Reported Lifetime Aberrant Drug-Taking Behaviors Are Predictive of Current Substance Use and Mental Health Problems in Primary Care Patients | Pain Medicine

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class="issue">Issue 8</div> </div> <div class="ii-pub-date"> November 2008 </div> </div> </a> </div> </div> <div class="content-nav"> <div class="widget widget-ArticleJumpLinks widget-instance-OUP_ArticleJumpLinks_Widget"> <h3 class="contents-title" >Article Contents</h3> <ul class="jumplink-list js-jumplink-list"> <li class="section-jump-link head-1" link-destination="28607835"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#28607835">ABSTRACT</a> </div> </li> <li class="section-jump-link head-1" link-destination="28607837"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#28607837">Introduction</a> </div> </li> <li class="section-jump-link head-1" link-destination="28607841"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#28607841">Methods</a> </div> </li> <li class="section-jump-link head-1" link-destination="28607853"> <div class="section-jump-link__link-wrap"> <a 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href="#28607887">References</a> </div> </li> </ul> </div> </div> <div class="widget widget-ArticleNavLinks widget-instance-OUP_ArticleNavLinks_Article"> <ul class="inline-list"> <li class="prev arrow"> <a href="/painmedicine/article/9/8/1091/1855565">< Previous</a> </li> <li class="next arrow"> <a href="/painmedicine/article/9/8/1107/1855622">Next ></a> </li> </ul> </div> </div> </div> </div> <div class="sticky-toolbar js-sticky-toolbar"></div> <div id="ContentColumn" class="page-column page-column--center"> <div class="article-browse-top article-browse-mobile-nav js-mobile-nav"> <div class="article-browse-mobile-nav-inner js-mobile-nav-inner"> <button class="toggle-left-col toggle-left-col__article btn-as-link"> Article Navigation </button> </div> </div> <div class="article-browse-top article-browse-mobile-nav mobile-sticky-toolbar js-mobile-nav-sticky"> <div class="article-browse-mobile-nav-inner"> <button class="toggle-left-col toggle-left-col__article btn-as-link"> Article Navigation </button> </div> </div> <div class="content-inner-wrap"> <div class="widget widget-ArticleTopInfo widget-instance-OUP_ArticleTop_Info_Widget"> <div class="module-widget article-top-widget"> <div class="access-state-logos all-viewports"> <span class="journal-info__format-label">Journal Article</span> </div> <div class="widget-items"> <div class="title-wrap"> <h1 class="wi-article-title article-title-main accessible-content-title at-articleTitle"> Reported Lifetime Aberrant Drug-Taking Behaviors Are Predictive of Current Substance Use and Mental Health Problems in Primary Care Patients <i class='icon-availability_free' title='Free' ></i> </h1> </div> <div class="wi-authors at-ArticleAuthors"> <div class="al-authors-list"> <span class="al-author-name-more js-flyout-wrap"> <button type="button" class="linked-name js-linked-name-trigger btn-as-link">Michael F. Fleming, MD</button><span class='delimiter'>, </span> <span class="al-author-info-wrap arrow-up"> <div class="info-card-author authorInfo_OUP_ArticleTop_Info_Widget"> <div class="name-role-wrap"> <div class="info-card-name"> Michael F. Fleming, MD <span class="info-card-footnote"><span class="xrefLink" id="jumplink-cor1"></span><a href="javascript:;" reveal-id="cor1" data-open="cor1" class="link link-ref link-reveal xref-default"></a></span> </div> </div> <div class="info-card-affilitation"> <div class="aff">Departments of Family Medicine</div> </div> <div class="info-author-correspondence"> <div content-id="cor1"><em>Reprint requests to:</em> Michael F. Fleming, MD, MPH, Professor of Family Medicine, 777 South Mills St., Madison, WI 53715, USA. Tel: 608-263-9953; Fax: 313-577-7636; E-mail: <a href="mailto:mfleming@fammed.wisc.edu" target="_blank">mfleming@fammed.wisc.edu</a>.</div> </div> <div class="info-card-search-label"> Search for other works by this author on: </div> <div class="info-card-search info-card-search-internal"> <a href="/painmedicine/search-results?f_Authors=Michael+F.+Fleming" rel="nofollow">Oxford Academic</a> </div> <div class="info-card-search info-card-search-pubmed"> <a href="http://www.ncbi.nlm.nih.gov/pubmed?cmd=search&term=Fleming M">PubMed</a> </div> <div class="info-card-search info-card-search-google"> <a href="http://scholar.google.com/scholar?q=author:%22Fleming Michael F.%22">Google Scholar</a> </div> </div> </span> </span> <span class="al-author-name-more js-flyout-wrap"> <button type="button" class="linked-name js-linked-name-trigger btn-as-link">James Davis, MD</button><span class='delimiter'>, </span> <span class="al-author-info-wrap arrow-up"> <div class="info-card-author authorInfo_OUP_ArticleTop_Info_Widget"> <div class="name-role-wrap"> <div class="info-card-name"> James Davis, MD </div> </div> <div class="info-card-affilitation"> <div class="aff">Internal Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin</div> </div> <div class="info-card-search-label"> Search for other works by this author on: </div> <div class="info-card-search info-card-search-internal"> <a href="/painmedicine/search-results?f_Authors=James+Davis" rel="nofollow">Oxford Academic</a> </div> <div class="info-card-search info-card-search-pubmed"> <a href="http://www.ncbi.nlm.nih.gov/pubmed?cmd=search&term=Davis J">PubMed</a> </div> <div class="info-card-search info-card-search-google"> <a href="http://scholar.google.com/scholar?q=author:%22Davis James%22">Google Scholar</a> </div> </div> </span> </span> <span class="al-author-name-more js-flyout-wrap"> <button type="button" class="linked-name js-linked-name-trigger btn-as-link">Steven D. Passik, PhD</button><span class='delimiter'></span> <span class="al-author-info-wrap arrow-up"> <div class="info-card-author authorInfo_OUP_ArticleTop_Info_Widget"> <div class="name-role-wrap"> <div class="info-card-name"> Steven D. Passik, PhD </div> </div> <div class="info-card-affilitation"> <div class="aff">Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA</div> </div> <div class="info-card-search-label"> Search for other works by this author on: </div> <div class="info-card-search info-card-search-internal"> <a href="/painmedicine/search-results?f_Authors=Steven+D.+Passik" rel="nofollow">Oxford Academic</a> </div> <div class="info-card-search info-card-search-pubmed"> <a href="http://www.ncbi.nlm.nih.gov/pubmed?cmd=search&term=Passik S">PubMed</a> </div> <div class="info-card-search info-card-search-google"> <a href="http://scholar.google.com/scholar?q=author:%22Passik Steven D.%22">Google Scholar</a> </div> </div> </span> </span> </div> </div> <div class="pub-history-wrap clearfix js-history-dropdown-wrap"> <div class="pub-history-row clearfix"> <div class="ww-citation-primary"><em>Pain Medicine</em>, Volume 9, Issue 8, November 2008, Pages 1098–1106, <a href='https://doi.org/10.1111/j.1526-4637.2008.00491.x'>https://doi.org/10.1111/j.1526-4637.2008.00491.x</a></div> </div> <div class="pub-history-row clearfix"> <div class="ww-citation-date-wrap"> <div class="citation-label">Published:</div> <div class="citation-date">19 November 2008</div> </div> </div> </div> </div> </div> <script> $(document).ready(function () { $('.article-top-widget').on('click', '.ati-toggle-trigger', function () { $(this).find('.icon-general-add, .icon-minus').toggleClass('icon-minus icon-general-add'); $(this).siblings('.ati-toggle-content').toggleClass('hide'); }); // In Chrome, an anchor tag with target="_blank" and a "mailto:" href opens a new tab/window as well as the email client // I suspect this behavior will be corrected in the future // Remove the target="_blank" $('ul.wi-affiliationList').find('a[href^="mailto:"]').each(function () { $(this).removeAttr('target'); }); }); </script> </div> <div class="widget widget-ArticleLinks widget-instance-OUP_Article_Links_Widget"> </div> <div class="article-body js-content-body"> <div class="toolbar-wrap js-toolbar-wrap"> <div class="toolbar-inner-wrap"> <ul id="Toolbar" role="navigation"> <li class="toolbar-item item-pdf js-item-pdf "> <a class="al-link pdf article-pdfLink" data-article-id="1855599" href="/painmedicine/article-pdf/9/8/1098/5249487/9-8-1098.pdf"> <img src=//oup.silverchair-cdn.com/UI/app/svg/pdf.svg alt="pdf" /><span class="pdf-link-text">PDF</span> </a> </li> <li class="toolbar-item item-with-dropdown item-views"> <a class="at-views-dropdown drop-trigger" href="javascript:;" data-dropdown="FilterDrop" aria-haspopup="true"> <i class="icon-menu_views"></i> <div class="toolbar-label"> <div class="toolbar-text">Views</div> <i class="icon-general-arrow-filled-down arrow-icon"></i> </div> </a> <ul id="ViewsDrop" class="f-dropdown js-dropdown-content" data-dropdown-content aria-label="submenu"> <div class="arrow-up"></div> <li class="article-content-filter js-article-content-filter" data-content-filter="article-content"> <a href="javascript:;"><span>Article contents</span></a> </li> <li class="at-figures-tables article-content-filter js-article-content-filter" data-content-filter="figures-tables"> <a href="javascript:;"><span>Figures & tables</span></a> </li> <li class="article-content-filter js-article-content-filter" data-content-filter="video"> <a href="javascript:;"><span>Video</span></a> </li> <li class="article-content-filter js-article-content-filter" data-content-filter="audio"> <a href="javascript:;"><span>Audio</span></a> </li> <li class="article-content-filter js-article-content-filter" data-content-filter="supplementary-data"> <a href="javascript:;"><span>Supplementary Data</span></a> </li> </ul> </li> <li class="toolbar-item item-cite js-item-cite"> <div class="widget widget-ToolboxGetCitation widget-instance-OUP_Get_Citation"> <a href="#" class="js-cite-button at-CiteButton" data-reveal-id="getCitation" data-reveal> <i class="icon-read-more"></i> <span>Cite</span> </a> <div id="getCitation" class="reveal-modal js-citation-modal" data-reveal> <h3 class="modal-title">Cite</h3> <div class="oxford-citation-text"> <p>Michael F. Fleming, James Davis, Steven D. Passik, Reported Lifetime Aberrant Drug-Taking Behaviors Are Predictive of Current Substance Use and Mental Health Problems in Primary Care Patients, <em>Pain Medicine</em>, Volume 9, Issue 8, November 2008, Pages 1098–1106, <a href="https://doi.org/10.1111/j.1526-4637.2008.00491.x">https://doi.org/10.1111/j.1526-4637.2008.00491.x</a></p> </div> <div class="citation-download-wrap"> <form action="/Citation/Download" method="get" id="citationModal"> <input type="hidden" name="resourceId" value="1855599" /> <input type="hidden" name="resourceType" value="3" /> <label for="selectFormat" class="hide js-citation-format-label">Select Format</label> <select required name="citationFormat" class="citation-download-format js-citation-format" id="selectFormat"> <option selected disabled >Select format</option> <option value="0" >.ris (Mendeley, Papers, Zotero)</option> <option value="1" >.enw (EndNote)</option> <option value="2" >.bibtex (BibTex)</option> <option value="3" >.txt (Medlars, 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js-advanced-search">Advanced Search</a></div> </div> <div class="navbar-search-collapsed"><a href="javascript:;" class="icon-menu_search js_expand-navsearch"><span class="screenreader-text">Search Menu</span></a></div> </div> </div> <input id="routename" name="RouteName" type="hidden" value="painmedicine" /> </div> </div> </div> </div> <div id="ContentTab" class="content active"> <div class="widget widget-ArticleFulltext widget-instance-OUP_Article_FullText_Widget"> <div class="module-widget"> <div class="widget-items" data-widgetname="ArticleFulltext"> <h2 scrollto-destination=28607835 id="28607835" class="abstract-title js-splitscreen-abstract-title" >ABSTRACT</h2> <section class="abstract"><p class="chapter-para"><strong>Background.</strong> The aim of this report is to determine the frequency of aberrant drug behaviors and their relationship to substance abuse disorders in a large primary sample of patients receiving opioids for chronic pain.</p><p class="chapter-para"><strong>Methods.</strong> The data utilized for this report was obtained from 904 chronic pain patients receiving opioid therapy from their primary care physician. A questionnaire was developed based on 12 aberrant drug behaviors reported in the clinical literature. The diagnosis of a current substance use disorder was determined using <em>Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition</em>(DSM-IV) criteria.