How We Measure Pain: The “Four A’s”

Because we don’t have a blood test or x-ray that measures pain, it can be difficult to explain, evaluate, and track. So, how can we “measure” in the doctor’s office?

One of the best methods that we have is to follow the “Four A’s:” Analgesia (pain relief), Activities of Daily Living (functioning at home & work), Adverse Effects (medication side effects), and “Aberrant Behaviors” (warning signs for addiction).

For “Analgesia” (pain relief), the standard method at this time is to use the “1-to-10” scale, where “10 is the worse pain you can imagine” and “1 is barely noticeable pain.” Variations on this scale include pictures of the scale with more detailed descriptions of each level of pain.

For many people, this is not an easy scale to use. But it is an important tool to help the healthcare provider to understand how much relief a person is getting from their current treatment. I often suggest “imagine that we stop all of your medication…let’s call that a ’10’…so, WITH the medication you are now taking, how far away from a ‘10’ does that get you? Is there a 50% reduction in your pain, or 20%, 80%...?”

This scale is a tool to help the healthcare provider understand if the pain is better or worse since the last change in medication dosage. It is also important to communicate about changes in how much medication was actually taken, any unauthorized dosage increases, or running out of medication early, and how changes in the amount of medication taken affected the pain.

“Activities of Daily Living” (ADL’s) refer to a person’s ability to perform usual activities in important areas of their life: as parent, spouse, friend, family member, work, leisure, and community activities. Sometimes, the level of pain does not change because the person will increase their activity until they get to a certain level of pain. So, if pain has stayed the same but the person is able to do twice as much activity as before, this would be considered a positive treatment outcome.

“Adverse Effects” refer to medication side effects. It is important for those taking medication to inform their healthcare provider of any symptoms that get worse with an increase in any medication dosage. Some Adverse Effects are not medically dangerous (such as dry mouth), what I think of as “nuisance” side effects. Others can be medically dangerous, such as heart rhythm abnormalities, or changes in liver or kidney functioning. Some medications have Adverse Effects can be detected early only with blood work, and can cause severe illness if the one waits until they feel sick before they investigate.

The most important thing here is the communication between healthcare provider and the patient regarding any worsening of any symptoms, and being informed about any “routine” tests which should be performed for medication(s) being taken on a regular basis.

“Aberrant Behaviors” is a term that healthcare providers use to refer to those behaviors that may be a “warning sign” for addiction, which can occur with narcotic pain medication (or other potentially habit-forming medication) in genetically susceptible individuals.

Examples of “Aberrant Behaviors” include taking pain medications for symptoms other than pain (such as anxiety or sleep); unauthorized dosage increases, adverse effects on mood, irritability, anxiety, or sleep; intoxication; or motor vehicle accidents. Each of these alone would not result in a diagnosis of addiction, but it is best for the healthcare provider, the person taking the medication, and the family should all “be on the lookout” for any adverse behavior changes that continue or worsen over time when taking any potentially habit-forming medication on a regular basis. It is also important to avoid drinking alcohol with narcotic pain medication.

Healthcare providers can provide safe and effective treatment for pain conditions, but only with good communication about “the Four A’s” can the best possible treatment outcomes be safely achieved.