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Managing Drug Abuse, Addiction, and Diversion in Chronic Pain: The 4 A's for Ongoing Monitoring

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The 4 A's for Ongoing Monitoring

Based on extensive clinical experience, 4 domains have been proposed as most relevant for ongoing monitoring of chronic pain patients on opioids: pain relief, side effects, physical and psychosocial functioning, and the occurrence of any potentially aberrant (or nonadherent) drug-related behaviors.[9,10] These domains have been summarized as the "4 A's" (analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors).[9] The monitoring of these outcomes over time should affect therapeutic decisions and provide a framework for documentation of the clinical use of these controlled drugs.

To test this notion, Passik and colleagues[10] conducted a study to examine the relationship between aberrant drug-taking behaviors and pain outcomes during long-term treatment with opioids for nonmalignant pain. In particular, the focus of the study was on providing the nature, frequency, and predictive value of drug-taking behaviors in pain management. This effort could ultimately assist physicians in the assessment and management of these behaviors, whether they resulted from the undertreatment of pain or a substance use disorder.

The main objective of the study was to develop a user-friendly checklist that physicians could employ to examine the 4 A's. In addition, it was hoped that this checklist could also be used to monitor pain and treatment outcomes for patients receiving long-term opioid therapy for chronic pain. The checklist was developed by a group of experts in pain and addiction medicine and distributed to participating physicians throughout the United States who treat pain patients. These physicians evaluated patients who had been receiving opioid therapy for at least a period of 3 months with a structured interview approach and clinical observations.

The results of the study were enlightening. Cross-sectional results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all 4 relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common (44.6% of the sample engaged in at least 1 aberrant behavior), but only viewed as an indicator of a problem (ie, addiction or diversion) in approximately 10% of cases. Thus, there is a clear need to document and assess the intricacies of aberrant drug-taking behavior in chronic pain patients.