</p><p class="chapter-para"><strong>Results.</strong> The average duration of chronic pain in the sample was 16 years and for opioid therapy, 6.4 years. Of the patients, 80.5% reported one or more lifetime aberrant drug behaviors. The most frequent behaviors reported included early refills (41.7%), increase dose without physician consent (35.7%), and felt intoxicated from opioids (32.2%). Only 1.1% of subjects with 1–3 aberrant behaviors (N = 464, 51.2%) met DSM-IV criteria for current opioid dependence compared with 9.9% of patients with four or more behaviors (N = 264, 29.3%). Persons with positive urine toxicology tests for cocaine were 14 times more likely to report four or more behaviors than no behaviors (14.1% vs1.1%). A logistic model found that subjects who reported four or more aberrant behaviors were more likely to have a current substance use disorder (odds ratio [OR] 10.14; 3.72, 27.64), a positive test for cocaine (odds ratio [OR] 3.01; 1.74, 15.4), an Addiction Severity Index (ASI) psychiatric composite score >0.5 (OR 2.38; 1.65, 3.44), male gender (OR 2.08: 1.48, 2.92), and older age (OR 0.69; 0.59, 0.81) compared with subjects with three or fewer behaviors. Pain levels, employment status, and morphine equivalent dose do not enter the model.</p><p class="chapter-para"><strong>Conclusions.</strong> Patients who report four or more aberrant drug behaviors are associated with a current substance use disorder and illicit drug use, whereas subjects with up to three aberrant behaviors have a very low probability of a current substance abuse disorder. Four behaviors—oversedated oneself, felt intoxicated, early refills, increase dose on own—appear useful as screening questions to predict patients at greatest risk for a current substance use disorders.</p></section> <div class="article-metadata-panel clearfix at-ArticleMetadata"></div> <div class="kwd-group"><a class="kwd-part kwd-main" href="javascript:;" data-keyword=""Aberrant Drug Behaviors"">Aberrant Drug Behaviors</a>, <a class="kwd-part kwd-main" href="javascript:;" data-keyword=""Chronic Pain"">Chronic Pain</a>, <a class="kwd-part kwd-main" href="javascript:;" data-keyword="Opioids">Opioids</a>, <a class="kwd-part kwd-main" href="javascript:;" data-keyword=""Primary Care"">Primary Care</a></div> <h2 scrollto-destination=28607837 id="28607837" class="section-title js-splitscreen-section-title" data-legacy-id=ss6>Introduction</h2> <p class="chapter-para">Treating chronic pain is one of the most challenging clinical issues facing primary care physicians <span class="xrefLink" id="jumplink-b1"></span><a href="javascript:;" reveal-id="b1" data-open="b1" class="link link-ref link-reveal xref-bibr">[1]</a>. Over the last decade, daily opioid therapy has become one of the principal treatments for chronic pain <span class="xrefLink" id="jumplink-b2 b3 b4"></span><a href="javascript:;" reveal-id="b2 b3 b4" data-open="b2 b3 b4" class="link link-ref link-reveal xref-bibr">[2–4]</a>. However, the presence of aberrant drug behaviors and concerns related to addiction and diversion often deter physicians from prescribing opioids <span class="xrefLink" id="jumplink-b5 b6 b7"></span><a href="javascript:;" reveal-id="b5 b6 b7" data-open="b5 b6 b7" class="link link-ref link-reveal xref-bibr">[5–7]</a>. “Aberrant drug-taking behavior” refers to a range of anomalous events involving prescribed opioid medication that are suggestive of patient opioid misuse and possibly a substance use disorder <span class="xrefLink" id="jumplink-b8"></span><a href="javascript:;" reveal-id="b8" data-open="b8" class="link link-ref link-reveal xref-bibr">[8]</a>. Specific aberrant drug behaviors reported in the literature include requesting early refills, requesting additional medication from on-call doctors, losing medications, using opioids to change mood, and regularly taking more medication than prescribed <span class="xrefLink" id="jumplink-b9 b10"></span><a href="javascript:;" reveal-id="b9 b10" data-open="b9 b10" class="link link-ref link-reveal xref-bibr">[9,10]</a>. Some authors also include illegal behaviors such as forging scripts and selling prescription opioids <span class="xrefLink" id="jumplink-b11 b12"></span><a href="javascript:;" reveal-id="b11 b12" data-open="b11 b12" class="link link-ref link-reveal xref-bibr">[11,12]</a>. Others include symptoms of addiction such as prior treatment for addiction or positive toxicology tests as aberrant drug-taking behaviors <span class="xrefLink" id="jumplink-b13 b14 b15 b16"></span><a href="javascript:;" reveal-id="b13 b14 b15 b16" data-open="b13 b14 b15 b16" class="link link-ref link-reveal xref-bibr">[13–16]</a>.</p><p class="chapter-para">How should a physician interpret these behaviors? What do they mean? Are these behaviors related to inadequate pain treatment or addiction <span class="xrefLink" id="jumplink-b17"></span><a href="javascript:;" reveal-id="b17" data-open="b17" class="link link-ref link-reveal xref-bibr">[17]</a>? How many of these behaviors are too many? When should the presence of these behaviors trigger a substance abuse assessment, referral to a pain center, or discontinuation of opioid medication? In order to address some of these clinical questions, we present findings of a primary care study designed to assess self-reported lifetime aberrant drug-taking behaviors, current substance use disorders, and other health factors in a sample of 904 patients receiving opioids for chronic pain.</p><p class="chapter-para">Aberrant drug behaviors for this report are limited to “legal” behaviors such as early refills, lost scripts, and other behaviors that are not self-incriminating. It is our experience that patients are reluctant to report illegal behavior to a researcher or a clinician. We elected not to include behaviors directly related to substance use disorders such as prior history of addiction or use of illegal drugs. The primary goal of this report is to assess the clinical utility of 12 aberrant prescription drug-taking behaviors.</p> <h2 scrollto-destination=28607841 id="28607841" class="section-title js-splitscreen-section-title" data-legacy-id=ss7>Methods</h2> <p class="chapter-para">Data used for this analysis were obtained from a chronic pain study conducted from 2002 to 2004 in the practices of 235 primary care physicians located in eight Wisconsin counties <span class="xrefLink" id="jumplink-b18"></span><a href="javascript:;" reveal-id="b18" data-open="b18" class="link link-ref link-reveal xref-bibr">[18]</a>. The final sample (N = 1,009) for the primary study included 801 subjects receiving daily opioid therapy, 115 patients receiving intermittent opioid therapy (20 or fewer days per month), and 93 patients not currently taking opioids. The subjects used for this analysis was limited to the 904 patients taking daily or intermittent opioids in the previous 6 months on whom we had complete data. The sample consisted of 23.1% African Americans, 75.9% Caucasians, and 1% Hispanics. A comparison of the overall sample used for this article revealed no significant differences on background characteristics, with the exception that the mean age of those excluded from the analysis was slightly higher (52.5 years) than those included (48.3 years).</p><p class="chapter-para">Subjects were recruited using clinic logs of patients on opioids, clinic pharmacy record searches, electronic medical record searches, and insurance claim files. Recruitment strategies varied by physician and primary care clinic. We obtained a list of all 465 primary care physicians who were members of the University of Wisconsin Medical Foundation (central Wisconsin), Dean Care (central Wisconsin), and Aurora (eastern Wisconsin). Each physician was contacted by the principal investigator (Fleming) by phone or by a face-to-face meeting. Out of this group, 235 primary care physicians, who were members of 46 group practices, met our criteria for participation. These criteria included the presence of patients receiving opioids for chronic pain in their practice, a system that would allow us to identify all of their patients on opioids, willingness to allow us access to patient records, and assistance in recruiting subjects from their practices. Of the 235 physicians who did meet our criteria, the most common reason for nonparticipation was a lack of interest and time to participate in research.</p><p class="chapter-para">The research team made a concerted effort to enroll 100% of chronic pain patients on opioids who were receiving care from the 235 primary care physicians in the study. Attention to potential selection bias was a high priority to investigators. As a result, the response rate was high, with 78% of potentially eligible subjects participating in the study. On average, each primary physician in the study had 4–5 patients on chronic opioid therapy.</p><p class="chapter-para">Interviews were conducted in primary care clinics and research offices of the principal investigator. Research subjects completed nine written questionnaires and five interview-based surveys. Variables of interest included substance use disorders, pain scales, aberrant behaviors, medical history, quality of life, mental health disorders, adverse effects, health care utilization, and health disparity. A number of articles have already been published or are in press from this data set <span class="xrefLink" id="jumplink-b18 b19 b20 b21"></span><a href="javascript:;" reveal-id="b18 b19 b20 b21" data-open="b18 b19 b20 b21" class="link link-ref link-reveal xref-bibr">[18–21]</a>. The interviews lasted about 2 hours per subject.</p><p class="chapter-para">The 12 aberrant opioid use behavior items were administered as lifetime questions in a standardized format and completed by patients currently undergoing opioid treatment for chronic pain. Each of the 12 questions had five possible responses: 0 (never), 1 (once), 2 (twice), 3 (three times), and 4 (four or more times). The specific questions are listed in <span class="xrefLink" id="jumplink-t1"></span><a href="javascript:;" reveal-id="t1" data-open="t1" class="link link-reveal link-table xref-fig">Table 1</a>.</p> <a id="28607847" scrollto-destination="28607847"></a> <div content-id="t1" class="table-modal table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t1" data-id="t1"><span class="label title-label" id="label-17990">Table 1</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607847" aria-describedby="label-17990"> Open in new tab </a></div><div class="caption caption-id-" id="caption-17990"><p class="chapter-para">Twelve aberrant drug behavior questions used in the study</p></div> </div><div class="table-overflow"><table role="presentation" aria-labelledby="
 label-17990" aria-describedby="
