Id: opioidcds-08 Url: Recommendation #8 - Naloxone Consideration Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_08_Order_Sign Title: Recommendation #8 - Naloxone Consideration Status: draft Experimental: true Type: system: http://terminology.hl7.org/CodeSystem/plan-definition-type code: eca-rule display: ECA Rule Date: 2025-08-06 Publisher: Centers for Disease Control and Prevention (CDC) Description: Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone. Logic Definitions: Library Name Name sequence OpioidCDSREC08 Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions 0 define "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions": ( Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) ) AmbulatoryOpioidPrescription where Routines."Is Subacute or Chronic Pain Prescription?"( AmbulatoryOpioidPrescription ) Library Name Name sequence OpioidCDSREC08 Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential 1 define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" ) Library Name Name sequence OpioidCDSCommonConfig Age Less than 18 Years Is Enabled 2 // CDC 2022 General Inclusion Criteria define "Age Less than 18 Years Is Enabled": true Library Name Name sequence OpioidCDSRoutines Patient Age Less Than 18 3 define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false Library Name Name sequence OpioidCDSCommonConfig Sickle Cell Check Enabled 4 // Sickle Cell define "Sickle Cell Check Enabled": true Library Name Name sequence OpioidCDSCommonConfig Sickle Cell Assumed Active 5 define "Sickle Cell Assumed Active": true Library Name Name sequence OpioidCDSCommon US Core-Categorized Conditions 6 // 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"] Library Name Name sequence OpioidCDSCommon Positive Sickle Cell Condition 7 define "Positive Sickle Cell Condition": if Config."Sickle Cell Check Enabled" and not Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" and C.clinicalStatus in "Active Condition" ) else if Config."Sickle Cell Check Enabled" and Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" ) else null Library Name Name sequence OpioidCDSRoutines Condition Positive for Sickle Cell 8 define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false Library Name Name sequence OpioidCDSCommonConfig Active Cancer Treatment Encounters Condition Is Enabled 9 // Active Cancer Treatment define "Active Cancer Treatment Encounters Condition Is Enabled": true Library Name Name sequence OpioidCDSRoutines Encounter Period 10 // End of Opioid Naive Routine /* ** Routine #3 ** Active Cancer Treatment Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** --------------------------------------------------------------------------------------------------------------------------------- ** Two office visits within the | No | Look for a minimum of two distinct | Office Visit ** past 12 months | | 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 visits with an | No | The encounter is performed by an | Oncology specialty ** oncology specialist | | oncologist as defined in the oncology | designations (NUCC) ** present | | specialty designations using the | ** | | National Uniform Claim Committee | ** | | (NUCC) classifications | ** --------------------------------------------------------------------------------------------------------------------------------- ** Office visits including CDC | No | The encounter diagnosis (primary or | CDC malignant cancer ** malignant cancer | | secondary or co-morbidity diagnosis) | conditions ** condition | | is listed in the CDC Malignant Cancer | ** | | Conditions value set | ** ---------------------------------------------------------------------------------------------------------------------------------- ** */ define "Encounter Period": Interval[Today() - 12 months, Today()) Library Name Name sequence OpioidCDSCommon USCore Encounter Cancer Diagnoses 11 define "USCore Encounter Cancer Diagnoses": [Condition: category in "Encounter Diagnosis Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions" Library Name Name sequence OpioidCDSRoutines Encounters with Cancer Diagnosis During Encounter Period 12 // encounter-diagnosis, problem-list and health-concern Conditions // define "US Core-Categorized Cancer Diagnoses": // Common."US Core-Categorized Conditions" C // where C.code in Common."CDC malignant cancer conditions" // define "Encounters with Cancer Diagnosis During Encounter Period": // [Encounter] Encounter // with "US Core-Categorized Cancer Diagnoses" CancerDiagnosis // such that date from Encounter.period."start".value in day of "Encounter Period" // and EndsWith(CancerDiagnosis.encounter.reference, Encounter.id) define "Encounters with Cancer Diagnosis During Encounter Period": [Encounter] Encounters where date from Encounters.period."start" in day of "Encounter Period" and exists ( Common."USCore Encounter Cancer Diagnoses" CancerDiagnoses where EndsWith(CancerDiagnoses.encounter.reference, Encounters.id) ) Library Name Name sequence OpioidCDSRoutines Number of Encounters with Cancer Diagnosis During Encounter Period 13 define "Number of Encounters with Cancer Diagnosis During Encounter Period": Count ("Encounters with Cancer Diagnosis During Encounter Period") Library Name Name sequence OpioidCDSRoutines Has Two or More Encounters with Cancer Diagnosis During Encounter Period 14 define "Has Two or More Encounters with Cancer Diagnosis During Encounter Period": "Number of Encounters with Cancer Diagnosis During Encounter Period" >= 2 Library Name Name sequence OpioidCDSCommon USCore Problem List Cancer Diagnoses 15 define "USCore Problem List Cancer Diagnoses": [Condition: category in "Problem List Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions" Library Name Name sequence OpioidCDSRoutines Has Active Cancer Diagnosis on Problem List 16 define "Has Active Cancer Diagnosis on Problem List": exists ( Common."USCore Problem List Cancer Diagnoses" CancerDiagnoses where CancerDiagnoses.category in Common."Problem List Condition Category" and exists( CancerDiagnoses.clinicalStatus.coding ClinicalStatus where ClinicalStatus.code ~ 'active' ) ) Library Name Name sequence OpioidCDSRoutines Is Active Cancer Treatment? 17 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" or "Has Active Cancer Diagnosis on Problem List" else false Library Name Name sequence OpioidCDSCommonConfig End-Stage Disease Criteria Enabled 18 // CDC 2022 General Inclusion Criteria define "End-Stage Disease Criteria Enabled": true Library Name Name sequence OpioidCDSRoutines Conditions Likely Terminal for Opioid Prescribing 19 define "Conditions Likely Terminal for Opioid Prescribing": 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 Library Name Name sequence OpioidCDSRoutines CDC 2022 Guideline General Inclusion Criteria 20 define "CDC 2022 Guideline General Inclusion Criteria": not "Patient Age Less Than 18" and not "Condition Positive for Sickle Cell" and not "Is Active Cancer Treatment?" and not "Conditions Likely Terminal for Opioid Prescribing" Library Name Name sequence OpioidCDSREC08 Inclusion Criteria 21 define "Inclusion Criteria": "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and Routines."CDC 2022 Guideline General Inclusion Criteria" Library Name Name sequence OpioidCDSREC08 Is Recommendation Applicable? 22 define "Is Recommendation Applicable?": "Inclusion Criteria" Library Name Name sequence OpioidCDSCommon Is Opioid Analgesic with Ambulatory Misuse Potential? 23 define function "Is Opioid Analgesic with Ambulatory Misuse Potential?"(value List<MedicationRequest>): ("Get MedicationRequest Medication as Code"(value)) Rx where Rx.medication in "Opioid analgesics with ambulatory misuse potential" and Rx.category in "Community" Library Name Name sequence OpioidCDSCommon Get MedicationRequest Medication as Code 24 define function "Get MedicationRequest Medication as Code"(value List<MedicationRequest>): value Rx let Med: if Rx.medication is Reference then singleton from ( [Medication] M where M.id = (Last(Split((Rx.medication as FHIR.Reference).reference, '/'))) ) else null return MedicationRequest { id: Rx.id, status: Rx.status, intent: Rx.intent, category: Rx.category, medication: if Rx.medication is Reference then Med.code else Rx.medication as CodeableConcept, subject: Rx.subject, authoredOn: Rx.authoredOn, recorder: Rx.recorder, dosageInstruction: Rx.dosageInstruction, dispenseRequest: Rx.dispenseRequest } Library Name Name sequence FHIRHelpers ToString 25 define function ToString(value string): value.value Library Name Name sequence FHIRHelpers ToConcept 26 define function ToConcept(concept FHIR.CodeableConcept): if concept is null then null else System.Concept { codes: concept.coding C return ToCode(C), display: concept.text.value } Library Name Name sequence FHIRHelpers ToCode 27 define function ToCode(coding FHIR.Coding): if coding is null then null else System.Code { code: coding.code.value, system: coding.system.value, version: coding.version.value, display: coding.display.value } Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Prescription? 