key: cord-0743894-nf6figib
authors: Mukhida, Karim; Stewart, Joanne; Mehrpooya, Reza; Fraser, John
title: Virtual care for patients with chronic pain and addictions during the COVID-19 pandemic
date: 2020-08-25
journal: Canadian journal of pain = Revue canadienne de la douleur
DOI: 10.1080/24740527.2020.1785856
sha: fb50cc116fa2650a0b9e24ea25222127b1722300
doc_id: 743894
cord_uid: nf6figib

nan

Recent correspondence from Webster et al. 1 and D'Alessandro et al. 2 has highlighted the challenges that the COVID-19 pandemic has posed to the provision of chronic pain care. That populations with the combination of chronic pain and a socioeconomically vulnerable or marginalized status have been particularly affected [1] [2] [3] [4] resonates strongly with our local experience managing patients with chronic pain and addictions or opioid use disorder. The pandemic has led to the suspension of all non-urgent ambulatory clinic visits and group sessions at the Queen Elizabeth II Health Sciences Center Pain Management Unit (QE2 PMU) as well as visits to a community-based outreach clinic for patients with chronic pain and addiction comorbidities in Halifax, Nova Scotia, as of March 18, 2020.

As at SickKids, 1 the QE2 PMU and outreach clinic immediately transitioned to providing virtual care in order to provide continuity of care to patients with addictions or opioid use disorder. To date, virtual care has been provided to 322 patients solely by telephone for a variety of reasons specific to the socioeconomic circumstances of this patient population. For example, although telemedicine has been used to liaise with our patients in rural communities, this has not been possible since community hospitals have stopped providing such services during the pandemic. Many of our patients do not have access to computers, nor adjuncts such as webcams, nor home access to internet services. Some patients do not have home telephones or cell phones and have had to borrow a phone in order to contact the clinics. Other patients have no fixed address. These barriers have posed challenges in providing ongoing care to these patients. In the past, patients could physically return to the clinics to obtain care, but this is no longer possible due to physical distancing and clinic closures. In order to maintain ongoing care during the pandemic, attempts have been made to set up specific dates and times for telephone follow-ups to facilitate patients' attempts to access a telephone. Because some patients may not have telephones of their own, the issue has been considered of how the QE2 PMU or outreach clinic can best contact patients without breaching patient confidentiality.

Although chronic pain assessments continue to occur in a multidisciplinary way with both a physician and nurse, virtual care has necessitated changes to certain elements of care provision. For example, it has not been possible to perform urine drug screens or urine tandem mass spectrometry that have been used as components of screening for opioid aberrant and addiction behaviors. It has been more challenging to assess nonverbal cues over the telephone, such as drug-related behavioral changes, and to evaluate for stigmata of recent intravenous drug use, such as track marks or infections. Patients have expressed increased anxiety and stress during the pandemic, which they found has affected their chronic pain. Some patients have endorsed using more medication than usual or more than has been prescribed as a manner of coping. This has resulted in some difficult conversations during which prescribers have resisted increasing opioid doses for what appears to be stress-related symptoms. Whereas some patients may have been going to the pharmacy on a frequent basis to pick up opioids or for witnessed dosing, given advice to maintain physical distancing, some patients have been allowed a greater number of days of carries of medications. For others, daily pickups and witnessed dosing have remained the safer option. We continue to liaise with pharmacists about their perspectives regarding aberrant opioid behaviors because they have the opportunity to see patients who continue to pick up their medications.

The COVID-19 pandemic has created challenges for patients with chronic pain and addictions that cannot be fully addressed by virtual care. Some of our patients have lost their jobs and have found that the costs of medications such as buprenorphine/naloxone are now prohibitive. Some of these patients have resorted to purchasing opioids on the street at lower cost. The Addictions Clinic at the Nova Scotia Hospital provided patients with an opportunity to obtain other types of care that are no longer available, including access to a place to sleep for a few hours, snacks, or the hospital library, as well as the opportunity to socialize with other patients.

Some aspects of virtual care for chronic pain and addiction management have been advantageous. Given the public health emphasis on physical distancing, many patients have been anxious to come to the QE2 PMU because of concerns of becoming infected with the novel coronavirus and so have appreciated the opportunity to obtain chronic pain care at least virtually. Finding transportation to get to the QE2 PMU or outreach clinic is challenging for some patients, and obtaining virtual care has therefore helped them avoid logistical and financial travel barriers. Pharmacists taking verbal orders for opioid prescriptions has been convenient for patients, who no longer have to visit the QE2 PMU or outreach clinic to pick up a duplicate opioid prescription. Pharmacies have also been delivering medications to patients at no cost. From the perspectives of the health care providers, the opportunity to interact with patients virtually has enabled some continuity of care. Indeed, it is anticipated that even once the pandemic has subsided to the extent that usual in-person clinic visits are possible, virtual care for patients with chronic pain and addictions will continue in some form.

Karim Mukhida does not have any conflicts of interest to declare. Joanne Stewart does not have any conflicts of interests to declare. Reza Mehrpooya does not have any conflicts of interests to declare. John Fraser does not have any conflicts of interest to declare. Research ethics board approval and informed consent from patients were not required for this letter to the editor.

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