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I appreciate the opportunity to clarify how we applied our criteria for assessing the quality of instruments for detecting aberrant drug-related behavior. 3 Chou R. Fanciullo G.J. Fine P.G. Miaskowski C. Passik S.D. Portenoy R.K. Opioids for chronic noncancer pain: Prediction and identification of aberrant drug-related behaviors: A review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009; 10: 131-146 Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar The case-control study by Atluri and Sudarshan 1 Atluri S.L. Sudarshan G. Development of a screening tool to detect the risk of inappropriate prescription opioid use in patients with chronic pain. Pain Physician. 2004; 7: 333-338 PubMed Google Scholar did not meet the criterion, “adequate description of method for identifying aberrant drug-related behaviors”, because no reproducible method for evaluating for presence of aberrant behaviors in the case group was provided. Some examples of aberrant behaviors resulting in clinic dismissal were described, but a systematically applied method for identifying and defining those behaviors was not. Although nearly 90% of patients had abnormal urine drug-screen results, it was unclear when and why urine drug screens were administered (eg, if urine drug screens were triggered by suspected aberrant behaviors or performed routinely at every visit). Given this lack of information, it is impossible to know whether cases were identified accurately, or to apply the methods to patients in another setting to assemble a comparable group of cases. 5 Whiting P. Rutjes A.W.S. Reitsma J.B. Bossuyt P.M.M. Kleijnen J. The development of QUADAS: A tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Medical Research Methodology. 2003; 3: 25 Crossref PubMed Scopus (2953) Google Scholar For this study, the methods used to identify patients with aberrant behaviors are particularly important to understand because the use of a case-control design already makes it highly susceptible to spectrum bias. 4 Lijmer J.G. Mol B.W. Heisterkamp S. Bonsel G.J. Prins M.H. van der Meulen J.H.P. Bossuyt P.M.M. Empirical evidence of design-related bias in studies of diagnostic tests. JAMA. 1999; 282: 1061-1066 Crossref PubMed Scopus (1448) Google Scholar Reconsideration of Assessment of the Quality of Studies on Accuracy of Screening Instruments to Identify Aberrant Drug-Related Behaviors in Patients Prescribed OpioidsThe Journal of PainVol. 11Issue 2PreviewTo the Editor: Full-Text PDF