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

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Official URL: http://fhir.org/guides/cdc/opioid-cds/ImplementationGuide/fhir.cdc.opioid-cds-r4				Version: 2022.1.0
Active as of 2017-02-06				Computable Name: Opioid_CDC

Introduction

This implementation guide provides resources and discussion in support of applying the Centers for Disease Control and Prevention (CDC) 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain:

2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain

This implementation guide was developed based on work initially done as part of the Clinical Quality Framework (CQF) Initiative, a public-private partnership sponsored by the Centers for Medicare & Medicaid Services (CMS) and the U.S. Office of the National Coordinator for Health Information Technology (ONC) to identify, develop, and harmonize standards for clinical decision support and electronic clinical quality measurement, as well as a joint effort by the Centers for Disease Control and Prevention (CDC) and the Office of the National Coordinator for Health IT (ONC) focused on improving processes for the development of standardized, shareable, computable decision support artifacts using the 2022 CDC Clinical Practice Guideline as a model case.

Feedback and contributions are welcome and can be submitted using the New Issue link in the footer of every page. Discussions on the use of this IG as well as other CQF projects take place regularly on the CPG-on-FHIR calls, a subworkgroup of the HL7 Clinical Decision Support Workgroup.

Scope

This implementation guide includes support for the following guideline recommendations:

• Recommendation #1 - Nonpharmacologic and Nonopioid Pharmacologic Therapy Consideration
• Recommendation #2 - Opioid Therapy Goals Discussion
• Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy
• Recommendations #4 and #5 - Lowest Effective Dose
• Recommendation #6 - Prescribe Lowest Effective Dose and Duration
• Recommendation #7 - Opioid Therapy Risk Assessment
• Recommendation #8 - Naloxone Consideration
• Recommendation #9 - Consider Patient’s History of Controlled Substance Prescriptions
• Recommendation #10 - Urine Drug Testing
• Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines
• Recommendation #12 - Evidence-based Treatment for Patients with Opioid Use Disorder

Getting Started

For a quick start to get up and running and see how the artifacts work, refer to the Quick Start

For clinical informaticists interested in how the behavior for the artifacts was determined, refer to the Process Documentation.

For an overview of how the artifacts are represented in the FHIR Clinical Reasoning resources, refer to the Integration Documentation.

For a detailed description of how to implement the functionality with CDS Hooks calling into a FHIR Clinical Reasoning server, refer to the Implementation Documentation.

For a detailed description of how to implement the functionality with a Java-based CDS Hooks service, refer to the Service Documentation.

Trigger Overview

Morphine Milligram Equivalent (MME) Calculation Cautions

Caution: All doses are in mg/day except for fentanyl, which is mcg/hr.

Caution: Equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics.

Caution: Do not use the calculated dose in MMEs to determine the doses to use when converting one opioid to another; when converting opioids, the new opioid is typically dosed at a substantially lower dose than the calculated MME dose to avoid overdose because of incomplete cross-tolerance and individual variability in opioid pharmacokinetics. Consult the FDA approved product labeling for specific guidance on medications.

Caution: Use particular caution with methadone dose conversions because methadone has a long and variable half-life, and peak respiratory depressant effect occurs later and lasts longer than peak analgesic effect.

Caution: Use particular caution with transdermal fentanyl because it is dosed in mcg/hr instead of mg/day, and its absorption is affected by heat and other factors.

Caution: Buprenorphine products approved for the treatment of pain are not included in the table because of their partial µ-receptor agonist activity and resultant ceiling effects compared with full µ-receptor agonists.

Caution: These conversion factors should not be applied to dosage decisions related to the management of opioid use disorder.

Morphine milligram equivalent doses for commonly prescribed opioids for pain management table

Opioid	Conversion Factor
Codeine	0.15
Fentanyl transdermal (in mcg/hr)	2.4
Hydrocodone	1.0
Hydromorphone	5.0
Methadone	4.7
Morphine	1.0
Oxycodone	1.5
Oxymorphone	3.0
Tapentadol 1	0.4
Tramadol 2	0.2

Intellectual Property

This publication includes IP covered under the following statements.

