Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel.

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Decreased tibial nerve movement in patients with failed back surgery syndrome and persistent leg pain.

PURPOSE: To measure and compare the total and normalised tibial nerve movements during forward bending in patients with and without failed back surgery syndrome (FBSS) and persistent leg pain following anatomically successful lumbar decompression surgery and demonstrated no psychological stress. Nerve pathomechanics may contribute to FBSS with persistent leg pain following anatomically successful lumbar decompression surgery. METHODS: Tibial nerve movement during forward bending was measured in two groups of patients following anatomically successful lumbar decompression surgery. FBSS group (N = 37) consisted of patients with persistent leg pain following lumbar surgery, and non-FBSS (N = 37) were patients with no remaining leg pain following lumbar surgery. Total and normalised tibial nerve movement at the popliteal fossa was measured by a previously validated ultrasound imaging technique and compared between the two groups, and also between the painful and non-painful leg within the FBSS group. RESULTS: Both the mean total and normalised tibial nerve movement were significantly decreased in the FBSS group in both legs when compared to the non-FBSS group (P < 0.05). The total and normalised tibial nerve movements were also more restricted in the painful leg (P < 0.05) when compared to the non-painful side within the FBSS group. CONCLUSION: This was the first study to quantify the decreased total and normalised tibial nerve mobility in FBSS patients with persistent leg pain when compared with non-FBSS patients following anatomically successful lumbar decompression surgery. Further research could investigate the efficacy of intervention, such as nerve mobilisation in this particular group of patients with failed back surgery syndrome and limited nerve mobility. These slides can be retrieved under Electronic Supplementary Material.

Eliciting health state utilities from the general public for severe chronic pain.

OBJECTIVE: There is an absence of data on public preferences for health states (HSs) associated with severe chronic pain. The aim of this study was to develop accurate HS descriptions for severe chronic pain requiring intrathecal (IT) therapy and to derive utility weights that describe the health-related quality of life (HRQL) impact of chronic pain associated with malignant (MP) and non-malignant (NMP) aetiologies. RESEARCH DESIGN AND METHOD: Eight visual analogue scale pain index (VAS-PI) HSs were defined using ranges 0-40, 41-60, 61-80 and 81-100 applied to both MP and NMP. Additionally, eight HSs representing common adverse events associated with IT therapy were identified. The content and description of the HSs were ascertained by interviews with five United Kingdom clinical experts. In total, 16 HSs were compiled. These HS descriptions and HS questionnaires were administered to 102 members of the public, utilising a time trade off (TTO) approach to estimate utilities for the HSs. RESULTS: Participants generally were well matched to the general public in England and Wales, with some differences in mean age, race and education. A substantial decline in utility was observed with more severe VAS-PI values. The mean TTO utility values also decreased from mild pain to severe pain. Participants were able to differentiate between the side effects. CONCLUSION: The study shows a clear decrement in utility moving from different severity levels of severe chronic pain.

Does intrathecal fentanyl produce acute cross-tolerance to i.v. morphine?

We have examined the hypothesis that intrathecal fentanyl at operation can increase postoperative i.v. morphine requirements. We studied 60 patients undergoing Caesarean section. All received intrathecal 0.5% plain bupivacaine 2 ml combined with either fentanyl 0.5 ml (25 micrograms) (group F) (n = 30) or normal saline 0.5 ml (group S) (n = 30). In addition, 10 ml of an extradural solution (fentanyl 1 ml (50 micrograms) combined with 0.5% bupivacaine 9 ml) was administered after delivery. Extradural solution was only given before delivery if the intrathecal injection failed to produce a block above T6 or the patient required further analgesia. Postoperative analgesia was provided with i.v. morphine patient-controlled analgesia. At operation, intrathecal fentanyl reduced the need to administer extradural solution before delivery, increased the anaesthetist's satisfaction with analgesia and reduced nausea, but increased pruritus. Up to 6 h after delivery there was no difference in postoperative morphine requirements or pain scores. Between 6 h and 23 h there was a 63% increase in morphine requirements in group F. We consider the most likely explanation for this finding to be that intrathecal fentanyl induced acute spinal opioid tolerance.

Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after Caesarean section.

In this randomized, double-blind study of 60 patients, we have assessed the analgesic efficacy of extradural bupivacaine and extradural fentanyl, either alone or in combination, after Caesarean section. Patients received 0.1% bupivacaine (group B), fentanyl 4 micrograms ml-1 (group F) or 0.05% bupivacaine combined with fentanyl 2 micrograms ml-1 (group BF) by patient-controlled extradural analgesia (PCEA). Adding fentanyl to bupivacaine reduced the dose of bupivacaine by up to 68%, improved analgesia at rest and decreased PCEA use. Motor and sensory block were decreased, but there was more pruritus. Overall patient satisfaction was increased. Adding bupivacaine to fentanyl reduced the dose of fentanyl by up to 57% without altering pain scores or PCEA use. Sensory block increased but pruritus did not decrease. Bupivacaine 0.05% produced clinically significant leg weakness in three patients. Overall patient satisfaction was not altered. There was a significant additive analgesic effect between 0.05% bupivacaine and fentanyl but no clinical benefit was demonstrated from using the combination compared with fentanyl alone for this group of postoperative patients.