How Are Chronic Pain Patients in Covid Era?
COVID 19 or Corona virus disease is a viral infection caused by SARS-COV2 virus. It is a RNA virus and is transmitted by respiratory passage. The spread of virus was so deadly that COVID 19 disease is pandemic worldwide affecting not only the developing low income source countries but mostly the highly developed countries. The test done for it is RT PCR Test. Till now, India becomes the World’s 3rd country with largest infection rate in a day. It has killed nearly 7 lakh population worldwide. Many countries are now in Lockdown period to control the spread of disease, with strict quarantine and isolation of the suspects and with positive tests. World Health Organization (WHO) has been continuously updating the steps to control this disease.
Apart from lung pathology and breathing problem, experts have discussed about its impact on Immunity as well. Pain physician are now showing concern for their chronic pain patients including neuropathic and cancer pain. Thinking that virus may be transmitted on attending the hospital and visiting for consultation with the treating physician, chronic pain patients themselves step backward unless they experienced severe unbearable pain.
Pain restrict movements and if severe, even daily routine activities are affected. It causes sleep deprivation or insomnia. Elderly chronic pain patients has osteoporotic changes with degenerative arthropathy. Many also suffer from Vitamin D deficiency. They feel pain even during turning on the bed while sleeping. Many of them have comorbid conditions like diabetes mellitus, hypertension, heart disease, respiratory problems, renal disease, stroke, cancer etc. These comorbidities make them more vulnerable for infections. Restricted mobility, sleep deprivation, vitamin D deficiency, old age as well as these comorbidities are said to reduce immunity, physical and mental well-being during this COVID 19.
Anti-inflammatory therapy eg. commonly prescribed NSAIDs Ibuprofen, reduce interleukin-6 in human tissues and in sputum might prevent fatal uncontrolled release of inflammatory cytokine storm of Covid-19. On the other hand, uncontrolled inflammation due to active arthritis is associated with an increased risk of infection. The WHO declared to press that there is no evidence of an increased risk of death with the use of NSAIDs in Covid-19. In view of these, many experts suggest to continue its use in chronic pain patients.
Epidural or intra-articular steroid injections and disease modifying agents like methotrexate, sulfasalazine prescribed for rheumatoid arthritis and spondyloarthropathies are the most concern medicines when we talk about immunity. One of the disease modifying agent, hydroxycholroquine, has been used as a prophylaxis to health workers who were enrolled in treating Covid 19 patients in India as published by Indian Council of Medical research though many recent literatures do not support its use in relation to Covid 19 in sick patients.
About role of steroid in Covid 19 patients, expert’s opinions and commentary varies widely. Glucocorticoids have an overall immunosuppressive effect, and these are often used in patients with inflammatory and autoimmune diseases. But, it is often prescribed in Sepsis. But, evidence are not available for its role in viral lung inflammation. Some suggest to manage patients who are on long term steroid by gradually tapering doses to 5–7.5 mg/ daily during this pandemic. Also, recent trail had shown positive effect of low dose dexamethasone with early recovery of COVID 19 patients. WHO is in the process of updating treatment guidelines to include dexamethasone or other steroid.
Current international society recommendations suggest that patients with rheumatic diseases on immunosuppressive therapy should not stop glucocorticoids during COVID-19 infection, although minimum possible doses may be used. Disease-modifying medicines should be continued. Cessation may be considered during infection episodes as per standard practices.
Immune depression and propensity to respiratory depression are more likely with opioids if used chronically or misused. Individuals who are opioid-dependent also present with a range of additional co-morbidities, social deprivation, and hopelessness. In such patients, COVID-19 infection may be dangerous. Some suggest that patients with chronic pain taking opioids might be more susceptible to COVID-19. But there is no clinical data reported to support this prediction.
The use of medical Ozone in pain management and Platelet-rich plasma injection for chronic pain management is also not reported to cause any adverse effects during this pandemic environment.
Relying on expert opinion and rapidly accumulating evidence is currently the best way to avoid major mistakes. Empirical preventive measures should be implemented while waiting for evidence-based recommendations. Whether the benefits outweigh the risks of any procedure in the individual chronic pain patient during this pandemic must be considered. Balanced and well-informed actions by all specialists and the whole society are urgently needed.
Life style modification including brisk walking in fresh air for at least 30 minutes a day, changes in dietary habits with a diet rich in minerals and vitamins, green leafy vegetables and fruits, tight controlled of blood sugar, aerobic exercises and physiotherapy to improve range of movements of affected joints and also to prevent disuse muscle atrophy, adequate sleep are very useful and give promising results while staying at home during this lockdown period in the country. In addition to physical restriction, chronic pain also affect emotionally and psychologically. So, pain patients must also have some recreational activities at home and need love and care from their family members.
Taking precautions by keeping social distancing, wearing face mask, frequent hand washing and using sanitizers, they can visit their pain management hospital if pain is unbearable. Most of the hospitals and treating physicians are well prepared with needful arrangement. Till date, no any high quality evidence based reports are available that limits the use of pain medicines and the procedures during this Covid 19 era.
The burden of chronic pain in long covid with lots of other post covid symptoms are also going to be challenging.
I wish everyone to be pain free and healthy physically and mentally.
We will win against this pandemic soon.
- Dr. Laxmi Pathak
- Pain Fellow at Daradia Pain Hospital
- New Town, Kolkatta, West Bengal, India
- Email: pathak0laxmi@gmail.com