 caption-17990"><tbody><tr><td>Q1.</td><td>How often have you purposely oversedated yourself with your narcotic pain medication?</td></tr><tr><td>Q2.</td><td>Have you ever felt intoxicated from your narcotic pain medication?</td></tr><tr><td>Q3.</td><td>Have you been involved in a motor vehicle or other accident while you were on your narcotic pain medication?</td></tr><tr><td>Q4.</td><td>How often have you requested early renewals of your narcotic pain medication?</td></tr><tr><td>Q5.</td><td>How often have you increased the dose of your narcotic pain medication without doctor authorization?</td></tr><tr><td>Q6.</td><td>How often have you lost or had your narcotic pain medication prescription stolen?</td></tr><tr><td>Q7.</td><td>Have you tried to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q8.</td><td>How often have you been successful in your efforts to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q9.</td><td>How many times have you used your narcotic pain medication for purposes other than prescribed (e.g., to help sleep)?</td></tr><tr><td>Q10.</td><td>How often have you had a drink of alcohol to relieve your pain?</td></tr><tr><td>Q11.</td><td>How often did you miss an appointment with your physician for your pain condition this year?</td></tr><tr><td>Q12.</td><td>Have you ever hoarded narcotic pain medication?</td></tr></tbody></table></div><div class="table-modal"><table><tbody><tr><td>Q1.</td><td>How often have you purposely oversedated yourself with your narcotic pain medication?</td></tr><tr><td>Q2.</td><td>Have you ever felt intoxicated from your narcotic pain medication?</td></tr><tr><td>Q3.</td><td>Have you been involved in a motor vehicle or other accident while you were on your narcotic pain medication?</td></tr><tr><td>Q4.</td><td>How often have you requested early renewals of your narcotic pain medication?</td></tr><tr><td>Q5.</td><td>How often have you increased the dose of your narcotic pain medication without doctor authorization?</td></tr><tr><td>Q6.</td><td>How often have you lost or had your narcotic pain medication prescription stolen?</td></tr><tr><td>Q7.</td><td>Have you tried to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q8.</td><td>How often have you been successful in your efforts to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q9.</td><td>How many times have you used your narcotic pain medication for purposes other than prescribed (e.g., to help sleep)?</td></tr><tr><td>Q10.</td><td>How often have you had a drink of alcohol to relieve your pain?</td></tr><tr><td>Q11.</td><td>How often did you miss an appointment with your physician for your pain condition this year?</td></tr><tr><td>Q12.</td><td>Have you ever hoarded narcotic pain medication?</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t1_note24"></span><div content-id="t1_note24" class="footnote"><span class="fn"><p class="chapter-para">For all 12 questions, subjects were presented with the following response options: never, once, twice, three times, four or more times. During the analysis, these responses were assigned numeric values of 0, 1, 2, 3, and 4, respectively.</p></span></div></div></div></div><div class="table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t1" data-id="t1"><span class="label title-label" id="label-17990">Table 1</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607847" aria-describedby="label-17990"> Open in new tab </a></div><div class="caption caption-id-" id="caption-17990"><p class="chapter-para">Twelve aberrant drug behavior questions used in the study</p></div> </div><div class="table-overflow"><table role="presentation" aria-labelledby="
 label-17990" aria-describedby="
 caption-17990"><tbody><tr><td>Q1.</td><td>How often have you purposely oversedated yourself with your narcotic pain medication?</td></tr><tr><td>Q2.</td><td>Have you ever felt intoxicated from your narcotic pain medication?</td></tr><tr><td>Q3.</td><td>Have you been involved in a motor vehicle or other accident while you were on your narcotic pain medication?</td></tr><tr><td>Q4.</td><td>How often have you requested early renewals of your narcotic pain medication?</td></tr><tr><td>Q5.</td><td>How often have you increased the dose of your narcotic pain medication without doctor authorization?</td></tr><tr><td>Q6.</td><td>How often have you lost or had your narcotic pain medication prescription stolen?</td></tr><tr><td>Q7.</td><td>Have you tried to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q8.</td><td>How often have you been successful in your efforts to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q9.</td><td>How many times have you used your narcotic pain medication for purposes other than prescribed (e.g., to help sleep)?</td></tr><tr><td>Q10.</td><td>How often have you had a drink of alcohol to relieve your pain?</td></tr><tr><td>Q11.</td><td>How often did you miss an appointment with your physician for your pain condition this year?</td></tr><tr><td>Q12.</td><td>Have you ever hoarded narcotic pain medication?</td></tr></tbody></table></div><div class="table-modal"><table><tbody><tr><td>Q1.</td><td>How often have you purposely oversedated yourself with your narcotic pain medication?</td></tr><tr><td>Q2.</td><td>Have you ever felt intoxicated from your narcotic pain medication?</td></tr><tr><td>Q3.</td><td>Have you been involved in a motor vehicle or other accident while you were on your narcotic pain medication?</td></tr><tr><td>Q4.</td><td>How often have you requested early renewals of your narcotic pain medication?</td></tr><tr><td>Q5.</td><td>How often have you increased the dose of your narcotic pain medication without doctor authorization?</td></tr><tr><td>Q6.</td><td>How often have you lost or had your narcotic pain medication prescription stolen?</td></tr><tr><td>Q7.</td><td>Have you tried to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q8.</td><td>How often have you been successful in your efforts to get narcotic pain medication from more than one doctor at a time?</td></tr><tr><td>Q9.</td><td>How many times have you used your narcotic pain medication for purposes other than prescribed (e.g., to help sleep)?</td></tr><tr><td>Q10.</td><td>How often have you had a drink of alcohol to relieve your pain?</td></tr><tr><td>Q11.</td><td>How often did you miss an appointment with your physician for your pain condition this year?</td></tr><tr><td>Q12.</td><td>Have you ever hoarded narcotic pain medication?</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t1_note24"></span><div content-id="t1_note24" class="footnote"><span class="fn"><p class="chapter-para">For all 12 questions, subjects were presented with the following response options: never, once, twice, three times, four or more times. During the analysis, these responses were assigned numeric values of 0, 1, 2, 3, and 4, respectively.</p></span></div></div></div></div><p class="chapter-para">In the logistic regression models, the outcome variable was “presence” or “absence of” an opioid-specific substance use disorder (based on <em>Diagnostic and Statistical Manual of Mental Health Disorders-Fourth Edition</em> (DSM-IV) criteria for abuse or dependence). This diagnosis was determined for each subject during the interview process using the Substance Dependence Severity Scale (SDSS), developed by Drs. Miele and Haskins at the New York Psychiatric Institute with the support of a contract with the National Institute on Drug Abuse <span class="xrefLink" id="jumplink-b22"></span><a href="javascript:;" reveal-id="b22" data-open="b22" class="link link-ref link-reveal xref-bibr">[22]</a>. The SDSS was designed to identify recent (last 30 days) symptoms of abuse or dependence for specific substances, including opioids, based on DSM-IV criteria. It includes a severity of symptoms scale for each DSM-IV criterion, including “absent,” “subthreshold,” “mild,” “moderate,” “severe,” and “extreme.” The test–retest reliability of the scales ranged from good to excellent for alcohol, cocaine, heroin, and cannabis. Internal consistency, diagnostic concordance, and concurrent validity results were comparable to the test–retest findings <span class="xrefLink" id="jumplink-b23 b24"></span><a href="javascript:;" reveal-id="b23 b24" data-open="b23 b24" class="link link-ref link-reveal xref-bibr">[23,24]</a>.</p><p class="chapter-para">The SDSS contains three sections. The first section assesses frequency, quantity, heaviest use, last use, and pattern of use for each of the following drugs: alcohol, cocaine, heroin, cannabis, hallucinogens, sedatives, stimulants, painkillers, methadone, and other illicit drugs. The second section asks seven primary questions designed to detect symptoms of dependence. Each of the seven questions starts with an open-ended question. Depending on the subject's response to this initial question, additional questions are indicated that focus on the extent and severity of symptoms. All seven dependence questions were asked for every drug. The third section of the SDSS focused on DSM-IV criteria for abuse. The interview schedule provided a conservative estimate of substance use disorders.</p><p class="chapter-para">Other instruments used in the study included the Addiction Severity Scale <span class="xrefLink" id="jumplink-b25"></span><a href="javascript:;" reveal-id="b25" data-open="b25" class="link link-ref link-reveal xref-bibr">[25]</a>. This measure assesses seven areas, including alcohol, drugs, employment, legal problems, family and social problems, medical issues, and psychiatric problems <span class="xrefLink" id="jumplink-b26"></span><a href="javascript:;" reveal-id="b26" data-open="b26" class="link link-ref link-reveal xref-bibr">[26]</a>. Results of concurrent reliability studies indicate that trained technicians can estimate the severity of patients' treatment problems with an average concordance of 0.89. Test–retest studies show that the information obtained from the ASI is consistent over a 3-day interval, even with different interviewers. Comparisons of the ASI severity ratings and composite measures with a battery of previously validated tests indicate evidence of concurrent and discriminant validity. The reliability and validity results were consistent across subgroups of patients categorized by age, race, gender, primary drug problem, and treatment center <span class="xrefLink" id="jumplink-b27"></span><a href="javascript:;" reveal-id="b27" data-open="b27" class="link link-ref link-reveal xref-bibr">[27]</a>. The ASI utilizes a composite severity score for each of the seven areas ranging from 0 to 1.0 to assess the severity and extent of problems in each of these areas.</p><p class="chapter-para">We included the ASI psychiatric composite as a measure of mental health problems. The psychiatric composite is derived from questions related to number of mental treatment events, such as number of days hospitalized and intensity of outpatient treatment. The severity scores are relative based on population norms and range from 0 to 1.0. A score of 0.5 indicates moderately severe psychiatric illness. An ASI study conducted in a large primary care sample found an average ASI psych composite score of <0.03. Disability was assessed using the ASI. The ASI inquires about full-time and part-time employment, unemployment, and social security disability. Pain level was assessed using a 10-point Likert scale, with 1 being “almost no pain” and 10 “being worst imaginable pain.” Pain was assessed at its best, worst, and average pain level in the past 6 months. All patients were asked to give a urine toxicology test at the end of the interview. Opioid medications were converted in morphine dose equivalents with the range of opioids in the sample varying from 5 mg/day to 1,040 mg/day. There were more than 50 pain diagnoses reported by patients. The 10 most common pain diagnoses in the sample were osteoarthritis (24.3%), chronic low back pain (18.1), migraine (8.1%), neuropathy not otherwise classified (5.5%), trauma and other injuries (3.9%), fibromyalgia (3.9%), rheumatoid arthritis (3.0%), diabetic neuropathy (3.0%), cervical spine disease (2.9%), and lupus (2.6%).</p><p class="chapter-para">Human Subjects Committees at the University of Wisconsin and at all the participating health centers approved the study. Researchers reviewed all aspects of the consent forms with patients prior to asking patients to sign the human subjects and Health Insurance Privacy and Accountability Act consent forms. Subjects were paid $50 for participating in the 2-hour interview. Transportation vouchers were provided when patients requested assistance. Subjects were assured that none of the information provided would be shared with their physicians or entered into their medical records. A National Institutes of Health certificate of confidentiality was obtained to protect the legal rights of the subjects and investigators.</p> <h2 scrollto-destination=28607853 id="28607853" class="section-title js-splitscreen-section-title" data-legacy-id=ss8>Analysis</h2> <p class="chapter-para">Data analysis was conducted using SPSS 13 software (SPSS Inc., Chicago, IL). Analyses began with examination of general frequency distribution to ensure data quality and to determine the most appropriate techniques for subsequent bivariate models. The data in <span class="xrefLink" id="jumplink-t2"></span><a href="javascript:;" reveal-id="t2" data-open="t2" class="link link-reveal link-table xref-fig">Table 2</a> were designed to describe the sample on the variables of interest for this article. <span class="xrefLink" id="jumplink-t3 t4"></span><a href="javascript:;" reveal-id="t3 t4" data-open="t3 t4" class="link link-reveal link-table xref-fig">Tables 3 and 4</a> report the frequency of the 12 aberrant behaviors in persons with and without a substance abuse diagnosis.</p> <a id="28607855" scrollto-destination="28607855"></a> <div content-id="t2" class="table-modal table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t2" data-id="t2"><span class="label title-label" id="label-17990">Table 2</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607855" aria-describedby="label-17990"> Open in new tab </a></div><div class="caption caption-id-" id="caption-17990"><p class="chapter-para">Profile of subjects (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-17990" aria-describedby="
