Opioid Use Disorder

Should We Use COMM (Current Opioid Misuse Measure) to Screen for Opioid Abuse in Patients With Cancer Pain?

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Background

Among the most difficult challenges presented by the prescription opioid abuse crisis are its implications for the treatment of cancer pain. Access of patients with cancer pain to opioid analgesia has decreased significantly, including at the end of life.

On the other hand, although exempt from 2016 CDC restrictions and other national and state guidelines, patients taking opioids for cancer pain may have premorbid or develop iatrogenic opioid use disorder (OUD).1–5 OUD during cancer treatment and survivorship may increase patients’ morbidity and mortality by decreasing adherence to cancer treatment, compromising relationships between the patient and treatment team, and undermining social support networks.5–8 Of 1,144 US cancer centers surveyed in a recent study, only 45.5% offered chemical dependency services, with some of them limited to alcohol.9 Another recent study showed that 69% of surveyed clinicians expressed concerns about addiction in patients with cancer and 63% about associated undertreatment of cancer pain, and only 23% to 35% reported adequate knowledge and confidence in caring for patients with cancer and OUD.10 Without special training, clinicians either “use opioids sparingly,” resulting in poor pain management, or believe it is not necessary to address comorbid OUD while prescribing opioids to patients with cancer.11,12 Without evidence-based clinical pathways or validated screening tools, identification of aberrant opioid use is based on individual practitioners’ personal biases, previous experience, and various education backgrounds.13,14

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain recommend use of the Current Opioid Misuse Measure (COMM), a self-assessment risk tool to screen for OUD during opioid treatment.15 It has not been validated in patients with cancer pain.

COMM assesses 5 domains: signs and symptoms, emotional problems, appointment patterns, evidence of lying, and medication misuse (supplemental eTable 1, available with this article at JNCCN.org). A cutoff score of ≥9 is considered positive for current opioid misuse in patients with noncancer pain, with a sensitivity of 0.76 and specificity of 0.66.16 A cutoff of ≥13 offers a sensitivity of 0.77 and specificity of 0.77.17 COMM has been used but has not been validated in patients treated for cancer pain.18–20

Another known screening tool for OUD risk assessment is a clinician-administered Cut Down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire.20 A score of ≥2 of 4 is considered suggestive of alcohol use disorder and has been shown to predict longer use of opioids during cancer treatment, use of illicit drugs, OUD, and urine drug studies (UDS) positive for aberrant drug use.21,22 One study showed that patients with head and neck cancer and a history of alcoholism used opioids for a longer duration than those with no such history (261 vs 93 days; P=.008) after receiving curative radiation therapy.23

The Supportive Care and Anesthesia Pain services at Memorial Sloan Kettering Cancer Center (MSKCC) adopted a patient-reported outcome (PRO) COMM and a clinician-administered CAGE.24 At MSKCC, UDS is not performed routinely but ordered if a clinician suspects opioid misuse. Finally, if present, OUD diagnosis is recorded in medical records as a CPT diagnostic code.

The purpose of this study was to determine the utility of COMM for patients with cancer-related pain.

Cancer pain is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”25 The IASP defines chronic cancer-related pain is defined as “chronic pain caused by the primary cancer itself or metastases (chronic cancer pain) or its treatment (chronic postcancer treatment pain).”26

To determine the utility of COMM to identify symptoms, behaviors, and outcomes suggestive of OUD in patients with cancer-related pain, we aimed to (1) compare rates of completion of COMM versus the Brief Pain Inventory (BPI) at 2 time points within 100 days (T1 and T2); (2) evaluate the prevalence of a positive COMM score, the internal consistency of the result, and the direction of change between T1 and T2; (3) compare the results of COMM in patients with cancer pain and (a) clinical suspicion of OUD measured by orders for UDS and UDS results, (b) CAGE results, and (c) CPT codes for OUD; (4) determine whether COMM is associated with patient demographics, cancer diagnosis, pain relief ≥2 points on the BPI, opioid doses required, and/or morbidity (proximity to death was used as a proxy for morbidity); and (5) examine individual items of COMM for face validity by comparing COMM items with common symptoms reported during cancer treatment.

Discussion

Growing concerns about OUD and the resulting decrease in opioid availability for patients with cancer pain have led to increased attention to screening for aberrant opioid use in oncology.44 Our study examined the use of the COMM screener, one of the NCCN-recommended tools to identify aberrant opioid use, and challenged the validity of its use in patients with cancer pain, of whom 56% died since the end of the study. This is the first longitudinal study of COMM in patients with cancer pain.

