Regular a
Prescription Opioid Misuse Index: A b
art
, E
nwea
onwe
orm 4
use
n add
s and
or m
& Gfroerer, 2006; Drug Abuse Warning Network [DAWN],
2007; National Institute on Drug Abuse, 2006; Substance
with the abuse and/or nonmedical use of opioids. According
to the 2005 Treatment Episode Data Set, there was a four-
Journal of Substance Abuse TreatmenAbuse and Mental Health Services Administration
[SAMHSA], 2006a, 2006b). The 2005 National Survey on
Drug Use and Health (NSDUH) reported that approximately
1.5 million persons older than 12 years were dependent on or
abused narcotics during the previous year, and more than 11
million individuals engaged in the nonmedical use of
fold increase in admissions for treatment of nonheroin
opioids from 1% in 1995 to 4% in 2005. (SAMHSA, 2006a,
2006b). Significant increases in emergency room visits with
mentions of opioid drugs have also been reported over the
last decade (SAMHSA, 2003). Most recently, DAWN
estimates indicate that one third of nonmedical-use visits
involve opioid analgesics (DAWN, 2007).
With the growing concern on the dramatic increase in the
abuse and nonmedical use of prescription narcotics and
subsequent health problems, it is important to develop
⁎ Corresponding author. 1457 Harding Road, Blacksburg, VA 24060,
USA. Tel.: +1 540 239 7132; fax: +1 540 231 6298.
E-mail address: mwunsch@vcom.vt.edu (M.J. Wunsch).Keywords: Screening instrument; Prescription drug abuse; Opioids; Pain
1. Introduction
Numerous epidemiological surveys in the last several
years have demonstrated an increase in the prevalence
of narcotic addiction and nonmedical use of prescrip-
tion opioids in the United States (Colliver, Kroutil, Dai,
prescription pain relievers in the previous year (SAMHSA,
2006a, 2006b). Between 2002 and 2005, rates of initial
nonmedical opioid use were stable; however, the annual
average of first time nonmedical use was approximately 2.3
million people (NSDUH, 2007). Data from treatment
surveys also indicate an increase in problems associatedsensitive and specific instrument for identifying patients who misutheir medication. When comparing drug abuse/dependence in subjects classified as misusers or users, significantly more misusers received a
diagnosis for alcohol (p b .01), illicit drugs (p b .05), and other prescription medications (p b .05) and reported greater lifetime use of alcohol
(p b .002) and illicit drugs (p b .01). No between-group differences were found regarding psychiatric problems. The POMI appears to be a
se opioid medications. © 2008 Elsevier Inc. All rights reserved.Janet S. Knisely, (Ph.D.)a, M
Karen L. Cropsey, (Psy.D.)a,2
aDepartment of Psychiatry, Virginia Commo
bDepartment of Biostatistics, Virginia Comm
Received 16 July 2007; received in revised f
Abstract
The Prescription Opioid Misuse Index (POMI) was developed and
in pain patients prescribed OxyContin, patients treated for OxyConti
The POMI was administered to 40 subjects with addiction problem
operating characteristic curve analysis indicated that endorsing two1 Present address: Addiction Medicine, Edward Via Virginia College of
Osteopathic Medicine, 2265 Kraft Drive, Blacksburg, Virginia, USA 24060.
2 Present address: Department of Psychiatry and Behavioral Neurobiol-
ogy, University of Alabama School of Medicine, Birmingham, AL 35209.
0740-5472/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2008.02.001rticle
rief questionnaire to assess misuse
ha J. Wunsch, (M.D.)a,⁎,1,
leanor D. Campbell, (M.S.)b
lth University, Richmond, VA 23298, USA
alth University, Richmond, VA 23298, USA
February 2008; accepted 18 February 2008
d in a larger study designed to assess correlates of OxyContin abuse
iction, and individuals incarcerated for OxyContin-related charges.
34 pain patients who had received OxyContin for pain. Receiver
ore of six items reliably classified a person as at risk for misuse of
t 35 (2008) 380–386methods of detection of those at risk for misuse of
prescription narcotics (Compton & Volkow, 2006; Zacny
et al., 2003). The development of a screening instrument for
opioid misuse that can be used quickly and effectively in a

known addiction problems and pain patients and compared
nce Aclinical setting has been a challenge for the field. An early
attempt to develop and evaluate such an instrument was
accomplished by Compton, Darakjian, and Miotto (1998),
who found that scores on a 42-item Prescription Drug Use
Questionnaire (PDUQ) were significantly different for a
group meeting the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) criteria for
abuse or dependence as compared with those not meeting
DSM-IV criteria. They also reported that three factors taken
in unison—the tendency to increase analgesic dose or
frequency, preference for a mode of administration, and
patient considering himself/herself addicted—distinguished
substance-abusing and substance-dependent patients from
the nonaddicted patients. This interview, however, is
designed to be administered by a trained mental health
professional and takes time to administer. These limitations
make it impractical for health care practitioners to use this
instrument with most of their patient population.
