Dear Editor,
Healthcare providers struggle to balance appropriate pain relief when prescribing opioids while avoiding opioid-associated risks.1 Guidelines from the Centers for Disease Control and Prevention (CDC)2 strongly recommend the use of validated screening instruments designed to identify individuals at higher risk of opioid misuse in clinical practice.3
The Current Opioid Misuse Measure (COMM) is a popular 17-item self-report questionnaire that assesses states of abuse risk.4 The COMM has been cross-validated and used extensively in clinics and research protocols.5 It is widely acknowledged that questionnaires should be presented to individuals in their primary language and that English-language questionnaires should not be administered to non-English speakers.6 The COMM has been translated into Portuguese and Chinese,7,8 but not into Spanish. Since Spanish is the second most popular language in the United States (fourth most popular in the world) and spoken among over 62 million people living in the United States,9 a Spanish translation of the COMM would be clinically useful.
We conducted a study aimed to develop a linguistically validated Spanish-language COMM (COMM-S). We undertook a systematic linguistic validation process to establish a reliable, valid, and conceptually equivalent translation for the COMM to be used in clinic settings among Spanish-speakers.
Methods
We performed this translation and validation according to the recommended Patient-Reported Outcome (PRO) Consortium translation process.10 Similar steps have also been recommended by the US Food and Drug Administration (FDA) and the International Society for Pharmacoeconomics and Outcomes Research translation process.6 The description of the translation process is detailed in the supplemental file.
Results
Two females and one male Spanish-speakers provided feedback about the translation of the COMM. We followed the recommended universal translation pathway. The consensus was reached through the discussion of each discrepancy among the three translators, in which they looked for the best non-cultural translation to avoid jargon specific to any one culture. Twenty-one participants reviewed the COMM-S and answered the survey questions. Most respondents were between 25 and 45 years of age (47.6%), were Hispanic or Latino (90.4%), and 9 (42.9%) were female (Table 1).
Table 1.
Demographic characteristics of survey respondents (N = 21).
| Characteristic | Number (%) |
|---|---|
| Age | |
| 25–34 | 10 (47.6) |
| 35–44 | 8 (38.1) |
| 45+ | 3 (14.2) |
| Gender (female) | 9 (42.9) |
| Race/ethnicity | |
| Hispanic/Latino | 19 (90.4) |
| Caucasian | 2 (9.5) |
| Education level | |
| High school | 3 (14.3) |
| Bachelors | 5 (23.8) |
| Graduate degree | 13 (61.9) |
| Marital status (married) | 6 (28.6) |
| Employment status (employed) | 17 (81.0) |
Clarification was requested from seven respondents regarding items that differed from the COMM based on the back-translation. There was some perceived confusion in the translation that the information would be stored in the individual’s medical record and available to anyone with access to their records. Further clarification was needed for the translation of specific items such as: (1) #3 “How often have you had to go to someone other than your prescribing physician to get sufficient relief from your medications?” The literal translation was “How often have you had to go to someone other than your doctor to get enough pain management with your medications?”; (2) #5 “How often have you seriously thought about hurting yourself?” The Spanish version had a missing article; however, this correction did not alter the Spanish translation; (3) #15 “How often have you borrowed pain medication from someone else?” The Spanish translation of this question had a structural error, often seen in translations. By consensus, the literal translation in English was perceived to be unaffected.
One respondent felt filling in numbers (0–4) rather than checking boxes avoided confusion among users. Another participant recommended changing the Spanish translation of the scale from “Nunca, Rara vez, A veces, A menudo, Muy a menudo” to “Nunca, Casi nunca, A veces, Casi siempre, Siempre”. This change allows for better understanding, especially among those with low literacy. Consensus was reached about the best ways to translate these items of the questionnaire.
The survey showed that 14 of the respondents felt the translation was the same as the intended meaning, and contained no errors, omissions, or additions while seven of the respondents pointed out minor changes. All but one of the respondents (95.2%) felt that the translation was clear and intelligible and that there were no confusing non-standard words, expressions, or grammar in the translated COMM-S. Most (66.6%) also felt that the translation was accurate with no mistranslations, omissions, or additions. Only five respondents felt that a minor revision was needed. Particularly, discussion centered on use of the translation of “meetings” vs “appointments” and of “opioids” vs. “narcotics.” Feedback from the respondents allowed for improvement of the language in the COMM-S. Consensus was reached by the investigators in the final accepted Spanish translation of the COMM (Table 2).
Table 2.
