Clinical Challenges and Considerations in Management of Chronic Pain Patients During a COVID-19 Pandemic.

Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions. Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.

Metabolic and endocrinal effects of epidural glucocorticoid injections.

INTRODUCTION: Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS: 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS: Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION: Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.

Pregabalin and Radicular Pain Study (PARPS) for Cervical Spondylosis in a Multiracial Asian Population.

BACKGROUND: Pain from cervical spondylosis (CS) may result from degenerative spinal canal stenosis (cervical spondylotic myelopathy (CSM)) or lateral recesses compromise, leading to nerve root compression (cervical spondylotic radiculopathy (CSR)). Pregabalin was shown to be effective in randomized, placebo-controlled trials for post-herpetic neuralgia and diabetic neuropathy. We evaluate its efficacy in CS with underlying CSR or CSM in a prospective study comprising Asian patients for the first time. METHODS: Patients with CS and CSR or CSM (clinical, MRI, or electrophysiological evidence) presenting with neuropathic pain were recruited. We excluded patients with diabetes, underlying neurological disease or who were previously on antiepileptics. Pregabalin 75 mg bd was administered for 4 weeks, after which dosage was increased to 150 mg bd for another 4 weeks if the visual analog scale (VAS) was not reduced by 50%. In addition, we monitored the short form McGill pain questionnaire (SFMPQ) at baseline, 4 weeks and 8 weeks. Mood changes were monitored using the hospital anxiety and depression score (HADS) with an identical timeline. RESULTS: We recruited 50 patients, of which 23 completed the trial. Of the 27 who withdrew, 12 (44%) were for somnolence. Thirteen patients' (54%) dosages remained at 75 mg and 11 patients' (46%) dosages were escalated to 150 mg bd. There were significantly reducing trends from baseline for VAS (ANOVA, F(1, 21) = 25.4, P < 0.0005), SFMPQ (sensory) (F(1, 22) = 11.2, P = 0.003), and SFMPQ (affective) (F(1, 21) = 10.9, P = 0.008). For VAS, there was significant reduction at 4 weeks (P = 0.001) and 8 weeks (P < 0.0005) compared to baseline. For SFMPQ (sensory), there was significant reduction at 4 weeks (P = 0.01) and 8 weeks (P = 0.006) in scores compared to baselines. For SFMPQ (affective), there was significant reduction at 4 weeks (P = 0.04) and 8 weeks (P = 0.008) in scores compared to baseline. No significant anxiety (F(1, 4) = 1.3, P = 0.32) or depression (F(1, 4) = 0.06, P = 0.82) changes were observed in the HADS. CONCLUSION: Pregabalin is efficacious in alleviation of pain symptoms related to CSR as a first-line single agent, evaluated by quantitative severity and other experiential scales. No significant mood changes reported in other studies were demonstrated. Somnolence was commonest adverse effect leading to high dropout rates, occurring early even at the lowest dose. The findings suggest the need for further studies of efficacy at lower dosages, particularly in the Asian population.

Use of strong opioids for chronic non-cancer pain: a retrospective analysis at a pain centre in Singapore.

INTRODUCTION: The use of opioids in chronic non-cancer pain (CNCP) is controversial, as it presents both benefits and risks. There is currently no available data on the incidence, prescription pattern, functional outcomes and adverse effects of opioids in patients with CNCP in Singapore. This study aimed to address the aforementioned deficit. METHODS: All records of patients who were prescribed strong opioids (for > 3 months per year) for the management of CNCP over a two-year period were retrospectively analysed. Factors including type of opioid, indications for opioid prescription, uncontrolled side effects, functional status, coexisting psychological issues and suspicion of aberrant drug-seeking behaviour were studied. RESULTS: Out of the 1,389 new patients who visited the centre, 42 (3.0%) with CNCP received strong opioids for more than three months a year. The most commonly prescribed opioid was methadone (42.9%). The principal diagnosis for opioid prescription was spinal pain (38.1%). Ten patients had severe side effects. 15 patients saw improvement in activities of daily living scores. Although ten patients returned to work, one stopped following the commencement of opioids. Aberrancy was seen in 5 (11.9%) patients, while 19 (45.2%) had psychological issues and 10 (23.8%) required psychiatric co-management. CONCLUSION: Opioids are not a panacea for chronic pain. Therefore, functional outcomes should be considered more important end points than mere reductions in pain scores. A multidisciplinary team approach is essential for the effective management of patients with CNCP who are on opioids.