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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 71-84

Indian society for study of pain position statement for pain medicine practice during the COVID pandemic


1 DY Patil University School of Medicine, Navi Mumbai, India
2 Interventional Pain and Spine Center, New Delhi, India
3 Pain Clinic of India, Mumbai, Maharashtra, India
4 Department of Anaesthesiology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
5 Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
6 Head of Department, Artemis Hospital, Gurgaon, NCR, Jaipur, Rajasthan, India
7 Department of Anaesthesiology, SMS Medical College, Jaipur, Rajasthan, India
8 Interventional Spine and Pain Specialist, Interventional Pain and Spine Center, New Delhi, India
9 Pain Physician, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
10 Pain Physician, Health Village Hospital, Bhubaneshwar, Odisha, India
11 Pain Physician, Livewell Pain and Spine Hospital, Ahmedabad, Gujarat, India

Date of Submission09-May-2020
Date of Decision13-May-2020
Date of Acceptance30-May-2020
Date of Web Publication06-Aug-2020

Correspondence Address:
Dr. Sidharth Verma
Associate Professor and In Charge, Pain Clinic, DY Patil University School of Medicine, Dr D Y Patil Vidyanagar, Sector 7, Nerul, Navi Mumbai, Maharashtra - 400 706
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_62_20

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  Abstract 


The COVID pandemic due to the severe acute respiratory syndrome-coronavirus-2, also known as SARS-CoV-2 (COVID-19), has affected humans across the globe. This document on pain practice reflects the current position statement of the Indian Society for Study of Pain.

Keywords: COVID, Indian Society for Study of Pain, pain medicine, pain practice, pain


How to cite this article:
Verma S, Surange P, Kothari K, Malhotra N, Ghai B, Jain A, Sharma G, Goyal G N, Bhat S, Rath S, Patel H. Indian society for study of pain position statement for pain medicine practice during the COVID pandemic. Indian J Pain 2020;34:71-84

How to cite this URL:
Verma S, Surange P, Kothari K, Malhotra N, Ghai B, Jain A, Sharma G, Goyal G N, Bhat S, Rath S, Patel H. Indian society for study of pain position statement for pain medicine practice during the COVID pandemic. Indian J Pain [serial online] 2020 [cited 2020 Dec 2];34:71-84. Available from: https://www.indianjpain.org/text.asp?2020/34/2/71/291550




  Introduction Top


The SARS-COV-2 (COVID-19) pandemic has engulfed the world in a short span of time. It has posed significant challenges to almost all the nations across the globe. With time, it has become clear that the pandemic is here to stay for long.

Chronic pain patients are a special subset of population because:

  1. Pain is difficult to measure and hence the categorization or triage of patients into emergency and nonemergency patients is difficult. There is generally a poor correlation between imaging findings, pain, and disability and a bi-directional relationship between chronic pain and psychiatric comorbidities such as depression.[1],[2] Therefore, the triage of chronic pain patients poses a significant challenge to the health-care system
  2. Susceptibility of chronic pain patients to infectious diseases (such as COVID-19) is higher as many are elderly and have multiple comorbidities.[3],[4] In a large study with 1,751,841 people, pain was the most common condition co-existing with diabetes, coronary artery disease, chronic obstructive pulmonary disease, and cancer[3]
  3. Immunity changes are present in a patient affected with COVID-19.[5],[6] Chronic pain also effects the immune system, leading to immunosuppression in some patients[7]
  4. Opioid treatment may cause immunity suppression in some patients, and different opioids have different potential for immune suppression[8],[9]
  5. Steroids may cause suppression of immunity. Corticosteroid injections in joints are linked to higher viral infection risk[10]
  6. Management of chronic pain is a moral and ethical priority. It mitigates against future physical and psychosocial effects.[11],[12],[13]


The pain physicians in India had stopped their nonemergency practice during the nationwide lockdown as per the government instructions. However, as the government instructions are changing now, the scenario is about to change and shall require all doctors including pain physicians to resume their practice. Given these circumstances, it would be wise to prepare for the challenges ahead with some clarity on the matters of day-to-day practice. Fortunately, detailed guidelines have been published by the related organizations throughout the world and some of them can be applied to the Indian scenario as well. Indian government organizations – such as the Indian Council of Medical Research (www.icmr.gov.in) and the Ministry of Health and Family Welfare (MoHFW) (www.mohfw.gov.in) are regularly coming up with information on the subject as well. This document articulates the relevant insights and aims to guide and arm the pain physicians of India with up-to-date information to resume their practice safely.


  Methods Top


Working within constraints of time, we have ensured that there is a broad consensus on the statements mentioned. The subtopics are based on previous data and publications available on the subject as obtained from the Google and databases – Pubmed/Medline and EMBASE – with a database search for the following MeSH terms:

  1. “COVID 19” or “Coronavirus” or “Severe Acute Respiratory Syndrome/SARS,”
  2. “Pain” or “Chronic Pain”
  3. “Guidelines” or “Recommendations.”


