POMI test article

Journal of Substance Abuse Treatment 35 (2008) 380 – 386

Regular article

Prescription Opioid Misuse Index: A brief questionnaire to assess misuse
Janet S. Knisely, (Ph.D.) a , Martha J. Wunsch, (M.D.) a,⁎,1 ,
Karen L. Cropsey, (Psy.D.) a,2 , Eleanor D. Campbell, (M.S.) b
a

Department of Psychiatry, Virginia Commonwealth University, Richmond, VA 23298, USA
Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23298, USA

b

Received 16 July 2007; received in revised form 4 February 2008; accepted 18 February 2008

Abstract
The Prescription Opioid Misuse Index (POMI) was developed and used in a larger study designed to assess correlates of OxyContin abuse
in pain patients prescribed OxyContin, patients treated for OxyContin addiction, and individuals incarcerated for OxyContin-related charges.
The POMI was administered to 40 subjects with addiction problems and 34 pain patients who had received OxyContin for pain. Receiver
operating characteristic curve analysis indicated that endorsing two or more of six items reliably classified a person as at risk for misuse of
their medication. When comparing drug abuse/dependence in subjects classified as misusers or users, significantly more misusers received a
diagnosis for alcohol (p b .01), illicit drugs (p b .05), and other prescription medications (p b .05) and reported greater lifetime use of alcohol
(p b .002) and illicit drugs (p b .01). No between-group differences were found regarding psychiatric problems. The POMI appears to be a
sensitive and specific instrument for identifying patients who misuse opioid medications. © 2008 Elsevier Inc. All rights reserved.
Keywords: Screening instrument; Prescription drug abuse; Opioids; Pain

1. Introduction
Numerous epidemiological surveys in the last several
years have demonstrated an increase in the prevalence
of narcotic addiction and nonmedical use of prescription opioids in the United States (Colliver, Kroutil, Dai,
& Gfroerer, 2006; Drug Abuse Warning Network [DAWN],
2007; National Institute on Drug Abuse, 2006; Substance
Abuse and Mental Health Services Administration
[SAMHSA], 2006a, 2006b). The 2005 National Survey on
Drug Use and Health (NSDUH) reported that approximately
1.5 million persons older than 12 years were dependent on or
abused narcotics during the previous year, and more than 11
million individuals engaged in the nonmedical use of
⁎ Corresponding author. 1457 Harding Road, Blacksburg, VA 24060,
USA. Tel.: +1 540 239 7132; fax: +1 540 231 6298.
E-mail address: mwunsch@vcom.vt.edu (M.J. Wunsch).
1
Present address: Addiction Medicine, Edward Via Virginia College of
Osteopathic Medicine, 2265 Kraft Drive, Blacksburg, Virginia, USA 24060.
2
Present address: Department of Psychiatry and Behavioral Neurobiology, University of Alabama School of Medicine, Birmingham, AL 35209.
0740-5472/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2008.02.001

prescription pain relievers in the previous year (SAMHSA,
2006a, 2006b). Between 2002 and 2005, rates of initial
nonmedical opioid use were stable; however, the annual
average of first time nonmedical use was approximately 2.3
million people (NSDUH, 2007). Data from treatment
surveys also indicate an increase in problems associated
with the abuse and/or nonmedical use of opioids. According
to the 2005 Treatment Episode Data Set, there was a fourfold increase in admissions for treatment of nonheroin
opioids from 1% in 1995 to 4% in 2005. (SAMHSA, 2006a,
2006b). Significant increases in emergency room visits with
mentions of opioid drugs have also been reported over the
last decade (SAMHSA, 2003). Most recently, DAWN
estimates indicate that one third of nonmedical-use visits
involve opioid analgesics (DAWN, 2007).
With the growing concern on the dramatic increase in the
abuse and nonmedical use of prescription narcotics and
subsequent health problems, it is important to develop
methods of detection of those at risk for misuse of
prescription narcotics (Compton & Volkow, 2006; Zacny
et al., 2003). The development of a screening instrument for
opioid misuse that can be used quickly and effectively in a

