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Canadian Journal of Pain
Revue canadienne de la douleur
Volume 4, 2020 - Issue 1
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Research Article

COVID-19 impact and response by Canadian pain clinics: A national survey of adult pain clinics

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Pages 204-209 | Received 13 May 2020, Accepted 12 Jun 2020, Published online: 10 Sep 2020

ABSTRACT

Background: As the result of public health authority responses to the COVID-19 pandemic, pain clinics have had to cease providing in-person appointments to reduce contact between patients and staff. Over the past decade, Canadians living with chronic pain have faced long waiting times for care within multidisciplinary pain clinics. We are concerned that ceasing in-person pain services exacerbates the daily hardships already faced by Canadians living with chronic pain.

Aims: The aim of this study was to evaluate the impact of the COVID-19 pandemic on Canadian pain clinics, their responses, and changes to clinic practices that might be maintained when the pandemic is over.

Methods: A survey of Canadian adult multidisciplinary pain clinics was conducted to determine impacts on medical and allied health care services and the strategies used to deliver care to patients during the COVID-19 pandemic.

Results: Responses received from 17 adult pain clinics across Canada showed that adult multidisciplinary pain clinics had to cease or significantly reduce in-person patient contacts during the COVID-19 pandemic and responded by offering telehealth options. Despite their efforts, patients are waiting longer and have lost access to usual care. Increased levels of pain, stress, and medication use, particularly opioids and cannabinoids, were reported.

Conclusions: Access to adaptable and innovative technologies, such as telehealth, can assist in the care of the one in five Canadians living with chronic pain during times of crises and must be included as a vital component of a comprehensive Canadian pain strategy.

RÉSUMÉ

Contexte: Suite aux mesures prises par les autorités de santé publique en réponse à la pandémie de COVID-19, les cliniques antidouleur ont dû cesser de proposer des rendez-vous en personne afin de réduire les contacts entre les patients et le personnel. Au cours de la dernière décennie, les Canadiens vivant avec la douleur chronique ont dû faire face à de longs délais d’attente pour obtenir des soins dans les cliniques antidouleur multidisciplinaires. Nous sommes préoccupés par le fait que l’arrêt des services antidouleur en personne exacerbe les difficultés quotidiennes auxquelles sont déjà confrontés les Canadiens qui vivent avec la douleur chronique.

Objectifs: Cette étude visait à évaluer les repercussions de la pandémie de COVID-19 sur les cliniques antidouleur au Canada, leurs réactions et les changements dans leurs pratiques qui pourraient être maintenus en raison de la pandémie.

Méthodes: Une enquête a été menée auprès des cliniques antidouleur multidisciplinaires pour adultes au Canada afin de determiner les répercussions sur les services médicaux et les services paramédicaux, ainsi que les strategies utilisées pout fournir des soins de santé aux patients pendant la pandémie de COVID-19.

Résultats: Les réponses reçues de 17 cliniques antidouleur pour adultes au Canada ont montré que les cliniques antidouleur multidisciplinaires pour adultes avaient dû cesser ou réduire considérablement les contacts en personne avec les patients pendant la COVID-19 et qu’elles ont réagi en proposant des options de télésanté. Malgré leurs efforts, les patients attendent plus longtemps et n’ont plus accès aux soins habituels. L’augmentation des niveaux de douleur, de stress et de médication, en particulier les opioïdes et les cannabioïdes, a été signalée.

Conclusion: L’accès à des technologies adaptables et innovantes, telles que la télésanté, peut contribuer aux soins des 20 % de Canadiens vivant avecla douleur chronique en période de crise et doit constituer un élément essentiel d’une stratégie canadienne globale de lutte contre la douleur.

Introduction

Across Canada, in order to comply with government directives for physical distancing, multidisciplinary pain clinics have ceased providing in-person contact between patients and staff in order to help prevent the spread of the novel coronavirus SARS-CoV-2. Over the past decade, people living with pain have already faced long waiting times for the assessment and management of their pain in these clinics.Citation1 In March 2019, the federal government established the Canadian Pain Task Force. In June 2019, the Canadian Pain Task Force’s initial report confirmed that Canadians have inadequate access to pain services and that waiting times for available services are long, resulting in devastating impacts on individuals living with pain, their families, communities, and the Canadian economy.Citation2 The COVID-19 pandemic has led to major changes in delivery of pain care internationally. A recent review discussed the international impact of COVID-19 on pain treatment centers, the adverse consequences of not treating chronic pain, and strategies for the rapid introduction of remotely supported pain services.Citation3

Based on clinical experience, we predicted that ceasing in-person pain services would exacerbate the daily hardships faced by the Canadians living with chronic pain. We aimed to study the impact of the COVID-19 pandemic on Canadian pain clinics, how they responded, and what changes may be maintained when the pandemic is over. This study involved a survey designed to explore the impact on the ability of Canadian adult multidisciplinary pain clinics to provide care and the strategies they are using to deliver care to patients during the COVID-19 pandemic.