Locally relevant topics were considered and added as per consensus. Each author has been given a core subtopic, which has been reviewed by all others through an open discussion through E-mails, WhatsApp group discussions, and series of Zoom meetings including one panel discussion attended by pain physicians across the country. All the members are actively engaged in treating patients with chronic pain and have good experience and appropriate training in applied research.

Position statement

Assumptions and presumptions

  • The following represents the current position based on the best available evidence and opinion. The document was last updated on June 23, 2020
  • As the situation is dynamic and evolving frequently, many guidelines are changing; this position statement may also be subject to update or change
  • The statement is relevant to all pain physicians, for pain practice in India
  • These are suggestions and not binding. It is expected that the pain physicians should act in best interest of their patients and themselves
  • Government guidelines refers to the guidelines issued by the center and state governments (specific to your place of practice) in India. Websites such as mohfw.gov.in can be referred to for updated information.


A. How to prepare your practice?

  1. Outpatient department/pain clinic:[14]


    1. Formulate standard operating protocols (SOPs) using updated government guidelines for non-COVID facilities
    2. Screen everyone (including all doctors) who enter the facility using temperature readings and symptom/history assessment questionnaire [Appendix 1][15],[16]
    3. Rearrange the hardware and equipment to enable and implement social-distancing protocols
    4. Tele consult and triage all patients before they arrive at your facility. Use a “NO WALK-IN” policy if possible
    5. Educate the patients about the new protocols and answer their questions through teleconsultation BEFORE they visit
    6. Ensure that you are appropriately stocked with protective equipment for patients and follow updated sanitation protocols issues by government on mohfw.gov.in
    7. Limit the unwarranted patient escorts. One attendant policy should be strictly followed
    8. Visual aids such as signboards should be put up at strategic locations to reinforce the new protocols
    9. Increase the disinfection and sanitation frequency. In case of detection of any suspected COVID-19 patient, the facility should be sanitized prior to reuse. Detailed instructions are available on mohfw.gov.in[16]
    10. Technology updation for teleconsultation and increased compliance with regulation
    11. Prepare education material for your patients as well as personnel
    12. Appropriate waste disposal should be available and protocolized
    13. Follow rational use of personal protective equipment (PPE) [Table 1].[14],[17]
    Table 1: Rational use of personal protective equipment for non-COVID hospitals and non-COVID treatment areas of a hospital which has a COVID block (adapted from mohfw.gov.in)

    Click here to view



  2. Personnel


    1. Education and training to be conducted regularly to reinforce SOPs using updated government guidelines. Special emphasis should be on hand hygiene, social distancing, and donning and doffing protective equipment. Aids such as simulation, drills, and online learning should be encouraged
    2. Ensure availability of adequate and appropriate PPE
    3. Post exposure policy should be formulated, explained, and followed
    4. Stress management sessions and counseling should be available
    5. Training for self-symptom assessment.
    6. Operation theater (OT) for procedures


    1. Carry moderate risk so must have N95 medical mask, splashguard, sterile latex gloves, and goggles for personnel involved in aerosol-generating procedures
    2. Sanitation is important
    3. Updated guidelines should be followed. The recent guidelines on COVID OT by the Indian Society of Anaesthesiologists is an excellent resource[18]
    4. Testing recommendations would change over time. Since the incubation period is long, all patients for procedures should be presumed positive irrespective of testing results and appropriate precautions should be taken
    5. Hospital stay should be minimized.


In lines with the checklist issued by the American Society of Interventional Pain Physicians,[19] we recommend the physicians to go through a checklist before resuming their practice as per [Appendix 2].



B. Pain triage: How to differentiate between red flag situations, emergent, urgent, and elective chronic pain conditions?

Pain is subjective, and patients report their pain differently. Taking care of multiple factors such as patient rights, public health risk to the community, and risk to the health-care providers triage can be done using predetermined criteria and set protocols. Possible decision can be made on the urgency of the condition using the following criteria:[20],[21]

  • Acuity
  • Comorbid psychiatric (e.g., severe pain-related depression) and social (e.g., single mother of young children with limited resources) considerations
  • The level of pain and impairment of function
  • Whether the visit/procedure con provide significant benefit
  • What are the chances that the patient will seek emergency services, or be started on opioids
  • Is physical examination needed
  • Risk associated with in-person visit or procedure
  • Job/business status (e.g., is the patient working or likely to resume work with adequate treatment)
  • Prioritizing first-responders will provide the greatest benefit for the society.


Whenever possible, telemedicine should be used to evaluate and triage the urgency and to arrange suitable management.

We suggest that patients should be triaged for procedures [Table 2][20] and even for outpatient department (OPD) [Table 3].[20] For cases deemed emergent, proceed immediately. For “urgent” cases, discuss risks and benefits with patients, participating health-care personnel, and facility leadership. Then proceed if resources support.
Table 2: Pain Clinic or OPD triage and decision making (Modified from Cohen et al.)