J.S. Knisely et al. / Journal of Substance Abuse Treatment 35 (2008) 380–386

clinical setting has been a challenge for the field. An early
attempt to develop and evaluate such an instrument was
accomplished by Compton, Darakjian, and Miotto (1998),
who found that scores on a 42-item Prescription Drug Use
Questionnaire (PDUQ) were significantly different for a
group meeting the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) criteria for
abuse or dependence as compared with those not meeting
DSM-IV criteria. They also reported that three factors taken
in unison—the tendency to increase analgesic dose or
frequency, preference for a mode of administration, and
patient considering himself/herself addicted—distinguished
substance-abusing and substance-dependent patients from
the nonaddicted patients. This interview, however, is
designed to be administered by a trained mental health
professional and takes time to administer. These limitations
make it impractical for health care practitioners to use this
instrument with most of their patient population.
Using a large sample of chronic pain patients consisting
of 100 with substance abuse and 400 without substance
abuse histories, Manchikanti, Singh, Damron, Beyer, and
Pampati (2003) examined a comprehensive 27-item assessment instrument that evaluated several domains including
focus on and excessive need of opiates, nonphysiological
behavior, substance abuse, nonfunctional status, legal status,
and psychological status. Results of their study suggested
that 8 of the 12 domains studied were useful in identifying
misuse and that three factors correctly identified 90% of the
cases: excessive opiate needs, lying to obtain the medication,
and doctor shopping.
More recently, Butler, Budman, Fernandez, and Jamison
(2004) developed a self-administered 24-item questionnaire
(Screener and Opioid Assessment for Patients with Pain
[SOAPP]) to identify characteristics of chronic pain patients
to predict future misuse. The final 14-item instrument has
demonstrated good reliability and validity when compared
with aberrant drug use behavior as determined by either a
high score on the PDUQ, positive drug screening, or
clinician ratings of a drug problem.
Webster and Webster (2005) validated a brief office-based
screening tool, the Opioid Risk Tool (ORT), to predict the
probability of a patient displaying aberrant behavior when
prescribed opioids for chronic pain. This self-administered
screen requires less than 10 minutes of the patient's time and
is composed of five risk factors, which were derived from a
search of the literature and the author's clinical experience:
family and personal history of substance abuse, age, history
of preadolescent sexual abuse, and specific mental disorders.
Scores from the ORT predicted aberrant behaviors during the
12-month monitoring period among patients prescribed
opioids for chronic pain with a high degree of sensitivity
and specificity. Most frequent aberrant behaviors recorded
via chart review included obtaining prescription opioids
from alternative providers, using more than prescribed,
using additional opioids than those prescribed, and failing to
keep appointments.

381

The goal of the present investigation was to assess a
brief interview focused specifically on prescription use
behaviors rather than general predictive factors associated
with substance abuse (i.e., family history of substance
abuse, others' concern regarding potential drug abuse
problem, previous substance abuse treatment, etc.). The
investigators of this study standardized questions frequently
used in their clinical practice to assess potential misuse of
prescription medications. The eight-item interview, Prescription Opioid Misuse Index (POMI), also included a
question regarding adequate pain relief to confirm that any
increase in prescription use reported was not due to
inadequate pain control. This question was included to
elucidate behaviors characteristic of those individuals
displaying pseudo-addiction (American Academy of Pain
Medicine [AAPM], American Pain Society [APS], &
American Society of Addiction Medicine [ASAM],
2001). Pseudo-addiction occurs in a patient with unrelieved
pain who becomes focused on obtaining medications and
displays behaviors that may otherwise seem inappropriately
“drug seeking.” Sometimes, illicit drug use and deception
may occur in efforts to obtain relief. Unlike the patient with
addiction, these behaviors resolve when pain is effectively
treated. The POMI was administered to subjects with
known addiction problems and pain patients and compared
with DSM-IV diagnoses obtained through a structured
interview. Other potential correlates of misuse were also
assessed including alcohol and illicit drug abuse/dependence and psychiatric histories.

