COVID-19 and the Evolving Psychology of Pain

Pain management has had a long and checkered history in this country. When I started the pain management division at Johns Hopkins, the dominant clinical approach was to ignore pain that had no obvious biologic causes, believing that if not reinforced with attention, patients’ pain would simply go away. These patients were often branded either as malingerers or drug-seekers, and dismissed. This prevailing medical attitude led to poor care, poor outcomes, and escalating costs. Chronic pain in America was costing us more than cancer and heart disease combined.

In the late 1990s, the one-size-fits-all solution was drugs, opiates, as the simplest and apparently most cost-effective approach to the treatment of pain. The appeal of this approach was that it negated the need for searching for identifiable sources of pain, as anything could be managed with one of the plethora of available drugs. Ultimately, that approach precipitated the opiate crisis that plagues us today. We know its costs all too well.

COVID-19 Highlights Dilemmas in the Area of Pain

Thirty years after I entered the field of pain management, in some ways it appears we’ve come full circle. COVID-19 is presenting physicians with a new set of dilemmas, including pain issues, and the response has so far not been much better. With about 130 million people worldwide diagnosed with COVID, it is estimated that between 10-30 percent of them are left with significant medical problems ranging from headaches and brain fog to neuropathies, pulmonary problems, and gastrointestinal problems. At least, by now we should have learned the results of a one-size-fits-all approach to treatments: patients feeling marginalized, poor outcomes, and high costs.

The approaches of the past were severely flawed in that they did not always recognize an existing biologic basis of pain, nor the importance of emotions in managing pain. Over the last twenty years, we have concentrated on establishing diagnoses and understanding how emotions can affect the experience of pain. In thinking about this mind-body connection as it relates to pain, I recall the work of my father, Arthur W. Staats, who was a pioneer of behavioral psychology and worked to unify the cognitive and behavioral fields of psychology. He pointed out that they were inseparable. Working with Professor Hamid Hekmat on "The Psychological Behaviorism Theory of Pain: A Basis for Unity,” we both echoed and expanded my father’s work as we sought to unify what had been considered separate disciplines in the field of pain medicine. Like my father, we wanted to foster validation of patients’ concerns, establish the need for clear diagnoses, and advocate for appropriate treatment based on what was wrong.

Unlike chronic pain, which came upon us gradually, COVID-19 is a major healthcare crisis that has hit us like a tsunami, and we don’t have a comprehensive approach or plan. The extended care of long-COVID patients, patients with long-term disabilities we have yet to sufficiently understand, is going to run the risk of overwhelming us. We don’t have physicians trained in long-COVID, and we don’t have good treatment strategies. We don’t have disability policies or reimbursement policies in place.

Relying on Pain-Killers or Wishing Pain Away Does Not Work

Hundreds of thousands of patients continue to suffer from complaints that we don’t fully understand. And when I speak with patients, I hear story after story of poor treatment by the medical community. I truly believed, as my father would surely have, that we need a theoretical understanding of what is going on with these long-haulers. But indeed, there are striking similarities to how patients with chronic pain were treated 30 years ago. Once again, the lack of validation leaves patients feeling ignored, wondering if it is “in their head.” I see history repeating itself in the medical community with these patients.

Pain has taught us a clear lesson: While we may not always know its direct physical cause, reverting to pain-killer drug therapy or wishful “it will pass” thinking just won’t cut it, and our evolution at least to that point gives me some hope.

The Development of New Therapies May Help

New therapies are being developed. For example, one of the most common long-COVID patient complaints is migraine, which can last long after the virus itself is gone, and it has been proven that non-invasive, external electrical stimulation of the vagus nerve can help. The vagus nerve, which extends from the brainstem through the neck and the thorax down to the abdomen, is associated with a wide range of crucial functions, including mood, immune response, digestion, heart rate, and others. It’s even linked to headaches and strokes.

Stimulation of the vagus nerve apparently affects how the brain is signaled to produce a headache, reducing the occurrence of these headaches and decreasing the need for other treatments. The vagus nerve may well be the next step of understanding mind-body medicine. Its stimulation is even being studied as a therapy for the once-mysterious fibromyalgia.

Even with the development of therapies like vagus nerve stimulation, we have a long way to go in establishing therapeutic approaches, guidelines, and diagnostic tools for treating the sometimes-elusive post-COVID symptoms.

We Need to Incorporate the Five Basic Tenets of Pain Management

Believe and validate our patients' concerns. They are real.

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Establish a rational diagnosis. This may involve new studies and types of approaches, but understanding the cytokine effects, coagulation damage, and the end-organ damage from this virus will be critical.

Repurpose therapeutics that are in our armamentarium today. Once we establish what is happening at a pathophysiologic level, we can retool medical devices and pharmaceuticals or simply pull them off the shelf. Try those that are safe.

Study the outcomes with well-designed clinical trials.

Use that information to create guidelines for practitioners in the trenches. These guidelines will certainly change as new information becomes available, but doctors need treatments today.

Only by adopting this strategy will we be able to avoid the wave of pain, disability, and dysfunction barreling down upon us with long-term COVID.