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Table of Contents 
PERSPECTIVES
Year : 2020  |  Volume : 26  |  Issue : 5  |  Page : 106-115

Approaches and best practices for managing cancer pain within the constraints of the COVID-19 pandemic in India


1 Department of Palliative Medicine, Tata Memorial Hospital, Homi Bhaba National Institute, Mumbai, Maharashtra, India
2 Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Onco- Anaesthesia and Palliative Medicine, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
4 Department of Pain and Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
5 Department of Palliative Medicine, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Visakhapatnam, Andhra Pradesh, India
6 Department of Pain and Palliative Medicine, Narayana Super Speciality Hospital, Andul Road, Howrah, West Bengal, India
7 Consultant, Pain and Palliative Medicine, Indian Institute of Head and Neck Oncology, Indore, Madhya Pradesh, India
8 Palliative Care Consultant-BARC Hospital; Palliative Care Consultant and Director-Quality Improvement Hub-India, National Cancer Grid, Tata Memorial Centre, Homi Bhaba National Institute, Mumbai, Maharashtra, India

Date of Submission07-Jun-2020
Date of Acceptance08-Jun-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Nandini Vallath
Room No. 821, Homi Bhaba Building, Tata Memorial Hospital, Dr E Borges Road, Parel Mumbai - 400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPC.IJPC_216_20

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 » Abstract 


Novel corona virus disease 2019 (COVID-19) is an ongoing pandemic that has impacted the entire world. The Indian government has responded strongly and very stringently to the crisis, through a nationwide lockdown. The health-care (HC) systems in the country are striving hard to maintain equitable care across illness spectra, while responding the emergencies imposed by the COVID-19 crisis. Under these circumstances, guidelines for managing several diseases including that for cancer care have been modified. As modified guidelines for cancer care have their focus on disease management, cancer pain management and maintaining continuity of care for patients with advanced progressive disease have taken a backseat in the available cancer care guidelines. This article describes the challenges, approaches to solutions with evidence-based practices that can be utilized to ensure competent management of cancer pain during the COVID-19 pandemic in India. It provides an overview of adapting to telehealth consultations for identification, evaluation and management of cancer pain, safe and rational use of analgesics and adjuvant drugs, recognizing and responding to holistic care needs and addressing the total pain, ensuring continuity of pain management, and strategies when complying with narcotic drug regulations, while ensuring safety of patients and HC providers.


Keywords: Neoplasms, pain management, severe acute respiratory syndrome coronavirus 2


How to cite this article:
Damani A, Ghoshal A, Salins N, Bhatnagar S, Sanghavi PR, Viswanath V, Ostwal S, Chinchalkar G, Vallath N. Approaches and best practices for managing cancer pain within the constraints of the COVID-19 pandemic in India. Indian J Palliat Care 2020;26, Suppl S1:106-15

How to cite this URL:
Damani A, Ghoshal A, Salins N, Bhatnagar S, Sanghavi PR, Viswanath V, Ostwal S, Chinchalkar G, Vallath N. Approaches and best practices for managing cancer pain within the constraints of the COVID-19 pandemic in India. Indian J Palliat Care [serial online] 2020 [cited 2020 Jul 13];26, Suppl S1:106-15. Available from: http://www.jpalliativecare.com/text.asp?2020/26/5/106/288411




“In the midst of this catastrophe, more than looking in to find serenity we need to look out for one another to practice humanity.”

–Abhijit Naskar


 » Introduction Top


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.[1] Not only has it majorly impacted the global health; it has brought the economic, social, and political processes around the world to its brink.[2],[3] As a response to this global crisis, the Government of India announced a nationwide lockdown to contain the spread of infection.[4],[5] 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.[6] Poorly managed pain negatively impacts quality of life, adversely affects adherence to treatment, worsens prognosis, and should be prevented.[7],[8],[9]

Cancer patients have higher vulnerability for COVID-19 infection as they are immune compromised and have greater morbidity and mortality once infected.[10],[11] 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.[12],[13],[14] 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.[15],[16]

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”[16] 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.


 » Access to an Appropriate Health-Care Facility Top


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.[17] 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.[18]

This impacted access to competent care for homebound advanced cancer patients with poor general status, suffering with severe pain.[19]


 » Approaches, Solutions, Best Practices Top


A simple system of online issue of electronic passes (e-pass) for travel[20] 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.[21] There is a need and scope for better and more robust solutions to address these challenges.


