Ann Quinlan-Colwell, PhD, RNBC, DAAPM
During the last five years, the focus upon, and priority for effective management of pain have dramatically shifted. After more than a decade of efforts to improve the awareness of pain and appreciate the need for pain management, health care system administrators and providers were keenly aware that pain management was an important health care need. In addition, in 2013 they learned that the patient experience of care constituted 30% of the weight of value based purchasing (CMS, 2013). At the same time, they realized that patient satisfaction with pain management was an important component of the general patient experience of care. They also realized that patient satisfaction with pain management was an important component of the patient experience. Pain was a strong focus of health care system administrators, clinicians. Then in 2016, the opioid crisis emerged and served as a potent change agent. The focus and attention of heath care system administrators and clinicians shifted from concern about patient satisfaction with pain to preventing opioid misuse and abuse. It is not possible to know to what degree, on a visceral level the opioid crisis touched clinicians who had been taught to submerge their ophiophobic fears. They now could quote support for not prescribing opioids or at least not as many opioids. Although I have not done a literature comparison, it certainly seemed as time passed information about opioids and substance use disorder far supplanted information about pain in the literature during the last few years. Then in 2019, two icons of pain management ceased to exist. The loss of the American Pain Society and the Academy of Integrative Pain Management as sources of leadership, guidance and research were significant. As we entered 2020, I was hopeful that we had suffered the worst blows to pain management. Yet new challenges face us.
In January 2020, the 2019 novel coronavirus (COVD- 19) was reported in Lancet. On the surface many may wonder what negative impact COVID-19 could have on people living with pain. Unfortunately, during this time the barriers that people living with pain face are bolstered and in some cases expanded. Many people living with chronic pain have serious co-morbidities venturing outside their home is not recommended (Szalavitz, 2020). It is difficult to maintain a safe distance of 3 to 6 feet in community settings or stores. As an example, last week, I was standing 6 feet behind a man in a supermarket who was 6 feet behind the person in front of him. A late middle aged woman started to stand in front of me. I explained that I was in line and maintaining safe space and social distancing. She waved her hand and said “Whatever!” She then proceeded not to respect space behind me. She didn’t seem to understand or accept the concept of personal space and social distancing. Currently when it is necessary for people who live with pain to go outside for a clinician visit or to refill a prescription transportation options may be more limited, less safe or unavailable. Some may feel they need to choose whether to comply with quarantines and go without pain medicine or break the quarantines to obtain the medicine (Szalavitz, 2020).
Last week, the following important information regarding opioid prescriptions during the COVID-19 pandemic was written by members of the Practical Pain Management Editorial Board (PPMEB, 2020): “with federal law superseding state law, and with the current coronavirus declared as a public health emergency, providers are in fact able to prescribe controlled substances, such as opioids, via telemedicine. The DEA’s Diversion Control Division has noted that, “For as long as the Secretary’s designation of a public emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided the following conditions are met: The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice; The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and The practitioner is acting in accordance with applicable Federal and State laws.” Additional information is available at www.deadiversion.usdoj.gov/coronavirus.html.
Other limitations are facing people living with pain who are trying to access integrative therapies which help them to manage pain. Physical therapy, massage, chiropractic, yoga, tai chi, water aerobics, swimming and fitness centers are not currently accessible in many communities. Again, technology can be of help for some. There are apps on smart phones and tablets that guide yoga and tai chi. There are dance and exercise videos available as well. Certain out-patient physical therapy groups are guiding family members and patients via teleconferencing while some nurses are working with patients with relaxation techniques over the telephone or via teleconferencing. For most people, living during this COVID 19 pandemic is a stressful time that can lead to sleep difficulty, anxiety and depression. For people living with pain, each of those can make the perception of pain more intense and/or can make it more difficult to manage. Similar to yoga and tai chi, there are many apps on electronic devices to facilitate relaxation and promote sleep. Psychological oriented hot lines are available to support people with anxiety or depression. Some clinicians are modifying their work to a teleconferencing mode. Recently the Centers for Medicare and Medicaid Services (CMS) expanded access to and coverage for telehealth care including virtual check-in and e-visits provided by clinicians including physicians, nurse practitioners, and licensed clinical psychologists (Drakulich, 2020).
CMS.gov table available at https://www.practicalpainmanagement.com/sites/default/files/imagecache/lightbox-large/images/2020/03/26/03.17.2020%20Summary%20of%20Medicare%20Telemedicine%20Services%20Chart.png
Continuing patient education is imperative for clinicians and for people living with pain to learn about the new modifications for opioid prescribing and the expanded telehealth options. It is also important for them to learn that there are a number of scams alleging to be from Medicare and Social Security. People living with pain may be vulnerable to these and need to know to be cautious. One patient with a long history of mental health issues, responded to a spam and unwittingly surrendered her Medicare coverage and agreed to a very pricey private insurance that did not meet her needs. Fortunately, a strong patient advocate was able to intervene and reverse the agreement.
There is no doubt that during 2020 patients living with pain will be challenged with stress and barriers. As professionals there are ways that we can be supportive and helpful. We may even find that by meeting the challenges of COVID-19 we will learn new options for helping and caring for people living with pain. We may even find that they may be more effective.
Centers for Medicare & Medicaid Services. (CMS). (2013). Hospital Value-Based Purchasing. Available at http://www.qualitynet.org/dcs/ContentServer?cid=1228772237147&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page. Accessed 3/30/2020.
Drakulich, A. (2020). Telemedicine in the Time of Coronavirus. March 16, 2020. Practical Pain Management.
Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., … & Cheng, Z. (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet, 395(10223), 497-506.
Practical Pain Management Editorial Board. (PPMEB). (2020). Managing pain and related symptoms during coronavirus. March 16, 2020. Practical Pain Management.
Stephen, P. (2016). Study – Wilmington No. 1 in opioid abuse. Star News. https://www.starnewsonline.com/article/NC/20160421/NEWS/605049449/WM. Accessed 3/30/2020.
Szalavitz, M. (2020). People who take opioid painkillers are getting skrewed thanks to coronavirus. https://www.vice.com/en_us/article/z3b5nj/coronavirus-shows-just-how-cruel-our-drug-laws-are-for-pain-patients-and-methadone-users Accessed: 3/30/2020.