Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The DIRE Score, or Diagnosis, Intractability, Risk, and Efficacy Score, is a clinical calculator used in the management of chronic pain patients who are being considered for long-term opioid therapy. This scoring system is designed to assess the patient's risk of opioid misuse and to determine the appropriateness of opioid prescription. 

The DIRE Score applies to adult patients with chronic non-cancer pain who are being evaluated for long-term opioid therapy. It is particularly useful in stratifying patients based on their risk of opioid misuse, thus aiding clinicians in making informed decisions about opioid prescription. 

The DIRE Score considers four main factors: Diagnosis (the nature and extent of the patient's pain condition), Intractability (the degree to which the pain is resistant to treatment), Risk (the patient's risk of opioid misuse or addiction), and Efficacy (the likelihood that opioid therapy will be effective for the patient's pain). 

There are no specific exclusion criteria for the use of the DIRE Score, but it should be noted that it is not intended for use in patients with cancer-related pain or in those who are already on long-term opioid therapy. It is also not a substitute for a comprehensive clinical assessment and should be used in conjunction with other clinical tools and

DIRE score for opioid prescription in chronic pain

# Criteria
 ## Diagnosis
A. Benign chronic condition, minimal objective findings or no definite diagnosis (such as fibromyalgia, migraine headaches, non-specific back pain) (+1)
B. Slowly progressive condition concordant with moderate pain or fixed condition with moderate objective findings (such as failed back surgery syndrome, back pain with moderate degenerative changes, neuropathic pain) (+2)
C. Advanced condition concordant with severe pain with objective findings (such as severe ischemic vascular disease, advanced neuropathy, severe spinal stenosis) (+3)
## Intractability
D. Few therapies tried, patient takes a passive role in pain management process (+1)
E. Most customary treatments have been tried but patient not fully engaged in pain management process or barriers prevent (examples: insurance, transportation, medical illness) (+2)
F. Patient fully engaged in spectrum of appropriate treatments but with inadequate response (+3)
## Psychological risk
G. Serious personality dysfunction or mental illness interfering with care (such as personality disorder, severe affective disorder, significant personality issues) (+1)
H. Personality or mental health interferes moderately (such as depression or anxiety disorder) (+2)
I. Good communication with clinic, no significant personality dysfunction or mental illness (+3)
## Chemical health risk
J. Active or very recent use of illicit drugs, excessive alcohol, or prescription drug abuse (+1)
K. Chemical coper (uses medications to cope with stress) or history of chemical dependence in remission (+2)
L. No chemical dependence history, not drug-focused or chemically reliant (+3)
## Reliability risk
M. History of numerous problems (medication misuse, missed appointments, rarely follows through) (+1)
N. Occasional difficulties with compliance but generally reliable (+2)
O. Highly reliable patient with meds, appointments, and treatment (+3)
## Social support risk
P. Life in chaos, little family support, few close relationships, loss of most normal life roles (+1)
Q. Reduction in some relationships and life roles (+2)
R. Supportive family/close relationships, involved in work or school and no social isolation (+3)
## Efficacy
S. Poor function or minimal pain relief despite moderate to high doses (+1)
T. Moderate benefit with improved function in a number of ways (or insufficient information, hasn't tried opioid yet, or very low doses/trial too short) (+2)
U. Good improvement in pain/function and quality of life with stable doses over time (+3)

# Conditions
- score <= 13
- score >= 14
- score == 0

Shoulder osteoarthritis

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