During the 40-plus years of my medical practice, I have never observed disruption on the scale we are experiencing today. The changes we are observing could easily be compared to those faced by a community after a tsunami devastates their land and creates unimaginable chaos.
It was just a few months ago that we were negotiating with patients face-to-face, providing treatment that was focused on, centered around, and specific to their needs. The emergence and spread of COVID-19 has changed everything. Whether we like it – or how long it takes us to adapt to it – the SARS-CoV-2 pandemic is the foundation underlying significant changes being made to medical practice, and it is likely that these changes will become permanent.
Shifting Patient Visits During COVID-19
Changes in the large academic center where I work are evolving at an accelerated pace – sometimes adaptation occurs twice a day or just daily. We began with phone visits, which were suitable for follow-ups, welcomed by the patients, and satisfied social distancing needs. We ceased face-to-face visits unless deemed urgent or emergent. This shift took a relatively short time but required flexibility across all involved parties.
We then switched to video-based visits, but the technology kept changing. Conducting video or virtual visits while trying to use electronic health records (EHR) engendered a host of problems. So our team began to use a broader video platform (WebEx) that had fewer issues, and from there, Microsoft Teams, and more recently, Doximity. More servers were needed, requiring more instructions on how to facilitate the platforms, along with problems with the programs themselves.
And then came the other major challenge: Did the patient have the equipment and ability to satisfy their side of the equation during a virtual visit?
At first, patients would agree to a video meeting and staff would spend time trying to get them onto our platform of choice. If one platform did not work, we would try another. In some cases, patients simply lacked the ability, the equipment, or the right applications to enable the video session. So these visits reverted to phone visits.
Technology that worked one day would, on occasion, be dysfunctional the next day. While I could sail through many phone or video calls one afternoon, the next might send me to a page with an error noting that I “had no permissions,” or “a poor connection.”
Throughout these predictable growing pains, staff across multiple departments continue to do everything they can to meet patients’ needs. Despite all the ups and downs, research on several fronts shows that the use of telemedicine in this infectious environment is appropriate; it protects the provider and the patient.¹⁻⁹ Despite shelter-at-home orders and a few stumbles through technology, we are meeting patients’ needs.
The Virtual Neurological Exam
As a headache and pain specialist, I prefer to physically work with a new patient to conduct musculoskeletal, neurological, and general examinations and to reach a firm diagnosis. But many colleagues and I have found that we cannot perform a full neurological examination virtually. To complete even an abridged exam requires a family member or clinical nurse, for example, to be with the patient at their home to assist.
While certain neurological cases, such as a patient with Parkinson’s disease, may enable a clinician to “see” more aptly on video examination any physiological changes secondary to the ravages of the disease, this is not the case with chronic pain or headache. It has been difficult to deal with the types of pain that I cannot see. With my new patients, therefore, I have found it more important than ever to get the best history possible. In some cases, pencil and paper tests can aid in the diagnosis, such as the New Clinical Fibromyalgia Diagnostic Criteria,¹⁰ and the Montreal Cognitive Assessment.¹¹ The fact remains – headache or pain, when chronic, encompasses biopsychosocial phenomena, making it essential to look into all aspects of the problem.
What Pain Care Will Look Like After COVID
Clinicians Will Increase Telemedicine Services
The Patient’s Perspective. In my experience thus far, patients like that they can be “seen” on video and speak on the phone. They are able to discuss their needs, changes in symptoms, share iatrogenic events, and more. They can still obtain renewals of their medications or request medication changes.
I have many patients who come from miles, hours, or states away. They prefer these remote visits, and I will bet that they will not want them to end when the pandemic goes, at least, into remission. Given that most patients and clinicians appear to appreciate telehealth, and that it is working for patients, telemedicine will likely remain a part of medical practice – whether in pain medicine, primary care, or specialty care.¹⁻⁹
There will always be patients who greatly anticipate the face-to-face visit, and we have all seen patients whose social lives revolve around visits to various clinical providers, but we can now see that there is a broader scope.
The Size of the Practice. Working in a large, academic institution is undoubtedly different than working in a small private practice or a larger group practice. The latter depends, most typically, on a fee-for-service basis that helps them maintain billing and overhead practice costs. But the fact is, without telemedicine, many physicians and their practices would be financially under-water right now.
