Recommendation #11 Order Select Variation - Concurrent Use of Opioids and Benzodiazepines - 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 #11 Order Select Variation - Concurrent Use of Opioids and Benzodiazepines

Recommendations #11 (2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain):

Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants (recommendation category: B; evidence type: 3).

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
Opioid Review Useful
Content
Example Data/Requests

Functional Description

When

Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting or
Provider is prescribing a benzodiazepine or other central nervous system depressant medication
Opioid review is useful for this patient:

Patient is 18 or over
Patient does not have evidence of sickle cell disease
Patient does not have findings indicating limited life expectancy
Patient does not have orders for therapies indicating end of life care
Patient is not undergoing active cancer treatment:

Patient has had at least 2 office visits within the past 12 months with an oncology specialist present, or
Patient has had at least 2 office visits within the past 12 months with a CDC malignant cancer condition diagnosis

Patient does not have conditions likely terminal for opioid prescribing present

Patient prescribed opioid analgesic with ambulatory misuse potential and benzodiazepine or other central nervous system depressant medication concurrently

Then

Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently:

Document - Will modify prescription
Snooze - Benefits outweigh risks, 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 analgesics with ambulatory misuse potential?	Yes	Trigger based on a new prescription (order) for opioid analgesics with ambulatory misuse potential - ideally the prescription should be selected prior to being committed to the system	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Order for benzodiazepine or other central nervous system depressant medications?	Yes	Trigger based on a new prescription (order) for opioids or benzodiazepines or other central nervous system depressant in the relevant value sets - ideally the prescription should be selected prior to being committed to the system	Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Receiving both opioid with ambulatory use potential and benzodiazepine or other central nervous system depressant ?	Yes	New prescription is for an opioid and existing use of benzodiazepine or other central nervous system depressant evident, OR New prescription is for benzodiazepine or other central nervous system depressant and existing use of opioids evident	Opioid analgesics with ambulatory misuse potential Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category

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 #11 Order Select	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #11 Order Select
Recommendation #11 Order Select - concurrent opioid pain medication and benzodiazepines or other central nervous system depressant prescriptions	Library	Defines the data requirements to support evaluation of recommendation #11 Order Select
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-select hook

Description	CDS Hooks Request	Expected Response
Patient is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options: i. Revise ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once 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 is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options: i. Revise ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once 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 is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days.
This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options:
i. Revise
ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once 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 is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days.
This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options:
i. Revise
ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once 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