 caption-17990"><thead><tr><td></td><td colspan="3">Number of Different Aberrant Behaviors<hr /></td></tr><tr><td></td><td>None</td><td>1–3</td><td>4 or more</td></tr></thead><tbody><tr><td></td><td>(N = 176)</td><td char=".">(N = 464)</td><td char=".">(N = 264)</td></tr><tr><td>Male (%)</td><td char=".">27.3</td><td char=".">27.8</td><td char=".">39.4</td></tr><tr><td colspan="4">Age (%)</td></tr><tr><td> 18–30</td><td char=".">3.4</td><td char=".">4.7</td><td char=".">6.4</td></tr><tr><td> 31–50</td><td char=".">34.7</td><td char=".">50.2</td><td char=".">65.9</td></tr><tr><td> >50</td><td char=".">61.9</td><td char=".">45.0</td><td char=".">27.7</td></tr><tr><td colspan="4">Employment (%)</td></tr><tr><td> Full-time work</td><td char=".">37.8</td><td char=".">35.5</td><td char=".">22.3</td></tr><tr><td> Part-time work</td><td char=".">13.3</td><td char=".">9.6</td><td char=".">5.9</td></tr><tr><td> Disabled and unable to work</td><td char=".">13.2</td><td char=".">36.5</td><td char=".">61.4</td></tr><tr><td> Other</td><td char=".">35.6</td><td char=".">18.4</td><td char=".">10.5</td></tr><tr><td colspan="4">Marijuana (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">82.4</td><td char=".">80.8</td><td char=".">69.3</td></tr><tr><td> Positive urine toxicology test</td><td char=".">13.6</td><td char=".">15.9</td><td char=".">28.0</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td colspan="4">Cocaine (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">94.9</td><td char=".">91.6</td><td char=".">82.6</td></tr><tr><td> Positive urine toxicology test</td><td char=".">1.1</td><td char=".">5.2</td><td char=".">14.8</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td>SUD—any (%)</td><td char=".">0.6</td><td char=".">4.7</td><td char=".">24.2</td></tr><tr><td rowspan="2">SUD—opioid only (%)</td><td char=".">0</td><td char=".">1.1</td><td char=".">9.9</td></tr><tr><td>1.1</td><td char=".">9.9</td><td char=".">0</td></tr><tr><td>Pain severity mean 0–10 score</td><td char=".">6.2</td><td char=".">6.4</td><td char=".">6.3</td></tr><tr><td colspan="4">Addiction severity psychiatric composite score (0–1.0)</td></tr><tr><td> Median</td><td char=".">0.09</td><td char=".">0.25</td><td char=".">0.39</td></tr><tr><td> Mean</td><td char=".">0.18</td><td char=".">0.26</td><td char=".">0.34</td></tr><tr><td> SD</td><td char=".">0.20</td><td char=".">0.23</td><td char=".">0.25</td></tr><tr><td> % with composite score >0.49</td><td char=".">9.1</td><td char=".">19.8</td><td char=".">33.7</td></tr><tr><td colspan="4">Opioid medication dose levels (mg) of morphine equivalent doses</td></tr><tr><td> Median</td><td char=".">30.0</td><td char=".">40.0</td><td char=".">40.0</td></tr><tr><td> Mean</td><td char=".">81.7</td><td char=".">91.6</td><td char=".">87.5</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td></td><td colspan="3">Number of Different Aberrant Behaviors<hr /></td></tr><tr><td></td><td>None</td><td>1–3</td><td>4 or more</td></tr></thead><tbody><tr><td></td><td>(N = 176)</td><td char=".">(N = 464)</td><td char=".">(N = 264)</td></tr><tr><td>Male (%)</td><td char=".">27.3</td><td char=".">27.8</td><td char=".">39.4</td></tr><tr><td colspan="4">Age (%)</td></tr><tr><td> 18–30</td><td char=".">3.4</td><td char=".">4.7</td><td char=".">6.4</td></tr><tr><td> 31–50</td><td char=".">34.7</td><td char=".">50.2</td><td char=".">65.9</td></tr><tr><td> >50</td><td char=".">61.9</td><td char=".">45.0</td><td char=".">27.7</td></tr><tr><td colspan="4">Employment (%)</td></tr><tr><td> Full-time work</td><td char=".">37.8</td><td char=".">35.5</td><td char=".">22.3</td></tr><tr><td> Part-time work</td><td char=".">13.3</td><td char=".">9.6</td><td char=".">5.9</td></tr><tr><td> Disabled and unable to work</td><td char=".">13.2</td><td char=".">36.5</td><td char=".">61.4</td></tr><tr><td> Other</td><td char=".">35.6</td><td char=".">18.4</td><td char=".">10.5</td></tr><tr><td colspan="4">Marijuana (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">82.4</td><td char=".">80.8</td><td char=".">69.3</td></tr><tr><td> Positive urine toxicology test</td><td char=".">13.6</td><td char=".">15.9</td><td char=".">28.0</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td colspan="4">Cocaine (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">94.9</td><td char=".">91.6</td><td char=".">82.6</td></tr><tr><td> Positive urine toxicology test</td><td char=".">1.1</td><td char=".">5.2</td><td char=".">14.8</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td>SUD—any (%)</td><td char=".">0.6</td><td char=".">4.7</td><td char=".">24.2</td></tr><tr><td rowspan="2">SUD—opioid only (%)</td><td char=".">0</td><td char=".">1.1</td><td char=".">9.9</td></tr><tr><td>1.1</td><td char=".">9.9</td><td char=".">0</td></tr><tr><td>Pain severity mean 0–10 score</td><td char=".">6.2</td><td char=".">6.4</td><td char=".">6.3</td></tr><tr><td colspan="4">Addiction severity psychiatric composite score (0–1.0)</td></tr><tr><td> Median</td><td char=".">0.09</td><td char=".">0.25</td><td char=".">0.39</td></tr><tr><td> Mean</td><td char=".">0.18</td><td char=".">0.26</td><td char=".">0.34</td></tr><tr><td> SD</td><td char=".">0.20</td><td char=".">0.23</td><td char=".">0.25</td></tr><tr><td> % with composite score >0.49</td><td char=".">9.1</td><td char=".">19.8</td><td char=".">33.7</td></tr><tr><td colspan="4">Opioid medication dose levels (mg) of morphine equivalent doses</td></tr><tr><td> Median</td><td char=".">30.0</td><td char=".">40.0</td><td char=".">40.0</td></tr><tr><td> Mean</td><td char=".">81.7</td><td char=".">91.6</td><td char=".">87.5</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t2_note110"></span><div content-id="t2_note110" class="footnote"><span class="fn"><p class="chapter-para">SUD = substance use disorder; SD = standard deviation.</p></span></div></div></div></div><div class="table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t2" data-id="t2"><span class="label title-label" id="label-17990">Table 2</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607855" aria-describedby="label-17990"> Open in new tab </a></div><div class="caption caption-id-" id="caption-17990"><p class="chapter-para">Profile of subjects (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-17990" aria-describedby="
 caption-17990"><thead><tr><td></td><td colspan="3">Number of Different Aberrant Behaviors<hr /></td></tr><tr><td></td><td>None</td><td>1–3</td><td>4 or more</td></tr></thead><tbody><tr><td></td><td>(N = 176)</td><td char=".">(N = 464)</td><td char=".">(N = 264)</td></tr><tr><td>Male (%)</td><td char=".">27.3</td><td char=".">27.8</td><td char=".">39.4</td></tr><tr><td colspan="4">Age (%)</td></tr><tr><td> 18–30</td><td char=".">3.4</td><td char=".">4.7</td><td char=".">6.4</td></tr><tr><td> 31–50</td><td char=".">34.7</td><td char=".">50.2</td><td char=".">65.9</td></tr><tr><td> >50</td><td char=".">61.9</td><td char=".">45.0</td><td char=".">27.7</td></tr><tr><td colspan="4">Employment (%)</td></tr><tr><td> Full-time work</td><td char=".">37.8</td><td char=".">35.5</td><td char=".">22.3</td></tr><tr><td> Part-time work</td><td char=".">13.3</td><td char=".">9.6</td><td char=".">5.9</td></tr><tr><td> Disabled and unable to work</td><td char=".">13.2</td><td char=".">36.5</td><td char=".">61.4</td></tr><tr><td> Other</td><td char=".">35.6</td><td char=".">18.4</td><td char=".">10.5</td></tr><tr><td colspan="4">Marijuana (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">82.4</td><td char=".">80.8</td><td char=".">69.3</td></tr><tr><td> Positive urine toxicology test</td><td char=".">13.6</td><td char=".">15.9</td><td char=".">28.0</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td colspan="4">Cocaine (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">94.9</td><td char=".">91.6</td><td char=".">82.6</td></tr><tr><td> Positive urine toxicology test</td><td char=".">1.1</td><td char=".">5.2</td><td char=".">14.8</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td>SUD—any (%)</td><td char=".">0.6</td><td char=".">4.7</td><td char=".">24.2</td></tr><tr><td rowspan="2">SUD—opioid only (%)</td><td char=".">0</td><td char=".">1.1</td><td char=".">9.9</td></tr><tr><td>1.1</td><td char=".">9.9</td><td char=".">0</td></tr><tr><td>Pain severity mean 0–10 score</td><td char=".">6.2</td><td char=".">6.4</td><td char=".">6.3</td></tr><tr><td colspan="4">Addiction severity psychiatric composite score (0–1.0)</td></tr><tr><td> Median</td><td char=".">0.09</td><td char=".">0.25</td><td char=".">0.39</td></tr><tr><td> Mean</td><td char=".">0.18</td><td char=".">0.26</td><td char=".">0.34</td></tr><tr><td> SD</td><td char=".">0.20</td><td char=".">0.23</td><td char=".">0.25</td></tr><tr><td> % with composite score >0.49</td><td char=".">9.1</td><td char=".">19.8</td><td char=".">33.7</td></tr><tr><td colspan="4">Opioid medication dose levels (mg) of morphine equivalent doses</td></tr><tr><td> Median</td><td char=".">30.0</td><td char=".">40.0</td><td char=".">40.0</td></tr><tr><td> Mean</td><td char=".">81.7</td><td char=".">91.6</td><td char=".">87.5</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td></td><td colspan="3">Number of Different Aberrant Behaviors<hr /></td></tr><tr><td></td><td>None</td><td>1–3</td><td>4 or more</td></tr></thead><tbody><tr><td></td><td>(N = 176)</td><td char=".">(N = 464)</td><td char=".">(N = 264)</td></tr><tr><td>Male (%)</td><td char=".">27.3</td><td char=".">27.8</td><td char=".">39.4</td></tr><tr><td colspan="4">Age (%)</td></tr><tr><td> 18–30</td><td char=".">3.4</td><td char=".">4.7</td><td char=".">6.4</td></tr><tr><td> 31–50</td><td char=".">34.7</td><td char=".">50.2</td><td char=".">65.9</td></tr><tr><td> >50</td><td char=".">61.9</td><td char=".">45.0</td><td char=".">27.7</td></tr><tr><td colspan="4">Employment (%)</td></tr><tr><td> Full-time work</td><td char=".">37.8</td><td char=".">35.5</td><td char=".">22.3</td></tr><tr><td> Part-time work</td><td char=".">13.3</td><td char=".">9.6</td><td char=".">5.9</td></tr><tr><td> Disabled and unable to work</td><td char=".">13.2</td><td char=".">36.5</td><td char=".">61.4</td></tr><tr><td> Other</td><td char=".">35.6</td><td char=".">18.4</td><td char=".">10.5</td></tr><tr><td colspan="4">Marijuana (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">82.4</td><td char=".">80.8</td><td char=".">69.3</td></tr><tr><td> Positive urine toxicology test</td><td char=".">13.6</td><td char=".">15.9</td><td char=".">28.0</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td colspan="4">Cocaine (%)</td></tr><tr><td> Negative urine toxicology test</td><td char=".">94.9</td><td char=".">91.6</td><td char=".">82.6</td></tr><tr><td> Positive urine toxicology test</td><td char=".">1.1</td><td char=".">5.2</td><td char=".">14.8</td></tr><tr><td> Missing data</td><td char=".">4.0</td><td char=".">3.2</td><td char=".">2.7</td></tr><tr><td>SUD—any (%)</td><td char=".">0.6</td><td char=".">4.7</td><td char=".">24.2</td></tr><tr><td rowspan="2">SUD—opioid only (%)</td><td char=".">0</td><td char=".">1.1</td><td char=".">9.9</td></tr><tr><td>1.1</td><td char=".">9.9</td><td char=".">0</td></tr><tr><td>Pain severity mean 0–10 score</td><td char=".">6.2</td><td char=".">6.4</td><td char=".">6.3</td></tr><tr><td colspan="4">Addiction severity psychiatric composite score (0–1.0)</td></tr><tr><td> Median</td><td char=".">0.09</td><td char=".">0.25</td><td char=".">0.39</td></tr><tr><td> Mean</td><td char=".">0.18</td><td char=".">0.26</td><td char=".">0.34</td></tr><tr><td> SD</td><td char=".">0.20</td><td char=".">0.23</td><td char=".">0.25</td></tr><tr><td> % with composite score >0.49</td><td char=".">9.1</td><td char=".">19.8</td><td char=".">33.7</td></tr><tr><td colspan="4">Opioid medication dose levels (mg) of morphine equivalent doses</td></tr><tr><td> Median</td><td char=".">30.0</td><td char=".">40.0</td><td char=".">40.0</td></tr><tr><td> Mean</td><td char=".">81.7</td><td char=".">91.6</td><td char=".">87.5</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t2_note110"></span><div content-id="t2_note110" class="footnote"><span class="fn"><p class="chapter-para">SUD = substance use disorder; SD = standard deviation.