Across the world, pain treatment centres have closed their doors. Because of the COVID-19
pandemic, healthcare providers are abruptly changing their care delivery to protect
patients and staff from infection and to reallocate resource towards the greatest
acute needs. Elective, routine, and nonemergency casework has stopped in secondary
and tertiary centres, while in primary care, patients are requested to stay away or
“socially distance,” and in residential care facilities and hospices, strict isolation
and separation protocols have been introduced.
Before the COVID-19 pandemic, telemedicine and eHealth approaches were being developed
and tested in a gradual fashion with many studies focusing on lessons learned and
barriers to using digital solutions.
Overnight, however, treating or supporting people with non-urgent and long-term conditions
at a distance from healthcare providers has become imperative. These immediate changes
are happening across healthcare systems. Telemedicine is being used to demand-manage
the flow of patients with respiratory distress accessing emergency departments
; video consultation is being introduced in multiple settings
; and using social media is being discussed positively for its potential to direct
people to trusted resources, to counteract misinformation, and to provide psychological
Pain management providers face the challenge of delivering face-to-face service through
different modes. Fortunately, there is a rich stream of research and clinical experience
in the use of different technological solutions. Table 1 provides a summary of the
definitions and terminology in use.
Definitions and terminology used in remotely supported pain management.
We consider 4 related factors to help guide healthcare professionals caring for patients
with chronic pain: (1) the public health consequences of COVID-19 for patients with
pain; (2) the consequences of not treating these patients for the unknown duration
of this pandemic; (3) options for remote assessment and management; and (4) clinical
evidence supporting remote therapies. Finally, we provide guidance for those attempting
to rapidly transition to remote care with technology and discuss the lessons for the
future of the pain treatment centre.
2. Public health considerations
Pain prevention and control—particularly for chronic pain—will inevitably be disrupted
by the COVID-19 pandemic. Diversion of resources will be planned (eg, cancelling elective
surgery and outpatient procedures for chronic disease management) and unplanned (eg,
medication shortages due to panic buying and inaccessibility of remaining healthcare
options during movement restrictions). Longer-term, healthcare workers are likely
to be at higher risk of lasting psychological morbidity based on evidence from the
2002 to 2003 SARS epidemic.
The effect of the pandemic on pain burden will be differentially distributed across
and within populations, depending on population characteristics emerging as determinants
of the pandemic, including older age, population density, socioeconomic gradient,
smoking prevalence, levels of chronic disease morbidity, availability of diagnostic
testing, and access to health care. Some of these characteristics are also associated
with higher levels of chronic pain prevalence and burden (eg, older age, socioeconomic
status, smoking prevalence, chronic disease comorbidity, and access to health care).
Therefore, populations with higher existing pain burden are more likely to experience
higher incidence of COVID-19 infections, greater disruption to their usual healthcare
access, and worse downstream consequences of abruptly altered health care. In addition,
some at-risk population subgroups also have poor access to technologies used in remote
Prevention of chronic pain within populations currently depends on best practice management
of acute pain and early recognition of the risk of progression to chronic pain.
Drivers of acute pain burden include injury-related pain and treatment-related pain
(eg, after surgery). Social isolation measures will directly influence the number
and type of injuries experienced within populations (eg, fewer road traffic and workplace
accidents, increases in conflict/interpersonal violence, and domestic injuries). Changes
in the overall volume and type of surgery (more emergency and high acuity elective
surgery) are occurring as health systems pivot to respond to the pandemic. Preventing
chronic pain is complex at the best of times, but in a global health pandemic, risk
factors for pain morbidity and mortality will be magnified.
3. Not treating chronic pain
The high prevalence of chronic pain risks inuring us to suffering, one can easily
mistake common for trivial. When people with chronic pain are denied assessment and
treatment, their condition can worsen significantly; spontaneous recovery is rare.
People living with chronic pain have the largest global morbidity, measured by years
lived in disability.
People waiting for assessment often report severe levels of pain that interfere with
their ability to function, and reports of severe pain are associated with more severe
levels of depression in 50% and suicidal thinking in 34.6%.
Children and adolescents also report high symptom burden when awaiting evaluation.
Furthermore, people waiting over 6 months for assessment experience deteriorating
health-related quality of life, increased pain, and increased depression.
The risks of harm from undertreatment can be exacerbated further by the risk of harm
from inappropriate treatment. In many countries, most notably the United States and
Canada, chronic pain management is practiced in the shadow of a crisis of the oversupply
and overuse of opioids.47 Given that best practice for prevention of opioid harms
is unclear, referral to pain professionals for pain medicine management is common.
In the United States, few pain clinics can care for high volumes of patients, and
referring everyone for opioid stewardship is unrealistic.
In North America, we already see an increase in serious mental health problems as
some turn to illicit sources of opioids, while others suffer in silence.
Not treating chronic pain will have consequences for individuals, healthcare systems,
and providers in the short- and long-term, increasing quantity, severity, and complexity
4. Distance assessment and treatment with technology
To address the needs of people with chronic pain, one should look first to pervasive
and inexpensive technology such as the telephone.
Telemedicine, including telephone consultation, short message services, and video
conferencing are used worldwide and are broadly analogous to traditional care, although
the benefits and costs of telemedicine are still largely unknown.
They are minimally disruptive and require a broadly similar healthcare resource.
