A Pain Management Physician on Adapting Practices During the Pandemic

By Robert Bolash, MD

In light of the COVID-19 pandemic, the speed with which pain management providers at Cleveland Clinic have adapted their practices to ensure patient safety has been remarkable. At the start of 2020, less than 5% of our patient encounters were completed via virtual health technologies. Now, current rates of utilization for our Pain Management Department are exceeding 75%. This has been an expeditious and dramatic shift in less than a month’s time.

This adaptation has required us to quickly scale up our virtual visit platforms, train additional staff to complete these encounters, and redesign internal workflows for nearly every process we have historically undertaken. Processes are now designed, then frequently redesigned later in the day, always with the aim of improving care for our pain patients. The ability and openness from our team to adapt to changes has been extraordinary.

What has been similarly notable is the willingness of our patients to adapt to these novel processes aimed at ensuring their safety. I am consistently impressed by the ease with which most patients set up and leverage our technological offerings to maintain continuity of care. It’s become clear that patients value the relationships built with their physicians, just as much as we physicians aim to nurture the rapport we have with them.

These real-time interactive communications utilizing audio and video links are facilitating care for patients with a large proportion of the same problems we see in traditional office visit. Refills and titration of medications, discussing the risks and benefits of various treatments, and patient counseling occur essentially in identical ways across internet connections. Patients are doing their part as well to maintain social distancing by requesting 90-day prescriptions of stable medications, rather than looking to visit the pharmacy every 30 days.

Other aspects of the encounter, such as the examination itself, require some creativity. Many of the exam techniques can be adapted, and utilizing our video platform and careful instruction to the patient, can be performed at home by the patient. One of our physicians has taken the initiative to teach others best practices to adapt physical examination techniques for the virtual environment.

Patients are completing physical therapy and mindfulness activities utilizing a variety of apps and instructional videos. Some are connecting with their physical therapist via similar remote video platforms, while others are performing desensitization physical therapy in their own bathtubs rather than at a facility with water therapy. It’s been noteworthy and instructional to see people’s ingenuity.

So, will we be able to abandon our office space and shutter our doors forever? Certainly not. I’ve yet to determine the best way to perform an interventional pain procedure remotely. Even basic procedures require a skill set, license and expertise to perform. We can’t impart these abilities or deliver these valuable forms of care to patients on a virtual visit.

Elective interventional procedures

Almost all patients have adapted favorably to the change in practice environment. Like Cleveland Clinic, many healthcare organizations have responded to government guidelines to postpone elective interventional pain procedures with the aim of preserving needed stores of personal protective equipment (PPE) and reducing the risk of COVID-19 spread. This has without a doubt, temporarily curtailed some of our options for a multimodal pain strategy. We also know that many of our patients are elderly, have multiple medical comorbidities, and may concomitantly be utilizing immunosuppressive agents, positioning them at a heightened risk for the virus.

The American Society of Regional Anesthesiology and Pain Medicine has provided us with some guidance on how to best adapt our procedural practice. While the majority of chronic pain interventions are elective, intrathecal pump refills are a necessary procedure to maintain functionality of the implanted device. While rare, implantable device infections are also urgent, and warrant uninterrupted continuation.

Some interventions are clear-cut, with many other procedural scenarios warranting consideration on a case-by-case basis. Is the patient with intractable cancer pain who is failing management with conservative therapy an elective undertaking? Early complex regional pain syndrome ? An acute disk herniation with worsening radicular symptoms? Arguments could be made in either direction. Clearly these patients remain well-suited for interventional pain procedures, as we have a substantial body of evidence in support of their efficacy in these discrete use cases. How has the COVID-19 pandemic altered the risk-benefit ratio for including steroids in these procedures; we know that joint corticosteroids are associated with heightened risks of influenza. What about coronavirus? We just don’t know.

The interventional pain physician in the United States has rarely been faced with questions surrounding allocation of resources, and it takes a certain degree of separation to distance ourselves from our own interests to put the greater interests of the entire population first.