Opioid Protective Behavioral Strategies Scale (OPBSS)

Abstract

The Opioid Protective Behavioral Strategies Scale (OPBSS) is an empirically validated psychometric instrument developed by Margo C. Hurlocker and Matthew R. Pearson (2025) at the University of New Mexico’s Center on Alcohol, Substance Use, and Addictions (CASAA). Designed to address an urgent gap within addiction science and public health surveillance, the OPBSS evaluates the cognitive and behavioral tactics that individuals employ before, during, after, or instead of using licit or illicit opioids to mitigate adverse outcomes, overdose, and substance-related consequences. Originating from an initial pool of 60 items adapted from established alcohol and cannabis harm reduction measures and clinical literature, the scale was refined through rigorous item analysis and exploratory factor analysis (EFA) into a comprehensive 46-item self-report questionnaire. The instrument features a robust two-factor structure: Controlled Opioid Use (COU; 31 items), which captures self-regulatory behaviors regarding the timing, frequency, dosage, and social contexts of use; and Serious Harm Reduction (SHR; 15 items), which indexes high-impact risk-mitigation practices such as testing drugs for fentanyl, avoiding concurrent central nervous system depressant use (e.g., alcohol, benzodiazepines), and preventing unmonitored consumption. Items are scored on a 6-point Likert-type frequency scale ranging from 1 (Never) to 6 (Always). Psychometric evaluations in U.S. community-dwelling adults demonstrating past-month opioid use indicate high subscale internal consistency, acceptable one-month test-retest reliability (.40 < ICCs < .64), and robust criterion, concurrent, predictive, and convergent validity. The OPBSS serves as an indispensable resource for clinical trialists, harm reduction researchers, and behavioral health practitioners seeking to quantify self-directed protective behaviors across diverse opioid-using populations.

Keywords

Opioid Protective Behavioral Strategies Scale, OPBSS, protective behavioral strategies, harm reduction, opioids, controlled opioid use, serious harm reduction, overdose prevention, psychometrics, factor analysis, substance use measurement

Authors

The OPBSS was conceptualized, developed, and psychometrically evaluated by clinical psychologists and quantitative addiction specialists at the University of New Mexico:

• Margo C. Hurlocker, Ph.D.
  Affiliation: Center on Alcohol, Substance Use, and Addictions (CASAA), University of New Mexico, Albuquerque, NM, United States.
  ORCID: 0000-0002-9744-8551
  Email: [email protected]
  Mailing Address: University of New Mexico, Center on Alcohol, Substance Use, and Addictions, 2650 Yale Boulevard Southeast, MSC11 6280, Albuquerque, New Mexico 87106, USA.
• Matthew R. Pearson, Ph.D.
  Affiliation: Center on Alcohol, Substance Use, and Addictions (CASAA), University of New Mexico, Albuquerque, NM, United States.

Purpose

The primary purpose of the Opioid Protective Behavioral Strategies Scale (OPBSS) is to provide an empirically grounded, standardized metric for assessing the behavioral and cognitive harm-reduction strategies individuals utilize to attenuate risks associated with opioid consumption. While the public health landscape has historically prioritized abstinence-only endpoints, contemporary addiction science recognizes the vital role of incremental harm reduction. Individuals who use opioids—whether obtained via medical prescription for chronic pain management, diverted pharmaceutical sources, or illicit street supplies—often engage in deliberate self-protective practices to manage their tolerance, prevent severe intoxication, avoid legal repercussions, and eliminate fatal overdose.

Prior to the inception of the OPBSS, robust, multi-dimensional instruments existed for assessing protective behavioral strategies (PBS) in the domains of alcohol (e.g., the Protective Behavioral Strategies Survey; Martens et al., 2005) and cannabis (e.g., the Protective Behavioral Strategies for Marijuana Scale; Pedersen et al., 2016). However, the unique pharmacological, physical, and epidemiological dangers of opioids—most notably the acute risk of fatal respiratory depression and toxic drug adulteration—demanded a substance-specific assessment tool. The OPBSS was established to fill this clinical and empirical void.

In clinical settings, the OPBSS allows clinicians, addiction counselors, and medical providers to identify an individual’s existing self-regulation repertoire, facilitate non-judgmental motivational interviewing discussions, and collaboratively build behavioral safety plans. In academic research, the scale provides a quantitative framework to examine whether targeted interventions (such as peer-led harm reduction, mobile health nudges, or contingency management) enhance protective strategy uptake, and whether heightened utilization of these strategies prospectively mediates reductions in emergency department visits, non-fatal overdoses, and functional impairment.

