The DIRE score: predicting outcomes of opioid prescribing for chronic pain

J Pain. 2006 Sep;7(9):671-81. doi: 10.1016/j.jpain.2006.03.001.


The objective of this retrospective study was to test the validity and reliability of a scoring tool (the DIRE Score), for use by clinicians, that predicts which chronic noncancer pain patients will have effective analgesia and be compliant with long-term opioid maintenance treatment. DIRE scores were assigned to 61 cases from the pain center's databases. These cases were abstracted into vignettes that were reviewed and scored by 6 physicians. Repeat scoring was carried out on a subset of 30 vignettes after 2 weeks. The main outcome measures were: global impression of compliance and efficacy as indicated in the medical record and by interview with the patient's treating clinician; and final disposition, ie, whether or not opioids were continued or discontinued at the time of last clinical documentation. Internal consistency of the factors making up the DIRE Score was high (Cronbach's alpha = .80). Sensitivity and specificity of the DIRE Score for predicting patient compliance were 94% and 87%, respectively. For efficacy, sensitivity and specificity were 81% and 76%. For disposition, the sensitivity and specificity were 86% and 73%. Intraclass correlation was 0.94 for interrater reliability and 0.95 for intrarater reliability.

Perspective: Public controversy about the use of long-term opioids for chronic pain fuels physician ambivalence about the prescribing process. In this initial retrospective study, validity and reliability of the DIRE Score are demonstrated. The score correlated well with measures of patient compliance and efficacy of long-term opioid therapy.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Analgesics, Opioid / therapeutic use*
  • Chronic Disease
  • Female
  • Humans
  • Male
  • Middle Aged
  • Minnesota
  • Outcome Assessment, Health Care / methods*
  • Pain Measurement / methods*
  • Pain, Intractable / diagnosis
  • Pain, Intractable / drug therapy*
  • Pain, Intractable / psychology
  • Patient Compliance / statistics & numerical data
  • Predictive Value of Tests
  • Reproducibility of Results
  • Retrospective Studies
  • Treatment Outcome


  • Analgesics, Opioid