key: cord-1000950-uu3b529c authors: Song, Xue-Jun; Xiong, Dong-Lin; Wang, Zhe-Yin; Yang, Dong; Zhou, Ling; Li, Rong-Chun title: Pain Management During the COVID-19 Pandemic in China: Lessons Learned date: 2020-04-22 journal: Pain Med DOI: 10.1093/pm/pnaa143 sha: 8a76aa66596769fac77d752fee2d9c8a5d8e5a07 doc_id: 1000950 cord_uid: uu3b529c nan It was late January, during the cold winter before the Lunar New Year, when Wuhan began its 76-day lockdown in response to an outbreak of COVID-19. The rest of China followed suit shortly thereafter with the implementation of strictly enforced quarantine measures (1, 2) . The Chinese central government issued a nation-wide order by listing COVID-19 as a Level 2 infectious disease warranting priority management (2) , which has been invoked in the past for deadly infectious diseases such as smallpox, anthrax, and cholera. The subsequent emergence and spread of SARS-CoV-2 around the world has ignited a global crisis, with the World Health Organization (WHO) issuing a global health pandemic notice and urging the avoidance of non-essential travel (3) . In China, while non-essential workers were requested to stay home, those working in healthcare, emergency services, and disaster control found themselves with more responsibility than ever, mobilized like troops during war. In the initial stages of the pandemic spanning late January to early February, medical systems in Wuhan faced overwhelming shortages of health care workers and key medical resources including medical-grade personal protective equipment, as well as limited space in hospitals for managing the surge of patients with COVID-19. In the face of these challenges, the central government quickly organized. A total of 42,600 health care providers and workers as well as millions of tons of medical supplies were sent to Wuhan and its neighboring areas in the Hubei province from all over the country (4), with additional aid coming from other countries and various international humanitarian aid organizations (5, 6) . Those working on the front lines in Wuhan have been serving as part of the ongoing fight against the COVID-19 pandemic, a largescale global public health challenge. Having born witness to such ongoing devastation, the world is recognizing the importance of examining our existing public health and health care systems, their potential to be maximally effective during the pandemic, and how they can be improved. Here, we report some of our personal experiences as Chinese physicians and scientists working in the field of pain medicine in Wuhan as well as Shenzhen, another large metropolis in China severely hit by COVID-19. We discuss strategies that have been helpful in pain management for our patients during the pandemic and provide recommendations based on the lessons we learned. Though first reports of SARS-CoV-2 emerged in December 2019, the government and the public ignored these warnings that emerged from the heart of Wuhan, failing to realize the potential threat of the novel coronavirus. As a result, members of the public, hospitals, and medical workers did not realize they were being exposed to SARS-CoV-2 until hospitals were overwhelmed. The numbers of patients with fever, pneumonia, and other related symptoms rose exponentially, quickly using up most available resources in hospitals. In order to concentrate available resources to help patients with the most severe conditions, most Wuhan medical services not directly involved in intensive care were partially or completely shut down, with their resources redistributed to intensive care units and COVID-19 related procedures. These closures included the closure of pain management departments, posing a challenge for patients with medical conditions causing severe chronic pain such as cancer, as well as for vulnerable populations who rely on our services such as the elderly and disabled. In our pain management departments, we implemented a series of practical strategies to better take care of our most vulnerable patients during the epidemic. During government-mandated quarantine, patients were allowed to file requests for outpatient care. After screening by the strict control requirements, patients who appeared in pain clinic were roughly triaged into different levels of care. The first level included patients with mild to moderate pain with relatively clear etiopathogenesis and who were relatively few comorbidities and in good condition. They were given prescription medications to manage their pain at home along with necessary telemedicine support. Those who have had close contact with any individuals diagnosed with or suspected to have COVID-19 or who had recently travelled to or from the epidemic area were required to self-quarantine at home and report for further observation. The second level of patients included those with mild to moderate pain and those who either had COVID-19-like symptoms or had close contact with individuals diagnosed with COVID-19. The third level included those with severe pain or with emergency conditions. These patients received immediate treatment in clinic or were admitted