Psychological Construct

The psychological construct captured by the OPBSS is Opioid Protective Behavioral Strategies (PBS), defined as actionable, conscious behavioral actions and cognitive self-restraints enacted before, during, after, or instead of opioid consumption to moderate consumption volume, curtail adverse drug reactions, and avert catastrophic harm. Rather than representing passive traits, PBS reflect dynamic, modifiable self-regulatory behaviors. The OPBSS divides this broad construct into two primary, interrelated dimensions:

1. Controlled Opioid Use (COU)

The Controlled Opioid Use dimension encompasses 31 items assessing self-management routines oriented around lifestyle integration, role performance preservation, and consumption boundaries. Individuals scoring high on COU exhibit cognitive control over when, where, and why they consume opioids. Key behavioral markers within this construct include:

• Temporal and contextual boundary setting: Restricting consumption to times after daily occupational, academic, or familial responsibilities are completed (e.g., avoiding consumption before work or school, limiting use to weekends or nighttime).
• Affective and coping regulation: Actively refraining from using opioids as a primary coping mechanism for negative affect, emotional distress, depression, anxiety, or boredom.
• Tolerance and physical dependency management: Taking planned hiatuses (e.g., taking breaks for a week or two to decrease physical tolerance) and monitoring consumption frequency to circumvent habitual, compulsive use patterns.
• Social accountability and self-monitoring: Enlisting trusted friends to give feedback when consumption thresholds have been reached, leaving environments where peer pressure is present, and refusing to ride in motor vehicles with intoxicated drivers.

2. Serious Harm Reduction (SHR)

The Serious Harm Reduction dimension comprises 15 items measuring targeted, high-stakes safety practices directly aligned with mortality reduction, biological safety, and legal self-protection. Unlike COU, which largely mirrors traditional moderation and behavioral self-control constructs seen in alcohol literature, SHR reflects the life-and-death realities of contemporary opioid use within an illicit market characterized by synthetic opioids. Core facets include:

• Polysubstance avoidance: Deliberately refusing to combine opioids with other central nervous system (CNS) depressants, such as benzodiazepines (e.g., diazepam, alprazolam, clonazepam) or ethanol, as well as potent stimulants (e.g., avoiding “speedballing” with cocaine), which exponentially amplify respiratory arrest risks.
• Point-of-consumption surveillance and testing: Utilizing fentanyl test strips or chemical reagent testing to verify the composition of substances before use.
• Environmental and interpersonal safety: Consuming substances solely in private, safe quarters (such as one’s home), sourcing opioids only from verified, trusted vendors, and ensuring the physical presence of individuals capable of administering naloxone or initiating resuscitation protocols in an overdose event.
• Route of administration risk minimization: Avoiding higher-risk ingestion methods, specifically parenteral/injectable administration, which carries pronounced risks of blood-borne viral transmission (e.g., HIV, Hepatitis C), endocarditis, and rapid-onset overdose.

Theoretical Framework

The OPBSS is conceptualized at the intersection of several foundational psychological paradigms, notably Bandura’s Social Cognitive Theory, Marlatt’s Relapse Prevention and Harm Reduction models, and the Behavioral Economics of Addiction.

Social Cognitive Theory and Self-Regulation

Albert Bandura (1986, 1991) posited that human behavior is guided by triadic reciprocal determinism among personal cognitive factors, environmental influences, and behavioral execution. Central to this model is the self-regulatory system, which operates through self-monitoring, judgment of behavior against internal standards, and affective self-reaction. In the context of the OPBSS, protective behavioral strategies represent the behavioral operationalization of self-regulation. Individuals who possess higher self-efficacy regarding their ability to regulate their opioid use deploy strategies (e.g., setting dosage ceilings, planning safe transportation) to proactively navigate cues that would otherwise lead to uncontrolled use.

The Harm Reduction Paradigm

Pioneered in psychological substance use treatment by G. Alan Marlatt (1996, 1998), the harm reduction framework recognizes that substance use exists on a continuum of risk. Complete abstinence, while a valid and optimal outcome for many, is neither the sole criterion of therapeutic success nor immediately attainable for all individuals. By reframing safety behaviors as measurable clinical targets, the OPBSS operationalizes Marlatt’s view that any step toward decreased substance-related morbidity constitutes a legitimate, positive clinical progression. The SHR factor specifically operationalizes the public health priority of preserving life and somatic integrity regardless of whether frequency of use has reached zero.

Behavioral Economics and Cost-Benefit Decision Making

From a behavioral economic vantage point, substance use reflects an ongoing dynamic evaluation of immediate reward versus delayed, probabilistic punishment (Bickel et al., 2014). Operant principles indicate that opioid consumption provides potent, rapid neurobiological reinforcement. Protective behavioral strategies increase the cognitive and physical barriers to impulsive, heavy consumption, functioning as pre-commitment mechanisms (e.g., buying smaller amounts, pacing usage, refusing to use alone). By introducing structural constraints into the environment, PBS mitigate the impact of delay discounting, shifting behavioral allocation away from hazardous intake patterns toward safer, controlled behavioral repertoires.

