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15 Articles in Volume 20, Issue #6
Using Photobiomodulation to Treat Trigeminal Neuralgia
20/20 with Mark Wallace: Where Cannabis Fits into Pain Practice
A Commentary on Opioid Stewardship: Fentanyl, Sufentanil, and Perioperative Pain
Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions
Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power
Analgesics of the Future: Janus Kinase Inhibitors
Case Report: Quadratus Lumborum Block for Managing Pathologic Pain to the Hip
Chronic Pain and the Short-term Effects of Medical Cannabis
Differential Diagnosis: Polymyalgia Rheumatica or Rheumatoid Arthritis
Genicular Nerve Blocks: Field Tips on Prognostic Value and Technical Considerations
Guideline Update: ACR Promotes Pharmacologic Treatment for Osteoarthritis
Navigating New York's Medical Marijuana Program: A Patient Handout
Person-Centered Care: Lessons from the VA’s Whole Health Model
Psychedelics for Chronic Pain: Is It Time?
Resident’s Corner: What Pain Medicine Education is Missing in the COVID Era

Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power

PPM’s Resident APPs Theresa Mallick-Searle and Jeremy Adler on how NPs and PAs have more than risen to the occasion in managing patients during COVID – but will their role still be respected when the pandemic ends?

Introductory Note from the Authors

In 2018, PPM introduced a new column called “Ask the APP” to bring awareness of the issues APRNs, NPs, and PAs face when practicing in the specialty of pain management. I have enjoyed exploring various aspects of care and practice during this time, including how to fit into a new practice and how to manage high-dose opioid patients, highlighting many of the questions that I am asked about, relevant to the advanced practice provider (APP) career.

Jeremy and I have collaborated over the years on many projects involving education, practice, and legislative issues. When thinking about how to best enhance this column as we head toward 2021 and how to better represent the APP population, I asked my friend and colleague to co-write this column with me.

You will notice a new column name to reflect our joint efforts. Please help me in welcoming Jeremy to the PPM family and enjoy our first joint contribution, focusing on what’s happening right now – COVID’s impact on advanced practice providers. –Theresa

Thank you for the warm welcome…. I am thrilled to join you in raising awareness of important issues facing APRNs, NPs, and PAs practicing in the specialty of pain management. Jeremy

Providers in Flux

The COVID-19 pandemic has rapidly changed how healthcare is and is likely to be delivered going forward, with telemedicine being the most obvious example. Lesser known to the public is how health systems were stretched (in an almost unthinkable manner) to meet the demand of patients with the novel coronavirus.

According to a survey conducted by the American Academy of PAs, between April 25, 2020, and May 6, 2020, 22% of surveyed PAs indicated they had been furloughed and 3.7% had their positions terminated.1 Similarly, the American Association of Nurse Practitioners (AANP) reported that between May 8, 2020, and May 18, 2020, 16% of NPs did not stay with their same employer.2 Additionally, 65% of NPs reported a change in work hours and 36% experienced reduced income.

During the same period, the Primary Care Collaborative and the Larry A. Green Center jointly reported the results of a survey of primary care physicians. Of those surveyed, 13% were predicting practice closure with the next month and 20% had already temporarily closed. They further shared that 42% had furloughed employees and 51% were uncertain about their financial future.3

With both the potential for practice closures and volatility in the healthcare workforce, patients with chronic pain conditions have been particularly vulnerable to interruptions in their pain care as well as challenges in accessing care for their many comorbid conditions. When opioids are a component of a patient’s treatment plan, for instance, the risk for developing or relapsing a substance use disorder (including OUD) goes up in such a crisis, making enhanced healthcare provider vigilance in screening and monitoring patients a necessity for adequate oversight. We have already seen reports of increased opioid overdoses in parallelwith the pandemic.4 Further complicating factors include increased patient unemployment, patient financial hardships, and loss of insurance coverage.


