In August, we hosted a question and answer session about telehealth and accessing pain care during the COVID-19 pandemic with Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, FFSMB, a pharmacist who specializes in pain care. Below, we recap some of his answers — and share his responses to a few questions we didn’t get to.
Q: What equipment do I need to do a telehealth visit and will it work with Wi-Fi?
A: Telehealth will work with Wi-Fi and I encourage accessing any platform with Wi-Fi versus the general internet, because you may not have unlimited minutes or associated fees. You can use a smartphone (one of those flip phones is not going to work), and any smart device or a laptop that has a camera on it will be good. Almost all laptops and desktop computers now have cameras, but if it’s old, you can buy an inexpensive camera that clips to the top of the screen.
Q: How can the doctor diagnose me without actually doing a physical exam?
A: Right now, most people are asking, “How can someone get a physical exam if they’re not in the same place as their doctor?” Any new patient who’s being examined for pain an in-office visit will most likely hear, “Take your foot and press up against my hand. Raise your arm and press down. Does it hurt if you do this?” We can still do those things on telehealth!
There are also other things we can do: we can get your pulse, or if you’re with somebody, we can show that person how to take your pulse. You can certainly take your temperature. If a patient is on a lot of blood pressure medication, I‘d tell them that they need to buy a blood pressure cuff, and some insurance companies will pay for that. Generally speaking, some very sophisticated telehealth equipment exists now that allows patients to be monitored in real-time, even at home (although, again, paying for it has to be approved by your insurer).
Q: When COVID-19 is over, will we still have telemedicine?
A: I think it would be great if it happened, and I think that insurance companies are starting to see that this is very doable and cost-effective for all involved. The federal government has been doing this for years, as well as the Department of Defense and VA hospitals; and I know for certain that Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) are looking at continuing these services. The waiver that they put in place on March 6 now allows beneficiaries in any geographic area to receive telehealth service. So that’s tremendous.
So telehealth, first of all, is giving people an opportunity to see real specialists. COVID-19 has actually made me busier because I can communicate with a patient and a doctor in Ohio when I’m physically in New York. So the accessibility is absolutely phenomenal; you can tap into specialists from all over the country.
There’s going to be a continuation of this. It’s new for a lot of people, and I think insurance companies saw fraud as a potential risk for telehealth. I’m not seeing that at all; I’m seeing doctors who are more accessible and extending hours because they don’t have to spend time in traffic and can work from home. Insurance companies are starting to see that the outcomes are actually great.
Q: Can an individual establish pain care in a first visit by subscribing to telehealth and its requirements?
A: I have the regulation right here: the CARES Act allows any geographic area to remain in their homes for telehealth appointments and it is reimbursed by Medicare and allows interactive visits to be delivered by smartphone with real-time audio and video. The Medicare document states that the requirement for live visits is removed during COVID-19 and that providers can offer telehealth services and treat the beneficiary receiving these services through a separate provision that allows federally qualified health centers and rural health clinics to provide telehealth services to Medicare beneficiaries during COVID-19 emergency period. So, you can be a brand new patient, somebody can see you by telehealth, and it should be covered.
A new provider will want previous records if you’re transferring to another doctor. You could be a brand new patient that’s never seen: that may make a pain care provider more squeamish and they may want to see you in person. But that’s okay! They may say, “I need to see you one time, and then we can have appointments via telehealth,” which I understand because people are being so highly scrutinized with opioid prescribing today, both patients and providers need to be careful.
Q: How can I help my doctor understand the severity of my pain via telehealth?
A: You have to use descriptors. Not only is it difficult for the patient to express to the provider what their pain is, it’s difficult for the provider to understand what patients are dealing with on a daily basis. So for example, I’ll say to a patient, “What’s your pain on a scale of 0 to 10, 0 being nothing and ten being the worst imaginable?” If it’s a woman I always say, “Have you had a child? We’re going to call childbirth the worst absolute pain.” If it’s a man I’ll say, “Listen, if I was to take a hot iron and place it on your tongue, that’s a 10.”
I realize that one person’s 10 is not another person’s 10, and that’s why using a numerical scale is not 100%. You need to tell a provider, “It feels like somebody put ice on a sore tooth,” or “It feels like sticking a knife in my belly and twisting it, it’s a jabbing kind of pain.” You need to be very descriptive. You also need to tell them the things that you can do, the things that you can’t do, and the things that you want to do.
Q: I retired and now live in North Carolina having moved from Pennsylvania. My pain management doctor is still in Pennsylvania. I travel there once a month and have to get my prescription filled in Pennsylvania. The pharmacy here in North Carolina has refused to fill the prescription, but I haven’t had enough time to find a doctor locally. What should I do?
