The 4 A’s
Treating pain is not like treating blood pressure. When treating a complex physical and emotional problem such as chronic pain in complicated human beings, using treatments with potential for abuse (such as opioids), a successful outcome doesn't boil down to simple lowering of a number on a pain scale.
However, it wasn't all that long ago that a caricature of assessing and documenting outcomes in pain management was emerging that almost made it seem as if the 0 to 10 pain scales were viewed as the optimal assessment for pain documentation. The problem wasn’t with the 0 to 10 scales themselves (even if the best empirical validation of their use was in acute postoperative pain or cancer pain), but was more of an issue regarding the mind-set of clinicians treating patients with pain and the limited meaning of these tools within the context of chronic pain.
The appropriate mind-set for treating chronic pain is recognizing that it is a debilitating, sometimes demoralizing, and exhausting disease—not a mere symptom. Thus, the goal of chronic pain management is not simply to lower pain intensity, but to help a person with chronic pain to live as full and meaningful a life as possible by relieving pain to the extent that is reasonably possible. This must be done while providing access to the myriad other components of multidimensional therapy in an artful and coordinated way.
These other multidimensional therapies (see Issue 4
in this series) are intended to enhance quality of life, teach coping skills, and improve vitality. They’re also meant to remove barriers to living better with chronic pain that stem from comorbid depression, deconditioning, inflexible coping style, and/or unhealthy lifestyle. Appropriate documentation of chronic pain management must account for all of the above and, at the same time, reflect the appropriate and legitimate use of controlled substances such as opioid analgesics.
Documentation can be a daunting task, but it has been codified by the mnemonic "4 A’s" of pain management,1
which helps organize observations of outcomes in the 4 key domains of opioid therapy:
- Analgesia (pain relief)
- Activities of daily living (ADLs; functional outcomes)
- Adverse effects (side effects)
- Aberrant drug-related behaviors (appropriate use and adherence vs misuse or addiction-related outcomes).
The 4 A‘s can also be used to facilitate communication between people with pain and their pain team, and to address any barriers to improving outcomes in each domain. An informed patient is one who understands that the legitimate use of opioids in medical practice requires a good outcome in all domains of the 4 A’s.
The patient should also work in good faith with their clinician to engage in the suggested multidimensional, nondrug aspects of therapy in addition to being adherent with pharmacologic therapies. Thus, if the patient has acceptable pain control but is still not attaining functional goals, the clinician can work with the patient to assess barriers and employ additional strategies, as necessary. Alternatively, if the patient is realizing good outcomes in the first 3 domains, but has a history of recreational marijuana use, for instance, he or she can work with the clinician to find ways to discontinue use of all illegal drugs to satisfy the requirement for a good outcome in the aberrant behavior domain. (Note: in jurisdictions where “medical marijuana” is available, this becomes a more complicated decision process; that discussion is beyond the scope of this article.)
A good outcome in a person with chronic pain receiving opioid therapy is not a pain level of 0 (frequently unattainable as it is) if it comes at the cost of sedation that makes functioning impossible or if it requires overuse of medications. On the other hand, a 30% to 60% reduction in pain in patients who use their medications as prescribed (not an atypical degree of relief reported in patients receiving opioids), accompanied by stabilized or improved ability to work, play, and live, is an example of an acceptable outcome. Clinicians' dictated notes should always reflect an assessment and examples of outcomes in each of the 4 domains.
Shortly after the initial 4 A’s paper was published,1
the 4 A’s were applied to study outcomes in opioid therapy, and it became clear that there was a need for a tool that clinicians could use to record the 4 A’s. The result was the Pain Assessment and Documentation Tool (PADT),2
which is a template (and preliminarily validated) chart note based on the 4 A’s. This tool has been incorporated by clinicians in whole or in part, and some have even designed their electronic medical records around it. Its main advantage is that it offers a simple checklist approach to all 4 domains of opioid therapy in a single tool.
