Id: opioidcds-01 Url: Recommendation #1 - Nonpharmacologic and Nonopioid Pharmacologic Therapy Consideration Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_01_Order_Sign Title: Recommendation #1 - Nonpharmacologic and Nonopioid Pharmacologic Therapy Consideration Status: draft Experimental: true Type: system: http://terminology.hl7.org/CodeSystem/plan-definition-type code: eca-rule display: ECA Rule Date: 2024-11-19 Publisher: Centers for Disease Control and Prevention (CDC) Description: Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy. Logic Definitions: Library Name Name sequence OpioidCDSREC01 Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions 0 define &quot;Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions&quot;: ( Common.&quot;Is Opioid Analgesic with Ambulatory Misuse Potential?&quot;( ContextPrescriptions ) ) AmbulatoryOpioidPrescription where Routines.&quot;Is Acute Pain Prescription?&quot;( AmbulatoryOpioidPrescription ) Library Name Name sequence OpioidCDSREC01 Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential 1 define &quot;Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential&quot;: exists( &quot;Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions&quot; ) Library Name Name sequence OpioidCDSRoutines Patient Age Less Than 18 2 define &quot;Patient Age Less Than 18&quot;: if (Config.&quot;Age Less than 18 Years Is Enabled&quot;) then AgeInYearsAt(Today()) &lt; 18 else false Library Name Name sequence OpioidCDSRoutines Condition Positive for Sickle Cell 3 define &quot;Condition Positive for Sickle Cell&quot;: if (Config.&quot;Sickle Cell Check Enabled&quot;) then exists( Common.&quot;Positive Sickle Cell Condition&quot; ) else false Library Name Name sequence OpioidCDSCommon US Core-Categorized Conditions 4 // 3. Medications indicating end of life /* or exists ( &quot;Medications Indicating End of Life&quot; ) */ define &quot;US Core-Categorized Conditions&quot;: [Condition: category in &quot;Encounter Diagnosis Condition Category&quot;] union [Condition: category in &quot;Problem List Condition Category&quot;] union [Condition: category in &quot;US Core Health Concern Condition Category&quot;] Library Name Name sequence OpioidCDSRoutines Conditions Indicating End Of Life Present 5 define &quot;Conditions Indicating End Of Life Present&quot;: exists ( Common.&quot;US Core-Categorized Conditions&quot; LLEC where LLEC.code in Common.&quot;Limited life expectancy conditions&quot; and LLEC.clinicalStatus in Common.&quot;Active Condition&quot; ) Library Name Name sequence OpioidCDSRoutines Is Active Cancer Treatment? 6 define &quot;Is Active Cancer Treatment?&quot;: if (Config.&quot;Active Cancer Treatment Encounters Condition Is Enabled&quot;) then &quot;Has Two or More Encounters with Cancer Diagnosis During Encounter Period&quot; else false Library Name Name sequence OpioidCDSRoutines Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present 7 define &quot;Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present&quot;: if (Config.&quot;End-Stage Disease Criteria Enabled&quot;) then exists ( Common.&quot;US Core-Categorized Conditions&quot; EOLC where EOLC.code in Common.&quot;Conditions likely terminal for opioid prescribing&quot; and EOLC.clinicalStatus in Common.&quot;Active Condition&quot; ) else false Library Name Name sequence OpioidCDSRoutines Is Opioid Review Useful? 8 define &quot;Is Opioid Review Useful?&quot;: not &quot;Patient Age Less Than 18&quot; and not &quot;Condition Positive for Sickle Cell&quot; and not &quot;Conditions Indicating End Of Life Present&quot; and not &quot;Is Active Cancer Treatment?&quot; and not &quot;Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present&quot; Library Name Name sequence OpioidCDSRoutines Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days 9 define &quot;Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days&quot;: if (Config.&quot;Opioid Naive Prescription Condition Is Enabled&quot;) then exists (&quot;Opioid RX with Ambulatory Abuse Potential In Past 90 Days&quot;) else false Library Name Name sequence OpioidCDSRoutines Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days 10 define &quot;Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days&quot;: if (Config.&quot;Opioid Naive Prescription Condition Is Enabled&quot;) then exists (&quot;Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days&quot;) else false Library Name Name sequence OpioidCDSRoutines Is Opioid Naive? 11 // NOTE: MedicationStatement-dependent logic comment out due to bug in Publisher not supporting MedicationStatement in AllTypes. define &quot;Is Opioid Naive?&quot;: not (&quot;Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days&quot;) /* and not (&quot;Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days&quot;) */ and not (&quot;Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days&quot;) Library Name Name sequence OpioidCDSREC01 Inclusion Criteria 12 define &quot;Inclusion Criteria&quot;: &quot;Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential&quot; and Routines.&quot;Is Opioid Review Useful?&quot; and Routines.&quot;Is Opioid Naive?&quot; Library Name Name sequence OpioidCDSREC01 Exclusion Criteria 13 define &quot;Exclusion Criteria&quot;: false Library Name Name sequence OpioidCDSREC01 Is Recommendation Applicable? 14 define &quot;Is Recommendation Applicable?&quot;: &quot;Inclusion Criteria&quot; and not &quot;Exclusion Criteria&quot; Knowledge Capability: shareable computable executable publishable Use Context: code value display focus 182888003 Medication requested (situation) focus 274663001 Acute pain (finding) Purpose: The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care. Usage: Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain Libraries: Library - Recommendation #1 - Nonpharmacologic and Nonopioid Pharmacologic Therapy Consideration Actions: Consider Nonopioid Treatment Options for Acute Pain: For many types of acute pain, clinicians should maximize the use of nonpharmacologic (for example, physical therapy) and nonopioid pharmacologic therapies (for example, NSAIDs), as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.#xD; #xD; [Recommendation 1 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation1) provides nonopioid therapy options for common acute pain conditions.