Approaches and best practices for managing cancer pain within the constraints of the COVID-19 pandemic in India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/IJPC.IJPC_216_20
Source of Support: None, Conflict of Interest: None
Keywords: Neoplasms, pain management, severe acute respiratory syndrome coronavirus 2
“In the midst of this catastrophe, more than looking in to find serenity we need to look out for one another to practice humanity.”
Corona virus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus has rapidly progressed to a stage of public health emergency of international concern. Not only has it majorly impacted the global health; it has brought the economic, social, and political processes around the world to its brink., As a response to this global crisis, the Government of India announced a nationwide lockdown to contain the spread of infection., These events have compromised equitable health care (HC) to an extent and has specifically jeopardized the health of chronically ill, such as cancer patients.
Pain is highly prevalent in cancer and managing pain is an integral part of caring for cancer patients. 55% of patients on active treatment and 66% with advanced disease experience pain. Of these, >50% patients suffer with moderate to severe pain. Poorly managed pain negatively impacts quality of life, adversely affects adherence to treatment, worsens prognosis, and should be prevented.,,
Cancer patients have higher vulnerability for COVID-19 infection as they are immune compromised and have greater morbidity and mortality once infected., Hospitals act as hotspots and become sources of very high transmission. To thwart the increased COVID-related morbidity and mortality within hospital environment, cancer care guidelines have emerged with prioritization criteria including risk versus benefit ration for withholding or postponement of cancer treatment. Oncology treatment protocols that caused immune suppression have also been modified.,, Yet, the guidelines have no clear recommendation for managing cancer pain management within the modified dynamics of the present situation. The management guidelines for chronic pain, specific to COVID-19 pandemic, also have not addressed the specific concerns of managing pain in cancer patients.,
This paper is the result of structured interactions among pain and palliative care teams at 7 tertiary cancer hospitals of the National Cancer Grid-India network. The participating centers were located in tier one or two cities, with five of them situated in the “red zones” with a substantial number of COVID-19-positive cases and high level of infectivity in the region. The challenges and mitigating practices at the seven centers were sought, and collated, along with scoping of literature. The teams provided information on their practices specifically related to managing cancer pain as per their institutional policies, modifications for patient interactions, systems in-place for evaluation, criteria and planning for patient admissions, alterations in drug regimens and methods for review. They also shared experiences on using virtual platforms, on the challenges faced and approaches found useful in providing psychosocial care.
The unique challenges in managing cancer pain in tertiary cancer care settings, during COVID-19 pandemic contextual to the Indian sociocultural-economic settings listed in [Box 1], are described in detail.
Each section below describes a challenge along with approaches to find solutions and improve care with best practices where relevant.
The government has acquired and reserved a substantial percentage of out-patient consultation space and hospital beds in both the government and private sector, for caring of COVID-19 patients. The prolonged lockdown in many regions has affected all movements, including public and private transport facilities. There is a paucity of available means of transport for sick patients who must travel long distances to access a palliative care specialist service. They often depend on taxis, private vehicles, and ambulances, which have increased their charges due to surge in demand, and suffer financially. The hospices, homecare services, and private nursing homes have scaled down their services, worsening the already limited access to pain and symptom management for cancer patients.
This impacted access to competent care for homebound advanced cancer patients with poor general status, suffering with severe pain.
A simple system of online issue of electronic passes (e-pass) for travel is currently active in 17 states of India. Various community-based organizations have also extended support with provision for free or low-cost ambulance services to and from hospitals. Informing and supporting families on using this method has resolved transport issues for some patients. For those patients who require in-person consultation, but are unable to travel in spite of these provisions, liaison with a local family physician over teleconsultations (described below) has been valuable. There is a need and scope for better and more robust solutions to address these challenges.
During the current stage of pandemic with high community level transmission, suggesting in-person visits to outpatient departments or admitting to inpatients have become much more of a grey area than ever before. The focus of HC facilities on COVID-19 infected patients has impacted access to specialist-consultation, in-patient (IP) admissions, and the overall care for distressed patients with cancer pain.,, Patients requiring laboratory or radiological investigations for establishing a pain diagnosis and those who need disease modifying treatments for managing emergencies do require in-person visits to hospitals. Recurrent hospital visits for uncontrolled symptoms increases the risk of contracting COVID-19 infection and causes financial burden for the patients. The case example described in [Box 2] illustrates how these issues compound together and aggravate the situation for individual patients.