A: As you know, being able to prescribe and mail order prescriptions over state lines is a complicated issue that varies by state. During COVID-19, the federal law has lifted a lot of those restrictions across state lines, depending on the situation. In this particular situation, it’s always been legal for a pharmacy to fill a prescription from another state. My understanding is that the pharmacist is refusing to fill the prescription because the doctor is out of state and because it’s been such a long period of time has gone by. I, personally, think that’s unreasonable. The federal government has made exceptions and depending on the state, states have made exceptions and you could file a complaint. Of course, by the time the complaint is heard, it could be another couple of months that go by.
But I wouldn’t alienate the pharmacy or the pharmacist. I’d make an appointment in advance and say, “I’d like to come in and speak in person to the pharmacist to explain my situation. I’m not asking for any promises, I just want you to understand what’s going on.”
In advance of doing that, I would contact the physician in Pennsylvania, and ask that physician to write a letter. In that letter, invite the pharmacist to call and speak to the physician and the physician will, hopefully, be humble enough to say, “I’ll provide you with any information you need. This patient is in a difficult situation because of the COVID-19 pandemic, and we are doing regular visits by telehealth. If you need transcripts for that or chart notes, we’re happy to supply them, as long as they sign a HIPAA waiver.”
Make an appointment with the pharmacist, put on a mask (maybe two masks, maybe a face shield!), and say, “This is my situation: I’m seeing a physician in Pennsylvania, and I would like nothing more than to have a local physician– if you can help me find one, you’d be my best friend!” The pharmacists have, according to federal law, an equal and corresponding responsibility with physicians to ensure that prescriptions filled are for a legitimate purpose. The pharmacist probably doesn’t think that it’s an issue anyway, but they’re filling hundreds and hundreds of prescriptions and they don’t want to take a chance. So that’s how I would approach it.
Q: How do I ask for an increase in my medication and make sure I am taken seriously but do not raise any red flags?
A: Have an open and honest discussion with your doctor and tell him/her your reluctance to discuss the topic and why. One option for you is to change to another opioid. Because of something called cross-tolerance, when people stop responding well to one opioid, they can switch to another at a 20% reduced dose, which for you might actually seem like an increase due to the phenomena known as cross-tolerance. That could be a win-win for you and the doctor. The mere suggestion to your doctor will show that you’re educated about these medications and that you’re willing to compromise. If that doesn’t work, the dose of the new medication can be increased to an equivalent of what you were previously on with the original medication. Although that is not technically a “dose increase,” essentially it would be for you, since your opioid tolerance to the new drug is not exact to the previous one. The result? Everyone wins. See “Opioid Equivalency” for more information.
Q: My clinician won’t see me anymore because I tested positive for medical cannabis, which is legal in my state of Missouri. What should I do?
A: If you signed an opioid agreement that precludes the use of cannabis, there isn’t much you can do because you made a promise to follow certain rules. For example, if I learned that a patient was using alcohol regularly by testing their urine for ethyl glucuronide, while I was prescribing opioids and perhaps a benzodiazepine like alprazolam, I would not continue the medications even though alcohol, like cannabis in your state, is legal. Irrespective of the laws governing cannabis use in your state, there are drug interactions with cannabis and opioids. Since your doctor is prescribing opioids, he/she needs to be concerned about your safety and their own liability.
Q: Some providers seem afraid to prescribe over telehealth even though it is allowed. What can we do to educate and empower providers about the new rules?
A: Show him/her the CARES Act: American Medical Association COVID-19 pandemic telehealth fact sheet. This shows information supported both by government agencies and by your doctor’s peer group.
About Dr. Fudin
Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, FFSMB, is the Clinical Pharmacy Specialist and Director, PGY-2 Pharmacy Pain Residency Programs, at the Stratton VA Medical Center in Albany, New York. He is also the CEO and founder of Remitigate Therapeutics, a virtual pain management consulting firm, and owner and managing editor for paindr.com. Dr. Fudin holds adjunct faculty positions at Western New England University College of Pharmacy and the Albany College of Pharmacy & Health Sciences; he also serves as Section Editor for Pain Medicine, Co-Editor-At-Large for Practical Pain Management, Senior Editor for Pain Medicine, and as a peer reviewer for several professional journals. In addition, Dr. Fudin is the Founder and Board of Trustee for the Society of Pain and Palliative Care Pharmacists, where he serves on several committees and is a Diplomate to the Academy of Integrative Pain Management and a Fellow to the American College of Clinical Pharmacy, the American Society of Health-system Pharmacists, and the Federation of State Medical Board. Dr. Fudin is a prolific lecturer, writer with over 300 publications, and researcher on pain management topics.
The Aug. 24 webinar on telehealth was sponsored by Salix Pharmaceuticals.