#xD; #xD; **Nonopioid Pharmacological Therapy**#xD; - [Dental pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=The%20American%20Dental%20Association%20(ADA)%20recommends%20NSAIDs%20as%20first%2Dline%20treatment%20for%20acute%20dental%20pain%20management)#xD; - [Dental pain (surgical)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=NSAIDs%20have%20been%20found%20to%20be%20more%20effective%20than%20opioids%20for%20surgical%20dental%20pain)#xD; - [Kidney stone pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=For%20acute%20kidney%20stone%20pain%2C%20NSAIDs%20are%20at%20least%20as%20effective%20as%20opioids%20(124%E2%80%93127)%2C%20can%20decrease%20the%20ureteral%20smooth%20muscle%20tone%20and%20ureteral%20spasm%20(128)%20causing%20kidney%20stone%20pain%2C%20and%20are%20preferred%20for%20kidney%20stone%20pain%20if%20not%20contraindicated.)#xD; - [Low back pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=NSAIDs%20have%20been%20found%20to%20be%20more%20effective%20than%20opioids%20for%20surgical%20dental%20pain%20and%20kidney%20stone%20pain%20and%20similarly%20effective%20to%20opioids%20for%20low%20back%20pain)#xD; - [Migraine pain (episodic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=For%20episodic%20migraine%2C%20triptans%2C%20NSAIDs%2C%20antiemetics%2C%20dihydroergotamine%2C%20calcitonin%20gene%2Drelated%20peptide%20antagonists%20(gepants)%2C%20and%20lasmiditan%20are%20associated%20with%20improved%20pain%20and%20function%20with%20usually%20mild%20and%20transient%20adverse%20events)#xD; - [Musculoskeletal pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=A%20systematic%20review%20found%20that%20for%20musculoskeletal%20injuries%20such%20as%20sprains%2C%20whiplash%2C%20and%20muscle%20strains%2C%20topical%20NSAIDs%20provided%20the%20greatest%20benefit%2Dharm%20ratio%2C%20followed%20by%20oral%20NSAIDs%20or%20acetaminophen%20with%20or%20without%20diclofenac)#xD; - [Postpartum pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=Pain%20Management%20for%20Pregnant%20and%20Postpartum%20Persons)#xD; #xD; **Nonpharmacologic Treatments**#xD; - [Back pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=The%20American%20College%20of%20Physicians%20(ACP)%20recommends%20nonpharmacologic%20treatment%20with%20superficial%20heat%2C%20massage%2C%20acupuncture%2C%20or%20spinal%20manipulation%20as%20a%20cornerstone%20of%20treatment%20for%20acute%20low%20back%20pain)#xD; - [Migraine pain (episodic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=remote%20electrical%20neuromodulation%20for%20acute%20pain%20related%20to%20episodic%20migraine)#xD; - [Musculoskeletal pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=acupressure%20for%20acute%20musculoskeletal%20pain)#xD; - [Postoperative pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=massage%20for%20postoperative%20pain) When: Named Event: order-sign If: Applicability: Check whether the current order is for an opioid with ambulatory misuse potential, the patient is opioid naive and if an opioid review is appropriate for the patient (Is Recommendation Applicable?) Then: : Document - Record reason for opioid therapy Then: : Snooze* - Attempt alternative therapy, snooze 3 months Then: : Order - Select alternative therapies from order set Then: : Snooze* - N/A see comment, snooze 3 months Then: : Remove - Will remove triggering medication order Then:
Value set Opioid analgesics with ambulatory misuse potential
Value set Encounter Diagnosis Condition Category
Value set Problem List Condition Category
Value set US Core Health Concern Condition Category
Value set Limited life expectancy conditions
Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
define "Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions": ( Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) ) AmbulatoryOpioidPrescription where Routines."Is Acute Pain Prescription?"( AmbulatoryOpioidPrescription )
Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential
define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )
define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false
define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false
// 3. Medications indicating end of life /* or exists ( "Medications Indicating End of Life" ) */ define "US Core-Categorized Conditions": [Condition: category in "Encounter Diagnosis Condition Category"] union [Condition: category in "Problem List Condition Category"] union [Condition: category in "US Core Health Concern Condition Category"]
Conditions Indicating End Of Life Present
define "Conditions Indicating End Of Life Present": exists ( Common."US Core-Categorized Conditions" LLEC where LLEC.code in Common."Limited life expectancy conditions" and LLEC.clinicalStatus in Common."Active Condition" )
define "Is Active Cancer Treatment?": if (Config."Active Cancer Treatment Encounters Condition Is Enabled") then "Has Two or More Encounters with Cancer Diagnosis During Encounter Period" else false
Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present
define "Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present": if (Config."End-Stage Disease Criteria Enabled") then exists ( Common."US Core-Categorized Conditions" EOLC where EOLC.code in Common."Conditions likely terminal for opioid prescribing" and EOLC.clinicalStatus in Common."Active Condition" ) else false
define "Is Opioid Review Useful?": not "Patient Age Less Than 18" and not "Condition Positive for Sickle Cell" and not "Conditions Indicating End Of Life Present" and not "Is Active Cancer Treatment?" and not "Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present"
Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days
define "Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days": if (Config."Opioid Naive Prescription Condition Is Enabled") then exists ("Opioid RX with Ambulatory Abuse Potential In Past 90 Days") else false
Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days
define "Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days": if (Config."Opioid Naive Prescription Condition Is Enabled") then exists ("Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days") else false
// NOTE: MedicationStatement-dependent logic comment out due to bug in Publisher not supporting MedicationStatement in AllTypes. define "Is Opioid Naive?": not ("Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days") /* and not ("Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */ and not ("Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days")
define "Inclusion Criteria": "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and Routines."Is Opioid Review Useful?" and Routines."Is Opioid Naive?"
