Id: opioidcds-11-order-select Url: Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines (order-select) Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_11_Order_Select Title: Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines (order-select) 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: 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. Logic Definitions: Library Name Name sequence OpioidCDSREC11OrderSelect Opioid Analgesic with Ambulatory Misuse Potential Prescriptions 0 define "Opioid Analgesic with Ambulatory Misuse Potential Prescriptions": Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) Library Name Name sequence OpioidCDSREC11OrderSelect Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential 1 define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" ) Library Name Name sequence OpioidCDSCommonConfig Can the implementing EHR support queries for past medications by date range? 2 // Subroutine 2 - Past Medications define "Can the implementing EHR support queries for past medications by date range?": true Library Name Name sequence OpioidCDSCommon Active Medication List 3 define "Active Medication List": [MedicationRequest: status in { 'active' }] ActiveMeds where ActiveMeds.category in "Community" Library Name Name sequence OpioidCDSCommon Active Ambulatory Benzodiazepine or CNS Depressant Rx 4 define "Active Ambulatory Benzodiazepine or CNS Depressant Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Active Medication List") ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Benzodiazepine medications" or Rx.medication in "CNS Depressant Medications" else List<FHIR.MedicationRequest>{} Library Name Name sequence OpioidCDSREC11OrderSelect Benzodiazepine or CNS Depressant Prescriptions 5 define "Benzodiazepine or CNS Depressant Prescriptions": Common."Is Benzodiazepine or CNS Depressant?"( ContextPrescriptions ) Library Name Name sequence OpioidCDSREC11OrderSelect Patient Is Being Prescribed Benzodiazepine or CNS Depressant 6 define "Patient Is Being Prescribed Benzodiazepine or CNS Depressant": exists( "Benzodiazepine or CNS Depressant Prescriptions" ) Library Name Name sequence OpioidCDSCommon Active Ambulatory Opioid Rx 7 define "Active Ambulatory Opioid Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest])) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Opioid analgesics with ambulatory misuse potential" else List<FHIR.MedicationRequest>{} Library Name Name sequence OpioidCDSCommonConfig Age Less than 18 Years Is Enabled 8 // CDC 2022 General Inclusion Criteria define "Age Less than 18 Years Is Enabled": true Library Name Name sequence OpioidCDSRoutines Patient Age Less Than 18 9 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 10 // Sickle Cell define "Sickle Cell Check Enabled": true Library Name Name sequence OpioidCDSCommonConfig Sickle Cell Assumed Active 11 define "Sickle Cell Assumed Active": true Library Name Name sequence OpioidCDSCommon US Core-Categorized Conditions 12 // 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 13 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 14 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 15 // Active Cancer Treatment define "Active Cancer Treatment Encounters Condition Is Enabled": true Library Name Name sequence OpioidCDSRoutines Encounter Period 16 // 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 17 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 18 // 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 19 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 20 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 21 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 22 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? 23 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 24 // CDC 2022 General Inclusion Criteria define "End-Stage Disease Criteria Enabled": true Library Name Name sequence OpioidCDSRoutines Conditions Likely Terminal for Opioid Prescribing 25 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 26 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 OpioidCDSREC11OrderSelect Inclusion Criteria 27 define "Inclusion Criteria": ( ( "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and exists Common."Active Ambulatory Benzodiazepine or CNS Depressant Rx" ) or ( "Patient Is Being Prescribed Benzodiazepine or CNS Depressant" and exists Common."Active Ambulatory Opioid Rx" ) ) and Routines."CDC 2022 Guideline General Inclusion Criteria" Library Name Name sequence OpioidCDSCommon Conditions Indicating End of Life or With Limited Life Expectancy 28 define "Conditions Indicating End of Life or With Limited Life Expectancy": ( "US Core-Categorized Conditions" C where C.code in "Conditions likely terminal for opioid prescribing" and C.clinicalStatus in "Active Condition" ) union ( "US Core-Categorized Conditions" C where C.code in "Limited life expectancy conditions" and C.clinicalStatus in "Active Condition" ) Library Name Name sequence OpioidCDSCommonConfig Hospice Findings Exclusion Enabled 29 // OpioidCDSCommon define "Hospice Findings Exclusion Enabled": false Library Name Name sequence OpioidCDSCommon Admitted/Referred/Discharged to Hospice Care 30 define "Admitted/Referred/Discharged to Hospice Care": ( if (Config."Hospice Findings Exclusion Enabled") then [Observation: code in "Hospice Finding Codes"] O where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' }) else {} ) union ( [Encounter] E where date from E.period.start 1 year or less on or before Today() and ( if E.hospitalization.dischargeDisposition.coding is null or not exists (E.hospitalization.dischargeDisposition.coding) then false else E.hospitalization.dischargeDisposition in "Hospice Disposition" ) and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' } ) Library Name Name sequence OpioidCDSCommon End of Life Assessment 31 define "End of Life Assessment": // 1. Conditions indicating end of life or with limited life expectancy exists ( "Conditions Indicating End of Life or With Limited Life Expectancy" ) // 2. Admitted/referred/discharged to hospice care or exists ( "Admitted/Referred/Discharged to Hospice Care" ) Library Name Name sequence OpioidCDSREC11OrderSelect Exclusion Criteria 32 define "Exclusion Criteria": Common."End of Life Assessment" Library Name Name sequence OpioidCDSREC11OrderSelect Is Recommendation Applicable? 33 define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria" Library Name Name sequence OpioidCDSCommon Is Opioid Analgesic with Ambulatory Misuse Potential? 34 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 35 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 36 define function ToString(value string): value.value Library Name Name sequence FHIRHelpers ToConcept 37 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 38 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 FHIRHelpers ToDateTime 39 define function ToDateTime(value dateTime): value.value Library Name Name sequence OpioidCDSCommon Is Benzodiazepine or CNS Depressant? 40 define function "Is Benzodiazepine or CNS Depressant?"(value List<MedicationRequest>): ("Get MedicationRequest Medication as Code"(value)) Rx where Rx.medication in "Benzodiazepine medications" or Rx.medication in "CNS Depressant Medications" and Rx.category in "Community" Library Name Name sequence OpioidCDSCommon Get Active Ambulatory Medication Requests 41 define function "Get Active Ambulatory Medication Requests" (value List<MedicationRequest>) returns List<MedicationRequest>: value Rx where Rx.status.value = 'active' and Rx.category in "Community" Knowledge Capability: shareable computable executable publishable Use Context: code value display focus 182888003 Medication requested (situation) focus 82423001 Chronic pain (finding) 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 use particular caution when prescribing opioid pain medication and benzodiazepines concurrently. In addition, clinicians should consider whether benefits outweigh risks for concurrent use of opioids with other central nervous system depressants. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain Libraries: Library - Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines Actions: Use Particular Caution When Prescribing Opioid Pain Medication and Benzodiazepines or Other CNS Depressants Concurrently: Consider whether the benefits outweigh the risks of concurrently prescribing opioids and benzodiazepines, or other central nervous system depressant medications.#xD; #xD; When co-prescribing risks outweigh benefits, consult [Recommendation 11 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=evidence%20type%3A%203).-,Implementation%20Considerations,-Although%20in%20some) for further guidance.#xD; #xD; [For patients being treated for opioid use disorder who are also taking benzodiazepines or other medications that depress the central nervous system, the CDC recommends not withholding buprenorphine or methadone](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=gabapentin%20and%20pregabalin).-,Buprenorphine%20or%20methadone%20for%20opioid%20use%20disorder%20should%20not%20be%20withheld%20from%20patients%20taking%20benzodiazepines%20or%20other%20medications%20that%20depress%20the%20central%20nervous%20system.,-Clinicians%20should%20check).#xD; #xD; If the decision is made to taper benzodiazepine medications, [the CDC recommends tapering benzodiazepines gradually prior to discontinuation](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20taper%20benzodiazepines%20gradually%20before%20discontinuation%20because%20abrupt%20withdrawal%20can%20be%20associated%20with%20rebound%20anxiety%2C%20hallucinations%2C%20seizures%2C%20delirium%20tremens%2C%20and%2C%20rarely%2C%20death.%20The%20rate%20of%20tapering%20should%20be%20individualized). When: Named Event: order-select If: Applicability: Check whether the current order results in the concurrent use of opioid pain medication and benzodiazepines or other central nervous system depressants and if the 2022 CDC guideline general inclusion criteria is met. (Is Recommendation Applicable?) Then: : Document - Will modify prescription Then: : Snooze* - Benefits outweigh risks, snooze 3 months Then: : Snooze* - N/A see comments, snooze 3 months Then:
Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
define "Opioid Analgesic with Ambulatory Misuse Potential Prescriptions": Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions )
Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential
define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )
Can the implementing EHR support queries for past medications by date range?