One report indicates that about 50% of physicians are using telemedicine visits.¹²Researchers at Harvard University and health tech company Phreesia looked at visit volumes for 50,000 providers and found that ambulatory practices had a 60% decrease in volume from mid-March to April 2020.¹³
In my state of North Carolina, the Medical Board deems it appropriate to use telemedicine if one can obtain sufficient clinical information from the patient during the consultation to provide care that meets no less than minimally accepted standards of care.¹⁴
The Coronavirus Preparedness and Response Supplemental Appropriations Act and 1135 waiver, starting March 6, 2020, has permitted the Centers for Medicare and Medicaid Services (CMS) to expand telemedicine by authorizing Medicare payments at the same rate as face-to-face visits for “office, hospital and other visits” furnished via telehealth across the country including in patients’ places of residence. While licensing for telemedicine is at each state’s discretion, and all states had required providers to be licensed in the state in which the patient receives the care, there are – as of May 1, 2020 – at least 12 states that offer special telemedicine licenses that allow cross-state line visits.¹⁵
Thanks to CMS, many other insurers, and the broadened states’ approvals, patients “locked down” at home are getting the medical care they need during the current crisis. I hope this will not change when the pandemic impact flattens.
Pain Care Will Be a Fundamental Human Right
As of March 21, 2020, chronic pain patients have been permitted to be seen via telemedicine for return visits and to receive appropriate Schedule II medication. Per the DEA rules, while no refills can be ordered, physicians can write up to three prescriptions with fill dates, not to exceed 90 days, using telemedicine for patient encounters and following proper medical procedures.²⁰ This adaption to a changing practice model is welcomed.
That practical point being made, there are some significant issues. For one, pain is the primary reason people seek medical care. Chronic pain problems make up three of the top four leading causes of years lost to disability in the US (back pain, general musculoskeletal disorders, and cervical pain).²¹˒²² In 2010 dollars, chronic pain cost the US between $560 billion and $650 billion a year, according to the 2008 medical expenditure Panel Survey. This eclipses the costs of heart disease, cancer, and diabetes.²³
Access to pain management services has been described as a fundamental human right, similar to the right to access basic medical care, housing, and free speech.²⁴˒²⁵ The undertreatment of pain resulting from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain has been causally linked to the “opioid crisis,” and chronic pain at high levels has been associated with increased mortality rates in cancer patients, structural and functional changes in the brain, poverty, and decreased life expectancy when controlling for other factors.²⁶⁻³⁰
The COVID-19 pandemic has strained medical resources, making it more difficult for these patients to receive appropriate analgesic medications, with fear being a major problem. Clinicians well know that individuals living with chronic pain often live in constant fear of being unable to find a physician willing to treat them and then unable to obtain their prescribed medication from a pharmacy. These are issues I have previously addressed in detail.³¹˒³²
Finally, practitioners need to consider morbidity and complications stemming from COVID-19, which have been found, so far, primarily in the elderly and immunocompromised patients. The effect of opioids on the immune system is complex, with variables including the type of opioid, the dose, the type of immunity (different opioids have different effects on different immune cells), and the context or reason for its use.³³ Infection, in general, has been linked to individuals on chronic opioid therapy.³⁴ Pain itself may induce immunosuppressive effects, such that the use of opioids to alleviate acute and chronic pain may even enhance the immune response.³⁵ The same may be possible when treating acute exacerbations of pain in the face of chronic pain (ie, breakthrough pain).³⁶
Therefore, it remains important to maintain appropriate pain management to prevent emergency room visits during the COVID-19 pandemic, which may unleash a second wave in the fall or winter of 2020-2021. We need to keep pain patients safe at home, minimize face-to-face interactions, and continue to provide effective and appropriate treatment. And, in cases where opioids may induce a reduction in the immune system’s abilities, we should help prevent patients from endangering themselves.³⁷
In over 40 years, however, I cannot say that I have seen any issue secondary to a reduced immune response in any chronic pain patient who is appropriately treated, yet issues with the immune system have always been spoken of. I have, however, seen evidence of immune problems in patients with significant untreated pain over time. Either way, that does not mean that under the overhanging threat of COVID-19 it isn’t meaningful. We are in a new world.
In Summary
As we all look ahead with weary eyes and unpredictable charts, at the very least, telemedicine has given us the tools to treat acute and chronic pain patients without putting them in harm’s way of the COVID-19 pandemic. This option is good for both the patients and the clinical personnel who treat them. As the coronavirus continues to shift, other changes may be necessary to maintain excellent patient care – all to be evaluated when those needs arise.
PPM's COVID and Pain Management Resource Center (updated regularly)