with Christopher Eccleston, PhD, director of the University of Bath’s Center for Pain Research
The COVID-19 pandemic continues to reshape the relationships between providers and patients, notably by the need to adopt telemedicine almost overnight. While telehealth strategies have been developed gradually over the years, especially among psychotherapists, the sudden push for its use across all specialties and for patients with non-urgent, long-term conditions – such as individuals with chronic pain – is stretching the capabilities of its providers.
But when it comes to pain patients and their need for ongoing treatment, including the management of pain flares and the monitoring of medications, the development of telehealth best practices is crucial, according to Christopher Eccleston, PhD, director of the University of Bath’s Center for Pain Research. He, along with peers from universities and clinical research centers across the UK, US, and Australia, just published a paper on this topic in Pain.
“People do not spontaneously recover from chronic pain,” Dr. Eccleston told PPM,noting that there are three main risks that come with a lack of, or undertreatment of, chronic pain:
“Changing practice [to apply telemedicine] in such an unplanned way will have positive and negative consequences, many unforeseen,” concluded Dr. Eccleston, et al, in their paper, which aims to guide clinicians working under these far-from-routine circumstances. A summary of their findings follows, including some practical tips from Dr. Eccleston.
It has been well reported that older age (65 and up) and underlying and/or immune medical conditions put individuals more at risk of contracting the COVID-19 virus and/or of developing complications. Some of the reported risk factors are also “associated with higher levels of chronic pain prevalence and burden,” wrote Eccleston’s team. For instance: socioeconomic status, smoking prevalence, chronic disease comorbidity, and access to healthcare. “Therefore, populations with higher existing pain burden are more likely to experience a higher incidence of COVID-19 infections, greater disruption to their usual healthcare access, and worse downstream consequences of abruptly altered healthcare,” they wrote.
And while many patients living with chronic pain may be less mobile, and therefore already more socially isolated than healthy individuals, this new level of isolation can have both positive and negative effects. Injuries stemming from activity or driving may go down, for instance, wrote the researchers, but domestic violence and household injuries, as well as the postponement of elective surgeries, may actually increase the population of patients living with chronic pain and disability.
Undertreating patients can exacerbate or prolong their problems, noted Eccleston and colleagues.
“When people with chronic pain are denied assessment and treatment, their condition can worsen significantly; spontaneous recovery is rare,” they wrote. They also cited data demonstrating that individuals waiting to see a doctor to assess chronic pain may suffer from increased pain and depression, and poor quality of life, especially among those who wait more than 6 months for answers and/or treatment.
These risks extend to children and adolescents living with pain as well, as they also report a high burden of symptoms while waiting for clinical evaluations.
For clinicians scrambling to find ways to assess and treat chronic pain remotely, start with the basics, such as the telephone, advised Eccleston and co-authors.
Remote patient assessment – as well as follow-up care – is possible when clinicians use cameras or other devices to share images of paper assessments and outcome measures. In addition, web-based systems such as the Collaborative Health Outcomes Information Registry (CHOIR) developed by Stanford University in partnership with the National Institutes of Health, enables providers to perform a basic, multidisciplinary patient assessment before even meeting a patient.
“Although there are limitations to the lack of hands-on physical examination possible with telehealth, a modified virtual examination may allow an initial treatment plan to be started,” they urged.
In addition, providers can encourage pain self-management—whether it be a home-care pain-relieving device, a video exercise program, or stress-reducing mediations—that they trust. “These interventions aim to provide the same information and training in self-management skills as provided in face-to-face pain management programs but use technology in different ways,” although they have not undergone controlled trials, the researchers explained.
The unexpected expansion of full-scale telemedicine for chronic pain management means that data on its benefits (and risks) is limited. In general, emphasized the researchers in their paper, “the evidence is similar to that from primary care studies and is cautiously optimistic but recognizes barriers to implementation, unforeseen harm, and potential for inequity in access and use.”
Concerns around tracking patient compliance virtually, especially among disadvantaged populations who may struggle with technology access, as well as issues of privacy and transparency, will remain. But the authors did include in their report some practical recommendations for clinicians aiming to quickly adapt to this new paradigm (see Table 2 of the published paper).
A key strategy is to remain flexible. “This is a stressful time for everyone, but particularly for those with long-term conditions. Each patient will be dealing with extra pressures (eg, financial, childcare, and health of others) that may be influencing her or his pain and ability to cope.”
In Dr. Eccleston’s clinical experience, “Patients are typically interested in all treatment options, including telehealth, and this is even more frequent when the choice is between telehealth or nothing.”
He noted that several myths persist about different groups of patients and their use of technology related to telemedicine:
The reality is that the main barriers to current telehealth use are systems-based, explained Dr. Eccleston. “For example, we have heard from one US state that the reason they are slow to implement telemedicine for chronic pain was that it was hard to bill, and licensing issues for different practitioners with patients from different jurisdictions caused problems,” he noted.
However, the current and future benefits of telehealth should outweigh these barriers, he said. “Telemedicine increases access and can increase access to a broader base of expertise,” he told PPM. In addition, “a larger telehealth and eHealth solution (with some automation) can increase access at scale, and a smarter eHealth and mHealth solution (with use of remote sensing) can increase access, at scale, and provide personalization and, so, improve treatment.”
For clinicians, there is no downside to here, he added, only benefits, such as “seeing more patients, personalizing more treatments, increasing speed of access.” Even when pain patients are able to return to in-person sessions, telemedicine will likely continue, requiring work in several areas to maximize its effectiveness for both the patient and the provider.
In fact, Dr. Eccleston and his co-authors urged clinicians to make note of how things go while using telecare. “When we come to redesign services after the pandemic, we will need to share that experience and use it to learn what works, to modify what does not work, and to build new models of care for people living with chronic pain.”
More specifically, added Dr. Eccleston, “We need to wholescale re-imagine the chronic pain clinic to include a needs-based planning system for people with chronic pain across the lifespan, with the person at the center of care, a shift on expertise from individuals to systems, and widespread adoption of computing technology, using both small and big data to understand how people behave when in pain,” he emphasized.