To the Editor,
We read with interest the literature review by Widyadharma and colleagues on pain as clinical manifestations of coronavirus disease 2019 (COVID-19) and its management in the pandemic era. The authors highlight the association of psychiatric disorders such as depression to pain in these patients, which leads to a significant decrease in the quality of life .
The pandemic brought about by COVID-19 has resulted in the need for the public to isolate or “maintain social distance” to prevent the spreading of the disease. A survey carried out by the Spanish Pain Society on 340 participants shows that 91.4% of people with chronic pain believe that the lockdown has affected their emotional state, and 63% say that their quality of sleep is worse than before the pandemic .
Pain as a cause of stress and its sensory and emotional dimensions are widely connected and there are several factors, whether psychological, social, or neurobiological, which determine this circle, which is often so difficult to break unless a biopsychosocial therapeutic approach is used [3, 4]. We also reflect on whether the stress caused by this situation, the anxiety, and even the resulting depression negatively contribute by closing this vicious circle, which undoubtedly is the case . In fact, patients with chronic pain who must, just like any other citizen, be in isolation or observe social distancing due to the COVID-19 pandemic may experience a decline in their physical and emotional well-being .
In their review, the authors also make reference to the use of opioids, non-steroidal anti-inflammatory drugs, and corticosteroids in patients with COVID-19 . Taking into account the assumptions made, are any special recommendations necessary regarding the use of antidepressants in these patients? We are aware that most clinical practice guidelines concur that tricyclic antidepressants (amitriptyline) and serotonin and noradrenaline reuptake inhibitors venlafaxine and duloxetine are first-line drugs for the treatment of peripheral neuropathic pain , which may also be present in patients with COVID-19 . In the event that the patient is undergoing treatment with drugs for COVID-19 which prolong the QTc interval, normally under clinical trial, we must check that they do not interact with the antidepressants. For example, amitriptyline and venlafaxine may cause QTc interval prolongation, but currently, evidence is lacking on any risk of Torsades de Pointes when they are administered at the recommended dose. For this reason, we recommend monitoring using an electrocardiogram in the event of a combination or considering an alternative such as duloxetine . It is also necessary to be aware of the possible interactions of these analgesic and adjuvant drugs with the pharmacological treatment applied to patients who are COVID-19 positive and affected by the illness. With regard to the latter, while these clinical and therapeutic dilemmas are resolved, specific information can be found on these medical interactions at trustworthy sites, such as https://www.hep-druginteractions.org/checker .
It unfortunately seems quite likely that COVID-19 is here to stay, so we must ensure that all necessary means are set in motion so that the care of chronic pain sufferers is not undermined.