Recommendations #4 & #5 (2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain)

4: When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients (recommendation category: A; evidence type: 3).

5: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages (recommendation category: B; evidence type: 4).

Functional Description

• When
• Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting
• 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 Morphine Milligram Equivalent (MME) greater than or equal to 50
• Then
• Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages:
• Document - Will prescribe a lower dose
• Document - Will calibrate a gradual change in dosage
• Snooze - Benefits outweigh risks, snooze 3 months
• Snooze - Short term benefits outweigh risks, snooze 1 month
• Snooze - N/A add 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 analgesic with ambulatory misuse potential	Yes	Order for opioid analgesics with ambulatory misuse potential	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.dispenseRequest.expectedSupplyDuration, MedicationRequest.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Calculate MME for prescription + active opioids	N/A	Current calculation uses known order (prescription) data. Note - for as needed (PRN) medication, the daily dose assumes the maximum dose the patient may take any given day if a range is present. Ideally, dispensed data could be used to determine the medication dispensed to the patient		MedicationRequest	MedicationRequest.medication.coding.code and MedicationRequest.dosageInstruction
MME≥50?	Yes	MME result is ≥ 50

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