The novel coronavirus (COVID-19) has threatened world health. The morbid complications
of COVID-19 include but are not limited to acute respiratory distress syndrome (ARDS),
shock, arrhythmia, cardiac dysfunction, and secondary infections. Health care delivery
for patients with COVID-19 infection is challenged by the virus’s high rate of transmission
and resource limitations. Precautions during the COVID-19 outbreak have strained the
US health care system in unique ways, such as rationing of personal protective equipment
(PPE), personnel safety, and widespread cancellation of elective health care services
[1]. The US Centers for Disease Control and Prevention (CDC) recommended developing
individual practice triaging systems stratified by care urgency for ambulatory providers
[2].
Interventional pain management represents an important pillar of care for many pain
conditions. However, pain interventions have traditionally been considered elective,
with few exceptions. In late March 2020, the American Society of Regional Anesthesia
and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy
(ESRA) released a joint advisory for the practice of chronic pain management during
the COVID-19 “shelter in place” ordinance [3]. This advisory stated that “semi-urgent”
scenarios that merit in-clinic procedures include intractable cancer pain, acute herpes
zoster, intractable post-herpetic neuralgia, acute herniated disc with lumbar radiculopathy,
complex regional pain syndrome (CPRS), acute cluster and/or intractable headache,
and case-by-case medically refractory intractable pain. Yet, some state governments
undermine the nuances of these “semi-urgent” scenarios with executive orders to halt
elective procedures that do not “spare life or limb” altogether [4].
In March of 2020, hospitals across the United States deescalated elective procedures
in anticipation of future surges in need for intensive care space, inpatient beds,
ventilators, blood products, trained personnel, and PPE use. The American Hospital
Association challenged the universal cancellation of elective procedures, stating
that personnel and bed space allocation for surgical care must be nuanced to meet
the current and predicted future demands of hospitals [5]. Truly elective matters,
even in pain management, may become urgent if postponed long enough [3]. The American
College of Surgeons (ACS) offers guidance on the urgency of an elective procedure
from most necessary to least [6]. Yet, reports have documented continuation of the
performance of truly elective procedures in the United States despite guidance from
government entities and medical societies [7]. The response to the COVID-19 outbreak
has underscored a dearth of systematic prioritization of procedural urgency based
on ethical principles and patient acuity factors.
In light of the redistribution of care to remote patient–provider encounters, conservative
therapies have become paramount to pain management. Medications, complementary medicine,
and psychological care comprise conservative measures accessible by remote means.
Yet many analgesics induce immunosuppression, a feature that is potentially harmful
to patients at risk for COVID-19. The US Food and Drug Administration (FDA) suggested
judicious use of nonsteroidal anti-inflammatory drugs (NSAIDs) for ongoing pain, while
noting that interference in the detection of fever may pose diagnostic risks [8].
High fever, regardless of the cause, in patients utilizing transdermal fentanyl increases
patient risk for increased plasma levels and subsequent side effects, including respiratory
depression and coma. The in vivo immunomodulatory effects of enteral opioid therapy
raise concerns for immunosuppression, yet untreated pain may also have detrimental
immune effects [9]. Indeed, situations exist wherein the risks of alternative therapy
may not be ideal for patients. Thus, pain physicians must now weigh new risks in deciding
whether to perform elective procedures during the COVID-19 pandemic.
Through two vignettes, we explore the pain physician’s quandaries stemming from an
inability to perform medically necessary pain interventions during the COVID-19 pandemic.
We explore the ethical considerations for common targeted pain interventions vs systemic
therapies.
Case 1
Mr. Smith is a 76-year-old man with radicular lower back and leg pain in an S1 nerve
root distribution, status post-L4-L5 lumbar posterior spinal fusion. He developed
recurrent radicular pain six weeks ago. An absence of lower extremity motor strength
changes was corroborated over telemedicine video encounters, as his toe-walking gait
and single-leg-standing calf raises were intact, and he noted pain but no subjective
strength asymmetry during these tests. His lancinating pain remained refractory to
weeks of home exercising including guided physical therapy via a virtual platform.
