Clinicians recognize the importance of monitoring aberrant medication-related behaviors of chronic pain patients while being prescribed opioid therapy. The purpose of this study was to develop and validate the Current Opioid Misuse Measure (COMM) for those pain patients already on long-term opioid therapy. An initial pool of 177 items was developed with input from 26 pain management and addiction specialists. Concept mapping identified six primary concepts underlying medication misuse, which were used to develop an initial item pool. Twenty-two pain and addiction specialists rated the items on importance and relevance, resulting in selection of a 40-item alpha COMM. Final item selection was based on empirical evaluation of items with patients taking opioids for chronic, noncancer pain (N=227). One-week test-retest reliability was examined with 55 participants. All participants were administered the alpha version of the COMM, the Prescription Drug Use Questionnaire (PDUQ) interview, and submitted a urine sample for toxicology screening. Physician ratings of patient aberrant behaviors were also obtained. Of the 40 items, 17 items appeared to adequately measure aberrant behavior, demonstrating excellent internal consistency and test-retest reliability. Cutoff scores were examined using ROC curve analysis and reasonable sensitivity and specificity were established. To evaluate the COMM's ability to capture change in patient status, it was tested on a subset of patients (N = 86) that were followed and reassessed three months later. The COMM was found to have promise as a brief, self-report measure of current aberrant drug-related behavior. Further cross-validation and replication of these preliminary results is pending.

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

The original Screener and Opioid Assessment for Patients with Pain (SOAPP) is a conceptually derived self-report questionnaire designed to predict aberrant medication-related behaviors among chronic pain patients considered for long-term opioid therapy. The purpose of this study was to develop and validate an empirically-derived version of the SOAPP (SOAPP-R) that addresses some limitations of the original SOAPP. In successive steps, items were reduced from an initial pool of 142 to a 97-item beta version. The beta version was administered to 283 chronic pain patients on long-term opioid therapy. Items were evaluated based on data collected at follow-up, including correlation with the Aberrant Drug Behavior Index (ADBI), derived from interview data, physician ratings, and urine toxicology screens. Twenty-four items were retained and comprise the final SOAPP-R. Coefficient α was .88, and receiver operating characteristics (ROC) curve analysis yielded an area under the curve (AUC) of .81 (p < .001). A cutoff score of 18 showed adequate sensitivity (.81) and specificity (.68). The obtained psychometrics, along with the use of a predictive criterion that goes beyond self-report, suggest that the SOAPP-R is an improvement over the original version in screening risk potential for aberrant medication-related behavior among persons with chronic pain. Perspective:There is need for a screener for abuse risk in patients prescribed opioids for pain. This study presents a revised version of the Screener and Opioid Assessment for Patients with Pain (SOAPP-R) that is empirically-derived with good reliability and validity, but is less susceptible to overt deception then the original SOAPP v.1.

Sixteen therapists were enrolled in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy (TLDP). The training program successfully changed therapists' interventions in line with prescriptions of the TLDP manual, but some unanticipated changes ran counter to the intent of the training, including increased negative interpersonal transactions as indicated by process measures such as the Structural Analysis of Social Behavior (SASB). We examined therapist variables, patient variables, and training variables that appeared to mediate therapist responses to the training program. Results indicate that patient difficulty may mediate certain aspects of therapists' responses to training. Therapists with self-reported hostile and controlling introjects showed the greatest technical adherence, which was intriguing because prior research has linked hostile therapist introject to greater frequency of countertherapeutic interpersonal process. Of special interest were differences in effects of training associated with individual training faculty. This finding, if generalizable, has important implications for manualized therapy research, especially multisite trials.The 5-year Vanderbilt II project examined the effects of 1 year's training in a manualized form of dynamic psychotherapy (time-limited dynamic psychotherapy [TLDP]; Strupp & Binder, 1984) on 16 experienced therapists across 80 cases. Because of the increasing use and acceptance of treatment manuals in psychotherapy research, a primary aim of the study was to explore the process of manualized training itself. A number of therapist behaviors in different domains were measured preand posttraining, with therapists serving as their own controls. Thus, the design focused on the effects of training in a single treatment manual rather than comparing the differential outcome efficacy of several competing protocol therapies.Analyses of therapist changes at the group level revealed both intended and unintended results (Henry, Strupp, Butler, Schacht, & Binder, 1993). The training program successfully changed therapists' technical interventions in line with prescriptions in the TLDP manual. Therapists showed significant increases in interventions, such as focusing the therapeutic process on in-session transactions and the articulation of cyclical maladaptive interpersonal patterns (CMPs). However, other changes were unexpected and ran counter to the intent of the training. These included an increase in negative interpersonal transactions as reflected by such process measures as the Struc-