</p></span></div></div></div></div> <a id="28607856" scrollto-destination="28607856"></a> <div content-id="t3" class="table-modal table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t3" data-id="t3"><span class="label title-label" id="label-1628">Table 3</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607856" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Number of lifetime events reported for each aberrant drug behaviors (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td rowspan="2">Aberrant Behavior</td><td colspan="5">Number of Events, N (%)<hr /></td></tr><tr><td>None</td><td>1</td><td>2</td><td>3</td><td>≥4</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>705 (78.0)</td><td> 60 (6.6)</td><td> 49 (5.4)</td><td> 37 (4.1)</td><td> 53 (5.9)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>613 (67.8)</td><td>108 (11.9)</td><td> 63 (7.0)</td><td> 28 (3.1)</td><td> 92 (10.2)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td>838 (92.7)</td><td> 51 (5.6)</td><td> 10 (1.1)</td><td> 4 (0.4)</td><td> 1 (0.1)</td></tr><tr><td> 4. Requested an early refill</td><td>527 (58.3)</td><td>141 (15.6)</td><td>119 (13.2)</td><td> 42 (4.6)</td><td> 75 (8.3)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>581 (64.3)</td><td> 99 (11.0)</td><td> 74 (8.2)</td><td> 43 (4.8)</td><td>107 (11.8)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>664 (73.5)</td><td>151 (16.7)</td><td> 64 (7.1)</td><td> 17 (1.9)</td><td> 8 (0.9)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td>850 (94.0)</td><td> 28 (3.1)</td><td> 12 (1.3)</td><td> 4 (0.4)</td><td> 10 (1.1)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td>847 (93.7)</td><td> 30 (3.3)</td><td> 13 (1.4)</td><td> 5 (0.6)</td><td> 9 (1.0)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>760 (84.1)</td><td> 31 (3.4)</td><td> 48 (5.3)</td><td> 14 (1.5)</td><td> 51 (5.6)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>726 (80.3)</td><td> 26 (2.9)</td><td> 36 (4.0)</td><td> 27 (3.0)</td><td> 89 (9.8)</td></tr><tr><td>11. Missed an appointment for pain condition</td><td>679 (75.1)</td><td> 98 (10.8)</td><td> 71 (7.9)</td><td> 33 (3.7)</td><td> 23 (2.5)</td></tr><tr><td>12. Hoarded opioid medication</td><td>807 (89.3)</td><td> 28 (3.1)</td><td> 18 (2.0)</td><td> 15 (1.7)</td><td> 36 (4.0)</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td rowspan="2">Aberrant Behavior</td><td colspan="5">Number of Events, N (%)<hr /></td></tr><tr><td>None</td><td>1</td><td>2</td><td>3</td><td>≥4</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>705 (78.0)</td><td> 60 (6.6)</td><td> 49 (5.4)</td><td> 37 (4.1)</td><td> 53 (5.9)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>613 (67.8)</td><td>108 (11.9)</td><td> 63 (7.0)</td><td> 28 (3.1)</td><td> 92 (10.2)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td>838 (92.7)</td><td> 51 (5.6)</td><td> 10 (1.1)</td><td> 4 (0.4)</td><td> 1 (0.1)</td></tr><tr><td> 4. Requested an early refill</td><td>527 (58.3)</td><td>141 (15.6)</td><td>119 (13.2)</td><td> 42 (4.6)</td><td> 75 (8.3)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>581 (64.3)</td><td> 99 (11.0)</td><td> 74 (8.2)</td><td> 43 (4.8)</td><td>107 (11.8)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>664 (73.5)</td><td>151 (16.7)</td><td> 64 (7.1)</td><td> 17 (1.9)</td><td> 8 (0.9)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td>850 (94.0)</td><td> 28 (3.1)</td><td> 12 (1.3)</td><td> 4 (0.4)</td><td> 10 (1.1)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td>847 (93.7)</td><td> 30 (3.3)</td><td> 13 (1.4)</td><td> 5 (0.6)</td><td> 9 (1.0)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>760 (84.1)</td><td> 31 (3.4)</td><td> 48 (5.3)</td><td> 14 (1.5)</td><td> 51 (5.6)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>726 (80.3)</td><td> 26 (2.9)</td><td> 36 (4.0)</td><td> 27 (3.0)</td><td> 89 (9.8)</td></tr><tr><td>11. Missed an appointment for pain condition</td><td>679 (75.1)</td><td> 98 (10.8)</td><td> 71 (7.9)</td><td> 33 (3.7)</td><td> 23 (2.5)</td></tr><tr><td>12. Hoarded opioid medication</td><td>807 (89.3)</td><td> 28 (3.1)</td><td> 18 (2.0)</td><td> 15 (1.7)</td><td> 36 (4.0)</td></tr></tbody></table></div></div></div><div class="table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t3" data-id="t3"><span class="label title-label" id="label-1628">Table 3</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607856" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Number of lifetime events reported for each aberrant drug behaviors (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td rowspan="2">Aberrant Behavior</td><td colspan="5">Number of Events, N (%)<hr /></td></tr><tr><td>None</td><td>1</td><td>2</td><td>3</td><td>≥4</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>705 (78.0)</td><td> 60 (6.6)</td><td> 49 (5.4)</td><td> 37 (4.1)</td><td> 53 (5.9)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>613 (67.8)</td><td>108 (11.9)</td><td> 63 (7.0)</td><td> 28 (3.1)</td><td> 92 (10.2)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td>838 (92.7)</td><td> 51 (5.6)</td><td> 10 (1.1)</td><td> 4 (0.4)</td><td> 1 (0.1)</td></tr><tr><td> 4. Requested an early refill</td><td>527 (58.3)</td><td>141 (15.6)</td><td>119 (13.2)</td><td> 42 (4.6)</td><td> 75 (8.3)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>581 (64.3)</td><td> 99 (11.0)</td><td> 74 (8.2)</td><td> 43 (4.8)</td><td>107 (11.8)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>664 (73.5)</td><td>151 (16.7)</td><td> 64 (7.1)</td><td> 17 (1.9)</td><td> 8 (0.9)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td>850 (94.0)</td><td> 28 (3.1)</td><td> 12 (1.3)</td><td> 4 (0.4)</td><td> 10 (1.1)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td>847 (93.7)</td><td> 30 (3.3)</td><td> 13 (1.4)</td><td> 5 (0.6)</td><td> 9 (1.0)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>760 (84.1)</td><td> 31 (3.4)</td><td> 48 (5.3)</td><td> 14 (1.5)</td><td> 51 (5.6)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>726 (80.3)</td><td> 26 (2.9)</td><td> 36 (4.0)</td><td> 27 (3.0)</td><td> 89 (9.8)</td></tr><tr><td>11. Missed an appointment for pain condition</td><td>679 (75.1)</td><td> 98 (10.8)</td><td> 71 (7.9)</td><td> 33 (3.7)</td><td> 23 (2.5)</td></tr><tr><td>12. Hoarded opioid medication</td><td>807 (89.3)</td><td> 28 (3.1)</td><td> 18 (2.0)</td><td> 15 (1.7)</td><td> 36 (4.0)</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td rowspan="2">Aberrant Behavior</td><td colspan="5">Number of Events, N (%)<hr /></td></tr><tr><td>None</td><td>1</td><td>2</td><td>3</td><td>≥4</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>705 (78.0)</td><td> 60 (6.6)</td><td> 49 (5.4)</td><td> 37 (4.1)</td><td> 53 (5.9)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>613 (67.8)</td><td>108 (11.9)</td><td> 63 (7.0)</td><td> 28 (3.1)</td><td> 92 (10.2)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td>838 (92.7)</td><td> 51 (5.6)</td><td> 10 (1.1)</td><td> 4 (0.4)</td><td> 1 (0.1)</td></tr><tr><td> 4. Requested an early refill</td><td>527 (58.3)</td><td>141 (15.6)</td><td>119 (13.2)</td><td> 42 (4.6)</td><td> 75 (8.3)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>581 (64.3)</td><td> 99 (11.0)</td><td> 74 (8.2)</td><td> 43 (4.8)</td><td>107 (11.8)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>664 (73.5)</td><td>151 (16.7)</td><td> 64 (7.1)</td><td> 17 (1.9)</td><td> 8 (0.9)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td>850 (94.0)</td><td> 28 (3.1)</td><td> 12 (1.3)</td><td> 4 (0.4)</td><td> 10 (1.1)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td>847 (93.7)</td><td> 30 (3.3)</td><td> 13 (1.4)</td><td> 5 (0.6)</td><td> 9 (1.0)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>760 (84.1)</td><td> 31 (3.4)</td><td> 48 (5.3)</td><td> 14 (1.5)</td><td> 51 (5.6)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>726 (80.3)</td><td> 26 (2.9)</td><td> 36 (4.0)</td><td> 27 (3.0)</td><td> 89 (9.8)</td></tr><tr><td>11. Missed an appointment for pain condition</td><td>679 (75.1)</td><td> 98 (10.8)</td><td> 71 (7.9)</td><td> 33 (3.7)</td><td> 23 (2.5)</td></tr><tr><td>12. Hoarded opioid medication</td><td>807 (89.3)</td><td> 28 (3.1)</td><td> 18 (2.0)</td><td> 15 (1.7)</td><td> 36 (4.0)</td></tr></tbody></table></div></div></div> <a id="28607857" scrollto-destination="28607857"></a> <div content-id="t4" class="table-modal table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t4" data-id="t4"><span class="label title-label" id="label-1628">Table 4</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607857" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Any reported incidence of lifetime aberrant drug behavior by presence or absence of a substance or opioid use disorder (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td>Aberrant Drug Behavior</td><td>No SUD (N = 817) %</td><td>Any SUD (N = 87) % (Spearman's correlation)</td><td>Opioid SUD (N = 31) % (Spearman's correlation)</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>18.0</td><td>59.8 (0.32)</td><td>77.4 (0.29)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>29.3</td><td>59.8 (0.21)</td><td>77.4 (0.22)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td> 6.7</td><td>12.6 (0.07)</td><td> 9.7 (0.02)</td></tr><tr><td> 4. Requested an early refill</td><td>38.9</td><td>67.8 (0.19)</td><td>77.4 (0.16)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>31.8</td><td>72.4 (0.28)</td><td>87.1 (0.24)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>24.8</td><td>42.5 (0.12)</td><td>38.7 (0.05)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td> 4.7</td><td>18.4 (0.17)</td><td>29.0 (0.18)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td> 5.0</td><td>18.4 (0.16)</td><td>29.0 (0.18)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>13.0</td><td>43.7 (0.26)</td><td>61.3 (0.24)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>16.3</td><td>51.7 (027)</td><td>32.3 (0.07)</td></tr><tr><td>11. Missed an appointment for pain treatment</td><td>23.7</td><td>35.6 (0.08)</td><td>35.5 (0.04)</td></tr><tr><td>12. Hoarded opioid medication</td><td> 9.9</td><td>18.4 (0.08)</td><td>19.4 (0.04)</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td>Aberrant Drug Behavior</td><td>No SUD (N = 817) %</td><td>Any SUD (N = 87) % (Spearman's correlation)</td><td>Opioid SUD (N = 31) % (Spearman's correlation)</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>18.0</td><td>59.8 (0.32)</td><td>77.4 (0.29)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>29.3</td><td>59.8 (0.21)</td><td>77.4 (0.22)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td> 6.7</td><td>12.6 (0.07)</td><td> 9.7 (0.02)</td></tr><tr><td> 4. Requested an early refill</td><td>38.9</td><td>67.8 (0.19)</td><td>77.4 (0.16)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>31.8</td><td>72.4 (0.28)</td><td>87.1 (0.24)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>24.8</td><td>42.5 (0.12)</td><td>38.7 (0.05)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td> 4.7</td><td>18.4 (0.17)</td><td>29.0 (0.18)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td> 5.0</td><td>18.4 (0.16)</td><td>29.0 (0.18)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>13.0</td><td>43.7 (0.26)</td><td>61.3 (0.24)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>16.3</td><td>51.7 (027)</td><td>32.3 (0.07)</td></tr><tr><td>11. Missed an appointment for pain treatment</td><td>23.7</td><td>35.6 (0.08)</td><td>35.5 (0.04)</td></tr><tr><td>12. Hoarded opioid medication</td><td> 9.9</td><td>18.4 (0.08)</td><td>19.4 (0.04)</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t4_note52"></span><div content-id="t4_note52" class="footnote"><span class="fn"><p class="chapter-para">Pearson's correlation coefficient was calculated between each aberrant drug behavior (0–4 Likert scale) with any SUD (0,1) and any opioid SUD (0,1).</p></span></div><span id="fn-t4_note53"></span><div content-id="t4_note53" class="footnote"><span class="fn"><p class="chapter-para">SUD = substance use disorder.