Research Article| Volume 20, ISSUE 7, P842-851, July 2019

Download started.


Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain

Published:January 25, 2019DOI:


      • The Opioid Risk Tool was evaluated on pain patients with and without an opioid use disorder.
      • The opioid Risk Tool was able to discriminate between patients with and without opioid use disorders (odds ratio, 1.624).
      • An Opioid Risk Tool removing the preadolescent sexual abuse item had similar results (odds ratio, 1.648).
      • An unweighted Opioid Risk Tool without the sexual abuse item was superior (odds ratio, 3.085).


      The Opioid Risk Tool (ORT) is a commonly used measure of risk of aberrant drug-related behaviors in patients with chronic pain prescribed opioid therapy. In this study, the discriminant predictive validity of the ORT was evaluated in a unique cohort of patients with chronic nonmalignant pain (CNMP) on long-term opioid therapy who displayed no evidence of developing an opioid use disorder (OUD) and a sample of patients with CNMP who developed an OUD after commencing opioid therapy. Results revealed that the original ORT was able to discriminate between patients with and without OUDs (odds ratio = 1.624; 95% confidence interval [CI] = 1.539–1.715, P < .001). A weighted ORT eliminating the gender-specific history of preadolescent sexual abuse item revealed comparable results (odds ratio = 1.648, 95% CI = 1.539–1.742, P < .001). A revised unweighted ORT removing the history of preadolescent sexual abuse item was notably superior in predicting the development of OUD in patients with CNMP on long-term opioid therapy (odds ratio = 3.085; 95% CI = 2.725–3.493; P < .001) with high specificity (.851; 95% CI = .811–.885), sensitivity (.854; 95% CI = .799–.898), positive predictive value (.757; 95% CI = .709–.799), and negative predictive value (.914; 95% CI = .885–.937).
      Perspective: The revised ORT is the first tool developed on a unique cohort to predict the risk of developing an OUD in patients with CNMP receiving opioid therapy, as opposed to aberrant drug-related behaviors that can reflect a number of other issues. The revised ORT has clinical usefulness in providing clinicians a simple, validated method to rapidly screen for the risk of developing OUD in patients on or being considered for opioid therapy.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Busse JW
        • Craigie S
        • Juurlink DN
        • Buckley DN
        • Wang L
        • Couban RJ
        • Agoritsas T
        • Akl EA
        • Carrasco-Labra A
        • Cooper L
        • Cull C
        • da Costa BR
        • Frank JW
        • Grant G
        • Iorio A
        • Persaud N
        • Stern S
        • Tugwell P
        • Vandvik PO
        • Guyatt GH
        Guideline for opioid therapy and chronic noncancer pain.
        CMAJ. 2017; 189: E659-E666
        • Belgrade M
        • Schamber C
        • Lindgren B
        The DIRE score: Predicting outcomes of opioid prescribing for chronic pain.
        J Pain. 2006; 7: 671-681
        • Butler S
        • Budman S
        • et al.
        Validation of a screener and opioid assessment measure for patients with chronic pain.
        Pain. 2004; 112: 65-75
        • Butler S
        • Budman SH
        • Fernandez KC
        • et al.
        Development and validation of the Current Opioid Misuse Measure.
        Pain. 2007; 130: 144-156
        • Cheatle MD
        • O'Brien CP
        Opioid therapy in patients with chronic noncancer pain: Diagnostic and clinical challenges.
        Adv Psychosom Med. 2011; 30: 61-91
        • Cheatle MD
        • O'Brien CP
        • Mathai K
        • Hansen M
        • Grasso M
        • Yi P
        Aberrant behaviors in a primary care-based cohort of patients with chronic pain identified as misusing prescription opioids.
        J Opioid Manag. 2013; 9: 315-324
      1. Cheatle MD, O'Brien CP, Berrentini W, Turk D, Webster LR: Clinical and genetic characteristics of opioid addiction in chronic pain. NIH/NIDA R01 DA032776-05

        • Chou R
        • Ballantyne JC
        • Fanciullo GJ
        • Fine PG
        • Miaskowski C
        Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline.
        J Pain. 2009; 10: 147-159
        • Chou R
        • Fanciullo GJ
        • Fine PG
        • Adler JA
        • Ballantyne JC
        • Davies P
        • Donovan MI
        • Fishbain DA
        • Foley KM
        • Fudin J
        • Gilson AM
        • Kelter A
        • Mauskop A
        • O'Connor PG
        • Passik SD
        • Pasternak GW
        • Portenoy RK
        • Rich BA
        • Roberts RG
        • Todd KH
        • Miaskowski C
        American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
        J Pain. 2009; 10: 113-130
        • Clark MR
        • Hurley RW
        • Adams MCB
        Re-assessing the validity of the Opioid Risk Tool in a tertiary academic pain management center population.
        Pain Med. 2018; 19: 1382-1395
        • Cleland CM
        • Lanza ST
        • Vasilenko SA
        • Gwadz M
        Syndemic risk classes and substance use problems among adults in high-risk urban areas: A latent class analysis.
        Front Public Health. 2017; 5: 237-249
      2. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994