// Subroutine 2 - Past Medications define "Can the implementing EHR support queries for past medications by date range?": true
define "Active Medication List": [MedicationRequest: status in { 'active' }] ActiveMeds where ActiveMeds.category in "Community"
Active Ambulatory Benzodiazepine or CNS Depressant Rx
define "Active Ambulatory Benzodiazepine or CNS Depressant Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Active Medication List") ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Benzodiazepine medications" or Rx.medication in "CNS Depressant Medications" else List<FHIR.MedicationRequest>{}
Benzodiazepine or CNS Depressant Prescriptions
define "Benzodiazepine or CNS Depressant Prescriptions": Common."Is Benzodiazepine or CNS Depressant?"( ContextPrescriptions )
Patient Is Being Prescribed Benzodiazepine or CNS Depressant
define "Patient Is Being Prescribed Benzodiazepine or CNS Depressant": exists( "Benzodiazepine or CNS Depressant Prescriptions" )
define "Active Ambulatory Opioid Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest])) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Opioid analgesics with ambulatory misuse potential" else List<FHIR.MedicationRequest>{}
// 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 exists Common."Active Ambulatory Benzodiazepine or CNS Depressant Rx" ) or ( "Patient Is Being Prescribed Benzodiazepine or CNS Depressant" and exists Common."Active Ambulatory Opioid Rx" ) ) and Routines."CDC 2022 Guideline General Inclusion Criteria"
Conditions Indicating End of Life or With Limited Life Expectancy
define "Conditions Indicating End of Life or With Limited Life Expectancy": ( "US Core-Categorized Conditions" C where C.code in "Conditions likely terminal for opioid prescribing" and C.clinicalStatus in "Active Condition" ) union ( "US Core-Categorized Conditions" C where C.code in "Limited life expectancy conditions" and C.clinicalStatus in "Active Condition" )
// OpioidCDSCommon define "Hospice Findings Exclusion Enabled": false
Admitted/Referred/Discharged to Hospice Care
define "Admitted/Referred/Discharged to Hospice Care": ( if (Config."Hospice Findings Exclusion Enabled") then [Observation: code in "Hospice Finding Codes"] O where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' }) else {} ) union ( [Encounter] E where date from E.period.start 1 year or less on or before Today() and ( if E.hospitalization.dischargeDisposition.coding is null or not exists (E.hospitalization.dischargeDisposition.coding) then false else E.hospitalization.dischargeDisposition in "Hospice Disposition" ) and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' } )
define "End of Life Assessment": // 1. Conditions indicating end of life or with limited life expectancy exists ( "Conditions Indicating End of Life or With Limited Life Expectancy" ) // 2. Admitted/referred/discharged to hospice care or exists ( "Admitted/Referred/Discharged to Hospice Care" )
define "Exclusion Criteria": Common."End of Life Assessment"
define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion 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 }
define function ToDateTime(value dateTime): value.value
define function "Is Benzodiazepine or CNS Depressant?"(value List<MedicationRequest>): ("Get MedicationRequest Medication as Code"(value)) Rx where Rx.medication in "Benzodiazepine medications" or Rx.medication in "CNS Depressant Medications" and Rx.category in "Community"
Get Active Ambulatory Medication Requests
define function "Get Active Ambulatory Medication Requests" (value List<MedicationRequest>) returns List<MedicationRequest>: value Rx where Rx.status.value = 'active' and Rx.category in "Community"
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
Value set Limited life expectancy conditions
Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines (order-select)
Centers for Disease Control and Prevention (CDC)
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.
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 use particular caution when prescribing opioid pain medication and benzodiazepines concurrently. In addition, clinicians should consider whether benefits outweigh risks for concurrent use of opioids with other central nervous system depressants.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Use Particular Caution When Prescribing Opioid Pain Medication and Benzodiazepines or Other CNS Depressants Concurrently
Consider whether the benefits outweigh the risks of concurrently prescribing opioids and benzodiazepines, or other central nervous system depressant medications. When co-prescribing risks outweigh benefits, consult [Recommendation 11 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=evidence%20type%3A%203).-,Implementation%20Considerations,-Although%20in%20some) for further guidance. [For patients being treated for opioid use disorder who are also taking benzodiazepines or other medications that depress the central nervous system, the CDC recommends not withholding buprenorphine or methadone](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=gabapentin%20and%20pregabalin).-,Buprenorphine%20or%20methadone%20for%20opioid%20use%20disorder%20should%20not%20be%20withheld%20from%20patients%20taking%20benzodiazepines%20or%20other%20medications%20that%20depress%20the%20central%20nervous%20system.,-Clinicians%20should%20check). If the decision is made to taper benzodiazepine medications, [the CDC recommends tapering benzodiazepines gradually prior to discontinuation](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20taper%20benzodiazepines%20gradually%20before%20discontinuation%20because%20abrupt%20withdrawal%20can%20be%20associated%20with%20rebound%20anxiety%2C%20hallucinations%2C%20seizures%2C%20delirium%20tremens%2C%20and%2C%20rarely%2C%20death.%20The%20rate%20of%20tapering%20should%20be%20individualized).
Check whether the current order results in the concurrent use of opioid pain medication and benzodiazepines or other central nervous system depressants and if the 2022 CDC guideline general inclusion criteria is met.
Snooze* - Benefits outweigh risks, snooze 3 months
Snooze* - N/A see comments, snooze 3 months