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Documentation and Potential Toolsin Long-Term Opioid Therapy for Pain

*,Kenneth L. Kirsh, PhD

Albany Medical College, Department of Anesthesiology, 47 New Scotland Avenue,MC-131 Albany, New York 12208, USA

Pharmacy Practice and Science, University of Kentucky, 725 Rose Street, 401C,Lexington, KY 40536-0082, USA

Tremendous progress has been made in the study and treatment of painin the past 2 decades[1,2]. Eﬀorts have been undertaken to make painassessment and treatment a priority of medical care and to use all of theweapons in our arsenal to bring relief to the millions of people with chronicpain[3,4]. However, this progress has been somewhat tempered by the sour-ing of the regulatory climate and the growth of prescription drug abuse.Because of this, there has been a trend for clinicians to shy away from usinghigh opioid doses or even using this modality at all in the treatment of chronic pain[5–7].Despite these setbacks, the use of long-term opioid therapy (LTOT) totreat chronic noncancer pain is growing, based in part on evidence fromclinical trials and a growing consensus among pain specialists[8–12]. Theappropriate use of these drugs requires skills in opioid prescribing, knowl-edge of addiction medicine principles, and a commitment to perform anddocument a comprehensive assessment repeatedly over time. Inadequate as-sessment can lead to undertreatment, compromise the eﬀectiveness of ther-apy when implemented, and prevent an appropriate response whenproblematic drug-related behaviors occur[13–15].Fortunately, there is a growing interest in the development of tools thatcan be useful for screening patients up front to determine relative risk forpatients having problems with prescription drug abuse or misuse. Regarding

A version of this article originally appeared in the 91:2 issue of Medical Clinics of NorthAmerica.* Corresponding author.

E-mail address:

SmithH@mail.amc.edu(H.S. Smith).1932-2275/07/$ - see front matter

anesthesiology.theclinics.com

Anesthesiology Clin25 (2007) 809–823

brief screening instruments, a number have arisen, including the ScreeningTool for Addiction Risk (STAR)[16], Drug Abuse Screening Test(DAST)[17], Screener and Opioid Assessment for Patients with Pain(SOAPP)[18], and the Opioid Risk Tool (ORT)[19]among others. The choice in tools for more thorough ongoing assessment, however, has beensomewhat more limited up until now and will be the focus of our discussion.Regulatory agencies, state medical boards, and various peer-reviewgroups among others not only expect appropriate medical care but also re-quire proper documentation. In cases of LTOT for chronic pain, aside fromthe usual ‘‘SOAP’’ (ie, subjective/objective/assessment/plan)-style medicalprogress notes, various other issues may deserve documentation. Althoughthere are no explicit requirements spelled out as to what and how to docu-ment issues related to LTOT, it is felt by some that the use of specific tools/instruments in the chart on some or all visits may boost adherence to doc-umentation expectations as well as consistency of such documentation.Assessment tools may also be helpful in the analysis of persistent pain[20].It must be cautioned that physicians who adequately assess patients be-fore and during opioid therapy may still encounter problems as a result of poor documentation. In a chart review of 300 patients with chronic pain,61% had no documentation of a treatment plan[21]. Similarly, a reviewof the initial consultation notes of 513 patients with acute musculoskeletalpain revealed that only 43% of historical findings and 28% of physicalexamination findings were documented[22]. In a review of 520 randomlyselected visits at an outpatient oncology practice, quantitative assessmentof pain scores occurred in less than 1% of cases and qualitative assessmentof pain occurred in only 60% of cases[23]. Finally, a review of medicalrecords of 111 randomly selected patients who underwent urine toxicologyscreens in a cancer center found that documentation was infrequent:37.8% of physicians failed to list a reason for the test, and 89% of the chartsdid not include the results of the test[24].

Areas of interest for documentation

Clearly, strategies are needed to translate these recommendations forpatient assessment during long-term opioid therapy to frontline practice.This effort would certainly benefit from the availability of a consistentmethod of documentation. As one potential framework, it is important toconsider four main domains in assessing pain outcomes and to better protectyour practice for those patients you maintain on an opioid regimen: (1) painrelief, (2) functional outcomes, (3) side effects, and (4) drug-related behav-iors. These domains have been labeled the ‘‘Four A’s’’ (Analgesia, Activitiesof daily living, Adverse effects, and Aberrant drug-related behaviors) forteaching purposes[25]. There are, of course, many different ways to thinkabout these domains, and multiple attempts to capture them will be dis-cussed in this article.

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The Pain Assessment and Documentation Tool

The Pain Assessment and Documentation Tool (PADT) is a simplecharting device based on the 4 A’s concept that is designed to focus onkey outcomes and provide a consistent way to document progress in painmanagement therapy over time. Twenty-seven clinicians completed the pre-liminary version of the PADT for 388 opioid-treated patients[26,27]. Nine-teen clinicians (17 physicians, 1 nurse, and 1 psychologist) participated ina debriefing phase. Twelve of the 19 clinicians had participated in the fieldtrial before the debriefing. The debriefing interview for these cliniciansused the same standard questions to evaluate both the original and revisedPADT.The result of this work is a brief, two-sided chart note that can be readilyincluded in the patient’s medical record. It was designed to be intuitive,pragmatic, and adaptable to clinical situations. In the field trial, it took cli-nicians between 10 and 20 minutes to complete the tool. The revised PADTis substantially shorter and should require a few minutes to complete. Byaddressing the need for documentation, the PADT can assist clinicians inmeeting their obligations for ongoing assessment and documentation.Although the PADT is not intended to replace a progress note, it is wellsuited to complement existing documentation with a focused evaluation of outcomes that are clinically relevant and address the need for evidence of appropriate monitoring.The decision to assess the four domains subsumed under the shorthanddesignation, the ‘‘Four A’s,’’ was based on clinical experience, the positivecomments received by the investigators during educational programs onopioid pharmacotherapy for noncancer pain, and an evolving nationalmovement that recognizes the need to approach opioid therapy witha ‘‘balanced’’ response. This response recognizes both the legitimate needto provide optimal therapy to appropriate patients and the need to acknowl-edge the potential for abuse, diversion, and addiction[25]. The value of assessing pain relief, side effects, and aspects of functioning has been empha-sized repeatedly in the literature[21,28–31]. Documentation of drug-relatedbehaviors is a relatively new concept that is being explored for the first timein the PADT.

Assessing opioid therapy adverse eﬀects

Documentation of adverse effects in a majority of charts from many painclinics tend to be addressed (or in many cases not addressed) in their chartsby a brief note of the presence or absence of one or more adverse effects (eg,nausea, constipation, itching), noted by busy clinicians. Similar to the goalof the PADT, having a standardized form that is used at every visit andfilled out by the patients before being seen by health care providers may pro-vide certain advantages.

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