opioidcds-04-05
type: PlanDefinition
node role: treeRoot
id:
  v: opioidcds-04-05
meta:
  profile:
    v: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-recommendationdefinition
    l: cpg-recommendationdefinition
  profile:
    v: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-publishableplandefinition
    l: cpg-publishableplandefinition
text:
  status:
    v: extensions
  div:
    v: Id: opioidcds-04-05 Url: Recommendations #4 and #5 - Lowest Effective Dose Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_04_05_Order_Sign Title: Recommendations #4 and #5 - Lowest Effective Dose 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: Recommendation 4: When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. Recommendation 5: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages. Logic Definitions: Library Name Name sequence OpioidCDSREC04And05 Chronic Pain Opioid Analgesic with Ambulatory Misuse P…
contained: Library
  id:
    v: effective-data-requirements
  status:
    v: active
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/library-type
        l: library-type
      code:
        v: module-definition
  related artifact:
    type:
      v: depends-on
    display:
      v: Library Common
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommon|2022.1.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommon
  related artifact:
    type:
      v: depends-on
    display:
      v: Library FHIRHelpers
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers|4.0.1
      l: http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers
  related artifact:
    type:
      v: depends-on
    display:
      v: Library Routines
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSRoutines|2022.1.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSRoutines
  related artifact:
    type:
      v: depends-on
    display:
      v: Library Common
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommon|2022.1.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommon
  related artifact:
    type:
      v: depends-on
    display:
      v: Library MMECalculator
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/MMECalculator|3.0.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/MMECalculator
  related artifact:
    type:
      v: depends-on
    display:
      v: Library OMTKLogic
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/OMTKLogic|3.0.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/OMTKLogic
  related artifact:
    type:
      v: depends-on
    display:
      v: Library OMTKData
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/OMTKData|3.0.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/OMTKData
  related artifact:
    type:
      v: depends-on
    display:
      v: Library FHIRHelpers
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers|4.0.1
      l: http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers
  related artifact:
    type:
      v: depends-on
    display:
      v: Library ConversionFactors
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/ConversionFactors|3.0.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/ConversionFactors
  related artifact:
    type:
      v: depends-on
    display:
      v: Library CDCMMEClinicalConversionFactors
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/CDCMMEClinicalConversionFactors|3.0.0
      l: http://fhir.org/guides/cdc/opioid-cds/Library/CDCMMEClinicalConversionFactors
  related artifact:
    type:
      v: depends-on
    display:
      v: Library FHIRHelpers
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers|4.0.1
      l: http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers
  related artifact:
    type:
      v: depends-on
    display:
      v: Code system Usage Context Type
    resource:
      v: http://terminology.hl7.org/CodeSystem/usage-context-type
      l: usage-context-type
  related artifact:
    type:
      v: depends-on
    display:
      v: Code system CDC MME Usage Context Codes
    resource:
      v: http://fhir.org/guides/cdc/opioid-mme-r4/CodeSystem/CDCMMEUsageContextCodes
      l: CDCMMEUsageContextCodes
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Opioid analgesics with ambulatory misuse potential
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-analgesics-with-ambulatory-misuse-potential
      l: opioid-analgesics-with-ambulatory-misuse-potential
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Community
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/medicationrequest-category-community
      l: medicationrequest-category-community
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Encounter Diagnosis Condition Category
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-encounter-diagnosis-category
      l: condition-encounter-diagnosis-category
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Problem List Condition Category
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-problem-list-category
      l: condition-problem-list-category
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set US Core Health Concern Condition Category
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-us-core-health-concern-category
      l: condition-us-core-health-concern-category
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Limited life expectancy conditions
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/limited-life-expectancy-conditions
      l: limited-life-expectancy-conditions
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Active Condition
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-clinical-status-active
      l: condition-clinical-status-active
  related artifact:
    type:
      v: depends-on
    display:
      v: Value set Conditions likely terminal for opioid prescribing
    resource:
      v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/conditions-likely-terminal-for-opioid-prescribing
      l: conditions-likely-terminal-for-opioid-prescribing
  parameter:
    name:
      v: ContextPrescriptions
    use:
      v: in
    min:
      v: 0

v: *

v: MedicationRequest

name:
  v: ErrorLevel
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: string

name:
  v: ConversionFactorSupplementName
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: string

name:
  v: Is Recommendation Applicable?
use:
  v: out
min:
  v: 0
max:
  v: 1
type:
  v: boolean

type:
  v: Condition
profile:
  v: http://hl7.org/fhir/StructureDefinition/Condition
  l: Condition
must support:
  v: category
code filter:
  path:
    v: category
  value set:
    v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-encounter-diagnosis-category
    l: condition-encounter-diagnosis-category

