The ABC’s of Pain

Mnemonics in the field of pain medicine provide practical and useful devices for mental checklists.
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Who can make it through a bowl of alphabet soup without finding at least a few delicious words to savor? Likewise, when digesting knowledge, mental appetizers can prepare the mind’s palate for the main course. Staunch academicians may frown upon the use of simplistic memory aids, but clinicians have always loved mnemonics. There is universal acceptance of the ABC’s (Airway, Breathing, Circulation) of BLS (Basic Life Support). We throw RICE at a sprain (Rest, Ice, Compression, Elevation). Charting would be filthy without SOAP notes (Subjective, Objective, Assessment, Plan). Collections of letters such as these dot every specialty. Over the past ten years, Pain Medicine has come into its own as a true medical specialty worthy of its own acronyms. The following sections describe eight such memory aids, which are particularly valuable for anyone who treats chronic pain (see summary in Table 1).

Table 1. Summary of Pain Medicine Mnemonics
MNEMONIC DESCRIPTION
PQRST Evaluation of the pain patient
VINDICATE Help determine etiology of a painful condition
SMART Setting goals for the chronic pain patients
PPPP Differential diagnosis when medications are reported to be inadequate
AAAA Documentation of clinical visits
COMPLIANCE Staying out of regulatory trouble with comprehensive workups, diagnosis, vigilance, and thorough documentation
CAGE Screening tool for alcoholism and drug addiction/abuse
DDDD Self-realization of physicians at odds with the regulatory environment

Table 1. Summary of Pain Medicine Mnemonics

PQRST— for evaluation of the patient with pain. One cannot know too much about one’s patient. Accurate diagnosis depends upon a comprehensive history and detailed physical examination. The chief complaint, history of the present illness, past medical history, systems review, family history, social history, and occupational history require exploration — the degree of which depends upon the complexity of the case.1 Gathering information in an orderly and routine manner allows one to catalogue pertinent aspects of the pain complaint quickly and comprehensively.

Pain Where is the pain? Head? Chest? Muscle? Bones? Viscera?
Quality What is the quality, character, and intensity of the pain? Sharp? Dull? Burning? Lancinating? Shock-like?
Resolves What actions or treatments make the pain better? Worse?
Symptoms Any associated symptoms? Weakness? Numbness? Bowel/bladder dysfunction? Nausea? Ataxia? Fever?
Timing All temporal aspects of the pain — Start? Duration? How often? What time of day is the pain least/most?

VINDICATE— helps determine the etiology of a painful condition. Chronic pain can become a disease in and of itself, and almost always is a co-morbid condition. It behooves the clinician to seek the cause of the pain. When the underlying pathological process is properly treated, often the need for ongoing pain management is greatly diminished. One tool for assessing the etiology of a painful condition is to VINDICATE the diagnosis.2

Virus Any infectious process, including viral, bacterial, or fungal.
Inflammation Vasculopathies, neuropathies, and arthropathies.
Neoplasm Tumors, metastases, and cancer related conditions.
Degenerative Connective tissue pathology, spinal and bone disorders.
Ischemia Ischemia and hypoxemia can create neural hyperexcitability and claudication.
Congenital Inborn errors of metabolism and genetic diseases may result in aberrant pain and sensory processing.
Autoimmune Antigen/antibody reactions, host-response cellular changes, protein metabolism abnormalities and related co-morbidities.
Trauma Painful tissue destruction and toxic neuropathies from substance abuse and chemical exposure.
Endocrine Endocrine and metabolic changes due to abnormal hormone levels, glucose metabolism, and electrolyte variations.

SMART— help develop goals for chronic pain patients. Improving quality of life is the cornerstone of Pain Medicine, but quantifying levels of improvement can be difficult, especially in circumstances where the most realistic outcome is to merely slow the rate of decline. Still, monitoring progress is important when trying to determine (and demonstrate to reviewers, regulators, and third-party payers) the success of a therapeutic regimen. Achieving goals is very self-affirming for patients. However, goal setting can be difficult. Many patients set goals that are unrealistic, vague, and counterproductive. The key is to set goals that are SMART.3

Specific help determine a specific goal, how to achieve it, and when.
Measurable One must be able to mark progress and completion of a goal.
Attainable One’s goal should be within reasonable reach.
Realistic The goal should be within one’s capabilities.
Trackable Able to note progress and achievements along the way.

PPPP— differential diagnosis when meds are reported to be inadequate. It is important to prescribe medications in a logical manner consistent with accepted practice. It is also important to prescribe within the confines of one’s comfort zone. A clinician’s comfort zone is unique and is based upon such factors as:

First published on: March 1, 2005