• This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
  Show Usage
  • LOINC: ALCOHOL_DRUG_URINE_SCREENING_TESTS, AMPHETAMINE_DRUG_URINE_SCREENING_TESTS... Show 13 more, CANNABINOID_DRUG_URINE_SCREENING_TESTS, COCAINE_URINE_DRUG_SCREENING_TESTS, FENTANYL_TYPE_URINE_DRUG_SCREENING_TESTS, GENERAL_OPIATE_URINE_DRUG_SCREENING_TESTS, METHADONE_DRUG_URINE_SCREENING_TESTS, NON_OPIOID_DRUG_URINE_SCREENING, OPIATE_SPECIFIC_URINE_DRUG_SCREENING_TESTS, OPIOID_DRUG_URINE_SCREENING, Observation/example-opioidcds, PAIN_TREATMENT_PLAN, PHENCYCLIDINE_URINE_DRUG_SCREENING_TESTS, SYNTHETIC_OPIOID_URINE_DRUG_SCREENING_TESTS and XYLAZINE_DRUG_URINE_SCREENING_TESTS
• This material contains content that is copyright of SNOMED International. Implementers of these specifications must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/get-snomed or info@snomed.org.
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  • SNOMED Clinical Terms® (SNOMED CT®): ActivityDefinition_Risk_Assessment_ServiceRequest, ActivityDefinition_Urine_Screening_ServiceRequest... Show 40 more, CDC_opioid_01, CDC_opioid_02, CDC_opioid_03, CDC_opioid_04_05, CDC_opioid_06, CDC_opioid_07, CDC_opioid_08, CDC_opioid_09, CDC_opioid_10, CDC_opioid_11, CONDITIONS_DOCUMENTING_SUBSTANCE_ABUSE, CONDITIONS_LIKELY_TERMINAL_FOR_OPIOID_PRESCRIBING, Condition/end-of-life, Condition/terminal, ConversionFactors, HOSPICE_DISPOSITION, HOSPICE_FINDING, HOSPICE_PROCEDURE, LIMITED_LIFE_EXPECTANCY_CONDITIONS, MMECalculator, MedicationRequest/example-opioidcds, OFFICE_VISIT, OMTKData, OMTKLogic, OPIOID_COUNSELING_PROCEDURE, OPIOID_MISUSE_ASSESSMENT_PROCEDURE, OPIOID_MISUSE_DISORDERS, OPIOID_TREATMENT_ASSESSMENT_PROCEDURE, PAIN_MANAGEMENT_PROCEDURE, PDMP_DATA_REVIEWED_FINDING, PDMP_REVIEW_PROCEDURE, PlanDefinition_Recommendation_10_Order_Sign, PlanDefinition_Recommendation_10_Patient_View, PlanDefinition_Recommendation_11_Patient_View, PlanDefinition_Recommendation_12_Patient_View, SICKLE_CELL_DISEASES, SLEEP_DISORDERED_BREATHING, SUBSTANCE_MISUSE_BEHAVIORAL_COUNSELING, ServiceRequest/palliative-care and THERAPIES_INDICATING_END_OF_LIFE_CARE
• This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license
  Show Usage
  • Condition Category Codes: Condition/cancer-diagnosis, Condition/terminal, ENCOUNTER_DIAGNOSIS_CONDITION_CATEGORY and PROBLEM_LIST_CONDITION_CATEGORY
  • DefinitionTopic: ActivityDefinition_Risk_Assessment_ServiceRequest and ActivityDefinition_Urine_Screening_ServiceRequest
  • QualityOfEvidenceRating: CDC_opioid_01, CDC_opioid_02... Show 12 more, CDC_opioid_03, CDC_opioid_04_05, CDC_opioid_06, CDC_opioid_07, CDC_opioid_08, CDC_opioid_09, CDC_opioid_10, CDC_opioid_11, PlanDefinition_Recommendation_10_Order_Sign, PlanDefinition_Recommendation_10_Patient_View, PlanDefinition_Recommendation_11_Patient_View and PlanDefinition_Recommendation_12_Patient_View
  • LibraryType: CDCMMEClinicalConversionFactors, CDC_opioid_01... Show 40 more, CDC_opioid_02, CDC_opioid_03, CDC_opioid_04_05, CDC_opioid_06, CDC_opioid_07, CDC_opioid_08, CDC_opioid_09, CDC_opioid_10, CDC_opioid_11, ConversionFactors, FHIR, FHIRHelpers, HelloWorld, HelloWorldPatientView, MMECalculator, OMTKData, OMTKData2020, OMTKLogic, OMTKLogicMK2020, OpioidCDSCommon, OpioidCDSCommonConfig, OpioidCDSREC01, OpioidCDSREC02, OpioidCDSREC03, OpioidCDSREC04And05, OpioidCDSREC06, OpioidCDSREC07, OpioidCDSREC08, OpioidCDSREC09, OpioidCDSREC10, OpioidCDSREC10Common, OpioidCDSREC10PatientView, OpioidCDSREC11, OpioidCDSREC11PatientView, OpioidCDSREC12PatientView, OpioidCDSRoutines, PlanDefinition_Recommendation_10_Order_Sign, PlanDefinition_Recommendation_10_Patient_View, PlanDefinition_Recommendation_11_Patient_View and PlanDefinition_Recommendation_12_Patient_View
