Recommendation #7 - Opioid Therapy Risk Assessment - 2022 CDC Clinical Practice Guideline for Prescribing Opioids Implementation Guide v2022.1.0

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

Recommendation #7 - Opioid Therapy Risk Assessment

Recommendations #7 (2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain):

Clinicians should evaluate benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients (recommendation category: A; evidence type: 4).

Contents

Functional Description
For Subacute or Chronic Pain
Opioid Review Useful
Content
Example Data/Requests

Functional Description

When

Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting
Prescription is for treating subacute and/or chronic pain.
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

Opioid risk benefit assessment has not been performed in the past 90 days

Then

Regularly Evaluate the Benefits and Risks of Opioid Therapy:

Document - Conducted benefit and risk assessment
Snooze - Conducted assessment, snooze 3 months
Snooze - N/A see comment, snooze 3 months

The following table describes the flowchart decisions and sub-routines for the recommendation
Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Opioid order for subacute or chronic pain?	Yes	See For Subacute or Chronic Pain sub-routine
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Opioid risk - benefit assessment procedure not performed in last 90 days?	Yes	Absence of an opioid treatment assessment procedure in the last 90 days	Opioid treatment assessment procedure	Procedure	Procedure.code, and Procedure.performed

Effective Data Requirements

For Subacute or Chronic Pain

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Order for opioid analgesic with expected supply duration ≥ 28 days	Yes	Order for opioid analgesics with ambulatory misuse potential with a supply duration ≥ 28 days • Subacute definition = order for opioid analgesic with ambulatory misuse potential with a supply duration of one to two months • Chronic pain definition = order for opioid analgesic with ambulatory misuse potential with a supply duration of ≥ two months	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication and MedicationRequest.dispenseRequest.expectedSupplyDuration

Opioid Review Useful

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Age < 18 years?	No	Calculate age from date of birth; exclude patients with age less than 18 years at the time of the prescription	Date of birth	Patient	Patient.birthDate
Evidence of sickle cell disease?	No	Look for patients with a diagnosis or problem list entry indicating sickle cell disease	Sickle cell disease condition	Condition	Condition.category, Condition.code, and Condition.clinicalStatus
Limited life expectancy conditions present?	No	Look for documented findings consistent with those listed in the limited life expectancy value set (terminal illness, bad prognosis, pre-terminal)	Limited life expectancy conditions	Condition	Condition.category and Condition.code
Order for therapies indicating end of life care in past 90 days?	No	Look for patients with an existing order for therapies indicating end of life care written within past 90 days	Therapies indicating end of life care	ServiceRequest	ServiceRequest.status, ServiceRequest.intent, ServiceRequest.authoredOn, and ServiceRequest.code
Active cancer treatment?	No	See Active Cancer Treatment sub-routine	See Active Cancer Treatment sub-routine
Conditions Likely Terminal for opioid prescribing present?	No	Look for patients with active conditions in the value set end-of-life-conditions	Conditions likely terminal for opioid prescribing	Condition	Condition.category, Condition.code, and Condition.clinicalStatus

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Two office visits within the past 12 months?	No	Look for a minimum of two distinct encounters within 12 months of the date of the current visit for which each of the following is true: • the encounter diagnosis (primary or secondary or co-morbidity diagnosis) is listed in the CDC Malignant Cancer Conditions value set	Office Visit	Encounter	Encounter.class and Encounter.period.start
Office visits with an oncology specialist present?	No	• The encounter is performed by an oncologist as defined in the oncology specialty designations using the National Uniform Claim Committee (NUCC) classifications	Oncology specialty designations (NUCC)	PractitionerRole and Encounter	PractitionerRole.specialty, Encounter.participant.type, and Encounter.participant.individual
Office visits including CDC malignant cancer condition?	No	• The encounter diagnosis (primary or secondary or co-morbidity diagnosis) is listed in the CDC Malignant Cancer Conditions value set	CDC malignant cancer conditions	Condition and Encounter	Condition.category, Condition.code, and Encounter.diagnosis

Content

The following artifacts formalize the description of the logic and behavior defined by this recommendation.

Resource	Type	Description
2022 CDC Clinical Practice Guideline Recommendation #7	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #7
Recommendation #7 - benefits and harms of starting and/or continuing opioid therapy for subacute or chronic pain	Library	Defines the data requirements to support evaluation of recommendation #7
Opioid Terminology Management Knowledge-base Data (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support Logic	Library	CQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration Logic	Library	CQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines Logic	Library	CQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion Logic	Library	CQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation

Example Data/Requests

Description	CDS Hooks Request	Expected Response
Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502).one tablet per day for 30 days. Patient is also being prescribed maCarbinoxamineleate 0.4 MG/ML / Hydrocodone Bitartrate 1 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution (RXNorm 1012727) 3 tablets per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) 1 tablet per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) one tablet per 1 day for 7 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm one tablet per 1 day for 7 days. "Assessment of risk for opioid use procedure." Patients on opioid therapy should be evaluated for benefits and harms within 1 to 4 weeks of starting opioid therapy and every 3 months or more subsequently. Assessment of risk for opioid abuse (procedure)	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet. (RXNorm 1049502) one tablet per 1 day for 6 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (Rxnorm 0149502) one tablet per 1 day for 6 days.The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) one tablet per 1 day for 30 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) one tablet per 1 day for 63 days. This will trigger the message "No evaluation for benefits and harms associated with opioid therapy has been performed for the patient in the past 3 months" Patients on opioid therapy should be evaluated for benefits and harms within 1 to 4 weeks of starting opioid therapy and every 3 months or more subsequently.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) 1 tablet per 1 day for 30 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) 1 tablet per 1 day for 62 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON

Description

CDS Hooks Request

Expected Response

Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502).one tablet per day for 30 days. Patient is also being prescribed maCarbinoxamineleate 0.4 MG/ML / Hydrocodone Bitartrate 1 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution (RXNorm 1012727) 3 tablets per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) 1 tablet per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) one tablet per 1 day for 7 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm one tablet per 1 day for 7 days. "Assessment of risk for opioid use procedure." Patients on opioid therapy should be evaluated for benefits and harms within 1 to 4 weeks of starting opioid therapy and every 3 months or more subsequently. Assessment of risk for opioid abuse (procedure)

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet. (RXNorm 1049502) one tablet per 1 day for 6 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (Rxnorm 0149502) one tablet per 1 day for 6 days.The patient will be excluded and no message will be triggered - an empty set of cards will be returned.

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) one tablet per 1 day for 30 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) one tablet per 1 day for 63 days. This will trigger the message "No evaluation for benefits and harms associated with opioid therapy has been performed for the patient in the past 3 months" Patients on opioid therapy should be evaluated for benefits and harms within 1 to 4 weeks of starting opioid therapy and every 3 months or more subsequently.

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) 1 tablet per 1 day for 30 days. Patient has also been prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RXNorm 1049502) 1 tablet per 1 day for 62 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.

Request JSON

Response JSON