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
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
| Draft as of 2023-05-01 |
<PlanDefinition xmlns="http://hl7.org/fhir">
<id value="opioidcds-11"/>
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value="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-recommendationdefinition"/>
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value="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-publishableplandefinition"/>
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<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table class="grid dict">
<tr>
<th scope="row"><b>Id: </b></th>
<td style="padding-left: 4px;">opioidcds-11</td>
</tr>
<tr>
<th scope="row"><b>Url: </b></th>
<td style="padding-left: 4px;"><a href="PlanDefinition-opioidcds-11.html">PlanDefinition - 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain: Recommendation #11</a></td>
</tr>
<tr>
<th scope="row"><b>Version: </b></th>
<td style="padding-left: 4px;">2022.1.0</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>value: </b> <span>cdc-opioid-guidance</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Name: </b></th>
<td style="padding-left: 4px;">CDC_opioid_11</td>
</tr>
<tr>
<th scope="row"><b>Title: </b></th>
<td style="padding-left: 4px;">PlanDefinition - 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain: Recommendation #11</td>
</tr>
<tr>
<th scope="row"><b>Status: </b></th>
<td style="padding-left: 4px;">draft</td>
</tr>
<tr>
<th scope="row"><b>Experimental: </b></th>
<td style="padding-left: 4px;">true</td>
</tr>
<tr>
<th scope="row"><b>Type: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>system: </b> <span><a href="http://terminology.hl7.org/5.3.0/CodeSystem-plan-definition-type.html">PlanDefinitionType</a></span>
</p>
<p style="margin-bottom: 5px;">
<b>code: </b> <span>eca-rule</span>
</p>
<p style="margin-bottom: 5px;">
<b>display: </b> <span>ECA Rule</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Date: </b></th>
<td style="padding-left: 4px;">2023-05-01</td>
</tr>
<tr>
<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">Centers for Disease Control and Prevention (CDC)</td>
</tr>
<tr>
<th scope="row"><b>Description: </b></th>
<td style="padding-left: 4px;">Concurrently prescribing opioid medications with benzodiazepines increases the risk of harm for the patient.</td>
</tr>
<tr>
<th scope="row"><a name="effective-data-requirements"> </a><b>Logic Definitions: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Get Summary</td>
<td>0</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Get Summary&quot;:
if &quot;Is Recommendation Applicable?&quot;
then 'Avoid prescribing opioid pain medication and benzodiazepine concurrently whenever possible.'
else null</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Opioid Analgesic with Ambulatory Misuse Potential Prescriptions</td>
<td>1</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Opioid Analgesic with Ambulatory Misuse Potential Prescriptions&quot;:
Common.&quot;Is Opioid Analgesic with Ambulatory Misuse Potential?&quot;( ContextPrescriptions )</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential</td>
<td>2</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential&quot;:
exists( &quot;Opioid Analgesic with Ambulatory Misuse Potential Prescriptions&quot; )</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Active Ambulatory Benzodiazepine Rx</td>
<td>3</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Active Ambulatory Benzodiazepine Rx&quot;:
if Config.&quot;Can the implementing EHR support queries for past medications by date range?&quot; then
(
&quot;Get MedicationRequest Medication as Code&quot;(&quot;Get Active Ambulatory Medication Requests&quot;([MedicationRequest]))
) Rx
where date from Rx.authoredOn 2 years or less on or before Today()
and Rx.medication in &quot;Benzodiazepine medications&quot;
else
List&lt;FHIR.MedicationRequest&gt;{}</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Benzodiazepine Prescriptions</td>
<td>4</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Benzodiazepine Prescriptions&quot;:
Common.&quot;Is Benzodiazepine?&quot;( ContextPrescriptions )</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Patient Is Being Prescribed Benzodiazepine</td>
<td>5</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Patient Is Being Prescribed Benzodiazepine&quot;:
exists( &quot;Benzodiazepine Prescriptions&quot; )</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Active Ambulatory Opioid Rx</td>
<td>6</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Active Ambulatory Opioid Rx&quot;:
if Config.&quot;Can the implementing EHR support queries for past medications by date range?&quot; then
(
&quot;Get MedicationRequest Medication as Code&quot;(&quot;Get Active Ambulatory Medication Requests&quot;([MedicationRequest]))
) Rx
where date from Rx.authoredOn 2 years or less on or before Today()
and Rx.medication in &quot;Opioid analgesics with ambulatory misuse potential&quot;
else
List&lt;FHIR.MedicationRequest&gt;{}</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Patient Age Less Than 18</td>
