Pain management amid COVID-19 requires balance between need, safety
Pain management during the COVID-19 pandemic requires balancing access to care with minimizing exposure risk for front-line health care providers and vulnerable patients, according to a panel of experts who developed guidelines on best practices.
In a 2018 MMWR report, researchers estimated that approximately 50 million Americans experience chronic pain — or about 20% of all U.S. adults.
Telehealth or in-person visit?
According to the best practices, physicians should consider the following when deciding to see patients in person or via telehealth:
- comorbid psychiatric and social considerations;
- pain level and coexisting functional impairment;
- the likelihood of the visit or procedure providing meaningful benefit;
- the likelihood of the patient to seek limited emergency services or be started on opioids;
- the need for physical examination;
- the risk associated with in-person visits or procedures;
- work status (eg, whether the patient is currently working or likely to return to work with adequate pain treatment); and
- profession (ie, prioritizing first responders will offer the greatest benefit for society).
“Patients who come in should be spaced out and have escort requirements waived,” Steven P. Cohen, MD, chief of pain medicine at the Johns Hopkins School of Medicine and lead author on the best practices, told Healio Primary Care.
Patients should also receive face masks if they are available, according to the guidance, and employee presence and patient visitors should be limited to those who are deemed most essential. For the most common procedures, patients should be positioned face down, and the contact area should be sterilized.
Lewis Nelson, MD, chair of emergency medicine at Rutgers New Jersey Medical School, told Healio Primary Care that telemedicine should be used as much as possible.
“I wish we had unlimited resources where we could see everybody the minute they walk in,” said Nelson, who was not involved in the development of the guidance. “But the health care system is going to go in the other direction, and there's probably going to be less available in-person care for people.”
Epidural, other steroid injections
When steroids are needed, physicians should use the lowest dose possible and inform patients of the potential for immunosuppression and the risk for infection, according to the experts on the panel. Patients who are already immunosuppressed and at high-risk for SARS-CoV-2 infection and complications may receive steroid injections only after the benefits and risks have been weighed.
“There’s mixed evidence that steroids can suppress the immune system,” Cohen said, “but the risk appears to be very, very low.”
HHS recently provided a waiver allowing health care providers to prescribe opioids via telehealth visits, and most regions allow electronic opioid prescriptions. According to the best practices, “it is reasonable” for physicians to prescribe short-term opioids to patients who experience acute pain or a severe exacerbation of pain as long as providers assess their patients’ risk for developing opioid use disorder and screen for “red flags.”
Providers should also check the prescription drug monitoring program and develop an “exit strategy” for their patients, the experts said. If opioids are to be continued in these patients beyond 1 to 2 weeks, the panel recommends an in-person visit within 1 month to conduct a physical examination, ascertain the severity of pathology and review the patient’s need for a procedural intervention or subspecialty referral.
Lack of professional diversity
The panel that developed the best practices included pain management specialists and anesthesiologists.
Nelson said he was concerned about the absence of other medical specialists, suggesting that decision-making among like-minded medical experts invites cognitive bias.
“In the case of pain management — since pain is not one syndrome, is not managed similarly across the spectrum of health care, and carries serious adverse consequences — having others such as emergency physicians, medical toxicologists and addiction specialists at the drafting table would provide greater objectivity and generalizability,” he said.
Cohen, who is also a retired Colonel within the U.S. military, noted that a wide range of health care professionals that were used to develop the best practices.
“Every author was a pain specialist, but there were also two board-certified psychiatrists, two physical medicine and rehabilitation physicians, a neurologist — including the chief of pain for the Veterans’ Affairs Health System, three active duty military personnel who are pain specialty leaders for the Army, Navy and Air Force and a pain physician.”
Cohen added that one of the best practice reviewers was a psychiatrist. – by Janel Miller
Disclosures: Cohen reports no relevant financial disclosures. Nelson is a former chair of FDA’s Drug Safety and Risk Management Advisory Committee.