APS Pain in Childhood SIG: Chronic Pain Management in times of the Coronavirus

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These are interesting and challenging times. But as with all challenging times, they are

20181217_Photo_Arno_Ebner

Dr Arno Ebner

times and times will pass and humans will without a doubt carry on; they always do. I find most people around me, including my patients are relaxed about the situation and home schooling and teaching your child became an interesting experience for many parents.

When COVID-19 emerged and social distancing measures kicked in, I was wondering if the way of talking about and dealing with the Coronavirus situation needs to be different for children and adolescents with chronic pain conditions compared to healthy children or children with other chronic health conditions.

But I could not find any more specific suggestions for children and adolescents with pain beside the usual recommendations of social distancing and self-care while isolation measures are in place. Now after a couple of weeks, I find this true at least from my personal experience.

Like for all patients with a chronic health problem, the lack of access to family and friends, school, and after school activities like a walk at the beach, sports and social clubs, and the limited face to face visits to their professional health team is probably the most challenging aspect.

Hence, here I just want to give you a real good resource for families, parents, carers, children and adolescents about the Coronavirus, what one can do and how to talk to children and relieve all the anxiety and stress.

One of the best general resources is this website, it is run by Australian paediatricians and is continuously updated providing many resources for adults, teenagers, and young children, including for children with special needs: https://paediatrics.online/COVID-19

Our patients with chronic pain have luckily not an increased risk for coronavirus complications.

There are some confusion and concerns about the use of non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen after a tweet from the French Health Minister Olivier Veran, a Neurologist. He warned these drugs could increase the risk for a more severe course of a coronavirus infection, as they dampen the immune system.

Another hypothesis is that NSAIDs could increase angiotensin-converting enzyme (ACE) expression and as the Coronavirus binds to the human target cells via ACE, this may increase the risk for more severe COVID-19 disease. ACE-inhibitors and angiotensin-receptor blockers (ARB) are naturally even more suspicious here.

So far, these concerns are only very theoretical and the World Health Organization, the American Food and Drug Administration and the RACGP is currently not recommending against the use of an NSAID if a patient requires it. There is though the advice to rather use Paracetamol if it is a possible alternative and good reputation medical journals have published articles suggesting pre-cautions with Ibuprofen.

As so often with something new in the world, we just do not have enough data, and high-level evidence for or against NSAID is not available yet. Hence, available information and recommendations will always be somewhat conflicting and unclear, until we know more.  Using judicious judgement when deciding pro NSAIDs use, and discussing the options, risks and benefits with the patient is always a good thing to do. But withholding NSAIDs unnecessarily for fear of COVID-19 complications may do more harm than good.

References

Can angiotensin receptor-blocking drugs perhaps be harmful in the COVID-19 pandemic. Esler, Murray, Esler Danielle, Journal of Hypertension, 38(5):5781-5782, May 2020

Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection. Lei Fang, George Karakiulakis, Michael Roth, The Lancet, e21 Vol 8 April 2020

Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. Michael Day, BMJ 2020; 368:m1086

https://www.australianpharmacist.com.au/should-ibuprofen-used-covid-19-symptoms

https://www1.racgp.org.au/newsgp/clinical/ibuprofen-and-covid-19-what-gps-need-to-know

https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19

https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19

https://twitter.com/WHO/status/1240409217997189128

https://twitter.com/olivierveran/status/1238776545398923264

Kind regards and stay happy and healthy

Dr Arno Ebner, MD PhD FRACP

Paediatrician in Cairns

I can be contacted via the APS Secretariat at aps@apsoc.org.au