The PADT is not the only tool that can be used to improve the documentation of outcomes in opioid therapy. Clinicians can combine several scales that assess single or multiple domains to account for all of the 4 A’s. For example, the Brief Pain Inventory or Pain Disability Index can also be used to assess analgesia and pain-related interference with ADLs. A side effect checklist for specific side effects such as hypogonadism or sleep problems (such as the Pittsburgh Sleep Quality Index) can be used to assess adverse events; and tools like the Current Opioid Misuse Measure (COMM) can be used to assess aberrant drug-related behaviors. Such measures add a patient self-report component, which should then be synthesized into the final impression and treatment plan documented by the clinician.
It is unrealistic to suggest that such an extensive review is feasible for every patient at every return visit; rather, clinicians should decide the frequency of review according to how high-risk or atypical each individual is based on implicit or explicit community standards (colloquially known as “in and out of the box” prescribing3
; see Issue 4 in this series). More information and samples of some of the above referenced tools are available in the American Pain Society (APS)/American Academy of Pain Medicine (AAPM) Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain (available at http://download.journals.elsevierhealth.com/pdfs/journals/1526-5900/PIIS1526590008008316.pdf
Thorough documentation can be time-consuming and is labor intensive to be sure, but it is called for in today's world where clinicians and patients must recognize that opioid therapy is practiced against a backdrop of our society, which in recent years has focused its appetites for drug experimentation and misuse squarely on prescription drugs in general and on opioids in particular. Given the new reality in which we must address 2 significant public health problems in a balanced fashion (chronic pain and prescription drug abuse), what constitutes appropriate documentation does not end with the 4 A’s. Indeed, what is also required visit-by-visit is a description of any changes in physical findings (with the implied focused physical exam having been performed) and corroboration of self-reports, particularly in terms of functional status and appropriate drug use.
Trust and Verify
Patients are often less than forthcoming about behaviors of which they are ashamed. Information regarding the use of illegal drugs, misuse of their prescribed medicines, and sharing medications is unlikely to be readily offered up by patients who are desperate for help with their pain. This is particularly true because they recognize that such behaviors may jeopardize their access to pain medication. A recent study found that when pain clinicians thought patients were nonadherent with the rules of opioid therapy, clinicians were correct 7/10 times.5
However, when clinicians thought that patients were adherent, clinicians were correct only 3/10 times when adherence was assessed via urine drug testing on their own patients, whom they were allowed to preselect for each category based on any criteria they thought appropriate.
It is clear that documentation of opioid therapy should include the recording of results from measures to corroborate self-report (urine test, pill count, patch count, report from state prescription monitoring programs [where available], and reports from a patient-designated work monitor [if appropriate]). The frequency should be decided based on the risk level of each individual, with frequency being a function of level of risk, varying as much as from once per year to every visit. Patients can view this ongoing monitoring as a way of doing their part to keep pain management safe and available, by demonstrating that they are the only ones using their medications and that their medications are accounted for and kept secure.
For those who have had previous difficulty adhering to the expectations of appropriate medication use or those with actual histories of substance abuse, these measures can be viewed as similar to stepping on the scale at a weight loss meeting or attending a recovery support meeting. These measures can help to render patients accountable for their actions and eliminate any denial that comes with such histories. Failure to disclose the necessary information may lead the clinician to believe that the patient is less than completely trustworthy.
Other Important Documentation Items
The preceding sections mainly focus on the documentation of progress from time to time, visit in, visit out. However, at the outset of opioid therapy, it is also necessary to include some additional items to set the stage for the type of ongoing documentation described previously.
Consistent with established guidelines,4
the clinician and patient should document a mutually agreed upon treatment plan with specific functional goals. Additionally, the rules and expectations of opioid therapy should be discussed and documented, sometimes in the form of a treatment agreement, sometimes in less formal documentation. Some states require that an informed consent be separately signed and made part of the record. A discussion of safe drug storage should also be documented. (See Issues 1
of this series for more information on initiation of chronic opioid therapy and informed consent and opioid management plans.)
In conclusion, as expectations for clinician adherence to standards of care in pain assessment and management become the norm, use of validated tools and efficient, effective processes of care will ensure better outcomes for all.