</p></span></div></div></div></div><div class="table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t4" data-id="t4"><span class="label title-label" id="label-1628">Table 4</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607857" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Any reported incidence of lifetime aberrant drug behavior by presence or absence of a substance or opioid use disorder (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td>Aberrant Drug Behavior</td><td>No SUD (N = 817) %</td><td>Any SUD (N = 87) % (Spearman's correlation)</td><td>Opioid SUD (N = 31) % (Spearman's correlation)</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>18.0</td><td>59.8 (0.32)</td><td>77.4 (0.29)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>29.3</td><td>59.8 (0.21)</td><td>77.4 (0.22)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td> 6.7</td><td>12.6 (0.07)</td><td> 9.7 (0.02)</td></tr><tr><td> 4. Requested an early refill</td><td>38.9</td><td>67.8 (0.19)</td><td>77.4 (0.16)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>31.8</td><td>72.4 (0.28)</td><td>87.1 (0.24)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>24.8</td><td>42.5 (0.12)</td><td>38.7 (0.05)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td> 4.7</td><td>18.4 (0.17)</td><td>29.0 (0.18)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td> 5.0</td><td>18.4 (0.16)</td><td>29.0 (0.18)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>13.0</td><td>43.7 (0.26)</td><td>61.3 (0.24)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>16.3</td><td>51.7 (027)</td><td>32.3 (0.07)</td></tr><tr><td>11. Missed an appointment for pain treatment</td><td>23.7</td><td>35.6 (0.08)</td><td>35.5 (0.04)</td></tr><tr><td>12. Hoarded opioid medication</td><td> 9.9</td><td>18.4 (0.08)</td><td>19.4 (0.04)</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td>Aberrant Drug Behavior</td><td>No SUD (N = 817) %</td><td>Any SUD (N = 87) % (Spearman's correlation)</td><td>Opioid SUD (N = 31) % (Spearman's correlation)</td></tr></thead><tbody><tr><td> 1. Purposely oversedated yourself with opioids</td><td>18.0</td><td>59.8 (0.32)</td><td>77.4 (0.29)</td></tr><tr><td> 2. Felt intoxicated from opioids</td><td>29.3</td><td>59.8 (0.21)</td><td>77.4 (0.22)</td></tr><tr><td> 3. Motor vehicle accident while taking opioids</td><td> 6.7</td><td>12.6 (0.07)</td><td> 9.7 (0.02)</td></tr><tr><td> 4. Requested an early refill</td><td>38.9</td><td>67.8 (0.19)</td><td>77.4 (0.16)</td></tr><tr><td> 5. Increased opioid without physician consent</td><td>31.8</td><td>72.4 (0.28)</td><td>87.1 (0.24)</td></tr><tr><td> 6. Lost or had opioids stolen</td><td>24.8</td><td>42.5 (0.12)</td><td>38.7 (0.05)</td></tr><tr><td> 7. Tried to obtain opioids from more than one clinician</td><td> 4.7</td><td>18.4 (0.17)</td><td>29.0 (0.18)</td></tr><tr><td> 8. Successfully obtained opioids from more than one clinician</td><td> 5.0</td><td>18.4 (0.16)</td><td>29.0 (0.18)</td></tr><tr><td> 9. Used opioids for other purposes besides pain</td><td>13.0</td><td>43.7 (0.26)</td><td>61.3 (0.24)</td></tr><tr><td>10. Used alcohol to deal with pain</td><td>16.3</td><td>51.7 (027)</td><td>32.3 (0.07)</td></tr><tr><td>11. Missed an appointment for pain treatment</td><td>23.7</td><td>35.6 (0.08)</td><td>35.5 (0.04)</td></tr><tr><td>12. Hoarded opioid medication</td><td> 9.9</td><td>18.4 (0.08)</td><td>19.4 (0.04)</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t4_note52"></span><div content-id="t4_note52" class="footnote"><span class="fn"><p class="chapter-para">Pearson's correlation coefficient was calculated between each aberrant drug behavior (0–4 Likert scale) with any SUD (0,1) and any opioid SUD (0,1).</p></span></div><span id="fn-t4_note53"></span><div content-id="t4_note53" class="footnote"><span class="fn"><p class="chapter-para">SUD = substance use disorder.</p></span></div></div></div></div><p class="chapter-para"><span class="xrefLink" id="jumplink-t5"></span><a href="javascript:;" reveal-id="t5" data-open="t5" class="link link-reveal link-table xref-fig">Table 5</a> reports the result of a logistic regression modeling. This model was used to assess the relationship of a number of potential explanatory variables in predicting the number of aberrant behaviors. Independent variables selected for inclusion in the model included current DSM-IV substance use disorder, toxicology testing for marijuana or cocaine, average pain level in the past month, psychiatric severity based on the ASI, opioid dose, employment status, gender, and age. Each of these variables was selected a priori based on previous research conducted by the principal investigator and other investigators. All the variables listed above were included in one model.</p> <a id="28607859" scrollto-destination="28607859"></a> <div content-id="t5" class="table-modal table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t5" data-id="t5"><span class="label title-label" id="label-1628">Table 5</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607859" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Logistic regression model predicting incidence of four or more different lifetime aberrant behavior on the basis of selected covariates (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td></td><td rowspan="2">N</td><td rowspan="2">OR</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td></tr><tr><td></td><td>Lower</td><td>Upper</td></tr></thead><tbody><tr><td>Substance use disorder (opioid)</td><td> 31</td><td>10.14</td><td>3.72</td><td>27.64</td><td><0.001</td></tr><tr><td>Positive cannabis toxicology screen</td><td>172</td><td> 1.52</td><td>1.03</td><td> 2.23</td><td> 0.034</td></tr><tr><td>Positive cocaine toxicology screen</td><td> 65</td><td> 3.06</td><td>1.74</td><td> 5.40</td><td><0.001</td></tr><tr><td>0–20 morphine equivalents vs ≥100</td><td>320</td><td> 0.91</td><td>0.60</td><td> 1.38</td><td> 0.662</td></tr><tr><td>21–99 morphine equivalents vs ≥100</td><td>332</td><td> 1.31</td><td>0.87</td><td> 1.95</td><td> 0.193</td></tr><tr><td>ASI Psych ≥ 0.50 vs <0.50</td><td>191</td><td> 2.38</td><td>1.65</td><td> 3.44</td><td><0.001</td></tr><tr><td>Pain severity ≥ 6.4 vs <6.4<span class="xrefLink" id="jumplink-t5n1"></span><a href="javascript:;" reveal-id="t5n1" data-open="t5n1" class="link link-ref link-reveal xref-fn js-xref-fn">*</a></td><td>204</td><td> 1.4</td><td>1.1</td><td> 1.6</td><td> 0.234</td></tr><tr><td>Male vs female</td><td>272</td><td> 2.08</td><td>1.48</td><td> 2.91</td><td><0.001</td></tr><tr><td>Each additional 10 years of age</td><td></td><td> 0.69</td><td>0.59</td><td> 0.81</td><td><0.001</td></tr><tr><td>Disability<span class="xrefLink" id="jumplink-t5n2"></span><a href="javascript:;" reveal-id="t5n2" data-open="t5n2" class="link link-ref link-reveal xref-fn js-xref-fn">**</a></td><td>415</td><td> 2.23</td><td>1.85</td><td> 4.1</td><td><0.01</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td></td><td rowspan="2">N</td><td rowspan="2">OR</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td></tr><tr><td></td><td>Lower</td><td>Upper</td></tr></thead><tbody><tr><td>Substance use disorder (opioid)</td><td> 31</td><td>10.14</td><td>3.72</td><td>27.64</td><td><0.001</td></tr><tr><td>Positive cannabis toxicology screen</td><td>172</td><td> 1.52</td><td>1.03</td><td> 2.23</td><td> 0.034</td></tr><tr><td>Positive cocaine toxicology screen</td><td> 65</td><td> 3.06</td><td>1.74</td><td> 5.40</td><td><0.001</td></tr><tr><td>0–20 morphine equivalents vs ≥100</td><td>320</td><td> 0.91</td><td>0.60</td><td> 1.38</td><td> 0.662</td></tr><tr><td>21–99 morphine equivalents vs ≥100</td><td>332</td><td> 1.31</td><td>0.87</td><td> 1.95</td><td> 0.193</td></tr><tr><td>ASI Psych ≥ 0.50 vs <0.50</td><td>191</td><td> 2.38</td><td>1.65</td><td> 3.44</td><td><0.001</td></tr><tr><td>Pain severity ≥ 6.4 vs <6.4<span class="xrefLink" id="jumplink-t5n1"></span><a href="javascript:;" reveal-id="t5n1" data-open="t5n1" class="link link-ref link-reveal xref-fn js-xref-fn">*</a></td><td>204</td><td> 1.4</td><td>1.1</td><td> 1.6</td><td> 0.234</td></tr><tr><td>Male vs female</td><td>272</td><td> 2.08</td><td>1.48</td><td> 2.91</td><td><0.001</td></tr><tr><td>Each additional 10 years of age</td><td></td><td> 0.69</td><td>0.59</td><td> 0.81</td><td><0.001</td></tr><tr><td>Disability<span class="xrefLink" id="jumplink-t5n2"></span><a href="javascript:;" reveal-id="t5n2" data-open="t5n2" class="link link-ref link-reveal xref-fn js-xref-fn">**</a></td><td>415</td><td> 2.23</td><td>1.85</td><td> 4.1</td><td><0.01</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t5n1"></span><div content-id="t5n1" class="footnote"><span class="fn"><span class="label fn-label"><span rel="nofollow" data-fn-id="t5n1" class="end-note-link">*</span></span><p class="chapter-para">Pain severity was assessed on a 1–10 scale of average daily pain in the past months.</p></span></div><span id="fn-t5n2"></span><div content-id="t5n2" class="footnote"><span class="fn"><span class="label fn-label"><span rel="nofollow" data-fn-id="t5n2" class="end-note-link">**</span></span><p class="chapter-para">Disability was defined as the presence or absence of social security disability (0,1). ASI = Addiction Severity Index; CI = confidence interval; OR = odds ratio.</p></span></div></div></div></div><div class="table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t5" data-id="t5"><span class="label title-label" id="label-1628">Table 5</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607859" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Logistic regression model predicting incidence of four or more different lifetime aberrant behavior on the basis of selected covariates (N = 904)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td></td><td rowspan="2">N</td><td rowspan="2">OR</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td></tr><tr><td></td><td>Lower</td><td>Upper</td></tr></thead><tbody><tr><td>Substance use disorder (opioid)</td><td> 31</td><td>10.14</td><td>3.72</td><td>27.64</td><td><0.001</td></tr><tr><td>Positive cannabis toxicology screen</td><td>172</td><td> 1.52</td><td>1.03</td><td> 2.23</td><td> 0.034</td></tr><tr><td>Positive cocaine toxicology screen</td><td> 65</td><td> 3.06</td><td>1.74</td><td> 5.40</td><td><0.001</td></tr><tr><td>0–20 morphine equivalents vs ≥100</td><td>320</td><td> 0.91</td><td>0.60</td><td> 1.38</td><td> 0.662</td></tr><tr><td>21–99 morphine equivalents vs ≥100</td><td>332</td><td> 1.31</td><td>0.87</td><td> 1.95</td><td> 0.193</td></tr><tr><td>ASI Psych ≥ 0.50 vs <0.50</td><td>191</td><td> 2.38</td><td>1.65</td><td> 3.44</td><td><0.001</td></tr><tr><td>Pain severity ≥ 6.4 vs <6.4<span class="xrefLink" id="jumplink-t5n1"></span><a href="javascript:;" reveal-id="t5n1" data-open="t5n1" class="link link-ref link-reveal xref-fn js-xref-fn">*</a></td><td>204</td><td> 1.4</td><td>1.1</td><td> 1.6</td><td> 0.234</td></tr><tr><td>Male vs female</td><td>272</td><td> 2.08</td><td>1.48</td><td> 2.91</td><td><0.001</td></tr><tr><td>Each additional 10 years of age</td><td></td><td> 0.69</td><td>0.59</td><td> 0.81</td><td><0.001</td></tr><tr><td>Disability<span class="xrefLink" id="jumplink-t5n2"></span><a href="javascript:;" reveal-id="t5n2" data-open="t5n2" class="link link-ref link-reveal xref-fn js-xref-fn">**</a></td><td>415</td><td> 2.23</td><td>1.85</td><td> 4.1</td><td><0.01</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td></td><td rowspan="2">N</td><td rowspan="2">OR</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td></tr><tr><td></td><td>Lower</td><td>Upper</td></tr></thead><tbody><tr><td>Substance use disorder (opioid)</td><td> 31</td><td>10.14</td><td>3.72</td><td>27.64</td><td><0.001</td></tr><tr><td>Positive cannabis toxicology screen</td><td>172</td><td> 1.52</td><td>1.03</td><td> 2.23</td><td> 0.034</td></tr><tr><td>Positive cocaine toxicology screen</td><td> 65</td><td> 3.06</td><td>1.74</td><td> 5.40</td><td><0.001</td></tr><tr><td>0–20 morphine equivalents vs ≥100</td><td>320</td><td> 0.91</td><td>0.60</td><td> 1.38</td><td> 0.662</td></tr><tr><td>21–99 morphine equivalents vs ≥100</td><td>332</td><td> 1.31</td><td>0.87</td><td> 1.95</td><td> 0.193</td></tr><tr><td>ASI Psych ≥ 0.50 vs <0.50</td><td>191</td><td> 2.38</td><td>1.65</td><td> 3.44</td><td><0.001</td></tr><tr><td>Pain severity ≥ 6.4 vs <6.4<span class="xrefLink" id="jumplink-t5n1"></span><a href="javascript:;" reveal-id="t5n1" data-open="t5n1" class="link link-ref link-reveal xref-fn js-xref-fn">*</a></td><td>204</td><td> 1.4</td><td>1.1</td><td> 1.6</td><td> 0.234</td></tr><tr><td>Male vs female</td><td>272</td><td> 2.08</td><td>1.48</td><td> 2.91</td><td><0.001</td></tr><tr><td>Each additional 10 years of age</td><td></td><td> 0.69</td><td>0.59</td><td> 0.81</td><td><0.001</td></tr><tr><td>Disability<span class="xrefLink" id="jumplink-t5n2"></span><a href="javascript:;" reveal-id="t5n2" data-open="t5n2" class="link link-ref link-reveal xref-fn js-xref-fn">**</a></td><td>415</td><td> 2.23</td><td>1.85</td><td> 4.1</td><td><0.01</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t5n1"></span><div content-id="t5n1" class="footnote"><span class="fn"><span class="label fn-label"><span rel="nofollow" data-fn-id="t5n1" class="end-note-link">*</span></span><p class="chapter-para">Pain severity was assessed on a 1–10 scale of average daily pain in the past months.