2. Materials and methods
2.1. Subjects
Of the 137 subjects recruited from community substance
abuse treatment programs, regional jails, pain clinics, and
private internal medicine practices in southwestern Virginia
for a study investigating correlates of OxyContin addiction
(see Wunsch, 2007), 74 had been prescribed OxyContin for
pain and served as subjects in this study. A total of 40
subjects were known opioid abusers (from addiction
treatment programs and those incarcerated), and 34 were
pain patients. All subjects signed consent forms approved by
the Western Institutional Review board (WIRB), and study
procedures were consistent with WIRB standards.
2.3. Procedures
Substance abuse and dependence diagnoses were
determined via the DSM-IV checklist (modified from
Hudziak et al., 1993). This structured interview queried
for use of alcohol, amphetamine, cannabis, cocaine,
hallucinogens, inhalants, nicotine, opiates, phencyclidine,
and sedatives/benzodiazepines in the previous year. A
modified version of the Addiction Severity Index 5th

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Edition (ASI; McLellan et al., 1985) was also administered
to evaluate medical, employment, alcohol, drugs, legal,
family/social, and psychiatric problems. Finally, to assess
behaviors commonly associated with the misuse of
prescription medications, an eight-item inventory was
developed by the investigators (POMI). The POMI included
questions regarding dose, frequency of use, the need for
early refills, a doctor expressing concern of misuse, feeling
high from the medication, taking medication due to stress,
obtaining prescriptions from multiple physicians, and pain
control (see Appendix A for a copy of the POMI).
Interviews were conducted by experienced researchers
who hold advanced degrees and are experienced in clinical
research. Subjects recruited from community treatment
programs and pain clinics were compensated for participation ($50 gift certificate), but due to state regulations, the
incarcerated subjects did not receive compensation.
2.3. Statistical analyses
To test for reliability, Cronbach's alpha (.848) was
calculated using all eight questions of the POMI (1 = yes,
2 = no for each item except Item 4, which was reverse
scored). Two subjects left one response blank. This was
handled by substituting the mean of each one's seven
remaining responses for the missing response (mean replacement method). Cronbach's alpha was virtually the same when
the two subjects having one missing response were eliminated
from the data. A principal component analysis was run to test
how each item related with the entire test, Items 1 to 3 and 6 to
8 had correlation coefficients with the total test ranging from
.663 to .769. The correlation of Item 4 with the total test was
.048, and that of Item 5 was 0.359. Cronbach's alpha for the

Table 1
Sensitivity and specificity of the POMI (n = 74)
POMI
cutoff a

Sensitivity b

Specificity c

1−specificity d

Sensitivity +
specificity e

0
1
2
3
4
5
6

1.000
0.852
0.820
0.754
0.623
0.541
0.361

0
0.692
0.923
0.923
1.000
1.000
1.000

1.000
0.308
0.077
0.077
0.000
0.000
0.000

1.000
1.544
1.743
1.677
1.623
1.541
1.361

a

The cutoff POMI indicates that a test at or above that level would be a
positive test (believed to have misused). A test reading below that level
would indicate no prescription misuse.
b
Sensitivity is the percentage of positive tests (using a cutoff value)
when the DSM-IV classified as abuse/dependence.
c
Specificity is the percentage of negative tests (using a cutoff value)
when the DSM-IV classified as no abuse/dependence.
d
1−specificity is the percentage of false-positive tests using a cutoff
value (e.g., percentage of no abuse/dependence on DSM-IV classified as
misusers on the POMI).
e
Sensitivity + specificity was calculated to identify the optimal POMI
cutoff with the highest combined sensitivity and specificity.

