Steroid injections, nerve blocks, and stimulation devices are often part of an integrated care plan for those living with chronic pain conditions. These procedures and devices can help to manage pain for weeks or months at a time, and for many people, they provide welcome alternatives to medication-based treatments.
However, as a result of the coronavirus pandemic, many of these procedures have been deemed “non-essential” and put on hold. Certain types of steroid injections may weaken the immune system, raising additional concerns about the use of these treatments during the COVID-19 crisis. In the meantime, patients are seeking other options for pain relief and remain eager to know when they may be able to resume their procedure regimens.
PPM spoke with Jay Joshi, MD, CEO/Medical Director of the National Pain Centers in Illinois and a member of our editorial advisory board, and Corey Hunter, MD, executive director of the Ainsworth Institute of Pain Management in New York, to get some answers.
Dr. Joshi: Patients rely on interventional pain management procedures just as much as other pain management modalities, such as medications and therapy. In some cases, they may rely on interventions more than the other options. For instance, in my practice, there are many patients living with ongoing pain who only need a procedure to gain significant relief, thus reducing or negating the need for other treatments or further reliance on the healthcare system.
However, pain management procedures across the country have reduced dramatically as a result of the coronavirus pandemic; in some cases, they have ceased completely. The reasons behind these restrictions include state regulations, patients’ fear of entering an office, surgery center, or hospital; medical staffing issues; shortages or personal protective equipment (eg, masks); social distancing measures; and even physicians fear of contracting the virus from patients.
As a result, many patients are experiencing increasing pain and decreased function, and in some cases, may be requesting more pain medication as a result. In addition, those patients unable to attend physical therapy or go to their gym have not been exercising as much. Further, anxiety and depression has increased globally in a drastic nature – impacting this already vulnerable population even more so.
Dr. Hunter: In New York state, where I practice, elective procedures are beginning to resume in a staggered fashion (as of mid-May 2020). The hospitals that are opening are being told to give priority to higher complexity cases first and work done the line. Pain falls in a gray zone since and these patients will likely need to wait a few weeks once the backlog of the more complex cases has been cleared first.
Dr. Joshi: Steroids can reduce the immune system's ability to fight an infection - this is well established - however, the details matter. Oral, high dose steroids are quite different systemically compared to localized low dose steroids. That said, there is always an increased risk by exposure to the public, having any procedure, and having any steroid.
As with every other decision in a patient’s health plan, there has to be a risk/benefit discussion. One argument is that there may be greater risk to not treating a patient, who may then have decreased function, decreased health, increased stress, and turn to more medication. Each case is different and decisions need to be made in consultation between the patient and provider.
Dr. Hunter: Corticosteroids have a number of side effects, even when given appropriately: elevating blood pressure in those with hypertension, elevating blood sugar in those with diabetes, and increasing white blood cell count, most notably neutrophils. The reason we give them in pain management is due to their ability to decrease inflammation – and herein lies the problem – inflammation IS the immune system. Inflammation is the body’s nature immune response to a pathogen. Corticosteroids inhibit the body’s natural ability to create inflammation (for better or for worse) which in turn affects its ability to mount an immune response.
However, as Dr. Joshi notes, the amount of corticosteroid needed to sufficiently disrupt the immune system is typically more than what is given in most pain procedures. More importantly, the corticosteroids given for injections is just a single dose which is much less likely to have a significant effect on the immune system as opposed to a consistent regimen taken daily.
Dr. Joshi: Ketamine infusions have been very important during this global pandemic. They are not steroid-based and, thus, do not reduce the immune system’s ability to fight infection. In fact, with lower sympathetic response and lower stress levels, the patient's immune system may actually be in a better position to fight an infection.
See also, One Patient's Journey with Ketamine Infusions(CRPS)
Dr. Hunter: Some offices, like mine, are remaining open for the patients that are in true need. We are trying to triage our patients and delay procedures for high-risk patients as long as possible, whenever possible. Opioids, in addition to all of the other potential side effects, may not be a safe option right now as they have been shown to inhibit the immune system (see more below).
We are trying to use NSAIDs and other non-opioid pain relievers for those patients who cannot risk going outside. For those that can, or in cases where the pain is just too much to handle, we are offering injections and other evidence-based treatments.
Editor’s Note Regarding Opioid Therapy During COVID-19: The American Society of Regional Anesthesia and Pain Medicine (ASRA) has released recommendations for pain management during the pandemic. In general, they note that opioids may cause immune suppression – however, the type of opioid matters. For example, while buprenorphine has been shown to have less effect on animals’ immune systems,it is not clear if this is always the case in humans. Some research has suggested that there may be beneficial immune effects by opioids. Regarding individuals who take opioids and contract COVID-19, it is possible they may be more susceptible to respiratory depression; in addition, the absorption of fentanyl during transdermal administration (fentanyl patch) may increase with fever. The bottom line:
As with any medication, always check with your doctor before changing your regimen and avoid stopping any medication abruptly, as it can exacerbate systemic disease.
Dr. Joshi: This is an opportune time to focus on the basics and take control and responsibility for your own health and well-being. That includes Diet, Exercise, Nutrition, and Stress Relief (or what I call DENS). There are countless free videos on healthy cooking, exercise and stretching, mediation and mindfulness, and more. I encourage patients to start or continue focusing on staying as healthy as possible at home.
For those patients with complex and severe painful issues, whereby home remedies simply are not enough or appropriate, I encourage using telemedicine to consult with your physician about potential solutions and strategies (eg, breathing exercises, home care devices).