</p></span></div><span id="fn-t5n2"></span><div content-id="t5n2" class="footnote"><span class="fn"><span class="label fn-label"><span rel="nofollow" data-fn-id="t5n2" class="end-note-link">**</span></span><p class="chapter-para">Disability was defined as the presence or absence of social security disability (0,1). ASI = Addiction Severity Index; CI = confidence interval; OR = odds ratio.</p></span></div></div></div></div><p class="chapter-para">The third part of the analysis utilized receiver operating curves to assess the sensitivity and specificity of aberrant behavior patterns in predicting a substance use disorder diagnosis. Whereas aberrant behavior was the dependent variable in the regression analysis, it serves as a predictor in the receiver operating characteristic curve analysis. The R value represents the area under the curve with an R value of 1.0 representing a 100% sensitivity and specificity and a value of 0.5 representing no relationship between aberrant behaviors and a substance abuse diagnosis. Likelihood ratios were not calculated due to the small sample size (i.e., there were only 31 patients who met the criteria for current substance dependence).</p> <h2 scrollto-destination=28607861 id="28607861" class="section-title js-splitscreen-section-title" data-legacy-id=ss9>Results</h2> <p class="chapter-para"><span class="xrefLink" id="jumplink-t2"></span><a href="javascript:;" reveal-id="t2" data-open="t2" class="link link-reveal link-table xref-fig">Table 2</a> presents a profile of the sample based on the number of aberrant drug behaviors reported by the 904 patients included in this analysis. We divided the sample into three groups. There were 176 (19.5%) subjects who reported no behaviors, 464 (51.2%) reported 1–3 different behaviors, and 264 (29.3%) reported four or more (maximum of 12). The table suggests minimal difference in reported behaviors by gender. Subjects >50 years of age were least likely to report aberrant behaviors (61.9%) and persons aged 31–50 years were most likely to report four or more behaviors (65.9%).</p><p class="chapter-para">One of the most interesting findings in <span class="xrefLink" id="jumplink-t2"></span><a href="javascript:;" reveal-id="t2" data-open="t2" class="link link-reveal link-table xref-fig">Table 2</a> is that not one subject who reported zero aberrant behaviors met criteria for an opioid use disorder. The frequency of any substance abuse disorder in the no aberrant behavior group was 0.6% compared with 24.2% in the four or more aberrant group. Persons with positive urine toxicology tests for cocaine were 14 times more likely to report four or more behaviors than no behaviors (14.1% vs 1.1%).</p><p class="chapter-para">Subjects with four or more behaviors were three times more likely to have an ASI psychiatric composite score of >0.49 (33.7% vs 9.1%). There were no apparent differences in the frequency of behaviors by opioid dose, with the mean and median dose of opioids similar in the three groups. Pain levels were similar across all three groups.</p><p class="chapter-para"><span class="xrefLink" id="jumplink-t3"></span><a href="javascript:;" reveal-id="t3" data-open="t3" class="link link-reveal link-table xref-fig">Table 3</a> reports the number of subjects who reported any of the 12 behaviors. As one can see, 77.4% of subjects who met DSM-IV criteria for an opioid use disorder endorsed the question “purposely over-sedating yourself with opioids,” compared with 18% of subjects who did not meet DSM-IV criteria. Question 2, “felt intoxicated from opioids,” found a similar difference in the frequency of this behavior (77.4% vs 29.3%). Question 4, early refills (77.4% vs 38.9%), and Question 5, increased dose without physician supervision (87.1% vs 31.8%), were also more likely to be reported by the opioid use disorder group. There were more limited differences between substance use disorders groups for Question 3, “motor vehicle accident while taking opioids”; Question 6, “had opioids lost or stolen”; Question 11, “missed an appointment”; and Question 12, “hoarded pain medication.”<span class="xrefLink" id="jumplink-t3"></span><a href="javascript:;" reveal-id="t3" data-open="t3" class="link link-reveal link-table xref-fig">Table 3</a> suggests some aberrant behaviors are more closely related to substance use disorders than others.</p><p class="chapter-para"><span class="xrefLink" id="jumplink-t4"></span><a href="javascript:;" reveal-id="t4" data-open="t4" class="link link-reveal link-table xref-fig">Table 4</a> lists the number of times subjects reported the 12 aberrant behaviors during their lifetime. There was great variability in the number of occurrences reported for each of these behaviors. For example, the frequency subjects reported of a particular behavior was similar across the response categories, whereas for other questions the frequency increased or decreased. For example, for Question 1 (“purposely over-sedating oneself”), subjects reported a similar frequency across all four categories—6.6%, 5.4%, 4.1%, and 5.9%. For Question 6 (“lost or stolen opioids”), the frequency decreased from 16.7% for a one-time occurrence to 0.9% for four or more times. Question 10 went the opposite direction, with only 2.9% reporting the use of alcohol to treat pain once and 9.8% reporting alcohol use four or more times.</p><p class="chapter-para"><span class="xrefLink" id="jumplink-t5"></span><a href="javascript:;" reveal-id="t5" data-open="t5" class="link link-reveal link-table xref-fig">Table 5</a> is a logistic model based on the frequency of aberrant behaviors. For the dependent variable, the12 behaviors were dichotomized into “0–3 behaviors” vs “four or more.” Five variables were strongly associated with four or more behaviors and four were not. The strongest predictor were subjects who met DSM-IV criteria for opioid use disorder (OR 10.08, 3.70, 27.47). Surprisingly, low dose opioids (<20 mg/day) were no more likely to predict aberrant behaviors than high dose use (>100 mg/day). In addition, there was no apparent relationship between pain severity and these behaviors.</p><p class="chapter-para"><span class="xrefLink" id="jumplink-t6"></span><a href="javascript:;" reveal-id="t6" data-open="t6" class="link link-reveal link-table xref-fig">Table 6</a> illustrates the sensitivity and specificity of the behaviors using three different clusters of behaviors. First, we elected to assess the predictive value of the individual 12 questions (see <span class="xrefLink" id="jumplink-t1"></span><a href="javascript:;" reveal-id="t1" data-open="t1" class="link link-reveal link-table xref-fig">Table 1</a>). Second, we assessed the values of using a 0–4 scale for each of the 12 behaviors or total possible score ranging from 0 to 48 (0 = never, 1 = once, 2 = twice, 3 = three times, 4 = four or more times). Third, we selected four (purposely oversedated oneself, felt intoxicated, early refills, increase dose on own) of the 12 behaviors for inclusion as a brief screening tool and assessed the sensitivity and specificity of these four questions using a scale of 0–4 for each question for a total possible score of 0–16.</p> <a id="28607869" scrollto-destination="28607869"></a> <div content-id="t6" class="table-modal table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t6" data-id="t6"><span class="label title-label" id="label-1628">Table 6</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607869" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Receiver operating characteristic analysis comparison of predictors for substance use disorder (opioid)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td></td><td rowspan="2">Area Under Curve</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td><td colspan="3">Optimal<hr /></td></tr><tr><td></td><td>Lower</td><td>Upper</td><td>Cutoff</td><td>Sensitivity</td><td>Specificity</td></tr></thead><tbody><tr><td>N Behaviors (0–12)</td><td>0.87</td><td>0.82</td><td>0.93</td><td><0.001</td><td>4+</td><td>0.839</td><td>0.726</td></tr><tr><td>12-item index (0–48)</td><td>0.90</td><td>0.86</td><td>0.95</td><td><0.001</td><td>9+</td><td>0.935</td><td>0.784</td></tr><tr><td>4-item index (0–16)</td><td>0.93</td><td>0.90</td><td>0.97</td><td><0.001</td><td>6+</td><td>0.903</td><td>0.864</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td></td><td rowspan="2">Area Under Curve</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td><td colspan="3">Optimal<hr /></td></tr><tr><td></td><td>Lower</td><td>Upper</td><td>Cutoff</td><td>Sensitivity</td><td>Specificity</td></tr></thead><tbody><tr><td>N Behaviors (0–12)</td><td>0.87</td><td>0.82</td><td>0.93</td><td><0.001</td><td>4+</td><td>0.839</td><td>0.726</td></tr><tr><td>12-item index (0–48)</td><td>0.90</td><td>0.86</td><td>0.95</td><td><0.001</td><td>9+</td><td>0.935</td><td>0.784</td></tr><tr><td>4-item index (0–16)</td><td>0.93</td><td>0.90</td><td>0.97</td><td><0.001</td><td>6+</td><td>0.903</td><td>0.864</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t6_note34"></span><div content-id="t6_note34" class="footnote"><span class="fn"><p class="chapter-para">CI = confidence interval.</p></span></div></div></div></div><div class="table-full-width-wrap"><div class="table-wrap table-wide standard-table"><div class="table-wrap-title" id="t6" data-id="t6"><span class="label title-label" id="label-1628">Table 6</span><div class="
 graphic-wrap table-open-button-wrap
 "><a class="fig-view-orig at-tableViewLarge openInAnotherWindow btn js-view-large" role="button" target="_blank" href="
 /view-large/28607869" aria-describedby="label-1628"> Open in new tab </a></div><div class="caption caption-id-" id="caption-1628"><p class="chapter-para">Receiver operating characteristic analysis comparison of predictors for substance use disorder (opioid)</p></div> </div><div class="table-overflow"><table role="table" aria-labelledby="
 label-1628" aria-describedby="