Table 2
POMI misuse risk scores by DSM-IV opiate diagnoses for subjects known to
have an addiction problem compared to pain patients prescribed OxyContin
Addiction (n = 40)

Pain (n = 34)

Misuse risk
score

Opiate
diagnosis

No opiate
diagnosis

Opiate
diagnosis

No opiate
diagnosis

0
1
2
3
4
5
6

0
0
2
4
4
9
21

0
0
0
0
0
0
0

9
2
2
4
1
2
1

9
3
0
1
0
0
0

test with each of the items removed was highest (.883) with
Item 4 removed and second highest (.857) with Item 5
removed. Removing each of the other items lowered
Cronbach's alpha. As a result, Items 4 and 5 of the POMI
were eliminated from the total score. Receiver operating
characteristic curve (ROC) analysis was used to compare
POMI risk scores and DSM-IV-derived opiate diagnoses to
determine the optimum POMI cutoff score. Sensitivity and
specificity were calculated for each possible score (range = 06). On the basis of the analyses, those scoring 2 or more were
assigned to the misuse group (sensitivity = 0.820, specificity =
0.923, total = 1.743). Differences between the two study
groups (abuse and pain) and the use and misuse groups were
evaluated using the chi-square tests for categorical data and
t tests for continuous variables.
3. Results
There were no group differences regarding gender,
ethnicity, or education when abuse and pain groups were
compared. Most of the subjects in both groups were
Caucasian (abuse 92%, pain 97%) with a high school
education (abuse M = 12.6 years, pain M = 13 years).
Although there were more females in the pain group (56%)
than in the abuse group (35%), statistical significance was
not found. Significant group differences were found for age
and marital status. Those in the abuse group were
significantly younger (M = 33.8 years) than those in the
pain group (M = 43.9 years, p b .0001) and were also less
likely to be married (abuse 30%, pain 53%, p b .01).
ROC analysis, comparing POMI risk score and DSM-IV
opiate diagnosis, yielded an area under the curve of 0.887
(p b .0001). On the basis of sensitivity and specificity, it was
determined that the optimal POMI cutoff score indicating
risk for misuse was 2 (sensitivity = 0.820 and specificity =
0.923; see Table 1).
POMI scores for the abuse and pain groups with and
without an opioid diagnosis are presented in Table 2. Using
the POMI cutoff score of two, 100% of the subjects in the
abuse group were correctly classified as misusers, and 32%
in the pain group were classified as misusers. One pain

J.S. Knisely et al. / Journal of Substance Abuse Treatment 35 (2008) 380–386

383

Fig. 1. Percentage of abuse and pain subjects endorsing each item of the POMI.

patient who did not have a diagnosis for opiate abuse or
dependence received a POMI score of 3. The percentage of
subjects endorsing each item on the POMI is presented for
abuse and pain groups in Fig. 1. Significant group
differences were observed for all POMI items with the
exception of adequate pain relief and a doctor expressing
concern regarding prescription use. Although most of the
subjects in both groups reported adequate pain relief from
prescribed OxyContin (abuse 82%, pain 76%), most of the
abuse subjects endorsed six of the seven risk behaviors
assessed by the POMI, and approximately 25% to 35% of
the pain patients responded affirmatively to four of the
seven items.
Abuse/Dependence diagnoses comparing subjects classified as users and misusers (based on a POMI score of 2 or
more) are presented in Fig. 2. Significantly more misusers
received a diagnosis for alcohol (p b .01), cannabis (p b .05),
cocaine (p b .05), and sedative/benzodiazepine (p b .05)
abuse or dependence as compared with users. Similarly,
misusers reported significantly greater lifetime use of alcohol
(p b .002), cannabis (p b .01), and cocaine (p b .01) than

users (see Fig. 3). Subjects in both groups had substantial
previous experience with opioids prior to prescription of
OxyContin; however, misusers had used significantly more
opioids (M = 4.9) than users (M = 3.9, p b .03), and at least
twice as many misusers had previously used heroin,
oxycodone, meperidine, codeine, morphine, hydrocodone,
pentazocine, propoxyphene, and hydromorphone as compared with users.
Significant group differences were not observed between
users and misusers regarding reports of psychiatric problems
on the ASI. Rates for depression and anxiety exceeded 68%
for both groups, and although not significantly different,
reports of suicide ideation (use 30%, misuse 49%) and
suicide attempts (use 22%, misuse 29%) were higher for the
misuse group as compared with the use group. Reported use
of medications for psychiatric problems was 70% and 63%
by the use and misuse groups, respectively, and mean
number of psychiatric problem days in the previous month
was 5.9 and 10.5 for the use and misuse group, respectively.
Significant group differences were found for family history
of drug use (use 45%, misuse 72%, p b .04) but not for

Fig. 2. Percentage of users and misusers meeting DSM-IV criteria for current abuse/dependence of alcohol, cannabis, cocaine, sedatives/benzodiazepines,
and amphetamines.