Click here to view
Table 3: Procedure Triage and Decision Guide (Modified from Cohen et al.)A

Click here to view


C. Resuming pain practice: Should the pain physicians resume their practice?

This is no longer a matter of choice but compulsion. All physicians including pain physicians have to resume their outpatient practice as per government instructions other than the containment zones.

The list is updated frequently and is available under the link “Hotspot districts” on https://www.mygov.in/covid-19.

D. Changes in pain practice: How the COVID pandemic has changed pain practice?

The current scenario is unprecedented and unique because of:

  1. Ever-changing government rules and recommendations
  2. Apprehension in both patients' and physicians' mind regarding the pandemic
  3. Pain physicians must decide on their judgment which patients to consult in person
  4. Introduction of new technologies such as telemedicine in patient care
  5. Increased need for proper record keeping
  6. Increase in the costings involved due to laboratory testing and PPEs used.


Overall, the goals must be to avoid deterioration of function; reliance on opioids; or avoidance of unnecessary visits that increase the risk of exposure [Figure 1].
Figure 1: Goals of pain practice

Click here to view


E. Telemedicine: Why to use? What to use? How to use?

Providing health care is challenging in disasters and pandemics. Because of lockdown/curfew, social/physical distancing requirements, or with the fear that health facilities may be infected, patients avoid visiting health-care facilities in person. Under such circumstances, telemedicine services (TMSs) becomes an important asset with imperative implications across the entire health-care delivery spectrum. Although telemedicine will not help to solve them all, it is well suited for scenarios in which doctors can evaluate and manage patients.

Advantages of telemedicine

TMSs offer several advantages especially in routine/nonurgent care. One of the major advantages is reducing the risks of exposing both health-care workers and patients to virus/infections in the time of such outbreaks. TMSs reduce the need of PPE, leading to reduction in resource consumption. TMSs improve access to health care and reduce resource use across the already-stressed health-care infrastructure during the current pandemic. These all can provide substantial economic savings at all levels.

Telemedicine Indian perspective

The concept of telemedicine in India was started with the fact of providing health-care services to remote areas especially rural patients where long traveling is involved to save cost and effort. In India, many governmental organizations such as the Indian Space Research Organization, Directorate of Information Technology, Ministry of External Affairs, and MoHFW have played a vital role in the development of TMSs[22] and helped the Government of India (GOI) to take up a large number of digital health projects.[22],[23] Still, TMSs have not been widely used by individual Indian physicians for patient interactions.[23] This is because till March 25, 2020, there were no guidelines available on the practice of telemedicine in India. The 2018 judgment of the Hon'ble High Court of Bombay added on the insecurity regarding the practice of telemedicine at physician level.[24] Given the ongoing COVID-19 crisis, on March 25, 2020, the Board of Governors of the Medical Council of India along with Niti Aayog recognized the need and released the long-awaited “Telemedicine Practice Guidelines.”[25],[26] It is now legal to provide telemedicine consultation and prescription by RMPs in accordance with the compliance of guidelines. These guidelines should be used in conjunction with the other national clinical standards, protocols, policies, and procedures. Readers are strongly suggested to go through these guidelines document to get well versed with them.[25],[26]


  Challenges of Telemedicine With Indian Perspective Top


Despite the advantages mentioned above, telemedicine practice can pose unique challenges as follows:

  1. Setting up infrastructure: At present, majority of the institutes are having one or two telemedicine units. The infrastructure will have to be expanded to start official tele-consultation for all specialties including pain clinic OPD
  2. Training of staff: The other facade is training the needs of physician and staff accustomed to in-person working. In India, majority of the pain physicians are anesthesiologists who are front liners during the COVID pandemic and may be facing a time crunch to learn the technological issues of telemedicine
  3. Separate OPD hours/sessions/days: For tele-consultation, separate OPD hours/sessions must be allotted. It may be difficult to do tele-consultation when regular pain clinic OPD is going on simultaneously
  4. First consult: The follow-up patients may be better beneficiaries of telemedicine consult. First consult usually needs complete physical examination for treating physician and would require face-to-face consultation
  5. Free distribution of medicines: In many of the public institutes, free medicines (15–30 days) are provided to the poor patients. The patient will still have to send somebody to receive the medicines
  6. Patients with rural background: Many of the patients in India are from rural uneducated background, and TMSs will be difficult for them to access due to issues pertaining to low technical skills and internet connectivity issues. However, this challenge may get minimized in the coming time as rural India is developing at a fast pace under the Digital India Initiative. This paradigm shift may be helpful for telemedicine to reach to rural India in future.