28 // End of Active Cancer Treatment Routine /* ** Routine #4 ** For Subacute or Chronic Pain Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** ----------------------------------------------------------------------------------------------------------------------------------- ** Order for opioid analgesic | Yes | Order for opioid analgesics with ambulatory | Opioid analgesics with ** with expected supply | | misuse potential with a supply duration of >= | ambulatory misuse potential ** duration >= 28 days | | 28 days | ** | | | ** | | - Subacute definition = order for opioid | ** | | analgesics with ambulatory misuse | ** | | potential with a supply duration of one to | ** | | two months. | ** | | - Chronic pain definition = order for opioid | ** | | analgesics with ambulatory misuse | ** | | potential with a supply duration of >= two | ** | | months. | ** ----------------------------------------------------------------------------------------------------------------------------------- ** */ define function "Is Subacute or Chronic Pain Prescription?"(prescription FHIR.MedicationRequest): "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription) or "Is Subacute or Chronic Pain Using Validity Period"(prescription) Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Using Expected Supply Duration 29 define function "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription FHIR.MedicationRequest): ( prescription.dispenseRequest is not null and prescription.dispenseRequest.expectedSupplyDuration is not null and ( Common.GetDurationInDays(prescription.dispenseRequest.expectedSupplyDuration) >= 28 days ) ) Library Name Name sequence OpioidCDSCommon GetDurationInDays 30 define function GetDurationInDays(value FHIR.Duration): if value is null then null else case when value.code.value ~ 'a' then System.Quantity{ value: value.value.value * 365.0, unit: 'days' } when value.code.value ~ 'mo' then System.Quantity{ value: value.value.value * 30.0, unit: 'days' } when value.code.value ~ 'wk' then System.Quantity{ value: value.value.value * 7.0, unit: 'days' } when value.code.value ~ 'd' then System.Quantity{ value: value.value.value, unit: 'days' } when value.code.value ~ 'h' then System.Quantity{ value: value.value.value / 24.0, unit: 'days' } when value.code.value ~ 'min' then System.Quantity{ value: value.value.value / 60.0 / 24.0, unit: 'days' } when value.code.value ~ 's' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0, unit: 'days' } when value.code.value ~ 'ms' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0 / 1000.0, unit: 'days' } when value.code.value is null then Message(1000, true, 'Undefined', 'Error', 'Duration unit code is null') else Message(1000, true, 'Undefined', 'Error', 'Unsupported duration unit code: ' + value.code.value) end Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Using Validity Period 31 define function "Is Subacute or Chronic Pain Using Validity Period"(prescription FHIR.MedicationRequest): ( prescription.dispenseRequest is not null and prescription.dispenseRequest.validityPeriod is not null and ( days between prescription.dispenseRequest.validityPeriod.start and prescription.dispenseRequest.validityPeriod.end >= 28 ) ) Library Name Name sequence FHIRHelpers ToDateTime 32 define function ToDateTime(value dateTime): value.value Knowledge Capability: shareable computable executable publishable Use Context: code value display focus 182888003 Medication requested (situation) focus 82423001 Chronic pain (finding) focus Purpose: The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. Usage: Clinicians should offer naloxone when prescribing opioids. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain Libraries: Library - Recommendation #8 - Naloxone Consideration Actions: Incorporate Risk Mitigation Strategies Into Opioid Therapy: Recommend incorporating strategies to mitigate opioid therapy risks, including offering naloxone.