The American Academy of Pain Medicine recently released guidelines on the management of pain during public health emergencies, such as the current COVID-19 pandemic, to provide a reference for pain practitioners, healthcare leaders, regulatory bodies, and institutions.
Chronic pain has been found to be the leading cause of disability in the world and its undertreatment can profoundly impact patients as well as the rest of society. Access to pain management has been deemed a fundamental human right, however, according to the new guidelines, “The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with a responsibility to limit spread of the contagion, and their responsibility to treat the patients they are entrusted to care for.”
In order to provide national guidance addressing issues surrounding pain management practices, an expert panel was convened to provide a framework for pain practitioners and institutions. A variety of topics are addressed in the guidelines, including risk mitigation (general and intervention-specific), issues with patient flow and staffing plans, telemedicine options, recommendations on triaging, mental health considerations for both patients and providers, and pharmacological treatment.
According to the guidelines, providers are advised to follow the general recommendations put forth by the Centers for Disease Control and Prevention (CDC), but to also take extra precautions to ensure the health and safety of patients and staff as well. Some examples of precautionary measures that should be instituted include: wearing N95 masks (if deemed appropriate)/face shields and protective gear, avoiding use of common areas, spacing out necessary in-person clinic appointments, having non-essential employees work remotely if possible, limiting the number of personnel present when performing necessary in-person surgical procedures, and utilizing telemedicine when possible.
Recommendations on opioid management are also included in the guidelines. According to the Department of Health and Human Services, practitioners are permitted to prescribe opioids during telehealth visits and via electronic prescriptions, provide interim short-term opioids for specific situations, and provide temporary increases in the quantity of opioids prescribed in patients already taking them. A flowchart on how to prescribe controlled substances to patients during the COVID-19 public health emergency is available on the Drug Enforcement Administration website.
As for corticosteroid therapy, the panel recommends continuing with epidural and other steroid injections as necessary, however, the lowest dose should be used and patients should be informed that this may put them at risk for infection. Given the lack of available data, the experts were unable to make conclusive statements on the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Recently, the Food and Drug Administration announced that there is not enough scientific evidence to link NSAIDs to worsening symptoms of COVID-19.
“The COVID-19 pandemic represents an unprecedented global health crisis that requires carefully weighing the dynamic balance between access to pain care, which can have long-term personal and socioeconomic benefits, with the immediate goal of minimizing exposure risk for frontline healthcare providers and vulnerable patients,” the authors concluded, adding that “It is important to recognize that these recommendations are meant to serve as guidelines, not standards, which come from an undisputed, unquestioned authority, and are therefore less subject to interpretation and modification.”
Cohen SP, Baber ZB, Buvanendran A, et al; Pain Management Best Practices from Multispecialty Organizations during the COVID-19 Pandemic and Public Health Crises [published online April 7, 2020]. Pain Medicine. doi: 10.1093/pm/pnaa127