If someone tried to design a “perfect storm” for people with serious back problems, it would be pretty close to the current situation in the United States and many other countries. The world is experiencing the greatest interruption in spine care since World War II. It is not at all clear how long this pandemic-related interregnum will last—or if there will ever be a return to “usual care.”
In the spring of 2020, back care systems in the United States are in disarray. Many practices are closed. Others are only interacting with patients via telemedicine, apps, and telephone. In many states, hospitals and clinics are no longer performing nonessential spine surgery or pain interventions.
To compound these problems, many organizations within the healthcare system are severely strained financially—as the revenues from usual care and common surgical procedures have dried up. Some are actually laying off front-line medical personnel—and reducing the pay of others, at a time when those providers are being asked to risk their lives treating patients with COVID-19.
In preparation for this article, a BackLetter editor contacted several back care providers in areas affected by COVID-19—including specialty care, primary care, mental health services, and complementary/alternative medicine. Most said they were not doing any face-to-face treatments and only a modest number of telemedicine procedures.
Delaying care probably doesn't pose a major threat to most individuals with back pain. For many people with back symptoms, there is no hurry to seek medical care. Much of back care is purely discretionary. Despite the claims of proponents, most common therapies for low back pain have only marginal or modest effects. And medical care often does not have a major influence on recovery. The favorable natural history of most forms of back pain has a greater influence.
For those with serious anatomic problems, many hospital and clinics are still performing essential spine surgery—for victims of trauma, those with progressive neurologic disease, and patients with cancer. And there are sensible triage guidelines available for hospitals and ambulatory clinics that want to define “essential” spine procedures
However, even people with more severe problems appear reluctant to seek hospital care for fear of contracting the virus that causes COVID-19. For example, many hospitals are reporting a major fear-driven reduction in the number of patients seeking urgent care for dire conditions such as heart attacks and stroke. The same is likely to hold true for people with serious spine problems such as traumatic injuries, progressive myelopathy, and other worrisome neurological conditions.
It is sad to say, but some people may benefit from not being exposed to standard US back care. Some have argued that the back care system in the United States is inherently disabling. The costs of back care in the United States jumped from $37 billion in 1996 to $135 billion in 2016 without any discernable improvement in the prevalence of back pain, chronic back pain, and disabling back pain. (See Dieleman et al., 2020.) This suggests that a substantial portion of back care—including medications, physical treatments, pain interventions, and surgery—may be ineffective or even counterproductive on a population basis.
However, it would be naive to suggest that the COVID-19 pandemic will have a broadly positive impact on back pain and spinal health. It important to recognize that the social, economic, and medical disruption posed by the pandemic may cause pain problems to proliferate. The pandemic has brought massive unemployment, poverty, economic uncertainty, social disruption, physical inactivity, loss of confidence in the future, and varied mental health problems. All of these can be viewed as risk factors for the development of high-impact disabling chronic pain problems.
As of late April 2020, at least 30 million US residents had filed unemployment claims. But this figure underestimates the unemployment problem. There is an additional large group of Americans who have withdrawn from the workforce altogether but are not considered unemployed—because they are not looking for work.
The proportion of the US population of adults participating in the workforce has been declining steadily over the last few decades. For men over the age of 25, labor force participation dropped from nearly 90% in 1948 to less than 75% in 2016, according to a study by the late Alan Krueger, PhD. (See Krueger, 2016.)
For example, Krueger found that about 11% of prime age men—roughly seven million individuals—are out of the work force altogether. Many of these relatively young men are ailing. “Forty percent of non-labor force prime age men report that pain prevents them from working on a full-time job for which they are qualified,” according to Krueger. “Survey evidence indicates that almost half of prime age NLF [non-labor force] men take pain medication on a daily basis.” There is also a large group of prime-age women who are outside of the labor force.
So there may be millions of people with pain and disability problems that aren't reflected in unemployment figures.
