Why Documenting the 4 A’s Is Critical for Opioid Therapy

Though opioid therapy is used to treat chronic pain, accurate and complete documentation of pain management is imperative to reflect the appropriate and legitimate use of controlled substances (substances having the potential for abuse) like opioids, especially when there is increased pressure from regulatory agencies regarding the continuation, or even initial use, of opioids in pain patients. Four domains have been proposed as most appropriate for ongoing monitoring of chronic pain patients who are on opioids — pain relief, side effects, physical and psychosocial functioning, and the occurrence of any potentially aberrant (or non-adherent) drug-related behaviors. These domains are summarized as “4 A’s” and are vital data to enter in the medical record as they provide a framework for the appropriate documentation via a medical transcription service or an EMR of the clinical use of controlled drugs including opioids.

It is required to address and document the “4 A’s” during each visit. The four A’s are the following:


This refers to the effectiveness of pain control. It is possible to set up realistic analgesia goals in the treatment plan.  The log of pain levels of the patient with various treatments can then inform management decisions.


These include activities of daily living and functional activities. The latter activities are chosen according to the patient’s input and they are individualized based on their particular goals. The goals might include the ability to work, engage in hobbies, develop and maintain relationships, be active in home, complete therapy or progress towards life goals.

Adverse Effects

This represents side effects from medicines. It is particularly important since opioids can cause sedation, respiratory depression, constipation and other adverse effects that can result in dangerous complications.

Aberrant Drug-related Behaviors

This domain must be assessed as well as documented in a consistent manner for all chronic pain patients. With urine drug tests, you can provide evidence for or against diversion and use of other substances of abuse. At the same time, through a review of your state’s controlled-substance database, you can provide evidence for or against doctor-shopping.

If there arise issues with any of the parameters related to the 4 A’s mentioned above, they should be managed as soon as possible according to the treatment plan or the plan should be modified based on the physician’s best judgment. The 4 A’s facilitate better communication between chronic pain patients and their pain team and address any obstacles to improving outcomes in each domain. A patient who understands the legitimate use of opioids in medical practice should have a good outcome in all 4 A domains.

Patients often hesitate to disclose the details of their behaviors of which they are ashamed such as the use of illegal drugs, sharing medications and misuse of their prescribed medicines. If the patient fails to disclose the necessary information to clinicians, they will believe the patient is less than completely trustworthy. With careful documentation of 4 A’s in the context of Trust and Verify (physicians know everything about patient history) and appropriate treatment plan, physicians can end their struggle to enforce appropriate care at the right time.

Effective Documentation of 4 A’s

Pain Assessment and Documentation Tool (PADT) has been incorporated by clinicians in whole or part or they are using electronic health records designed to record the 4 A’s. It is a template and preliminarily validated chart notes based on 4 A’s. Though it provides a simple checklist approach to record all four domains and helps clinicians to assess and document their observation easily while treating chronic patients on opioid therapy, it has several imitations such as:

  • More studies are required to confirm the reliability as well as the validity of individual items and sections
  • Not possible to capture several characteristics of pain or domains that could be affected by pain and its treatment
  • Not intended to predict drug-seeking behavior, a quantitative approach to pain management or predict both positive and negative outcomes of opioid therapy

With an approach combining EHR and transcription, physicians can document the 4 A’s more effectively. In this approach, physician’s observations can be transcribed with the help of experienced and professional transcriptionists and then the transcribed data filled in relevant EHR fields. A quality assessment team can check the transcribed data before sending it to the electronic documentation system. This will ensure that the data within EHR is accurate. The combined approach can seize the benefit of narrative description as well.