Validity

The psychometric evaluation conducted by Hurlocker and Pearson (2025) established robust empirical support for the construct, criterion, concurrent, predictive, and convergent validity of the OPBSS across adult samples reporting past-month opioid use.

Criterion-Related Validity

Criterion validity was confirmed through one-way analyses of variance (ANOVAs) evaluating mean differences in OPBSS subscale scores across distinct pharmacological and behavioral profiles:

• Opioid Substance Class: Significant main effects were observed for the primary type of opioid used on both Controlled Opioid Use, F(3, 323) = 4.13, p = .007, and Serious Harm Reduction, F(3, 322) = 6.08, p < .001. Individuals utilizing illicit opioids exhibited distinct risk-mitigation profiles compared to those taking legally prescribed therapeutic regimens.
• Route of Administration: Route of intake demonstrated profound criterion-related differences across both subscales. A highly significant main effect emerged for route of administration on Controlled Opioid Use, F(2, 278) = 9.94, p < .001, and an exceptionally large effect was identified on Serious Harm Reduction, F(2, 277) = 36.77, p < .001. Those using non-oral or injection routes reported significantly different engagement patterns in specific harm-reduction behaviors relative to oral-only consumers.

Concurrent and Predictive Validity

Regression and correlational analyses partially supported concurrent and longitudinal predictive validity. At baseline (Time 1):

• OPBSS subscales accounted for significant variance in at-risk opioid use, ΔF(2, 190) = 23.97, ΔR² = .146, p < .001.
• Subscale scores were significantly protective against opioid-related adverse consequences, ΔF(2, 243) = 12.49, ΔR² = .063, p < .001.

Convergent Validity

Convergent validity was documented through bivariate correlations with parallel constructs in the addiction literature. OPBSS factor scores demonstrated positive correlations with established alcohol protective behavioral strategies (Protective Behavioral Strategies Survey) and cannabis protective strategies (Protective Behavioral Strategies for Marijuana Scale), corroborating the theoretical assumption that generalized protective competencies transcend specific drug classes. Furthermore, higher scores on both COU and SHR were inversely correlated with objective measures of opioid-related problems and distress across both assessment waves.

Reliability

The psychometric evaluation of the OPBSS demonstrated acceptable to high reliability coefficients across both subscales, supporting its utility in both cross-sectional assessment and repeated-measures clinical trials.

Internal Consistency

Internal consistency analyses revealed elevated homogeneity across items within both dimensions. The subscales demonstrated high internal consistency coefficients (Cronbach’s α and McDonald’s ω values exceeding .85 for both Controlled Opioid Use and Serious Harm Reduction), reflecting strong inter-item covariance and minimal measurement error variance. The large item composition of the COU factor (31 items) provides extensive domain coverage without introducing redundant, multicollinear item phrasing.

Test-Retest Reliability and Temporal Stability

The stability of the instrument over time was evaluated over a one-month test-retest interval. Overall, temporal stability was supported across the subscales, yielding intraclass correlation coefficients ranging between acceptable and moderate levels (.40 < ICCs < .64). This moderate-to-substantial stability reflects the reality that protective behaviors are state-influenced, adaptive skills that fluctuate in response to situational risk environments, supply changes, and personal motivation.

Notably, item-level test-retest investigations flagged two specific items exhibiting poor temporal consistency: Item 6 (“Limited use to weekends?”) and Item 37 (“Limited the amount/dose of opioids you used in one sitting?”). Researchers and clinicians are advised to consider situational context when interpreting these two individual metrics, as fluctuating work schedules or acute pain flares can induce rapid, natural variations in weekend scheduling and single-sitting dosing.

Factor Analysis

The structural composition of the OPBSS was established through iterative exploratory factor analysis (EFA) utilizing robust extraction methods suited for ordinal behavioral data.

Initial Extraction and Item Reduction

The initial instrument pool comprised 60 candidate items derived from adapted alcohol/cannabis PBS scales and extensive opioid clinical literature. An initial exploratory factor analysis was conducted on adults reporting past-month opioid use. Both Horn’s Parallel Analysis and model fit indices supported a two-factor latent framework. The initial two-factor model demonstrated an acceptable Standardized Root Mean Squared Residual (SRMR = .043).

During the primary EFA, six items were eliminated due to near-equivalent cross-loadings across both latent dimensions, which threatened simple structure. Re-estimation of the remaining 54 items reinforced the two-factor solution. Successive iterations removed an additional seven items due to insufficient theoretical distinctiveness or low communalities.