<td>7</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Patient Age Less Than 18&quot;:
if (Config.&quot;Age Less than 18 Years Is Enabled&quot;) then
AgeInYearsAt(Today()) &lt; 18
else
false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Condition Positive for Sickle Cell</td>
<td>8</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Condition Positive for Sickle Cell&quot;:
if (Config.&quot;Sickle Cell Check Enabled&quot;) then
exists(
Common.&quot;Positive Sickle Cell Condition&quot;
) else
false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>US Core-Categorized Conditions</td>
<td>9</td>
</tr>
</table>
<pre><code class="language-cql">// 3. Medications indicating end of life
/* or exists (
&quot;Medications Indicating End of Life&quot;
) */
define &quot;US Core-Categorized Conditions&quot;:
[Condition: category in &quot;Encounter Diagnosis Condition Category&quot;]
union [Condition: category in &quot;Problem List Condition Category&quot;]
union [Condition: category in &quot;US Core Health Concern Condition Category&quot;]</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Conditions Indicating End Of Life Present</td>
<td>10</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Conditions Indicating End Of Life Present&quot;:
exists (
Common.&quot;US Core-Categorized Conditions&quot; LLEC
where LLEC.code in Common.&quot;Limited life expectancy conditions&quot;
and LLEC.clinicalStatus in Common.&quot;Active Condition&quot;
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Service Requests</td>
<td>11</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Service Requests&quot;:
[ServiceRequest] SR
return SR</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Palliative Care Lookback Period</td>
<td>12</td>
</tr>
</table>
<pre><code class="language-cql">/*
** Routine #1
** Opioid Review Useful Routine
**
** Definition | Answer to Proceed | Details | Data (Terminology) Requirement
** ------------------------------------------------------------------------------------------------------------------------------------
** Age &lt; 18 years? | No | Calculate age from date of birth; exclude | Date of birth
** | | patients with age less than 18 years at the |
** | | time of the prescription |
** ------------------------------------------------------------------------------------------------------------------------------------
** Evidence of | No | Look for documented findings consistent | Sickle cell disease conditions
** sickle cell disease? | | with those listed in the sickle cell |
** | | value set |
** ------------------------------------------------------------------------------------------------------------------------------------
** Limited life | No | Look for documented findings consistent | Limited life expectancy conditions
** expectancy conditions | | with those listed in the limited life |
** present? | | expectancy value set (terminal illness, bad |
** | | prognosis, pre-terminal) |
** ------------------------------------------------------------------------------------------------------------------------------------
** Order for therapies | No | Look for patients with an existing order for | Therapies indicating end of life care
** indicating end of life | | therapies indicating end of life care |
** care in past 90 days? | | written within past 90 days |
** ------------------------------------------------------------------------------------------------------------------------------------
** Active cancer | No | See sub-routine 3 | See sub-routine 3
** treatment? | | |
** ------------------------------------------------------------------------------------------------------------------------------------
** Conditions Likely | No | Look for patients with active conditions in | Conditions likely terminal for opioid
** Terminal for opioid | | the value set end-of-life-conditions | prescribing
** prescribing present? | | |
** ------------------------------------------------------------------------------------------------------------------------------------
**
*/
define &quot;Palliative Care Lookback Period&quot;:
Interval[Today() - 90 days, Today()]</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Order For Palliative Care In Past 90 Days</td>
<td>13</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Order For Palliative Care In Past 90 Days&quot;:
exists (
Common.&quot;Service Requests&quot; SR
where SR.status in { 'active', 'completed'}
and SR.intent in {'proposal', 'plan,', 'directive', 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}
and FHIRHelpers.ToDateTime(SR.authoredOn) during day of &quot;Palliative Care Lookback Period&quot;
and SR.code in Common.&quot;Therapies indicating end of life care&quot;
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Active Cancer Treatment?</td>
<td>14</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Is Active Cancer Treatment?&quot;:
if (Config.&quot;Active Cancer Treatment Encounters Condition Is Enabled&quot;) then
&quot;Has Two or More Encounters with Cancer Diagnosis During Encounter Period&quot;
else
false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present</td>