  Evidence of Telemedicine for Chronic Pain Management Top


Full-scale use of telemedicine in chronic pain is rare till now. However, with the current backdrop of this pandemic, TMSs can become an imperative tool for managing pain clinic patients. Chronic pain management requires frequent visits to the physician for both nonpharmacological and pharmacological advice and adjustment of treatment. Telemedicine can help patients to consult physician especially for follow-up visits. Nonpharmacological options such as health education, self-management, lifestyle modifications, exercises, and psychological intervention constitute a major part of chronic pain management. These can be easily delivered using TMSs. Most of the evidence for the use of TMSs for chronic pain management focus on delivering these interventions remotely and have been reported to be as effective as in-person therapies.[27],[28],[29],[30],[31] However, most of the evidence come from a small number of randomized controlled trials, with small sample size, lack of long-term evaluation, and lack of assessment of harms. Hence, there is still a dearth of rigorous trials of TMS usage for chronic pain management. To the best of our knowledge, only one RCT from India has evaluated the effect of smartphone app (Snapcare) compared to written prescription in patients with chronic low back pain and reported significantly greater decline in pain and disability in Snapcare group.[32]

ISSP statement about telemedicine for chronic pain management

The risk of COVID-19 will extend well beyond the current period and may last for the coming years ahead. TMSs will be attempted by almost all the health-care facilities including public hospitals, big cooperate setups, and private clinics. Universal electronic communication technology is relatively inexpensive to access and can be adopted in future especially with the release of telemedicine guidelines.

TMSs can be of immense help to the pain physician if he/she actively takes charge of his/her practice and uses telemedicine to triage or consult patients toward the goal of achieving a safe, yet effective practice. The ISSP algorithm for Pain Practice in the COVID situation shall be helpful to transform telemedicine to a potent instrument toward that goal.

F. Interventional pain procedures/minimally invasive pain and spine intervention (MIPSI): What are recommendations for procedure selection?

Whenever possible, reschedule interventional pain procedures (nonurgent) with the ultimate goal of reducing interpersonal exposure. This will also reduce the potential for disease transmission for patients, staff, and the general community.

The final decision regarding performing interventional pain procedure/MIPSI should be made by the pain physician after considering various risks posed to the patient due to the presence of COVID-19 in the community. Risks to medical personnel should also be considered. Patients must be actively involved in this process. The final decision should be a joint decision between the patient and the doctor.

Performing the procedure may be appropriate in cases with excellent chances of a favorable outcome. In these cases, delaying (rescheduling) an interventional pain procedure/MIPSI may expose patient to increased risk via the alternative treatment option. In such cases, it is better to perform the procedure in the same visit as the evaluation to reduce the exposure to the virus.[20]

G. Peri-procedure protocols: A patient is scheduled for an interventional pain procedure. How will you proceed?

The ISSP algorithm for Pain Practice in the COVID situation shall be helpful in this regard.

For all patients:

  • Ensure appropriate preprocedural workup once the decision has been made
  • Ensure that all health-care professionals and the patients' caregivers know the plan
  • Ensure that informed written consent with modifications for the COVID pandemic is incorporated
  • Clearly identify and segregate aerosol-generating procedures
  • Follow the PPE guidelines as per the algorithm
  • The most experienced person should do the procedure and only essential staff should enter the procedure room. However, help should be readily available.
  • Segregate COVID from non-COVID patients and follow disinfection and sanitation protocols
  • Patients should always wear triple-layered surgical mask to minimize droplet spread.
  • Equipment such as ultrasound machine, probes, and reusable consumables should be appropriately shielded using disposable drapes. Postprocedural disinfection and sanitation protocols should be followed.
  • Full aseptic technique should be followed as usual
  • Minimize hospital stay and preferably send them home the same day
  • Reconfirm benefit–risk disclosure before procedure.


For a COVID-19-positive or a high-risk patient:

  • Only perform emergency/emergent procedures
  • Procedure should be performed in a COVID OT[18]
  • Avoid use of common areas
  • Use N95 mask without exhalation valve on the patient to minimize droplet spread. Educate and train patient for its use taking appropriate precautions
  • Full PPE including disposable body suits, double gloves, N95 mask, eye protection, splashguard (face shield), and disposable gown should be used
  • Because the risk of transmission is highest during the doffing/removal of protective gear, proper precautions taken to remove and dispose protective equipment is helpful. Hands should be washed thoroughly after the procedure. Physicians should avoid touching their face or other surfaces beforehand
  • Take measures such as simulation sessions and presence of an observer (buddy) during the donning and doffing procedure for training staff.



  Preprocedural Testing Top


The understanding regarding SARS-CoV-2 is being updated regularly and new presentations of COVID-19 are being reported regularly. A vast majority (up to 85%) of patients infected with SARS-CoV-2 can be asymptomatic. Therefore, preprocedure testing for SARS-CoV-2 is recommended before any interventional pain procedure. Extra caution should be taken in patients who are more than 60 years of age, with co-morbidities such as ischemic heart disease, chronic renal disease, bronchial asthma, and diabetes mellitus.

What test should be done?