define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria"
Recommendation #1 - Nonpharmacologic and Nonopioid Pharmacologic Therapy Consideration
Centers for Disease Control and Prevention (CDC)
Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.
The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.
Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Consider Nonopioid Treatment Options for Acute Pain
For many types of acute pain, clinicians should maximize the use of nonpharmacologic (for example, physical therapy) and nonopioid pharmacologic therapies (for example, NSAIDs), as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy. [Recommendation 1 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation1) provides nonopioid therapy options for common acute pain conditions. **Nonopioid Pharmacological Therapy** - [Dental pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=The%20American%20Dental%20Association%20(ADA)%20recommends%20NSAIDs%20as%20first%2Dline%20treatment%20for%20acute%20dental%20pain%20management) - [Dental pain (surgical)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=NSAIDs%20have%20been%20found%20to%20be%20more%20effective%20than%20opioids%20for%20surgical%20dental%20pain) - [Kidney stone pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=For%20acute%20kidney%20stone%20pain%2C%20NSAIDs%20are%20at%20least%20as%20effective%20as%20opioids%20(124%E2%80%93127)%2C%20can%20decrease%20the%20ureteral%20smooth%20muscle%20tone%20and%20ureteral%20spasm%20(128)%20causing%20kidney%20stone%20pain%2C%20and%20are%20preferred%20for%20kidney%20stone%20pain%20if%20not%20contraindicated.) - [Low back pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=NSAIDs%20have%20been%20found%20to%20be%20more%20effective%20than%20opioids%20for%20surgical%20dental%20pain%20and%20kidney%20stone%20pain%20and%20similarly%20effective%20to%20opioids%20for%20low%20back%20pain) - [Migraine pain (episodic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=For%20episodic%20migraine%2C%20triptans%2C%20NSAIDs%2C%20antiemetics%2C%20dihydroergotamine%2C%20calcitonin%20gene%2Drelated%20peptide%20antagonists%20(gepants)%2C%20and%20lasmiditan%20are%20associated%20with%20improved%20pain%20and%20function%20with%20usually%20mild%20and%20transient%20adverse%20events) - [Musculoskeletal pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=A%20systematic%20review%20found%20that%20for%20musculoskeletal%20injuries%20such%20as%20sprains%2C%20whiplash%2C%20and%20muscle%20strains%2C%20topical%20NSAIDs%20provided%20the%20greatest%20benefit%2Dharm%20ratio%2C%20followed%20by%20oral%20NSAIDs%20or%20acetaminophen%20with%20or%20without%20diclofenac) - [Postpartum pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=Pain%20Management%20for%20Pregnant%20and%20Postpartum%20Persons) **Nonpharmacologic Treatments** - [Back pain (acute)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=The%20American%20College%20of%20Physicians%20(ACP)%20recommends%20nonpharmacologic%20treatment%20with%20superficial%20heat%2C%20massage%2C%20acupuncture%2C%20or%20spinal%20manipulation%20as%20a%20cornerstone%20of%20treatment%20for%20acute%20low%20back%20pain) - [Migraine pain (episodic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=remote%20electrical%20neuromodulation%20for%20acute%20pain%20related%20to%20episodic%20migraine) - [Musculoskeletal pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=acupressure%20for%20acute%20musculoskeletal%20pain) - [Postoperative pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w#:~:text=massage%20for%20postoperative%20pain)
Check whether the current order is for an opioid with ambulatory misuse potential, the patient is opioid naive and if an opioid review is appropriate for the patient
Document - Record reason for opioid therapy
Snooze* - Attempt alternative therapy, snooze 3 months
Order - Select alternative therapies from order set
Snooze* - N/A see comment, snooze 3 months
Remove - Will remove triggering medication order