COVID-19 Pandemic and Management of Chronic Pain in Nursing Homes.

To the Editor:

The coronavirus disease (COVID-19) pandemic has disproportionally affected frail, older adults residing in nursing homes (NHs). The pandemic triggered many negative consequences beyond physical health, including social isolation, loneliness, and depression. In the NH setting, many residents suffered physical, emotional, and psychological trauma due to active COVID-19 infection, repeated testing for the virus, and/or lack of visitation by family members and loved ones. This has further complicated chronic pain management in the NH setting.

As chronic pain is influenced by psychological, biological, and social elements, NH residents can experience exacerbation of chronic pain during the COVID-19 pandemic requiring more pain medications, including opioids. Furthermore, residents with COVID-19 may need additional attention to pain management because of physical pain from infection (eg, headaches and myalgias), limited mobility outside of the room because of infection control practices, psychosocial stress, depression, or anxiety. Neurologic complications associated with COVID-19 infection, including peripheral neuralgia or post-stroke pain syndrome, can further exacerbate pain. Javed et al reported a higher number of narcotic prescriptions during the COVID-19 pandemic from March to April 2020 in part because of changes in public policy (eg, temporary waiver in Texas permitting telephone refills).

Management of chronic pain in the NH requires an interdisciplinary approach, which has been particularly important during the pandemic. For instance, nursing staff can assist the medical team with the assessment and monitoring of exacerbation of chronic pain and other somatic symptoms associated with COVID-19 including but not limited to myalgias, arthralgias, referred pain, depression, and insomnia. Additional members of the Interdisciplinary Team have their unique contributions: pharmacists can assist with pharmacologic approaches, the physical therapists can use heat/cold therapy and therapeutic exercises, and psychologists can use cognitive behavioral therapy and psychological counseling.

Nonpharmacologic interventions can alleviate mild pain; pharmacologic agents can be added to nonpharmacologic interventions to control moderate to severe pain. Opioids should be reserved for severe pain. Some opioids can affect the immune response and should be carefully considered as a treatment option for exacerbation of chronic pain during COVID-19 infection. , Opioids can also suppress cough associated with COVID-19 infection. Risks vs benefits of each treatment option should be evaluated by the medical team and discussed with the resident and caregivers prior to its initiation.

During the COVID-19 pandemic, all medications should be assessed for their necessity, including the need for continuation of opioids and other pharmacologic agents for chronic pain. Reducing the number of medications can decrease pill burden among the residents. A decreased number of medication passes also reduces workload burden during staffing shortages arising from the pandemic. , It also helps decrease (1) the number of interactions with COVID-19–positive residents, (2) costs associated with personal protective equipment, and (3) potential exposure to the nursing staff.

Clinicians should be aware that several factors can hinder successful tapering of opioids during the pandemic, including but not limited to.

scarce availability of rehabilitation team for various nonpharmacologic approaches,

lack of support from family and loved ones owing to limited visitation policies, and

the requirement to limit out-of-the facility appointments (eg, pain specialists).

In summary, management of chronic pain should not be delayed in times of COVID-19, but the way we approach treatment has become increasingly complicated and requires an integrated multidisciplinary approach. Although undertreated chronic pain can lead to immune suppression, which can further complicate COVID-19 infection, opiate therapy can also lead to a blunted immune response and decreased cough reflex. Chronic pain medications should not be stopped abruptly, as it can lead to exacerbation of pain and withdrawal symptoms. Person-centered pain management during the pandemic has been particularly challenging; however, it is critical to improving quality of life and function for older adults in nursing homes.