COVID Long Haulers Prescribed Opioids at Higher Rates
August 23, 2021
With multisystem symptoms and no clear treatment path, post COVID syndrome continues to challenge clinicians. Could the resulting prescribing exacerbate the existing opioid crisis?By Jennifer Lutz
with Lillie Rosenthal, DO
Opioid-related overdoses have drastically risen during the COVID-19 pandemic, in some moments outpacing deaths caused by the virus itself.1 And while these illnesses ravage communities, another chronic concern looms: a growing number of COVID survivors are being identified as long haulers, and those suffering from this post COVID syndrome are experiencing a constellation of symptoms.2
To further complicate matters, researchers recently found that that COVID long haulers are being prescribed opioids at higher rates than those without a previous COVID-19 diagnosis.3 The unknown outcomes of post COVID syndrome and the increased propensity of providers to prescribe opioids to these individuals could push the opioid crisis to the brink.
Post COVID Syndrome, Pain, and Opioids
The new research, published in Nature, used VHA electronic databases to identify 6-month outcomes after incidence of COVID-19 infection. The study is one of the largest to date and incorporated 379 diagnostic categories, 380 medication categories, and laboratory abnormalities from 62 different lab tests. Concerning medication, the researchers found an increase in the prescription of both opioids and benzodiazepines. Opioids were prescribed to COVID long haulers at an extra 9 times per 1,000 patients. Benzodiazepines were prescribed an extra 22 times per 1,000 patients. It is also well known that co-prescribing of benzodiazepines and opioids can present risks to the patient and that drug monitoring must be part of the treatment plan.
This prescribing-up trend contrasts with nationwide decreases in opioid prescriptions among the general patient population4 (as well as decreased benzodiazepine prescribing). “Providers really don’t know what long-haulers syndrome is, what causes it, or how to treat it. Unfortunately, when we don’t know, we generally do the most because we’re at a loss. We tend to think more is better, but often, it isn’t,” says Lillie Rosenthal, DO, a board-certified physical medicine and rehabilitation physicianwho has been treating people with chronic pain and post COVID syndrome.
Treatment options are often best assigned to a specific diagnosis but post COVID syndrome encompasses a broad range of symptoms, including but not limited to: shortness of breath, coughing, brain fog, joint pain, body aches, headache, sleep difficulties, anxiety, depression, chest pain, and gastrointestinal problems.5,6 Without available resources or directives, clinicians may more readily resort to higher risk treatments, such as opioids and benzodiazepines. “Doctors are trying to be compassionate but potentially doing harm,” says Dr. Rosenthal.
Such compassion could soon lead to a spike in opioid use disorder (OUD). When looking at population size, an April 2021 analysis by the UK Office of National Statistics (ONS) reported that 13.7% of patients who tested positive for the novel coronavirus reported at least one symptom of post-COVID syndrome 12-weeks after initial infection.7 An early prevalence analysis in the US, published by researchers at Columbia University Medical Center in New York, reported that among those people who had been hospitalized for COVID-19, between32.6% and 87.4% of themreported at least one symptom persisting after several months.2And while the VHA data review noted above had its limitations (including a mostly male population, despite more women suffering as long haulers), it highlights an important issue. It is hoped that this new information on opioid and benzodiazepine prescribing will alert providers before the problem outpaces the solution.
Treating Chronic Pain in COVID Long Haulers and Limiting Opioid Prescriptions
When it comes to pain, individuals with post COVID symptoms face a particular challenge. Not only can the cause of pain vary based on the individual response to COVID and what systems the virus affected but intensive care is shown to increase pain incidence after infection.8 Additionally, comorbidities (which are more common in COVID survivors) can further complicate pain.8
Clinicians who are not pain specialists should be aware that the chronification of pain involves neurological, hormonal, and neurochemical changes in both the central and peripheral nervous systems. In other words, the experience of COVID long haulers may not be much different than that of other people living with chronic pain.
“Let’s take the COVID factor out for a moment and treat the pain in a similar way to other chronic pain,” suggests Dr. Rosenthal. “We need to get more granular as to where exactly the pain is coming from.” Long haulers may share a common precipitating (or worsening) factor, but pain management should involve comprehensive treatment in response to the patient profile. “We need to stick with basics and start with a comprehensive nonpharmacological approach,” she notes.
When treating chronic pain in general or due to post COVID infection, it’s important for clinicians to approach the problem systematically.9 For instance, consider:
- Where is the pain coming from? Is it headache pain, joint pain, specific muscle pain, back pain, neurogenic pain, or all-over muscle pain, such as in fibromyalgia?
- How does the pain feel? Different pain sensations should be treated differently. Is the pain aching, shooting, burning, squeezing, stiffness, stinging, or throbbing?
- How frequent is the pain? Is the pain persistent or does it come and go? Do certain activities increase or alleviate pain?
- What treatments/medications has the patient tried in the past? Understanding what treatments have and have not helped before, can point providers in the right direction – including where to refer if a specialist is needed.
Opioids can be like “nuclear arms and should be used thoughtfully with a consideration of the side effects,” suggests Dr. Rosenthal. In the case of chronic pain, a biopsychosocial approach continues to show efficacy across a broad patient population.10 Adds Dr. Rosenthal, “It’s not just a COVID patient in front of you, it’s a person and this is an opportunity to optimize their health. We can be as specific as possible to the type of pain, and still be multifactorial.”
While post COVID syndrome is new and remains without formal diagnostic criteria, chronic pain is not – and the lessons learned on treating pain, when it comes to opioids for instance, are not, says Dr. Rosenthal. When faced with such unchartered waters, focusing on what is known may just separate compassionate care from compassionate harm.View SourcesLast updated on: August 23, 2021