His medical history was significant for carotid arterial stenosis and a left carotid
artery stent, managed with clopidogrel and aspirin. He was intolerant to gabapentinoids
due to dizziness, mental fogging, and falls associated with prior use. Prior lumbar
transforaminal epidural steroid injection (TFESI) provided 80% pain relief for over
six months, and he was able to reestablish a baseline quality of physical functioning.
Unfortunately, the reallocation of clinical resources to accommodate a projected surge
in COVID-19 patients resulted in widespread elective procedure cancellations at the
outpatient clinic.
Due to the evolving events with COVID-19, the pain physician must now triage whether
Mr. Smith’s scheduled TFESI is urgent, elective, or “semi-urgent.” Treatment of discogenic
lumbar radicular pain by TFESI results in clinically meaningful pain reduction, functional
improvement, and surgical sparing in a proportion of patients [10]. Based on the American
Society of Regional Anesthesia & Pain Medicine (ASRA) and European Society of Regional
Anaesthesia & Pain Therapy (ESRA) COVID-19 advisory, pursuing TFESI for the above
radicular pain is reasonable [3]. In the absence of lower extremity motor dysfunction,
emergency decompressive surgery is likely not indicated. Although minimally invasive
decompressive surgery (e.g., microdiscectomy) may provide pain relief, this represents
an elective procedure whose performance would redirect personnel, equipment, operating
room, and hospital space reserved for more emergent procedures during a pandemic.
Presentation to the hospital or emergency department for inpatient pain management
may result in higher risk of COVID-19 exposure to the patient.
Should the physician offer an epidural steroid injection despite widespread cancellations
and fears surrounding viral exposure in health care settings? The relevant ethical
question is whether it is responsible pain medicine to offer semi-urgent treatment
in light of the myriad factors raised by the COVID-19 pandemic. There are at least
three levels of thought relevant to the ethical analysis. The first concerns the risk–benefit
to the patient himself, who is at increased risk for significant morbidity and mortality
from COVID-19 infection should he contract it. As a result, any physician considering
the proposed intervention must both 1) carefully evaluate whether the benefit of the
procedure could reasonably outweigh its risk and 2) clearly communicate all of the
relevant information to the patient so that he can make a genuinely autonomous decision
about whether to move forward with the procedure. In Mr. Smith’s case, it is relevant
that corticosteroids depress innate immunity and may increase the likelihood and/or
severity of respiratory disease should viral exposure occur. As depressed serum cortisol
levels may last up to nearly two to three weeks after epidural corticosteroid administration,
decreased corticosteroid doses should be considered in order to attenuate this risk
of immunosuppression [3, 11]. Moreover, lower epidural corticosteroid doses than are
typical in routine clinical practice may be equally efficacious [12]. After epidural
steroid administration, patients may reasonably follow CDC guidelines put forth for
immunosuppressed patients. These risks must be made clear to the patient before clinic
presentation and appropriate COVID-19 infection screening [13].
The second level of ethical analysis concerns whether the physician is obligated to
offer services that are semi-urgent. In other words, the framework of elective/urgent/semi-urgent
procedures allows individual physicians to attempt to be more or less aggressive in
treating patients or in preserving resources. How, then, is a responsible physician
to act? The response to the COVID-19 pandemic has forced pain practices to weigh the
risks of personnel and patient virus exposure. Patient symptom and travel history
screening tools, distancing patients more than six feet apart, escalating sanitation
practices to include high-touch-volume surfaces, and the proper donning and doffing
of PPE have been encouraged to limit clinic-based viral inoculation [3]. However,
health care personnel may feel personally unsafe in providing care in a clinic/ambulatory
surgery center during nonurgent procedures. Moreover, the limited availability of
masks and other PPE further complicates this calculus.
