higher prevalence of anxiety, depression, catastrophising and suicidal ideation [47] . This may worsen during a period of crisis. Chronic pain patients also experience: social isolation; stigma; loss of personal identity; and financial stress. These all negatively impact on psychological health, social circumstances, and ongoing pain, which are likely further exacerbated during a pandemic. It is imperative these issues are addressed during a pandemic and this is best achieved by using a biopsychosocial model of pain management. A summary of therapeutic considerations and recommendations for chronic pain management during the COVID-19 pandemic is displayed in Table 1 . and acceptance for telehealth services including for patients requiring post-procedural follow-up and with chronic disease states [49, 50] . There is an enormous potential for cost reduction and time savings with telehealth services Table 1 Summary of therapeutic considerations and recommendations for chronic pain management during the COVID-19 pandemic. In-patient visits • Any elective in-person patient visits or meetings should be suspended. • No elective pain procedures should be performed, except specific semi-urgent procedures. • Use telemedicine as the first approach and exclusively in most cases. • Ensure adherence to the subscribed needs of telemedicine required by individual state or country of practice. Biopsychosocial management of pain • Telemedicine platforms are available to engage in multidisciplinary interactions. • Whenever possible, online self-management programmes that integrate components of exercise, sleep hygiene, pacing and healthy lifestyle should be considered. • Multidisciplinary therapies could be helpful in overcoming increased opioids needs and/or procedures during the pandemic. • Use telemedicine to evaluate, initiate and continue opioid prescriptions. • Ensure all patients receive their appropriate prescription of opioids to avoid withdrawal. • Naloxone education and prescription for high-risk patients. • Inform patients of the risks and impact of long-term opioid therapy on the immune system. • Communicate with other healthcare providers in the patients' circle-of-care including family physicians, pharmacists and nurses. • We recommend all patients prescribed or who use non-steroidal anti-inflammatory drugs on a regular basis to continue their use, whilst monitoring for adverse effects. • We recommend educating patients on non-steroidal anti-inflammatory drugs that any mild fever or new myalgia should be promptly reported. • Steroids increase potential for adrenal insufficiency and altered immune response. • In COVID-19 suspected or symptomatic patients, consider the possibility of delaying the refill if the low reservoir alarm date allows a time frame until the patient has served a recommended self-isolation period. • Following a thorough discussion with the patient, consider: the risk benefit balance of discontinuing ITP therapy in high-risk patients on ziconotide therapy where no withdrawal effects have been reported; and the risk benefit ratio of using higher drug concentrations for the period of the pandemic in order to reduce ITP refill related visits. • Avoid any new trials or implants. • Use telemedicine as much as possible to resolve patient concerns. An audiovisual interview makes it easier to evaluate or troubleshoot most issues. Principles for semi-urgent visits/procedures • Comprehensive evaluation required and the need to help patients make informed decisions. • Use telemedicine to evaluate the patient, triage the urgency, and make suitable arrangements for treatment. This will minimise delay and prevent unnecessary visits. NSAIDS, non-steroidal anti-inflammatory drugs; ITP, intrathecal pump. [50] . In any pandemic, it is important that physicians continue to provide medical services in a safe and effective way and telehealth can help meet these needs. Preliminary Microsoft Teams is currently being integrated by NHS digital into its security platform and was made available to all NHS email users from 20 March 2020 [53] . Whilst outside the scope of these recommendations, the review by Eccleston et al. outlines more details regarding considerations for rapid integration of remotely supported pain management services [16] . It is imperative for patients with pain to have access to trained psychologists, physical therapists and social workers to address the psychological and physical impact of their pain and other comorbidities. Social distancing precautions in response to this pandemic pose unique challenges for multidisciplinary care. However advances in telemedicine outlined above, including interactive audio-video platforms, provide an opportunity to comprehensively assess patients and deliver virtual biopsychosocial and physical care that can be supplemented with in-person consultations at a later stage. Multidisciplinary pain self-management programs and strategies for self-management of pain can and are being delivered online [54] . Individual studies report excellent outcomes [55] and a systematic review of internet interventions for chronic pain found that those based on cognitive behavioural therapy can be efficacious [56] . Examples of interventions that can be delivered effectively over the internet for patients with chronic pain include: managing stress; addressing sleep disturbances; teaching mindfulness practices; cognitive strategies; pacing activities; social support programs; simple physical exercises; and observing a healthy lifestyle. Guidelines on opioid prescribing already exist to help minimise the harm from their application in chronic pain management [57, 58] . Broadly, these considerations include: the need to determine when to initiate or continue opioids for chronic pain; appropriate opioid selection, dosage, duration, follow-up and discontinuation; and assessment of risks and harms of opioid use. Ideally, changes to opioid prescriptions should be made only after in-person careful evaluation of ongoing treatment, which includes a history and physical examination. However, during the current COVID-19 health emergency, physicians may not be able to adhere to such a practice. In view of this, many countries have made changes to their policy on controlled substances. Such temporary allowances include enabling pharmacists to: extend prescriptions for a limited period of time; act on a verbal order by a physician for refill of controlled substances; deliver prescriptions of controlled substances to patient's homes or other locations of selfisolation; and permitting registered practitioners to prescribe opioids without an in-person medical evaluation as long as some necessary conditions are met [59, 60] . Although controlled substances may be provided without a direct in-person medical evaluation, it is still recommended that opioid safe prescribing procedures be performed including: assessing for adequate response; adverse events; aberrant behaviours; function; and quality of life improvements [61] . Pill counts can still be performed and informed consent obtained via video communication. Patients should continue to be educated on the risks and benefits of opioids, naloxone should be prescribed when appropriate and the review of medical history and medications that impact opioid prescribing should be continued. We must be cognisant that psychological stress may exacerbate pain leading to greater opioid requirements and that patients may use medically prescribed opioids for nonpain-related conditions such as: anxiety; depression; and insomnia despite evidence that in the long-term they can worsen these conditions [62] . Therefore, any significant, sustained increase in opioid dose requires an in-person evaluation. A substantial number of chronic pain patients use nonsteroidal anti-inflammatory drugs (NSAIDs) for their pain control [63] . Non-steroidal anti-inflammatory drugs exert their analgesic effect primarily through peripheral inhibition of prostaglandin synthesis by acting on the cyclo-oxygenase enzyme, although other peripheral and central mechanisms of analgesic action exist. There are two structurally distinct forms of the cyclo-oxygenase enzyme (COX-1 and COX-2) [64] . COX-1 is constitutively expressed in normal cells, whereas COX-2 is induced in inflammatory cells. One of the mechanisms underlying antihypertensive actions of angiotensin converting enzyme (ACE) inhibitors involves the kinin-prostaglandin system [65] . An observation by the current French health minister had initially prompted some physicians to advice against the use of ibuprofen or other NSAIDs, based on the assumption that its use may increase the severity of COVID-19 disease [66] . This was based on the assumption that NSAIDs could increase the levels of ACE. However this has not been substantiated by other any reports and multiple regulatory bodies have since refuted this assertion [67] [68] [69] . However, NSAIDs may mask early symptoms of the disease such as fever and myalgias. withdrawal may still occur with high-dose oral baclofen [71] . Although clonidine is not currently approved as intrathecal therapy [72] , it is often used in clinical practice and the Polyanalgesic Consensus Conference panel recommendations for intrathecal drug delivery assigned grade B evidence for its use in neuropathic and nociceptive pain [73] . Intrathecal clonidine withdrawal can result in hypertensive crisis and cardiomyopathy [74] . It should be noted that there are no reported withdrawal symptoms when intrathecal ziconotide as a sole therapy was discontinued [73] . In general, all patients at high risk of intrathecal drug withdrawal should be identified and Although not urgent, some situations may warrant a careful evaluation of individual risks and benefits so that a patient may be considered for an in-patient visit. These circumstances meet the criteria of semi-urgent pain patient visits or procedures during the COVID-19 pandemic. Decision-making on such occasions should be based on factors such as: the acuteness of the condition; potential for significant morbidity without intervention; the need for additional resources (such as monitoring for ketamine infusions); the likelihood of benefit; and the potential for the patient to use emergency services. Overall, the goals must be to avoid: deterioration of function; reliance on opioids; or emergency service visits that increase risk of exposure. Such procedural scenarios may include, but not limited to, the following: intractable cancer pain; acute herpes zoster or subacute, intractable post-herpetic neuralgia; acute herniated disc and/or worsening lumbar radiculopathy; intractable trigeminal neuralgia; early complex regional pain syndrome; acute cluster headaches and other intractable headache conditions; and other intractable medically resistant pain syndromes. Chronic pain causes significant suffering, leading to a The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care The economic costs of pain in the United States Chronic pain: a review of its epidemiology and associated factors in