#xD; #xD; For guidance regarding assessing opioid therapy risks, see [Recommendation 8 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation8)#xD; #xD; For more information about prescribing naloxone see https://prescribetoprevent.org#xD; #xD; **MME Calculator Cautions**#xD; 1) All doses are in mg/day except for fentanyl, which is mcg/hr. #xD; 2) Equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics. #xD; 3) Do not use the calculated dose in MMEs to determine the doses to use when converting one opioid to another; when converting opioids, the new opioid is typically dosed at a substantially lower dose than the calculated MME dose to avoid overdose because of incomplete cross-tolerance and individual variability in opioid pharmacokinetics. Consult the FDA approved product labeling for specific guidance on medications. #xD; 4) Use particular caution with methadone dose conversions because methadone has a long and variable half-life, and peak respiratory depressant effect occurs later and lasts longer than peak analgesic effect. #xD; 5) Use particular caution with transdermal fentanyl because it is dosed in mcg/hr instead of mg/day, and its absorption is affected by heat and other factors. #xD; 6) Buprenorphine products approved for the treatment of pain are not included in the table because of their partial µ-receptor agonist activity and resultant ceiling effects compared with full µ-receptor agonists. #xD; 7) These conversion factors should not be applied to dosage decisions related to the management of opioid use disorder.#xD; - Tapentadol is a µ-receptor agonist and norepinephrine reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tapentadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists.#xD; - Tramadol is a µ-receptor agonist and norepinephrine and serotonin reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tramadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists. When: Named Event: order-sign If: Applicability: Check whether the current order is for an opioid with ambulatory misuse potential and the 2022 CDC guideline inclusion criteria is met. (Is Recommendation Applicable?) Then: : Order - Naloxone ordered Then: : Document - Verified patient is on Naloxone an has been educated on use, snooze 3 months Then: : Document - Naloxone discussed but declined, snooze 3 months Then: : Snooze* - N/A see comment, snooze 3 months Then:
Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
define "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions": ( Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) ) AmbulatoryOpioidPrescription where Routines."Is Subacute or Chronic Pain Prescription?"( AmbulatoryOpioidPrescription )
Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential
define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )
// CDC 2022 General Inclusion Criteria define "Age Less than 18 Years Is Enabled": true
define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false
// Sickle Cell define "Sickle Cell Check Enabled": true
define "Sickle Cell Assumed Active": true
// 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"]
define "Positive Sickle Cell Condition": if Config."Sickle Cell Check Enabled" and not Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" and C.clinicalStatus in "Active Condition" ) else if Config."Sickle Cell Check Enabled" and Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" ) else null
define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false
Active Cancer Treatment Encounters Condition Is Enabled
// Active Cancer Treatment define "Active Cancer Treatment Encounters Condition Is Enabled": true
// End of Opioid Naive Routine /* ** Routine #3 ** Active Cancer Treatment Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** --------------------------------------------------------------------------------------------------------------------------------- ** Two office visits within the | No | Look for a minimum of two distinct | Office Visit ** past 12 months | | 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 visits with an | No | The encounter is performed by an | Oncology specialty ** oncology specialist | | oncologist as defined in the oncology | designations (NUCC) ** present | | specialty designations using the | ** | | National Uniform Claim Committee | ** | | (NUCC) classifications | ** --------------------------------------------------------------------------------------------------------------------------------- ** Office visits including CDC | No | The encounter diagnosis (primary or | CDC malignant cancer ** malignant cancer | | secondary or co-morbidity diagnosis) | conditions ** condition | | is listed in the CDC Malignant Cancer | ** | | Conditions value set | ** ---------------------------------------------------------------------------------------------------------------------------------- ** */ define "Encounter Period": Interval[Today() - 12 months, Today())