  • Reverse transcription-polymerase chain reaction (RT-PCR) test should be done for the qualitative detection of nucleic acid from SARS-CoV-2 in oropharyngeal and nasopharyngeal swabs
  • There is a possibility that the patient is in incubation period of SARS-CoV-2 infection. Hence, a repeat RT-PCR test after 7 days of intervention is preferable.
  • Indian Council of Medical Research (ICMR), in its recent advisory[33] has recommended that real time RT PCR is the gold standard for COVID-19 testing. Truenat (Trademark) and CBNAAT (cartridge based nucleic acid amplification test) are also comparable in efficacy and have been recommended. In addition, the ICMR has recommended “Standard Q COVID-19 Ag kit” manufactured by SD Biosensor, Manesar, Gurugram, India. This is a Rapid Point-of-Care (PoC) Antigen Detection Test. On validation, the test has been found to have a very high specificity with moderate sensitivity. It is recommended to be used in combination with the gold standard RT-PCR test in screening as well as hospital settings. The test is done and if the results are positive, no confirmation by RT PCR is needed. However, if the results are negative, they need to be confirmed by methods relying on RT PCR testing. These recommendations are valid only if tests are performed as per the advised protocol.


What is the purpose of preprocedural testing?

  • To protect the health-care workers getting infected from a patient who is suffering from SARS-CoV-2 infection and vice-versa
  • To decrease morbidity in patients. There are reports of increased morbidity in SARS-CoV-2-infected patients who underwent surgical procedures


If preprocedural testing is not available/feasible or the report is awaited, the personnel working in pain OT should follow all precautions as if dealing with a COVID-positive patient.

H. Nonsteroidal anti-inflammatory drugs (NSAIDs): What about NSAIDs?

Nonpeer-reviewed case reports of several young patients infected with SARS-CoV-2 deteriorating after taking ibuprofen generated concerns from health-care providers and patients about the safety of NSAIDs during the COVID-19 pandemic.[34] On March 18, 2020, the World Health Organization advised patients experiencing COVID-19 symptoms to avoid the use of ibuprofen, which was a position reversed by the organization the following day. The theory postulated for this was that NSAIDs could increase the levels of angiotensin-converting enzyme-2, which could increase susceptibility to infection or aggravate symptoms. Currently, neither the FDA nor the European Medicines Agency is aware of any evidence linking the use of ibuprofen or other NSAIDs to worsening COVID-19 symptoms,[35],[36] though the agencies do caution that “the pharmacological activity of NSAIDs in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infections.”

We recommend that the patients using NSAIDs should continue using them. NSAIDs may mask fever or myalgia. Such patients should be educated to promptly report new myalgia or mild fever.

I. Corticosteroids: What about corticosteroid usage?

The Faculty of Pain Medicine of the Royal College of Anaesthetists' position statement advocates caution while using injected steroids during the COVID-19 pandemic.[37]

Oral corticosteroid administration

If the patient is already on oral steroids, then don't stop current steroids but taper their dose if possible and clinically safe to do so. The physician should think before starting steroids in the current pandemic.[38] For rheumatology patients under care, recent documents from the National Health Service, United Kingdom,[39],[40] or American College of Rheumatology guidelines[41] can be followed. Consider alternatives to steroids wherever possible. If needed, use the lowest possible dose as 10 mg of prednisone or equivalent and for the shortest possible time.[41]

Local/intra-articular/epidural/systemic corticosteroid injections

Using steroids routinely for all patients as a treatment adjunct for the treatment of COVID-19 is not recommended.[42] Injections of corticosteroids into joints were shown to be associated with a higher risk of viral illness such as influenza.[10] The duration of immune suppression could vary with the agent used. Therefore, a pain physician should consider evaluation of the risks and benefits of steroid injections. Using a decreased dose can be helpful specifically in high-risk patients.

Steroid use, whether oral or injected in established musculoskeletal conditions, arthritis and painful joints, should NOT be stopped suddenly, but tapered if possible and clinically safe, with medical supervision.[41] Give steroid injections only if the patient has significant disease activity and there are no alternatives.

We advise against steroid injections in individuals with active infections. Long-acting, insoluble formulations have been shown to cause a variable degree of adrenal suppression for at least few weeks.[43] Perform any steroid injections only in those pain procedures where there is definite clinical evidence to support its use.


  Effect of Corticosteroids on Future Live Vaccination Top


Recent administration of systemic glucocorticoids is not a contraindication to live virus vaccination when the steroid therapy is short term. Topical, inhaled, intra-articular, bursal, tendon injections are not contraindications to vaccination at low-to-moderate doses. Live virus vaccination should be deferred for 1 month or more after discontinuing high-dose systemically absorbed glucocorticoid therapy for more than 14 days.[44],[45]

Considering above, we recommend that the pain physician should make his/her decision on case-to-case basis in the best interest of the patient. Patient involvement in decision-making can make the process better.

J. Opioids/narcotics: What about opioid usage?

Chronic pain patients on opioids could potentially be more susceptible to COVID-19 and other secondary infections.