<td>15</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present&quot;:
if (Config.&quot;End-Stage Disease Criteria Enabled&quot;) then
exists (
Common.&quot;US Core-Categorized Conditions&quot; EOLC
where EOLC.code in Common.&quot;Conditions likely terminal for opioid prescribing&quot;
and EOLC.clinicalStatus in Common.&quot;Active Condition&quot;
)
else
false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Opioid Review Useful?</td>
<td>16</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Is Opioid Review Useful?&quot;:
not &quot;Patient Age Less Than 18&quot;
and not &quot;Condition Positive for Sickle Cell&quot;
and not &quot;Conditions Indicating End Of Life Present&quot;
and not &quot;Order For Palliative Care In Past 90 Days&quot;
and not &quot;Is Active Cancer Treatment?&quot;
and not &quot;Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present&quot;</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Inclusion Criteria</td>
<td>17</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Inclusion Criteria&quot;:
(
(
&quot;Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential&quot;
and exists Common.&quot;Active Ambulatory Benzodiazepine Rx&quot;
)
or (
&quot;Patient Is Being Prescribed Benzodiazepine&quot;
and exists Common.&quot;Active Ambulatory Opioid Rx&quot;
)
)
and Routines.&quot;Is Opioid Review Useful?&quot;</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Conditions Indicating End of Life or With Limited Life Expectancy</td>
<td>18</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Conditions Indicating End of Life or With Limited Life Expectancy&quot;:
(
&quot;US Core-Categorized Conditions&quot; C
where C.code in &quot;Conditions likely terminal for opioid prescribing&quot;
and C.clinicalStatus in &quot;Active Condition&quot;
)
union
(
&quot;US Core-Categorized Conditions&quot; C
where C.code in &quot;Limited life expectancy conditions&quot;
and C.clinicalStatus in &quot;Active Condition&quot;
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Admitted/Referred/Discharged to Hospice Care</td>
<td>19</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Admitted/Referred/Discharged to Hospice Care&quot;:
(
[Procedure: code in &quot;Hospice Procedure Codes&quot;] P
where P.status.value in { 'in-progress', 'completed' }
)
union
(
&quot;Service Requests&quot; SR
where SR.code in &quot;Hospice Procedure Codes&quot;
and SR.status.value in { 'active', 'completed' }
)
union
(
if (Config.&quot;Hospice Findings Exclusion Enabled&quot;) then
[Observation: code in &quot;Hospice Finding Codes&quot;] O
where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' })
else
{}
)
union
(
[Encounter] E
where date from E.period.start 1 year or less on or before Today()
and (
if E.hospitalization.dischargeDisposition.coding is null
or not exists (E.hospitalization.dischargeDisposition.coding)
then false
else E.hospitalization.dischargeDisposition in &quot;Hospice Disposition&quot;
)
and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' }
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>End of Life Assessment</td>
<td>20</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;End of Life Assessment&quot;:
// 1. Conditions indicating end of life or with limited life expectancy
exists (
&quot;Conditions Indicating End of Life or With Limited Life Expectancy&quot;
)
// 2. Admitted/referred/discharged to hospice care
or exists (
&quot;Admitted/Referred/Discharged to Hospice Care&quot;
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Exclusion Criteria</td>
<td>21</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Exclusion Criteria&quot;:
Common.&quot;End of Life Assessment&quot;</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Is Recommendation Applicable?</td>
<td>22</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Is Recommendation Applicable?&quot;:
&quot;Inclusion Criteria&quot;
and not &quot;Exclusion Criteria&quot;</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Get Detail</td>
<td>23</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Get Detail&quot;:
if &quot;Is Recommendation Applicable?&quot;
then
'Consider whether the benefits outweigh the risks of concurrently prescribing opioids and benzodiazepines, or other central nervous system depressant medications.
When co-prescribing risks outweigh benefits, consult the [2022 CDC Clinical Practice Guideline Recommendation 11](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=evidence%20type%3A%203).-,Implementation%20Considerations,-Although%20in%20some) for further guidance.
[For patients being treated for opioid use disorder who are also taking benzodiazepines or other medications that depress the central nervous system, the CDC recommends not withholding buprenorphine or methadone](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=gabapentin%20and%20pregabalin).-,Buprenorphine%20or%20methadone%20for%20opioid%20use%20disorder%20should%20not%20be%20withheld%20from%20patients%20taking%20benzodiazepines%20or%20other%20medications%20that%20depress%20the%20central%20nervous%20system.,-Clinicians%20should%20check).
