Pain Control in Telemedicine

Pain control is a common complaint brought up during a medical visit, whether that visit is in-person or electronic. How doctors proceed while addressing these concerns via electronic means with little or no previous relationship with the patient can be tricky. During the times of COVID, states have lessened the prescribing regulations for controlled substances. Many states still require an in-person evaluation prior to Controlled Dangerous Substances (CDS) prescribing.

Determining the patient’s pain scale, assessing the type of pain, and prescribing an appropriate therapy can be tricky, to say the least. As dedicated telemedical providers, we must do what we can to balance proper prescribing practices with state and federal laws and company policies.

Chronic vs Acute Pain

One distinction you can use when categorizing pain is chronic and acute. These two types of pain are both uncomfortable and unpleasant, but their main difference is how they are treated.

Chronic pain:

The same as any other definition, chronic is defined as lasting over three months duration of continued symptoms. Identifying the cause of the pain is important to its treatment plan.

• Other specialties should be instituted-pain management, orthopedist, physical therapy
• Consider antidepressantNarcotics are being utilized less frequently
• Imaging may be required
• Chronic comorbid conditions may be affected by chronic pain

Acute pain:

Acute pain is usually sudden, and caused by something. The pain will go away where there is no longer an underlying cause.

• NSAIDs are the main-stay of acute therapy
• Narcotics can be used for acute pain (short-term duration)
• Non-pharmacological modalities can be implemented such as ice, rest, splinting
• Recent studies have demonstrated that NSAIDs and Tylenol can be as effective as narcotic analgesics

Telemedicine Boundaries With Pain Control

Acute pain management is much more of a simple treatment for a telemedicine-only encounter. This type of pain can usually be addressed with simple medications such as Tylenol or ibuprofen (as appropriate) and referred back to the patient’s primary care provider.

When the telemedicine provider gets involved in a chronic pain management situation, problems can occur. There is a distinct lack of clinical documentation and the potential for interfering with the primary care provider’s treatment plan.

Common boundaries with treating pain in a telemedical situation include a lack of relevant clinical data (MRI, CT, or other imaging modalities). There is also a lack of a relationship between the clinician and the patient. This not only decreases the continuity of care but fails to meet most state requirements for prescribing controlled substances.

Another boundary for pain assessment and management over a digital platform is the lack of a complete and thorough physical examination. While a qualified and experienced provider can conduct an examination over the audio and video platform, this does not substitute for a provider’s hands on the patient. Understanding what the underlying cause of the pain is an essential aspect of care and allows high-quality care to be rendered.

State and Federal CDS laws

• Usually requires in-person visits prior to narcotic prescriptions
• Have limits on the schedule of pharmacological agent that is provided and quantity limitations may apply
• Most states have either a stand-alone prescription monitoring system or a joint system that allows for clinicians to see previous controlled substances prescribed for a patient
• Only very few states allow for CDS to be prescribed without an initial encounter being completed in-person

Work Site Policies

Telemedicine-only platforms such as Wheel usually have prohibitions on controlled substances being prescribed by their clinicians. This is to protect the provider, patient, and platform.

COVID-19 Changes to Controlled Dangerous Substances (CDS)

Controlled Dangerous Substances (CDS) prescriptions have transformed during the COVID-19 crisis. Furthermore, Congress is taking measures to expand telemedicine prescription. Most of the usual prescribing guidelines for controlled substances still apply, but the following major changes have happened:

• DEA made changes to prescribing practices
• Schedule 2 narcotics can be called in for an “emergency” supply
• Telemedicine can be used to meet the face-to-face requirements

There has been an increase in controlled substance (pharmaceutical and street narcotics) use and abuse during the COVID-19 public health emergency.

Classes of Pain Medications

There are many different kinds of pain medications that have different purposes and use.