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J.S. Knisely et al. / Journal of Substance Abuse Treatment 35 (2008) 380–386

Fig. 3. Mean number of years of lifetime heroin, methadone, other opiates, alcohol, alcohol to intoxication, cannabis, cocaine, and sedative/benzodiazepine use
(ASI) for users and misusers.

alcohol use (use 70%, misuse 88%) or psychiatric disorders
(use 55%, misuse 61%).

4. Discussion
Results from the POMI clearly demonstrate that patients
may be classified as those using their prescription
appropriately and those who are at risk for misuse using
a series of clinically relevant questions. Although eight
questions were part of the original instrument, principal
component analysis demonstrated the utility of a six-item
instrument. An affirmative answer to more than one
question correctly classified an individual as an opioid
misuser with high sensitivity (0.82) and specificity (0.92)
when compared with DSM-IV opioid abuse or dependence
criteria. This is important because chronic pain patients
may meet two of the necessary three diagnostic criteria for
dependence due to signs of physical dependence (tolerance
and withdrawal) even when using the medication appropriately as prescribed by their physician. In this study, 21 of
34 chronic pain patients (61.7%) met DSM-IV criteria for
opioid abuse or dependence; however, 11 of 21 (52.3%)
who met criteria were not classified as at risk for misuse
based on the POMI score. In addition, 100% of those
subjects who were known to have addiction problems were
correctly classified as at risk for misuse. Thus, the POMI is
believed to be a sensitive and specific way of identifying
patients who misuse opioid medications.
Subject characteristics of opioid misusers identified in
this study are consistent with previous findings suggesting
that age and past alcohol and cocaine abuse may be
predictors of opioid misuse. From a sample of 196 chronic
pain patients, Ives et al. (2006) identified 32% of the group
as misusers and reported that misusers were significantly

younger and more than twice as likely to have past alcohol
abuse and more than four times more likely to have past
cocaine abuse as compared with pain patients not classified
as misusers. Other investigators evaluating correlates of
opioid misuse have reported similar age differences and drug
use histories as well as lack of group differences regarding
psychiatric problems (Manchikanti et al., 2003; Potter,
Hennessy, Borrow, Greenfield, & Weiss, 2004; Reid et al.,
2002). The present data suggest significant rates of
depression and anxiety in both abuse and pain groups.
Other clinical groups have developed screening instruments, and each group has made significant contribution to
the literature and identification of the patient at risk for
misuse and abuse of prescription opioids (Butler et al., 2004;
Compton et al., 1998; Manchikanti et al., 2003). Important
shared concepts identified by screening instruments and the
POMI include identification of a previous history of
substance abuse and patterns of use of medications.
However, the strengths of the POMI are the brevity of six
clearly defined questions, the ease of administration by
nonphysician in a busy pain practice, and the clear criteria
that were used in identifying those subjects who meet criteria
for dependence using the ASI and Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision
subjects. In contrast, the diagnosis of substance abuse was
made elsewhere for those 100 subjects who were the
comparison group for Manchikanti et al. in the validation
of the 8 of 12 previously identified criteria and narrowing to
three predictive categories. In addition, some criteria used in
this study, such as “bizarre symptoms” or “multiple” or
“repeated” behaviors, are not clearly defined by the authors.
The 42-item instrument developed by Compton et al.,
designed to be administered by trained mental health
practitioners, provides a good foundation but is lengthy.
Butler et al. (2004) built upon an exciting use of concept