If the decision is made to taper benzodiazepine medications, [the CDC recommends tapering benzodiazepines gradually prior to discontinuation](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20taper%20benzodiazepines%20gradually%20before%20discontinuation%20because%20abrupt%20withdrawal%20can%20be%20associated%20with%20rebound%20anxiety%2C%20hallucinations%2C%20seizures%2C%20delirium%20tremens%2C%20and%2C%20rarely%2C%20death.%20The%20rate%20of%20tapering%20should%20be%20individualized).'
else null</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC11</td>
<td>Get Indicator</td>
<td>24</td>
</tr>
</table>
<pre><code class="language-cql">define &quot;Get Indicator&quot;:
if &quot;Is Recommendation Applicable?&quot;
then 'warning'
else null</code></pre>
<br/><br/>
</td>
</tr>
<tr>
<th scope="row"><b>Knowledge Capability: </b></th>
<td style="padding-left: 4px;">
shareable computable executable publishable
</td>
</tr>
<tr>
<th scope="row"><b>Use Context: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>code</b></th><th><b>value</b></th><th><b>display</b></th></tr>
<tr>
<td>focus</td>
<td>182888003</td>
<td>Medication requested (situation)</td>
</tr>
<tr>
<td>focus</td>
<td>82423001</td>
<td>Chronic pain (finding)</td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Jurisdiction: </b></th>
<td style="padding-left: 4px;">US</td>
</tr>
<tr>
<th scope="row"><b>Purpose: </b></th>
<td style="padding-left: 4px;"><div><p>The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Usage: </b></th>
<td style="padding-left: 4px;">Clinicians should avoid prescribing opioid pain medication and benzodiazepines or other central nervous system depressant concurrently whenever possible.</td>
</tr>
<tr>
<th scope="row"><b>Copyright: </b></th>
<td style="padding-left: 4px;"><div><p>© CDC 2016+.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Related Artifacts: </b></th>
<td style="padding-left: 4px;">
<p><b>Documentation</b></p>
<ul>
<li>
<a href="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"> 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain</a>
</li>
<li>
<a href="https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf"> MME Conversion Tables</a>
</li>
</ul>
</td>
</tr>
<tr>
<th scope="row"><b>Libraries: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><td><a href="Library-OpioidCDSREC11.html">Library - Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines</a></td></tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Actions: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<td>
<b> Existing patient has concurrent opioid and benzodiazepine prescriptions.:</b> Checking if the trigger prescription meets the inclusion criteria for recommendation #11 workflow.<br/>
<b>When:</b> <i>named-event:</i> order-select<br/>
<b>If:</b> <i>applicability:</i> Check whether the existing patient is using opioids concurrently with benzodiazepines. <i>(Is Recommendation Applicable?)</i><br/>
<b>Then:</b>
<table class="grid-dict">
<tr>
<td>
<b> :</b> Document - Will modify prescription<br/>
<b>Then:</b>
</td>
</tr>
<tr>
<td>
<b> :</b> Snooze* - Benefits outweigh risks, snooze 3 months<br/>
<b>Then:</b>
</td>
</tr>
<tr>
<td>
<b> :</b> Snooze* - N/A see comment, snooze 3 months<br/>
<b>Then:</b>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</text>
<contained>
<Library>
<id value="effective-data-requirements"/>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/library-type"/>
<code value="module-definition"/>
</coding>
</type>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Common"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommon|2022.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library FHIRHelpers"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers|4.0.1"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Routines"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSRoutines|2022.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Opioid analgesics with ambulatory misuse potential"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-analgesics-with-ambulatory-misuse-potential"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Community"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/medicationrequest-category-community"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Benzodiazepine medications"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/benzodiazepine-medications"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Encounter Diagnosis Condition Category"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-encounter-diagnosis-category"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Problem List Condition Category"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-problem-list-category"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set US Core Health Concern Condition Category"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-us-core-health-concern-category"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Limited life expectancy conditions"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/limited-life-expectancy-conditions"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Active Condition"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-clinical-status-active"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Therapies indicating end of life care"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/therapies-indicating-end-of-life-care"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Conditions likely terminal for opioid prescribing"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/conditions-likely-terminal-for-opioid-prescribing"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Hospice Procedure Codes"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/hospice-procedure"/>
</relatedArtifact>
<parameter>
<name value="ContextPrescriptions"/>
<use value="in"/>
<min value="0"/>
<max value="*"/>
<type value="MedicationRequest"/>
</parameter>
<parameter>
<name value="Get Summary"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="string"/>
</parameter>
<parameter>
<name value="Is Recommendation Applicable?"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="Get Detail"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="string"/>
</parameter>
<parameter>
<name value="Get Indicator"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="string"/>
</parameter>
<dataRequirement>
<type value="Medication"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Medication"/>
<mustSupport value="id"/>
<codeFilter>
<path value="id"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="category"/>
<codeFilter>
<path value="category"/>
<valueSet
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-encounter-diagnosis-category"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="category"/>
<codeFilter>
<path value="category"/>
<valueSet
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-problem-list-category"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="category"/>
<codeFilter>
<path value="category"/>
<valueSet
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-us-core-health-concern-category"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="ServiceRequest"/>
<profile
value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
</dataRequirement>
<dataRequirement>
<type value="ServiceRequest"/>
<profile
value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
<mustSupport value="status"/>
<mustSupport value="intent"/>
<mustSupport value="authoredOn"/>
<mustSupport value="code"/>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="status"/>
<mustSupport value="status.value"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/hospice-procedure"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="ServiceRequest"/>
<profile
value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
<mustSupport value="code"/>
<mustSupport value="status"/>
<mustSupport value="status.value"/>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="period"/>
<mustSupport value="period.start"/>
<mustSupport value="status"/>
<mustSupport value="status.value"/>
</dataRequirement>
</Library>
</contained>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="shareable"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="computable"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="executable"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="publishable"/>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem">
<valueReference>🔗
<reference value="Device/cqf-tooling"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Get Summary"/>
</extension>
<extension url="statement">
<valueString
value="define "Get Summary":
if "Is Recommendation Applicable?"
