It seems safe to say that COVID-19 has substantially increased stress levels to some degree for all Americans. Many are concerned about being in public settings where they may contract the virus; some have been dealing with COVID-related illnesses, either in themselves or in someone close to them; and those subject to stay-at-home orders have suffered a major disruption to their lives, with many now working from home while also providing child care and homeschooling.
That’s a lot to deal with even if you don’t have a pain condition.
For those with pain, however, the impact of COVID-19 can be even greater. Many people who live with pain have medical conditions that make them more vulnerable to infection and to the effects of that infection. Some treatments for painful conditions may impair immune responses and make people with pain more vulnerable—think about the immune system modifiers used to treat various types of arthritis and GI disorders, chemotherapy for people with cancer, and immunosuppressants for those who have had transplants (more on at-risk patients with rheumatic disease and diabetes/other immune diseases).
There are even some data to suggest that immune function may be impaired because of long-term opioid therapy (see ASRA’s recommendations on opioid regimens during the pandemic ).
This increased vulnerability can drive stress levels through the roof, taking anxiety and depression along with them. How does all of this additional anxiety affect people with pain, and what should we as clinicians recommend to counteract it?
First, we know that increased anxiety and depression are likely to result in increased pain, given the bidirectional relationship between pain and negative thoughts and emotions. We should be sure to educate our patients about this; in fact, it provides a helpful teaching moment for us, as we can call on patients to recognize that their pain likely has increased as their distress has increased.
We can reflect with our patients that it may be more important than ever for them to maximize self-care strategies because they may be unable to receive some of their usual treatments due to prohibitions against non-essential care such as physical therapy and invasive procedures. (Which begs the question: who decides which treatments are essential in this setting? I suspect patients may have different opinions about that than their healthcare providers.)
It is especially important for people with pain to address their stress proactively, because un-remediated stress can lead to several much more adverse consequences. A week ago, I was on a conference call with colleagues and told the group that, among my patients, I have sensed a shift from anxiety to depression, as the stay-at-home period has dragged on.
In the beginning, people were on edge, needing help to calm down and find firm ground under the feet, but as this has gone on, more and more are sinking into despair. I believe this is primarily born of isolation, removal from pleasurable activities, and a sense of doom-and-gloom that is (perhaps not all that inaccurately) portrayed by the media.
This depression can cause major setbacks in patients’ self-care and motivation to cope with pain, not to mention increase the risk that they will seek escape by using alcohol and other substances. On top of that, the strain in relationships that comes from continual exposure for weeks on end can lead to more stress and less support in efforts to get well. For these reasons, and others, meeting this stress head-on is really important.
After educating them, we can then set about enhancing patients’ coping skills by using strategies that have the added benefit of helping them deal with their pain conditions.
Following are a few things I have encouraged my patients to do.
Ordinarily, we live our lives subject to certain structured routines. We get up at a certain time each morning; we get to work or scheduled activities by a certain time; we may have routines while at in those environments, such as standing meetings; we take time to eat lunch; we work some more, then go home; once home, we have dinner, engage in our usual evening activities, and get to bed in time to get some sleep. All that structure provides us with a certain rhythm makes it unnecessary for us to make conscious decisions about what to do next and then prevents us from having unstructured time that can devolve into rumination about our problems.
Suddenly being deprived of those routines due to COVID-19 can be much more stressful than one might think, and it can create the kind of bind experienced by our disabled patients, for whom every day can be like this. I tell my patients that having a schedule turn into an amoeba is a toxic event, and I encourage them to develop a self-imposed routine if one is not imposed by others. Having a plan, and knowing what comes next, can be a significant stress reliever.
I am always struck when I see reviews by the Agency for Healthcare Research and Quality (AHRQ) revews of non-invasive, non-pharmacological treatments for pain: the single most effective such treatment, across multiple types of pain, is exercise.
We have to work with patients to help them develop effective pacing strategies and to figure out which kinds of exercise will work for them. I view exercise as vital with respect to coping with stress and self-managing pain. In the context of COVID-19, we may be challenged by the fact that our patients cannot go to their gyms or PT clinics, but there are ample opportunities for exercise apart from the gym. We are fortunate that the pandemic has hit during springtime because this makes it more feasible and pleasurable to go for a walk outside—my #1 recommendation for my patients.
Arm curls and other exercises with canned vegetables substituting for dumbbells may be appropriate. Calisthenics and stretching are options. The possibilities are limited only by our creativity.
Add or Increase Use of Relaxation/Meditation Exercises, Tai Chi, Yoga, and Similar Activities
Dozens of websites offer free or low-cost relaxation and meditation exercises, some of which are specifically oriented toward pain management (PPM has some relaxation technique demos for patients as well). YouTube has scores of videos for people who want to try tai chi and yoga at home, including some that are modified to enable those with limited physical functioning to do the exercises.
Building time into the daily routine to clear one’s mind, while supporting the chi and possibly while also exercising one’s body is a terrific stressbuster and pain reliever. Those AHRQ reviews that are so positive about exercise also find evidence for the efficacy of these interventions in relieving the most common types of chronic pain. What better time to learn them than when you are staying at home anyway?
I advise my patients to have a stack of books they have always wanted to read, but never had the time for, in a visible location of their home. I urge them to take up container gardening or another activity they perhaps used to enjoy, but have not touched for a few years.
Building an old or new hobby into the daily routine may be more possible now with less scheduled activities, or less commuting. If a patient has children at home, I have encouraged them to introduce them to some board games or card games that let the whole family interact. Activities like these serve the dual purpose of distracting people with pain from their pain and substituting positive experiences for the negatives resulting from filling that time with pain-focused thoughts and emotions.
Share with your patients this PPM demo on using creativity to cope with pain.
Recognize What Is, and Is Not, Under Your Control, and Act Accordingly
Once again, the famous Serenity Prayer comes into play. There is much about this pandemic that is not under our control. If we spend our time obsessing about the actions of others and timelines for returning to whatever our “new normal” might be, we are just going to make ourselves more anxious and depressed. We need to focus on what we can do and then do those things well.
We can ensure that we wear masks when we venture out on necessary errands, that we maintain recommended social distancing, that we minimize risk by maximizing the use of online shopping and home delivery or curbside pickup, that we wash our hands and keep them away from our faces when they might be contaminated. Doing those sorts of things will feed our need for an internal locus of control while mitigating our risk of infection and reducing stress.
I share with my patients that the key to coping with COVID-19 related stress is to look at our circumstances with three thoughts in mind:
(You might also refer to patents to Dr. Michael’s Clarks’ tips for heightened anxiety.)
Using these questions to assess the changes we all are facing will lead to healthy coping strategies that are limited only by our creativity and the boundaries imposed because of the virus. Overall, these healthy coping strategies, if sustained after the pandemic wanes, can serve people with pain extraordinarily well in the long run, helping them live lives that are much less limited by their pain experiences.