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02 APRIL 2020

In this time of uncertainty, we are all asking questions and questions are being asked of us.  As a health worker, there is enormous discussion, debate and anxiety regarding our current and future practices, both at work and at home.  For the person living with persistent pain, this pandemic can be especially troubling, in part due to the unknown.

The name COVID-19 (COronaVIrus Disease 2019) refers to the illness following infection with a novel coronavirus, initiated in late 2019; coronavirus infections are not uncommon (making up to 5-10% of the common colds), with high impact endemics occurring in 2002-3 (SARS) and to some degree ongoing in certain countries (MERS, Middle Eastern Acute Respiratory Syndrome 2012).  COVID-19 is just as infectious and potent, but due to rapid spread and society structural issues (including health systems), is having a greater impact on the health of countries around the world.

In relation to risk, two aspects are being reported: the risk of contracting the virus, and the subsequent risk of severe illness following infection.  The first relates to exposure, being in close proximity to someone with active infection (and perhaps in the 24-48 hrs before symptoms), via droplets (following cough and sneeze) and surface contact following such (as the virus may survive for variable amounts of time).  Hence the importance of respiratory etiquette, hand washing and limiting touching the face, not to mention social distancing.

The second risk relates to a person’s potential to develop a severe form of the illness: the majority have mild symptoms, some develop moderate respiratory symptoms, while a minority develop a severe form, with pneumonia, respiratory failure and risk of death.  The most reported risk for the severe form is increasing age, although the young can also become severely ill (and have similar risk of contracting the virus).  While experience is still being accumulated, co-morbid health conditions appear to increase risk, namely cardiovascular disease (including hypertension), diabetes and pre-existing lung disease (including smoking).  The reports of increased mortality in males is disputed, as they may carry an increased burden of other conditions and possibly have greater exposure.

For people living with chronic pain, a number of issues arise, noting a higher incidence of pain in the older person, the physical deconditioning which may result from pain and the high rates of anxiety and depression.  Early discussion of risk related to ibuprofen, a NSAID commonly used for pain (and widely used overseas for the control of fever), with suggestions its regular use contributed to both heightened risk of contracting the virus and of developing a severe form of the illness.  The reported comments were based on theoretical considerations based on animal studies, rather than direct reports from the clinical outcomes within the pandemic, such that ceasing its use for pain is not recommended; caution remains of its use to control fever although there is little basis for this in the current evidence.

Opioids are commonly prescribed for debilitating severe pain, with lack of evidence of sustained benefit and potential harm meaning they are no longer advised for the majority with chronic non-cancer pain.  Animal studies suggest immune system effects, with potential for immune-suppression when used in clinical practice; one large study found a higher rate of respiratory infections in those on moderate to high dose opioid therapy.  We need to presume those on high doses of opioids for their pain would be a higher risk for more severe illness re COVID-19, however data is lacking.  That said, rapid opioid dose reduction also poses risks, of more severe pain and neuro-psychological effects, so careful consideration following consultation with a prescribing practitioner is advised.

In addition to the personal questions, a range of challenges are facing the health care system in Australia.  We are currently seeing the preparation phase, with development of increased capacity, specifically in initial assessment (including testing), intensive care provision and follow-up care plans (including beds for the older person suffering COVID-19).  This means training, recruitment and redeployment of staff and limitations to non-essential services; recognise many hospital-based pain services are being limited but not completely inactive (our service, for example, is operating at about half normal activity).  There are benefits, however, with rapid uptake of telehealth-based services and an emphasis on community-based care (including allied health where appropriate).  People with pain can expect delays in access but be assured these are temporary and access by phone for patients and GPs remain.

Experiencing pain provokes psychological responses (via neurological mechanisms), such that high rates of anxiety, depression and sleep issues are reported, which, if poorly managed, can exacerbate the pain experience.  It is important, in these times, to respect that anxiety related to the pandemic can exacerbate pain and mental health conditions; the health authorities recognise this with funding allocations to increase access to support services which should be used to compliment current management strategies.  At times of stress, a simplified, behavioural approach is advocated by some, taking things step by step, focusing on small activity goals and seeking support from those close.  Recognising that the COVID-19 pandemic is just that, a period in time, with evolution and resolution expected can be reassuring, knowing that pain management and living life will outlive this outbreak.

Associate Professor Malcolm Hogg
Painaustralia Clinical Advisor and Board Director