We examined individual items of COMM for face validity. Two items describing opioid diversion were “taking someone else’s medications” and “borrowed pain medications.” The prevalence of these behaviors identified by COMM was only 3% at T1 and 2% at T2. Such a low prevalence of these aberrant drug behaviors is reassuring. Many of the items on COMM are subtle to compensate for possible underreporting or not admitting to opioid misuse. These subtle items (eg, memory problems and mood disorders, as pointed out in Table 2) may not apply to patients with a severe life-threatening disease, such as patients with cancer pain. Most other COMM items are related to the burden of cancer-related symptoms; for example, the frequency of positive answers correlates with the reported prevalence of symptoms and behaviors such as memory problems, fatigue, anger, and desire for hastened death. Contrary to inappropriate off-schedule calls, clinic, and emergency department visits for pain management by patients with chronic noncancer pain described in COMM as “doctor shopping,” during cancer treatment these patient behaviors are part of the treatment plan and therefore appropriate and encouraged. Our patients scored relatively high in response to questions asking if the patients or others are thinking or worried about their medications. Such worries have become a reality for patients, caregivers, and clinicians witnessing decreased opioid availability for cancer pain.

Using the current version of COMM may create an additional barrier to patients’ access to opioid pain management. Nearly half of the patients seen at MSKCC pain clinics for severe cancer pain would be considered to have aberrant drug use if the cutoff of 9 were used. Chronic exposure to opioids is considered a risk factor for OUD, but in our study using the cutoff of 9, as patients continued to receive opioids for 49 to 100 days, conversion from positive to negative was 2.4 times more likely than the reverse. Data from OUD codes, urine toxicology screens, and CAGE scores were available in only a minority of patients and are subject to poor reliably based on the current medical practice at MSKCC. To decrease the possibility of false-positive results, we elected the COMM cutoff of 13, and even with this cutoff, nearly one-third of the patients would be considered as having aberrant drug use. Furthermore, as patients remained on opioids for 49 to 100 days, the likelihood of improving COMM score (turning from ≥13 to <13) was 6.1 times greater than the reverse, the opposite of what would be expected in patients with extended exposure to opioids. Our study finds that using COMM in a cancer population may significantly overestimate opioid misuse. As a result, this tool has been retired from our institution’s standard PROs.

Conclusions

COMM ≥13 in our patient population may be diagnosing a greater symptom burden of cancer and predicting earlier mortality since patients with COMM ≥13 at T1 were 1.9 times more likely to die within 12 months than those with COMM <13 (Table 1).

The role of prescription opioids for cancer-related pain is a standard of care. Inappropriate identification of aberrant opioid use may stigmatize patients with cancer and prevent them from receiving effective pain control, including patients with advanced cancer (at the time of writing, 65% of our patients have died since study completion). Using COMM without modifications can create an additional barrier to cancer pain management, such as limiting appropriate opioid use. We used only 1 of several screening tools recommended by the NCCN. A self-reported monitoring scale adapted to this patient population is urgently needed. Further studies on opioid use disorder in patients treated for cancer-related chronic pain are needed to inform institutional and national guidelines to identify patients at increased risk, allocate resources, frame standard of care, and inform both patients and health care professionals of recommended approaches.

Confronting the Stigma of Opioid Use Disorder—and Its Treatment.

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The death of Philip Seymour Hoffman from a heroin overdose tragically adds another name to the list of celebrities who have lost their lives to addiction. Increasing numbers of overdoses from prescription opioids and a more recent increase in heroin-associated fatalities have caused heartbreak in communities across the country. More than 30 000 deaths from unintentional drug overdose were reported in the United States in 2010, the most recent year for which data are available.1

Given the severity of this national epidemic, it is time to confront the stigma associated with opioid use disorder and its treatment with medications. By limiting the availability of care and by discouraging people who use opioids from seeking effective services, this stigma is impeding progress in reducing the toll of overdose.

According to the National Institute on Drug Abuse (NIDA), the long-acting medications methadone and buprenorphine are “a critical component of opioid addiction treatment” because “scientific research has established that medication-assisted treatment of opioid addiction increases patient retention and decreases drug use, infectious disease transmission, and criminal activity.”2Researchers have documented that treatment with these medications is life-extending for individuals with opioid use disorder.3

Medication-assisted treatment of opioid use disorder is also supported by the Substance Abuse and Mental Health Services Administration, the Institute of Medicine, and the World Health Organization. Major expansions in access to care with buprenorphine have been associated with declines in overdose deaths from heroin of more than 50% in France4 and 37% in Baltimore, Maryland.5

Opioid use disorder, like all substance use disorders, is a chronic illness for which there is no cure. The goal is holistic recovery that allows affected individuals to live productive, fulfilled lives as they effectively manage the symptoms of their illness. Extended treatment that includes medications is a proven path to recovery and is associated with a lower risk of relapse. Such care is not only effective, but there is no other treatment approach supported by the same level of evidence.

