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Treating Chronic Pain During the COVID-19 Pandemic

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Treating Chronic Pain During the COVID-19 Pandemic

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The Pain of COVID-19:
Treatment of Chronic Pain During the COVID-19 Pandemic

Faculty presenters for this session include:
Bennet Davis, MD;
Pain Program Director,
Sierra Tucson
Amy Kennedy, PharmD, BCACP;
Clinical Assistant Professor,
University of Arizona College Pharmacy;
Clinical Pharmacist,
El Rio Health
Kathy Davis, RN, BSN, ANP-C;
Nurse Practitioner,
El Rio Health Pain Program

September 2, 2020

The Pain of COVID-19:
Treatment of Chronic Pain During the COVID-19 Pandemic

Faculty presenters for this session include:
Bennet Davis, MD;
Pain Program Director,
Sierra Tucson
Amy Kennedy, PharmD, BCACP;
Clinical Assistant Professor,
University of Arizona College Pharmacy;
Clinical Pharmacist,
El Rio Health
Kathy Davis, RN, BSN, ANP-C;
Nurse Practitioner,
El Rio Health Pain Program

September 2, 2020

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Treating Chronic Pain During the COVID-19 Pandemic

  1. 1. The Pain of COVID-19 Treating Chronic Pain During the COVID-19 Pandemic September 2, 2020
  2. 2. CME Credit • Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State Medical Society to sponsor continuing medical education for physicians. The Bridgeport Hospital Yale New Haven Health designates this live activity for a maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only credits commensurate with the extent of their participation in the various activities. • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State Medical Society to provide continuing medical education for physicians. • The content of this activity is not related to products or services of an ACCME- defined commercial interest; therefore, no one in control of content has a relevant financial relationship to disclose and there is no potential for conflicts of interest. 2
  3. 3. Managing Chronic Pain During Covid-19
  4. 4. 6,073,121 cases on 9/1/20 up from 5,746,940 cases on 8/25/20 184,644 deaths https://coronavirus.jhu.edu/map.html COVID-19 in the United States
  5. 5. Average daily cases in the last week
  6. 6. COVID-19 News updates • Plasma? – Emergency Use Authorization - Food and Drug Administration • Aug. 23 – There are currently no data from well controlled, adequately powered randomized clinical trials that demonstrate the efficacy and safety of convalescent plasma for the treatment of COVID- 19 - NIH
  7. 7. COVID-19 News updates • New York City is delaying the start of the school year by 10 days • Other schools with problems: – University of South Carolina – suspended students • World: – Indonesia: 100+ and 70 nurses died COVID-19 – Russia passed 1 million cases • #4 in the world
  8. 8. Resources • Nuvance health 1000+ articles reviewed: https://spark.adobe.com/page/qrH7iY0Gi0hU9/ • CDC: https://www.cdc.gov/coronavirus/2019-ncov/index.html https://emergency.cdc.gov/coca/calls/2020/ • WHO: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 • Johns Hopkins: https://coronavirus.jhu.edu/map.html • Others https://www.thelancet.com/coronavirus https://covidactnow.org/
  9. 9. The Pain of COVID-19 Treating Chronic Pain During the COVID- 19 Pandemic Bennet Davis, M.D. Kathy Davis, ANP-C Amy Kennedy, PharmD
  10. 10. What is Pain? • Nociceptive pain • Neuropathic pain from physical nerve damage or disease • Neuropathic pain from a Threat Adapted Nervous System (Nociplastic pain) • “Emotional” Pain: Grief, Rejection, Isolation An experience produced by any combination of:
  11. 11. What is Pain? “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.” Nociplastic Pain: https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Nociplasticpain International Association for the Study of Pain. 2017
  12. 12. What is Pain? • Culture, Beliefs, Values, Assumptions • Anxiety, depression An experience produced by any combination of the 4 processes, interpreted through the lens of the individual’s life experience and emotional state:
