Lockdowns: Implications for Pain...

[drusso]

Is your state in Lockdown? How will it affect your practice?

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[SSdoc33]

Local hospitals are starting to cancel elective surgeries again. As long as your injection patients dont end in the ER or taking up a hospital bed, i dont think it will have a big effect this time around. I am not going to cancel my RFs, mbbs, and SIJs unless there is a mandatory stay at home order

 

[hyperalgesia]

Local hospitals are starting to cancel elective surgeries again. As long as your injection patients dont end in the ER or taking up a hospital bed, i dont think it will have a big effect this time around. I am not going to cancel my RFs, mbbs, and SIJs unless there is a mandatory stay at home order

Seriously they're canceling elective cases again? I didn't think that would happen again sheesh.

 

[lobelsteve]

Seriously they're canceling elective cases again? I didn't think that would happen again sheesh.

They are only canceling his cases.

 

[SSdoc33]

They are only canceling his cases.

Ha. Id be ok with it. More patients than i know what to do with

 

[SandmanMD]

If the hospital we have a transfer agreement with is full and on bypass then we would be forced to cancel procedures in our ASC.

That did happen last week to an ASC last week a few cities away.

Hospitals canceling their own internal cases wouldn’t impact us.

 

[10KHertz]

Lots of admissions , but ICUs not overwhelmed. So electives are go for now in northeast . Covid Death and severe complication rates are lower for all age groups for many reasons.

 

[NOSfan]

Here was a rebuttal AGAINST prohibiting pain procedures from earlier this year by The Spine Pain Institute of NY.

March 20, 2020
Given the current COVID-19 outbreak and the emergency declaration, we have been advised that cases considered to be ‘elective’ are to be rescheduled in as long as 6 to 8 weeks. This declaration is of vital importance in an effort to decrease the spread of the COVID-19 virus. However, we must do so with consideration for each patient the possible secondary ramifications of them not receiving their care.

Cancellation of elective cases was designed in emergency declarations to help free/preserve medical resources, personnel, and equipment as well as decreasing viral spread via crowded waiting rooms or the possibility of infecting healthcare providers who may come in contacted with sick patients. Special considerations with the COVID-19 virus are its involvement of the respiratory system and necessity for general anesthesia, both intraoperatively and post operatively.

While some may consider the field of pain management to be “elective” in nature, this vantage point does not fully account for the impact of delaying pain management procedures, let alone the magnitude of what it would mean to a vulnerable population having to contemplate remaining in excruciating pain for 6-8 weeks, or more. While these measures are being taken to decrease the threat of COVD-19, limiting interventional pain procedures may actually increase risk to our patients and community in the following ways:

1. Opioid Use:
   1. The progress made over the last 6 years in decreasing opioids use, maintaining patients on the lowest possible doses, and fighting the opioid epidemic can be easily erased. Interventional pain procedures are a treatment for pain and, importantly, present an alternative/adjunct to opioid pain medications. Patients who present to pain management have typically failed conservative treatments already, are significantly disabled secondary to pain and are looking for the next option in the treatment algorithm for their condition. Without pain procedures, patients in need will inevitably turn to opioids. Patients who are told they cannot be treated for 6-8 weeks will have no choice but to turn to opioids, and we as physicians will have no choice but to abide them as our hands will have been tied. For patients who are opioid naïve or those that we have weaned down, the introduction or increase in opioid medications due to the recommended delay of pain procedures will increase the risk of dependency or addiction. In 2017, the Center for Disease Control (CDC) published a study their Morbidity and Mortality Weekly Report that showed patients can develop dependency on opioids in as little as 5-days and their risk of becoming long-term opioid users increases by 13% after just 8 days of use. Considering that in 2016 there were 42,245 deaths related to opioids, which equaled 1 in 65 deaths in the United States (Gomez), we cannot afford even a 1% increase in addiction.

Aside from the risk of addiction and the consequences it carries, the associated side effects of opioids use carries additional burdens. In a study published in 1996, the authors reported: ‘Overwhelming evidence suggests that opioid use affects both innate immunity and adaptive immunity. Chronic administration of opioids decreases the proliferative capacity of macrophage progenitor cells and lymphocytes’ (1) More recently, in 2018 in the British Journal of Pharmacology, the authors found an inverse relationship between opioids and the immune system such that the more opioids one consumed, the weaker their immune system became (2). As we are in the middle of a pandemic, we should be doing everything possible to avoid medications that weaken the immune system.

