Recommendation #9 - Consider Patient's History of Controlled Substance Prescriptions - 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 #9 - Consider Patient's History of Controlled Substance Prescriptions

Recommendations #9 (2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain):

When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose (recommendation category: B; evidence type: 4).

Contents

Functional Description
Opioid Review Useful
Content
Example Data/Requests

Functional Description

When

Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting
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

PDMP data has not been reviewed in the past 90 days or
PDMP review procedure has not been performed in the past 90 days

Then

Before Ordering Opioids, Review PDMP Data:

Access Data - Launch app to review PDMP data
Document - PDMP data reviewed, 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
Order for opioid analgesic with ambulatory misuse potential	Yes	Order for opioid analgesics with ambulatory misuse potential	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
PDMP review procedure in past 90 days?	No	Look for evidence of a prescription drug monitoring program (PDMP) review procedure (may need to modify time interval for review based on local practice / regulation) [Evidence for the PDMP review procedure may potentially originate in a PDMP Smart App that provides the code once PDMP review procedure has been completed]	PDMP review procedure	Procedure	Procedure.code, Procedure.status, and Procedure.performed
PDMP data reviewed finding in past 90 days?	No	Documentation (i.e., a finding that PDMP review has occurred) in last 90 days (may need to modify time interval for review based on local practice / regulation)	PDMP data reviewed finding	Observation	Observation.status, Observation.code, and Observation.effective

Effective Data Requirements

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 #9	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #9
Recommendation #9 - Consider Patient's History of Controlled Substance Prescriptions	Library	Defines the data requirements to support evaluation of recommendation #9
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 Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) Patients "Dosage Instructions" are 1 FIlm per day for 30 days. This will trigger the message "PDMP Data Review"	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) Patients "Dosage Instructions" are 1 Film 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

Description

CDS Hooks Request

Expected Response

Patient is 18 or older. Patient has been prescribed Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) Patients "Dosage Instructions" are 1 FIlm per day for 30 days. This will trigger the message "PDMP Data Review"

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) Patients "Dosage Instructions" are 1 Film 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