Final Factor Solution

In the subsequent 47-item re-estimation, one additional item failed to achieve the predefined factor loading threshold (λ ≥ .40) and was consequently excised. The final exploratory factor analysis conducted on the refined 46-item set yielded an optimal, clean two-factor solution characterized by superior fit:

• Fit Indices: Final Standardized Root Mean Squared Residual (SRMR) was .040, indicating minimal residual discrepancy between the sample covariance matrix and the implied model matrix.
• Factor 1: Controlled Opioid Use (COU): Accommodated 31 items displaying primary loadings ranging from .41 to .82 on self-regulation, lifestyle scheduling, and emotional coping restraint.
• Factor 2: Serious Harm Reduction (SHR): Accommodated 15 items displaying strong loadings on polysubstance avoidance, drug checking, safe-setting protocols, and overdose prevention tactics.
• Factor Correlation: An oblique rotation revealed a moderate, positive correlation between the COU and SHR factors, validating the conceptual model that these domains operate as distinct yet mutually supportive dimensions of a broader protective behavioral repertoire.

Instrument / Measurement Tool

• Instrument Name: Opioid Protective Behavioral Strategies Scale (OPBSS)
• Acronym: OPBSS
• Authors: Margo C. Hurlocker & Matthew R. Pearson
• Publication Year: 2025
• Test Type: Original Self-Report Rating Scale
• Administration Format: Paper-and-pencil, computer-administered, or mobile survey
• Target Population: Human adults (aged 18 years and older) who report licit and/or illicit opioid use within the preceding month
• Administration Time: Approximately 8 to 12 minutes
• Item Count: 46 total items
  • Controlled Opioid Use (COU): 31 items (Items 1 to 31)
  • Serious Harm Reduction (SHR): 15 items (Items 32 to 46)
• Recall Period: Past 30 days
• Response Format: 6-point Likert-type frequency scale:
  • 1 = Never
  • 2 = Rarely
  • 3 = Occasionally
  • 4 = Sometimes
  • 5 = Usually
  • 6 = Always
• Scoring Instructions:
  • Subscale scores are typically calculated by taking the arithmetic mean of the items corresponding to each factor: COU Mean = (Sum of Items 1–31) / 31; SHR Mean = (Sum of Items 32–46) / 15.
  • Alternatively, sum scores can be calculated (COU Range: 31–186; SHR Range: 15–90).
  • Higher scores indicate a higher frequency of implementing protective behavioral strategies. None of the items are reverse-coded.

Permissions & Fee and Test Year

The Opioid Protective Behavioral Strategies Scale was published in 2025 by the American Psychological Association (APA). The scale was developed for open scientific advancement in public health and addiction medicine:

• Commercial Use: No commercial licensing is required for purely non-profit academic research or clinical training. Commercial packaging within proprietary software systems requires permission from the authors or copyright holders.
• Fee: Free of charge ($0.00) for empirical research, educational purposes, and non-profit harm reduction programs.
• Permissions: Researchers and educators are granted permission to reproduce and administer the OPBSS for research and teaching purposes, provided appropriate scholarly attribution is maintained. Inquiries regarding scale modifications or large-scale clinical integration may be directed to Dr. Margo C. Hurlocker at [email protected].

References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Bandura, A. (1991). Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes, 50(2), 248–287. https://doi.org/10.1016/0749-5978(91)90022-L
• Bickel, W. K., Johnson, M. W., Koffarnus, M. N., MacKillop, J., & Murphy, J. G. (2014). The behavioral economics of substance use disorders: Reinforcement pathologies and their repair. Annual Review of Clinical Psychology, 10, 641–677. https://doi.org/10.1146/annurev-clinpsy-032813-153724
• Hurlocker, M. C., & Pearson, M. R. (2025). Opioid Protective Behavioral Strategies Scale (OPBSS): Development and psychometric evaluation. Experimental and Clinical Psychopharmacology, 33(1), 100–108. https://doi.org/10.1037/pha0000738
• Marlatt, G. A. (1996). Harm reduction: Coming to terms with alcohol and drugs. Cognitive and Behavioral Practice, 3(2), 205–211. https://doi.org/10.1016/S1077-7229(96)80016-0
• Marlatt, G. A. (1998). Harm reduction: Pragmatic strategies for managing high-risk behaviors. Guilford Press.
• Martens, M. P., Ferrier, A. G., & Cimini, M. D. (2005). Do protective behavioral strategies mediate the relationship between drinking motives and alcohol-related problems? Journal of Studies on Alcohol, 68(1), 106–114. https://doi.org/10.15288/jsa.2007.68.106
• Pedersen, E. R., Huang, W., Grant, S., & Prince, M. A. (2016). The Protective Behavioral Strategies for Marijuana Scale: Further examination using item response theory. Psychology of Addictive Behaviors, 31(5), 548–559. https://doi.org/10.1037/adb0000271

13. Items of the Scale (Questionnaire)