The Addiction Behaviors Checklist: Validation of a New ... - Westat

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Vol. 32 No. 4 October 2006 Addiction Behaviors Checklist343which opioids are therapeutically prescribed,a consensus statement was developed by theAmerican Academy of Pain Medicine, theAmerican Pain Society, and the American Societyof Addiction Medicine in 2001 that providedinitial definitions for addiction inchronic pain populations. Addiction is definedin this public policy statement as ‘‘a primary,chronic, neurobiological disease, with genetic,psychosocial, and environmental factors influencingits development and manifestations’’and ‘‘characterized by behaviors that includeone or more of the following: impaired controlover drug use, compulsive use, continued usedespite harm, and craving.’’ 10Thus, in the context of chronic pain treatment,addiction is determined by the presenceof certain observable patient behaviors, the descriptionof which are nearing clinical agreement.For example, ‘‘behaviors suggestive ofaddiction’’ identified in the above consensusstatement include an inability to adhere tothe prescription schedule, insistence on certainforms or routes of medication, and resistanceto other nonopioid treatments. 10Portenoy and Payne 11 listed 10 aberrantdrug-related behaviors suggesting an addictiondisorder: selling prescription drugs; forgingprescriptions; stealing drugs; injecting oral formulations;obtaining drugs from nonmedicalsources; concurrently abusing alcohol or otherdrugs; evidence of deterioration in function;and failing to comply with dosing regimen, losingmedications, and/or seeking prescriptionsfrom other medical sources on multipleoccasions.In their analysis, Chabal et al. 8 focused onmedication-related issues, including an overwhelmingfocus on opioid issues, using supplementalsources of opioids, and patterns ofearly refills, multiple telephone calls, unscheduledvisits, and episodes of lost or stolenprescriptions, as behaviors indicative of problematicopioid use. These medication-relatedbehaviors are consistent with those predictingfuture opioid medication misuse in theconcept mapping analysis of Butler et al. 12Modeled after the consensus statement criterianoted above, Savage 3 categorized many of thesame behaviors as either due to the consequences,loss of control or compulsivity, andcraving or preoccupation related to medicationuse, with an emphasis on behaviors thatcan be detected during the visit, such as sedatedappearance, a preference for opioidswith high reward value, and reported poor tolerancefor nonopioid and nonpharmacologicalinterventions. Adding patients’perceptions of their medication use, Adamset al. 13 found that patients who believe theyneed a higher dose of medication than thatprescribed, report having difficulty gettingthe medication they need from the physician,and worry that they may be ‘‘too dependent’’on the medication were those most likely tosuffer addiction.The development of valid instruments fortracking behaviors characteristic of addictionin the context of opioid medications prescribedfor patients with chronic pain is animportant step in improving clinicalcare. 1e3,13e15 The Addiction Behaviors Checklist(ABC) was, therefore, developed in an effortto organize and provide an operationaltool for use by clinicians to monitor ongoingand current behaviors characteristic of addictionin patients with chronic pain and treatedwith opioid analgesics on a continuing basis.The majority of tracked behaviors includedin the ABC are consistent with those behaviorssuggested within the consensus definition bythe American Academy of Pain Medicine, theAmerican Pain Society, and the American Societyof Addiction Medicine. 10The aims of this study were as follows: 1) introducethe item development and the specificitems of the ABC, 2) examine interrater reliability,3) examine indicators of validity forthe sum score from the items as well as individualitems, and 4) introduce results regardingthe sensitivity and specificity for cut-off scoresfor the ABC. This study improves upon previousefforts in that ongoing, prospective datafrom both the ABC and other validity indicatorsare collected across multiple time points,enabling cross-validation of the ABC withother measures of problematic behaviors.MethodsParticipantsThis study included 136 chronic pain patientswho were being prescribed long-termopioid medications to treat their chronic painproblem. Participants were veterans recruitedfrom a chronic pain clinic at the Greater Los
344 Wu et al.Vol. 32 No. 4 October 2006Angeles Veterans Affairs (VA) HealthcareSystem.This study was approved by the local institutionalreview board. Data were collected as partof a larger data collection effort following patientswho were receiving long-term opioidmedication treatment over the course of oneyear. Participants visited the chronic pain clinicon a monthly basis in order to refill their opioidprescriptions. During the course of thesevisits, participants received various assessmentsreviewing their levels of pain over the course ofthe month and other areas related to potentiallyproblematic medication use. Participantswere asked to give signed consent prior to enrollmentinto this research study.MeasuresAddiction Behaviors Checklist. The developmentof ABC items was based upon an extensivereview of the relevant literature, 3,7,8,10,16,17 withan overriding aim to keep the tool concise,easy to complete, and otherwise useful ina busy clinical setting. Integrating observablebehaviors identified in and across the work ofpublished experts on indicators of addictionin chronic pain patients resulted in the synthesisof items for the ABC (Appendix). The fullset of 20 items initially selected was used inall the analyses presented in this paper. Allbehaviors tracked in the ABC reflect thosesuggested in the consensus document by theAmerican Academy of Pain Medicine,the American Pain Society, and the AmericanSociety of Addiction Medicine. 10The tool was designed to be administered inan interview format and scored based uponthe participant’s responses to questions, the interviewer’sobservations of displayed behaviorsduring the session, and pertinent informationgathered from medical chart review. Itemswere classified into two major categories: 1) addictivebehaviors noted between visits (e.g.,‘‘patient running out of medications early,’’‘‘receiving narcotics from other providers’’)and 2) addictive behaviors observed withinthe visit (e.g., ‘‘patient appearing sedated,’’‘‘patient expressing concern about future availabilityof narcotic’’). In addition to these twomajor categories, another question wasincluded that could be used if the patient’sfamily members were present in session(‘‘significant others express concern overpatient’s use of analgesics’’). Family memberswere rarely present within the setting of thecurrent data collection, therefore producinginsignificant influence on study results. Thisitem was retained in the instrument, however,because this information might be more availablewithin other medical settings. A total of 20items were included in the instrument, with dichotomousresponse scoring. Each affirmativeresponse was counted as one point, and pointswere added to calculate the total score, consequentlyresulting in scores ranging from 0 to20. While some of the items on the ABC areclearly based on patients’ reports and henceare subject to reporting bias, the primary emphasisof the scale and item scoring is on observablebehaviors or objective informationderived from the patient or other sources toindicate opioid misuse. Participants wereassessed on a monthly basis using the ABC.Prescription Drug Use Questionnaire. To evaluateconstruct validity for the ABC, the PrescriptionDrug Use Questionnaire (PDUQ) 16 wasadministered to all subjects at the 4-monthclinic visit. Unique in that scores have beencross-validated with clinical expert diagnosisof addiction, the PDUQ consists of 39 itemsevaluating five different domains of problematicopioid analgesic use in chronic pain patients,including the characteristics of thepain condition, opioid use patterns, social/family factors, familial/personal history of substanceabuse/addiction, and psychiatric history.Initial analyses of PDUQ scores providesuggested cut-off values indicative of the diagnosisof substance abuse and substance dependence.16 Since it includes historical data, thePDUQ was developed primarily to assess addiction(or addiction risk) at a single time pointand, therefore, is not a redundant measurewith the ABC. However, both measures dooverlap in their aim to measure the constructof current addiction behaviors and thusshould show moderate positive correlations.Global Clinical Judgment. A common criterionvariable in studies of opioid misuse is an expertclinician’s global judgment. 14,16 For thecurrent study, subjects were rated at each visitby their treating pain clinician on a dichotomousglobal question (‘‘Do you think patient
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