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11 Articles in Volume 21, Issue #1
Advanced Practice Matters with Theresa & Jeremy: Mentorship
Ask the PharmD: What is a true opioid allergy?
Behavioral Medicine: How Clinicians Can Reduce the Stigma Attached to Chronic Pain
Cardiovascular Disease and COVID-19 Infection: A Look at Long Haulers
Chronic Headache: How to Conduct a Virtual Neurological Examination
How COVID Has Changed Pain Practice and Policies
How to Conduct a Pain Evaluation Using Telemedicine
Inside the Potential of Biologics for the Treatment of Rheumatoid Arthritis
Managing Pain in Parkinson’s Disease
Spinal Cord Stimulation Shown to Improve Pain and Movement in Parkinson’s Disease
TeleRheumatology Before and During the COVID-19 Pandemic

How COVID Has Changed Pain Practice and Policies

A recap of the protocols modified in 2020 and which pandemic-related policies are likely to stick around.

It has been just about a year since the United States entered into a variety of voluntary and mandatory lockdown measures in response to COVID-19, forcing the face of healthcare to change almost overnight. Providers have had to contend with clinic closures, delayed lab work, postponed surgeries.,1 confusion over which services are considered “essential,” and an explosion in the utilization of telehealth – all while trying to provide the highest quality pain care to their patients.

(Editor’s Note: PPM has been tracking these changes and their impact – including potential cardiovascular disease – on its Chronic Pain and Coronavirus Resource Page)

Like the federal policy changes, most of these state-level policies are being issued as temporary rules contingent on the length of the public health crisis. As a result, healthcare professionals need to be careful to stay on top of updates as time moves on. (Image: iStock)

Pain Management Programs Face Setbacks Due to Risks and Restrictions

Pain management practitioners are no strangers to policy change. Spurred first by the Institute of Medicine’s “Relieving Pain in America” report released in 2011,2 followed soon after by the CDC’s recognition of opioid-related deaths as an epidemic in 2013,3 pain-related policies were adopted and amended at an unprecedented rate in the past decade. Between 2016 and 2018 alone, more than 500 statutes, regulations, and guidelines were adopted at the state and federal levels pertaining to pain-related opioid use, such as limits on opioid prescribing and mandatory utilization of prescription drug monitoring programs4 – not to mention the plethora of recent policy changes associated with telehealth, electronic medical records, and mandatory continuing education related to the treatment of pain.

Still reeling from the decade’s sweeping policy changes, providers of pain management services began last year confronted with the reality of treating an already vulnerable patient population amidst a pandemic −a reality that immediately necessitated many of its own policy changes in an effort to reduce transmission of COVID-19.

In early 2020, the effort to “slow the spread” had the unfortunate effect of impeding standard pain treatment. The Interdisciplinary Pain Management Centers at Madigan Army Medical Center, which typically offers both traditional interventional pain management services, as well as a broad array non-interventional pain therapies, was closed to routine patient care for months.5 According to Sharad Kohli, MD, Federally Qualified Health Centers (FQHCs), which serve around 30 million uninsured and underinsured patients, have also experienced significant problems. “At a time when our patients may really need the support of our pain program,” said Dr. Kohli, “we’ve had to limit our in-clinic offerings. We’ve had to cancel our acupuncture, group visits […] and postponed starting our yoga therapist.”6

It did not take long for the effects of the altered healthcare system on people living with pain to become agonizingly clear. In March 2020, nearly 30% of patient readers who responded to a Practical Pain Management poll reported that they were experiencing trouble having a prescription refilled, and 20% were having trouble reaching their doctor(s) for a follow-up.7 Just a few weeks later, the US Pain Foundation surveyed patients and found that 63% were experiencing increased pain, and 77% were experiencing barriers to medical care.8

In response to reports such as these, the AMA strongly urged legislators, regulators, and governors to remove barriers to pain treatment to help ensure that patients with pain were able to access the treatments prescribed by their physician while reducing travel and unnecessary exposure to potential infection.9

With the evidence of increased human suffering so intensely obvious, and COVID-19 showing no signs of abating, it became clear to clinicians and policymakers that immediate and sweeping changes were needed to continue providing optimal pain care.

Telehealth Use Skyrocketed, Forcing Change

The most immediate way to enable clinicians to continue treating their patients was to increase utilization of telemedicine. As soon as clinic doors were closed, computers and mobile devices were opened, with a 154% increase in telehealth visits during the last week of March 2020 as compared to one year earlier, just as stay-at-home orders went into effect.10 As the year went on, the numbers became nothing short of astonishing, with UnitedHealthcare reporting that utilization of telehealth went from 0.1% of patients to 40% in their Medicare population.11

The swift expansion of telehealth has greatly improved access to care for many patients, but it has not been without its challenges and limitations. Large numbers of patients have reported that they do not understand their insurer’s telecare coverage policies, that they have not been informed by anyone of their virtual care options, and that their clinics were not offering remote appointments for a variety of reasons.8 Clinicians have reported trouble determining best practices for providing telemedicine, including how to manage prescribing for pain management.

