Paul L. Gianutsos, MD, MPH

Evidence summary

Drug-seeking behaviors—known as aberrant behaviors in chronic pain literature—may suggest a substance abuse disorder (TABLE).² At least 4 validated screening tools are available for predicting or monitoring aberrant behaviors in patients with chronic, nonmalignant pain disorders who are being considered for, or receiving, opioid therapy:

The Screener and Opioid Assessment for Patients with Pain (SOAPP-R) is a 24-item, self-administered questionnaire that stratifies patients being considered for opioid therapy into lower or higher risk for future opioid-related aberrant behaviors.² Each item queries frequency of behaviors and emotions consistent with opioid misuse and can be scored as 0 (never) to 4 (very often). The items on the SOAPP-R were developed by a consensus panel of pain and addiction experts.

In a multidisciplinary pain center study, the SOAPP-R was administered to 283 chronic pain patients who were followed for 5 months. At a cutoff score of ≥18, the test had a positive likelihood ratio (LR+) of 3.80 and a negative likelihood ratio (LR–) of 0.29 for detecting opioid misuse. At this cutoff, the SOAPP-R was 81% sensitive and 68% specific for predicting patients at high risk for aberrant behavior.

The Opioid Risk Tool (ORT) is a self-administered, 5-item questionnaire used to predict and monitor aberrant behavior.³ Potential scores range from 0 to 26. When administered to 185 consecutive new patients at a chronic pain clinic, a score of <4 had an LR– of 0.08 and a score of ≥8 had an LR+ of 14 for manifesting opioid-related aberrant behaviors. Some ORT scoring criteria have not shown consistent results in other studies.⁴

The Current Opioid Misuse Measure (COMM) is used to monitor aberrant behaviors in patients on opioid therapy.⁵ Scoring for the 17-item, self-administered test is similar to the SOAPP-R. In a study of 86 patients at a multidisciplinary pain center, a score of ≥9 detected opioid misuse with an LR– of 0.08 and an LR+ of 3.48, at a sensitivity of 77% and specificity of 66%.

The Addiction Behaviors Checklist (ABC) is a 20-item Yes or No questionnaire administered by staff.⁶ At a cutoff score of 3 positive items, it had a sensitivity of 88% and specificity of 86% for detecting opioid misuse in 136 consecutive patients at a multidisciplinary pain center.

TABLE
Red flags for a substance abuse disorder

Limitations of the studies

These studies have several limitations. The investigators who validated or evaluated the SOAPP-R and ORT included only patients at chronic pain clinics, so the instruments may not be applicable to patients in primary care settings^2-4; the ORT study lacked standard measures of addiction³; and the ABC was tested in a population that was predominantly male.⁶

Recommendations

A 2006 guideline of the American Society of Interventional Pain Physicians describes behaviors that suggest abuse or misuse of opioid medication.⁷ These behaviors, which are similar to those listed in the TABLE, include failure to experience pain relief from high-dose opioids, lying to obtain opioids, obtaining drugs from multiple prescribers, functional deterioration or lack of functional improvement, exaggerating pain, and forgery. The guideline recommends monitoring patients for such behaviors.

Evidence summary

Drug-seeking behaviors—known as aberrant behaviors in chronic pain literature—may suggest a substance abuse disorder (TABLE).² At least 4 validated screening tools are available for predicting or monitoring aberrant behaviors in patients with chronic, nonmalignant pain disorders who are being considered for, or receiving, opioid therapy:

The Screener and Opioid Assessment for Patients with Pain (SOAPP-R) is a 24-item, self-administered questionnaire that stratifies patients being considered for opioid therapy into lower or higher risk for future opioid-related aberrant behaviors.² Each item queries frequency of behaviors and emotions consistent with opioid misuse and can be scored as 0 (never) to 4 (very often). The items on the SOAPP-R were developed by a consensus panel of pain and addiction experts.

In a multidisciplinary pain center study, the SOAPP-R was administered to 283 chronic pain patients who were followed for 5 months. At a cutoff score of ≥18, the test had a positive likelihood ratio (LR+) of 3.80 and a negative likelihood ratio (LR–) of 0.29 for detecting opioid misuse. At this cutoff, the SOAPP-R was 81% sensitive and 68% specific for predicting patients at high risk for aberrant behavior.