Challenges due to mandated social distancing, time constraints, and minimizing interactions impacted detailed nursing assessment, physical assessment, history taking, verbal and nonverbal communications, and counseling. This caused difficulties in establishing a pain diagnosis. Requirements for personal protective equipment (PPE), skeletal staffing, and the need to avoid congested workspaces led to reduction of the number of ongoing consultations at any point in time. This affected privacy, increased the waiting period for patients, and affected therapeutic relationship with the patient. These problems were enhanced by the fear of contagion in health-care professionals (HCPs) as well as patients and caregivers.
Various steps were taken at multiple levels during a patient's journey in the hospital to minimize transmission and to prevent risk of infection of HCPs, patients, and their relatives [Box 3].
Although every situation needs to be judiciously examined with risks/benefits and empathetic communication, an institutional policy guided by the cardinal principles of medical ethics was used to support decision-making.
Limiting patient movements within the hospital was one strategy adopted. Guidelines with generalist competencies for managing cancer pain were activated to enable oncology professionals to treat cancer pain as a part of comprehensive cancer management plan. Indicators for referrals based on the complexity of the pain or patient's distress helped triage those requiring specialists palliative care.
Inpatient admissions protocols were adapted from ESMO guidelines for managing emergency pain situation. The choice for aggressive interventions was guided by NHS guidelines that featured prognostication, frailty score, and patient wishes for individual decision-making.,,,,
All institutions had their own protocols-based urgency of situation, which guided the need for laboratory or radiological investigations and for prioritizing for disease modifying treatments such as radiotherapy. For example, patients with pathological fractures requiring emergency surgical stabilization or those with spinal cord compression or symptomatic brain metastasis needing urgent radiotherapy were prioritized for early interventions.
Virtual care was adopted as an interim solution to social distancing policies. According to 2019 Telecom statistics, 90% Indians have access to telephone connections. This penetration of telephones supported the implementation of telemedicine guidelines put forth by the Ministry of Health and Family Welfare in collaboration with Medical Council of India (MCI), to ensure timely, quick, effort, and cost-saving HC provision to people across the country during pandemic situation.
The guidelines encompass audio, video, text-based, and asynchronous (emails/fax/recordings) consultations. Video consultation is a viable option for the urban population as 97% have access to internet connection. However, this is not an option for those who live in rural India, as 75% population do not have internet access. The advantages and concerns about of virtual consultations are mentioned in [Box 4].
The best practices adapted for assessing, triaging, and managing pains and for monitoring impact of pain management through virtual care are depicted in [Figure 1] and [Table 1].
The elements of telemedicine consultation that are considered and adapted for cancer pain management are described in [Table 1].
This structured process accompanied with meticulous documentation is a solution to overcome challenges in virtual pain assessment and management. The process teleconsultation may further be facilitated using simple follow-up tools such as scanned notes, reports, or E-mails to the patients.
The general principles that guide cancer pain management during the COVID-19 crisis are listed in [Box 5].
The specific challenges to managing cancer pain are categorized under (i) choice of medications, (ii) prescribing practice, (iii) regulatory mandates, (iv) accessing medications, (v) reviews and titrations, and switching of medication, and (vi) ensuring uninterrupted supply of narcotic medications.
Paracetamol and NSAIDs are approved as over-the-counter medications through teleconsultation, easy to access for patients. Adjuvant analgesics such as steroids, anticonvulsants, antidepressants, antispasmodics, and bisphosphonates are required alone or in combination to manage complex cancer pain syndromes., Their use reduces the overall opioid requirement, [Table 2].
Although WHO Step 2 analgesics work partly through opioid receptors, most drugs from this group which are available in India, such as tramadol, tapentadol, and buprenorphine are included in Schedule H class of prescription drugs in India, and hence prescription only drugs. with exception of codeine, they are not prohibited for use through teleconsultation [Table 3].
Morphine, fentanyl, and methadone are the step 3 narcotic analgesics available in India. These are safe, economic, and effective for the management of severe cancer pain when used rationally. They have no ceiling dose., In India, morphine is available as immediate release and controlled release tablets and injections, fentanyl as transdermal patches and injections and methadone is available as oral liquid and tablets. The narcotic drug law categorizes them under Essential Narcotic Drugs (ENDs) and mandates certain regulatory requirements when using them.