There has been a need for a brief assessment tool for providers who treat chronic pain patients to determine potential risk of abuse when prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a self-administered screening tool (Screener and Opioid Assessment for Patients with Pain, SOAPP) for chronic pain patients considered for long-term opioid therapy. A consensus of 26 pain and addiction experts was obtained on important characteristics of chronic pain patients that predict future medication misuse using concept mapping. A 24-item SOAPP (version 1.0) was developed based on this consensus and was administered to 175 patients who were taking opioids for chronic pain. After 6 months, 95 of these patients were re-evaluated. Validation of the SOAPP was conducted by identifying those patients exhibiting aberrant drug-related behavior as determined by any of the following: a positive score on the Prescription Drug Use Questionnaire (PDUQ) interview, positive urine toxicology screen, and/or ratings by staff as to whether patients had a serious drug problem. Of the original 24 items, 14 SOAPP items appeared to predict subsequent aberrant behaviors. Coefficient alpha for these 14 items was acceptable for a short scale (0.74). Receiver operating characteristics curve analysis yielded an area under the curve of 0.881 (P<0.001), suggesting adequate sensitivity and specificity for a screening device. These reliability and predictive validity results suggest that the SOAPP is a promising step toward screening risk potential for substance misuse among persons with chronic pain.

Sixteen therapists were enrolled in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy (TLDP). The training program successfully changed therapists' interventions in line with prescriptions of the TLDP manual, but some unanticipated changes ran counter to the intent of the training, including increased negative interpersonal transactions as indicated by process measures such as the Structural Analysis of Social Behavior (SASB). We examined therapist variables, patient variables, and training variables that appeared to mediate therapist responses to the training program. Results indicate that patient difficulty may mediate certain aspects of therapists' responses to training. Therapists with self-reported hostile and controlling introjects showed the greatest technical adherence, which was intriguing because prior research has linked hostile therapist introject to greater frequency of countertherapeutic interpersonal process. Of special interest were differences in effects of training associated with individual training faculty. This finding, if generalizable, has important implications for manualized therapy research, especially multisite trials. The 5-year Vanderbilt II project examined the effects of 1 year's training in a manualized form of dynamic psychotherapy (time-limited dynamic psychotherapy [TLDP]; Strupp & Binder, 1984) on 16 experienced therapists across 80 cases. Because of the increasing use and acceptance of treatment manuals in psychotherapy research, a primary aim of the study was to explore the process of manualized training itself. A number of therapist behaviors in different domains were measured preand posttraining, with therapists serving as their own controls. Thus, the design focused on the effects of training in a single treatment manual rather than comparing the differential outcome efficacy of several competing protocol therapies. Analyses of therapist changes at the group level revealed both intended and unintended results (Henry, Strupp, Butler, Schacht, & Binder, 1993). The training program successfully changed therapists' technical interventions in line with prescriptions in the TLDP manual. Therapists showed significant increases in interventions, such as focusing the therapeutic process on in-session transactions and the articulation of cyclical maladaptive interpersonal patterns (CMPs). However, other changes were unexpected and ran counter to the intent of the training. These included an increase in negative interpersonal transactions as reflected by such process measures as the Struc

Psychiatric factors, such as a history of mood disorder, psychologic problems, and psychosocial stressors, may place patients at risk for misuse of prescription opioids. Future studies to elucidate the risk of medication misuse and aberrant drug behavior among this patient population are needed.

BackgroundEvaluation of tamper resistant formulations (TRFs) and classwide Risk Evaluation and Mitigation Strategies (REMS) for prescription opioid analgesics will require baseline descriptions of abuse patterns of existing opioid analgesics, including the relative risk of abuse of existing prescription opioids and characteristic patterns of abuse by alternate routes of administration (ROAs). This article presents, for one population at high risk for abuse of prescription opioids, the unadjusted relative risk of abuse of hydrocodone, immediate release (IR) and extended release (ER) oxycodone, methadone, IR and ER morphine, hydromorphone, IR and ER fentanyl, IR and ER oxymorphone. How relative risks change when adjusted for prescription volume of the products was examined along with patterns of abuse via ROAs for the products.MethodsUsing data on prescription opioid abuse and ROAs used from 2009 Addiction Severity Index-Multimedia Version (ASI-MV®) Connect assessments of 59,792 patients entering treatment for substance use disorders at 464 treatment facilities in 34 states and prescription volume data from SDI Health LLC, unadjusted and adjusted risk for abuse were estimated using log-binomial regression models. A random effects binary logistic regression model estimated the predicted probabilities of abusing a product by one of five ROAs, intended ROA (i.e., swallowing whole), snorting, injection, chewing, and other.ResultsUnadjusted relative risk of abuse for the 11 compound/formulations determined hydrocodone and IR oxycodone to be most highly abused while IR oxymorphone and IR fentanyl were least often abused. Adjusting for prescription volume suggested hydrocodone and IR oxycodone were least often abused on a prescription-by-prescription basis. Methadone and morphine, especially IR morphine, showed increases in relative risk of abuse. Examination of the data without methadone revealed ER oxycodone as the drug with greatest risk after adjusting for prescription volume. Specific ROA patterns were identified for the compounds/formulations, with morphine and hydromorphone most likely to be injected.ConclusionsUnadjusted risks observed here were consistent with rankings of prescription opioid abuse obtained by others using different populations/methods. Adjusted risk estimates suggest that some, less widely prescribed analgesics are more often abused than prescription volume would predict. The compounds/formulations investigated evidenced unique ROA patterns. Baseline abuse patterns will be important for future evaluations of TRFs and REMS.