Hello, I am Dr. Kenneth L. Kirsh. I am the director of Behavioral Medicine at The Pain Treatment Center of the Bluegrass located in Lexington, Kentucky. We have a question about what are the four domains to consider for assessing pain outcomes? Now, Dr. Steve Passik and I are probably most known for putting out this notion of the 4 A’s in the pain literature. While not necessarily comprehensive of everything you want to do, we wanted an easy mnemonic, something that would be handy and something that would get you all the groundwork of what you should assess and document when you are looking at treating patients and considering the use of opioids in your treatment algorithms. So the 4 A’s are fairly straight forward. The first A is ‘Analgesia.’ So simply, are we getting any bang for our buck? Are we helping the patients that we see? Are they getting some pain relief? Now, the second A to my mind is probably the most important and that is the ‘Activities of Daily Living.’ So especially in a chronic setting, and with chronic opioid use, are we helping patients to increase functionality? Now, in an ideal world, if we can get folks back to work, back to making a living, and identifying roles for themselves again, that is wonderful. But even in a situation where folks may not get back to employment, if we increase activity, if we help them to get out and enjoy time with family more, get out to a restaurant just to be able to sit comfortably, we need to see gains in this arena, probably more than any other because the first A of analgesia, we rarely get people pain free and so we want to do the best job we can but I think usually treating to the A of activities of daily living. The third A is ‘Adverse Side Effects.’ When we use opioids, indeed when we use any pharmaceutical agents, there are always side effects. We have never had a miraculous pill that was wonderful to take pain away with no side effects at all. So we do need to assess what is happening. Are the side effects tolerable? And it also guides what you should do next with that patient. Is that a particular opioid that needs to be altered or changed, maybe a reduced dose? Maybe it is something where adjuvants can come in or need to be done to help them with things like constipation, itching, nausea, etc. Now, the final A is also extremely important, and this one is worth a moment of time. It was the ‘Aberrant Drug Taking Behaviors.’ Now, that is the fourth A we came up with and Dr. Passik and I maybe oversold the idea with the term aberrant drug taking because as soon as you hear that term, many of us go straight to the thing of addiction. We think this is truly problematic. This is something we cannot tolerate. Aberrant behaviors are really things that patients should not be doing with their medications or activities they should not be acting out on, but we need to assess why that is. It might be an indicator of addiction. It might be an indicator of undertreated pain, and we have talked about the idea of pseudoaddiction and certainly that has been out in the literature for years now, maybe chemical coping. So things that do not necessarily indicate addiction, but they are worrisome. They are flags for you to pay attention to, to assess, and again I think that will help to guide how you document, how you look to help your patients, and how we move them forward with hopefully some better quality of life.