Nonetheless, there is significant resistance to the treatment of opioid use disorder with medications. For instance, some communities have opposed having medication-assisted treatment services located in their neighborhoods, some local officials have proposed legislation in violation of the Americans with Disabilities Act that would change zoning codes to exclude medication-assisted treatment centers, some health insurers have imposed arbitrary limits on the duration of treatment of opioid use disorder with medications, and even some clinicians have acted as though patients taking methadone or buprenorphine are still using illicit drugs, missing the critical distinction between addiction and the treatment of addiction.6

Four factors contribute to the stigma associated with opioid use disorder and its treatment with medications.

First, the understanding of opioid use disorder as a medical illness is still overshadowed by its misconception as a moral weakness or a willful choice.6 This misconception has historically separated this illness and its treatment from the rest of health care. Within the substance use treatment community, many still believe that recovery depends solely on willpower to abstain from all opioids, including methadone and buprenorphine. As a result, many who provide residential services force patients receiving methadone or buprenorphine to taper off of medication as a condition of initial or continued treatment, and many counselors consider taking medication a character weakness.

People effectively managing their illness with medications for years may even be scared to mention methadone or buprenorphine in mutual support groups for fear of being ostracized. Narcotics Anonymous, for example, has historically seen medication-assisted treatment as contrary to its philosophy, and chapters may exclude people taking methadone or buprenorphine from holding leadership positions or attending meetings.7

Second, the separation of opioid use disorder treatment from the rest of health care has meant that clinicians who treat these patients have not always paid sufficient attention to other substance use, mental health, and physical health conditions. Methadone and buprenorphine effectively treat opioid use disorder, but not cocaine, sedative, cannabis, nicotine, or alcohol use disorder, and not depression, diabetes, hypertension, asthma, schizophrenia, bipolar disorder, or HIV infection. Regulation and oversight of medication-assisted treatment has historically focused primarily on the medication and narrow aspects related to opioid use disorder. Reimbursement for treatment may cover only the most basic services, including medication delivery and a weekly professional encounter. Patients with complex conditions, however, may need more counseling, care management, and different pharmacologic therapy. In the meantime, other health care practitioners, family members, and the public may attribute the signs and symptoms of these nonopioid disorders to methadone and buprenorphine, adding to the stigma.

Third, language mirrors and perpetuates the stigma related to treatment of opioid use disorder with medications. The health care system, and therefore the public, does not routinely talk about opioid use disorder and its treatment as medical care, but rather often may assign judgmental, pejorative terms. Urine test results are called “clean” or “dirty” rather than “positive,” “expected,” “negative,” or “unexpected.” Medically indicated situations in which patients receiving methadone or buprenorphine are tapering or decreasing their doses are described as “detoxification,” as though the medications are toxins poisonous to the body. Patients with opioid use disorder are referred to as “clean” when they are in recovery or managing symptoms and are referred to as “dirty” if they are still demonstrating symptoms of their illness. Within the substance use treatment sector, therapy that does not involve a medication is known as “drug-free” with the implication that by taking a medication such as methadone or buprenorphine, a person cannot be in recovery. Health care practitioners, and many lay people, refer to people with opioid use disorder as “junkies.” While the term “junkie” originated because of the heroin individuals were using, it now is broadly associated particularly with the people who use illicit opioids. Who would use similar terms about a patient with diabetes and an elevated hemoglobin A1C level?

Fourth, the criminal justice system often fails to defer to medical judgment in the treatment of opioid use disorders.8 Some judges have prohibited participation in medication-assisted treatment from satisfying a condition of probation requiring treatment for opioid use disorder. If incarcerated, people taking methadone or buprenorphine as part of treatment rarely are allowed to continue to receive their medications as they would insulin or other prescription medications. They are left to deal with the discomfort of the withdrawal syndrome that occurs with all opioids. Because the body acclimates to the lower intake of opioids, this practice may significantly increase the risk of fatal overdose if the individual relapses after release from incarceration. Physicians working in jails and prisons are seldom allowed to prescribe buprenorphine or methadone.

The stigma associated with opioid use disorder and its treatment is unhealthy, but it is not inevitable. Health care practitioners can counter stigma by adopting accurate, nonjudgmental language to describe this disorder, those it affects, and its therapy with medications. States can promote the provision of comprehensive health services in opioid treatment programs and expand access to effective therapies in the criminal justice system. The public can fight back against the rising threat of overdose by supporting broad access to effective treatment with medications.

Affected neighbors, colleagues, family members, friends, and children, as well as celebrities, need care—and they all deserve the best care available. Their lives may well depend on it.