  • Observation Category Codes: OBSERVATION_CATEGORY_LABORATORY and OBSERVATION_CATEGORY_PROCEDURE
  • PlanDefinitionType: CDC_opioid_01, CDC_opioid_02... Show 12 more, CDC_opioid_03, CDC_opioid_04_05, CDC_opioid_06, CDC_opioid_07, CDC_opioid_08, CDC_opioid_09, CDC_opioid_10, CDC_opioid_11, PlanDefinition_Recommendation_10_Order_Sign, PlanDefinition_Recommendation_10_Patient_View, PlanDefinition_Recommendation_11_Patient_View and PlanDefinition_Recommendation_12_Patient_View
  • StrengthOfRecommendationRating: CDC_opioid_01, CDC_opioid_02... Show 12 more, CDC_opioid_03, CDC_opioid_04_05, CDC_opioid_06, CDC_opioid_07, CDC_opioid_08, CDC_opioid_09, CDC_opioid_10, CDC_opioid_11, PlanDefinition_Recommendation_10_Order_Sign, PlanDefinition_Recommendation_10_Patient_View, PlanDefinition_Recommendation_11_Patient_View and PlanDefinition_Recommendation_12_Patient_View
  • UsageContextType: ActivityDefinition_Risk_Assessment_ServiceRequest, ActivityDefinition_Urine_Screening_ServiceRequest... Show 18 more, CDC_opioid_01, CDC_opioid_02, CDC_opioid_03, CDC_opioid_04_05, CDC_opioid_06, CDC_opioid_07, CDC_opioid_08, CDC_opioid_09, CDC_opioid_10, CDC_opioid_11, ConversionFactors, MMECalculator, OMTKData, OMTKLogic, PlanDefinition_Recommendation_10_Order_Sign, PlanDefinition_Recommendation_10_Patient_View, PlanDefinition_Recommendation_11_Patient_View and PlanDefinition_Recommendation_12_Patient_View
• This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
  Show Usage
  • ActionType: CDC_opioid_07, CDC_opioid_10, PlanDefinition_Recommendation_10_Order_Sign and PlanDefinition_Recommendation_10_Patient_View
  • Condition Clinical Status Codes: CONDITION_CLINICAL_STATUS_ACTIVE, Condition/cancer-diagnosis, Condition/end-of-life and Condition/terminal
  • DoseAndRateType: MedicationRequest/example-opioidcds
  • MedicationRequest Category Codes: MedicationDispense/ambulatory-opioid, MedicationRequest/ambulatory-opioid and Valueset_medicationrequest_category_community
• This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
  Show Usage
  • ActCode: Encounter/cancer-diagnosis and Encounter/oncologist-participant
  • ObservationInterpretation: Observation/example-opioidcds
• Using RxNorm codes of type SAB=RXNORM as this specification describes does not require a UMLS license. Access to the full set of RxNorm definitions, and/or additional use of other RxNorm structures and information requires a UMLS license. The use of RxNorm in this specification is pursuant to HL7's status as a licensee of the NLM UMLS. HL7's license does not convey the right to use RxNorm to any users of this specification; implementers must acquire a license to use RxNorm in their own right.
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  • RxNorm: AMPHETAMINES_CLASS_MEDICATIONS, BENZODIAZEPINE_MEDICATIONS... Show 13 more, BUPRENORPHINE_AND_METHADONE_MEDICATIONS, CNS_DEPRESSANT_MEDICATIONS, EXTENDED_RELEASE_OPIOID_WITH_AMBULATORY_MISUSE_POTENTIAL, FENTANYL_TYPE_MEDICATIONS, METHADONE_MEDICATIONS, MedicationDispense/ambulatory-opioid, MedicationRequest/ambulatory-opioid, MedicationRequest/example-opioidcds, NALOXONE_MEDICATIONS, NON_OPIOID_CNS_DEPRESSANT_MEDICATIONS, NON_SYNTHETIC_OPIOID_MEDICATIONS, OPIOID_ANALGESICS_WITH_AMBULATORY_MISUSE_POTENTIAL and SYNTHETIC_OPIOID_MEDICATIONS

