DIRE Score

1. See Also
   1. Chronic Pain Management
   2. Opioid Risk Tool
2. Indications
   1. Assessment of a patient on selection for Chronic Opioid management
3. Criteria: Diagnosis
   1. Score 1: Benign chronic condition, minimal objective signs (e.g. Fibromyalgia, Migraines, low back)
   2. Score 2: Slowly progressive condition with moderate pain (e.g. failed back surgery, Neuropathy)
   3. Score 3: Advanced condition associated with severe pain (e.g. severe spinal stenosis)
4. Criteria: Intractability
   1. Score 1: Few therapies tried and patient is passively involved in management
   2. Score 2: Most therapies tried but patient not completely engaged in management, or barrier limited
   3. Score 3: Inadequate response to full spectrum of therapy despite maximally engaged patient
5. Criteria: Risk - Psychological
   1. Score 1: Serious mental illness or Personality Disorder
   2. Score 2: Moderate interference from mental health condition (e.g. depression, Anxiety Disorder)
   3. Score 3: No significant underlying mental illness and communicates well in clinic
6. Criteria: Risk - Chemical Health
   1. Score 1: Active or recent use of Illicit Drugs, excessive Alcohol or prescription drug use
   2. Score 2: Uses medications to cope with stress or prior Chemical Dependency now in remission
   3. Score 3: No Chemical Dependency or maladaptive medication use
7. Criteria: Risk - Reliability
   1. Score 1: Numerous problems with prior medications (misuse, missed appointments, non-compliant)
   2. Score 2: Generally reliable, but occasional lapses in compliance
   3. Score 3: Highly reliable patient
8. Criteria: Risk - Social Support
   1. Score 1: Chaotic life with minimal family support, close relationships or life roles
   2. Score 2: Relationships and life roles with some reduction
   3. Score 3: No social isolation with maintained family, friends and work/school involvement
9. Criteria: Efficacy
   1. Score 1: Minimal pain relief or poor function despite moderate to high doses
   2. Score 2: Moderate benefit with improved function or insufficient trial
   3. Score 3: Good improvement in pain, function, quality of life with stable doses over time
10. Scoring
    1. Add the 7 scores above (D + I + 4R + E) = 7 to 21
11. Interpretation
    1. Score 7-13: Not suitable candidate for longterm OpioidAnalgesic therapy
    2. Score 14-21: Good candidate for longterm OpioidAnalgesic therapy
12. References
    1. Belgrade (2009) Chronic Pain Managament UMN CME, Minneapolis