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Treating individuals with chronic pain, who often have co-existing physical and mental health conditions, has long posed a unique set of challenges for healthcare providers both inside and outside the workers’ compensation industry. With COVID-19 now creating a myriad of additional obstacles, providers must implement new ways to help their patients cope with pain and strive to achieve a sense of wellbeing given limited access to doctors, therapists and, in some cases, medications they rely upon. To shed light on a variety of issues patients and providers alike are confronting, workers’ compensation experts Kimberly George and Mark Walls, in their second Out Front Ideas webinar addressing COVID-19, talk to pain specialists Beth Darnall, Ph.D., Associate Professor at Stanford University School of Medicine, and Steven Stanos, D.O., Director of Pain Medicine and Services at Swedish Health System in Seattle, Washington.
Darnall and Stanos have been indispensable in the workers’ compensation community when it comes to issues surrounding chronic pain. Both agree that with COVID-19 making it increasingly difficult for chronic pain patients to access medical treatment, these patients are experiencing stressors that leave them feeling more isolated and vulnerable than ever before.
When asked how healthcare providers in the industry are addressing these issues, Stanos describes a multi-prong approach he and his team are utilizing to offer treatment and support remotely. For one, Stanos and his colleagues are scheduling phone appointments with their patients in place of face-to-face meetings. Stanos emphasizes the importance of communication, and strongly believes the key to combatting pain and anxiety during the pandemic is to take the focus off his patients’ pain and, instead, concentrate on activity levels and relaxation techniques. According to Stanos, more than 800 doctors at Swedish Health are now providing telemedicine as opposed to only a handful of doctors who were providing these services pre-COVID-19.
In addition to phone appointments, Stanos’s team provides access to virtual pain rehabilitation programs that contain the same content used pre-COVID-19 and offer various breathing and relaxation techniques, including guided meditation, yoga, and tai chi demonstrations, to reduce pain and stress. Stanos’s patients also have the option of participating in a virtual round-robin of physical therapy, occupational therapy, psychological treatment, and relaxation therapy, as well as a HIPAA-compliant Zoom group therapy program.
According to Darnall, the Stanford pain clinic also transitioned to remote care after COVID-19, making available Zoom-based psychological treatment and wellness programs for individuals and groups, as well as on-demand treatment for self-management of chronic pain. The on-demand options have been popular as they are not tethered to therapists and give patients control over when and how to access treatment. Darnall explains that the on-demand alternatives, offered through the company AppliedVR, utilize “digital therapeutics” for acute and chronic pain in a home-based virtual reality setting where patients engage in 3-D visual content and audio programming through a headset.
Darnall is enthusiastic about the new interactive digital treatment platform as it allows patients to completely immerse themselves in the therapeutic setting. Moreover, it teaches individuals suffering from chronic pain new skills while they engage in rehabilitation, which Darnall says has proven effective for reducing pain intensity and interference. Darnall believes that personalized on-demand treatment is valuable in the age of patient-centered pain care as it gives chronic pain sufferers more power over their own treatment and improves access to evidence-based therapies. Additionally, notes Darnall, virtual immersive environments optimize self-regulatory skills, in part, because they offer visual biofeedback allowing individuals to see in real time how their own stress and pain levels can change. Darnall feels that these emergent technologies will be particularly helpful in the area of workers’ compensation because they can be specifically tailored to injured workers with chronic pain and/or mental health issues to include key content and address unique concerns existing in the workers’ compensation context.
Stanos is likewise a proponent of virtual rehabilitation as it relies on a number of mind-body techniques that have proven beneficial in pain treatment. He compared virtual rehab to graded motor imagery (GMI), a mirror therapy designed to treat chronic pain, in that both treatments involve concepts of retraining the brain’s response to pain and are helpful in the treatment of even very challenging pain conditions and phantom pain. Stanos notes that GMI has been successfully used to treat patients with work-related injuries who go on to develop chronic regional pain syndrome, a condition which can be difficult to manage.
Darnall says the virtual interventions have shown to be equivalent in efficacy to in-person therapy for the treatment of psychological and mental health disorders such as depression and anxiety, and, with respect to pain, they are particularly effective when pain is severe. Darnall cited a study at Cedars-Sinai Health System undertaken by digital health technologies researcher Brennan Spiegel, M.D., indicating that the low cost and easy access of virtual treatments allow these treatments to better meet the needs of pain patients than face-to-face therapies.
The American Academy of Pain Medicine recently released a statement regarding the best practices for treatment of pain during the COVID-19 pandemic, describing chronic pain as the leading cause of disability in the world, associated with multiple psychiatric co-morbidities and strongly linked to the opioid crisis in the U.S. The report touches on issues surrounding telemedicine and virtual treatments, mental health concerns, including stress and other psychological sequelae in caregivers/healthcare providers, the use of steroids and NSAIDs, and opioid management, and emphasizes the importance of balancing the access to pain care, and its long-term socioeconomic and personal tolls, against the immediate goal of minimizing risks for frontline healthcare providers and vulnerable patients. [PDF can be viewed here: https://academic.oup.com/painmedicine/advance-article/doi/10.1093/pm/pnaa127/5817092].
On the issue of opioids, Darnall has seen an increase in patients interested in tapering their usage following the outbreak of COVID-19. Although opioid weaning during a time of crisis seems counterintuitive, Darnall says that patients’ fear of losing access to their medication during the pandemic due to pharmacy closures or inability to meet with a physician has made them more motivated to regain control over treatment of their own pain. In fact, Darnall has noted a recent boost in participation in Stanford’s voluntary prescription opioid tapering program for individuals interested in reducing opioid medication very slowly, over a lengthy time period.
Stanos agrees that patients with chronic pain are generally worried about access to medication refills due to the COVID-19 restrictions. His clinic is e-prescribing to make refilling prescriptions easier. According to Stanos, many patients who struggle with opioids have, in addition to pain, poor coping mechanisms and high anxiety that are exacerbated by the COVID-19 crisis. With these high-risk patients, Stanos and his colleagues are doing bi-weekly or monthly phone visits in an attempt to curb opioid misuse.
Given the added stress caused by COVID-19, George and Walls encourage workers’ compensation service providers and claims teams to consider well checks for workers with open claims who cannot access care and may lack social support. George emphasized the importance of maintaining communication to determine if these individuals may be candidates for telehealth or a health benefit program offered by their employers. If communication suffers, George says, it may be more difficult in the future to ensure injured workers are getting the medical treatment and benefits they need.
Interested readers can listen to the full webinar here: https://goto.webcasts.com/viewer/event.jsp?ei=1291805&tp_key=32c5e6b020
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