Cross Version Analysis

This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B systems. Packages for both R4 (fhir.cdc.opioid-cds-r4.r4) and R4B (fhir.cdc.opioid-cds-r4.r4b) are available.

Dependencies

Package hl7.fhir.uv.extensions.r4#5.1.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sat, Apr 27, 2024 18:39+1000+10:00)

Package hl7.fhir.uv.cpg#1.0.0 Implementation guidance for creating Clinical Practice Guidelines with formal artifacts to facilitate sharing and implementation of the guideline (built Thu, Feb 11, 2021 20:29+0000+00:00)

Package fhir.cqf.common#4.0.1 This implementation guide contains common FHIR assets for use in CQFramework content IGs, including FHIRHelpers and the FHIR-ModelInfo libraries. (built Fri, Nov 12, 2021 16:25+1100+11:00)

Package hl7.fhir.us.qicore#4.1.1 The QICore Implementation Guide defines a set of FHIR profiles with extensions and bindings needed to create interoperable, quality-focused applications. The profiles in this implementation guide derive from and extend the US Core profiles to provide a common foundation for building, sharing, and evaluating knowledge artifacts across quality improvement efforts in the US Realm. (built Thu, Mar 31, 2022 16:41+0000+00:00)

Package hl7.fhir.us.cqfmeasures#3.0.0 The Fast Healthcare Interoperability Resource (FHIR) Quality Measure Implementation Guide (this IG) describes an approach to representing electronic Clinical Quality Measures (eCQMs) using the FHIR Clinical Reasoning Module and Clinical Quality Language (CQL) in the US Realm. However, this Implementation Guide can be usable for multiple use cases across domains, and much of the content is likely to be usable outside the US Realm. (built Thu, Apr 28, 2022 14:46+0000+00:00)

Package fhir.cdc.opioid-mme-r4#3.0.0 Opioid Morphine Milligram Equivalent (MME) calculation logic in FHIR and Clinical Quality Language (CQL) (built Thu, Nov 25, 2021 15:13+1100+11:00)

Globals

There are no Global profiles defined