Current Opioid Misuse Measure (COMM)

Why use it

Long-term opioid therapy requires ongoing monitoring for misuse and diversion. The COMM provides a standardized, validated self-report tool to detect current aberrant behaviors — bridging clinical interview and objective urine drug testing. It captures a broader behavioral picture than urine screens alone, including emotional dysregulation, drug craving, medication seeking from other sources, and inconsistent urine results.

About

The Current Opioid Misuse Measure (COMM) is a validated 17-item self-report questionnaire designed to identify aberrant drug-related behaviors (ADRBs) in patients currently receiving long-term opioid therapy for chronic non-cancer pain. Developed by Butler and colleagues at Inflexxion in 2007, the COMM was specifically designed to monitor ongoing opioid misuse — as opposed to baseline risk tools (e.g., ORT, SOAPP-R) that predict future misuse risk. Each item is rated on a 5-point Likert scale (0 = Never to 4 = Very Often) covering the past 30 days. A total score ≥ 9 is the validated threshold for identifying current aberrant behavior with high sensitivity (0.77) and specificity (0.66). The COMM has been validated in multiple chronic pain populations and is widely used in opioid treatment agreements and risk monitoring programs.

When to use

• Routine monitoring visits for patients on long-term opioid therapy for chronic non-cancer pain
• Reassessment when urine drug screen results are inconsistent or unexpected
• Follow-up after a prior positive COMM screen to assess treatment response
• Quarterly or semi-annual monitoring in primary care or pain clinic settings
• Before opioid therapy escalation or transition to extended-release formulations
• As part of a structured opioid risk management program (with PDMP review and UDS)

Formula

Pearls & pitfalls

• The validated cut-off score is ≥ 9 (sensitivity 77%, specificity 66%). Scores should be interpreted in the context of the full clinical picture — not in isolation.
• The COMM measures CURRENT behavior (past 30 days) — it is distinct from baseline risk tools (SOAPP-R, ORT) which predict FUTURE risk before opioid initiation.
• Item 15 (urine screen positive for unprescribed drugs) is one of the highest-weighted clinical indicators — a single positive UDS should always prompt COMM re-administration.
• Patients with undertreated pain may endorse some items (e.g., taking more medication than prescribed) without having true misuse disorder — always contextualize with pain severity and functional status.
• The COMM has been validated in VA, primary care, and pain clinic settings but NOT in cancer pain or acute pain populations — use only for chronic non-cancer pain patients on long-term opioids.
• Combining COMM with urine drug screens, PDMP review, and pill counts improves detection of aberrant behavior compared to any single method alone.
• A COMM score ≥ 9 does NOT diagnose opioid use disorder (OUD) — it flags for further evaluation. DSM-5 criteria require structured clinical assessment.
• The COMM can be self-administered in the waiting room, taking approximately 5–10 minutes, and scored before the physician visit to guide the clinical encounter.

Next steps

COMM < 9 (Low/No Current Misuse): Continue current monitoring. Reassess at next scheduled visit. Reinforce safe storage and disposal. COMM 9–16 (Positive Screen — Moderate): Review the specific endorsed items. Discuss findings directly with the patient. Consider urine drug screen, pill count, or PDMP query. Increase monitoring frequency. Refer to addiction medicine or behavioral health if indicated. COMM ≥ 17 (Positive Screen — High): High likelihood of current aberrant behavior. Mandatory clinical follow-up. Structured opioid therapy review: consider dose tapering, opioid risk stratification, or transition to buprenorphine/naloxone if OUD is suspected. Behavioral health referral strongly recommended.

Evidence

Butler SF et al. Development and validation of the Current Opioid Misuse Measure. Pain. 2007;130(1-2):144-156. PMID:17493754. Validated in 3 studies (n=195, n=321, n=150). Sensitivity 77%, specificity 66% at cut-off ≥9. Area under the ROC curve 0.81. Further validated in: Meltzer EC et al. Aberrant drug-related behaviors: a systematic review of the literature and proposed classification. J Opioid Manag. 2011;7(4):331-340.

References

1. Butler SF et al. Development and validation of the Current Opioid Misuse Measure. Pain. 2007;130(1-2):144-156. — link
2. Butler SF et al. Validation of the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4):360-372. — link
3. Meltzer EC et al. Aberrant drug-related behaviors: a systematic review of the literature and proposed classification schema. J Opioid Manag. 2011;7(4):331-340. — link