key: cord-0690946-za8v0poy authors: Rahman, Sarah; Speed, Traci; Xie, Anping; Shecter, Ronen; Hanna, Marie N title: Perioperative Pain Management During the COVID-19 Pandemic: A Telemedicine Approach date: 2020-09-11 journal: Pain Med DOI: 10.1093/pm/pnaa336 sha: f16ff908cb2c7997cf4613d17108b46e2d7732be doc_id: 690946 cord_uid: za8v0poy nan 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 SAMHSA Issues Guidance on OUD Treatment During COVID-19. Psychiatric News American Psychiatric Association An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19 Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic Suicide and the Great Recession of 2007-2009: the role of economic factors in the 50 U.S. states An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19 AMA quick guide to telemedicine in practice Virtually Perfect? Telemedicine for Covid-19 The Role of Telehealth in the Medical Response to Disasters Seven years of telemedicine in Médecins Sans Frontières demonstrate that offering direct specialist expertise in the frontline brings clinical and educational value Number of telehealth patients worldwide The role of telemedicine in postoperative care Telemedicinebased collaborative care for posttraumatic stress disorder: a randomized clinical trial Telemedicine: new technology, new promises? The costs of critical care telemedicine programs: a systematic review and analysis Navigating the digital divide: A systematic review of eHealth literacy in underserved populations in the United States Digital health interventions: widening access or widening inequalities? Public Health No Digital Divide? Technology Use among Homeless Adults The role of telemedicine in postoperative care An Innovative Perioperative Pain Program for Chronic Opioid Users: An Academic Medical Center's Response to the Opioid Crisis A model for an institutional response to the opioid crisis Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program Seven years of telemedicine in Médecins Sans Frontières demonstrate that offering direct specialist expertise in the frontline brings clinical and educational value A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety