DIRE Score: Patient Selection for Chronic Opioid Analgesia
For each factor, rate the patient’s score from 1-3 based on the explanations in the right-hand column
SCORE FACTOR EXPLANATION
DIAGNOSIS
1 = Benign chronic condition with minimal objective findings or no definite medical diagnosis.
Examples: fibromyalgia, migraine headaches, non-specific back pain.
2 = Slowly progressive condition concordant with moderate pain, or fixed condition with
moderate objective findings. Examples: failed back surgery syndrome, back pain with
moderate degenerative changes, neuropathic pain.
3 = Advanced condition concordant with severe pain with objective findings. Examples: severe
ischemic vascular disease, advanced neuropathy, severe spinal stenosis.
INTRACTABILITY
1 = Few therapies have been tried and the patient takes a passive role in his/her pain
management process.
2 = Most customary treatments have been tried but the patient is not fully engaged in the pain
management process, or barriers prevent (insurance, transportation, medical illness).
3 = Patient fully engaged in a spectrum of appropriate treatments but with inadequate response.
RISK
(R = Total of P+C+R+S below)
Psychological
1 = Serious personality dysfunction or mental illness interfering with care. Example: personality
disorder, severe affective disorder, significant personality issues.
2 = Personality or mental health interferes moderately. Example: depression or anxiety disorder.
3 = Good communication with clinic. No significant personality dysfunction or mental illness.
Chemical Health
1 = Active or very recent use of illicit drugs, excessive alcohol, or prescription drug abuse.
2 = Chemical coper (uses medications to cope with stress) or history of chemical dependence (CD)
in remission.
3 = No CD history. Not drug-focused or chemically reliant.
Reliability
1 = History of numerous problems: medication misuse, missed appointments, rarely follows
through.
2 = Occasional difficulties with compliance, but generally reliable.
3 = Highly reliable patient with meds, appointments & treatment.
Social Support
1 = Life in chaos. Little family support and few close relationships. Loss of most normal life roles.
2 = Reduction in some relationships and life roles.
3 = Supportive family/close relationships. Involved in work or school and no social isolation.
EFFICACY SCORE
1 = Poor function or minimal pain relief despite moderate to high doses.
2 = Moderate benefit with function improved in a number of ways (or insufficient info – hasn’t
tried opioid yet or very low doses or too short of a trial).
3 = Good improvement in pain and function and quality of life with stable doses over time.
Total score = D + I + R + E
Score 7-13: Not a suitable candidate for long-term opioid analgesia
Score 14-21: May be a good candidate for long-term opioid analgesia
NOTES
A DIRE Score of ≤13 indicates that the patient may not be suited to long-term opioid pain management.
Used with permission by Miles J. Belgrade, MD
