Table of Contents
The SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised) is one of the most widely studied and validated tools for assessing opioid misuse risk in chronic pain patients. This comprehensive guide covers everything clinicians need to know about administering, scoring, and interpreting the SOAPP-R in clinical practice.
1. What is the SOAPP-R?
The SOAPP-R is a 24-item self-report instrument developed to aid providers in predicting aberrant medication-related behaviors among chronic pain patients being considered for long-term opioid therapy.
Purpose
The SOAPP-R helps clinicians determine how much monitoring a patient on long-term opioid therapy might require. It is NOT a diagnostic tool—it is a risk stratification tool that informs the level of oversight needed during opioid treatment.
Key Point: The SOAPP-R accesses information not necessarily obtained during an initial evaluation, especially by a nonspecialist. Documentation of responses can prove helpful in medical/legal contexts by providing a basis for clinical decisions.
Development and Validation
Butler et al. developed the SOAPP-R to address limitations of the original SOAPP. The development process was rigorous:
- Started with initial pool of 142 items
- Refined to a 97-item beta version
- Administered to 283 chronic pain patients receiving long-term opioid therapy
- Items evaluated based on correlation with Aberrant Drug Behavior Index (ADBI)
- Final 24 items retained based on predictive criterion beyond self-report
High internal consistency reliability
Strong discriminative ability (p < .001)
Low scores reliably identify low risk
2. Who Should Complete the SOAPP-R?
Appropriate Use
- • Chronic pain patients being considered for opioid therapy
- • Patients starting long-term opioid treatment
- • Pain management consultations
- • Primary care opioid prescribing decisions
- • As part of comprehensive pre-opioid assessment
NOT Intended For
- • All patients (it is condition-specific)
- • Acute pain management
- • Post-surgical short-term opioids
- • Patients already on stable opioid therapy
- • General screening without opioid consideration
Administration Notes
- • Self-report tool: The patient completes the questionnaire themselves
- • Time frame: Questions ask about experiences in the past 30 days
- • Setting: Can be administered in waiting room or during clinical encounter
- • Format: Paper, electronic, or computerized versions available
- • Time to complete: Approximately 5-10 minutes
3. Scoring and Interpretation
Response Scale (Each Item)
| Response | Score | Description |
|---|---|---|
| Never | 0 | Has not occurred in past 30 days |
| Seldom | 1 | Rarely occurred |
| Sometimes | 2 | Occurred occasionally |
| Often | 3 | Occurred frequently |
| Very Often | 4 | Occurred very frequently |
Calculation: Sum all 24 item scores. Total possible range: 0 to 96
Score Interpretation
LOW RISK
Negative Screen
Patients with scores below 18 are at relatively low risk for aberrant medication-related behaviors.
- • Likely compliant with previous therapies
- • Responsible alcohol use history
- • No history of substance difficulties
- • Few symptoms of affective distress
- • May require minimal monitoring
ELEVATED RISK
Positive Screen
Patients with scores of 18 or higher are at elevated risk for opioid misuse.
- • May have history of substance issues
- • Possible prior discharge from care
- • History of noncompliance
- • May need enhanced monitoring
- • Consider alternative therapies first
Statistical Performance at Cutoff of 18
Interpretation: A positive SOAPP-R score (≥18) is 2.5 times more likely to come from someone who is actually at high risk. The high NPV (87%) means negative screens reliably rule out high risk.
Alternative Cutoff Scores
Some clinical guidelines use a higher cutoff for “high risk” classification:
- • Score ≥18: Elevated risk (standard cutoff)
- • Score ≥22: High risk (used by some guidelines)
- • Higher cutoffs increase specificity but decrease sensitivity
4. Clinical Application and Action Steps
The SOAPP-R score should inform—not dictate—clinical decision-making. Here are recommended actions based on score ranges:
Low Risk (Score <18): Standard Monitoring
Patients in this category can likely handle their medication safely with minimal additional oversight.