 » at the Health-Care Facility Top




Ethical 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.[13],[18],[22] 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 Related to In-Person Patient-Professional Interactions Top


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.


 » Approaches, Solutions, Best Practices Top


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.[12] The choice for aggressive interventions was guided by NHS guidelines that featured prognostication, frailty score, and patient wishes for individual decision-making.[12],[13],[23],[24],[25]

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 Consultations Top


Virtual care was adopted as an interim solution to social distancing policies. According to 2019 Telecom statistics, 90% Indians have access to telephone connections.[26] 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.[21]

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.[26] The advantages and concerns about of virtual consultations are mentioned in [Box 4].




 » Best Practices and Approach to Using Teleconsultations Top


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].
Figure 1: Triaging patients with cancer pain

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Table 1: Process of teleconsultation and best practices for cancer pain management

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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.


 » Management of Cancer Pain Top


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.


 » Who Step 1 Analgesics and Adjuvants Top


Paracetamol and NSAIDs are approved as over-the-counter medications through teleconsultation, easy to access for patients.[21] Adjuvant analgesics such as steroids, anticonvulsants, antidepressants, antispasmodics, and bisphosphonates are required alone or in combination to manage complex cancer pain syndromes.[27],[28] Their use reduces the overall opioid requirement[29],[30] [Table 2].
Table 2: WHO step 1 analgesics and adjuvants: Challenges and best practices during corona virus disease-19 pandemic

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 » Who Step 2 Analgesics Top


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.[31] with exception of codeine, they are not prohibited for use through teleconsultation[32] [Table 3].
Table 3: WHO step 2 analgesics: Challenges and best practices during corona virus disease-19 pandemic

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 » Who Step 3 Analgesics Top


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.[34],[35] 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.[33],[36],[37],[38],[39]


 » Best Practices, Approaches, and Solutions Top


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.[40]

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.




 » Continuity of Care and Follow-Ups Top


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.


 » Multidisciplinary Pain Management Top


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.[8] Approximately 8% of patients with cancer pain may benefit from interventional pain management procedures for nerve blocks.[41],[42]

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.


 » Special Considerations Top


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.


 » Academic and Research Activities Top


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.


 » Summary of Key Learnings Top


General

  • Although the pandemic has created unique challenges for managing patients with cancer pain, with diligence, many of the concerns can be overcome to continue to provide quality care
  • Discussions among teams facing common problems pave the pathway to solutions
  • The PC team needs to provide whole person care within the safety policies, and with some patience and teamwork, it is possible
  • There are team several support systems available in each locality – both government and non-governmental. Problems that may appear unique may be solved through focused search. E.g. list of 1200 post offices maintained for essential services by the Indian post on their website came into use for delivering medicine refills to patients living remotely
  • The teleconsultations guidelines are be adapted for providing quality cancer pain management
  • With collective effort and diligent pursuit, even regulatory restrictions can be modified for a worthy cause. For example, the petition signed by a few hundred prescribers has been submitted by the IAPC to the board of governors at MCI. This seeks permission to prescribe ENDs refills through teleconsultation for maintaining pain relief in a cancer patient and has received an initial positive response.


Specific to managing cancer pain

  • All patients are preferably screened through telephone to decide who may need in-person visits
  • Appropriate PPEs and universal hygiene measures are to be accepted as routine for in-person consultation
  • The duration of in-person consultations can be reduced using simple patient intake self-fill forms or using telephone to fill the form by an HCP
  • Teleconsultation guidelines by the MCI provide opportunity for detailed evaluation, through virtual platforms
  • All medications, especially opioids, need to be dispensed for longer periods, to reduce frequency of travel by the patient/family during these challenging times
  • Along with this, counseling the patient on the prescribed drugs and educating on details of storing, using, and returning the drug need to be even more stringent
  • Planned reviews for analgesia, activities, adverse effects, and abuse potential are vital for ensuring safe and rational opioid therapy
  • Pain diaries are excellent aids to assess effectiveness of dose, guide titration, ensure compliance, side effects, and continuity of care, and provide documentation for discussions
  • The opioid transportation norms provided in the NDPS Rules 2015 can be applied to ensure continuity of pain management IPs who are already on opioid analgesics and have stable pain relief
  • Education, training, and awareness activities can be continued without break, using virtual platforms


[45]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


 » Appendix Top






 
 » References Top

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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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