The Addiction Behaviors Checklist: Validation of a New ... - Westat
The Addiction Behaviors Checklist: Validation of a New ... - Westat The Addiction Behaviors Checklist: Validation of a New ... - Westat
Vol. 32 No. 4 October 2006 Addiction Behaviors Checklist349assembled an assessment tool relying on behavioralobservations that are both logicallyconsistent with accepted definitions of opioidaddiction and relatively objective (the behavioris either present or not present).Importance of Specific Behaviorsin AddictionAlthough there is general consensus regardingthe primary behaviors that make up addictionin chronic pain patients using opioids,there is as yet no diagnostic algorithm for compilingthese behaviors. In this context it is interestingto examine how individual ABC itemsrelate to expert global clinical judgments in orderto provide initial direction for the weightingof certain behaviors in the process ofidentifying addiction. The items that weremost frequently endorsed and most associatedwith the global clinical judgment included ‘‘difficultywith using medication agreement,’’ ‘‘increaseduse of narcotics (since last visit),’’‘‘used more narcotics than prescribed,’’ and‘‘patient indicated that s/he ‘needs’ or ‘musthave’ analgesic meds.’’ These same behaviorshave been variously emphasized in the frameworksof Savage, 3 Chabal et al., 8 and Portenoyand Payne, 11 and were likely to also be endorsedon the PDUQ. 16 Further, each of thesebehaviors is consistent with consensus criteriafor addiction in pain patients. These indicatorsof loss of control over opioid use and cravingfor opioids in chronic pain patients appear towarrant increased and/or emphasized concernin addiction assessment. Although the abovementioneditems could be considered forheavier weighting when assessing for behaviorscharacteristic of addiction, a weighting systemwas not incorporated into the current analysis.A future direction for the ABC would be to explorepossible weighting systems or further-developedscoring paradigms that might giveadded emphasis to more serious opioid misusebehaviors predictive of addiction.Since the ABC is a checklist, it may also be importantto include low-frequency items eventhough they did not display a significant bivariaterelationship with the global clinical judgmentin the current sample. An extremeexample of this is the item assessing if the patientbought medications on the street. This informationis very difficult to gather fromobservable behavior or the medical record andis usually only available from a patient reportor trusted collateral report. Though this itemshowed extremely low endorsement, we wouldargue that it should be left in the checklist sincea positive endorsement would be a clear warningsign to providers regarding continued prescriptionof opioid medications. Other itemsmight have low endorsement rates that are populationspecific. For example, the items regardingsignificant others’ concern about use ofanalgesics and receiving medications frommore than one provider also showed a low correlationwith the global clinical judgment inthis study. Both of these items had low endorsementrates, but this is hypothesized to be sampledependent. In the VA population, families arenot as frequently involved as in other settings,and the HMO nature of care and the computerizedpatient record effectively limit a patient’sability to receive opioid medications from multipleproviders. These items may well be morefrequent and useful in other contexts.Another issue in the interpretation of an instrumentdesigned to track behaviors indicativeof potential addiction is the concept ofpseudoaddiction. 19e22 Pseudoaddiction includesbehaviors that are similar to addictionbut that are due to the undertreatment ofpain. Therefore, it is important to consider ifthe behaviors tracked with the ABC are indeedrepresentative of behaviors suggestive of addictionor due to the undertreatment of pain.Though it is an important theoretical consideration,the actual extent of pseudoaddiction hasnot been empirically validated. Within thechronic pain clinic at the Greater Los AngelesVeterans Affairs Healthcare System, physiciansand providers are cognizant of the iatrogenicissues involved in pseudoaddiction and arecareful to not make decisions regarding opioidmedication discontinuation or addiction basedsolely on patients’ requests or behaviors thatare due to an increased medication need dueto poorly controlled pain.Use of the ABCAlthough further validation and refinementis important, the current data suggest severalareas of utility for the ABC. It can be used clinically,as it was in this study, to track abuse behaviorsat clinic visits. Scores of 3 or aboveshould flag for more careful monitoring of patients,including more frequent urine screens
