Recommendation #2 - Opioid Therapy Goals Discussion - 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 #2 - Opioid Therapy Goals Discussion

Recommendation #2 (2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain):

Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks (recommendation category: A; evidence type: 2).

Contents

Functional Description
For Subacute or Chronic Pain
Opioid Review Useful
Opioid Naive
Content
Example Data/Requests

Functional Description

When

Provider is prescribing an opioid 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

Patient is opioid naive:

No indication of opioid use in the past 90 days from a prescription, self report (for future implementation), or a dispensing event (for future implementation)

Pain management procedure in past 90 days is not present and
Pain treatment plan created, edited, or reviewed by the prescribing physician in past 90 days is not present

Then

Maximize Nonopioid Therapies as Appropriate:

Document - Collaborated with patient to identify treatment goals
Snooze - Attempting alternate therapy, snooze 3 months
Order - Select alternative therapies from order select
Snooze - N/A see comment, snooze 3 months
Remove - Will remove triggering medication order

The following table describes the flowchart decisions and sub-routines for the recommendation
Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
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
Opioid naïve?	Yes	See Opioid Naïve sub-routine
Pain treatment plan created or edited in past 90 days?	No	Look for a pain treatment plan that has been established or edited within the past 90 days (including the day of the visit). The following criteria should be met: • the treatment plan has an initiation date or an edited date within the past 90 days. • the treatment plan should have been created or reviewed within the past 90 days by the same individual who is writing the new prescription.	Pain treatment plan	CarePlan	CarePlan.category, CarePlan.status, CarePlan.created, CarePlan.lastUpdated, and CarePlan.author
Pain management procedure in past 90 days?	No	Look for a pain management procedure (including the procedure to review a pain management treatment plan) that occurred within the past 90 days (including the day of the visit).	Pain management procedure	Procedure and MedicationRequest	Procedure.performed, Procedure.performer.actor, and MedicationRequest.recorder

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 Definitions

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

Opioid Naive Definitions

An evaluation to determine if a patient is opioid naive is not possible when a EHR system does not support queries for past medications by date range.

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Opioid analgesics with ambulatory misuse potential prescription in past 90 days excluding the last 24 hours?	No	Look for an existing prescription (order) for opioid that is in the value set for opioid with ambulatory misuse potential authored within the past 90 days (excluding the last 24 hours)	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, MedicationRequest.category, and MedicationRequest.authoredOn
Opioid analgesics with ambulatory misuse potential reported as being taken excluding the last 24 hours?*	No	Look for evidence of active medication on the medication list that is in the value set for opioid with ambulatory care misuse potential (excluding the last 24 hours)	Opioid analgesics with ambulatory misuse potential	MedicationStatement	MedicationStatement.medication, MedicationStatement.status, and MedicationStatement.effective
Opioid analgesics with ambulatory misuse potential dispensing event in past 90 days excluding the last 24 hours?*	No	Look for evidence of a dispensing event for medication that is in the value set for opioid with ambulatory use potential occurring within the past 90 days (excluding the last 24 hours)	Opioid analgesics with ambulatory misuse potential	MedicationDispense	MedicationDispense.medication, MedicationDispense.status, and MedicationDispense.whenHandedOver
* Future consideration: Current algorithm addresses only orders (prescriptions). 1 - Implement one global configuration point to set all past medication queries at each particular site: “Can the implementing EHR support queries for past medications by date range? Yes or No”. An evaluation to determine if a patient is opioid naive is not possible when a EHR system does not support queries for past medications by date range. 2 - orders use RxNorm, but medication lists and dispensed medication will require an NDC value set and/or local mapping of NDC to RxNorm to enable this element

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 #2	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #2
Recommendation #2 - Opioid Therapy Goals Discussion	Library	Defines the data requirements to support evaluation of recommendation #2
Opioid Terminology Management Knowledge-base Data (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support Logic	Library	CQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration Logic	Library	CQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines Logic	Library	CQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion Logic	Library	CQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation

Example Data/Requests

Description	CDS Hooks Request	Expected Response
Patient is 18 years or older and has an outpatient Medication Request of Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) authored "Today" as well as an Opioid Treatment Care Plan updated 89 days prior to today. Patients "Dosage Instructions" are 1 Film per day for 30 days. This patient will not trigger any cards and there should not be a recommendation message.	Request JSON example-rec-02-in-careplan-revisited	Response JSON example-rec-02-in-careplan-revisited
Patient is 18 years or older and has an outpatient Medication Request of Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) authored "Today" as well as a Care Plan most recently updated 120 days prior to today. Patients "Dosage Instructions" are 1 Film per day for 30 days. Due to the most recent review of the Care Plan having been conducted more than 89 days prior to today this will result in a summary message: "Recommend creation, review or update of opioid treatment plan."	Request JSON example-rec-02-out-careplan-not-revisited	Response JSON example-rec-02-out-careplan-not-revisited

Description

CDS Hooks Request

Expected Response

Patient is 18 years or older and has an outpatient Medication Request of Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) authored "Today" as well as an Opioid Treatment Care Plan updated 89 days prior to today. Patients "Dosage Instructions" are 1 Film per day for 30 days. This patient will not trigger any cards and there should not be a recommendation message.

Request JSON example-rec-02-in-careplan-revisited

Response JSON example-rec-02-in-careplan-revisited

Patient is 18 years or older and has an outpatient Medication Request of Suboxone 2 MG / 0.5 MG Sublingual Film (RXNorm 1010603) authored "Today" as well as a Care Plan most recently updated 120 days prior to today. Patients "Dosage Instructions" are 1 Film per day for 30 days. Due to the most recent review of the Care Plan having been conducted more than 89 days prior to today this will result in a summary message: "Recommend creation, review or update of opioid treatment plan."

Request JSON example-rec-02-out-careplan-not-revisited

Response JSON example-rec-02-out-careplan-not-revisited