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To the Editor
Before COVID-19, the opioid epidemic was a primary public health priority, and important progress has been made to decrease reliance on opioids for postoperative pain management. The transitional pain service (TPS) model aims to identify patients at risk for persistent postoperative pain and assist them with pain management throughout the perioperative period, including opioid tapers. The University of Toronto program describes assisting 46% of opioid-naïve patients and 26% of opioid-experienced patients completely wean off opioids 6 months postoperatively without compromising pain control.1
Specific functions of the TPS, establishing new consults and managing perioperative opioid tapers, are threatened by the COVID-19 pandemic. As the world continues to battle COVID-19, other aspects of healthcare have been neglected. Elective surgeries have been canceled; patients are discouraged from making medical appointments unless ‘absolutely necessary’ due to shelter in place orders, and healthcare facilities are focusing resources on stockpiling personal protective equipment, medications, and ventilators in the face of shortages. As the pandemic continues, we anticipate an increase in anxiety and depression in our patients which are risk factors for prolonged postoperative opioid use.2
These issues demand innovation, and one avenue is telehealth. According to the Health Resources and Services Administration, telehealth involves the use of telecommunications to provide clinical healthcare, patient education, and public health.3 Evidence supports the use of telehealth for improving access to pain specialists for patients living in rural communities,4 but adoption of telehealth has been slow as technologies continue to be developed and tested.
With the start of the pandemic and new restrictions on non-urgent medical care, options for new TPS consults at our facility were limited to either placing all consults on hold or exclusively contacting by phone. Delaying preoperative consults would miss opportunities to optimize patients’ pain management regimens before the resumption of elective surgery. Limiting encounters to telephone calls lacked face-to-face contact, a necessary element for building rapport with patients, assessing non-verbal communication, and demonstrating procedures. As the Veterans Health Administration (VHA) liberalized the use of multiple platforms to encourage video telehealth, our TPS team quickly decided to adopt the VHA’s preferred videoconferencing software—Virtual Care Manager.
To implement telehealth, each TPS practitioner was required to complete a 2-hour online training, and our consult note template in the electronic health record had to be modified to meet documentation requirements for video telehealth appointments. The most challenging step in this process was ensuring that each practitioner received the necessary telecommunication devices in a timely fashion which required regular coordination with our information technology (IT) department. Clinicians tend to have less predictable schedules, and IT departments within large facilities have become increasingly busy during this pandemic. One way to reduce this barrier is to liberalize the use of existing technologies such as Facetime, Skype, Zoom or other videoconferencing platforms. Recently, the US Department of Health and Human Services relaxed Health Insurance Portability and Accountability Act (HIPAA) requirements for telehealth during the pandemic.5
An abrupt change in practice can be disorienting, but COVID-19 has taught us to be nimble. The transition to video telehealth will come with technical difficulties and logistical concerns, but patient access to a TPS and pain management specialists is more important than ever. High unemployment rates, mandated social distancing, and limited access to healthcare facilities have left many patients at higher risk for opioid misuse. The TPS may play a pivotal role in mitigating this risk in patients having surgery. Facilities and practitioners who are interested in implementing a virtual TPS with video telehealth should leverage recent literature,4 changes to the Centers for Medicare and Medicaid Services’ and the Drug Enforcement Administration’s telehealth policies,5 6 experienced colleagues, and their facility’s IT resources.
Twitter @TobiHunterDNP, @EMARIANOMD
Contributors OOH and TKH helped design the project, drafted and revised the initial manuscript, reviewed and approved the submitted manuscript. ERM drafted and revised the initial manuscript, reviewed and approved the submitted manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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