then 'Avoid prescribing opioid pain medication and benzodiazepine concurrently whenever possible.'
else null"/>
</extension>
<extension url="displaySequence">
<valueInteger value="0"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString
value="Opioid Analgesic with Ambulatory Misuse Potential Prescriptions"/>
</extension>
<extension url="statement">
<valueString
value="define "Opioid Analgesic with Ambulatory Misuse Potential Prescriptions":
Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions )"/>
</extension>
<extension url="displaySequence">
<valueInteger value="1"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString
value="Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"/>
</extension>
<extension url="statement">
<valueString
value="define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential":
exists( "Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )"/>
</extension>
<extension url="displaySequence">
<valueInteger value="2"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="Active Ambulatory Benzodiazepine Rx"/>
</extension>
<extension url="statement">
<valueString
value="define "Active Ambulatory Benzodiazepine Rx":
if Config."Can the implementing EHR support queries for past medications by date range?" then
(
"Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest]))
) Rx
where date from Rx.authoredOn 2 years or less on or before Today()
and Rx.medication in "Benzodiazepine medications"
else
List<FHIR.MedicationRequest>{}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="3"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Benzodiazepine Prescriptions"/>
</extension>
<extension url="statement">
<valueString
value="define "Benzodiazepine Prescriptions":
Common."Is Benzodiazepine?"( ContextPrescriptions )"/>
</extension>
<extension url="displaySequence">
<valueInteger value="4"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Patient Is Being Prescribed Benzodiazepine"/>
</extension>
<extension url="statement">
<valueString
value="define "Patient Is Being Prescribed Benzodiazepine":
exists( "Benzodiazepine Prescriptions" )"/>
</extension>
<extension url="displaySequence">
<valueInteger value="5"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="Active Ambulatory Opioid Rx"/>
</extension>
<extension url="statement">
<valueString
value="define "Active Ambulatory Opioid Rx":
if Config."Can the implementing EHR support queries for past medications by date range?" then
(
"Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest]))
) Rx
where date from Rx.authoredOn 2 years or less on or before Today()
and Rx.medication in "Opioid analgesics with ambulatory misuse potential"
else
List<FHIR.MedicationRequest>{}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="6"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Patient Age Less Than 18"/>
</extension>
<extension url="statement">
<valueString
value="define "Patient Age Less Than 18":
if (Config."Age Less than 18 Years Is Enabled") then
AgeInYearsAt(Today()) < 18
else
false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="7"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Condition Positive for Sickle Cell"/>
</extension>
<extension url="statement">
<valueString
value="define "Condition Positive for Sickle Cell":
if (Config."Sickle Cell Check Enabled") then
exists(
Common."Positive Sickle Cell Condition"
) else
false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="8"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="US Core-Categorized Conditions"/>
</extension>
<extension url="statement">
<valueString
value="// 3. Medications indicating end of life
/* or exists (
"Medications Indicating End of Life"
) */
define "US Core-Categorized Conditions":
[Condition: category in "Encounter Diagnosis Condition Category"]
union [Condition: category in "Problem List Condition Category"]
union [Condition: category in "US Core Health Concern Condition Category"]"/>
</extension>
<extension url="displaySequence">
<valueInteger value="9"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Conditions Indicating End Of Life Present"/>
</extension>
<extension url="statement">
<valueString
value="define "Conditions Indicating End Of Life Present":
exists (
Common."US Core-Categorized Conditions" LLEC
where LLEC.code in Common."Limited life expectancy conditions"
and LLEC.clinicalStatus in Common."Active Condition"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="10"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="Service Requests"/>
</extension>
<extension url="statement">
<valueString
value="define "Service Requests":
