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 analgesics with ambulatory misuse potential?	Yes	Trigger based on a new prescription (order) for opioid analgesics with ambulatory misuse potential - ideally the prescription should be selected prior to being committed to the system	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Order for benzodiazepine or other central nervous system depressant medications?	Yes	Trigger based on a new prescription (order) for opioids or benzodiazepines or other central nervous system depressant in the relevant value sets - ideally the prescription should be selected prior to being committed to the system	Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Receiving both opioid with ambulatory use potential and benzodiazepine or other central nervous system depressant ?	Yes	New prescription is for an opioid and existing use of benzodiazepine or other central nervous system depressant evident, OR New prescription is for benzodiazepine or other central nervous system depressant and existing use of opioids evident	Opioid analgesics with ambulatory misuse potential Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category

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 #11 Order Select	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #11 Order Select
Recommendation #11 Order Select - concurrent opioid pain medication and benzodiazepines or other central nervous system depressant prescriptions	Library	Defines the data requirements to support evaluation of recommendation #11 Order Select
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 is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options: i. Revise ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON
Patient is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options: i. Revise ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON

• When
• Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting or
• Provider is prescribing a benzodiazepine or other central nervous system depressant medication
• 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 prescribed opioid analgesic with ambulatory misuse potential and benzodiazepine or other central nervous system depressant medication concurrently
• Then
• Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently:
• Document - Will modify prescription
• Snooze - Benefits outweigh risks, snooze 3 months
• Snooze - N/A see 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 analgesics with ambulatory misuse potential?	Yes	Trigger based on a new prescription (order) for opioid analgesics with ambulatory misuse potential - ideally the prescription should be selected prior to being committed to the system	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Order for benzodiazepine or other central nervous system depressant medications?	Yes	Trigger based on a new prescription (order) for opioids or benzodiazepines or other central nervous system depressant in the relevant value sets - ideally the prescription should be selected prior to being committed to the system	Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Receiving both opioid with ambulatory use potential and benzodiazepine or other central nervous system depressant ?	Yes	New prescription is for an opioid and existing use of benzodiazepine or other central nervous system depressant evident, OR New prescription is for benzodiazepine or other central nervous system depressant and existing use of opioids evident	Opioid analgesics with ambulatory misuse potential Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category

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 #11 Order Select	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #11 Order Select
Recommendation #11 Order Select - concurrent opioid pain medication and benzodiazepines or other central nervous system depressant prescriptions	Library	Defines the data requirements to support evaluation of recommendation #11 Order Select
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 is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options: i. Revise ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON
Patient is 18 or older. Patient is being prescribed Flurazepam Hydrochloride 15 MG Oral Capsule (RxNorm code 1298088), once per day for 30 days. Patient is also being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. This triggers a message with the recommendation to avoid prescribing opioid pain medication and benzodiazepine concurrently with following three feedback options: i. Revise ii. Indicate that the benefits outweigh the risks 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 is 18 or older. Patient is being prescribed 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet (RxNorm code 1049502), once per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON