Padma Gulur, MB, BS, ASA Committee on Pain Medicine, Professor of Anesthesiology and Population Health, Executive Vice Chair, Anesthesiology, and Director, Pain Management Strategy and Opioid Surveillance, Duke Health, Durham, North Carolina.

Padma Gulur, MB, BS, ASA Committee on Pain Medicine, Professor of Anesthesiology and Population Health, Executive Vice Chair, Anesthesiology, and Director, Pain Management Strategy and Opioid Surveillance, Duke Health, Durham, North Carolina.

As of the end of September, over 7.1 million cases of both confirmed and presumptive positive cases of COVID-19 have been reported in the United States with more than 204,000 deaths. With almost one in five Americans suffering from chronic pain, the impact of this pandemic on patients in pain is widespread – especially for those who use opioids and those with opioid use disorder.

The American Medical Association urged caution recently over reports that as many as 30 states have reported an increase in opioid fatalities since the start of the pandemic.

In a survey of U.S. adults released by the Centers for Disease Control and Prevention, more than one in 10 respondents said they had started or increased substance use to deal with stress or emotions related to COVID-19.

The pandemic has affected many facets of life. The mental health sequelae of social isolation during the pandemic are highlighted by the higher levels of anxiety and depression in the population. Further, the economic impact has resulted in financial uncertainty for many.

COVID-19 and considerations with chronic pain

Patients in chronic pain have been identified as a population at risk for COVID-19 given that many suffer from multiple comorbidities and there is potential for immune suppression, especially with the use of opioids to manage their pain (Br J Anaesth 2013;111:80-8; Nat Med 2010;16:1267-76). In fact, the choice of opioid used has a differential impact on immune suppression (Front Immunol 2019;10:2914).

Interventional procedures used to manage pain may involve steroids, which could induce immunosuppression. Some studies have found steroid injections to be associated with higher risk of contracting influenza (Mayo Clin Proc Innov Qual Outcomes 2018;2:194-8). Further, patients who have suffered from COVID-19 are developing chronic pain conditions that may be an unforeseen sequela of this pandemic.

A significant concern is the impact of the interruption in care patients with chronic conditions like pain experienced during the COVID surge. There have been concerns around treatment access, which were significantly mitigated by telemedicine and the relaxation of rules and regulations around this form of care.

Another area that benefited from the quick action to ease regulatory burden was on the part of the Drug Enforcement Administration in relaxing rules around the prescription of controlled substances to ensure access. There also has been interruption in access to physical therapy and limited ability to exercise, which worsened the situation for many (Br J Anaesth 2020;125:436-40). Finally, there is the ongoing fear of contracting COVID that leads many patients to avoid engaging in these helpful measures.

COVID-19 and considerations for opioid use disorder

While it is not clear that the occurrence of COVID-19 is higher in people who use recreational drugs or have substance use disorder, the potential for immunosuppression raises concerns (Palliat Med 2006;20 S1:s9-15). The use of opioids can cause significant respiratory impairment in addition to the concerns of immunosuppression with chronic use. Smoking and vaping can both impact respiratory parameters.

The use of stimulants such as cocaine, amphetamine, and methamphetamine and their effect on vasculature can cause stroke, heart attacks, abnormal heart rhythm, and seizure. All of this can worsen the impact of COVID-19. Social isolation, self-quarantine, and physical distancing can impact those with opioid use disorder to an inordinate degree. This has limited the use of critical support networks such as family, treatment programs, and support groups for this population.

Poor coping skills combined with the stressors this pandemic has added can increase the risk of relapse in those with opioid use disorder. The increased unstructured time from this pandemic makes it harder for patients to stay with their abstinence routines. Further, physical isolation heightens the risk of overdose, as there is a lack of support to call for help, e.g., administer naloxone.

While many opioid treatment programs remain open as essential services during the COVID-19 pandemic, the fear of contracting COVID has decreased engagement from the folks who need it most. Patients may also experience a disruption in access to their regular illicit drug supply, which can lead to withdrawal and emotional distress or cause them to turn to synthetic contaminated products, which may speak to the increased fatal overdoses many states are experiencing.

Approach to patients with chronic pain and opioid use disorder during the pandemic

For patients in chronic pain, it is essential to ensure continued access to care. This can be safely assured through telehealth visits. Interventional options, especially those that are not steroid based, are important as part of an opioid-sparing multimodal approach and should be offered to patients. Non-pharmacologic pain management options should be optimized. Providing access to online resources for exercise, acupressure, meditation, etc., can be important adjuncts. Uninterrupted access to their pain medication regimen is essential. While there has been a relaxation on monitoring requirements, providers must make every attempt to identify and treat opioid use disorder.

For patients with opioid use disorder, access to care and treatment programs is critical. Encouraging virtual check-ins with their support groups when possible or ongoing check-ins with health care providers can abate the real risk isolation poses for these patients. Access to naloxone is equally important. As we navigate a new normal through this pandemic, our most vulnerable populations deserve extra recognition and care.

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