(See, PPM’s new telehealth visual infographic on what you can and cannot do in a virtual pain assessment, and clinical examples of how to conduct a remote neurological and rheumatic exam.)

The rapid uptake in telehealth has shone a bright light on the areas of related policy in need of urgent attention, and policymakers have responded with extraordinary speed. Here’s what’s happened, and what is likely to stay – or go – in 2021.

Federal Agencies Issued a Slew of Temporary Shifts

Since the start of the pandemic, the federal government has acted swiftly in a number of ways to respond to the challenges being faced by providers of pain management and the patients for whom they provide care.

The CMS has taken steps to improve access to telehealth through increased reimbursements, such as paying physicians the same rate for telehealth services as they do for in-person visits, and by paying for initial visits with a new practitioner conducted via telehealth.11

The DEA has also been deeply involved with the issues at hand, releasing a number of exceptions and guidance documents to address prescription and dispensation of controlled substances in light of the COVID-19 public health emergency, including a detailed decision tree aimed at helping DEA-registered practitioners to fully understand how they may and may not prescribe controlled substances without having to interact in-person with their patients.12-15 Through the new exceptions, DEA has allowed registered practitioners to prescribe controlled substances to patients in states in which they are not registered via telemedicine. Further, DEA has made it easier for providers to prescribe emergency Schedule II controlled substances orally, as opposed to written or electronic only.

The moves made by both CMS and DEA are currently considered temporary, and are not guaranteed beyond the time period of the public health emergency declared by HHS. Further, the DEA’s willingness to allow providers to prescribe controlled substances based on a telehealth visit does not override state laws that prohibit such behavior, so prescribers must ensure they understand their legal obligations at both a state and federal level.

 

State Regulators Are Doing Their Part

States, cognizant of the role they play in limiting and/or expanding access to telehealth services related to pain management, have also been scrambling to update their own laws and regulations to help patients and providers through this trying time.

The Texas Medical Board issued a temporary emergency rule allowing for telephone refill(s) of certain prescriptions for established chronic pain patients as long as the patient has been seen by the prescribing health professional in the last 90 days, either in-person or via telemedicine.16 However, without additional action, the temporary rule is set to expire on March 3, 2021, which will put prescribers and patients right back where they started.

Similarly, the State Medical Board of Ohio has adopted temporary rules that suspend the requirement for in-person visits related to prescribing controlled substances for pain, pain management more generally, medical marijuana recommendations and renewals, and office-based treatment for opioid addiction.17 (More from PPM and AMA on overdoses.) Similar policy changes have been adopted in Indiana and Georgia, among others.18,19

Like the federal policy changes, most of these state-level policies are being issued as temporary rules contingent on the length of the public health crisis. As a result, healthcare professionals need to be careful to stay on top of updates as time moves on. For better or worse, healthcare providers cannot rely upon these temporary policies to be around for the long haul.

 

The (Possible) Future of Pain Care Policy in a Post-Pandemic World

There are undeniably many well-intentioned policy updates occurring throughout the country at an astonishing pace in response to issues impacting pain management related to COVID-19, but whether these policies are doing their part to improve care is yet to be seen. Healthcare providers’ feelings on adapting to telehealth run the gamut, with some struggling to cope with technology and bemoaning the loss of the physical exam, and others appreciating the focused nature of each telehealth visit and cheering their ability to reach rural patients who would otherwise have gone without treatment, even pre-COVID.20

While 51% of patients in a recent survey expressed desire to continue using telehealth services after the pandemic has ended because of its convenience,21 a crucial next step in fine-tuning pain and telemedicine policies will be to examine the relative effectiveness of telehealth-delivered pain care compared with standard in-person pain care.22

As COVID-19 eventually abates, it is likely that some of the temporary changes will disappear entirely, such as waivers exempting prescribers from requirements related to periodic in-person visits, but there are no guarantees. It is entirely possible that states with large rural populations, for example, will adapt nicely to new telehealth regulations and choose to keep them in their altered forms. Other states may decide that patients receive better care when seen in-person and decline to extend their pandemic-related regulations that expanded access to telehealth. And, of course, all states will be at the mercy of any future changes made by DEA, CMS, and other federal agencies.

 

 

 

Health advocates are acutely aware that they have their work cut out for them as policymakers quickly work to incorporate the lessons learned from 2020, and they are already beginning to speak out in preparation for the next wave of changes.

The AMA, along with 70-plus healthcare organizations and associations representing medical professionals, are urging congressional leaders to “prevent the sudden unavailability of virtual health options for Medicare patients” after the national public health emergency has ended.23In agreement, Rick Vaglienti, MD, director of the West Virginia University Medicine Center for Integrative Pain Management, shares that he has appreciated being able to reach patients outside of the Center’s immediate geographic region, and is “hopeful that some of the waivers allowing direct patient-to-provider communication will remain in place.”24

Other advocates are pointing out the need for policymakers to address technology and disparity issues, because as wonderful as telehealth can be, it is not entirely available to the many Americans who lack access to reliable and affordable high-speed internet.25

Only one thing is for certain: more change is to come. For pain practitioners, change seems to be the status quo.

Last updated on: January 5, 2021
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