  • We do not recommend any changes to ongoing opioid treatment regimens in the absence of documented changes in pain and/or function.[46]
  • We do recommend careful monitoring of patients on transdermal opioids, as the rate of absorption with high fever can be unpredictable and can possibly result in respiratory depression.[46]


K. Opioid prescriptions: How to prescribe opioids during the COVID pandemic?

Ideally, changes to opioid prescriptions should be made only after in-person careful evaluation of ongoing treatment, which includes a detailed history and physical examination. In India, opioids are listed. As per the Telemedicine guidelines released by the MoHFW, GOI, the drugs listed in Schedule X of Drug and Cosmetic Act and Rules or any Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances, Act, 1985, have the potential to harm individual or society at large and hence CANNOT be prescribed through telemedicine. In India, opioids are included in schedule X. In such cases, the patient should be issued prescription for both new drugs and refills in person.[47],[48] This is the current status of the opioid prescriptions in India and should be adhered to till any further changes. However, during the current COVID-19 health emergency, physicians may not be able to adhere to such a practice. In view of this, many countries have made changes to their policy on controlled substances[46] and have allowed opioid prescriptions through telemedicine with caution.

L. Worry-free pain medicine practice: How to run a “worry-free” pain practice during the COVID pandemic?

Resuming a full medical practice should be based on locally prevalent conditions. Trend of active cases and total cases in the geographical area of your practice, should help you in taking this decision. One's city or locality, being moved out from red zone to orange zone to green zone (as described by government) gradually, is a good indication to resume routine work. Working with COVID is a new normal.

Rather than waiting passively, we suggest an active approach consisting of preparing your health-care facility and personnel to work in the COVID scenario. The need for alertness about viral infectivity should not undermine our efforts to care for every patient. Patients may be afraid to seek care by not visiting the clinics and hospitals to avoid being infected. Such patients should be cared for using telemedicine option. It is possible for many patients to defer their issues for weeks or even a few months, however, they will need medical attention in due course of time. Teleconsultation is helpful to triage or to defer the visit or avoid unnecessary visits to the outpatient department. However, it cannot replace personal consultation. Right now, the count of COVID-positive patients in India is 138,536 (May 25, 2020) and the numbers show an increasing trend. It is much easier to prepare our pain clinics to resume the practice now rather that do it when the cases multiply in number.

M. The ISSP algorithm for Pain Physicians in the COVID situation [Figure 2]
Figure 2:The ISSP Algorithm for pain practice during the COVID pandemic

Click here to view


This algorithm sums up the suggested approach of pain physicians practicing in India during the COVID pandemic. It should be used in accordance with the government regulations and institutional guidelines.


  Conclusion Top


The COVID pandemic has posed new challenges to the pain practice. Pain patients have to be classified as red flagged, emergent, urgent, or elective based on careful risk–benefit analysis. Patients should be actively involved in the process. The Indian Society for Study of Pain recommends an algorithmic approach to be implemented immediately for all pain patients to deliver effective, essential, and safe health care for the benefit of the society. This needs to be done now under prescribed safety precautions for best results.

Resources

  1. The MoHFW, GOI provides general guidelines and up-to-date resources on COVID-19 (https://www.mohfw.gov.in/)
  2. #IndiaFightsCorona COVID 19. It is a government website for the public (https://www.mygov.in/covid-19)
  3. Spine Intervention Society: It provides guidance on interventional pain procedures during the COVID-19 pandemic (https://www.spineintervention.org/page/COVID-19)
  4. The World Health Organization provides COVID-19 guidance on a per-country basis (https://www.who.int/emergencies/diseases/novel-coronavirus-2019)
  5. The Indian Society for Study of Pain provides specific guidance for pain physicians across India (https://www.issp-pain.org/).


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Burgstaller JM, Schüffler PJ, Buhmann JM, Andreisek G, Winklhofer S, Del Grande F, et al. Is there an association between pain and magnetic resonance imaging parameters in patients with lumbar spinal stenosis? Spine (Phila Pa 1976) 2016;41:E1053-62.  Back to cited text no. 1
    
2.
Vadivelu N, Kai AM, Kodumudi G, Babayan K, Fontes M, Burg MM. Pain and Psychology-A Reciprocal Relationship. Ochsner J 2017;17:173-80.  Back to cited text no. 2
    
3.
Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet 2012;380:37-43.  Back to cited text no. 3
    
4.
Mills SE, Nicolson KP, Smith BH. Chronic pain: A review of its epidemiology and associated factors in population-based studies. Br J Anaesth 2019;123:e273-83.  Back to cited text no. 4
    
5.
Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res 2020;7:11.  Back to cited text no. 5
    
6.
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. HLH Across Speciality Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.  Back to cited text no. 6
    
7.
Ren K, Dubner R. Interactions between the immune and nervous systems in pain. Nat Med 2010;16:1267-76.  Back to cited text no. 7
    
8.
Franchi S, Moschetti G, Amodeo G, Sacerdote P. Do all opioid drugs share the same immunomodulatory properties? A review from animal and human studies. Front Immunol 2019;10:2914.  Back to cited text no. 8
    
9.
Sacerdote P. Opioids and the immune system. Palliat Med 2006;20 Suppl 1:s9-15.  Back to cited text no. 9
    
10.
Sytsma TT, Greenlund LK, Greenlund LS. Joint Corticosteroid Injection Associated With Increased Influenza Risk. Mayo Clin Proc Innov Qual Outcomes 2018;2:194-8.  Back to cited text no. 10
    
