McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Appendix B-10: Aberrant Drug-Related Behaviours Resources

Table B Appendix 10.1 Aberrant Drug-Related Behaviours Indicative of Opioid Misuse

(Modified from Passik 2004)

Note: * = behaviours more indicative of addiction than the others

Indicator Examples
* Altering the route of delivery
  • Injecting, biting or crushing oral formulations
* Accessing opioids from other sources
  • Taking the drug from friends or relatives
  • Purchasing the drug from the "street"
  • Double-doctoring
Unsanctioned use
  • Multiple unauthorized dose escalations
  • Binge rather than scheduled use
Drug seeking
  • Recurrent prescription losses
  • Aggressive complaining about the need for higher doses
  • Harassing staff for faxed scripts or fit-in appointments
  • Nothing else "works"
Repeated withdrawal symptoms
  • Marked dysphoria, myalgias, GI symptoms, craving
Accompanying conditions
  • Currently addicted to alcohol, cocaine, cannabis or other drugs
  • Underlying mood or anxiety disorders not responsive to treatment
Social features
  • Deteriorating or poor social function
  • Concern expressed by family members
Views on the opioid medication
  • Sometimes acknowledges being addicted
  • Strong resistance to tapering or switching opioids
  • May admit to mood-leveling effect
  • May acknowledge distressing withdrawal symptoms

Supporting Information

  1. Aberrant drug-related behaviours are common in patients with chronic pain.

    A systematic review (Fishbain 2008) estimated that the prevalence of aberrant drug-related behaviours among chronic pain patients was 11.5% (range 0–44%). Urine drug screening with illicit drugs present was 14.5%, while a non-prescribed opioid or no opioid present was 20.4%.
  2. There is evidence that some aberrant drug-related behaviours are more predictive of opioid addiction than others.

    One study compared a sample of HIV patients with a history of substance abuse, to cancer patients without a history of substance abuse (Passik  2006a). Both groups were on opioids for chronic pain. Aberrant behaviours were significantly more common in the group with a history of substance abuse, and pain control was worse. Behaviours strongly predictive of opioid addiction (illegal activity, altering the route of delivery) were much more common in the group with a history of substance abuse than the group with no history of substance abuse. Aberrant behaviours in the group with a history of substance abuse were seen as frequently in patients who reported good pain control as in patients who reported poor pain control, suggesting that aberrant behaviours usually indicate something other than inadequately treated pain.

Tools used to assist in identifying aberrant drug-related behaviours

  • Addiction Behaviors Checklist (ABC): In 2006, Wu, Compton et al. also developed and tested the ABC, a 20-item instrument designed to identify problematic drug-use in chronic pain patients treated with opioids (Wu 2006).
  • Current Opioid Misuse Measure (COMM®): In 2007, Butler et al. developed and demonstrated the potential for a brief and easy-to-administer 17-item questionnaire, the COMM®, to identify aberrant drug-related behaviours (Butler 2007).
  • Patient Assessment and Documentation Tool (PADT): developed by Passik et al. 2004, Clin Ther. This instrument focuses on key outcomes and provides a consistent way to document progress in pain management therapy over time. Items assess four domains: pain relief, patient functioning, adverse events, and drug-related behaviors.
  • Prescription Drug Use Questionnaire (PDUQ): In 1998, Compton et al. developed and piloted the PDUQ for screening for addiction in chronic pain patients receiving opioids (Compton 1998). This is a 42-item interview to assess abuse/misuse for pain patients.
  • Prescription Opioid Therapy Questionnaire (POTQ): In 2004, Michna et al. developed and tested the POTQ, an 11-item scale where the provider answers “yes” or “no” to questions indicative of misuse of opioids (Michna 2004).
  • Screener and Opioid Assessment for Patients with Pain (SOAPP®-R). In 2004, Butler et al. developed the SOAPP® instrument (Butler 2004). In 2008 they published the revised SOAPP®-R, a 24-item self-report questionnaire that may also be useful for identifying risk of aberrant behaviours (Butler 2008).