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CHRONIC PAIN MANAGEMENT

Learning objectives
By the end of this educational module you should be able to:
1. understand the importance of addressing patients' physical functionality in pain management
2. recognise and assess different types of pain
3. interpret patients’ individual needs in pain management
4. understand the holistic approach to chronic pain management and the role your specialty can play
5. know how to address the needs of patients with chronic pain during the COVID-19 pandemic

Managing patients with chronic pain during the COVID-19 pandemic

As a result of the COVID-19 pandemic, elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled.31 Elective, routine, and non-emergency work has stopped in secondary and tertiary centres, while in primary care, patients are requested to stay away or socially distance.32

Important considerations that need to be recognised during the pandemic for people with chronic pain 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.31

  • CONSIDERATIONS FOR INDIVIDUALS

    Guidance on practice in care of patients with chronic pain during the pandemic was published in April 2020 by an expert panel comprising pain clinicians, psychologists and researchers from North America and Europe. The panel recommended the following pathway in care of patients with chronic pain:31

    Adapted from Shanthanna H et al, 202031
    ITP: intrathecal pump.

    The panel recommended the following in therapeutic considerations and recommendations for chronic pain management during the pandemic:31

    IN-PATIENTS VISITS
    • All elective in-person patient visits and meetings should be suspended
    • No elective pain procedures should be performed, except specific semi-urgent procedures
    USE OF TELEMEDICINE
    • 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, consider online self-management programmes that integrate components of exercise, sleep hygiene, pacing and healthy lifestyle
    • Multidisciplinary therapies could be helpful in overcoming increased opioids needs and/or procedures
    PRESCRIBING OPIOIDS

    These are the recommendations made within the international publication. Please refer to your local guidance for further information.

    • Use telemedicine to evaluate, initiate and continue opioid prescriptions
    • Ensure all patients receive their appropriate prescription of opioids to avoid withdrawal
    • Educate high-risk patients about naloxone use and prescribe naloxone for eligible 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 clinicians, pharmacists and nurses
    PRINCIPLES FOR USING NSAIDS
    • All patients prescribed or who use NSAIDs on a regular basis should continue their use, whilst monitoring for adverse effects
    • Inform patients on NSAIDs that any mild fever or new myalgia should be promptly reported
    PRINCIPLES FOR USING STEROIDS
    • Steroids increase potential for adrenal insufficiency and altered immune response
    • Intra-articular steroid injections could increase the risk of viral infection
    • Duration of immune suppression could be less with the use of dexamethasone and betamethasone
    • Consider evaluating risks and benefits of steroid injections and consider a decreased dose
    INTRATHECAL (ITP) DRUG DELIVERY SYSTEMS
    • Avoid insertion of any new ITP except for highly selected cancer pain cases where the benefit is considered to outweigh the risk. Consider proceeding straight to an implant, without a trial, for appropriate candidates
    • 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
    NEUROSTIMULATOR ISSUES
    • Avoid any new trials or implants
    • Use telemedicine as much as possible to resolve patient concerns. An audio-visual 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 to minimise delay and prevent unnecessary visits

    Guidance from the British Pain Society (BPS) on pain management during the pandemic states that, in some people with chronic pain who have a continuous dry cough, symptoms of pain may be exacerbated. The guidance recommends managing the underlying cough and associated symptoms in this case, rather than aiming for just symptomatic pain relief. Comparably, patients with fibromyalgia and other persistent pain conditions may experience exacerbation of pain symptoms and should be managed similarly to other COVID-19 cases but with additional supportive management of their analgesic requirements.33

    On use of transdermal opioids and medicines for neuropathic pain, BPS guidance warns that a high temperature or fever may increase absorption from transdermal opioid patches and could increase opioid side effects. Patients who are prescribed transdermal opioids may become increasingly drowsy or somnolent. This group may require the patch strength to be reduced, or alternatively their medication can be replaced with short-acting opioid formulations, until the person is feeling better and the fever is lowered.33

    BPS reminds us that opioids are also cough suppressants and they may mask or delay the initial symptoms that present with COVID-19 infection. Prescribed opioids and other medicines for neuropathic pain can lead to worsening of tiredness, nausea and gastrointestinal symptoms that are associated with COVID-19 infection.33

     

  • CONSIDERATIONS FOR PUBLIC HEALTH

    The effect of the pandemic on pain burden is expected to be differentially distributed across and within populations, depending on population characteristics including:32

    • older age
    • population density
    • socioeconomic gradient
    • smoking prevalence
    • levels of chronic disease morbidity
    • availability of diagnostic testing
    • access to healthcare

    Some of these characteristics such as older age, socioeconomic status, smoking prevalence, chronic disease comorbidity, and access to healthcare are also associated with higher levels of chronic pain prevalence and burden. This could mean populations with higher existing pain burden are more likely to experience higher incidence of COVID-19 infections, greater disruption to their usual healthcare access, and worse downstream consequences of abruptly altered healthcare. Some high-risk population subgroups may have poor access to technologies used in remote care.32

    Prevention of chronic pain within populations depends on best practice management of acute pain and early recognition of the risk of progression to chronic pain. Preventing chronic pain is complex and in a global pandemic, risk factors for pain morbidity and mortality are magnified. Best practice to avoid progression to chronic pain during the pandemic include using telemedicine, eHealth interventions and self-management. Changing practice in an unplanned way will have positive and negative consequences, many unforeseen. To minimise possible negative impacts, care systems can establish protocols that can enable them to oversee, monitor, and capture important patient and provider outcomes and perspectives.32

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© NICE 2017. Medicines optimisation in chronic pain. Available from: www.nice.org.uk/advice/ktt21. All rights reserved. Subject to Notice of rights
© NICE 2016. Low back pain and sciatica in over 16s: assessment and management. Available from: www.nice.org.uk/guidance/ng59. All rights reserved. Subject to Notice of rights
© NICE 2013. Neuropathic pain in adults: pharmacological management in non-specialist settings. Available from: www.nice.org.uk/guidance/cg173. All rights reserved. Subject to Notice of rights
© NICE 2019. Cannabis-based medicinal products. Available from www.nice.org.uk/guidance/ng144. All rights reserved. Subject to Notice of rights
 

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