The COVID-19 pandemic has put an enormous strain on the healthcare system, delaying nonemergency medical care and potentially creating a higher risk for pain patients. However, the behavioral health community is adjusting with transitions to telemedicine and other alternatives that allow their patients to receive the care they need.1
Knowing clinicians are feeling additional stress during this time, telehealth options are readily available for the healthcare community too. We cannot expect those working in health care to properly care for others unless we are prioritizing their mental health needs.
Two of the leading researchers and practitioners in pain medicine joined us for our special edition Out Front Ideas COVID-19 Briefing Webinar Series to discuss the challenges of treating pain patients during the pandemic and how the healthcare landscape is adapting.
Beth Darnall, PhD—pain psychologist and associate professor of the Department of Anesthesiology, Perioperative and Pain Management, at Stanford Health Care
Steven P. Stanos, DO—medical director of pain medicine and medical director of Occupational Medicine Services at Seattle's Swedish Health
Due to the additional stress that the pandemic has created for healthcare workers, behavioral health psychology and counseling have become available in many primary care facilities. The behavioral health industry has a concierge of services that allows doctors to work with a therapist confidentially in a time of need. This "care for caregivers" model also includes Zoom-based videos and lectures covering helpful techniques like tai chi demonstrations, breathing exercises, guided meditations, and chair yoga. These videos are then saved in an archive, making them readily available for later use when caregivers need them. While created to get through the stress of the pandemic, these videos will help to alleviate tension that healthcare workers face regularly.
Behavioral health, as well as many other clinical disciplines, had to rapidly adjust to telehealth visits, creating safer access for patients. Not only does this alleviate stress for the clinicians, but it also creates a safer workspace for clinicians and staff alike. In addition to the creation of video resources for the healthcare community, crisis management and wellness resources are available. Organizations like the American Psychological Association have created online resources that collate information for clinicians and administrative leaders, providing on-demand access when they need it most.
COVID-19 has created disruptions in all areas of our lives, but it has been especially challenging for those managing chronic pain. These patients are seeking stabilization in their lives, but continued disruptions have complicated their path to wellness. These disruptions can compound mental and physical ailments for a pain patient, making it especially difficult for those with comorbidities. The pandemic has exposed the vulnerability of opioid patients given the difficulty it has created for those that need access to medications. Some patients have requested options to taper off of opioids or reduce their usage since the current environment may leave them feeling even less in control.
Since patients are at the mercy of the elements currently, it is increasingly critical to utilize patient-centered communication. Many pain patients that were just beginning to develop regular schedules are now dealing with the stress from a lack of routine. Refreshing patients on skills learned through previous treatments may help create structure and give clinicians key insights into their at-home routines. Understanding a patient's stress level can make medication refills easier since conditions like anxiety may be exasperated currently, putting an opioid patient more at risk than usual. This continued communication will be key moving forward when there is a return to normalcy, to maintain consistency in the care of an injured worker.
Treating Pain during COVID-19
Accessibility is essential in treating pain patients throughout the pandemic. Nearly all visits have become telehealth visits, including psychological follow-ups and physical therapy. Behavioral medicine now offers options like individual or group sessions and on-demand treatments that can be utilized without a therapist. Immersive experimental treatments, like virtual reality (VR), have created more engaging therapy for patients, putting control in their hands so they can get help when they need it. This portfolio of options, including Internet-based treatments, creates readily accessible care for pain patients.
Patients who were involved in rehabilitative programs can now experience treatment virtually. The same content they would receive in-office, through physical therapy, pain education, and relaxation training, can be delivered through courses a few days a week. A couple of options for these treatments include Zoom group visits or private YouTube videos, which are Health Insurance Portability and Accountability Act compliant.
All of these virtual programs work to support the hospitals in a time when they need it most. For those experiencing significant pain and those with comorbidities, emergency procedure clinics are now open to avoid emergency room visits and waiting on an approval process through a hospital. These clinics help to reserve hospital capacity for patients that need it most during the pandemic.
The need for alternative treatments during the pandemic has created a wave of new research and guidelines for therapy. The National Institutes of Health introduced its "Heal Initiative" to reduce opioid usage and awards grants for tools creating alternative pain management. One of those viable options includes VR, which has shown to be equivalent and sometimes even more effective than in-person pain therapy. These concepts retrain a patient's brain and can optimize experiences based on biofeedback. This type of experimental treatment is especially helpful in areas where there are not enough trained clinicians to deal with those experiencing acute and chronic pain. As this technology gets increasingly cheaper, it will create better long-term tools for patients in need.
New guidelines created by the American Academy of Pain Medicine and American Society of Regional Anesthesia and Pain Medicine, in conjunction with Veterans Affairs and the Department of Defense, outline best practices for pain management during the pandemic. This document also addresses public health issues and the welfare of providers. It covers the potential issues surrounding telemedicine, how to treat opioid management, and mental health considerations for patients and healthcare providers and defines emergency procedures, like those associated with cancer patients. They discuss emergency procedures for patients with poorly controlled pain that need opioids and how to help those experiencing withdrawals from use. The document also advises the use of acetaminophen to treat pain since the topic is still controversial in its interactions with the treatment of COVID-19.
While this period of time is transcending longstanding barriers now that on-demand care has been proven necessary, it is also important to continue assessing pain from a multidimensional perspective. This includes evaluating the risk for each patient, so in-person psychological evaluations are being used to treat the more symptomatic patients. Using resources like patient records and history to discern their pain can provide insight into which patients may be more at risk. Though it may seem that telehealth visits could increase the risk of opioid abuse, there is no evidence on the extent of that risk when it is still the same patient reporting the same pain value, in-office or not. It is critical to take a patient's reporting at face value and remember that pain will always be subjective.
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