He also recommends that clinicians follow the "four As" for ongoing monitoring of pain treatment outcomes, a system developed by Steven D. Passik, Ph.D. These are analgesia (pain relief), activities of daily living (psychosocial functioning), adverse events (side effects), and aberrant drug taking (addiction-related outcomes).
"If you focus on those four As and document them, you can usually stay out of trouble when prescribing these medications," Dr. Mackey said. "Document everything in the medical record, because 95% of the problems that doctors run into with their state medical board have to do with failure to appropriately document."
Other efforts to mitigate risk include using predictive tools, urine drug testing when appropriate, and using your state’s prescription monitoring program. "Use family and friends and others to gather information to make sure that the patient is using the medication appropriately," he advised.
Potential signs of abuse and diversion include patients "who show up at the end of office hours and arrive without an appointment, or who often arrive right when your staff is trying to leave for the day," Dr. Mackey said. "They’re typically reluctant to have a thorough physical exam and don’t give you past medical records, they don’t follow up with appointments, and they have very unusual stories."
Dr. Mackey disclosed that he has received research funding from the National Institutes of Health, the Dodie and John Rosekrans Pain Research Endowment, and the Redlich Pain Research Endowment.