Evidence-Based Risk Mitigation and Stratification
during COVID-19 for Return to Interventional Pain
Practice: American Society of Interventional Pain
Physicians (ASIPP) Guidelines
Authors: Shah Shalini 
Published: February 2021

Background: Chronic pain patients require continuity of care even during the COVID-19
pandemic, which has drastically changed healthcare and other societal practices. The American
Society of Interventional Pain Physicians (ASIPP) has created the COVID-ASIPP Risk Mitigation and
Stratification (COVID-ARMS) Return to Practice Task Force in order to provide guidance for safe
and strategic reopening.
Objectives: The aims are to provide education and guidance for interventional pain specialists
and their patients during the COVID-19 pandemic that minimizes COVID-related morbidity while
allowing a return to interventional pain care.
Methods: The methodology utilized included the development of objectives and key questions
with utilization of trustworthy standards, appropriate disclosures of conflicts of interest, as well
as a panel of experts from various regions, specialities, and groups. The literature pertaining to all
aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity
and mortality, and literature related to risk mitigation and stratification were reviewed. The
principles of best-evidence synthesis of available literature and grading for recommendations as
described by the Agency for Healthcare Research and Quality (AHRQ), typically utilized in ASIPP
guideline preparation, was not utilized in these guidelines due to the limitation based on lack of
available literature on COVID-19, risk mitigation and stratification. Consequently, these guidelines
are considered evidence-informed with the incorporation of the best-available research and
practice knowledge.
Results: Numerous risk factors have emerged that predispose patients to contracting COVID-19
and/or having a more severe course of the infection. COVID-19 may have mild symptoms, be
asymptomatic, or may be severe and life-threatening. Older age and certain comorbidities, such
as underlying pulmonary or cardiovascular disease, have been associated with worse outcomes. In
pain care, COVID-19 patients are a heterogeneous group with some individuals relatively healthy
and having only a short course of manageable symptoms, while others become critically ill. It is
necessary to assess patients on a case-by-case basis and craft individualized care recommendations.
A COVID-19 ARMS risk stratification tool was created to quickly and objectively assess patients.
Interventional pain specialists and their patients may derive important benefits from evidenceinformed risk stratification, protective strategies to prevent infection, and the gradual resumption
of treatments and procedures to manage pain.
Limitations: COVID-19 was an ongoing pandemic at the time these recommendations were
developed. The pandemic has created a fluid situation in terms of evidence-informed guidance. As
more and better evidence is gathered, these recommendations may be modified.
Conclusions: Chronic pain patients require continuity of care, but during the time of the
COVID-19 pandemic, steps must be taken to stratify risks and protect patients from possible
infection to safeguard them from COVID-19-related illness and transmitting the disease to others.
Pain specialists should optimize telemedicine encounters with pain patients, be cognizant of risks of COVID-19 morbidity, and take steps to evaluate risk-benefit on a case-by-case basis. Pain specialists may return to practice with
lower-risk patients and appropriate safeguards.
Key words: Cardiovascular disease, COVID-19, interventional pain management, COVID risk factors, diabetes, hypertension,
interventional pain care, novel coronavirus, obesity, SARS-nCoV2, steroids