350 Wu et al.Vol. 32 No. 4 October 2006or increased medical chart review. Fig. 2, for example,shows some evidence for increasingabuse behaviors in visits preceding a majorproblem that led to removal of opioids. TheABC may be especially important in trainingclinics to cue clinicians to the range of possibleproblem behaviors and the need to examinespecific signs of misuse. The ABC may also bea good longitudinal outcome measure for researchstudies on effectiveness and risks of opioidmedications for chronic pain. A significantdifficulty with the existing literature is the lackof standardized measures of behaviors suggestiveof addiction, making comparisons acrosspopulations, medications, and settings very difficult.An advantage of the ABC in this regard isthat, in addition to reporting the total score,the pattern of behaviors suggestive of addictioncan be easily reported in tabular form.Study LimitationsThe present findings are based on data collectedin a single tertiary pain center in a largeurban VA Medical Center. While the sampledoes present with common pain problemsseen in most pain clinics, the results need replicationand extension in other contexts (primarycare settings, other pain clinics outside of theVA). One limitation of the study design wasthat not all patients who entered the pain cliniccould be included in the research study. A smallgroup of patients at the initial clinic assessmentwere found to already show significant problemswith opioid use. These patients were notrecommended to continue chronic opioidtreatment and were usually weaned off opioidmedications or voluntarily sought care elsewhere.The use of a sample of patients deemedappropriate for continued opioid use may haveresulted in fewer problems than the use of otherless restricted samples. Another limitation concernsthe use of a global clinical judgment asa major outcome criterion. While this measurehas high interrater reliability and care was takento make sure that raters were very familiar withthe patient’s past and present behaviors, it includesindividual clinician judgments and,therefore, may be prone to bias and both positiveand negative influence. In addition, anybias may be common to both the global judgmentand the ABC score leading to an inflatedvalidity estimate. The fact that the ABC was significantlyrelated to not only the global clinicaljudgment but also the discharge criterion andPDUQ moderates this limitation.SummaryIn summary, the ABC shows initial promise asan assessment instrument to quantify opioidmedication misuse in patients with chronicpain. It can be rated reliably across clinicians usinginformation typically available duringa clinic visit. The total score is significantly relatedto other misuse criteria including a globalclinical judgment and validated risk interview(PDUQ). The ABC can serve as a tool for providersto alert themselves when further interventionis needed, such as collecting randomurine toxicology screens or pill counts. It allowsfor more objective tracking of opioid medicationuse behaviors and changes in these behaviorsfor both clinical and research purposes.AcknowledgmentsThe authors thank Teresa Olivas for hereditorial assistance and the staff and patientsof the VAGLAHS pain clinic for their participationin this study. This study was supportedby the VA Health Services Research and Developmentprogram.References1. Portenoy RK. Opioid therapy for chronic nonmalignantpain: a review of the critical issues.J Pain Symptom Manage 1996;11:203e217.2. Passik SD, Kirsh KL, Whitcomb L, et al. A newtool to assess and document pain outcomes inchronic pain patients receiving opioid therapy.Clin Ther 2004;26:552e561.3. Savage SR. Assessment for addiction in pain--treatment settings. Clin J Pain 2002;18:S28eS38.4. American Psychiatric Association. Diagnosticand statistical manual of mental disorders (4thed.). Washington, DC: American Psychiatric Association,1994.5. Miotto K, Compton P, Ling W, Connolly M. Diagnosingaddictive disease in chronic pain patients.Psychosomatics 1996;37:223e235.6. Fishbain DA, Rosomoff HL, Rosomoff RS. Drugabuse, dependence, and addiction in chronic painpatients. Clin J Pain 1992;8:77e85.7. Sees KL, Clark HW. Opioid use in the treatmentof chronic pain: assessment of addiction. J PainSymptom Manage 1993;8:257e264.8. Chabal C, Erjavec MK, Jacobsen L, Mariano A,Chaney E. Prescription opiate abuse in chronic