type:
  v: Condition
profile:
  v: http://hl7.org/fhir/StructureDefinition/Condition
  l: Condition
must support:
  v: category
code filter:
  path:
    v: category
  value set:
    v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-problem-list-category
    l: condition-problem-list-category

type:
  v: Condition
profile:
  v: http://hl7.org/fhir/StructureDefinition/Condition
  l: Condition
must support:
  v: category
code filter:
  path:
    v: category
  value set:
    v: http://fhir.org/guides/cdc/opioid-cds/ValueSet/condition-us-core-health-concern-category
    l: condition-us-core-health-concern-category

type:
  v: Encounter
profile:
  v: http://hl7.org/fhir/StructureDefinition/Encounter
  l: Encounter
must support:
  v: period
must support:
  v: period.start
must support:
  v: status
must support:
  v: status.value

url:
  v: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability
  l: cpg-knowledgeCapability
value: Code
  v: shareable

url:
  v: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability
  l: cpg-knowledgeCapability
value: Code
  v: computable

url:
  v: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability
  l: cpg-knowledgeCapability
value: Code
  v: executable

url:
  v: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability
  l: cpg-knowledgeCapability
value: Code
  v: publishable

url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem
  l: cqfm-softwaresystem
value: Reference
  l: cqf-tooling
  reference:
    v: Device/cqf-tooling

id:
  v: effective-data-requirements
url:
  v: http://fhir.org/guides/cdc/opioid-cds/StructureDefinition/effectiveDataRequirements
  l: effectiveDataRequirements
value: Reference
  l: effective-data-requirements
  reference:
    v: #effective-data-requirements