- Standard opioid prescribing protocols may be appropriate
- Regular follow-up visits (monthly initially, then quarterly)
- Periodic urine drug screening (annually or as clinically indicated)
- Check PDMP at initiation and periodically
- Standard treatment agreement
Elevated Risk (Score ≥18): Enhanced Monitoring
Careful and thoughtful planning is necessary. These patients require additional structure and oversight.
- Consider alternatives first: Exhaust non-opioid interventions
- Behavioral health: Psychological or psychiatric evaluation/treatment
- More frequent visits: Weekly or biweekly initially
- Regular urine drug screens: Monthly or more frequently
- Pill counts: Random or scheduled compliance checks
- Strict treatment agreement: With clear boundaries and consequences
- PDMP checks: Every visit
- Consider counseling: Concurrent with opioid therapy
Best Practice: Review Individual Items
It is a good idea to review the SOAPP-R questions with the patient, especially those items the patient endorsed. This will help flesh out the clinical picture, so the provider can be in the best position to design an effective, workable treatment plan. The conversation itself can be therapeutic and build rapport.
5. SOAPP Versions Comparison
Several versions of the SOAPP exist. Understanding the differences helps select the appropriate tool:
| Version | Items | Cutoff | Notes |
|---|---|---|---|
| SOAPP-R (Revised) | 24 | ≥18 | Most validated, empirically derived, recommended |
| SOAPP (Original) | 14 | ≥7 | Earlier version, conceptually derived |
| SOAPP-SF (Short Form) | 5 | ≥4 | Brief screening, less validated |
| SOAPP-8 (Computer) | 8 | Varies | Adaptive computerized version |
6. Limitations and Considerations
Critical Limitations
- 1.Not a lie detector: Patients determined to misrepresent themselves will still do so. The SOAPP-R relies on honest self-report.
- 2.False positives (~30%): A high score will contain a significant percentage of false positives. Many flagged patients will NOT develop aberrant behaviors.
- 3.Not sole decision basis: Should be combined with clinical interview, physical exam, family history, lab findings, and medical records review.
- 4.Population specificity: Validated in chronic pain patients being considered for opioids—may not generalize to other populations.
Integrate with Other Data Sources
It is critical for providers to consider SOAPP-R results in the context of information from:
- • History and physical examination
- • Clinical interview
- • Discussions with family members
- • Laboratory findings
- • Review of medical records
- • Prescription Drug Monitoring Program (PDMP)
7. Frequently Asked Questions
What is the SOAPP-R screening tool?
The SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised) is a validated 24-item self-report questionnaire that predicts the risk of aberrant medication-related behaviors in chronic pain patients being considered for opioid therapy. It helps providers determine how much monitoring a patient may require.
What is a positive SOAPP-R score?
A SOAPP-R score of 18 or higher is considered positive and indicates higher risk for opioid misuse. This cutoff has 81% sensitivity (identifies 81% of high-risk patients) and 68% specificity. Some clinical guidelines use a score of 22 or higher for high-risk classification. Scores range from 0-96.
How is the SOAPP-R scored?
Each of the 24 SOAPP-R items is scored from 0-4: Never=0, Seldom=1, Sometimes=2, Often=3, Very Often=4. Item scores are summed for a total score ranging from 0-96. A score of 18+ indicates elevated risk. The questions ask about behaviors and experiences in the past 30 days.
Who should complete the SOAPP-R?
The SOAPP-R should be completed by chronic pain patients being considered for long-term opioid therapy. It is NOT intended for all patients - only those where opioid treatment is being contemplated. It is a patient self-report tool completed before initiating opioid therapy.
What are the limitations of the SOAPP-R?
The SOAPP-R is NOT a lie detector - patients determined to misrepresent themselves may still do so. A high score contains about 30% false positives. Results should be combined with clinical interview, physical examination, family history, laboratory findings, and medical records review. It should not be the sole basis for treatment decisions.
What is the difference between SOAPP and SOAPP-R?
The SOAPP-R is the revised, empirically-derived version with 24 items and improved psychometric properties (Cronbach alpha=0.88). The original SOAPP-14 has 14 items with a cutoff of 7. The SOAPP-SF (short form) has 5 items with a cutoff of 4. The SOAPP-R is considered the most validated version for clinical use.
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