[ServiceRequest] SR
return SR"/>
</extension>
<extension url="displaySequence">
<valueInteger value="11"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Palliative Care Lookback Period"/>
</extension>
<extension url="statement">
<valueString
value="/*
** Routine #1
** Opioid Review Useful Routine
**
** Definition | Answer to Proceed | Details | Data (Terminology) Requirement
** ------------------------------------------------------------------------------------------------------------------------------------
** Age < 18 years? | No | Calculate age from date of birth; exclude | Date of birth
** | | patients with age less than 18 years at the |
** | | time of the prescription |
** ------------------------------------------------------------------------------------------------------------------------------------
** Evidence of | No | Look for documented findings consistent | Sickle cell disease conditions
** sickle cell disease? | | with those listed in the sickle cell |
** | | value set |
** ------------------------------------------------------------------------------------------------------------------------------------
** Limited life | No | Look for documented findings consistent | Limited life expectancy conditions
** expectancy conditions | | with those listed in the limited life |
** present? | | expectancy value set (terminal illness, bad |
** | | prognosis, pre-terminal) |
** ------------------------------------------------------------------------------------------------------------------------------------
** Order for therapies | No | Look for patients with an existing order for | Therapies indicating end of life care
** indicating end of life | | therapies indicating end of life care |
** care in past 90 days? | | written within past 90 days |
** ------------------------------------------------------------------------------------------------------------------------------------
** Active cancer | No | See sub-routine 3 | See sub-routine 3
** treatment? | | |
** ------------------------------------------------------------------------------------------------------------------------------------
** Conditions Likely | No | Look for patients with active conditions in | Conditions likely terminal for opioid
** Terminal for opioid | | the value set end-of-life-conditions | prescribing
** prescribing present? | | |
** ------------------------------------------------------------------------------------------------------------------------------------
**
*/
define "Palliative Care Lookback Period":
Interval[Today() - 90 days, Today()]"/>
</extension>
<extension url="displaySequence">
<valueInteger value="12"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Order For Palliative Care In Past 90 Days"/>
</extension>
<extension url="statement">
<valueString
value="define "Order For Palliative Care In Past 90 Days":
exists (
Common."Service Requests" SR
where SR.status in { 'active', 'completed'}
and SR.intent in {'proposal', 'plan,', 'directive', 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}
and FHIRHelpers.ToDateTime(SR.authoredOn) during day of "Palliative Care Lookback Period"
and SR.code in Common."Therapies indicating end of life care"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="13"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Active Cancer Treatment?"/>
</extension>
<extension url="statement">
<valueString
value="define "Is Active Cancer Treatment?":
if (Config."Active Cancer Treatment Encounters Condition Is Enabled") then
"Has Two or More Encounters with Cancer Diagnosis During Encounter Period"
else
false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="14"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString
value="Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present"/>
</extension>
<extension url="statement">
<valueString
value="define "Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present":
if (Config."End-Stage Disease Criteria Enabled") then
exists (
Common."US Core-Categorized Conditions" EOLC
where EOLC.code in Common."Conditions likely terminal for opioid prescribing"
and EOLC.clinicalStatus in Common."Active Condition"
)
else
false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="15"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Opioid Review Useful?"/>
</extension>
<extension url="statement">
<valueString
value="define "Is Opioid Review Useful?":
not "Patient Age Less Than 18"
and not "Condition Positive for Sickle Cell"
and not "Conditions Indicating End Of Life Present"
and not "Order For Palliative Care In Past 90 Days"
and not "Is Active Cancer Treatment?"