1. The risk of non-treatment.
   1. Elderly population: Pain and disability in the geriatric population leads to an increased morbidity and mortality. Risks include pulmonary, hospitalizations, decreased independence, increased in incidence of depression. Hirsh et al reviewed 2 million Medicare claims demonstrated that in vertebral compression fractures, a condition that can be treated with conservative measures or a low risk procedure called a kyphoplasty, treating the fracture demonstrated that it took one procedure to save a life out of 15 procedures performed (3). This study underscores the implications of non-treatment of pain in the elderly patient. Additionally, opioid pain medications, neuropathic pain medications, and muscle relaxants in the geriatric population carry increase risk such as sedation, confusion, dizziness, respiratory depression, abnormal response to medications, constipation, urinary retention, to name a few (4).
      
      
   2. Emergency room visits: Low back pain is one of the top ten reasons for visits to the emergency room (5). The inability to appropriately diagnose and treat pain, through a combination of conservative treatments such as PT/Chiro, medical management, and interventional procedures will undoubtedly increase the number of emergency room visits, and would only exacerbate the issue of overcrowding in the ER and potentially expose more patients to pathogens such as COVID-19. Moreover, patients at home who have been told their pain procedure is going to be delayed 6-8 weeks will have little alternative but to turn to the emergency room for relief.
      
      
   3. Loss of function. A proportion of pain management practices are treating patients who are missing work secondary to pain. Economic hardship on these families secondary to loss of earnings in a time such as this can lead to longer times out of work and potentially the loss of their job. Given we are in a time where the concern for continued employment is the highest it has been in recent memory, we need to get these patients treated in order to avoid losing their employment.

This burden is also placed on the employer in these instances, as an injured worker cannot simply be ‘replaced’. The employer holds the position to give their employee a fair chance at improving, and simply hiring another employee is not a solution, given the injured employee can return to their position.

1. Potential for diversion and abuse. If patients are unable to control their pain with medications, or cannot get pain medications, we run the risk of patients now getting opioid medications from non-medical sources, or seeking illicit drugs such as heroin. While this may appear extreme, the opioid/heroin epidemic and ease of getting these substances should not be underestimated.

For these reasons, the performance of pain management procedures in a hospital or ambulatory surgical center setting for patients should be reevaluated. The morbidity and mortality of doing so could be worse than that of the COVID-19.

There are also several factors which limit exposure of resources to the health care system in the event of a sudden emergency:

1. Procedures typically last less than 15 minutes and patients are typically discharged in 30 minutes after the procedure. Should an emergency arise, a procedure can be completed or aborted.
2. General anesthesia is rarely needed for pain procedures. Therefore, the use of ventilators or the potential need to be in a closely monitored situation after a procedure are slim to none. These resources will remain available if needed.

Additional precautions can be taken for procedures, in addition to the CDC Guidelines on the matter, such as taking all staff, patients, and visitors temperature prior to entering building, limiting waiting room occupants to 10 people, and have patient escorts waiting outside, perhaps in their car, and they will be called for pickup.

Criteria for those to be considered for interventional procedures:
-Patients who have severe pain, with a rating >/= 8 and/or an ODI >40 (severe disability).
-Unable to control pain with pain medications, or the need for increased use of pain medications
-Patients who suffer from pain/disability that carries a severe impact on activities of daily living including the ability to work.
-Patients who have pain that would make them go to the emergency room or if they have recently been to the emergency room for this condition.

Patients that meet the above categories but require extra considerations:
-Is over the age of 65.
-With underlying cardiopulmonary compromise.
-Had a non-pain related emergency room visit within the last two weeks.
-Has traveled outside the country within the last 2 weeks to Europe, the Middle East, or Asia.
-Has a fever, cough, shortness of breath, or flu-like symptoms, or has had contact with someone with these symptoms in the last two weeks.
-Is expected to receive general anesthesia.

COVID-19 has made providing the best patient care and contributing to the overall good of society a balance. As physicians we must weigh the risks and benefits of patient care and in this case, containment and preparedness for COVID-19. The treating physician needs to use their best clinical judgement and these recommendations can provide a guideline in regard to their decision making and care should be individualized to each patient.

Kenneth B. Chapman, MD
Director, Pain Medicine
Staten Island University Hospital
ssistant Clinical Professor, NYU Langone Medical Center

 

[kstarm]

We have been told that it is very unlikely the state will shut down electives and it will be up to the individual hospitals to decide. We are having more issues with staffing leading to canceling procedures as so many people are out related to COVID, either themselves or usually some potential community exposure. My daughter had a cough and sore throat. I had to refrain from any in person visits until her COVID test came back. Every time the kids have a new cold symptom this is going to be the protocol. It will not be long before people just lie about symptoms/exposure due to the significant hassle it is and the loss of work/$.

Isaac