2022 CDC Clinical Practice Guideline for Prescribing Opioids Implementation Guide
2022.1.0 - CI Build

2022 CDC Clinical Practice Guideline for Prescribing Opioids Implementation Guide, published by Centers for Disease Control and Prevention (CDC). This guide is not an authorized publication; it is the continuous build for version 2022.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/opioid-cds-r4/ and changes regularly. See the Directory of published versions

Library: OpioidCDSREC08Library (Experimental)

Official URL: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSREC08 Version: 2022.1.0
Active as of 2024-05-28 Computable Name: OpioidCDSREC08
Id: OpioidCDSREC08
Url: Library - Recommendation #8 - Naloxone Consideration
Version: 2022.1.0
Name: OpioidCDSREC08
Title: Library - Recommendation #8 - Naloxone Consideration
Status: active
Experimental: true
Type:

system: LibraryType

code: logic-library

Date: 2024-05-28 16:37:24+0000
Publisher: Centers for Disease Control and Prevention (CDC)
Related Artifacts:

Dependencies

Parameters:
NameTypeMinMaxIn/Out
ContextPrescriptionsMedicationRequest01in
PatientPatient01out
Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential PrescriptionsMedicationRequest0*out
Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potentialboolean01out
On Benzodiazepineboolean01out
Total MMEQuantity01out
Has Substance Abuse Historyboolean01out
Inclusion Criteriaboolean01out
On Naloxoneboolean01out
Exclusion Criteriaboolean01out
Is Recommendation Applicable?boolean01out
Get Indicatorstring01out
Get Summarystring01out
Get Detailstring01out
Content: text/cql
library OpioidCDSREC08 version '2022.1.0'

using FHIR version '4.0.1'

include FHIRHelpers  version '4.0.1' called FHIRHelpers
include OpioidCDSCommon version '2022.1.0' called Common
include OpioidCDSCommonConfig version '2022.1.0' called Config
include OpioidCDSRoutines version '2022.1.0' called Routines
/*include fhir.cdc."opioid-mme-r4".MMECalculator version '3.0.0' called MMECalculator
 */
include MMECalculator version '3.0.0' called MMECalculator

/*
**
**  Recommendation #8
**    Before starting and periodically during continuation of opioid therapy, clinicians should 
**    evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should 
**    work with patients to incorporate into the management plan strategies to mitigate risk, 
**    including offering naloxone (recommendation category: A; evidence type: 4).
**
**  When
**    Order for opioid analgesics with ambulatory misuse potential:
**    Opioid review is useful for this patient:
**      Patient is 18 or over
**      Patient does not have evidence of sickle cell disease
**      Patient does not have findings indicating limited life expectancy
**      Patient does not have orders for therapies indicating end of life care
**      Patient is not undergoing active cancer treatment:
**        Patient has had at least 2 office visits within the past 12 months with an oncology specialist present, or
**        Patient has had at least 2 office visits within the past 12 months with a CDC malignant cancer condition diagnosis
**      Patient does not have conditions likely terminal for opioid prescribing present
**    Patient is not currently prescribed naloxone medications
**    Factors that increase risk for opioid overdose are present:
**      Currently receiving benzodiazepine or other central nervous system depressant medications, or
**      High opioid dosages (MME/day >= 50), or
**      History of substance use disorder, or
**      Diagnosed with sleep-disordered breathing condition
**  Then
**    Incorporate Risk Mitigation Strategies Into Opioid Therapy:
**      Order - Order naxalone
**      Document - Risk mitigation strategy implemented, snooze 3 months
**      Snooze - N/A see comment, snooze 3 months
**
*/

// META: Plan Definition: http://fhir.org/guides/cdc/opioid-cds-r4/PlanDefinition/opioid-cds-08

parameter ContextPrescriptions List<MedicationRequest>

context Patient

define "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions":
  ( Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) ) AmbulatoryOpioidPrescription
    where Routines."Is Subacute or Chronic Pain Prescription?"( AmbulatoryOpioidPrescription )

define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential":
  exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )

define "On Benzodiazepine":
  exists( Common."Active Ambulatory Benzodiazepine Rx" )

define "Total MME":
  MMECalculator.TotalMME(
    "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions"
      union Common."Active Ambulatory Opioid Rx"
  )

define "Has Substance Abuse History":
  exists (
    [Procedure: Common."Substance misuse behavioral counseling"]
  )
    or exists (
      Common."US Core-Categorized Conditions" C
        where C.code in Common."Conditions documenting substance misuse"
    )

define "Inclusion Criteria":
  "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
    and Routines."Is Opioid Review Useful?"
    and (
      "On Benzodiazepine"
        or "Total MME" >= 50 '{MME}/d'
        or "Has Substance Abuse History"
        // Need Concept for Diagnosed with a sleep-disordered breathing condition?
    )

define "On Naloxone":
  exists( Common."Active Ambulatory Naloxone Rx" )

define "Exclusion Criteria":
  (
    Config."Evidence of Naloxone Enabled"
      and "On Naloxone"
  )
    or Common."End of Life Assessment"

define "Is Recommendation Applicable?":
  "Inclusion Criteria"
    and not "Exclusion Criteria"

define "Get Indicator":
  if "Is Recommendation Applicable?"
    then 'warning'
  else null

define "Get Summary":
  if "Is Recommendation Applicable?"
    then 'Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present'
  else null

define "Get Detail":
  if "Is Recommendation Applicable?"
    then
      'Recommend incorporating strategies to mitigate opioid therapy risks, including offering naloxone

For more information about prescribing naloxone see 
https://prescribetoprevent.org

**MME Calculator Cautions**
1) All doses are in mg/day except for fentanyl, which is mcg/hr. 
2) Equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics. 
3) Do not use the calculated dose in MMEs to determine the doses to use when converting one opioid to another; when converting opioids, the new opioid is typically dosed at a substantially lower dose than the calculated MME dose to avoid overdose because of incomplete cross-tolerance and individual variability in opioid pharmacokinetics. Consult the FDA approved product labeling for specific guidance on medications. 
4) Use particular caution with methadone dose conversions because methadone has a long and variable half-life, and peak respiratory depressant effect occurs later and lasts longer than peak analgesic effect. 
5) Use particular caution with transdermal fentanyl because it is dosed in mcg/hr instead of mg/day, and its absorption is affected by heat and other factors. 
6) Buprenorphine products approved for the treatment of pain are not included in the table because of their partial µ-receptor agonist activity and resultant ceiling effects compared with full µ-receptor agonists. 
7) These conversion factors should not be applied to dosage decisions related to the management of opioid use disorder.
† Tapentadol is a µ-receptor agonist and norepinephrine reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tapentadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists.
§ Tramadol is a µ-receptor agonist and norepinephrine and serotonin reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tramadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists.'
  else null
Content: application/elm+xml
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