  13. 13. What is Pain? • Family • Work • Codependent relationships An experience produced by any combination of the 4 processes, felt and interpreted through the lens of the individual’s life experience and emotional state, and modified by the important relationships in the individuals life
  14. 14. The two brain pain circuits
  15. 15. Kross E. Proceedings of the National Academy of Sciences. 2011;108 (15): 6270-6275 Author’s conclusion: “These results give new meaning to the idea that social rejection ‘hurts.’”
  16. 16. Social interactions mediate pain perception 1. Socially isolated people have a lower pain threshold 2. Degree of social support at diagnosis of RA predicts pain intensity at 3 year follow up 3. Pain scores correlate positively with perceived social support in people with chronic musculoskeletal pain 1. Eisenberg N. Pain 2006;126:132-8 2. Evers A. Beh Res Ther. 2003;41:1295-1310 3. Hsu. Clin J Pain 2014;30:713-23
  17. 17. Our study provides evidence that the impact of pain is reduced in individuals who perceive a greater sense of inclusion from and engagement with others. The Impact of Social Isolation on Pain Interference (PROMIS® pain measures): A Longitudinal Study Karayannis N. Annals of Behavioral Medicine. 2019; 53: 65-74
  18. 18. Acetaminophen Reduces Social Pain: Behavioral and Neural Evidence Dewall C. Pschol. Sci. 2010 Jul;21(7):931-7 •. 2010 Jul;21(7):931-7 In two experiments, participants took acetaminophen or placebo daily for 3 weeks. Doses of acetaminophen reduced reports of social pain on a daily basis (Experiment 1). We used functional magnetic resonance imaging to measure participants' brain activity (Experiment 2), and found that acetaminophen reduced neural responses to social rejection in brain regions previously associated with distress caused by social pain and the affective component of physical pain (dorsal anterior cingulate cortex, anterior insula)
  19. 19. We used a Mu opioid receptor (MOR) radiotracer to measure changes in MOR binding potential (that is, in vivo receptor availability) with positron emission tomography during social feedback. We found that social rejection as well as acceptance activated the MOR system above baseline in different brain regions, showing that the endogenous opioid system responds to social feedback in humans. Activation levels extracted from the left amygdala were positively correlated with the personality trait resiliency, suggesting that during rejection high-resilient individuals are more capable of MOR activation, which may be protective or adaptive. Hsu D. Molecular Psychiatry 2013: 18: 1147 Endogenous opioid mediates response to social rejection And improves resilience to social rejection and isolation
  20. 20. Variation in the μ-opioid receptor gene (OPRM1) is associated with dispositional and neural sensitivity to social rejection Participants (n = 122) completed a self-report inventory of dispositional sensitivity to social rejection and a subsample (n = 31) completed a functional MRI session in which they were rejected from an online ball- tossing game played with two supposed others. The A118G polymorphism was associated with dispositional sensitivity to rejection in the entire sample and in the fMRI subsample. Consistent with these results, G allele carriers showed greater reactivity to social rejection in neural regions previously shown to be involved in processing social pain as well as the unpleasantness of physical pain PNAS September 1, 2009 106 (35) 15079-15084
  21. 21. Chronic pain and COVID 19 • Social isolation directly increases pain • Social isolation increases anxiety and depression • Social isolation increases fatigue • The endogenous opioid system is involved in regulating response to isolation • Some people have a variant of the opioid receptor that makes them more vulnerable to the effects of isolation
  22. 22. Chronic pain and COVID 19 • Cognitive barriers worsened by COVID and isolation – Fear avoidance – Feeling misunderstood – Worry about keeping up – Somatization • COVID 19 interferes with access to care and self care – Transportation challenges – Financial challenges – Gyms and pools closed – Alternative medicine closed – Elective procedures and surgeries closed
