Recommendation #10 Order Sign Variation - Urine Drug Testing - 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 #10 Order Sign Variation - Urine Drug Testing

Recommendations #10 (2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain):

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

Note that this recommendation is represented in multiple variations where each variation corresponds to the CDS Hook by which it was meant to be triggered/evaluated. Use the tabs below to navigate to each variation.

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

Nonopioid drug urine screening has not been performed in last 12 months or
Opioid drug urine screening has not been performed in last 12 months

Then

Consider the benefits and risks of conducting a urine toxicology screen:

Document - Order toxicology screen
Document risks outweigh benefits
Snooze - N/A see comment, snooze 3 months

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

Nonopioid drug urine screening has been performed in last 12 months and
Opioid drug urine screening has been performed in last 12 months and
Positive result for synthetic opioid in the past year and not currently prescribed synthetic opioid or
Positive result for phencyclidine(PCP) in the past year or
Positive result for fentanyl in the past year and not currently prescribed fentanyl or
Positive result for cocaine in the past year or
Positive result for amphetamine in the past year and not currently prescribed amphetamine or
Positive result for tetrahydrocannabinol (THC) in the past year and not currently prescribed tetrahydrocannabinol (THC) or
Positive result for opiate in the past year and not currently prescribed natural opiate or
Positive result for alcohol in the past year or
Positive result for methadone in the past year and not currently prescribed methadone

Then

Patient may have unexpected toxicology test results:

Document - Will repeat urine drug screening more frequently
Document - Will assess patient for substance use disorder
Snooze - Patient's test results were expected, snooze for 3 months
Snooze - N/A snooze for 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 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
Non-opioid drug urine screen test not performed within the last 12 months	Yes	No urine screening test performed within the last 12 months	Non-opioid drug urine screen	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Opioid drug urine screen test not performed within the last 12 months?	Yes	No opioid drug urine screening test performed within the last 12 months	Opioid drug urine screen	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Urine drug screen results contain cocaine?	Yes	Urine drug screen result contains cocaine	Cocaine urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain phencyclidine (PCP)?	Yes	Urine drug screen result contains phencyclidine (PCP)	Phencyclidine (PCP) urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain amphetamine and no active amphetamine medication?	Yes	Urine drug screen result contains amphetamine and patient does not have an active prescription for amphetamine	Amphetamine urine toxicology test result Amphetamine medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain opiate and no active opiate medication?	Yes	Urine drug screen result contains opiate and patient does not have an active prescription for opiate	Opiate urine toxicology test result Opiate medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain methadone and no active methadone medication?	Yes	Urine drug screen result contains methadone and patient does not have an active prescription for methadone	Methadone urine toxicology test result Methadone medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain synthetic opioid and no active synthetic opioid medication?	Yes	Urine drug screen result contains synthetic opioid and patient does not have an active prescription for synthetic opioid	Synthetic opioid urine toxicology test result Synthetic opioid medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain fentanyl and no active fentanyl medication?	Yes	Urine drug screen result contains fentanyl and patient does not have an active prescription for fentanyl	Fentanyl urine toxicology test result Fentanyl medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain tetrahydrocannabinol (THC)?	Yes	Urine drug screen result contains tetrahydrocannabinol (THC)	Tetrahydrocannabinol urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain alcohol?	Yes	Urine drug screen result contains alcohol	Alcohol urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value

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.

Sign

Resource	Type	Description
2022 CDC Clinical Practice Guideline Recommendation #10 Order Sign	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #10 Order Sign
Recommendation #10 Order Sign - urine drug testing when prescribing opioids for subacute or chronic pain	Library	Defines the data requirements to support evaluation of recommendation #10 Order Sign
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 - order-sign hook

Description	CDS Hooks Request	Expected Response
Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696), once every 12 days for 30 days. This triggers the message that urine drug screening is recommended with the following three feedback options: i. Perform the screening ii. Indicate that the prescription is not for subacute or chronic pain management and snooze for 3 months iii. Indicate that it is not applicable, log a comment and snooze for 3 months.	Request JSON	Response JSON
Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696) and a urine screening with the prescence of Phencyclidine is present. This triggers the message "Positive Cocaine or PCP in Urine Screening" with a note explaining this may be a false positive or indicate recreational or addictive use.	Request JSON	Response JSON

Description

CDS Hooks Request

Expected Response

Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696), once every 12 days for 30 days. This triggers the message that urine drug screening is recommended with the following three feedback options:
i. Perform the screening
ii. Indicate that the prescription is not for subacute or chronic pain management and snooze for 3 months
iii. Indicate that it is not applicable, log a comment and snooze for 3 months.

Request JSON

Response JSON

Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696) and a urine screening with the prescence of Phencyclidine is present. This triggers the message "Positive Cocaine or PCP in Urine Screening" with a note explaining this may be a false positive or indicate recreational or addictive use.

Request JSON

Response JSON