COVID-19 and the Opioid Epidemic: Two Public Health Emergencies That Intersect With Chronic Pain

Abstract

The COVID-19 pandemic has affected the entire world and catapulted the United States into one of the deepest recessions in history. While this pandemic rages, the opioid crisis worsens. During this period, the pandemic has resulted in the decimation of most conventional medical services, including those of chronic pain management, with the exception of virtual care and telehealth. Many chronic pain patients have been impacted in numerous ways, with increases in cardiovascular disease, mental health problems, cognitive dysfunction, and early death. The epidemic has also resulted in severe economic and physiological consequences for providers. Drug deaths in America, which fell for the first time in 25 years in 2018, rose to record numbers in 2019 and are continuing to climb, worsened by the coronavirus pandemic. The opioid epidemic was already resurfacing with a 5% increase in overall deaths from 2018; however, the preliminary data show that prescription opioid deaths continued to decline, while at the same time deaths due to fentanyl, methamphetamine, and cocaine climbed, with some reductions in heroin deaths. The health tracker data also showed that along with an almost 88% decline in elective surgeries, pain-related prescriptions declined 15.1%. Despite increases in telehealth, outpatient services declined and only began returning towards normal at an extremely slow pace, accompanied by reduced productivity and increased practice costs. This review, therefore, emphasizes the devastating consequences of concurrent epidemics on chronic pain management and the need to develop best practice efforts to preserve access to treatment for chronic pain.

Coexisting Substance Use Disorder and Chronic Pain During COVID-19

“…Factors common in chronic pain populations are older age, lower socioeconomic status, smoking status, co-occurring chronic diseases, residence in nursing facilities, and limited access to care (Manchikanti et al, 2021). These factors overlap with the risks associated with COVID-19 infection and poorer outcomes, and pain morbidity can be amplified during COVID-19 infections (Eccleston et al, 2020;Mun et al, 2021).…”

“…Acute pain management service teams have been diverted into the intensive care units, and available chronic pain services have decreased (Alonso-Matielo et al, 2021). During the peak of pandemic, there were medication shortages and a scarcity of resources such as ventilators or ECMO, with only emergency services available (Eccleston et al, 2020;Manchikanti et al, 2021). Patients were instructed to either stay away from health care or to socially distance (Eccleston et al, 2020), and if health care appointments were made, limitations of public transportation created barriers to getting to clinical setting (Frost, 2020).…”

“…Patients were instructed to either stay away from health care or to socially distance (Eccleston et al, 2020), and if health care appointments were made, limitations of public transportation created barriers to getting to clinical setting (Frost, 2020). Additionally, during lockdown, there were only emergency services available in many healthcare systems, creating near impossible circumstances for managing chronic pain by performing simple procedures, such as epidural injections, facet joint injections, and radiofrequency neurotomy (Manchikanti et al, 2021). In their survey early in the pandemic, Mun and colleagues (2021) found that most persons with chronic pain either postponed or canceled pain therapy appointments, often with no future session scheduled.…”

Kratom Use Within the Context of the Evolving Opioid Crisis and the COVID-19 Pandemic in the United States

“…Various investigators have noted that the increased interest in kratom seemed to coincide with several aspects of the evolving opioid crisis in the United States (Boyer et al, 2008;Prozialeck et al, 2012;Prozialeck, 2016;Bestha, 2018;Coe et al, 2019;Prozialeck et al, 2019) and that recent restrictions on access to prescription opioids for pain management may have further increased demand for kratom (Prozialeck, 2016;Prozialeck et al, 2019). With the emergence of COVID-19 in 2019, and the evolution of the COVID-19 pandemic in 2020, many patients may have faced even further reductions in access to prescription opioids, which could have contributed to an increase in the use of illicit "street" opioids such as heroin, fentanyl and new fentanyl analogs (Manchikanti et al, 2021;Nguyen and Buxton, 2021). It seems likely that this increase in the use of street opioids and the concomitant problems of opioid dependence may have further increased demand for kratom.…”

“…The lack of access to medicallyassisted care for patients with opioid use disorder during the COVID-19 pandemic has been particularly severe (Jacka et al, 2021;Joudrey et al, 2021). These factors have probably resulted in a well-documented surge in the abuse of street opioids and their many attendant problems (CDC, 2021;Manchikanti et al, 2021). At the same time, it would be expected that the demand for kratom products would increase concomitantly (Singh et al, 2020).…”