11.
Fayaz A, Ayis S, Panesar SS, Langford RM, Donaldson LJ. Assessing the relationship between chronic pain and cardiovascular disease: A systematic review and meta-analysis. Scand J Pain 2016;13:76-90.  Back to cited text no. 11
    
12.
Brennan F, Carr D, Cousins M. Access to pain management-still very much a human right. Pain Med 2016;17:1785-9.  Back to cited text no. 12
    
13.
Quinten C, Coens C, Mauer M, Comte S, Sprangers MA, Cleeland C, et al. Baseline quality of life as a prognostic indicator of survival: A meta-analysis of individual patient data from EORTC clinical trials. Lancet Oncol 2009;10:865-71.  Back to cited text no. 13
    
14.
Malhotra N, Joshi M, Datta R, Bajwa SJS, Mehdiratta L. Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID-19. Indian J Anaesth 2020;64:259-63.  Back to cited text no. 14
  [Full text]  
15.
Mayo Clinic COVID 19 Self-Assessment Tool. Available from: https://www.mayoclinic.org/covid-19-self-assessment-tool. [Last accessed on 2020 May 08].  Back to cited text no. 15
    
16.
Ministry of Health and Family Welfare Directorate General of Health Services [Emergency Medical Relief]. Coronavirus Disease 2019 (COVID-19): Standard Operating Procedure (SOP) for transporting a suspect/confirmed case of COVID-19. Available from: https://www.mohfw.gov.in/pdf/Standard Operating Procedure SOP for transportingasuspectorconfirmed case of COVID19.pdf. [Last accessed on 2020 May 05].  Back to cited text no. 16
    
17.
Novel Coronavirus Disease 2019 (COVID-19): Additional Guidelines on Rational use of Personal Protective Equipment (setting approach for Health functionaries working in non-COVID areas). Ministry of Health and Family Welfare, Government of India. Directorate General of Health Services [Emergency Medical Relief]; 2020. Available from: https://www.mohfw.gov.in/pdf/Additional guidelines on rational use of Personal Protective Equipment setting approach for Health functionaries working in non COVID areas.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 17
    
18.
Malhotra N, Joshi M, Datta R, Bajwa SJS, Mehdiratta L. Indian Society of Anaesthesiologists (ISA National) advisory and position statement regarding COVID-19. Indian J Anaesth 2020;64:259-63.  Back to cited text no. 18
  [Full text]  
19.
Manchikanti L, Soin A. Checklist and Risk Stratification for Opening of Interventional Pain Management Practices. Available from: http://www.asipp.org/asipp-updates/checklist-and-risk-stratification-for-opening-of-interventional-pain-management-practices [Last accessed on 2020 May 09].  Back to cited text no. 19
    
20.
Cohen SP, Baber ZB, Buvanendran A, McLean LTCBC, Chen Y, Hooten WM, et al. Pain Management Best Practices from Multispecialty Organizations during the COVID-19 Pandemic and Public Health Crises. Pain Med 2020 Apr 7:pnaa127. doi: 10.1093/pm/pnaa127. Epub ahead of print.  Back to cited text no. 20
    
21.
Shanthanna H, Cohen SP, Strand N, Lobo CA, Eldabe S, Bhatia A, Narouze S. Recommendations on Chronic Pain Practice during the COVID-19 Pandemic. Joint Statement by American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA). Available from: https://www.asra.com/page/2903/recommendations-on-chronic-pain-practice- during-the-covid-19-pandemic. [Last accessed on 2020 May 01].  Back to cited text no. 21
    
22.
Mishra SK, Kapoor L, Singh IP. Telemedicine in India: Current scenario and the future. Telemed J E Health 2009;15:568-75.  Back to cited text no. 22
    
23.
Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand? J Family Med Prim Care 2019;8:1872-6.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
25.
Telemedicine Practice Guidelines. Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. [This constitutes Appendix 5 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation, 2002]. BOARD OF GOVERNORS In supersession of the Medical Council of India; 2020. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last acessed on 2020 May 01].  Back to cited text no. 25
    
26.
Frequently Asked Questions [FAQs] on Telemedicine Practice Guidelines. BOARD OF GOVERNORS In supersession of the Medical Council of India; 2020. Available from: https://mciindia.org/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/FinalFAQ-TELEMEDICINE%20%206-4-2020.pdf. [Last accessed on 2020 May 01].  Back to cited text no. 26
    
27.
Dario AB, Moreti Cabral A, Almeida L, Ferreira ML, Refshauge K, Simic M, et al. Effectiveness of telehealth-based interventions in the management of non-specific low back pain: A systematic review with meta-analysis. Spine J 2017;17:1342-51.  Back to cited text no. 27
    
28.
Fisher E, Law E, Dudeney J, Eccleston C, Palermo TM. Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2019;4:CD011118.  Back to cited text no. 28
    
