| For each factor, rate the patient's score from 1 to 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 (eg, fibromyalgia, migraine headaches, nonspecific back pain) | |
| 2 = Slowly progressive condition concordant with moderate pain, or fixed condition with moderate objective findings (eg, failed back surgery syndrome, back pain with moderate degenerative changes, neuropathic pain) | ||
| 3 = Advanced condition concordant with severe pain with objective findings (eg, 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 (eg, 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 | |
| Psychological | 1 = Serious personality dysfunction or mental illness interfering with care (eg, personality disorder, severe affective disorder, significant personality issues) | |
| 2 = Personality or mental health interferes moderately (eg, 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 CD in remission | ||
| 3 = No CD history; not drug-focused or chemically reliant | ||
| Reliability | 1 = History of numerous problems (eg, medication misuse, missed appointments, rarely follows through) | |
| 2 = Occasional difficulties with compliance, but generally reliable | ||
| 3 = Highly reliable patient with medications, appointments, and treatment | ||
| Social support | 1 = Life in chaos (eg, 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 | 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 | ||