Narcotics

• Controversial application in pain management, especially chronic pain management
• Usually recommended only for acute pain or specific instances of chronic pain
• Requires strict monitoring protocols and parameters, usually, a pain management provider is involved
• Not usually allowed by telemedicine-only companies
• Usually requires face-to-face encounters, although specific circumstances during COVID-19 have relaxed some of these standards
• Different states require different parameters
• Common examples: Percocet, Tramadol, Nucynta, Vicodin, Morphine, Fentanyl

Antidepressants

• Newer application for pain management, mostly used for chronic pain
• Mostly used for musculoskeletal type pain
• Caution with patients being on other antidepressants for psychiatric history
• Some patients may have hesitation to be placed on this class of medication because of the stigma associated with it
• Common examples: Cymbalta, Elavil

Neuroleptics

• Used for neuropathic pain management (diabetic, nerve injury, post-stroke)
• These medications can be effective to treat specific types of pain (headaches, nerve and muscle pain, postoperative pain)
• Newer research is proving that this class of medications can replace opioids in postoperative and acute pain management
• Common examples: Lyrica, Gabapentin

Anti-Inflammatories; Non-steroidal

• Very common in pain management
• Can be used for acute and chronic types of pain
• Caution with patients with a history of ulcers and other gastric problems
• Common examples: Ibuprofen, Naprosyn, Celebrex, meloxicam, diclofenac

Anti-Inflammatories; Steroidal

• Steroidal medications such as prednisone can be used to treat acute pain
• Not usually recommended for chronic pain related to side effects of steroids (bone marrow, blood problems, ulcers)
• Caution in patients with gastric ulcer, bone disorders, liver or kidney impairments
• Caution also in uncontrolled diabetic patients as well (can increase hyperglycemia)
• Common examples: prednisone, methylprednisolone

Subjective vs Objective Measurements of Pain

This is one of the hardest assessments of the patient. Pain is an exceptionally subjective sensation. One person can be at 10/10 over a papercut while someone else can barely flinch getting a dislocated shoulder put back in place. While subjective relies solely on the patient, objective looks for context clues to allow for a more accurate assessment.

This is the same as an in-person exam, the patient’s body language, facial expression, and overall mannerisms can let the provider know how they are feeling.

Blood pressure (BP), heart rate (HR), and respiratory rate (RR) usually are elevated with acute pain. It is important to focus on the outward body language of the patient when assessing pain, especially if the patient is new to the clinician.

Remote Patient Monitoring (RPM) and Pain Control

• BP, HR, and RR can alert the provider how the patient is physiologically responding to a situation
• Home monitoring can allow for objective signs
• Wearable technology (such as the Apple or Samsung watch) has allowed providers to get an accurate biometric reading on the patient’s vital signs

As mentioned in the bullet points above, remote patient monitoring (RPM) can help providers assess the physiological signs of the patient when they are not there to actually assess the patient. While there is an emerging market for medical-grade RPM equipment, the vast majority of patients that have monitoring products at home will be using consumer-grade products.

However, in recent times, especially in the post-COVID existence we live in, consumer-grade products have the ability to offer a great amount of information. The trained and skilled telemedicine provider will be able to take the information provided from the patient and turn it into a medical fact that can aid diagnosis or help the clinician evaluate the level of severity.

Conclusion

Providing pain management is never easy. Despite following appropriate guidelines and current trends in acute vs chronic pain management, there are always going to be patients that don’t fit the mold. Being creative and using appropriate methods at our disposal as well as using an appropriate referral base for patients to follow-up in a brick and mortar location allows for proper control.

Utilizing objective pain scales can allow for more accurate management of pain.

Telemedicine is much more effective in managing acute pain in a single-episode situation.

Platforms such as Wheel which focus on fee-for-service situations should not be utilized for chronic pain management, with the exception of possibly providing a refill as needed (controlled substances excluded).

Observing the patient for physiologic signs of stress is an important examination technique that should be utilized by the telemedical clinician, especially if the patient is unknown to him or her. Biometrics measured by the patient, either with dedicated medical equipment or wearable technology, has allowed for the clinician to obtain hard facts about their patient. Advancements in modern wearables have allowed for more patient metrics to be collected in a simple, easy manner and shared with the telemedical provider.

The telemedical provider must remember their place in the care plan and as necessary communicate with the primary care provider, especially if there is anything suspicious about the patient’s behavior. The telemedicine system is there to support the chronic care management of a patient. Even in an acute situation, we act as a portion of the care team and must assure we remember how we fit into the situation.