and not "Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present""/>
</extension>
<extension url="displaySequence">
<valueInteger value="16"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Inclusion Criteria"/>
</extension>
<extension url="statement">
<valueString
value="define "Inclusion Criteria":
(
(
"Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
and exists Common."Active Ambulatory Benzodiazepine Rx"
)
or (
"Patient Is Being Prescribed Benzodiazepine"
and exists Common."Active Ambulatory Opioid Rx"
)
)
and Routines."Is Opioid Review Useful?""/>
</extension>
<extension url="displaySequence">
<valueInteger value="17"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString
value="Conditions Indicating End of Life or With Limited Life Expectancy"/>
</extension>
<extension url="statement">
<valueString
value="define "Conditions Indicating End of Life or With Limited Life Expectancy":
(
"US Core-Categorized Conditions" C
where C.code in "Conditions likely terminal for opioid prescribing"
and C.clinicalStatus in "Active Condition"
)
union
(
"US Core-Categorized Conditions" C
where C.code in "Limited life expectancy conditions"
and C.clinicalStatus in "Active Condition"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="18"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="Admitted/Referred/Discharged to Hospice Care"/>
</extension>
<extension url="statement">
<valueString
value="define "Admitted/Referred/Discharged to Hospice Care":
(
[Procedure: code in "Hospice Procedure Codes"] P
where P.status.value in { 'in-progress', 'completed' }
)
union
(
"Service Requests" SR
where SR.code in "Hospice Procedure Codes"
and SR.status.value in { 'active', 'completed' }
)
union
(
if (Config."Hospice Findings Exclusion Enabled") then
[Observation: code in "Hospice Finding Codes"] O
where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' })
else
{}
)
union
(
[Encounter] E
where date from E.period.start 1 year or less on or before Today()
and (
if E.hospitalization.dischargeDisposition.coding is null
or not exists (E.hospitalization.dischargeDisposition.coding)
then false
else E.hospitalization.dischargeDisposition in "Hospice Disposition"
)
and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' }
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="19"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="End of Life Assessment"/>
</extension>
<extension url="statement">
<valueString
value="define "End of Life Assessment":
// 1. Conditions indicating end of life or with limited life expectancy
exists (
"Conditions Indicating End of Life or With Limited Life Expectancy"
)
// 2. Admitted/referred/discharged to hospice care
or exists (
"Admitted/Referred/Discharged to Hospice Care"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="20"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Exclusion Criteria"/>
</extension>
<extension url="statement">
<valueString
value="define "Exclusion Criteria":
Common."End of Life Assessment""/>
</extension>
<extension url="displaySequence">
<valueInteger value="21"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Is Recommendation Applicable?"/>
</extension>
<extension url="statement">
<valueString
value="define "Is Recommendation Applicable?":
"Inclusion Criteria"
and not "Exclusion Criteria""/>
</extension>
<extension url="displaySequence">
<valueInteger value="22"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Get Detail"/>
</extension>
<extension url="statement">
<valueString
value="define "Get Detail":
if "Is Recommendation Applicable?"
then
'Consider whether the benefits outweigh the risks of concurrently prescribing opioids and benzodiazepines, or other central nervous system depressant medications.
When co-prescribing risks outweigh benefits, consult the [2022 CDC Clinical Practice Guideline Recommendation 11](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=evidence%20type%3A%203).-,Implementation%20Considerations,-Although%20in%20some) for further guidance.
[For patients being treated for opioid use disorder who are also taking benzodiazepines or other medications that depress the central nervous system, the CDC recommends not withholding buprenorphine or methadone](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=gabapentin%20and%20pregabalin).-,Buprenorphine%20or%20methadone%20for%20opioid%20use%20disorder%20should%20not%20be%20withheld%20from%20patients%20taking%20benzodiazepines%20or%20other%20medications%20that%20depress%20the%20central%20nervous%20system.,-Clinicians%20should%20check).
If the decision is made to taper benzodiazepine medications, [the CDC recommends tapering benzodiazepines gradually prior to discontinuation](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20taper%20benzodiazepines%20gradually%20before%20discontinuation%20because%20abrupt%20withdrawal%20can%20be%20associated%20with%20rebound%20anxiety%2C%20hallucinations%2C%20seizures%2C%20delirium%20tremens%2C%20and%2C%20rarely%2C%20death.%20The%20rate%20of%20tapering%20should%20be%20individualized).'
else null"/>
</extension>
<extension url="displaySequence">
<valueInteger value="23"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC11"/>
</extension>
<extension url="name">
<valueString value="Get Indicator"/>
</extension>
<extension url="statement">
<valueString
value="define "Get Indicator":
if "Is Recommendation Applicable?"
