Pain Management Providers in the Era of COVID-19: Who is Taking Care of Those Who Provide Care?

The overall quality of chronic pain management in the United States is woefully poor, and unfortunately getting worse. Schatman and Fortino recently elucidated many of the causes of this deterioration,¹ although revisiting these deficiencies is beyond the scope of this analysis. As a result of this state, neither patients nor healthcare providers who treat those with chronic pain are particularly satisfied. For example, patients are likely to see themselves as being treated in a system in which their voices are progressively less likely to be heard, where there is a lack of communication and responsiveness, a lack of comprehensive pain care, and rushed visits.² On the other hand, providers are dissatisfied by issues including a lack of resources for providing adequate treatment(s), unrealistic patient expectations for pain relief, and their own inadequate educations regarding pain management.³

COVID-19 has certainly not helped improve the quality of chronic pain management. Much has been written over the past year and a half regarding the effect of the pandemic on treatment that patients have received. The early literature addressed the use of telehealth to provide behavioral services to chronic pain patients,⁴ along with best practices consensus statements, which were focused on interventional pain medicine.^5,6 Progressively, other issues were addressed, including the impact of the pandemic on fellowship training,⁷ the safety of various medications during COVID-19,^8–10 the risks of developing chronic pain as a result of COVID-19 infection and treatment,¹¹ manifestations of characterological disturbances among chronic pain sufferers triggered by the pandemic,¹² dealing with disruptions of research on pain management due to the pandemic,¹³ the implications of postponed joint replacement surgeries for pain management,¹⁴ the impact of social distancing and other COVID-19-related phenomena on psychosocial aspects of chronic pain,^15,16 the impact of the redeployment of clinical staff from pain management departments due to the pandemic,¹⁷ and the effect of the pandemic on the opioid epidemic,^18,19 among several other areas of investigation. The focus of the extant medical literature on pain patient well-being and threats to it is certainly appropriate. Glaringly absent, however, in a thorough review of the literature are articles addressing the impact of COVID-19 on providers of chronic pain management services.

Amidst myriad adjustments observed in pain management practices across the US as a result of the COVID-19 pandemic, this analysis aims to underscore the critical issue of emotional distress amongst clinicians in pain medicine. These unprecedented times have introduced novel stressors into a panorama already marked by grave challenges. A cross-sectional study conducted prior to the pandemic found that 60.4% of pain medicine physicians in the US reported high emotional exhaustion and 35.7% reported high depersonalization, a critical symptom in the diagnosis of burnout and a potential symptom observed in PTSD.²⁰ With the COVID-19 pandemic, pain management providers have experienced the additional burden of staffing shortages,²¹ limited hospital resources,²¹ extended workloads,²² and risk of infection;²³ all whilst bearing witness to ongoing death, suffering, and noncompliance to scientifically proven measures aimed at helping us battle COVID-19 and its variants. Specifically, amongst anesthesiologists and interventional physiatrists caring for chronic pain patients, the challenges exerted by COVID-19 have been especially burdensome, as many became frontline healthcare workers within Emergency Departments and Intensive Care Units across the country. With this call to action, interventionalists faced longer and irregular hours, insufficient personal protective equipment, increased risk of contamination, and exposure to challenging decision-making processes stemming from the need to allocate limited resources.²⁴

Additionally, health services across the country have reported significant increases in workplace violence. According to The Joint Commission on Accreditation of Healthcare Organizations, healthcare workers are 20% more likely to become victims of workplace violence compared to workers from other industries.²⁵ In 2015 alone, approximately 75% of reported workplace assaults transpired within healthcare and social service settings.²⁵ This violence has undoubtedly escalated due to the COVID-19 pandemic, as a result of significant staffing shortages, long wait times, and inadequate security and mental health support.²⁵ Workplace violence in the setting of chronic pain management is consistent with that seen in other fields of medicine. Studies have demonstrated that clinicians in this specialty experience workplace violence and threats of violence on a frequent basis, particularly within the context of complex medical situations, opioid management, and Workers’ Compensation cases.²⁶

Consequently, the overwhelming impact of COVID-19 on healthcare systems and personnel has compounded a specialty, sufficiently challenging at its baseline, with substantial stressors, leading to critical emotional distress amongst its providers. While rates of burnout, insomnia, and depression have increased amongst healthcare workers during this pandemic,²⁷ research depicting the exact impact of COVID-19 across pain medicine providers’ mental health is needed. Previous data highlighting higher levels of burnout within this population compel us to hypothesize that this critical issue has only become worse.

Emotional distress and its associated consequences, including burnout, exert a multilayered effect. On an individual level, providers who experience burnout have a drastically reduced sense of well-being and are at increased risk for developing depression, substance abuse disorder, heart disease, and somatic symptoms.²⁸ Systemically, the implications of elevated rates of physician distress impact patient care and healthcare institutions. Burnout has been previously linked to suboptimal patient care, longer recovery times, and decreased patient satisfaction.²¹ Within healthcare institutions, burnout can lead to early retirement, job dissatisfaction, career change, and elevated turnover rates, likely due to augmented stress and significantly reduced professional fulfillment.^21,29,30 A recent study including 20,000 clinical and non-clinical healthcare workers across the US indicated that 24% of physicians and 40% of nurses reported a moderate, likely, or definite intent to leave their current practices by 2022.²² Given the shortage of trained pain physicians and lengthy wait times prior to accessing treatment that were identified well prior to the onset of the COVID-19 crisis,³¹ this phenomenon spells potential disaster for many suffering from chronic pain.

The central question becomes: how can we address and effectively improve emotional distress amongst clinicians in pain medicine? This is by no means a simple and straightforward question, nor are we assuming to know its full answer. However, there are concrete steps we can take now, as clinicians and institutions, to validate and care for the suffering of those who care for others. First and foremost, effective change emerges from awareness, which calls for a deep understanding of which stressors most saliently contribute to emotional distress and burnout in providers who care for chronically ill patients. Once we have an accurate depiction of the roots of emotional distress within our specialty, we will be able to tackle the issue similarly to how it presents itself, ie, in a multilayered manner. That said, the emotional distress that providers are currently experiencing needs to be addressed with individual, team, institutional and systemic strategies. For example, a randomized clinical trial conducted prior to the pandemic determined that offering clinicians protected time to address specific targets of emotional distress, including self-awareness and coping strategies, was successful in decreasing rates of depersonalization and increasing engagement at work.³² This study’s findings illustrate the importance of associating individual and institutional initiatives to mitigate the current crisis of physician burnout and dissatisfaction, given that there is a collective responsibility to foster healthcare workers’ well-being.³²

In sum, we believe that examining emotional distress amongst pain medicine clinicians will not only equip our specialty to better care for its providers, but will also shed light to the issue of mental health stigma amongst healthcare workers. The truth is that clinicians’ emotional distress was already a public health crisis long before COVID-19. As we are now bedeviled with a pandemic that has heightened the suffering amongst those who dedicate their lives to caring for others, we urge individuals, institutions, and governmental bodies to implement concrete and effective changes that will attend to and mitigate clinicians’ emotional distress.