The Opioid Risk Tool (ORT) is a self-administered, 5-item questionnaire used to predict and monitor aberrant behavior.³ Potential scores range from 0 to 26. When administered to 185 consecutive new patients at a chronic pain clinic, a score of <4 had an LR– of 0.08 and a score of ≥8 had an LR+ of 14 for manifesting opioid-related aberrant behaviors. Some ORT scoring criteria have not shown consistent results in other studies.⁴

The Current Opioid Misuse Measure (COMM) is used to monitor aberrant behaviors in patients on opioid therapy.⁵ Scoring for the 17-item, self-administered test is similar to the SOAPP-R. In a study of 86 patients at a multidisciplinary pain center, a score of ≥9 detected opioid misuse with an LR– of 0.08 and an LR+ of 3.48, at a sensitivity of 77% and specificity of 66%.

The Addiction Behaviors Checklist (ABC) is a 20-item Yes or No questionnaire administered by staff.⁶ At a cutoff score of 3 positive items, it had a sensitivity of 88% and specificity of 86% for detecting opioid misuse in 136 consecutive patients at a multidisciplinary pain center.

TABLE
Red flags for a substance abuse disorder

Limitations of the studies

These studies have several limitations. The investigators who validated or evaluated the SOAPP-R and ORT included only patients at chronic pain clinics, so the instruments may not be applicable to patients in primary care settings^2-4; the ORT study lacked standard measures of addiction³; and the ABC was tested in a population that was predominantly male.⁶

Recommendations

A 2006 guideline of the American Society of Interventional Pain Physicians describes behaviors that suggest abuse or misuse of opioid medication.⁷ These behaviors, which are similar to those listed in the TABLE, include failure to experience pain relief from high-dose opioids, lying to obtain opioids, obtaining drugs from multiple prescribers, functional deterioration or lack of functional improvement, exaggerating pain, and forgery. The guideline recommends monitoring patients for such behaviors.

Evidence summary

Drug-seeking behaviors—known as aberrant behaviors in chronic pain literature—may suggest a substance abuse disorder (TABLE).² At least 4 validated screening tools are available for predicting or monitoring aberrant behaviors in patients with chronic, nonmalignant pain disorders who are being considered for, or receiving, opioid therapy:

The Screener and Opioid Assessment for Patients with Pain (SOAPP-R) is a 24-item, self-administered questionnaire that stratifies patients being considered for opioid therapy into lower or higher risk for future opioid-related aberrant behaviors.² Each item queries frequency of behaviors and emotions consistent with opioid misuse and can be scored as 0 (never) to 4 (very often). The items on the SOAPP-R were developed by a consensus panel of pain and addiction experts.

In a multidisciplinary pain center study, the SOAPP-R was administered to 283 chronic pain patients who were followed for 5 months. At a cutoff score of ≥18, the test had a positive likelihood ratio (LR+) of 3.80 and a negative likelihood ratio (LR–) of 0.29 for detecting opioid misuse. At this cutoff, the SOAPP-R was 81% sensitive and 68% specific for predicting patients at high risk for aberrant behavior.

The Opioid Risk Tool (ORT) is a self-administered, 5-item questionnaire used to predict and monitor aberrant behavior.³ Potential scores range from 0 to 26. When administered to 185 consecutive new patients at a chronic pain clinic, a score of <4 had an LR– of 0.08 and a score of ≥8 had an LR+ of 14 for manifesting opioid-related aberrant behaviors. Some ORT scoring criteria have not shown consistent results in other studies.⁴

The Current Opioid Misuse Measure (COMM) is used to monitor aberrant behaviors in patients on opioid therapy.⁵ Scoring for the 17-item, self-administered test is similar to the SOAPP-R. In a study of 86 patients at a multidisciplinary pain center, a score of ≥9 detected opioid misuse with an LR– of 0.08 and an LR+ of 3.48, at a sensitivity of 77% and specificity of 66%.

The Addiction Behaviors Checklist (ABC) is a 20-item Yes or No questionnaire administered by staff.⁶ At a cutoff score of 3 positive items, it had a sensitivity of 88% and specificity of 86% for detecting opioid misuse in 136 consecutive patients at a multidisciplinary pain center.

TABLE
Red flags for a substance abuse disorder

Limitations of the studies

These studies have several limitations. The investigators who validated or evaluated the SOAPP-R and ORT included only patients at chronic pain clinics, so the instruments may not be applicable to patients in primary care settings^2-4; the ORT study lacked standard measures of addiction³; and the ABC was tested in a population that was predominantly male.⁶

Recommendations

A 2006 guideline of the American Society of Interventional Pain Physicians describes behaviors that suggest abuse or misuse of opioid medication.⁷ These behaviors, which are similar to those listed in the TABLE, include failure to experience pain relief from high-dose opioids, lying to obtain opioids, obtaining drugs from multiple prescribers, functional deterioration or lack of functional improvement, exaggerating pain, and forgery. The guideline recommends monitoring patients for such behaviors.