population-based studies Estimates of pain prevalence and severity in adults: United States Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies Assessing the relationship between chronic pain and cardiovascular disease: a systematic review and meta-analysis The state of US health, 1990-2010: burden of diseases, injuries, and risk factors The burden of common chronic disease on health-related quality of life in an elderly community-dwelling population in the UK Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study Access to pain management-still very much a human right Baseline quality of life as a prognostic indicator of survival: a meta-analysis of individual patient data from EORTC clinical trials The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug and Alcohol Dependence 2020 Recommendations on chronic pain practice during the COVID-19 pandemic Managing patients with chronic pain during the Covid-19 outbreak: considerations for the rapid introduction of remotely supported (e-health) pain management services Interactions between the immune and nervous systems in pain Role of the immune system in chronic pain The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop Evidence for central opioid receptors in the immunomodulatory effects of morphine: review of potential mechanism(s) of action Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone) Opioids and the immune system -friend or foe Opioid endocrinopathy: a clinical problem in patients with chronic pain and long-term oral opioid treatment Do all opioid drugs share the same immunomodulatory properties? A review from animal and human studies Opioids and the immune system Effects of fentanyl on natural killer cell activity and on resistance to tumor metastasis in rats. Dose and timing study Use of opioids or benzodiazepines and risk of pneumonia in older adults: a population-based case-control study Opioid analgesics and the risk of serious infections among patients with rheumatoid arthritis: a self-controlled case series study In brief: heat and transdermal fentanyl Iontophoretic drug delivery system: focus on fentanyl Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials Perioperative steroid management: approaches based on current evidence Effects of epidural steroid injections on bone mineral density and bone turnover markers in patients taking anti-osteoporotic medications Simultaneous bilateral knee injection of methylprednisolone acetate and the hypothalamic-pituitary adrenal axis: a single-blind case-control study Systemic effects of epidural steroid injections for spinal stenosis Joint corticosteroid injection associated with increased influenza risk Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Medicine 2020 Musculoskeletal complications of severe acute respiratory syndrome Steroid therapy and the risk of osteonecrosis in SARS patients: a dose-response metaanalysis Safe use of epidural corticosteroid injections: recommendations of the WIP Benelux Work Group The benefit of adding steroids to local anesthetics for chronic non-cancer pain interventions; a systematic review and meta-analysis of randomized controlled trials FPM response to concern related to the safety of steroids injected as part of pain procedures during the current COVID-19 virus pandemic Pain and the neuromatrix in the brain Pain psychology and the biopsychosocial model of pain treatment: ethical imperatives and social responsibility COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures Are people with chronic diseases interested in using telehealth? A crosssectional postal survey Patient preference for time-saving telehealth postoperative visits after routine surgery in an urban setting Evaluation of selfmanagement support functions in apps for people with persistent pain: systematic review Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency NHS staff to receive free access to Microsoft Teams and Locum's Nest Reboot online: a randomized controlled trial comparing an online multidisciplinary pain management program with usual care for chronic pain Internet interventions for chronic pain including headache: a systematic review Guideline for opioid therapy and chronic noncancer pain CDC Guideline for Prescribing Opioids for Chronic Pain -United States Diversion Control Division. COVID-19 Information Page Rethinking the role of opioids in the outpatient management of chronic nonmalignant pain Evaluation of how depression and anxiety mediate the relationship between pain catastrophizing and prescription opioid misuse in a chronic pain population Nonsteroidal anti-inflammatory drugs in chronic pain: implications of new data for clinical practice The mechanisms of action of NSAIDs in analgesia Reduction of the antihypertensive effect of captopril induced by prostaglandin synthetase inhibition Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19 EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19 Pain behavior and nerve electrophysiology in the CCI model of neuropathic pain Abrupt withdrawal from intrathecal baclofen: recognition and management of a potentially life-threatening syndrome Use caution with implanted pumps for intrathecal administration of medicines for pain management: FDA safety communication The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management Intrathecal clonidine pump failure causing acute withdrawal syndrome with 'stressinduced' cardiomyopathy Defense, Uniformed Services University, and the National Institutes of Health. No other external funding or competing interests declared.