Note: As the situation continues to rapidly evolve, the following represents current guidance based on the best available evidence and expert opinion. This document was last updated on March 27, 2020.
Novel coronovirus-2019 (initially referred as 2019-nCoV) is a human b-coronavirus that has been renamed as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). From the observation of the initial 1099 patients with confirmed COVID-19 infection, 6.1% patients had severe infection (ICU admission, invasive mechanical ventilated, or death). Common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). The median incubation period was 4 days (interquartile range, 2 to 7).1 Because of the highly infectious nature of the disease, the risk of transmission is high. The mortality rate seems to be higher than previous estimates noted from China; mortality rates would be 5.6% (95% CI 5.4–5.8) for China and 15.2% (95% CI 12.5–17.9) outside of China.2 These numbers are likely to change over time as COVID-19 testing increases, especially in asymptomatic patients, leading to more positive cases and a drop in fatality rates. Mortality and morbidity can be caused by acute respiratory distress syndrome, arrhythmia, shock, acute kidney injury, acute cardiac injury, liver dysfunction, and secondary infection.1,3
Any elective, in-person patient visits or meetings have to be suspended.
No elective pain procedures, except specific semi-urgent procedures, should be performed.
Intrathecal pump (ITP) refills and malfunction
Neurostimulator infection and malfunction
Significant immune changes occur in patients with COVID-19 disease.3,6 Most patients have normal or decreased white blood cell counts and lymphocytopenia. The potential for thrombocytopenia exists in severe cases.1,14 Opioids are recognized as causing immune suppression, and individual opioids differ in their potential.8,9 Although some have observed buprenorphine to have less effect on animals’ immune systems,9,15 it is not clear if this is consistently observed in humans.8 Some suggest that there may be beneficial immune effects by opioids as well.16 Patients with COVID-19 who are receiving opioids can be more susceptible to respiratory depression, and the absorption of fentanyl during transdermal administration (fentanyl patch) may increase with fever.
Changes to opioid prescriptions should be made only after careful evaluation of ongoing treatment, which ideally includes an in-person history and physical exam. However, considering the nature of the current COVID-19 health emergency, it is appropriate to make changes and/or continue prescriptions using telemedicine.
In the United States, the Secretary of Health and Human Services declared a public health emergency on January 31, 2020, under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D).17 Based on this edict, any telemedicine allowance under section 802(54)(D) applies to all schedule II-V controlled substances in all areas of the United States. Accordingly, the Drug Enforcement Administration (DEA) notes that DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided the following conditions are met:18
Although a single report suggested that the use of non-steroidal anti-inflammatory drugs may increase the severity of COVID-19 disease19, most health authorities note that the evidence is not definitive.20-22 However, anti-inflammatory drugs may mask early symptoms of the disease such as fever and myalgias.
Any patient who has been determined to need a procedure or an in-person meeting must be screened for the possibility of COVID-19. A history of travel to high-risk areas or countries and the presence of symptoms increase the likelihood of infection, but patients who self-quarantine may become infected and asymptomatic transmission is also possible. Once the community spread of COVID-19 becomes significant, all cases may be presumed to be COVID-19 positive. Local guidelines should be followed when making decisions. Detailed information for protection of patients and health care providers is provided in various websites, including the Centers for Disease Control (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html) and the European Centre for Disease Prevention and Control (https://www.ecdc.europa.eu/en/all-topics-z/coronavirus/threats-and-outbreaks/covid-19/preparedness-and-response-covid-19).
In a COVID-19 negative or a low-risk patient
In a COVID-19 positive or a high-risk patient
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