States Give APPs More Power

Advanced Practice Providers, such as NPs and PAs, comprise a significant number of the healthcare workforce in the United States. Although 23 states have authorized full practice authority for NPs, the majority of states require a legal relationship between PAs/NPs and a physician in order to practice.5 Examples of such requirements may include physician supervision, physician acceptance of liability, written agreements, medical record co-signatures, mandatory records reviews, maximum ratios between physicians and PAs/NPs, and prescribing limitations.

Prior to the COVID-19 crisis, discussions were already underway regarding ways to optimize the PA and NP workforce, such as in a jointly prepared report by the US Departments of Health and Human Services, Treasury, and of Labor.6  They recommended that states “consider eliminating requirements for rigid collaborative practice and supervision agreements.”

Following the US declaration of COVID-19  as a public health emergency in early 2020, a significant number of states enacted changes in the practice requirements for NPs and PAs. These changes generally focused on removing barriers to enhance the ability of these providers to practice in areas of greater need and to ease liability. The mechanisms used to make these changes were disaster provisions already written into statute, state governor executive orders, or public health orders.

Through previously passed disaster statutes and regulations, 13 states completely or partially waived physician supervision of PAs; two states did so for NPs.7,8 For example, Texas Occupations Code § 204.2045 states, “The supervision and delegation requirements do not apply to medical tasks performed by a PA during a disaster declared by the governor or United States government.”

In addition to statutory provisions, governors from eight states suspended or waived all or some of the supervision requirements for PAs through executive orders; 16 states similarly did so for NPs. For example, New York Governor Andrew Cuomo issued an executive order on March 23, 2020, which stated a PA may “provide medical services appropriate to their education, training and experience without oversight from a supervising physician and without civil or criminal penalty related to a lack of oversight by a supervising physician” and that “PAs shall be immune from civil liability for any injury or death alleged to have been sustained directly as a result of an act or omission in the course of providing medical services in support of the State’s response to the COVID-19 outbreak unless it is established that such injury or death was caused by gross negligence.”10

 In South Carolina, the Department of Labor, Licensing, and Regulation issued a public health order on March 23, 2020, that suspended restrictions on NP prescribing of Schedule II and II medications through telemedicine.11 These changes were necessary to facilitate the redeployment of PAs and NPs to settings where they were needed most, as highlighted in the AAPA survey, which found that during the 10 weeks before their survey, PAs changed specialties or practice settings at a rate nearly equal to the number of PAs who made similar changes over the entire year in 2019.12

Other changes during the national emergency of COVID-19 directly impacted all prescribers, including PAs and NPs. HHS Secretary Alex Azar, with the concurrence of the Acting DEA Administrator, on March 16, 2020, authorized telemedicine for issuing Schedule II-V controlled substances. There were three requirements: “the prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice; the telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and the practitioner is acting in accordance with applicable Federal and State laws.”13


Will COVID-Related Healthcare System Changes Stick?

With these changes in place, the APP community is unsure whether their increased flexibility will remain.

In the authors’ view, across many settings, PAs and NPs have demonstrated their professionalism and expertise effectively in delivering care. Their work supports that these professionals are fully capable of determining how to provide services at the practice level.

The US government’s pre-COVID report, Reforming American’s Healthcare System through Choice and Competition, advocated for enabling “all healthcare providers to practice to the top of their license, utilizing their full skill set,” emphasizing that such changes would foster increased care access, improved quality, and lower costs.6

The COVID emergency will have enduring effects on healthcare. For example, the rapid need for telemedicine has forced its evolution into a format that will likely forever enhance the way patients receive their care. Perhaps it too has taken an international disaster for PAs and NPs to be better acknowledged for their capabilities and for the speed with which they have risen to help meet patient care needs. Like telehealth, following the resolution of the crisis, it is reasonable to expect that advanced practice providers may continue contributing to healthcare in larger ways without these waivers and regulatory changes reverting back.



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