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Shorter Opioid Misuse Assessment Tool Highly Effective in the Pain Setting

January 10, 2018
A revised self-assessment questionnaire, the COMM-9, improves ease of use in less time with comparable accuracy in opioid monitoring as the original long form assessment.

With Stacey A. McCaffrey, PhD, and Michael E. Schatman, PhD

Clinicians attempting to identify opioid misuse patterns in patients may have improved on the original Current Opioid Misuse Measure (COMM) opioid misuse assessment tool to simplify patient self-assessment while still maintaining accuracy,1 according to a  report appearing in Pain Medicine.

The original COMM tool was intended for assessing the likelihood that a patient may be misusing an opioid treatment, in which the test was administered on a continuous basis during a patient’s treatment.2 It was not designed to be the only mechanism relied on by a clinician to identify possible opioid misuse by a patient, rather it was designed to supplement existing clinical information.

“Unlike the Screener and Opioid Assessment for Patients with Pain (SOAPP) and its revised version,3 which were developed to predict aberrancy in patients being considered for chronic opioid therapy, the COMM allows clinicians to assess self-reported behavior on an ongoing basis,1 which is important as the two measures (potential and actual behavior) do not correlate perfectly,” Dr. Schatman said.

Methodology for Shortening the COMM-9

Findings from an evaluation of the original 17-question COMM tool’s efficacy in primary care clinics indicated that a score of 13 or more on the test was 77% sensitive and 77% specific for identifying patients with prescription drug disorder based on DSM-IV criteria.2

While most patients have been able to complete the COMM in a timely manner, some patients complained about how hard it was to fill out the long questionnaires; this was particularly true of those who have a physical limitation or had a language barrier or difficulty reading.4

The COMM-9 was revised following an assessment of 517 patients receiving opioid treatment for chronic non-cancer pain, and who had completed the COMM.1 A subset of 55 patients had been re-tested a week later to evaluate the reliability of the test. The Prescription Drug Use Questionnaire, physician-report questionnaire data, and a urine toxicology screen were evaluated to categorize patients as positive or negative for aberrant drug-related behavior.1 About 37% (N=189) of the participants in the study were classified as showing a positive aberrant drug behavior index.

The questions selected from the original COMM to be included in the shortened questionnaire were identified using the LASSO statistical method with leave-one-out cross-validation.1,2  Logistic regression was employed to assess probabilities of finding positive aberrant drug-related behavior index scores from each analysis.

The analyses showed that nine of the initial 17 COMM questions were most predictive of aberrant drug-related behavior, and considerable overlap appeared between the shortened test and the original questionnaire for accuracy, as shown by receiver operating characteristic curves.1 Area-under-the-curve analyses of these data gave values of 0.79 for the COMM-9 model with all data, 0.77 for the model incorporating cross-validation data, and 0.78 for the full question COMM test.1

Reliability analysis of the COMM-9 through retesting showed an intraclass correlation coefficient (ICC) of 0.82 (95%, CI 0.70-0.89). This compares with an ICC of 0.86 (95%, CI 0.77-0.92) for the original COMM questionnaire.1

Clinical Practicality Improved in Shortened Format

“Providers should consider COMM and COMM-9 results in the context of information from other sources, including physical examination such as hepatic palpation, the clinical interview, discussions with family members, laboratory findings (eg, hepatitis), and review of medical records,” Dr. McCaffrey told Practical Pain Management.

“The COMM and COMM-9 were designed as an aid to monitor opioid risk for as long as the patient was on a long-term opioid regimen,” Dr. McCaffrey said, noting that “patients may be asked to take the self- assessment repeatedly—even at each visit. In this case, the reduction in time is a particular advantage of the shorter COMM-9.”5

 “Hopefully, some clinicians who have not used or stopped using the original COMM due to its length will begin to use the COMM-9 in routine practice, leading to detection of subtle risk factors for aberrancy resulting in improved opioid risk mitigation, less aberrancy, and fewer adverse events associated with overdose,” said Dr. Schatman.

Last updated on: January 17, 2018
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Assessment and Monitoring of Pain: Urine Drug Screening
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