There are groups of pain patients that may be disproportionally affected by the pandemic-related disruptions. The group that appears at greatest risk in the United States includes the many people suffering from opioid addiction, complex opioid dependency, and difficult opioid tapering issues.
Due to 20 years of intemperate and excessive opioid prescription for chronic pain, millions of patients are struggling with addiction and complex opioid-dependency problems in the United States. Roughly two million American have a substance abuse disorder—most typically involving opioids. And about half of these individuals have a substance abuse disorder and a mental health problem. They are in every back care practice—especially those that prescribe or have prescribed opioids for chronic pain.
According to various estimates, as many as eight million Americans are on long-term opioid therapy—many on perilously high-dose prescriptions. Numerous patients will require substantial help in tapering their opioid dosages—and the challenges that accompany that process.
Many patients with drug-related problems are not receiving any active treatment—including vital medication-assisted treatment with buprenorphine and methadone— for their pain and addiction issues at the moment. Like their fellow citizens, they are sheltering-in-place, engaging in social distancing, and avoiding going out. They are isolated, lonely, and ailing.
Unfortunately, this is a group that is clearly at significant risk of serious and even lethal outcomes from the suspension of usual care.
Their problems will likely snowball without effective treatment. Lack of effective medical care may push patients toward despair and dangerous use of street drugs, from heroin to carfentanyl to cocaine to methamphetamine—and various combinations of drugs. Individuals with addiction and dependency problems are vulnerable to loss of income, bankruptcy, homelessness, incarceration, and suicide.
“Although the pandemic threatens everyone, it is a particularly grave risk to the millions of Americans with opioid use disorder, who—already vulnerable and marginalized—are heavily dependent on face-to-face health care delivery. Rapid and coordinated action on the part of clinicians and policymakers is required if these threats are to be mitigated,” according to Caleb Alexander, MD, et al. in Annals of Internal Medicine. (See Alexander et al., 2020.) Yet the political leadership in many countries does not seem capable of rational, rapid, and coordinated action.
Disruption of Care
Alexander et al. pointed out in their commentary that one of the greatest threats to people with substance abuse disorders is disruption of care, particularly for patients receiving tightly controlled medications such as methadone and buprenorphine. And disruption of care is the rule rather than the exception right now.
The COVID-19 pandemic comes at a time when the United States was beginning to make some modest progress in opioid prescription and the management of opioid-related problems.
“The COVID-19 pandemic strikes at a moment when our national response to the opioid crisis was beginning to coalesce, with more persons gaining access to treatment and more patients receiving effective medications. COVID-19 threatens to dramatically overshadow and reverse this progress. Some disruptions in the care of patients with opioid use disorder are inevitable during the weeks and months to come. However, extraordinary planning and support can limit excessive disruption and its dire consequences. These efforts will require new partnerships, unprecedented use of technology, and the dismantling of antiquated regulations. The greatest strength of the treatment system has always been compassionate care for the most vulnerable—qualities needed now more than ever,” according to Alexander et al.
Many reading this article will say “I treat back pain and spinal problems. I don't offer addiction and dependency services. I'll refer those out.” But it is clear that there are not nearly enough pain and addiction specialists to go around. The vast majority of people with pain and addiction/dependency disorders will end up being treated by their main providers—often primary care physicians.
There is a dire need to address this situation. Everyone in the pain treatment community should lend a hand in this troubling time, both in the effective treatment of pain and in the rational management of substance abuse problems. The treatment of pain, particularly chronic back pain, played a key role in the development of the opioid crisis. And most people who developed dependency and addiction issues due to the treatment of pain still have pain problems.
Substance Abuse Problems Are Often Silent Problems
Unfortunately, many substance abuse issues are silent problems. People often do not volunteer that they have substance abuse issues. People in the United States with addiction and dependency disorders are heavily stigmatized. In many quarters, including many areas of medicine, addiction is still viewed as a moral failing rather than a serious disease.