then 'warning'
else null"/>
</extension>
<extension url="displaySequence">
<valueInteger value="24"/>
</extension>
</extension>
<extension
url="http://fhir.org/guides/cdc/opioid-cds/StructureDefinition/effectiveDataRequirements" id="effective-data-requirements">
<valueReference>
<reference value="#effective-data-requirements"/>
</valueReference>
</extension>
<url
value="http://fhir.org/guides/cdc/opioid-cds/PlanDefinition/opioidcds-11"/>
<identifier>
<use value="official"/>
<value value="cdc-opioid-guidance"/>
</identifier>
<version value="2022.1.0"/>
<name value="CDC_opioid_11"/>
<title
value="PlanDefinition - 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain: Recommendation #11"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/plan-definition-type"/>
<code value="eca-rule"/>
<display value="ECA Rule"/>
</coding>
</type>
<status value="draft"/>
<experimental value="true"/>
<date value="2023-05-01"/>
<publisher value="Centers for Disease Control and Prevention (CDC)"/>
<contact>
<telecom>
<system value="url"/>
<value value="https://www.cdc.gov"/>
</telecom>
</contact>
<description
value="Concurrently prescribing opioid medications with benzodiazepines increases the risk of harm for the patient."/>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="focus"/>
<display value="Clinical Focus"/>
</code>
<valueCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="182888003"/>
<display value="Medication requested (situation)"/>
</coding>
</valueCodeableConcept>
</useContext>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="focus"/>
<display value="Clinical Focus"/>
</code>
<valueCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="82423001"/>
<display value="Chronic pain (finding)"/>
</coding>
</valueCodeableConcept>
</useContext>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
<display value="United States of America"/>
</coding>
</jurisdiction>
<purpose
value="The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care."/>
<usage
value="Clinicians should avoid prescribing opioid pain medication and benzodiazepines or other central nervous system depressant concurrently whenever possible."/>
<copyright value="© CDC 2016+."/>
<topic>
<text value="Opioid Prescribing"/>
</topic>
<author>
<name value="Kensaku Kawamoto, MD, PhD, MHS"/>
</author>
<author>
<name value="Bryn Rhodes"/>
</author>
<author>
<name value="Floyd Eisenberg, MD, MPH"/>
</author>
<author>
<name value="Robert McClure, MD, MPH"/>
</author>
<relatedArtifact>
<type value="documentation"/>
<display
value="2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain"/>
<url value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"/>
<document>
<url value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"/>
</document>
</relatedArtifact>
<relatedArtifact>
<type value="documentation"/>
<display value="MME Conversion Tables"/>
<url
value="https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf"/>
<document>
<url
value="https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf"/>
</document>
</relatedArtifact>
<library
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSREC11"/>
<action>
<title
value="Existing patient has concurrent opioid and benzodiazepine prescriptions."/>
<description
value="Checking if the trigger prescription meets the inclusion criteria for recommendation #11 workflow."/>
<documentation>
<type value="documentation"/>
<display
value="2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain"/>
<url value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"/>
<document>
<url value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"/>
</document>
</documentation>
<documentation>
<type value="documentation"/>
<url
value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation11:~:text=nervous%20system%20depressants-,(recommendation%20category%3A%20B%3B%20evidence%20type%3A%203).,-Implementation%20Considerations"/>
<document>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-strengthOfRecommendation">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/recommendation-strength"/>
<code value="weak"/>
<display value="Weak"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-qualityOfEvidence">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/evidence-quality"/>
<code value="low"/>
<display value="Low quality"/>
</coding>
</valueCodeableConcept>
</extension>
<url
value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation11:~:text=nervous%20system%20depressants-,(recommendation%20category%3A%20B%3B%20evidence%20type%3A%203).,-Implementation%20Considerations"/>
</document>
</documentation>
<trigger>
<type value="named-event"/>
<name value="order-select"/>
</trigger>
<condition>
<kind value="applicability"/>
<expression>
<description
value="Check whether the existing patient is using opioids concurrently with benzodiazepines."/>
<language value="text/cql.identifier"/>
<expression value="Is Recommendation Applicable?"/>
</expression>
</condition>
<groupingBehavior value="visual-group"/>
<selectionBehavior value="any"/>
<dynamicValue>
<path value="action.description"/>
<expression>
<language value="text/cql.identifier"/>
<expression value="Get Detail"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="action.title"/>
<expression>
<language value="text/cql.identifier"/>
<expression value="Get Summary"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="action.extension"/>
<expression>
<language value="text/cql.identifier"/>
<expression value="Get Indicator"/>
</expression>
</dynamicValue>
<action>
<description value="Document - Will modify prescription"/>
</action>
<action>
<description
value="Snooze* - Benefits outweigh risks, snooze 3 months"/>
</action>
<action>
<description value="Snooze* - N/A see comment, snooze 3 months"/>
</action>
</action>
</PlanDefinition>