Pain and the pandemic

Along with the tragic loss of life and significant morbidity associated with COVID-19 infection, secondary impacts on the general health of Canadians will not be fully appreciated for years to come. From delayed diagnoses and fragmented healthcare to skyrocketing suicide rates and opioid overdoses, the isolation of lockdowns put in place to help Canadians will undoubtedly have negative ripple effects for the foreseeable future. Loneliness of chronic pain Chronic pain, in its own right, can be incredibly isolating. Fear avoidance (avoiding certain activities/situations due to concern over aggravating pain), financial concerns, comorbid depression and anxiety, limitations in function and mobility, chronic fatigue and stigma are merely a handful of reasons that pain often results in significant social isolation. During a pandemic that has used isolation as one of its primary transmission mitigation strategies, it is not surprising that Canadians suffering from chronic pain are feeling the effects of this additive isolation. A recent Canadian web-based study sought to investigate the impact of the COVID-19 pandemic on pain status in those living with chronic pain.(1) Two-thirds of respondents reported pain exacerbation since the start of the pandemic, and close to half reported significant psychological distress.(1) Evidence of worsening pain and increased anxiety and depression secondary to the pandemic have been observed outside of Canada as well.(2,3) “Perfect storm” for negative pain outcomes The pandemic has created ideal conditions for the exacerbation of an already rampant chronic pain epidemic. Those suffering from chronic pain may not be receiving optimal pain management due to technological challenges observed in transitions to virtual healthcare, complete cessation of many invaluable multimodal pain treatment strategies, significant financial strains limiting access to some pain interventions, and an overall fear of (or resistance to) attending medical appointments in person.(4-6) Recent findings show that 68%–98% of patients with chronic pain have had significantly reduced access to nonpharmacologic treatments (e.g., physiotherapy, exercise, pain psychology, support groups) during the pandemic.(3,6) Best practice for the management of chronic pain is through multimodal approaches; with many of these absent or significantly reduced during the pandemic, alternate ways of coping are being seen in this population. Cause for concern To compensate for the lack of multimodal care and worsening pain, many patients with chronic pain are looking elsewhere for relief. Recent Canadian data highlight that some are resorting to increased use of opioid medications—or in some cases, reintroducing opioids after successful tapering—as a result of the pandemic’s impact on their pain.(6) This is concerning on its own, as re-initiation of opioids or dose increases, especially when self-initiated, is associated with an increased risk of accidental opioid overdose.(7) Unfortunately, the situation gets even more alarming as this same study, and others, found that individuals with chronic pain are more frequently using other substances for coping, such as alcohol and illicit drugs, further increasing the risk of accidental overdose.(6,8) In Canada and around the world, the rate of opioid toxicity deaths has skyrocketed during the pandemic. From April to December 2020, more than 5,000 Canadians lost their lives due to opioid toxicity, an increase of nearly 90% from the same period in the year before the pandemic began.(9) Pharmacists and the pandemic In light of the undeniable strains the pandemic has inflicted on healthcare services in Canada, pharmacists have had to adapt quickly in order to ensure seamless provision of the best possible care. Although access to many chronic pain treatments has been disrupted, access to necessary medications and pharmacy services has been only minimally impacted.(6) In March 2020, Controlled Drug and Substances Act (CDSA) exemptions were issued by Health Canada, arming pharmacists with tools that would ultimately minimize the pandemic’s impact on the continued accessibility of controlled medications. However, we know that ensuring access is not where our involvement with these medications ceases; even more critically now, we need to ensure safer medication use. Frequent check-ins by the pharmacist (by phone, in-person or virtually) could have a profound impact on this patient population, as support and connection significantly improve pain outcomes.(4) Check-ins of this nature should include questions regarding pain levels, mood, sleep and functional status. As well, any new prescriptions presented for depression, anxiety or sleep in those with chronic pain should be flagged for further and more frequent pharmacist follow-up, whether dispensed in person or through delivery. Added isolation may increase the demand for prescription delivery for some pharmacies, adding further complexity to patient care during this already complicated time. This reduced in-person patient connection supports the implementation of more frequent phone and/or virtual follow-up by the pharmacist in this population. Further, in order to mitigate the potential harms of self-medication and other coping mechanisms, patients should be asked regularly about the use of alcohol and other substances; their responses could spark dialogue around risk and safer opioid use. Finally, naloxone kits should be offered to all individuals with chronic pain on long-term opioid therapy, regardless of their duration of opioid use, along with education on naloxone and opioid use for the patient and their close contacts. Summary Pharmacists have already shown the positive impact they can have on patient care during times of strain on the healthcare system. In chronic pain, we have the opportunity to improve care and ensure safer opioid use, both now and after the pandemic dust has settled. Keep the risk factors for opioid toxicity at the forefront of our minds—this should encourage us to practise with harm reduction and prevention principles guiding our clinical care decisions. Dana Turcotte, BSc(Pharm), PhD, is a clinical pharmacist at a multidisciplinary primary care clinic in Winnipeg, MB, and an Assistant Professor at the College of Pharmacy, University of Manitoba. Her practice focuses on safer opioid use and pain management. References 1. Pagé MG, Lacasse A, Dassieu L, et al. A cross-sectional study of pain status and psychological distress among individuals living with chronic pain: the Chronic Pain & COVID-19 Pan-Canadian Study. Health Promot Chronic Dis Prev Can 2021;41(5). 2. Nieto R, Pardo R, Sora B, et al. Impact of COVID-19 lockdown measures on Spanish people with chronic pain: an online study survey. J Clin Med 2020;9(11):3558. doi: 10.3390/jcm9113558. 3. Aloush V, Gurfinkel A, Shachar N, et al. Physical and mental impact of COVID-19 outbreak on fibromyalgia patients. Clin Exp Rheumatol 2021;39 Suppl 130(3):108-14. 4. Clauw DJ, Häuser W, Cohen SP, et al. Considering the potential for an increase in chronic pain after the COVID-19 pandemic. Pain 2020;161:1694-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302093/ (accessed July 8, 2021). 5. Lynch ME, Williamson OD, Banfield JC. COVID-19 impact and response by Canadian pain clinics: a national survey of adult pain clinics. Can J Pain 2020;4(1):204-9. 6. Lacasse A, Pagé MG, Dassieu L, et al. Impact of the COVID-19 pandemic on the pharmacological, physical, and psychological treatments of pain: findings from the Chronic Pain & COVID-19 Pan-Canadian Study. PAIN Reports 2021;6(1):e891. doi: 10.1097/PR9.0000000000000891. 7. Elzey MJ, Barden SM, Edwards ES. Patient characteristics and outcomes in unintentional, non-fatal prescription opioid overdoses: a systematic review. Pain Physician 2016;19(4):215-28. 8. Dietze PM, Peacock A. Illicit drug use and harms in Australia in the context of COVID-19 and associated restrictions: anticipated consequences and initial responses. Drug Alcohol Rev 2020;39:297-300. 9. Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioid- and stimulant-related harms in Canada. Ottawa: Public Health Agency of Canada; June 2021. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants (accessed July 8, 2021).