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

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Vol. 32 No. 4 October 2006 Addiction Behaviors Checklist347differences in PDUQ scores between participantswho received mean scores of 3 or greateron the ABC across the first 4e5 months andthose with mean scores below 3. Mean PDUQscores were higher for those participants witha mean ABC score greater than or equal to 3(mean ¼ 11.77, SD ¼ 3.99) than those withmean ABC scores less than 3 (mean ¼ 8.52,SD ¼ 4.05, t(86) ¼ 2.97, P ¼ 0.004). A similart-test was performed comparing participantswho received any ABC score greater than orequal to 3 over the first 4e5 months with thosewho consistently had scores less than 3 duringthis period. Mean PDUQ scores were againhigher for those participants who had at leastone ABC score greater than or equal to 3(mean ¼ 10.17, SD ¼ 4.35) than those who consistentlyhad scores less than 3 (mean ¼ 8.02,SD ¼ 3.80, t(86) ¼ 2.46, P ¼ 0.016).Trends Over Final Four Visits of StudyOver the course of the one-year data collectionfollow-up period, 38 participants had theiropioid medication prescriptions discontinueddue to objective misuse criteria establishedwithin the clinic setting. These objective criteriaincluded receiving a ‘‘bad’’ urine toxicologyscreen (e.g., positive urine findings of drugs ofabuse, numerous occurrences of absence ofprescribed medications within urine toxicologyscreens) or refusing to comply with themedication contract used within the clinic(e.g., failing to submit to random pill counts,repeatedly deviating from prescribed opioidmedication schedule). It should be notedthat the clinic used a sophisticated urinescreening methodology, including high-performanceliquid chromatography of all samples,which was both sensitive and specific for individualopioid compounds. Given the initial developmentof the ABC, participants did nothave their opioid medications discontinueddue to elevated scores on the ABC, but wereonly discontinued from their medicationsdue to the previously mentioned objectivemeasures of opioid misuse. Of these 38 participants,11 participants had their opioid medicationsdiscontinued due to alcohol or illicitsubstance abuse, 21 due to noncompliancewith prescribed medications, and 6 due tononcompliance with clinic procedures.It might be expected that objective signs ofopioid misuse and opioid prescriptiondiscontinuation would be preceded by an increasingtrend in misuse behaviors. To examinethis, the ABC scores were analyzed forthe final three to four visits for each patient.Comparisons were made between those participantswho were dropped from the study forone of the above-mentioned offenses vs. thoseparticipants who either completed the study orhad to drop out of the study for nonproblematicreasons (i.e., need for surgery, movedout of town). It should be noted that the lastvisit in this data set could either be the participant’scompletion of the one-year follow-upvisits or the point at which the patient wasdropped from the study, due to either problemsin opioid use or other reasons. Fig. 2 displaysa graphical representation of the trendsseen between the mean ABC scores for thesetwo groups in the last four visits of the study.As can be seen in Fig. 2, the ABC mean scoregradually increased, approaching a totalmean score of 3, as the participants nearedthe final visit in which they were droppeddue to problematic opioid medication use.ABC mean scores for participants who eithercompleted the study or were dropped due tononproblematic reasons tended to remainfairly stable around a mean score of about1.2e1.3. Based on t-test analysis, equalMean ABC Score3.02.52.01.51.00.50.03 Visits PriorCompleted or Non-problematic dropDropped due to a problem2 Visits Prior1 Visit Prior*Final Visit* P < 0.05 for scores at final visitFig. 2. Comparison of mean ABC scores over thefinal four visits in the study (n ¼ 136). Participantswho were discontinued due to opioid misuse problem(e.g., problem displayed in urine toxicology,noncompliance with clinic procedures) displayedan elevated ABC score (P < 0.05) at final visit ascompared to participants who completed or discontinuedthe study due to nonproblematic reasons(i.e., need for surgery).
348 Wu et al.Vol. 32 No. 4 October 2006variances not assumed, there was a significantdifference between these two groups at thefinal visit (t(47) ¼ 2.40, P ¼ 0.021).Correlations Between ABC Scoresand Pain ScoresIn the presence of pseudoaddiction, onemight expect that ABC scores would tend tocovary with pain scores (i.e., as patient receivesadequate pain relief and pain scores decrease,pseudoaddictive behaviors would decrease aswell). Table 2 displays correlation coefficientsbetween mean ABC scores and both usualand worst pain scores at the quarterly visit.This analysis found no significant correlationsbetween ABC scores and pain scores. This findinglends support to the concept that increasesin ABC scores would be indicative of inappropriatebehaviors suggestive of addiction ratherthan a pseudoaddiction process.DiscussionThe goal of this study was to test the psychometricproperties of the ABC, a new instrumentfor tracking behaviors suggestive ofaddiction related to opioid medications inchronic pain populations. The ABC showsstrong interrater correlations across three separateinterviewers, supporting the reliabilityand objective nature of the individual itemsand total score. The ABC total score alsoshowed good concurrent validity in terms ofTable 2Pearson Correlation CoefficientsBetween Mean ABC Scores and Usual Pain Scoreat Quarterly Visit PointsABC Mean ScoreInitialVisit4-MonthVisit8-Month 12-MonthVisit VisitUsual pain, initial visit 0.12 0.05 0.01 0.05Usual pain,0.12 0.04 0.04 0.024-month visitUsual pain,0.1 0.08 0.01 0.058-month visitUsual pain,0.12 0.09 0.00 0.1212-month visitWorst pain, initial visit 0.12 0.10 0.09 0.10Worst pain,0.16 0.06 0.04 0.024-month visitWorst pain,0.13 0.04 0.05 0.058-month visitWorst pain,12-month visit0.23 0.06 0.10 0.13its relationship with global clinical judgmentsof appropriate opioid use, as well as validitywith an opioid misuse risk assessment instrument,the PDUQ, which itself has shown verygood preliminary external validity. 16 The sensitivityand specificity analysis indicates thata cut-off score of 3 or more on the ABC providesa good general estimate of appropriatevs. inappropriate opioid use. This cut-off scoreshowed initially positive results in differentiatingopioid abuse as assessed by the PDUQ.Comparison with Other MeasuresThe ABC can be distinguished from otherrecently developed instruments in this areain that it is specifically focused on longitudinalassessment and tracking of problematic behaviorsand not determination of risk. There arenow several published measures for use withchronic pain patients to assess risk of opioidmisuse or addiction. 13,14,16 These measures includehistorical information (e.g., history ofsubstance abuse), current nonopioid abuse behaviors(e.g., nicotine craving), and opioidmedication-related behaviors. The focus onhistorical information is critical for assessmentof risk since previous substance abuse can bepredictive of future opioid abuse. 15,18 The natureof these scales, however, makes them lesslikely to change over time and they are notdesigned to track signs of misuse or flagbehaviors that signal increasing medicationproblems. Additionally, even though certainpredictors have suggested an increased riskfor future opioid abuse, the data indicatethat the prediction models are not highly robustand presence of these predictors doesnot provide certainty that chronic pain patientswould misuse their opioid medicationsin the future. For example, Compton et al. 16found that in a sample of 52 chronic pain patientsevaluated for opioid addiction, 27%and 50% of those who did not meet addictioncriteria still had a positive personal history andfamily history of addictive disease, respectively.This suggests that history variables, while cautionary,may not be clear enough indicatorsto withhold or modify opioid treatment decisions.On the other hand, the ABC representsthe first measure specifically designed and validatedfor longitudinal assessment of behaviorssuggestive of addiction. Because addictivedisease is essentially a disease of behavior, we
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