Using a large sample of chronic pain patients consisting
of 100 with substance abuse and 400 without substance
abuse histories, Manchikanti, Singh, Damron, Beyer, and
Pampati (2003) examined a comprehensive 27-item assess-
ment instrument that evaluated several domains including
focus on and excessive need of opiates, nonphysiological
behavior, substance abuse, nonfunctional status, legal status,
and psychological status. Results of their study suggested
that 8 of the 12 domains studied were useful in identifying
misuse and that three factors correctly identified 90% of the
cases: excessive opiate needs, lying to obtain the medication,
and doctor shopping.
More recently, Butler, Budman, Fernandez, and Jamison
(2004) developed a self-administered 24-item questionnaire
(Screener and Opioid Assessment for Patients with Pain
[SOAPP]) to identify characteristics of chronic pain patients
to predict future misuse. The final 14-item instrument has
demonstrated good reliability and validity when compared
with aberrant drug use behavior as determined by either a
high score on the PDUQ, positive drug screening, or
clinician ratings of a drug problem.
Webster and Webster (2005) validated a brief office-based
screening tool, the Opioid Risk Tool (ORT), to predict the
probability of a patient displaying aberrant behavior when
prescribed opioids for chronic pain. This self-administered
screen requires less than 10 minutes of the patient's time and
is composed of five risk factors, which were derived from a
search of the literature and the author's clinical experience:
family and personal history of substance abuse, age, history
of preadolescent sexual abuse, and specific mental disorders.
Scores from the ORT predicted aberrant behaviors during the
12-month monitoring period among patients prescribed
opioids for chronic pain with a high degree of sensitivity
and specificity. Most frequent aberrant behaviors recorded
via chart review included obtaining prescription opioids
from alternative providers, using more than prescribed,
using additional opioids than those prescribed, and failing to
J.S. Knisely et al. / Journal of Substakeep appointments.with DSM-IV diagnoses obtained through a structured
interview. Other potential correlates of misuse were also
assessed including alcohol and illicit drug abuse/depen-
dence and psychiatric histories.
2. Materials and methods
2.1. Subjects
Of the 137 subjects recruited from community substance
abuse treatment programs, regional jails, pain clinics, and
private internal medicine practices in southwestern Virginia
for a study investigating correlates of OxyContin addiction
(see Wunsch, 2007), 74 had been prescribed OxyContin for
pain and served as subjects in this study. A total of 40
subjects were known opioid abusers (from addiction
treatment programs and those incarcerated), and 34 were
pain patients. All subjects signed consent forms approved by
the Western Institutional Review board (WIRB), and study
procedures were consistent with WIRB standards.
2.3. Procedures
Substance abuse and dependence diagnoses were
determined via the DSM-IV checklist (modified from
Hudziak et al., 1993). This structured interview queried
for use of alcohol, amphetamine, cannabis, cocaine,
hallucinogens, inhalants, nicotine, opiates, phencyclidine,
and sedatives/benzodiazepines in the previous year. AThe goal of the present investigation was to assess a
brief interview focused specifically on prescription use
behaviors rather than general predictive factors associated
with substance abuse (i.e., family history of substance
abuse, others' concern regarding potential drug abuse
problem, previous substance abuse treatment, etc.). The
investigators of this study standardized questions frequently
used in their clinical practice to assess potential misuse of
prescription medications. The eight-item interview, Pre-
scription Opioid Misuse Index (POMI), also included a
question regarding adequate pain relief to confirm that any
increase in prescription use reported was not due to
inadequate pain control. This question was included to
elucidate behaviors characteristic of those individuals
displaying pseudo-addiction (American Academy of Pain
Medicine [AAPM], American Pain Society [APS], &
American Society of Addiction Medicine [ASAM],
2001). Pseudo-addiction occurs in a patient with unrelieved
pain who becomes focused on obtaining medications and
displays behaviors that may otherwise seem inappropriately
“drug seeking.” Sometimes, illicit drug use and deception
may occur in efforts to obtain relief. Unlike the patient with
addiction, these behaviors resolve when pain is effectively
treated. The POMI was administered to subjects with
381buse Treatment 35 (2008) 380–386modified version of the Addiction Severity Index 5th