Used additional opioids than those prescribed 			[ ]
Used additional opioids than those prescribed more than once	[ ] 

Forged prescription 	[ ]
Sold prescription	[ ]

Admitted to seeking euphoria from opioids 	[ ]
Admitted to wanting opioids for anxiety 	[ ]
Overdose and death 				[ ]
Injected drug 					[ ]

Abnormal urine/blood screen positive for 2 or more substances [ ]

Solicited opioids from other providers	[ ] 
Unauthorized ER visits			[ ]
Concurrent abuse of alcohol 		[ ]
Unauthorized dose escalation 		[ ]

Resisted therapy changes/alternative therapy	[ ]
Reported lost or stolen prescription		[ ]
Canceled clinic visit				[ ]
Requested early refills				[ ]
Requested refills instead of clinic visit	[ ]
Abused prescribed drug				[ ]
Was discharged from practice			[ ]
No show or no follow-up				[ ]

Third party required to manage patient’s medications[ ]

from:PAIN MEDICINE Volume 6, Number 6, 2005, 432–442
Predicting Aberrant Behaviors in Opioid-Treated Patients:Preliminary Validation of the Opioid Risk Tool
Lynn R. Webster, MD, and Rebecca M. Webster