as inpatients for further testing and treatment. For patients triaged to levels 2 or 3, those who presented with any symptoms and/or suspicious from physical examinations that might indicate a COVID-19 infection were immediately sent to an isolation ward for further testing and treatment. For inpatients, contact between the patient and health care workers was minimized by scheduling the minimal number of necessary pain treatments, and recovered patients were discharged and supported with telemedicine aid. For those patients with severe pain, we arranged necessary pain treatment including surgery as needed. Among our priorities was the timely identification of patients in our pain clinic who were at high risk of COVID-19 infection in order to provide aid to patients with severe cases of COVID-19, to reduce transmission, and to ensure the proper allocation of limited medical resources. With the help of public health systems, we were able to keep most patients home and provide them with necessary medical services including telemedicine support. These strategies brought tremendous benefits to both health care providers and patients and allowed our pain clinics to continue to function during the epidemic. Telemedicine became a convenient and effective way to provide necessary medical services to patients with chronic pain during the initial periods of the epidemic, as it allowed patients with nonemergent conditions to remain at home and allowed hospitalized patients who had been discharged early to maintain continuity of care. Via telemedicine, we have been able to provide our patients with instructions for administering prescription and non-prescription drugs as well as guidance for physical at-home exercises for pain relief. When possible, bedside procedures were performed during home visits for patients in urgent need. For instance, in our pain departments in Wuhan and in Shenzhen, some patients with cancer pain continued to receive continuous home treatment with programed intrathecal injection of opioids. We arranged regular home visits for these patients and provided minimally necessary management such as drug refills. During the nation-wide quarantine, city traffic was also greatly reduced, allowing physicians to make home visits more easily. Patients 6 with severe pain needing urgent treatment or with complex conditions were still seen at our pain clinic in-person or referred to other departments for further observation and treatment. The very first outpatient in the pain clinic at Wuhan Fourth Hospital to be An increasing concern among medical providers is that the fear of missing a COVID-19 infection can lead to the failure to recognize other urgent medical issues. At our Shenzhen hospital, a 34 year old man visited the pain clinic with moderate rightsided rib pain and mild fever. This patient had travelled from Wuhan one day before the city's lockdown and had already served two weeks of quarantine in Shenzhen. Medical staff immediately suspected COVID-19. He was sent home for another twoweek quarantine with telemedicine follow-up. During this second quarantine, the patient had persistent fever, worsening pain, and was partially paralytic when we saw him in our clinic two weeks later. Only at this point was the patient found to have a spinal neurotoma in the right 8 th thoracic region, with his temporary partial paralysis resulting from tumor compression of the spinal cord. The patient received surgical intervention and did well post-operatively. He was also confirmed negative for COVID- Some of our patients hospitalized with COVID-19 complained of mild to moderate body pain. Their COVID-19 associated pain was similar to patterns of pain we have seen in some outpatients as described previously, suggesting viral-induced myalgias. This pain may have also been due long hospital bed stays causing pain in the joints, spine, muscles and other soft tissues, as well as physically manifested pain associated with COVID-19 related psychological stress. Throughout their hospitalizations, we made sure to schedule regular visits to their isolation wards and provided appropriate pain consultant and management. The first lesson we learned was that we must ensure that key information regarding serious infectious diseases is as accurate and as transparent as possible with timely updates. As viruses have the potential to be spread to anyone, it is immensely important to keep the public informed of ways to stay hygienic and minimize the spreading of disease. Public administration and media should be honest and responsible in order to facilitate public awareness as well as reduce false rumors that can cause widespread panic and unease. The right to public discourse including constructive criticism of ongoing public health efforts should be protected and even encouraged in order to achieve optimal strategies in addressing various aspects of the pandemic. Humility in the face of the unknown is a strength. Globally, countries should take firm action and implement preventive and protective measures. Governmental support and coordination of efforts is necessary to ensure