define "USCore Encounter Cancer Diagnoses": [Condition: category in "Encounter Diagnosis Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions"
Encounters with Cancer Diagnosis During Encounter Period
// encounter-diagnosis, problem-list and health-concern Conditions // define "US Core-Categorized Cancer Diagnoses": // Common."US Core-Categorized Conditions" C // where C.code in Common."CDC malignant cancer conditions" // define "Encounters with Cancer Diagnosis During Encounter Period": // [Encounter] Encounter // with "US Core-Categorized Cancer Diagnoses" CancerDiagnosis // such that date from Encounter.period."start".value in day of "Encounter Period" // and EndsWith(CancerDiagnosis.encounter.reference, Encounter.id) define "Encounters with Cancer Diagnosis During Encounter Period": [Encounter] Encounters where date from Encounters.period."start" in day of "Encounter Period" and exists ( Common."USCore Encounter Cancer Diagnoses" CancerDiagnoses where EndsWith(CancerDiagnoses.encounter.reference, Encounters.id) )
Number of Encounters with Cancer Diagnosis During Encounter Period
define "Number of Encounters with Cancer Diagnosis During Encounter Period": Count ("Encounters with Cancer Diagnosis During Encounter Period")
Has Two or More Encounters with Cancer Diagnosis During Encounter Period
define "Has Two or More Encounters with Cancer Diagnosis During Encounter Period": "Number of Encounters with Cancer Diagnosis During Encounter Period" >= 2
define "USCore Problem List Cancer Diagnoses": [Condition: category in "Problem List Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions"
Has Active Cancer Diagnosis on Problem List
define "Has Active Cancer Diagnosis on Problem List": exists ( Common."USCore Problem List Cancer Diagnoses" CancerDiagnoses where CancerDiagnoses.category in Common."Problem List Condition Category" and exists( CancerDiagnoses.clinicalStatus.coding ClinicalStatus where ClinicalStatus.code ~ 'active' ) )
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" or "Has Active Cancer Diagnosis on Problem List" else false
// CDC 2022 General Inclusion Criteria define "End-Stage Disease Criteria Enabled": true
Conditions Likely Terminal for Opioid Prescribing
define "Conditions Likely Terminal for Opioid Prescribing": 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
CDC 2022 Guideline General Inclusion Criteria
define "CDC 2022 Guideline General Inclusion Criteria": not "Patient Age Less Than 18" and not "Condition Positive for Sickle Cell" and not "Is Active Cancer Treatment?" and not "Conditions Likely Terminal for Opioid Prescribing"
define "Inclusion Criteria": "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and Routines."CDC 2022 Guideline General Inclusion Criteria"
define "Is Recommendation Applicable?": "Inclusion Criteria"
Is Opioid Analgesic with Ambulatory Misuse Potential?
define function "Is Opioid Analgesic with Ambulatory Misuse Potential?"(value List<MedicationRequest>): ("Get MedicationRequest Medication as Code"(value)) Rx where Rx.medication in "Opioid analgesics with ambulatory misuse potential" and Rx.category in "Community"
Get MedicationRequest Medication as Code
define function "Get MedicationRequest Medication as Code"(value List<MedicationRequest>): value Rx let Med: if Rx.medication is Reference then singleton from ( [Medication] M where M.id = (Last(Split((Rx.medication as FHIR.Reference).reference, '/'))) ) else null return MedicationRequest { id: Rx.id, status: Rx.status, intent: Rx.intent, category: Rx.category, medication: if Rx.medication is Reference then Med.code else Rx.medication as CodeableConcept, subject: Rx.subject, authoredOn: Rx.authoredOn, recorder: Rx.recorder, dosageInstruction: Rx.dosageInstruction, dispenseRequest: Rx.dispenseRequest }
define function ToString(value string): value.value
define function ToConcept(concept FHIR.CodeableConcept): if concept is null then null else System.Concept { codes: concept.coding C return ToCode(C), display: concept.text.value }
define function ToCode(coding FHIR.Coding): if coding is null then null else System.Code { code: coding.code.value, system: coding.system.value, version: coding.version.value, display: coding.display.value }
Is Subacute or Chronic Pain Prescription?