The current guidelines for telemedicine consultations categorize them under 'prohibited drugs' for prescription. This has impacted follow-up opioid refills for patients with stable pain relief with opioid therapy and maintaining the continuity of care.
Another concern specifically in the pandemic is the potential of high-dose opioids for immune suppression, if continued for several weeks. This effect is highest with morphine and fentanyl and least with buprenorphine.,,,,
In-person consultation is mandated for initiating step 3 opioids. Best practices for selecting the right patient for opioid therapy based on type and severity of pain are continued along with screening for abuse potential and stablishing pain goal. Patients are counseled at length to clarify their questions, misconceptions, and fears about the drug. They are sensitized about side effects that may be expected and need for compliance, self-monitoring, keeping the pain diary [Appendix 1]. They are also provided with helpline contacts numbers for asking questions, reporting of adverse effects, or any other serious symptoms.
Monitoring of patients and dose titrations are done with the help of teleconsultations, reviewing of pain diaries using technological solutions such as scans, e-versions, or photographs of pain diaries. Patients can get stock of pain medications for 100 doses.
The petition by the Indian Association of Palliative Care to allow use of teleconsultations for refills and switching of ENDs to treat severe cancer pain condition, is under consideration by the Board of Governors of the MCI.
The article 52E of NDPS act provides certain guidelines on transport of ENDs by post, courier, rail, or road [Box 6]. This provision is now utilized for delivering the medicines to patients who do not have access to these controlled medicines within their locality for their medicine refills.
It is irresponsible to start opioid analgesics without provision for regular follow-up. The lockdown has become a significant hurdle for regular reviews. However, prompt publishing of telemedicine guidelines came as a huge support. The guidelines have clear provisions for liaison with local physicians and for cross-consultations with specialists, and these provisions have been used when relevant.
Some of the important approaches to multidisciplinary pain management are assessing and managing “total pain,” cognitive-behavior therapy, counseling, provision of psychosocial and spiritual support, physiotherapy, acupuncture, etc. Approximately 8% of patients with cancer pain may benefit from interventional pain management procedures for nerve blocks.,
Need for physical closeness or contact for certain multidisciplinary pain-relief inputs and difficulties with intervention pain management procedures are some of the challenges during the pandemic situations.
Concerns such as anxiety, social isolation, stigmatization, job loss, poverty, fears related to discontinuity of cancer treatment, disease progression, uncertainty, and fear of contracting COVID infection are all biopsychosocial factors that can interact with pain in a complex manner and enhance it to a state of “total pain.” These challenges can be addressed through telehealth consultations for psycho-socio-spiritual support, especially when using videos or video-based consultations. This mode of communication to express empathy and empower patients and caregivers by the counseling team member is useful even when patients visit the HC facility, to shorten the in-person meeting time.
Elective pain management procedures such as nerve blocks are deferred during the period of pandemic. If the indications are considered apt, and the required competencies are present in the locality of the patient, cross consultation facility provided by teleconsultation guidelines may be utilized to connect the patient with the intervention specialists to facilitate mitigation of pain.
Managing pain in pediatric population and at end-of-life is specifically challenging during pandemic. Using virtual teleconsultation platforms to liaise with family physicians, educate and support parents and family members, regular and frequent phone calls, and being available for any emergency teleconsultation are some of the implemented solutions. For families of deceased patients, bereavement support is extended in form of phone calls.
Ongoing clinical trials and research are facing challenges, due to the unanticipated pandemic situation. Acknowledging the long-term nature of the current situation, the research committees and regulatory authorities have developed pragmatic guidelines. For example, approval processes for studies focused on patients suffering from COVID-19 infection have been expedited. The participant information documents, and informed consent forms have been appraised and modified to reduce risk of visiting HC facility for the patients/research participants.
The educational and training activities for trainees and students as well as evaluations are using video-based platforms to ensure continuation of training and graduations. The IAPC initiated a nine weeklong ECHO-based interactive sessions on subjects relevant to the practice palliative care in India within the constraints of COVID-19 pandemic. One of the sessions dealt with for awareness about policies, regulations, and provisions for prescribing and dispensing ENDs and ensuring adequate access to cancer pain management.
Specific to managing cancer pain
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Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3]