J.S. Knisely et al. / Journal of Substance Abuse Treatment 35 (2008) 380–386

mapping with the Screener and SOAPP, but it is lengthy at 14
questions. In addition, the study did not include urine drug
screens on all patients and includes concerns about “drug
abuse behavior” by nonphysician staff with vague definitions
of such behavior.
Finally, in contrast to the ORT screening tool, the
POMI queries directly for the aberrant behaviors monitored by Webster and Webster (2005) and also includes
the question “Has your pain ever been adequately treated,”
which addresses the effects of pseudo-addiction as defined
by the 2001 Consensus Statement by the AAPM, the APS,
and the ASAM (AAPM, APS, & ASAM, 2001). By
asking specifically about the adequacy of treatment for
pain, the POMI identifies patient behaviors driven by
unrelieved pain rather than addiction. Unrelenting pain can
lead to behavior misinterpreted as drug seeking, a
phenomenon which resolves with effectively treated pain.
This is a strength of the POMI, in contrast to other brief
screening instruments.
Research focused on identification of patients at risk for
prescription abuse must be concise with clearly defined
diagnostic criteria for the physician and scientific rigor
employed by researchers addressing this issue. We should
tread carefully and acknowledge the importance of
balancing identification of the patient at risk for misuse,
abuse, and dependence upon opioid medications with
access to much needed pharmaceuticals for the treatment
of chronic pain.
Limitations of this study include the small and homogeneous sample of pain patients (all subjects had received a
prescription for OxyContin). Although a comprehensive
evaluation of medical acuity and history of pain-related
disorders was beyond the scope of this study, subjects who
endorsed prescription misuse behaviors reported adequate
pain relief from their current treatment regimen. Although it
is clear that most subjects had extensive experience with
other prescription narcotics, it is uncertain how other medical
diagnoses may be associated with an increased risk of opioid
misuse as has been demonstrated in other studies (Miller &
Greenfeld, 2004).
Finally, the investigators of this study selected a
structured interview for diagnostic purposes to eliminate
the potential confounding of differential diagnostic expertise
of clinicians from the various recruitment sites. Although
this advantage was thought to be important, it should be
noted that the diagnostic instrument used does not
differentiate physical dependence due to chronic use of
opioids and misuse of opioid medication.
Given the study parameters discussed above, generalizability of the findings is limited; however, the present
preliminary findings suggest that the POMI may be used to
identify patients at risk for misuse of prescription opioids.
Additional studies of different and more diverse pain
populations are needed to confirm that this brief instrument
is efficacious in discriminating persons who appropriately
use pain medications from those at risk for abuse.

385

Acknowledgments
This research was supported in part by Purdue Pharma L.
P. No limitations were made by Purdue Pharma L.P.
regarding data analysis or interpretation, and no limitations
on the use of data for publications or presentations were
made by the industry sponsor. Furthermore, no government
or industry sponsor participated in the writing of this article.
All those individuals involved with data collection, interpretation, and writing of the manuscript were employees of
Virginia Commonwealth University.
The authors thank Antoinette Braddock, Ph.D., for her
assistance with data collection and Christine Paine for her
assistance with manuscript preparation.

Appendix A. Prescription Opioid Misuse Index
1. Do you ever use MORE of your medication, that is, take a
higher dosage, than is prescribed for you?
2. Do you ever use your medication MORE OFTEN, that is,
shorten the time between dosages, than is prescribed for you?
3. Do you ever need early refills for your pain medication?
⁎4. Have you ever gotten enough pain medication to bring your
pain to a tolerable level (as prescribed)?
⁎5. Has a doctor ever told you that you were using too much pain
medication?
6. Do you ever feel high or get a buzz after using your pain
medication?
7. Do you ever take your pain medication because you are upset,
using the medication to relieve or cope with problems other
than pain?
8. Have you ever gone to multiple physicians including
emergency room doctors, seeking more of your pain
medication?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Yes No

Note. Questions noted by “⁎” were subsequently
eliminated as a result of the principal component analysis.

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