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#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. 
  • 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. 
  • 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 
Context: 
  • 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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Author(s):

  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP
  • Joey Ton PharmD

1. Argoff CE, Kahan M, Sellers EM. J Opioid Manag. 2014 Mar-Apr; 10(2):119-34.

2. Balbale SN, Trivedi I, O’Dwyer LC, et al. Dig Dis Sci. 2017 Oct; 62(10):2668-85.

3. Becker WC, Fraenkel L, Edelman EJ, et al. Pain. 2013 Jun; 154(6):905-16.

4. Blanchard J, Hunter SB, Osilla KC, et al. Mil Med. 2016 May; 181(5):410-23.

5. Canan C, Polinski JM, Alexander GC, et al. J Am Med Inform Assoc. 2017 Nov 1; 24(6):1204-1210.

6. Chou R, Fanciullo GJ, Fine PG, et al. J Pain. 2009 Feb; 10(2):131-46.

7. Cochran G, Woo B, Lo-Ciganic WH, et al. Subst Abus. 2015; 36(2):192-202.

8. Dowell D, Haegerich TM, Chou R. JAMA. 2016 Apr 19; 315(15):1624-45.

9. Lawrence R, Mogford D, Colvin L. Br J Anaesth. 2017 Dec 1; 119(6):1092-1109.

10. Shmulewitz D, Greene ER, Hasin D. Alcohol Clin Exp Res. 2015 Oct; 39(10):1878-900.

11. Smith SM, Dart RC, Katz NP, et al. Pain. 2013 Nov; 154(11):2287-96.

12. Smith SM, Paillard F, McKeown A, et al. J Pain. 2015 May; 16(5):389-411.

13. Solanki DR, Koyyalagunta D, Shah RV, et al. Pain Physician. 2011 Mar-Apr; 14(2):E119-31.

14. Turk DC, Swanson KS, Gatchel RJ. Clin J Pain. 2008 Jul-Aug; 24(6):497-508.

15. Knisely JS, Wunsch MJ, Cropsey KL, et al. J Subst Abuse Treat. 2008 Dec; 35(4):380-6.

16. Meltzer EC, Rybin D, Saitz R, et al. Pain. 2011 Feb; 152(2):397-402

17. Allan GM, Lindblad AJ, Comeau A, et al. Can Fam Physician. 2015; 61(10):857-67, e439-50.

18. Butler SF, Budman SH, Fernandez K, et al. Pain. 2004 Nov; 112(1-2):65-75.

19. Butler SF, Fernandez K, Benoit C, et al. J Pain. 2008 Apr; 9(4):360-72.

20. Compton PA, Wu SM, Schieffer B, et al. J Pain Symptom Manage. 2008 Oct; 36(4):383-95.

21. Jamison RN, Martel MO, Huang CC, et al. J Pain. 2016 Apr; 17(4):414-23.

22. Brown RL, Rounds LA. Wis Med J. 1995; 94(3):135-40.

23. Provincial Opioid Use Disorder Treatment Guideline Committee. A Guideline for the Clinical Management of Opioid Use Disorder. Available at: http://www.bccsu.ca/wp-content/uploads/2017/06/BC-OUD-Guidelines_June2017.pdf. Last Accessed: August 24, 2018.

24. CRISM National Guideline Review Committee. CRISM National Guideline for Clinical Management of Opioid Use Disorder. Available at: https://crism.ca/wp-content/uploads/2018/03/CRISM_NationalGuideline_OUD-ENG.pdf. Last Accessed: August 24, 2018.

25. Bruneau J, Ahamad K, Goyer ME, et al. CMAJ. 2018 Mar 5; 190(9):E247-E257

26. Hojsted J, Sjogren P. Eur J Pain. 2007 Jul; 11(5):490-518.

Authors do not have any conflicts of interest to declare.