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSREC04And05
extension:
  url:
    v: name
    l: name
  value: String
    v: Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Chronic Pain 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 )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 0
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSREC04And05
extension:
  url:
    v: name
    l: name
  value: String
    v: Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 1
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSRoutines
extension:
  url:
    v: name
    l: name
  value: String
    v: Patient Age Less Than 18
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 2
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSRoutines
extension:
  url:
    v: name
    l: name
  value: String
    v: Condition Positive for Sickle Cell
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 3
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: US Core-Categorized Conditions
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // 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"]
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 4
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSRoutines
extension:
  url:
    v: name
    l: name
  value: String
    v: Conditions Indicating End Of Life Present
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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" )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 5
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSRoutines
extension:
  url:
    v: name
    l: name
  value: String
    v: Is Active Cancer Treatment?
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 6
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSRoutines
extension:
  url:
    v: name
    l: name
  value: String
    v: Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 7
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSRoutines
extension:
  url:
    v: name
    l: name
  value: String
    v: Is Opioid Review Useful?
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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"
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 8
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OMTKData
extension:
  url:
    v: name
    l: name
  value: String
    v: DrugIngredients
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* This library contains drug ingredient data for opioid ingredients of combinations drugs as determined using the [RxNav](https://rxnav.nlm.nih.gov/) API. The content was produced using the process described [here](http://build.fhir.org/ig/cqframework/opioid-cds-r4/service-documentation.html#solution-component-1-medication-and-terminology-knowledge-base). This version of the content was generated on 2020-10-20 This product uses publicly available data courtesy of the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services; NLM is not responsible for the product and does not endorse or recommend this or any other product. Nelson SJ, Zeng K, Kilbourne J, Powell T, Moore R. Normalized names for clinical drugs: RxNorm at 6 years. J Am Med Inform Assoc. 2011 Jul-Aug;18(4)441-8. doi: 10.1136/amiajnl-2011-000116. Epub 2011 Apr 21. PubMed PMID: 21515544; PubMed Central PMCID: PMC3128404. [Full text](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128404/) */ /* DrugIngredients: List<{ drugCode Integer, drugName String, doseFormCode Integer, doseFormName String, ingredientCode Integer, ingredientName String, strength String, strengthValue Decimal, strengthUnit String }> */ // Generated from LocalDataStore_RxNav_OpioidCds-2020-10-20.sqlitedefine DrugIngredients: { { drugCode: 197696, drugName: '72 HR fentanyl 0.075 MG/HR Transdermal System', doseFormCode: 316987, doseFormName: 'Transdermal System', ingredientCode: 4337, ingredientName: 'Fentanyl', strength: '0.075 MG/HR', strengthValue: 0.075, strengthUnit: 'MG/HR' }, { drugCode: 197873, drugName: 'levorphanol tartrate 2 MG Oral Tablet', doseFormCode: 317541, doseFormName: 'Oral Tablet', ingredientCode: 6378, ingredientName: 'Levorphanol', strength: '2 MG', strengthValue: 2.0, strengthUnit: 'MG' }, { drugCode: 205533, drugName: '1 ML buprenorphine 0.3 MG/ML Injection [Buprenex]', doseFormCode: 1649574, doseFormName: 'Injection', ingredientCode: 1819, ingredientName: 'Bupr…
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 9
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: CDCMMEClinicalConversionFactors
extension:
  url:
    v: name
    l: name
  value: String
    v: CDCMMEClinicalConversionFactorsCodeSystem
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define CDCMMEClinicalConversionFactorsCodeSystem: CodeSystem { name: string { value: 'CDCMMEClinicalConversionFactors' }, supplements: canonical { value: 'http://www.nlm.nih.gov/research/umls/rxnorm' }, concept: List<FHIR.CodeSystem.Concept> { FHIR.CodeSystem.Concept { code: code { value: '2670' }, display: string { value: 'Codeine' }, property: List<FHIR.CodeSystem."Concept"."Property"> { FHIR.CodeSystem."Concept"."Property" { code: code { value: 'conversion-factor' }, value: decimal { value: 0.15 } } } }, FHIR.CodeSystem.Concept { code: code { value: '4337' }, display: string { value: 'Fentanyl' }, property: List<FHIR.CodeSystem."Concept"."Property"> { FHIR.CodeSystem."Concept"."Property" { code: code { value: 'dose-form-conversion-factor' }, value: string { value: '316987:7200@0.33333333' } } } }, FHIR.CodeSystem.Concept { code: code { value: '3423' }, display: string { value: 'Hydromorphone' }, property: List<FHIR.CodeSystem."Concept"."Property"> { FHIR.CodeSystem."Concept"."Property" { code: code { value: 'conversion-factor' }, value: decimal { value: 4 } } } }, FHIR.CodeSystem.Concept { code: code { value: '5489' }, display: string { value: 'Hydrocodone' }, property: List<FHIR.CodeSystem."Concept"."Property"> { FHIR.CodeSystem."Concept"."Property" { code: code { value: 'conversion-factor' }, value: decimal { value: 1 } } } }, FHIR.CodeSystem.Concept { code: code { value: '6813' }, display: string { value: 'Methadone' }, property: List<FHIR.CodeSystem."Concept"."Property"> { FHIR.CodeSystem."Concept"."Property" { code: code { value: 'dose-range-conversion-factor' }, value: string { value: '1-20:4' } }, FHIR.CodeSystem."Concept"."Property" { code: code { value: 'dose-range-conversion-factor' }, value: string { value: '21-40:8' } }, FHIR.CodeSystem."Concept"."Property" { code: code { value: 'dose-range-conversion-factor' }, value: string { value: '41-60:10' } }, FHIR.CodeSystem."Concept"."Property" { code: code { value: 'dose-range-conversion-factor' }, value: st…
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 10
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: ConversionFactors
extension:
  url:
    v: name
    l: name
  value: String
    v: ConversionFactorSupplement
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* The use of the CDCMMEClinicalConversionFactors is a workaround for the fact that we can't retrieve the formally defined CodeSystem resource (https://fhir.org/guides/cdc/opioid-mme-r4/CodeSystem-CDCMMEClinicalConversionFactors.html) from the FHIR server */ define ConversionFactorSupplement: CDCMMEClinicalConversionFactors."CDCMMEClinicalConversionFactorsCodeSystem" C where C.supplements.value = 'http://www.nlm.nih.gov/research/umls/rxnorm' and ( C.name.value = ConversionFactorSupplementName or exists ( C.useContext UC where UC.code ~ "Task Usage Context" and UC.value ~ "MME Calculation" ) )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 11
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: Active Ambulatory Opioid Rx
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Active Ambulatory Opioid Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest])) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Opioid analgesics with ambulatory misuse potential" else List<FHIR.MedicationRequest>{}
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 12
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSREC04And05
extension:
  url:
    v: name
    l: name
  value: String
    v: Total MME
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Total MME": MMECalculator.TotalMME( ( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" union Common."Active Ambulatory Opioid Rx" ) AmbulatoryOpioidPrescription where Routines."Is Subacute or Chronic Pain Prescription?"( AmbulatoryOpioidPrescription ) )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 13
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSREC04And05
extension:
  url:
    v: name
    l: name
  value: String
    v: Inclusion Criteria
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Inclusion Criteria": "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and Routines."Is Opioid Review Useful?" and "Total MME" >= 50 '{MME}/d'
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 14
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: Conditions Indicating End of Life or With Limited Life Expectancy
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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" )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 15
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: Admitted/Referred/Discharged to Hospice Care
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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' } )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 16
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: End of Life Assessment
extension:
  url:
    v: statement
    l: statement
  value: String
    v: 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" )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 17
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSREC04And05
extension:
  url:
    v: name
    l: name
  value: String
    v: Exclusion Criteria
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Exclusion Criteria": Common."End of Life Assessment"
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 18
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: OpioidCDSREC04And05
extension:
  url:
    v: name
    l: name
  value: String
    v: Is Recommendation Applicable?
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria"
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 19
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition
  l: cqfm-logicDefinition

