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.medication, and MedicationRequest.category
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
Non-opioid drug urine screen test not performed within the last 12 months	Yes	No urine screening test performed within the last 12 months	Non-opioid drug urine screen	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Opioid drug urine screen test not performed within the last 12 months?	Yes	No opioid drug urine screening test performed within the last 12 months	Opioid drug urine screen	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Urine drug screen results contain cocaine?	Yes	Urine drug screen result contains cocaine	Cocaine urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain phencyclidine (PCP)?	Yes	Urine drug screen result contains phencyclidine (PCP)	Phencyclidine (PCP) urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain amphetamine and no active amphetamine medication?	Yes	Urine drug screen result contains amphetamine and patient does not have an active prescription for amphetamine	Amphetamine urine toxicology test result Amphetamine medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain opiate and no active opiate medication?	Yes	Urine drug screen result contains opiate and patient does not have an active prescription for opiate	Opiate urine toxicology test result Opiate medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain methadone and no active methadone medication?	Yes	Urine drug screen result contains methadone and patient does not have an active prescription for methadone	Methadone urine toxicology test result Methadone medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain synthetic opioid and no active synthetic opioid medication?	Yes	Urine drug screen result contains synthetic opioid and patient does not have an active prescription for synthetic opioid	Synthetic opioid urine toxicology test result Synthetic opioid medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain fentanyl and no active fentanyl medication?	Yes	Urine drug screen result contains fentanyl and patient does not have an active prescription for fentanyl	Fentanyl urine toxicology test result Fentanyl medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain tetrahydrocannabinol (THC)?	Yes	Urine drug screen result contains tetrahydrocannabinol (THC)	Tetrahydrocannabinol urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain alcohol?	Yes	Urine drug screen result contains alcohol	Alcohol urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value

Effective Data Requirements

The following artifacts formalize the description of the logic and behavior defined by this recommendation.

Resource	Type	Description
2022 CDC Clinical Practice Guideline Recommendation #10 Order Sign	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #10 Order Sign
Recommendation #10 Order Sign - urine drug testing when prescribing opioids for subacute or chronic pain	Library	Defines the data requirements to support evaluation of recommendation #10 Order Sign
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

Description	CDS Hooks Request	Expected Response
Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696), once every 12 days for 30 days. This triggers the message that urine drug screening is recommended with the following three feedback options: i. Perform the screening ii. Indicate that the prescription is not for subacute or chronic pain management 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 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696) and a urine screening with the prescence of Phencyclidine is present. This triggers the message "Positive Cocaine or PCP in Urine Screening" with a note explaining this may be a false positive or indicate recreational or addictive use.	Request JSON	Response JSON

• When
• Provider is prescribing an opioid analgesic 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
• Nonopioid drug urine screening has not been performed in last 12 months or
• Opioid drug urine screening has not been performed in last 12 months
• Then
• Consider the benefits and risks of conducting a urine toxicology screen:
• Document - Order toxicology screen
• Document risks outweigh benefits
• Snooze - N/A see comment, snooze 3 months
• When
• Provider is prescribing an opioid analgesic 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
• Nonopioid drug urine screening has been performed in last 12 months and
• Opioid drug urine screening has been performed in last 12 months and
• Positive result for synthetic opioid in the past year and not currently prescribed synthetic opioid or
• Positive result for phencyclidine(PCP) in the past year or
• Positive result for fentanyl in the past year and not currently prescribed fentanyl or
• Positive result for cocaine in the past year or
• Positive result for amphetamine in the past year and not currently prescribed amphetamine or
• Positive result for tetrahydrocannabinol (THC) in the past year and not currently prescribed tetrahydrocannabinol (THC) or
• Positive result for opiate in the past year and not currently prescribed natural opiate or
• Positive result for alcohol in the past year or
• Positive result for methadone in the past year and not currently prescribed methadone
• Then
• Patient may have unexpected toxicology test results:
• Document - Will repeat urine drug screening more frequently
• Document - Will assess patient for substance use disorder
• Snooze - Patient's test results were expected, snooze for 3 months
• Snooze - N/A snooze for 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.medication, and MedicationRequest.category
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
Non-opioid drug urine screen test not performed within the last 12 months	Yes	No urine screening test performed within the last 12 months	Non-opioid drug urine screen	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Opioid drug urine screen test not performed within the last 12 months?	Yes	No opioid drug urine screening test performed within the last 12 months	Opioid drug urine screen	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Urine drug screen results contain cocaine?	Yes	Urine drug screen result contains cocaine	Cocaine urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain phencyclidine (PCP)?	Yes	Urine drug screen result contains phencyclidine (PCP)	Phencyclidine (PCP) urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain amphetamine and no active amphetamine medication?	Yes	Urine drug screen result contains amphetamine and patient does not have an active prescription for amphetamine	Amphetamine urine toxicology test result Amphetamine medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain opiate and no active opiate medication?	Yes	Urine drug screen result contains opiate and patient does not have an active prescription for opiate	Opiate urine toxicology test result Opiate medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain methadone and no active methadone medication?	Yes	Urine drug screen result contains methadone and patient does not have an active prescription for methadone	Methadone urine toxicology test result Methadone medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain synthetic opioid and no active synthetic opioid medication?	Yes	Urine drug screen result contains synthetic opioid and patient does not have an active prescription for synthetic opioid	Synthetic opioid urine toxicology test result Synthetic opioid medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain fentanyl and no active fentanyl medication?	Yes	Urine drug screen result contains fentanyl and patient does not have an active prescription for fentanyl	Fentanyl urine toxicology test result Fentanyl medication	Observation MedicationRequest	Observation.category, Observation.code, Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Urine drug screen results contain tetrahydrocannabinol (THC)?	Yes	Urine drug screen result contains tetrahydrocannabinol (THC)	Tetrahydrocannabinol urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Urine drug screen results contain alcohol?	Yes	Urine drug screen result contains alcohol	Alcohol urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value

Effective Data Requirements

The following artifacts formalize the description of the logic and behavior defined by this recommendation.

Resource	Type	Description
2022 CDC Clinical Practice Guideline Recommendation #10 Order Sign	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #10 Order Sign
Recommendation #10 Order Sign - urine drug testing when prescribing opioids for subacute or chronic pain	Library	Defines the data requirements to support evaluation of recommendation #10 Order Sign
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

Description	CDS Hooks Request	Expected Response
Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696), once every 12 days for 30 days. This triggers the message that urine drug screening is recommended with the following three feedback options: i. Perform the screening ii. Indicate that the prescription is not for subacute or chronic pain management 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 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696) and a urine screening with the prescence of Phencyclidine is present. This triggers the message "Positive Cocaine or PCP in Urine Screening" with a note explaining this may be a false positive or indicate recreational or addictive use.	Request JSON	Response JSON