  23. 23. 1. Opioid prescribing has increased 20% since Jan 2020 2. Overdose rates on fentanyl have increased since Jan 2020
  24. 24. At risk populations – Prescribed opioid for pain – risk of withdrawal – Using opioid to some degree as a psychotropic – Decreased social resources – Low financial resources – Transportation challenged – IT challenged – Geographically remote communities
  25. 25. What to do?? • Connection to others via electronics • Support groups • Hobbies • Pets • Self care – Diet – Exercise – Sleep – Meditation – Meter the news • Treat anxiety and depression • Recognize and treat trauma • Ease roadblocks to care • Level the tech playing field
  26. 26. Support groups to counter isolation • American Chronic Pain Association https://www.theacpa.org/about-us/support-groups/ • The Mighty https://themighty.com/topic/chronic-pain/ • The National Fibromyalgia and Chronic Pain Association https://www.fibroandpain.org/chronic-pain/chronic-pain- support-community • My Chronic Pain Team https://www.mychronicpainteam.com/users/sign_in • NAMI https://www.nami.org/Support-Education/Mental- Health-Education/NAMI-Peer-to-Peer
  27. 27. Prescribing opioids during COVID 19 Kathy Davis, ANP-C
  28. 28. COVID 19 OPIOID PRESCRIBING CHALLENGES TELEHEALTH • Telehealth visits – the new norm. – Keep Phone visits at a minimum vs. Virtual visits – Many possible technological interruptions during telehealth visits. Loss of focus, wastes valuable visit time. – Lack of privacy • Is it Ok to see a patient for the first visit via telemedicine?
  29. 29. COVID 19 OPIOID PRESCRIBING CHALLENGES Non-Opioids TREATMENTS – Patients find it difficult to follow through on chronic pain treatments due to COVID restrictions and fears. Examples: physical therapy, massage, acupuncture, referrals for interventional treatments, going to radiology for necessary films, going to group classes for exercise and weight loss programs, etc. – Not going to gyms. Some getting home equipment. – On line classes at our CHC, You Tube, Webinars, and Podcasts all available.
  30. 30. COVID 19 OPIOID PRESCRIBING CHALLENGES MONITORING Monitoring of patients on opioids • Toxicology screening, signing opioid agreement, completing mood and pain interference screening documents, etc. • Randomly bring patients in for in clinic visit so can get a UDS and sign opioid agreement. • Use risk stratification tools to determine frequency of UDS: ORT (opioid risk tool) or SOAPP-R • Document reasons for exceptions.
  31. 31. COVID 19 OPIOID PRESCRIBING CHALLENGES DOSAGE CHANGES • This is not the time to make major changes in opioid dosing up or down unless for safety reasons • Decreases and delays in elective surgery and procedures may cause the need to support with opioid longer or delay lowering dose plans • If need to wean, recommend these guidelines: Davis B, Archambault C, Davis K, et al. A Patient –Centered Approach to Tapering Opioids. VOL 68, NO 10 | DECEMBER 2019 | THE JOURNAL OF FAMILY PRACTICE
  32. 32. COVID 19 OPIOID PRESCRIBING CHALLENGES BEHAVIORAL HEALTH CONCERNS • Social isolation is increasing pain and mood disturbance, negatively impacting self-care. • Increased financial strain, Increased risk of diversion, more homelessness, high stress levels everywhere. • BH treatments may be on hold • What to do? Focus on the highest risk patients • Implement screening tools when come in, GAD 7, PHQ9, PROMIS pain interference and intensity, ACE and PCL-5 Initiate BH support.
  33. 33. Pharmacist perspective on pain in COVID-19 Amy K. Kennedy, PharmD, BCACP 2020
  34. 34. Factors worsening adherence • Impact on social interaction/mental health • Financial • Avoidance of care • Medication shortages and contamination • Changing pharmacy landscape
  35. 35. BRAIN Pharmacologic Agents Affect Pain Differently Descending Modulation Central Sensitization PNS Local Anesthetics Topical Analgesics Anticonvulsants Tricyclic Antidepressants Opioids Anticonvulsants Opioids NMDA-Receptor Antagonists Tricyclic/SNRI Antidepressants Anticonvulsants Opioids Tricyclic/SNRI Antidepressants CNS Spinal Cord Peripheral Sensitization Dorsal Horn
