The DIRE (Diagnosis, Intractability, Risk, Efficacy) Score is a clinician-rated 7-item tool developed in a specialist pain clinic to estimate which adults with chronic non-cancer pain are likely to obtain effective analgesia and remain adherent with long-term opioid therapy.

In the original retrospective study, six physicians applied DIRE to 61 existing chronic opioid cases from a pain centre, using treating clinicians’ global impressions of compliance, analgesic benefit and whether opioids were continued or stopped as outcomes. The score showed good internal consistency and very high inter- and intra-rater reliability, and a total score of ≤13 best separated patients with poor compliance, limited efficacy and opioid discontinuation from those with more favourable outcomes.

Later work has been limited. A small comparison study of patients who were subsequently discontinued from opioids for aberrant drug-related behaviour found that, when used to predict this outcome at baseline, DIRE was substantially less sensitive than the clinical interview or dedicated misuse-risk tools such as SOAPP. Systematic reviews performed for guideline development similarly judged the overall evidence base for opioid misuse-risk instruments, including DIRE, to be sparse and low quality.

Current opioid-prescribing guidance, including the 2022 CDC guideline and Australian pain and geriatric medicine statements, emphasises modest and uncertain long-term benefit from opioids in chronic non-cancer pain, important potential harms and a preference for multimodal non-opioid management, cautious time-limited opioid trials and structured tapering when harms outweigh benefits. Within this context, DIRE can be used, if available, as an adjunctive structured summary of diagnosis, treatment efforts and psychosocial risk, rather than a stand-alone determinant of whether to start, continue or stop opioids.

The score is not intended for acute or perioperative pain, cancer-related pain, or end-of-life and palliative care. Evidence is anchored to the original DIRE study.

DIRE Score for Opioid Treatment