// End of Active Cancer Treatment Routine /* ** Routine #4 ** For Subacute or Chronic Pain Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** ----------------------------------------------------------------------------------------------------------------------------------- ** Order for opioid analgesic | Yes | Order for opioid analgesics with ambulatory | Opioid analgesics with ** with expected supply | | misuse potential with a supply duration of >= | ambulatory misuse potential ** duration >= 28 days | | 28 days | ** | | | ** | | - Subacute definition = order for opioid | ** | | analgesics with ambulatory misuse | ** | | potential with a supply duration of one to | ** | | two months. | ** | | - Chronic pain definition = order for opioid | ** | | analgesics with ambulatory misuse | ** | | potential with a supply duration of >= two | ** | | months. | ** ----------------------------------------------------------------------------------------------------------------------------------- ** */ define function "Is Subacute or Chronic Pain Prescription?"(prescription FHIR.MedicationRequest): "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription) or "Is Subacute or Chronic Pain Using Validity Period"(prescription)
Is Subacute or Chronic Pain Using Expected Supply Duration
define function "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription FHIR.MedicationRequest): ( prescription.dispenseRequest is not null and prescription.dispenseRequest.expectedSupplyDuration is not null and ( Common.GetDurationInDays(prescription.dispenseRequest.expectedSupplyDuration) >= 28 days ) )
define function GetDurationInDays(value FHIR.Duration): if value is null then null else case when value.code.value ~ 'a' then System.Quantity{ value: value.value.value * 365.0, unit: 'days' } when value.code.value ~ 'mo' then System.Quantity{ value: value.value.value * 30.0, unit: 'days' } when value.code.value ~ 'wk' then System.Quantity{ value: value.value.value * 7.0, unit: 'days' } when value.code.value ~ 'd' then System.Quantity{ value: value.value.value, unit: 'days' } when value.code.value ~ 'h' then System.Quantity{ value: value.value.value / 24.0, unit: 'days' } when value.code.value ~ 'min' then System.Quantity{ value: value.value.value / 60.0 / 24.0, unit: 'days' } when value.code.value ~ 's' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0, unit: 'days' } when value.code.value ~ 'ms' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0 / 1000.0, unit: 'days' } when value.code.value is null then Message(1000, true, 'Undefined', 'Error', 'Duration unit code is null') else Message(1000, true, 'Undefined', 'Error', 'Unsupported duration unit code: ' + value.code.value) end
Is Subacute or Chronic Pain Using Validity Period
define function "Is Subacute or Chronic Pain Using Validity Period"(prescription FHIR.MedicationRequest): ( prescription.dispenseRequest is not null and prescription.dispenseRequest.validityPeriod is not null and ( days between prescription.dispenseRequest.validityPeriod.start and prescription.dispenseRequest.validityPeriod.end >= 28 ) )
define function ToDateTime(value dateTime): value.value
Value set Opioid analgesics with ambulatory misuse potential
Value set Encounter Diagnosis Condition Category
Value set Problem List Condition Category
Value set US Core Health Concern Condition Category
Value set CDC malignant cancer conditions
Value set Conditions likely terminal for opioid prescribing
Recommendation #8 - Naloxone Consideration
Centers for Disease Control and Prevention (CDC)
Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care.
Clinicians should offer naloxone when prescribing opioids.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Incorporate Risk Mitigation Strategies Into Opioid Therapy
Recommend incorporating strategies to mitigate opioid therapy risks, including offering naloxone. For guidance regarding assessing opioid therapy risks, see [Recommendation 8 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation8) For more information about prescribing naloxone see https://prescribetoprevent.org **MME Calculator Cautions** 1) All doses are in mg/day except for fentanyl, which is mcg/hr. 2) Equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics. 3) Do not use the calculated dose in MMEs to determine the doses to use when converting one opioid to another; when converting opioids, the new opioid is typically dosed at a substantially lower dose than the calculated MME dose to avoid overdose because of incomplete cross-tolerance and individual variability in opioid pharmacokinetics. Consult the FDA approved product labeling for specific guidance on medications. 4) Use particular caution with methadone dose conversions because methadone has a long and variable half-life, and peak respiratory depressant effect occurs later and lasts longer than peak analgesic effect. 5) Use particular caution with transdermal fentanyl because it is dosed in mcg/hr instead of mg/day, and its absorption is affected by heat and other factors. 6) Buprenorphine products approved for the treatment of pain are not included in the table because of their partial µ-receptor agonist activity and resultant ceiling effects compared with full µ-receptor agonists. 7) These conversion factors should not be applied to dosage decisions related to the management of opioid use disorder. - Tapentadol is a µ-receptor agonist and norepinephrine reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tapentadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists. - Tramadol is a µ-receptor agonist and norepinephrine and serotonin reuptake inhibitor. MMEs are based on degree of µ-receptor agonist activity; however, it is unknown whether tramadol is associated with overdose in the same dose-dependent manner as observed with medications that are solely µ-receptor agonists.
Check whether the current order is for an opioid with ambulatory misuse potential and the 2022 CDC guideline inclusion criteria is met.
Document - Verified patient is on Naloxone an has been educated on use, snooze 3 months
Document - Naloxone discussed but declined, snooze 3 months
Snooze* - N/A see comment, snooze 3 months