At the best of times, accessing effective treatment for addiction and dependency disorders (and chronic pain problems) is an uphill battle. In the midst of a massive pandemic, there are intimidating obstacles to effective care.
Living on a Knife's Edge
A BackLetter editor recently interviewed psychiatrist and addiction specialist Kenneth Stoller, MD, who coauthored the recent commentary in Annals of Internal Medicine by Alexander et al. He heads two addiction treatment programs in inner-city Baltimore, including the John Hopkins Broadway Center for Addiction.
Stoller emphasized several key points. He noted that outreach is key to the effective management of addiction and dependency problems. Many people struggling with addiction disorders are mistrustful of the health care and social welfare systems and are often reluctant to acknowledge these problems or seek help.
Many have comorbid mental health disorders complicating their management. As Stoller recently commented in the Baltimore Sun, “Mental health disorders and addiction are both diseases of the brain that are ‘tied together in a very dangerous way.’” For example, there is heavy overlap between addiction disorders and suicide. (See Cohn, 2020.)
People with these dual problems often live on a knife's edge. In that same Baltimore Sun article, Stoller said that those with substance use disorders often live on a continuum between wanting to live and wanting to die. Their feelings can waver depending on whether they are intoxicated or in withdrawal and in the throes of depression, for example.”
“When I get a chance to ask patients who survive their drug use, they tell me it's about escaping,” he said. “Whether someone wanted to escape permanently or absolutely wanted it to be temporary, or somewhere in between, it may be tough to tell.”
He noted in his BackLetter interview that people with addiction and dependency problems often need help in multiple areas: healthcare, employment, housing, and legal services. His organizations have dedicated staff who provide outreach and help in all these areas. Yet the US healthcare system in general does not provide adequate help in any of these areas.
Outreach a Priority
Outreach poses especially difficult challenges for healthcare providers in single or small-group practices. For example, primary care providers are over-scheduled and overburdened at the best of times—and that will be the case as medical practices start opening up again. Stoller said that every practice that manages opioid-related addiction disorders needs to organize outreach efforts. He believes that individual providers should devote time to this effort. And if they can't, each practice should appoint someone to regularly contact patients with addiction and dependency problems.
There is another major problem in this area. Many in the healthcare community do not have adequate knowledge about the management of addiction and complex dependency issues—and they don't prioritize developing expertise in this area of medicine.
A BackLetter editor asked Stoller how inexperienced healthcare providers could improve their capabilities in this area during the pandemic—a period in which traditional training programs are not going to be available to many providers.
He suggested that healthcare providers contact local branches—and the websites—of major addiction societies and other groups that support this area of medicine.
For example, the American Society of Addiction Medicine (ASAM) offers a variety of useful resources at ASAM.org. ASAM has organized a task force to make recommendations on the management of addiction disorders during the COVID-19 epidemic. And ASAM will update its resources in real time, as new recommendations become available.
The website is offering free webinars, general articles on the treatment of opioid addiction during COVID-19, and information on medication-assisted treatment with buprenorphine and other drugs. There are resources on the mitigation of infection risks during inpatient and outpatient services, drug testing protocols, telehealth, online support groups, in-person support groups with social distancing, and other key topics.
Stoller also emphasized the importance of organizing outreach and treatment services that minimize face-to-face contact between patients and providers, via online services and programs that prioritize social distancing. “Several members of our group have become infected with the virus. We can't afford to lose any more people,” he commented.
He pointed out that some of the restrictions on telehealth services and the remote prescription of medications have been relaxed, at least temporarily. So there is plenty of scope for effective management of these problems without compromising the health of key personnel.
But at best, the effective management of addiction and complex dependency issues is going to be a continual challenge going forward. For example, recent research suggests that about 30% of US primary care providers don't believe in, or prescribe, medication-assisted treatment for addiction and dependency problems. Yet the evidence is clear that treatment with buprenorphine or methadone is highly effective and can save lives. So everyone in the medical community needs to make a valiant effort to get up to speed in this area of medicine.
Disclosures: None declared.