COVID-19: Pain Medicine service guide (Devon)

Exacerbation of persistent pain with COVID-19.

• Some types of persistent pain (including neck pain, back pain, orofacial pain, headaches and cervical/ lumbar radicular pain like sciatica and brachialgia) may be exacerbated by a continuous dry cough associated with COVID-19. Management of the underlying cough and associated symptoms according to national guidelines are advised rather than just the symptomatic pain relief

• Fibromyalgia and other persistent pain conditions may experience exacerbation of their existing pain symptoms and should be managed similarly to other COVID-19 cases. Stress and social restriction may also be exacerbating factors. Management should be supportive. Analgesic requirements may increase due to pre-existing painful conditions and long-term analgesic use. Escalation should be done with caution, for a limited period. Strong opiates should be avoided

• Corticosteroids and interventions - Corticosteroids are often used in pain injections and they may reduce immune function. The effect of corticosteroids on the immune system in people with COVID-19 is unknown, but concerns have been raised regarding reduced survival benefit and possible harms, including avascular necrosis, psychosis, diabetes, and delayed viral clearance

• Elective pain procedures In order to minimise the number of people attending hospitals at present, routine interventions have stopped being performed. This is to free up capacity, both in terms of healthcare professional time and beds, and to better address the urgent requirement to treat patients with COVID-19 related symptoms. Most of the doctors working in the Pain Clinics are Anaesthetists and as such their skills and expertise are required to support colleagues in intensive care units, acute medical wards and in theatres. Hence, it is highly likely there will be unavoidable delays in the treatment of non-urgent patients with persistent pain

Urgent referrals for patients will be reviewed for triage for appropriate review or advice, and include:

• Trigeminal Neuralgia (TGN)
• Active Cancer-related pain
• Complex Regional Pain Syndrome (CRPS) (early, within 12 months)
• Spinal Cord Stimulators or Intrathecal Pumps in-situ, not implanted elsewhere (Acute emergencies such as suspected Cauda Equina Syndrome or meningitis etc should be referred via the appropriate acute on-call neurological service as usual)

Risk factors for face-to-face review will be determined on a case by case basis.

All new routine referrals will be clinically triaged and will either be added to a waiting list or, if appropriate, A&G will be given.

Please ensure that a practice-based system is in place to check daily for returning referrals with A&G.

Prior to making a routine referral, please ensure that any appropriate Policy or CRG has been reviewed and that all the suggested investigations and management options have been considered.

Existing new and follow-up routine appointments have been cancelled and changed to telephone / video consultation where appropriate.

Urgent advice for patients will be reviewed for triage for appropriate review or advice, and include:

• Trigeminal Neuralgia (TGN)
• Active Cancer-related pain
• Complex Regional Pain Syndrome (CRPS) (early, within 12 months)
• Spinal Cord Stimulators or Intrathecal Pumps in-situ, not implanted elsewhere (Acute emergencies such as suspected Cauda Equina Syndrome or meningitis etc should be referred via the appropriate acute on-call neurological service as usual)

Risk factors for face-to-face review will be determined on a case by case basis.

All other requests will be triaged as usual. Many will be deferred if considered able to wait several months.

Please write to the Pain Clinic as for routine referrals. Many will be deferred if considered able to wait several months.

Patients on long-term opioids should be maintained on existing treatment to prevent withdrawal and subsequent hospital admission.

Chronic opioids may cause immune suppression in some individuals. Dose escalation should be avoided if possible, especially in at-risk groups – treatment should be directed to underlying exacerbations such as viral illness or stress.

Absorption of transdermal preparations can increase unpredictably during fever risking respiratory depression and patients should therefore be monitored carefully for increased side effects. Patients who are prescribed transdermal opioids who become increasingly drowsy or somnolent may require the patch strength to be reduced, or alternatively replaced with short-acting opioid formulations, until the person is feeling better and the fever lowered.

Opioids are also cough-suppressants and this may mask or delay the initial presenting symptoms of COVID-19 infection. Tiredness, nausea and gastrointestinal symptoms that are associated with COVID-19 infection could be worsened by prescribed opioids and other medicines for neuropathic pain.

North Devon District Hospital Contact Details

We will do our best to reply to all enquiries in a prompt manner Monday to Friday however please be aware that there may be a delay in the time it takes to respond.

Monday – Friday telephone us on 01271 337820 or email: ndht.pain@nhs.net

Royal Devon & Exeter Contact details

Telephone us on 01392 411611 and ask for the pain team

Torbay & South Devon Foundation Trust Contact details

Telephone us on 01803 654590 or 01803 654251

Patient Information

Links to some useful videos on self-management strategies:

• Body reprogramming guide
• HunterBrainman
• MyLivewell with Pain
• People in Pain Network
• The Pain Toolkit resources for patients
• MyHealth-Devon: Pain Management

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Publication Date: May 2020