Physicians differ in how they weight the importance of their contribution to “flattening
the curve” in parallel with their own sense of economic well-being. Providing concrete
guidance on personal responsibility is difficult, as determining the importance of
moving forward with an interventional treatment will often require intimate knowledge
of the patient and intended procedure. Individual physicians are most capable of making
this determination. An ethical framework may be applied to assess circumstantial procedure
appropriateness: first, in a case with genuine uncertainty as to whether it is sufficiently
urgent to be performed during a pandemic, it is neither obligatory to perform the
procedure nor obligatory to refrain. Rather, it is permissible for the physician to
move forward if informed consent is obtained. Second, clinicians should decide whether
to perform a given procedure based only on their evaluation of risks and benefits
(to the patient, population, health care personnel, and oneself), and not on ulterior
financial incentives. Lastly, regular checks within practices should evaluate whether
some physicians abuse the leeway built into the concept of “semi-urgency” in order
to continue something close to practice as usual. This brings us to the third level
of ethical analysis, which concerns policy, rather than individual clinician behavior.
In the setting of a pandemic, providers must seek options that balance considerations
of beneficence with risk to others while maintaining conscientiousness about resource
allocation. This difficult equation might be better suited to institutional policy-makers
or triage committees. As the COVID-19 pandemic has worsened, leaders in ethics have
advised the use of triage committees in the hospital setting. Triage committees lighten
the onus of decision-making for individual physicians and can help to promote justice
by removing the potential for provider bias [14]. Thus, where reasonable, it may be
helpful to employ impartial committees to evaluate individual physicians’ opinions
on procedural urgency. However, the human resource of contributing to such a committee
may be a scarce one. Judging the importance of every nonurgent procedure may not be
realistic, especially in large hospital systems and practices. For smaller community
practices, the provision of impartial committees may be even less feasible. Despite
these obstacles, a plan for regular review of physician case load may prevent bias
and promote the public health goals of restricting nonurgent elective procedures.
Weighing the probability of adequate, durable pain control with remotely accessible
conservative therapies must be also considered in procedural planning. Over-the-counter
analgesics, information regarding home exercise programs, app-based meditation and
biofeedback tools, and online resources regarding pain psychology serve as important
alternative strategies. Yet, many of these modalities do not effectively treat acute
on chronic pain. Opioid analgesics pose significant risks to patients with limited
efficacy for lower back pain [15]. NSAIDs pose risks for stent thrombosis and cardiac
adverse events if used at higher doses, although selective cyclooxygenase (COX)-2
inhibitors at moderate doses may provider a greater cardiac safety profile than previously
thought [16]. Although oral steroids can improve physical functioning due to radicular
pain, the risks of immunosuppression and lack of analgesia are not optimal [15, 17].
Muscle relaxants (e.g., cyclobenzaprine, baclofen) come with inherent risks of sedation,
dizziness, and gait instability, with the potential for falls in elderly patients
[15]. In weighing these considerations during the COVID-19 pandemic scenario, an ideal
outcome is unlikely. Performing the procedure may be riskier than one would typically
prefer, while forgoing it may provide suboptimal care. The goal is to provide the
best care possible in challenging circumstances.
Case 2
Mrs. Jones is a 72-year-old woman who suffers from phantom limb pain after a traumatic
left lower extremity below-the-knee amputation. Ultrasound-guided residual limb sciatic
neuroma injections with phenol repeated every nine to 12 months effectively managed
her pain and facilitated physical function and mobility with her lower extremity prosthesis.
Her medical comorbidities include nonvalvular atrial fibrillation, complicated by
a prior stroke requiring ongoing anticoagulation therapy with warfarin, opioid use
disorder (OUD) now on sublingual buprenorphine maintenance therapy, well-controlled
anxiety, type 2 diabetes mellitus requiring daily insulin, and chronic kidney disease
(stage III). Notably, she has a history of multiple esophageal ulcers complicated
by gastrointestinal bleeding from heavy NSAID use in the past, which required red
blood cell transfusion and intensive care unit admission. Her current analgesic regimen
includes acetaminophen, lidocaine ointment, and topical capsaicin. She has had multiple
intolerances to neuropathic pain agents, including gabapentin, pregabalin, duloxetine,
and tricyclic antidepressants, due to significant adverse nonallergic reactions. The
patient calls her pain physician and communicates desperation, as her pain is intractable
to her usual analgesics and it has been nine months since her last phenol neurolysis
procedure.