        • Dowell D
        • Haegerich TM
        • Chou R
        CDC guideline for prescribing opioids for chronic pain — United States, 2016.
        MMWR Recomm Rep. 2016; 65: 1-49
        • Federation of State Medical Boards
        Guidelines for the chronic use of opioid analgesics. 2017.
        • Felitti VJ
        • Anda RF
        • Nordenberg D
        • Williamson DF
        • Spitz AM
        • Edwards V
        • Koss MP
        • Marks JS
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
        Am J Prev Med. 1998; 14: 245-258
        • Fine P
        • Portenoy RK
        Opioid Analgesia.
        McGraw-Hill, New York2004
        • Hah JM
        • Sturgeon JA
        • Zocca J
        • Sharifzadeh Y
        • Mackey SC
        Factors associated with prescription opioid misuse in a cross-sectional cohort of patients with chronic non-cancer pain.
        J Pain Res. 2017; 10: 979-987
        • Janke EA
        • Cheatle M
        • Keefe F
        • Dhingra L
        Society of Behavioral Medicine Health Policy Committee: Society of Behavioral Medicine (SBM) position statement: Improving access to psychosocial care for individuals with persistent pain: Supporting the National Pain Strategy's call for interdisciplinary pain care.
        Transl Behav Med. 2018; 8: 305-308
        • Jones CM
        • Christensen A
        • Gladden RM
        Increases in prescription opioid injection abuse among treatment admissions in the United States, 2004-2013.
        Drug Alcohol Depend. 2017; 176: 89-95
        • Jones T
        • Lookatch S
        • Grant P
        • McIntyre J
        • Moore T
        Further validation of an opioid risk assessment tool: The Brief Risk Interview.
        J Opioid Manage. 2014; 10: 353-364
        • Jones T
        • Lookatch S
        • Moore T
        Validation of a new risk assessment tool: The Brief Risk Questionnaire.
        J Opioid Manage. 2015; 11: 171-183
        • Jones T
        • Moore T
        • Levy JL
        • Daffron S
        • Browder JH
        • Allen L
        • Passik SD
        A comparison of various risk screening methods in predicting discharge from opioid treatment.
        Clin J Pain. 2012; 28: 93-100
        • Jones T
        • Moore T
        Preliminary data on a new opioid risk assessment measure: The Brief Risk Interview.
        J Opioid Manage. 2013; 9: 19-27
        • Jones T
        • Passik SD
        A comparison of methods of administering the Opioid Risk Tool.
        J Opioid Manage. 2011; 7: 347-351
        • Jones T
        • Schmidt M
        • Moore T
        Further validation of an opioid risk assessment tool: The Brief Risk Questionnaire.
        Ann Psychiatry Ment Health. 2015; 3: 1032-1039
        • Kendler KS
        • Bulik CM
        • Silberg J
        • Hettema JM
        • Myers J
        • Prescott CA
        Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and cotwin control analysis.
        Arch Gen Psychiatry. 2000; 57: 953-959
        • Moore TM
        • Jones T
        • Browder JH
        • Daffron S
        • Passik SD
        A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management.
        Pain Med. 2009; 10: 1426-1433
        • O'Connor AB
        • Turk DC
        • Dworkin RH
        • Katz NP
        • Colucci R
        • Haythornthwaite JA
        • Klein M
        • O'Brien C
        • Posner K
        • Rappaport BA
        • Reisfield G
        • Adams EH
        • Balster RL
        • Bigelow GE
        • Burke LB
        • Comer SD
        • Cone E
        • Cowan P
        • Denisco RA
        • Farrar JT
        • Foltin RW
        • Haddox JD
        • Hertz S
        • Jay GW
        • Junor R
        • Kopecky EA
        • Leiderman DB
        • McDermott MP
        • Palmer PP
        • Raja SN
        • Rauschkolb C
        • Rowbotham MC
        • Sampaio C
        • Setnik B
        • Smith SM
        • Sokolowska M
        • Stauffer JW
        • Walsh SL
        • Zacny JP
        Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations.
        Pain. 2013; 154: 2324-2334
        • Sheehan DV
        • Lecrubier Y
        • Sheehan KH
        • Amorim P
        • Janavs J
        • Weiller E
        • Hergueta T
        • Baker R
        • Dunbar GC
        The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
        J Clin Psychiatry. 1998; 59: 22-33
        • Smith SM
        • Paillard F
        • McKeown A
        • Burke LB
        • Edwards RR
        • Katz NP
        • Papadopoulos EJ
        • Rappaport BA
        • Slagle A
        • Strain EC
        • Wasan AD
        • Turk DC
        • Dworkin RH
        Instruments to identify prescription medication misuse, abuse, and related events in clinical trials: An ACTTION systematic review.
        J Pain. 2015; 16: 389-411
        • Webster LR
        • Webster RM
        Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool.
        Pain Med. 2005; 6: 432-442
        • Webster LR
        Risk factors for opioid-use disorder and overdose.
        Anesth Analg. 2017; 125: 1741-1748
        • VA/DoD Evidence-Based Clinical Practice Guideline Work Group
        VA/DoD Clinical practice guideline for opioid therapy for chronic pain.
        Department of Veterans Affairs, Department of Defense, Office of Quality and Performance, 2017