sufficient access to and distribution of medical resources for communities and health care systems in need. According to the WHO, quarantine and personal protection are two of the best ways to limit the spread of infectious respiratory diseases (7) . Wuhan's lockdown and China's nation-wide quarantine dramatically reduced the spread of COVID-19. Protecting oneself means protecting others, because one's own safety depends on the safety of the whole community. Since the early stages of COVID-19 in Wuhan, Chinese people were required to wear masks to reduce the spread of disease (8), a strategy which has also been recommended by WHO for most respiratory infectious diseases (7). Wuhan's experience provided us with both tragic and encouraging information about the importance and effectiveness of personal protection. A report showed that, in some of the Wuhan's hospitals, 54 physicians and nurses were infected with the SARS-CoV-2 virus from late January to March 2020. Of those infected, 22% were working in high risk departments such as infectious disease and intensive care units, while the majority (78%) worked in departments with less direct exposure to COVID-19 patients (9) . The Red Cross Society of China reported that 35% of infected doctors and nurses nationwide (n=2971) worked in high-risk departments and 65% in low-risk departments (10) . Amazingly, the 42,600 physicians and nurses sent to Wuhan from dozens of other provinces and cities to provide medical support to the city, none were infected with COVID-19 (11) despite working day and night on the front lines, likely because they were equipped with the adequate personal protective equipment. These data provide strong evidence that sufficient personal protection can prevent the spread of COVID-19. The epidemic provided many medical professionals an opportunity to incorporate telemedicine into pain management for the first time due to the urgent need for remote health care services. For many of patients with different types of chronic pain, telemedicine support in addition to necessary in-person visits may be a much better strategy for outpatient treatment, even outside of epidemic conditions, as it is both cost-effective and does not compromise quality care for patients with chronic pain. Telemedicine is increasingly being recognized as a valuable tool to both healthcare providers and patients and is worthy of further evaluation and implementation worldwide, particularly in China, where telemedicine support has not been widely used and there is great demand for both inpatient and outpatient health care. The national health council has recently emphasized the online services to further strengthen the prevention and control of epidemic situation in Hubei (12). During quarantine, patients with chronic pain were forced to stay home, while many patients who would have qualified for in-person clinic visits chose to stay home due to fear of COVID-19 infection. Now that quarantine is being lifted in many parts of China, many are still understandably wary of seeking in-person health care. We must consider strategies to encourage those with health issues needing management to seek outpatient care, as well as continue to provide telemedicine support. Meanwhile, health care providers should be aware that pain may be related to COVID-19 infection 11 in a variety of forms as we discussed in our cases-as an early sign of infection, or as a sequela of infection and iatrogenic effects such as prolonged bedrest and psychological stress. Of course, pain may very well be a manifestation of a non-COVID-19 related process. These patients can be better served with our improved strategies of pain management. We may prepare ourselves to see more patients who previously had COVID-19 infection visiting pain clinic as the epidemic slows. Chinese National Health Council: Document No Wuhan City Government Document No.1. 2020. Regarding Coronavirus Pneumonia Epidemic World Health Organization Director-General's statement on the advice of the IHR Emergency Committee on Novel Coronavirus Joint Prevention and Control Mechanism of State Council of China: Press Conference The Red Cross Society of China: Aid Programs for Anti-SARS-CoV-2 Wuhan Customs: Notice on Customs Clearance of Import Donations Used for Prevention and Control of New Type Coronavirus Pneumonia World Health Organization: Infection prevention and control during health care when COVID-19 is suspected. Interim guidance Office of the Chinese National Health Council: Circular on the issuance of technical guidelines for the prevention and control of new forms of coronavirus infection in medical institutions (1 st version Clinical Characteristics of 54 medical staff with COVID-19: A retrospective study in a single center in Wuhan The Red Cross Society of China: Byte Beat Medical Big Data Foundation Joint Prevention and Control Mechanism of State Council of China: Caring the frontline workers Joint Prevention and Control Mechanism of State Council of China: Notice on Developing Online Services to Further Strengthen the Prevention and Control of Epidemic Situation in Hubei Province