Spanish Translation of the Current Opioid Misuse Measure (COMM-S).
| COMM-S | ||||||
|---|---|---|---|---|---|---|
| Nombre: ______________________________________ | Fecha: _____________________ | |||||
| Las siguientes preguntas son hechas a nuestros pacientes que esta tomando opioides para manejar su dolor. Por favor responda cada una de las preguntas con la mayor sinceridad posible. Esta información será confidencial y almacenada en su historial medico. Tenga en cuenta que sus respuesta no van a determinar su tratamiento. Muchas gracias. | ||||||
| Por favor responda las siguientes preguntas usando la siguiente escala | ||||||
| En los últimos 30 días… | ||||||
| Nunca | Casi nunca | A veces | Casi siempre | Siempre | ||
| 0 | 1 | 2 | 3 | 4 | ||
| 1. ¿Con qué frecuencia ha tenido dificultad para pensar con claridad o ha tenido problemas de memoria? | ||||||
| 2. ¿Con qué frecuencia las personas se quejan de que usted no ha completado sus tareas? (Por ejemplo, realizar actividades tales como ir a clase, al trabajo o a reuniones) | ||||||
| 3. ¿Con qué frecuencia ha tenido que consultar a alguien diferente a su medico para obtener suficiente manejo del dolor con sus medicamentos? (Por ejemplo, otro medico o un doctor de urgencias) | ||||||
| 4. ¿Con qué frecuencia ha tomado sus medicamentos de una manera diferente como fueron prescritos? | ||||||
| 5. ¿Con qué frecuencia ha pensado seriamente en causarse daño? | ||||||
| 6. ¿Qué tanto de su tiempo ha gastado pensando sobre sus medicamentos para el dolor? (Por ejemplo, en tener suficientes, tomarlos de acuerdo al horario, etc) | ||||||
| 7. ¿Con qué frecuencia discute con la gente? | ||||||
| 8. Con qué frecuencia ha tenido problemas en controlar su ira? (Por ejemplo, cuando maneja un automóvil, gritarle a los demás, etc) | ||||||
| 9. ¿Con qué frecuencia necesito tomar medicamentos para el dolor que son de alguien más y no de usted? | ||||||
| 10. ¿Con qué frecuencia se ha preocupado por como usted esta manejando sus medicamentos? | ||||||
| 11. ¿Con qué frecuencia otras personas se han preocupado por como usted esta manejando sus medicamentos? | ||||||
| 12. ¿Con qué frecuencia ha tenido que hacer una llamada de emergencia o presentarse en la clínica sin cita previa? | ||||||
| 13. ¿Con qué frecuencia se ha enfadado con otras personas? | ||||||
| 14. ¿Con qué frecuencia ha tomado más medicamentos de lo que tiene prescrito? | ||||||
| 15. ¿Con qué frecuencia ha pedido prestado a otra persona medicamentos para el dolor? | ||||||
| 16. ¿Con qué frecuencia ha tomado medicamentos para el dolor con propósitos diferentes? (Por ejemplo, para ayudarlo a dormir, mejorar su estado de animo, o disminuir el estrés) | ||||||
| 17. ¿Con qué frecuencia ha tenido que visitar al servicio de emergencias del hospital? | ||||||
Translation feedback was obtained from healthcare providers and chronic pain patients and consensus was reached based on individual feedback and investigator discussion. This translation process mirrors the rigorous steps taken to translate the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) and other self-report measures.
Discussion
There are several study limitations that should be noted. This study only represents a first process towards validating the COMM-S. Long term follow-up of Spanish-speaking patients who are prescribed opioids is needed to determine the cutoff for risk of medication misuse. Administration of the COMM-S was limited to patients prescribed opioids for non-cancer post-operative and chronic pain. Future studies are needed to assess demographic factors that might influence aberrant drug-related behavior. Clinicians should also be aware that determining the risk of opioid misuse requires a thorough history, physical examination, review of past medical records, periodic urine toxicology screens, and tracking through the state prescription monitoring system.
Supplementary Material
Acknowledgments
This study was supported in part by an R34 grant (3R34DA048268-02S1) from DHHS. The authors appreciate the assistance of the many participants who helped to review earlier versions of the Spanish translations of the COMM.
Contributor Information
Laura Mendez-Pino, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States.
Diego Villela-Franyutti, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States.
Jeffrey L Schnipper, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States.
Richard D Urman, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Ohio State University, Columbus, OH, United States.
Sarah Corey, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States.
Patrick W Collins, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States.
Robert N Jamison, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States; Pain Management Center, Brigham and Women’s Hospital, Chestnut Hill, MA, United States.
Author contributions
Laura Mendez-Pino: This author conceived the idea, performed the literature search and Spanish translation, analyzed the data, drafted the manuscript, and approved the final manuscript.
Diego Villela-Franyutti: This author helped in the Spanish translation and in interpretation of data. He reviewed the manuscript and approved the final manuscript.
Jeffrey L. Schnipper: This author helped in the interpretation of data. He reviewed the manuscript and approved the final manuscript.
Richard D. Urman: This author helped in the interpretation of data. He reviewed the manuscript and approved the final manuscript.
Sarah Corey: This author helped in the interpretation of data. She reviewed the manuscript and approved the final manuscript.
Patrick W. Collins: This author helped in the interpretation of data. He reviewed the manuscript and approved the final manuscript.
Robert N. Jamison: This author helped in the drafting of the manuscript and interpretation of data. He reviewed the manuscript and approved the final manuscript.
Supplementary material
Supplementary material is available at Pain Medicine online.
Funding
This study was supported in part by an R34 grant (3R34DA048268-02S1) from DHHS.
Conflicts of interest: Richard Urman discloses Merck, Medtronic, AcelRx, and Pfizer.
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