Materials and Methods

A survey was developed to explore the initial impact and experiences of Canadian pain clinics in the context of COVID-19 pandemic (). The survey included questions about the location and activities of the clinics, the impact on services that were previously offered, impacts on patients, and whether new initiatives would continue after the pandemic. The survey was approved by the Nova Scotia Health Authority Research Ethics Board (#1025673) and informed consent was obtained from those completing the survey. The survey was distributed by e-mail to members of the Academic Pain Directors of Canada (APDOC), an association of the medical directors of university and regional health authority multi-/interdisciplinary pain clinics across Canada. A secure web application (REDCap) was used for building, collecting, and managing the survey data. Participants were asked to complete the survey within 2 weeks, and reminder e-mails were sent out after 1 week. Data were de-identified and aggregated.

Figure 1. The survey questions

Figure 1. The survey questions

Results

Surveys were sent to 29 members of APDOC representing 20 adult pain clinics and the medical directors of three additional university-affiliated multidisciplinary pain clinics who had been invited to become members of APDOC prior to completing the survey. One accepted the invitation (Kelowna) and completed the survey. We requested that only representatives of adult clinics respond to this survey and that an effort be made for each clinic to complete one survey. Data were collected between April 23 and May 5, 2020. There were 18 responses. One response was from a pediatric clinic and was excluded, so the final response rate was 17/23 (73.9%). Every question was answered by all responders. What follows is the descriptive data from the 17 responses.

Responses were received from across the country, with representation from Vancouver, Kelowna, Calgary, Edmonton, Winnipeg, Hamilton, Greater Toronto, London, Kingston, Montreal, Quebec City, and Halifax. The number of first visits and follow-up visits to clinics ranged from 400 to 23,000 per year, with six clinics reporting 10,000 or more visits, five clinics reporting 5000 to 9999, and six reporting less than 5000 visits per year. All clinics indicated that they had to cease or significantly reduce in-person clinic appointments, and all clinics reported providing care by other means. All were providing phone contact and 11 were providing additional options, including Zoom for Healthcare or nonspecified video options. Fifteen clinics (88%) were able to do assessments on some new patients; however, 13 clinics (76%) were also adding new referrals to a wait list. Eleven clinics (65%) reported that patients were waiting longer for care. Nine clinics (53%) were still trying to see all patients and eight clinics (47%) were using some form of triage (see ). All but one clinic provided physiotherapeutic, psychological, or educational services using phone or video technology. Most services were provided individually, but one site was offering group mindfulness and art therapy, and another two sites were about to commence group programs remotely. Six (35%) clinics were providing no procedures and 11 (65%) were providing limited access to procedures (see ). Thirteen clinics (76%) reported obstacles to providing virtual care, including lack of sufficient equipment, lack of administrative support, and delays in accessing authorized telehealth platforms (). Most reported that with time, experience, and access to staff, some of whom had been redeployed away from pain clinics, the issues were being gradually resolved.

Table 1. Responses to question “Are you still trying to see all patients or are you triaging? What criteria are you using for triage?”

Table 2. Answers to question “Are any procedures continuing? If yes, what procedures and what criteria are you using for urgent procedures?”

Table 3. Answers to question “What have the biggest obstacles to providing virtual care been? How do you see these obstacles being resolved?”

Thirteen clinics (76%) indicated that their patients reported increased pain levels. When asked about the key reasons for the increase in pain, 11 clinics (65%) reported that patients had decreased access to complementary treatments and 12 clinics (71%) reported decreased access to other treatments. Twelve clinics (71%) reported that pain levels might be increased due to increased stress related to COVID-19 issues; three clinics (18%) reported stress related to other issues, including social isolation, decreased activity, finances, layoffs, grief, and access to treatment; and six clinics (35%) reported patient decreased ability to exercise.

