When does chronic pain become an emergency? It's a question pain management practitioners have always considered, but the coronavirus disease (COVID-19) pandemic provides a new set of circumstances and risks beyond the inconvenience of middle-of-the-night calls or emergency room visits.
In the first weeks of the appearance of novel coronavirus in the United States, hospitals and health systems put an indefinite hold on all nonemergency surgeries and ambulatory care, in an effort to flatten the curve of the pandemic and to manage resources-especially the shortage of personal protective equipment (PPE) needed to protect healthcare workers.
Amid this very real danger, health systems and patients have had to weigh the risks of an in-person visit for pain care.
As of this writing, the country is only about 1 month into the appearance of the pandemic. A surge in hospitalized patients has begun, and the virus has appeared in all 50 states, with New York, California, and Washington being the states hardest hit.
Telemedicine is still evolving, but this is its moment-more patients and more health systems will begin to embrace it. But it's still impossible to administer an epidural corticosteroid injection or implant a spinal cord stimulator using telemedicine, so there is limit.
Billing for Telehealth
In Maryland, the governor has been praised for taking steps earlier than most others to plan for the impact of the virus. In March, he signed an executive order to expand current Medicaid reimbursement rules to receive payment for telehealth services.
“To respond to the state of emergency and catastrophic health emergency, health care providers must be permitted to deliver health care services at sites other than the sites at which patients are located,” the order stated. Under the order, providers can receive payment for audio-only calls or other communication that is not in-person provided in real time.
SAMHSA Issues Guidance on Take-Home Medications
In late March, the US Substance Abuse and Mental Health Services Administration (SAMHSA) issued several reports on its website for guidance in medication-assisted treatment (MAT) of opioid addiction. The guidelines were intended to allow more flexibility in taking home medications and in use of telehealth services.
In Maryland, for example, the state Department of Health announced that all stable patients in an addiction treatment program may receive 28 days of take-home doses of their medication for an opioid use disorder. Those who are less stable are allowed to receive 14 days of take-home medication.
Guidance for Private Practitioners
Much of this is new territory. If patients do come into a medical office for ambulatory care, what measures might be needed for disinfecting? Might the examination room need an interval of time before it can be used for the next patient, in addition to disinfecting of surfaces?
Private practice physicians and therapists should check their state medical society, state health department, and the US Centers for Disease Control and Prevention websites continuously. Physicians and other practitioners who work for large health systems are likely getting most of their information there.
To Our Readers
Editor's note: Please let us know how you are managing your pain patients amid the COVID-19 pandemic.
How are you using telemedicine—even if it's unofficial through Skype, Zoom, or FaceTime?
What kinds of cases have been worth the risk of exposure for you and your patient?
How are you disinfecting your office environment and equipment differently?
How are your patients coping?
Might any of this change pain care in the future?
Please email your answers to the associate editor, Anne Haddad, at Anne.Haddad1@gmail.com, and include your city and state.