#222 Does this patient taking prescription opioids have opioid use disorder?
CLINICAL QUESTION
What is the best tool to help identify patients with prescription opioid use disorder?
BOTTOM LINE
Despite over 50 studies in the literature, only two have compared case-finding tools to the Diagnostic and Screening Manual for Mental Disorders (DSM), the most commonly used diagnostic criteria for patients with opioid use disorder (OUD). A single, small study demonstrates that the Prescription Opioid Misuse Index (POMI), a 6-point questionnaire with strong predictive ability for OUD, may be a reasonable case-finding tool.
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EVIDENCE
14 systematic reviews, 6-50 studies, 16 different tools, and 23 different diagnostic criteria.1-14 Without clear diagnostic gold standard for OUD in the literature, we focused on studies comparing screening tools to DSM IV/5 criteria: POMI and COMM (Current Opioid Misuse Measure).15,16
- POMI, 6-question clinician-administered checklist, >2 points indicates potential OUD (Appendix).15
- One cohort study (74 patients prescribed oxycodone for pain):
- Area-Under-the-Curve (AUC)=0.89 (high predictive ability).
- By comparison, AUC for most cardiovascular calculators=~0.75-0.80 (closer to 1.0 is best).17
- Positive Likelihood Ratio=10.3 (large help ruling-in):
- Specificity=0.92.
- Negative Likelihood Ratio=0.20 (moderate help ruling-out):
- Sensitivity=0.82.
- Area-Under-the-Curve (AUC)=0.89 (high predictive ability).
- One cohort study (74 patients prescribed oxycodone for pain):
- COMM is a 40-point scale with 17 questions, greater or equal to 13-points suggest potential OUD:16
- One cohort study (238 patients prescribed an opioid in ≤12 months):
- AUC=0.84.
- Positive Likelihood Ratio: 3.35 (small help ruling-in):
- Specificity=0.77.
- Negative Likelihood Ratio: 0.30 (small-moderate help ruling-out):
- Sensitivity=0.77.
- Length of the tool could limit practical application.
- One cohort study (238 patients prescribed an opioid in ≤12 months):
- Limitations: One small validation study for each tool.
- Other tools were long (examples SOAPP/SOAPP-R),18,19 had weak predictive ability (example PDUQp),20,21 or were not studied in an OUD population (CAGE-AID).22
- Recent Canadian guidelines reference DSM-5 criteria for diagnosis of OUD.23-25
- DSM IV/5 criteria for OUD may be met by patients with chronic pain on opioids (with tolerance, withdrawal, unsuccessful efforts to cut down) but do not misuse the medication. We likely lack a true diagnostic standard for OUD in these patients.26
- There is no evidence to support a population-wide screening program. Case-finding in patients using prescription opioids with POMI may help management.
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