  36. 36. SSRI antidepressants • citalopram (Celexa) – Few drug-drug interactions (DDIs) – High serotonin specificity – Typical or less SSRI side effects – 10-40 mg/day (hepatic impairment consider 20 mg/day) • escitalopram (Lexapro) – no generic available – Simple dosing (10-20 mg/day) – “S” molecule of the “S” & “R” mirror-image mixture of citalopram molecules • fluoxetine (Prozac, Sarafem, Symbyax- with Zyprexa) – Very long half-life – Significant DDIs – Can be activating – Conflicting data on use in painful diabetic neuropathy and headache – 10-80 mg/day (lower doses in hepatic impairment)
  37. 37. SSRI antidepressants • fluvoxamine (Luvox) – OCD indication – Multiple significant DDIs – Conflicting evidence for migraine – 100-300 mg/day (lower dose or longer dosing interval in hepatic impairment • paroxetine (Paxil) – Significant DDIs – Some reports of associated weight gain – “Withdrawal” symptoms with missed doses – 10-75 mg daily (max of 40 mg in renal or hepatic impairment) • sertraline (Zoloft) – Moderate DDIs – Multi-step dosing – 25-200 mg/day (hepatic impairment consider lower doses)
  38. 38. Atypical antidepressants • venlafaxine (Effexor) – Similar to TCAs with less safety & side effect concerns – Can increase blood pressure – Minimal DDI – SE with missed doses – Class B effectiveness in pdn and migraines, unclear in LBP – Dosing: 75-225 mg/day, reduce dose by 25-50% in renal or hepatic impairment • duloxetine (Cymbalta) – SNRI profile minimally dose dependent – Class B effectiveness for pdn, conditionally recommended for hip and knee OA, FDA approval for fibromyalgia – Dosing: 60-120 mg/day (caution in hepatic impairment, do not use if CrCL<30 ml/min
  39. 39. Atypical antidepressants • bupropion (Wellbutrin, Zyban) – NE, dopamine reuptake inhibition – Can be activating – Dosing: 150-450 mg/day (consider reduction in renal and hepatic impairment) – Seizure risk in certain patients (↑ risk at ↑ dose) – Potential DDIs not often significant (except MAOIs) • Milnacipran (Savella) – Complex serotonin, NE (α2) activity – Increased bp and heart rate, headaches, significant GI AE – FDA approved for the treatment of fibromyalgia – Dosing: 50-100 mg bid, no adjustments for hepatic impairment, reduce dose after CrCl <30 ml/min
  40. 40. Anticonvulsants Gabapentin • FDA approved for postherpetic neuralgia, conflicting data in migraines, level B recommendation in PDN, short term benefit in radiculopathy • Anticonvulsant: uncertain mechanism, gaba mimetic • Limited intestinal absorption • Usually well tolerated; serious adverse effects rare – dizziness and sedation can occur • No significant drug interactions • Usual dosage range for neuropathic pain up to 3,600 mg/d (tid–qid)* Pregabalin • Gaba mimetic • More reliable oral absorption • Slightly different side effect profile • Doses: 75-300mg BID • Advantages include predictable absorption across the GI tract. Not metabolized or protein- bound. Minimal drug-drug interactions. • Multiple studies demonstrate effective pain relief and decreased sleep interference in PHN and PDN *Not approved by FDA for this use.
  41. 41. Antispasmodics • Consider baclofen or tizanidine or metaxolone • Less ideal options include cyclobenzaprine, carisoprodol and methocarbamol • Baclofen – Dosing • 5 mg orally TID • Can increase by 15 mg/day every 3 days • Max 80 mg/day – ADE: dizziness, N/V, fatigue • Tizanidine – Dosing • 2 mg orally • Can repeat every 6-8 hours • Can increase by 2-4 mg/dose every 1-4 days • Max 36 mg/day – ADE: xerostomia, dizziness, somnolence Others • Acetaminophen • Topicals – Lidocaine – NSAIDS – Capsaicin – Menthol • Over the counter products
  42. 42. Medication summary • Avoid drastic changes in therapy unless for safety • Address worsening pain thru psychotropics as applicable • Utilize topicals • Utilize OTC products • Utilize your local pharmacists to address financial barriers
  43. 43. 48 * This initiative is supported by 48
  44. 44. Thank You! www.weitzmaninstitute.org/coronavirus 49

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