Nine clinics (53%) reported that patient medication use had increased, with eight clinics (47%) reporting an increase in opioid and cannabinoid use, five clinics (29%) reporting an increase in anticonvulsant use, and four clinics (24%) reporting an increase in antidepressant use. Other medications noted to be increased included benzodiazepines (one clinic) and nonsteroidal anti-inflammatory drugs (two clinics). Four clinics reported other medication-related issues, including shortages, difficulty accessing medication, inability to do urine testing, and problems refilling opioid prescriptions. One clinic mentioned that pharmacists’ abilities to take phone orders on opioid prescriptions made it easier.

When asked what federal, provincial, or territorial support would be helpful to facilitate virtual care, 76% endorsed virtual platforms, 47% endorsed billing support, and 29% made additional suggestions (). The majority reported that they thought that virtual health care would continue even after the COVID-19 crisis is over, with several mentioning that appropriate billing support would facilitate this (). Under other takeaways, clinics reported that patients appreciated the option of phone or other virtual contact ().

Table 4. Answer to question “What federal, provincial, or territorial support would be helpful to facilitate providing virtual care?”

Table 5. Answers to question “What practices will your clinic continue once the COVID-19 crisis is over? Do you have any other comments or lessons learned while providing care during the COVID-19 pandemic?”

Discussion

This study found that adult multidisciplinary pain clinics across Canada have had to cease or significantly reduce in-person patient appointments during the COVID-19 pandemic, and every clinic responded by offering telehealth options including phone and Internet-based video appointments (most commonly Zoom for Healthcare). Despite these efforts, patients do not have access to usual care and are waiting longer for care at pain clinics. Only the most urgent procedures have continued, leaving many patients without access to other diagnostic or therapeutic interventional procedures. The majority have had no access to complementary therapies such as acupuncture, osteopathy, chiropractic treatment, or hands-on physiotherapy. Patients’ pain and stress levels were reported to be higher. Medication use has escalated, with most frequent increases being reported for opioids and cannabinoids but also including antidepressants and anticonvulsants.

Previous work has identified that people living with chronic pain conditions have very poor quality of life, with 50% experiencing severe or extremely severe levels of depression and 35% experiencing suicidal ideation.Citation4 There is a significant deterioration in health-related quality of life and psychological well-being while waiting for care, including increasing pain and depression.Citation5 It is clear that the public health response to the COVID-19 pandemic requiring pain clinics to cease in-person contact has caused significant harm to people living with chronic pain. The negative impact on their care persists despite creative efforts by clinic staff across the country to provide telehealth options. The current pandemic has accelerated the support and uptake of telehealth technologies, which is an improvement in delivery of care that should continue. These technologies will be useful when the COVID-19 pandemic is over. Telehealth is often more convenient for patients and provides additional, more cost-effective options for follow-up care.

A key limitation to this study is that it did not collect data directly from patients. This survey was answered from the perspective of the clinic directors or their designates. It will be important in a future study to obtain information directly from people living with pain conditions. We identified participants through APDOC membership, in order to survey a convenient sample over a time frame that enabled us to rapidly communicate possible solutions to the challenges that multidisciplinary pain clinics face in this time of crisis. Because most of the clinics involved in this study are large university-affiliated facilities, the challenges faced and solutions offered may not represent those of all multidisciplinary pain clinics across Canada.

Public health authorities must consider possible harms to people living with chronic pain when they consider their responses to the current and future pandemics. Further limiting access to care will exacerbate the impact of chronic pain on individuals, their families, communities, and the Canadian economy.Citation2 Only time and further study will tell the full story of the costs of the public health response to COVID-19 on people with chronic pain. Though it is vital to ensure that the health system can deal with the acute impacts of COVID-19, it is equally important that in planning for future crises we address the need to continue the treatment of chronic conditions and disease prevention programs, such as vaccination and cancer screening, in order to decrease ongoing morbidity and excess mortality due to these conditions. We must build upon the innovative approaches to improving the care of people living with pain that the multidisciplinary pain clinics have started or accelerated during COVID-19. We recommend that the Canadian Pain Task Force advise Health Canada that a coordinated approach to the management of chronic pain in times of crisis be included as a vital component of a comprehensive Canadian pain strategy.

Disclosure Statement

Author MEL has no conflict of interest, author ODW has no conflict of interest and author JCB has no conflict of interest.

Additional information

Funding

The authors thank the Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, for support of this study.

References