29.
Buhrman M, Gordh T, Andersson G. Internet interventions for chronic pain including headache: A systematic review. Internet Interv 2016;4:17-34.  Back to cited text no. 29
    
30.
Sundararaman LV, Edwards RR, Ross EL, Jamison RN. Integration of mobile health technology in the treatment of chronic pain: A critical review. Reg Anesth Pain Med 2017;42:488-98.  Back to cited text no. 30
    
31.
Slattery BW, Haugh S, O'Connor L, Francis K, Dwyer CP, O'Higgins S, et al. An evaluation of the effectiveness of the modalities used to deliver electronic health interventions for chronic pain: Systematic review with network meta-analysis. J Med Internet Res 2019;21:e11086.  Back to cited text no. 31
    
32.
Chhabra HS, Sharma S, Verma S. Smartphone app in self-management of chronic low back pain: A randomized controlled trial. Eur Spine J 2018;27:2862-74.  Back to cited text no. 32
    
33.
Indian Council of Medical Research (ICMR) Advisory. Newer Additional Strategies for COVID-19 Testing. Available on https://www.icmr.gov.in/pdf/covid/strategy/New_additional_Advisory_23062020_2.pdf. Last accessed on 23 June, 2020.   Back to cited text no. 33
    
34.
Day M. Covid-19: European drugs agency to review safety of ibuprofen. BMJ 2020;368:m1168.  Back to cited text no. 34
    
35.
European Medicines Agency. EMA Gives Advice on the use of Non-Steroidal Anti-Inflammatories for COVID-19; March, 2020. Available from: https://www.ema.europa.eu/en/news/emagives-advice-use-non-steroidal-anti- inflammatories-covid-19. [Last accessed on 2020 Mar 22].  Back to cited text no. 35
    
36.
U.S. Food and Drug Administration. FDA Advises Patients on use of Non-Steroidal anti-Inflammatory Drugs (NSAIDs) for COVID-19. Available from: https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-nonsteroidal-anti-inflammatory-drugs-nsaids-covid-19. [Last accessed on 2020 Mar 22].  Back to cited text no. 36
    
37.
Faculty of Pain Medicine. FPM Response to Concern Related to the Safety of Steroids Injected as Part of Pain Procedures during the Current COVID-19 Virus Pandemic; 2020. Available from: https://fpm.ac.uk/sites/fpm/files/documents/2020-03/FPM-COVID-19-Steroid-Statement-2020-v2.pdf. [Last accessed on 2020 Mar 31].  Back to cited text no. 37
    
38.
Popescu A, Patel J, Smith CC; Spine Intervention Society's Patient Safety Committee. Spinal injections in immunosuppressed patients and the risks associated with procedural care: To inject or not to inject? Pain Med 2019;20:1248-9.  Back to cited text no. 38
    
39.
Clinical Guide for the Management of Rheumatology Patients during the Coronavirus Pandemic. Version 2; April 2020. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/clinical-guide-rheumatology-patients-v2-08-april-2020.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 39
    
40.
Clinical Guide for the Management of Patients with Musculoskeletal and Rheumatic Conditions on Corticosteroids during the Coronavirus Pandemic. Version 1.; 25 March, 2020. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/CO0043_Specialty-guide-and-coronavirus_-MSK-corcosteroid_-v1.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 40
    
41.
Mikuls TR, Johnson SR, Fraenkel L, Arasaratnam RJ, Baden LR, Bermas BL, et al. American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 1. Arthritis Rheumatol 2020. doi: 10.1002/art.41301. Epub ahead of print.   Back to cited text no. 41
    
42.
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. HLH Across Speciality Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395:1033-4.   Back to cited text no. 42
    
43.
Friedly JL, Comstock BA, Heagerty PJ, Bauer Z, Rothman MS, Suri P. Systemic effects of epidural steroid injections for spinal stenosis. Pain 2018;159:876-83.  Back to cited text no. 43
    
44.
National Center for Immunization and Respiratory Diseases. General recommendations on immunization --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60:1-64.  Back to cited text no. 44
    
45.
Haynes BF, Fauci AS. The differential effect ofin vivo hydrocortis one on the kinetics of subpopulation of human peripheral blood thymus derived cells. J Clin Invest 1978;61:703-7.  Back to cited text no. 45
    
46.
Shanthanna H, Strand NH, Provenzano DA, Lobo CA, Eldabe S, Bhatia A, et al. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia 2020;75:935-44.  Back to cited text no. 46
    
47.
Telemedicine Practice Guidelines. Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. This constitutes Appendix 5 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation, 2002). BOARD OF GOVERNORS In supersession of the Medical Council of India; 2020. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 May 01].  Back to cited text no. 47
    
48.
Frequently Asked Questions [FAQs] on Telemedicine Practice Guidelines. BOARD OF GOVERNORS in Supersession of the Medical Council of India; 2020. Available from: https://mciindia.org/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/Final_FAQ-TELEMEDICINE%20%206-4-2020.pdf. [Last accessed on 2020 May 01].  Back to cited text no. 48
    


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