Id: opioidcds-03 Url: Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_03_Order_Sign Title: Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy 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: When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids. Logic Definitions: Library Name Name sequence OpioidCDSREC03 Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions 0 define &quot;Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions&quot;: ( Common.&quot;Is Opioid Analgesic with Ambulatory Misuse Potential?&quot;( ContextPrescriptions ) ) AmbulatoryOpioidPrescription where Routines.&quot;Is Subacute or Chronic Pain Prescription?&quot;( AmbulatoryOpioidPrescription ) and AmbulatoryOpioidPrescription.medication in Common.&quot;Extended release opioid with ambulatory misuse potential&quot; Library Name Name sequence OpioidCDSREC03 Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential 1 define &quot;Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential&quot;: exists( &quot;Chronic Pain Extended Release 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 OpioidCDSREC03 Inclusion Criteria 12 define &quot;Inclusion Criteria&quot;: &quot;Patient Is Being Prescribed Extended Release 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 OpioidCDSCommon Conditions Indicating End of Life or With Limited Life Expectancy 13 define &quot;Conditions Indicating End of Life or With Limited Life Expectancy&quot;: ( &quot;US Core-Categorized Conditions&quot; C where C.code in &quot;Conditions likely terminal for opioid prescribing&quot; and C.clinicalStatus in &quot;Active Condition&quot; ) union ( &quot;US Core-Categorized Conditions&quot; C where C.code in &quot;Limited life expectancy conditions&quot; and C.clinicalStatus in &quot;Active Condition&quot; ) Library Name Name sequence OpioidCDSCommon Admitted/Referred/Discharged to Hospice Care 14 define &quot;Admitted/Referred/Discharged to Hospice Care&quot;: ( if (Config.&quot;Hospice Findings Exclusion Enabled&quot;) then [Observation: code in &quot;Hospice Finding Codes&quot;] O where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' }) else {} ) union ( [Encounter] E where date from E.period.start 1 year or less on or before Today() and ( if E.hospitalization.dischargeDisposition.coding is null or not exists (E.hospitalization.dischargeDisposition.coding) then false else E.hospitalization.dischargeDisposition in &quot;Hospice Disposition&quot; ) and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' } ) Library Name Name sequence OpioidCDSCommon End of Life Assessment 15 define &quot;End of Life Assessment&quot;: // 1. Conditions indicating end of life or with limited life expectancy exists ( &quot;Conditions Indicating End of Life or With Limited Life Expectancy&quot; ) // 2. Admitted/referred/discharged to hospice care or exists ( &quot;Admitted/Referred/Discharged to Hospice Care&quot; ) Library Name Name sequence OpioidCDSREC03 Exclusion Criteria 16 define &quot;Exclusion Criteria&quot;: Common.&quot;End of Life Assessment&quot; Library Name Name sequence OpioidCDSREC03 Is Recommendation Applicable? 17 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 82423001 Chronic pain (finding) focus 274663001 Acute pain (finding) focus Purpose: The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. Usage: Clinicians should not treat acute pain with ER/LA opioids or initiate opioid treatment for subacute or chronic pain with extended-release and long-acting (ER/LA) opioids, and clinicians should not prescribe ER/LA opioids for intermittent or as-needed use. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain MME Conversion Tables Libraries: Library - Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy Actions: When Initiating Opioid Therapy, Utilize Immediate Release Opioids: Recommend prescribing immediate release opioids instead of extended-release or long-acting opioids#xD; #xD; [For guidance regarding prescribing extended release/ long-acting opioids, see Recommendation 3 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation3). When: Named Event: order-sign If: Applicability: Check whether the current order is for an extended-release 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 - Will prescribe immediate release opioid Then: : Snooze* - Benefits outweigh risks, snooze 3 months Then: : Snooze* N/A see comment, snooze 3 months Then:
Value set Opioid analgesics with ambulatory misuse potential
Value set Extended release opioid 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
Value set Conditions likely terminal for opioid prescribing
Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
define "Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions": ( Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) ) AmbulatoryOpioidPrescription where Routines."Is Subacute or Chronic Pain Prescription?"( AmbulatoryOpioidPrescription ) and AmbulatoryOpioidPrescription.medication in Common."Extended release opioid with ambulatory misuse potential"
Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential
define "Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Extended Release 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 Extended Release Opioid Analgesic with Ambulatory Misuse Potential" and Routines."Is Opioid Review Useful?" and Routines."Is Opioid Naive?"
Conditions Indicating End of Life or With Limited Life Expectancy
define "Conditions Indicating End of Life or With Limited Life Expectancy": ( "US Core-Categorized Conditions" C where C.code in "Conditions likely terminal for opioid prescribing" and C.clinicalStatus in "Active Condition" ) union ( "US Core-Categorized Conditions" C where C.code in "Limited life expectancy conditions" and C.clinicalStatus in "Active Condition" )
Admitted/Referred/Discharged to Hospice Care
define "Admitted/Referred/Discharged to Hospice Care": ( if (Config."Hospice Findings Exclusion Enabled") then [Observation: code in "Hospice Finding Codes"] O where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' }) else {} ) union ( [Encounter] E where date from E.period.start 1 year or less on or before Today() and ( if E.hospitalization.dischargeDisposition.coding is null or not exists (E.hospitalization.dischargeDisposition.coding) then false else E.hospitalization.dischargeDisposition in "Hospice Disposition" ) and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' } )
define "End of Life Assessment": // 1. Conditions indicating end of life or with limited life expectancy exists ( "Conditions Indicating End of Life or With Limited Life Expectancy" ) // 2. Admitted/referred/discharged to hospice care or exists ( "Admitted/Referred/Discharged to Hospice Care" )
define "Exclusion Criteria": Common."End of Life Assessment"
define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria"
Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy
Centers for Disease Control and Prevention (CDC)
When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care.
Clinicians should not treat acute pain with ER/LA opioids or initiate opioid treatment for subacute or chronic pain with extended-release and long-acting (ER/LA) opioids, and clinicians should not prescribe ER/LA opioids for intermittent or as-needed use.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
When Initiating Opioid Therapy, Utilize Immediate Release Opioids
Recommend prescribing immediate release opioids instead of extended-release or long-acting opioids [For guidance regarding prescribing extended release/ long-acting opioids, see Recommendation 3 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation3).
Check whether the current order is for an extended-release opioid with ambulatory misuse potential, the patient is opioid naive and if an opioid review is appropriate for the patient
Document - Will prescribe immediate release opioid
Snooze* - Benefits outweigh risks, snooze 3 months
Snooze* N/A see comment, snooze 3 months