The case of Mrs. Jones adds further nuance to the framework described for Case 1.
The urgency of providing an injection is heightened due to the particulars of the
case, which change the standard risk–benefit profile, for both opioid and nonopioid
analgesic agents. Her history and comorbidities place her at high risk of gastrointestinal
bleeding and acute kidney injury with initiating enteral NSAIDs. Furthermore, adverse
events related to antidepressants, gabapentinoids, analgesics, and muscle relaxants
may pose risks that may undermine her acute on chronic pain management. For patients
on medication-assisted therapy (MAT) for OUD, pain should be managed using a multidisciplinary
approach taking into account the perceived risk of relapse with buprenorphine cessation
and initiation of pure mu opioid agonists, such as morphine, fentanyl, hydromorphone,
and others [18]. Although not entirely inappropriate, the diagnostic and potentially
therapeutic avenue of hospital admission for pain management poses significant risks
of viral exposure. The risk of COVID-19 exposure in the hospital setting, given the
patient’s age and frailty, is likely greater than if she presented to ambulatory care
for her usual procedure with historically reliable efficacy.
In the complicated medical landscape during COVID-19, pressing forward with Mrs. Smith’s
standard therapy may well be permissible, so long as she autonomously endorses the
plan of care. Again, this does not imply that the treatment is obligatory for a physician
and/or health care team to provide. Freedom of choice to increase exposure and to
utilize health care resources in this way is important. For a willing physician and
health care team and a willing, informed patient, semi-urgent interventional pain
therapy for patients like Mrs. Smith can be reasonable during the COVID-19 pandemic.
Case 2 illustrates the limitations of blunt policies regarding elective procedures.
In the context of pain medicine, cancellation of outpatient procedures may change
physician opioid prescribing practices. Pain physicians may feel pressure to prescribe
opioids due to the restrictions of pain procedures imposed by the reaction to COVID-19.
In an effort to meet patient needs during the global emergency, the US Department
of Health and Human Services and the US Department of Justice Drug Enforcement Agency
(DEA) lifted the mandate for at least one in-person visit for new opioid prescriptions
in March of 2020 [19]. Thus, any provider with a license to prescribe controlled substances
may now prescribe these through a telemedicine encounter. While this measure provides
an avenue of delivering care remotely during a pandemic, the policy may risk undermining
efforts to limit the volume of opioid analgesic prescriptions in the community.
In patients like Mrs. Smith who carry the diagnosis of OUD, the impetus to continue
non-opioid-based therapy is even stronger. Although public health crises like the
COVID-19 pandemic may require policies such as canceling “elective” outpatient procedures
and increasing access to opioid therapy, responsible pain medicine requires treatment
to each unique patient using an individualized risk–benefit analysis. It may be preferable
to avoid opioid therapy for Mrs. Smith, even if she is placed at greater risk of exposure
to COVID-19. However, for patients who receive opioid therapy during the pandemic
as a nonideal plan of care, clinicians inherit additional obligations as well. As
has been recently argued, prescribing opioids comes with an obligation to safely and
comfortably taper off the opioid when no longer necessary [20]; this implies that
surplus prescriptions written in an effort to minimize outpatient procedures may result
in increased provider responsibility when patients’ pain can once again be treated
with a nonopioid strategy.
Medical care is not solely grounded in survivability but also in the relief of suffering.
International health emergencies present new ethical challenges in weighing the risks
and benefits in outpatient pain management. Pain interventions represent an essential
service for many patients, and cessation of procedural care may lead to adverse effects
yet to be well described. When possible, institutions should consider utilizing triage
committees to alleviate the burden of decision-making from individual pain physicians.
Such committees should recognize that the COVID-19 pandemic poses noninfectious risks
to patients if pain is undertreated.