 caption-1628"><thead><tr><td></td><td rowspan="2">Area Under Curve</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td><td colspan="3">Optimal<hr /></td></tr><tr><td></td><td>Lower</td><td>Upper</td><td>Cutoff</td><td>Sensitivity</td><td>Specificity</td></tr></thead><tbody><tr><td>N Behaviors (0–12)</td><td>0.87</td><td>0.82</td><td>0.93</td><td><0.001</td><td>4+</td><td>0.839</td><td>0.726</td></tr><tr><td>12-item index (0–48)</td><td>0.90</td><td>0.86</td><td>0.95</td><td><0.001</td><td>9+</td><td>0.935</td><td>0.784</td></tr><tr><td>4-item index (0–16)</td><td>0.93</td><td>0.90</td><td>0.97</td><td><0.001</td><td>6+</td><td>0.903</td><td>0.864</td></tr></tbody></table></div><div class="table-modal"><table><thead><tr><td></td><td rowspan="2">Area Under Curve</td><td colspan="2">95% CI<hr /></td><td rowspan="2"><em>P</em></td><td colspan="3">Optimal<hr /></td></tr><tr><td></td><td>Lower</td><td>Upper</td><td>Cutoff</td><td>Sensitivity</td><td>Specificity</td></tr></thead><tbody><tr><td>N Behaviors (0–12)</td><td>0.87</td><td>0.82</td><td>0.93</td><td><0.001</td><td>4+</td><td>0.839</td><td>0.726</td></tr><tr><td>12-item index (0–48)</td><td>0.90</td><td>0.86</td><td>0.95</td><td><0.001</td><td>9+</td><td>0.935</td><td>0.784</td></tr><tr><td>4-item index (0–16)</td><td>0.93</td><td>0.90</td><td>0.97</td><td><0.001</td><td>6+</td><td>0.903</td><td>0.864</td></tr></tbody></table></div><div class="table-wrap-foot"><span id="fn-t6_note34"></span><div content-id="t6_note34" class="footnote"><span class="fn"><p class="chapter-para">CI = confidence interval.</p></span></div></div></div></div><p class="chapter-para">Cronbach's alphas for the four and 12 item scales were calculated. For the four-item scale, the Cronbach's alpha was 0.663 and for the 12-item scale, the alpha was 0.704.</p><p class="chapter-para">As presented in <span class="xrefLink" id="jumplink-t6"></span><a href="javascript:;" reveal-id="t6" data-open="t6" class="link link-reveal link-table xref-fig">Table 6</a>, all three scales appear to have clinical value. The R values in <span class="xrefLink" id="jumplink-t6"></span><a href="javascript:;" reveal-id="t6" data-open="t6" class="link link-reveal link-table xref-fig">Table 6</a> range from 0.87 to 0.903. For the 12-behavior scale, four or more positive responses have the highest sensitivity and specificity values of 0.84 and 0.72. For the 48-point scale, which utilizes all 12 behaviors, a score of nine has a sensitivity of 0.93 and specificity of 0.78. For the 16-point scale, which utilizes four behaviors, a score of six yields a sensitivity of 0.93 and specificity of 0.87. The latter scale has the highest accuracy as a potential screening test. Likelihood ratios were not performed due to sample size limitations.</p> <h2 scrollto-destination=28607872 id="28607872" class="section-title js-splitscreen-section-title" data-legacy-id=ss10>Discussion</h2> <p class="chapter-para">The study provides new information on the frequency of aberrant drug behaviors in a large sample of primary care patients receiving long-term opioid therapy. The primary findings of the study are as follows: 1) aberrant drug behaviors are common, with nearly four out of five subjects reporting one or more aberrant drug behaviors; 2) the data support the strong relationship of four or more of these behaviors to substance use disorders and mental health severity; 3) these behaviors are apparently not related to opioid doses or pain severity; and 4) four of the behaviors can be used as a general screening test to determine which patients need an alcohol and drug assessment before initiating or continuing opioid therapy.</p><p class="chapter-para">What are the clinical implications of this study? First, as these behaviors are common, physicians need to have the skills and training to assess the etiology of these behaviors. While some patients may have a substance use disorder, others may not. The number of behaviors and the frequency that these behaviors occur appears relevant. Patients who report 1–3 lifetime behaviors or occurrences of behavior are less likely to have a substance abuse disorder than those who report four or more behaviors. Patients with a limited number of behaviors may have actually lost their medication. Some patients may truly have washed their pills down the drain or that their dog really ate the medication. Or, they ran out early because the physician did not make it clear what the patient should do if the pain became unbearable. Physicians need to listen to patients' stories, ask for confirmation by a family member, and try to sort out the reason behind the behavior. Referral to a pain medicine center may also be helpful to determine the role of other treatment modalities besides opioids <span class="xrefLink" id="jumplink-b28"></span><a href="javascript:;" reveal-id="b28" data-open="b28" class="link link-ref link-reveal xref-bibr">[28]</a>.</p><p class="chapter-para">Second, the most likely cause for frequent aberrant behaviors is an opioid use disorder or an untreated mental health problem. While patients often continually try to justify their behavior and rationalize, the chance of an addiction problem is high. Patients with repeated behaviors need to be referred for an addiction assessment and, if available, to an addiction medicine physician with experience in chronic pain management. Patients with multiple behaviors often need detoxification or referral to a methadone or suboxone addiction clinic. Primary care clinics are probably not the optimum setting for this subset of pain patients.</p><p class="chapter-para">In addition, patients need to be encouraged to try other therapies for pain treatment besides opioid therapy. Simply accepting a patient statement that “I tried—e.g., physical therapy; e.g., elavil; e.g., gabapentin once, and it did not work,” does not mean that physical therapy or warm water therapy or other medication are not therapeutic alternatives or adjuncts to mood-altering drugs. Many patients can improve in terms of decreased pain, improved cognitive function, and higher levels of motivation when they try other forms of pain treatment. Implementation of Gallagher's model of pain treatment <span class="xrefLink" id="jumplink-b29"></span><a href="javascript:;" reveal-id="b29" data-open="b29" class="link link-ref link-reveal xref-bibr">[29]</a> that includes greater collaboration between specialty pain clinics and primary care may be of immense help with patients who do not respond to usual therapy.</p><p class="chapter-para">Mental health problems are very common in patients suffering with chronic pain. Data from the ASI, collected for this study <span class="xrefLink" id="jumplink-b26"></span><a href="javascript:;" reveal-id="b26" data-open="b26" class="link link-ref link-reveal xref-bibr">[26]</a>, show that 24.7% of our sample had been hospitalized for psychiatric disorder, 60% had participated in mental health counseling, and 34.3% had experienced serious depression in the last 30 days. In addition, 36.6% had experienced anxiety severe enough to incapacitate them in the past 30 days and 18.6% had trouble controlling violent behavior. Moreover, 20.6% had made a serious attempt to end their life. Identifying and treating mental health disorders is an important aspect of chronic pain management.</p><p class="chapter-para">Third, the study supports the development of screening tests to identify patients at greatest risk for development of prescription drug problems with their medication. The Screener and Opioid Assessment for Patients with Pain <span class="xrefLink" id="jumplink-b30"></span><a href="javascript:;" reveal-id="b30" data-open="b30" class="link link-ref link-reveal xref-bibr">[30]</a> is a new instrument tested in 396 patients being treated in two pain centers. A combined analysis of the 14-item measure found five factors were found in patients at greatest risk. These included a history of substance abuse, legal problems, craving medication, heavy smoking, and mood swings. Another screening tool is the opioid risk tool developed by Webster and colleagues <span class="xrefLink" id="jumplink-b16"></span><a href="javascript:;" reveal-id="b16" data-open="b16" class="link link-ref link-reveal xref-bibr">[16]</a>. Another study assessed predictors of chronic pain in a sample of 196 patients followed prospectively over 3 months. This study found that younger age, cocaine use, and legal conviction for alcohol or drugs were associated with greater risk for opioid misuse <span class="xrefLink" id="jumplink-b31"></span><a href="javascript:;" reveal-id="b31" data-open="b31" class="link link-ref link-reveal xref-bibr">[31]</a>.</p><p class="chapter-para">This study has a number of strengths, including a large sample characterized by cultural diversity, inclusion of alcohol and illicit drug use measures, use of state-of-the-art research instruments and interview techniques, and a robust separation of aberrant behavior scores by group status. In addition, patients were recruited through over 200 primary care physicians from eight counties located throughout Wisconsin.</p><p class="chapter-para">The primary limitation of the study is the cross-sectional nature of the data. The study did not have detailed information on patients' substance use prior to the initiation of opioid therapy. We were not able to link patient data with the physician's perception of individual patients, nor did we attempt to corroborate the subject's story with a family member's perception of the patient's substance use. It is also unclear if patients would complete the behavioral questions with the same level of honesty in a clinical setting as opposed to a research setting. Moreover, while the DSM-IV substance use disorder diagnoses were based on the SDSS past 30 days, the aberrant opioid behavior measures were framed as lifetime questions.</p><p class="chapter-para">One of the challenges of this study was to select patient behaviors that should be included in a list of aberrant drug behaviors. There is currently no consensus on what is an aberrant drug behavior. We do not have a DSM-IV list of criteria or items. For example, the item “felt intoxicated from opioids” could be viewed as a normal biological effect rather than a risk factor or sign of addiction. The field needs to do more research to test the predictive validity of various aberrant drug behaviors against a gold standard such as DSM-IV diagnostic instruments like the Structural Clinical Interview for DSM-IV, Composite International Diagnostic Interview or SDSS.</p><p class="chapter-para">Potential reasons why we did not find a relationship between past and current substance use disorder in our primary care pain sample include 1) selection issues (i.e., patients with a lifetime problem were not started on opioids and therefore not eligible for our study); 2) sample size issues (only 31 patients met current opioid dependence criteria); and 3) varying criteria used in other chronic pain studies to determine a past history of substance abuse. Many studies reported in the literature rely on medical record documentation, positive toxicology testing, or self-reported use <span class="xrefLink" id="jumplink-b2 b5 b30 b31"></span><a href="javascript:;" reveal-id="b2 b5 b30 b31" data-open="b2 b5 b30 b31" class="link link-ref link-reveal xref-bibr">[2,5,30,31]</a>. In our study, patients needed to have participated in alcohol or drug treatment to be considered to have a lifetime history of a substance abuse disorder. We felt this was the most conservative and reliable measure of a past history of substance abuse disorder. Drug use alone is insufficient to make a diagnosis of a lifetime substance use disorder.</p> <h2 scrollto-destination=28607883 id="28607883" class="section-title js-splitscreen-section-title" data-legacy-id=ss11>Conclusions</h2> <p class="chapter-para">Aberrant drug-taking behaviors go hand in hand with the treatment of chronic pain. They are common and frequent. The key for physicians is to determine the etiology of the behaviors. Our data support an addiction assessment and urine toxicology testing in patients who demonstrate four or more aberrant behaviors. Primary care physicians need more clinical tools to be able to identify the patients who are at greatest risk for drug abuse and diversion. A valid screening and assessment tool would help them overcome some of their fears, frustrations, and competing demands in caring for this complex patient population <span class="xrefLink" id="jumplink-b32"></span><a href="javascript:;" reveal-id="b32" data-open="b32" class="link link-ref link-reveal xref-bibr">[32]</a>.</p> <h2 scrollto-destination=28607885 id="28607885" class="backacknowledgements-title js-splitscreen-backacknowledgements-title" data-legacy-id=ss12>Acknowledgments</h2> <p class="chapter-para">The study was supported by the National Institute on Drug Abuse grant number 5R01DA013686-02. No other sources of funding were used for this study. 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<tr> <td>November 2023</td> <td>6</td> </tr> <tr> <td>December 2023</td> <td>22</td> </tr> <tr> <td>January 2024</td> <td>21</td> </tr> <tr> <td>February 2024</td> <td>23</td> </tr> <tr> <td>March 2024</td> <td>16</td> </tr> <tr> <td>April 2024</td> <td>20</td> </tr> <tr> <td>May 2024</td> <td>13</td> </tr> <tr> <td>June 2024</td> <td>21</td> </tr> <tr> <td>July 2024</td> <td>12</td> </tr> <tr> <td>August 2024</td> <td>12</td> </tr> <tr> <td>September 2024</td> <td>16</td> </tr> <tr> <td>October 2024</td> <td>14</td> </tr> <tr> <td>November 2024</td> <td>9</td> </tr> </tbody> </table> </div> </div> <div class="artmet-stats-wrap clearfix"> <div class="artmet-item artmet-citations hide"> <div class="widget-title-2 artmet-widget-title-2">Citations</div> <div class="artmet-badges-wrap artmet-dimensions"> <div class="widget widget-DimensionsBadge widget-instance-ArticleLevelMetrics_DimensionsBadgeDetails"> <span class="__dimensions_badge_embed__" data-doi="10.1111/j.1526-4637.2008.00491.x" 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Reported Lifetime Aberrant Drug-Taking Behaviors Are Predictive of Current Substance Use and Mental Health Problems in Primary Care Patients | Pain Medicine | Oxford Academic