Clinical assessment relying on patient-reported outcome measures can be undertaken
remotely. Mobile telephones with camera technology allow for shareable images of paper
assessments. In addition, many local electronic health record systems already allow
for electronic administration of measures. Several web-based systems have been optimised
for people with pain, such as the CHOIR system in the United States
or the PAIN OUT system in Europe.
Such systems allow clinicians to review measures before appointments. Interdisciplinary
evaluations can be modified for distance use before the visit, supporting history
and interview. Even aspects of the physical examination can be undertaken virtually,
for example, in judging appearance, movement, or in self-examination under guidance.
Although there are limitations to the lack of hands-on physical examination possible
with telehealth, a modified virtual examination may allow an initial treatment plan
to be started.
Pain self-management options are available using different technologies (eg, the internet,
email, computers, and “smart” phones), which play a central role in health care provided
to patients. Most studies have been concerned with remotely delivered self-management
interventions for chronic pain, undertaken at one's convenience and without having
to leave the home.
These interventions aim to provide the same information and training in self-management
skills as provided in face-to-face pain management programs but use technology in
different ways. Interventions have been examined in controlled trials.
The focus on technology promises increased access and scalability, although evaluations
of their impact in reaching scale are scarce. Several of these interventions are already
freely available in some parts of the world, and many others are commercially in development
or are being offered.
A caveat on commercially developed interventions, however, is the current lack of
quality control over the content, security, and marketing claims. The burgeoning app
market is a good example, and caution should be exercised.
Table 2 summarises guidance for those unfamiliar with telemedicine and digital treatments
who are tasked with their rapid deployment.
Practical recommendations for the rapid introduction of remotely supported pain management.
5. Evidence for efficacy and harm of telemedicine and DTx interventions
Although telephones are in common clinical use, full-scale telemedicine for people
with chronic pain is rare. In general, the evidence is similar to that from primary
care studies and is cautiously optimistic but recognizes barriers to implementation,
unforeseen harm, and potential for inequity in access and use.
Most innovation has been in the development of internet-delivered therapies for people
with chronic pain. Many remotely delivered programs can be accessed directly and have
minimal requirements. In children and adolescents with mixed chronic pain (eg, sickle
cell disease, musculoskeletal pain, juvenile idiopathic arthritis, and headache),
remote psychological therapies delivered through the internet or mobile applications
show small beneficial effects for reducing pain intensity, including headache severity,
after treatment, but not maintained at follow-up.
The first Cochrane systematic review of technological interventions for chronic pain
in adults found 15 studies with 2000 participants.
Several systematic reviews have been published since.
Reviews identify small to moderate reductions in pain, disability, and distress in
intervention groups compared with any control (including active, standard care, or
Unsurprisingly, when compared with only active control (eg, face-to-face therapies),
no difference in treatment effect was found between remote and in-person therapies.
Remotely delivered physical exercise interventions are also available, with benefits
comparable with usual care for reducing pain and beneficial compared with no treatment.
Although promising, there are concerns related to the evidence underlying remote therapies;
relatively few studies assessed for harm, and dropout can be substantial. Access and
engagement are important to track and report, particularly as disadvantaged groups
use technology less (eg, older adults and disabled people).
“Therapeutic alliance” is important but may be more challenging to establish, foster,
and maintain remotely. That said, a large trial delivering psychological therapy through
an online pain course showed improvement in pain, disability, and emotional functioning
compared with waiting list but few differences between groups with varying amounts
of therapist contact.
Understanding who struggles to engage and use eHealth provision is crucial to maximise
effectiveness, as are concerns about privacy, transparency (eg, therapist-generated
vs automated messages), and training needs of staff accustomed to face-to-face working.
Virtual and augmented reality are rarely used with chronic pain but have potential
for remote use, going beyond distraction, with a focus on improving function and reducing
Early studies are promising but small.
COVID-19 will have consequences for people with chronic pain, a large population with
the greatest global burden of disease. The downstream consequences of disrupting treatments
for chronic pain have yet to be modelled but are likely to be substantial. Many healthcare
professionals specialising in pain have skills directly relevant to the acute response
to the pandemic and so will be redeployed; others may be able to maintain some service
delivery to affected individuals.
Telemedicine and eHealth interventions for service delivery will be attempted and
will be novel for many. Ubiquitous communication technology is relatively inexpensive
to access. It is practically possible to communicate with patients if the personnel
and infrastructure are available. In some treatments, such as psychologically orientated
self-management, investment in developing web-based or application-based platforms
delivering pain self-management has produced some evidence of efficacy, and some products
are freely available to download. Healthcare providers need to be aware that many
of the behavioural components of eHealth self-management are not only potentially
helpful for managing pain but also for emotional distress related to the COVID-19
pandemic. In Table 3, we suggest research priorities to improve the evidence for distance
interventions and learn from this abrupt change in our practice.
Research priorities for remotely supported (eHealth) pain management services.
Changing practice in such an unplanned way will have positive and negative consequences,
many unforeseen. Systems can establish protocols that can enable them to oversee,
monitor, and capture important patient and provider outcomes and perspectives. When
we come to redesign services after the pandemic, we will need to share that experience
and use it to learn what works, to modify what does not work, and to build new models
of care for people living with chronic pain.
Conflict of interest statement
The authors have no conflicts of interest to declare.