As the opioid crisis continues in the shadow of the COVID-19 pandemic, new restrictions present challenges to pain and opioid management for surgical patients. The opioid crisis continues as opioid addiction and overdose deaths persist nationwide. Acute surgical pain exacerbations in conjunction with limited access to social, mental, and medical resources 1, 2 increases the risk of excess opioid prescribing, diversion, misuse, and dependency. 3 This may manifest in unnecessary emergency department visits, hospital admissions, increased rates of drug overdoses, and suicide. 4 Health care systems must adapt to provide services for these patients. 5 Telemedicine Telemedicine allows real-time, audio-video communication between patients and clinicians in remote locations, 6 and can potentially address the novel challenges to pain management for surgical patients during the pandemic. 7, 8 Nascent literature has demonstrated increased utilization and acceptability of telemedicine services in the United States. 9,10 Benefits include saving travel time and cost, reduced missed visits, and improved inter-clinician communication 11 without comprised quality of care. A randomized clinical trial comparing telemedicine to usual care for rural veterans with post-traumatic stress disorder (PTSD) showed that patients using telemedicine were engaged in psychotherapy and had reduced PTSD symptoms compared with patients using usual care. 12 Official Journal of the American Academy of Pain Medicine Despite the benefits, telemedicine alters traditional patient-provider relationships. 13 The high cost of implementation and maintenance may render services unaffordable. 14 It may inadvertently widen healthcare disparities as a consequence of patients lacking access or ability to use technology. [15] [16] [17] A system-wide approach is necessary to manage knowledge gaps in confidentiality and HIPAA compliance. 18 The Johns Hopkins Perioperative Pain Program (PPP) during the COVID-19 Pandemic
To address the opioid crisis, the PPP has coordinated care for surgical patients on long-term opioid therapy (LTOT) and opioid-naïve patients at risk of LTOT by utilizing a personalized pain management plan centered in multimodal and regional techniques. [19] [20] [21] A prospective study of PPP patients showed significant reduction in morphine milligram equivalent, improved pain scores and self-reported physical function for postoperative patients on LTOT. 22 To provide services for new patients undergoing urgent or emergent surgeries and preexisting patients, the PPP has transitioned to telemedicine. Table 1 describes adaptations to the PPP operation. 23 As a clinic within a tertiary academic medical center, the PPP continues to receive referrals for patients undergoing urgent or emergent surgeries during the COVID-19 pandemic. To continue providing care for these patients, and for established patients who are undergoing opioid tapers that are individualized to their needs, we transitioned PPP to telemedicine using the existing infrastructure at Johns Hopkins. The COVID-19 public health emergency declared by the
Official Journal of the American Academy of Pain Medicine 4 without conducting in-person visits. Table 1 describes adaptations to the PPP work systems and processes to ensure a successful transition to telemedicine. 24 Table 1 Adaptations of PPP work systems and processes for telemedicine Many patients have already expressed their preference to continue using telemedicine; a preference predictably seen in patients who are out of state. Patients who require more frequent urine toxicology screenings or with greater medical acuity are seen in the clinic. We predict that
Official Journal of the American Academy of Pain Medicine 7 telemedicine will become an integral part of our practice and anticipate that 50% of our practice may remain this way during the remainder of the COVID19 pandemic and possibly after. This is pending barriers in reimbursement and state licensure laws as current telemedicine restrictions are transient during the duration of the CARES Act. 25
In the midst of the COVID-19 pandemic, the PPP's innovative transition to telemedicine has allowed us to provide continuity of care for patients. Further investigation is needed to assess whether telemedicine for pain management is efficacious compared to in-person visits, and if access to and quality of perioperative pain management is maintained. If equivalent, our program may serve as a model to adapt telemedicine for vulnerable patients with limited access to pain management and mental health specialists.
Official Journal of the American Academy of Pain Medicine