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350 Wu et al.Vol. 32 No. 4 October 2006or increased medical chart review. Fig. 2, for example,shows some evidence for increasingabuse behaviors in visits preceding a majorproblem that led to removal <strong>of</strong> opioids. <strong>The</strong>ABC may be especially important in trainingclinics to cue clinicians to the range <strong>of</strong> possibleproblem behaviors and the need to examinespecific signs <strong>of</strong> misuse. <strong>The</strong> ABC may also bea good longitudinal outcome measure for researchstudies on effectiveness and risks <strong>of</strong> opioidmedications for chronic pain. A significantdifficulty with the existing literature is the lack<strong>of</strong> standardized measures <strong>of</strong> behaviors suggestive<strong>of</strong> addiction, making comparisons acrosspopulations, medications, and settings very difficult.An advantage <strong>of</strong> the ABC in this regard isthat, in addition to reporting the total score,the pattern <strong>of</strong> behaviors suggestive <strong>of</strong> addictioncan be easily reported in tabular form.Study Limitations<strong>The</strong> present findings are based on data collectedin a single tertiary pain center in a largeurban VA Medical Center. While the sampledoes present with common pain problemsseen in most pain clinics, the results need replicationand extension in other contexts (primarycare settings, other pain clinics outside <strong>of</strong> theVA). One limitation <strong>of</strong> the study design wasthat not all patients who entered the pain cliniccould be included in the research study. A smallgroup <strong>of</strong> patients at the initial clinic assessmentwere found to already show significant problemswith opioid use. <strong>The</strong>se patients were notrecommended to continue chronic opioidtreatment and were usually weaned <strong>of</strong>f opioidmedications or voluntarily sought care elsewhere.<strong>The</strong> use <strong>of</strong> a sample <strong>of</strong> patients deemedappropriate for continued opioid use may haveresulted in fewer problems than the use <strong>of</strong> otherless restricted samples. Another limitation concernsthe use <strong>of</strong> a global clinical judgment asa major outcome criterion. While this measurehas high interrater reliability and care was takento make sure that raters were very familiar withthe patient’s past and present behaviors, it includesindividual clinician judgments and,therefore, may be prone to bias and both positiveand negative influence. In addition, anybias may be common to both the global judgmentand the ABC score leading to an inflatedvalidity estimate. <strong>The</strong> fact that the ABC was significantlyrelated to not only the global clinicaljudgment but also the discharge criterion andPDUQ moderates this limitation.SummaryIn summary, the ABC shows initial promise asan assessment instrument to quantify opioidmedication misuse in patients with chronicpain. It can be rated reliably across clinicians usinginformation typically available duringa clinic visit. <strong>The</strong> total score is significantly relatedto other misuse criteria including a globalclinical judgment and validated risk interview(PDUQ). <strong>The</strong> ABC can serve as a tool for providersto alert themselves when further interventionis needed, such as collecting randomurine toxicology screens or pill counts. It allowsfor more objective tracking <strong>of</strong> opioid medicationuse behaviors and changes in these behaviorsfor both clinical and research purposes.Acknowledgments<strong>The</strong> authors thank Teresa Olivas for hereditorial assistance and the staff and patients<strong>of</strong> the VAGLAHS pain clinic for their participationin this study. This study was supportedby the VA Health Services Research and Developmentprogram.References1. Portenoy RK. Opioid therapy for chronic nonmalignantpain: a review <strong>of</strong> the critical issues.J Pain Symptom Manage 1996;11:203e217.2. Passik SD, Kirsh KL, Whitcomb L, et al. A newtool to assess and document pain outcomes inchronic pain patients receiving opioid therapy.Clin <strong>The</strong>r 2004;26:552e561.3. Savage SR. Assessment for addiction in pain--treatment settings. Clin J Pain 2002;18:S28eS38.4. American Psychiatric Association. Diagnosticand statistical manual <strong>of</strong> mental disorders (4thed.). Washington, DC: American Psychiatric Association,1994.5. Miotto K, Compton P, Ling W, Connolly M. Diagnosingaddictive disease in chronic pain patients.Psychosomatics 1996;37:223e235.6. Fishbain DA, Rosom<strong>of</strong>f HL, Rosom<strong>of</strong>f RS. Drugabuse, dependence, and addiction in chronic painpatients. Clin J Pain 1992;8:77e85.7. Sees KL, Clark HW. Opioid use in the treatment<strong>of</strong> chronic pain: assessment <strong>of</strong> addiction. J PainSymptom Manage 1993;8:257e264.8. Chabal C, Erjavec MK, Jacobsen L, Mariano A,Chaney E. Prescription opiate abuse in chronic
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