(39) Using NCCN Recommended Tool to Screen for Opioid Misuse in Cancer Patients: Are We Overdiagnosing Addiction?

Although cancer patients are exempt from current opioid restrictions and guidelines recommended for patients with non-cancer pain, monitoring for addiction in cancer patients on prescription opioids is important for patients, caregivers and for public health. National Comprehensive Cancer Network (NCCN) Adult Cancer Pain panel recommends Comprehensive Opioid Misuse Measure (COMM) as a tool to be used in cancer pain management (NCCN, 2021). COMM is a 17-item, patient self-reported measure developed to identify signs and symptoms of drug misuse during chronic opioid treatment. While it is important to identify opioid misuse, it is also important not to over diagnose it. Inappropriate diagnosis of OUD/ addiction may stigmatize cancer patients and prevent them from receiving adequate and effective pain control. Furthermore, COMM has not been validated in cancer population. To our knowledge, this is the first study to assess COMM as a screening tool for patients with cancer-related pain.

The purpose of this study is to evaluate COMM as an opioid misuse screening tool in cancer patients on chronic opioid therapy by comparing COMM results with (1) CAGE and CAGE-AID screening (2) Current Procedural Terminology (CPT) diagnostic code for opioid use disorder (OUD) (3) Urine Drug Screen (UDS) as proxy for clinical suspicion. We analyzed Patient Reported Outcomes (PRO) of 287 consecutive patients who completed COMM. Patient Medical Records were electronically searched for the results of CAGE and CAGE-AID, CPT codes for OUD, and UDS. Charts of patients with positive aberrant UDS were further reviewed manually with cross references between two researchers.

Our analysis shows that the number of patients with positive CAGE was 13.7 times lower than the number of patients screened positive for opioid misuse using COMM (48 vs. 3.5%). We also found that the number of patients with CPT diagnosis code for OUD was 6.2 times lower than the number of patients with opioid misuse suggested by COMM (48 vs. 7.7%). The number of patients with true aberrant positive UDS was 4.9 times lower than the number of patients with opioid misuse identified by COMM screening (48 vs 9.8%). Majority of the patients did not have UDS ordered at all which indicated the lack of clinical suspicion of opioid misuse in 78.4% of patients by their clinicians. Our study finds that using only COMM in a cancer population without additional measures of opioid misuse can lead to an overestimate of opioid misuse resulting on an additional barrier to cancer pain management.

Disclosure:
The Registry was developed with the support of grant RC2 DA028928 from the National Institute on Drug Abuse and was supported in part by a grant from Purdue Pharm, Ltd, the MSK Cancer Center Support Grant/Core Grant (P30 CA008748), and the Weill Cornell Medical College Bridge Fund. None of the supporters read or had any editorial influence on the report.
The authors have no conflicts of interest to declare.

References: Butler, S. F., Budman, S. H., Fernandez, K. C., Houle, B., Benoit, C., Katz, N., & Jamison, R. N. (2007). Development and validation of the Current Opioid Misuse Measure. Pain, 130(1-2), 144–156. https://doi.org/10.1016/j.pain.2007.01.014

Carmichael, A. N., Morgan, L., & Del Fabbro, E. (2016). Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Substance abuse and rehabilitation, 7, 71–79. https://doi.org/10.2147/SAR.S85409
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Moryl N, Dave V, Glare P, Bokhari A, Malhotra VT, Gulati A, Hung J, Puttanniah V, Griffo Y, Tickoo R, Wiesenthal A, Horn SD, Inturrisi CE. Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients. J Pain. 2018 Mar;19(3):278-290. doi: 10.1016/j.jpain.2017.11.001. Epub 2017 Nov 14. PMID: 29154919; PMCID:

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