id:
  v: effective-data-requirements
url:
  v: http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements
  l: cqfm-effectiveDataRequirements
value: Reference
  l: effective-data-requirements
  reference:
    v: #effective-data-requirements

use:
  v: official
value:
  v: cdc-opioid-guidance

v: 2022.1.0

v: PlanDefinition_Recommendation_04_05_Order_Sign

v: Recommendations #4 and #5 - Lowest Effective Dose

coding:
  system:
    v: http://terminology.hl7.org/CodeSystem/plan-definition-type
    l: plan-definition-type
  code:
    v: eca-rule
  display:
    v: ECA Rule

v: draft

v: true

v: 2024-11-19

v: Centers for Disease Control and Prevention (CDC)

telecom:
  system:
    v: url
  value:
    v: https://www.cdc.gov

v: Recommendation 4: When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. Recommendation 5: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.

code:
  system:
    v: http://terminology.hl7.org/CodeSystem/usage-context-type
    l: usage-context-type
  code:
    v: focus
  display:
    v: Clinical Focus
value: CodeableConcept
  coding: http://snomed.info/id/182888003
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 182888003
    display:
      v: Medication requested (situation)

code:
  system:
    v: http://terminology.hl7.org/CodeSystem/usage-context-type
    l: usage-context-type
  code:
    v: focus
  display:
    v: Clinical Focus
value: CodeableConcept
  coding: http://snomed.info/id/82423001
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 82423001
    display:
      v: Chronic pain (finding)

code:
  system:
    v: http://terminology.hl7.org/CodeSystem/usage-context-type
    l: usage-context-type
  code:
    v: focus
  display:
    v: Clinical Focus
value: CodeableConcept
  coding: http://snomed.info/id/274663001
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 274663001
    display:
      v: Acute pain (finding)

code:
  system:
    v: http://terminology.hl7.org/CodeSystem/usage-context-type
    l: usage-context-type
  code:
    v: focus
  display:
    v: Clinical Focus
value: CodeableConcept
  text:
    v: Subacute pain

v: 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.

v: The recommendations related to opioid dosages are not intended to be used as an inflexible, rigid standard of care; rather, they are intended to be guideposts to help inform clinician-patient decision-making. Risks of opioid use, including risk for overdose and overdose death, increase continuously with dosage, and there is no single dosage threshold below which risks are eliminated. Therefore, the recommendation language emphasizes that clinicians should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients rather than emphasizing a single specific numeric threshold. Further, these recommendations apply specifically to starting opioids or to increasing opioid dosages, and a different set of benefits and risks applies to reducing opioid dosages.

v: © CDC 2016+.

text:
  v: Opioid Prescribing

name:
  v: Kensaku Kawamoto, MD, PhD, MHS

name:
  v: Bryn Rhodes

name:
  v: Floyd Eisenberg, MD, MPH

name:
  v: Robert McClure, MD, MPH

type:
  v: documentation
display:
  v: 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
url:
  v: https://www.cdc.gov/mmwr/volumes/71/rr/pdfs/rr7103a1-H.pdf
  l: rr7103a1-H.pdf
document:
  content type:
    v: application/pdf
  language:
    v: en-US
  url:
    v: https://www.cdc.gov/mmwr/volumes/71/rr/pdfs/rr7103a1-H.pdf
    l: rr7103a1-H.pdf

type:
  v: documentation
display:
  v: MME Conversion Tables
url:
  v: https://www.cdc.gov/opioids/providers/prescribing/pdf/calculating-total-daily-dose.pdf
  l: calculating-total-daily-dose.pdf
document:
  content type:
    v: application/pdf
  language:
    v: en-US
  url:
    v: https://www.cdc.gov/opioids/providers/prescribing/pdf/calculating-total-daily-dose.pdf
    l: calculating-total-daily-dose.pdf

title:
  v: Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages
description:
  v: When opioid therapy is considered appropriate, calibrate opioid dosages to lowest dose needed to achieve expected effects. For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. [For guidance in determining the lowest effective opioid dosage, see Recommendation 4 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation4) [For patients who have received opioid therapy for longer durations of time, if tapering, consider working closely with the patient to gradually taper dosages (no more than 10% per month)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=When%20patients%20have%20been%20taking%20opioids%20for%20longer%20durations%20(e.g.%2C%20for%20%E2%89%A51%20year)%2C%20tapers%20of%2010%25%20per%20month%20or%20slower%20are%20likely%20to%20be%20better%20tolerated%20than%20more%20rapid%20tapers.) For a tapering calculator, go to [https://agencymeddirectors.wa.gov/Calculator/TaperDoseCalculator.html](https://www.agencymeddirectors.wa.gov/Calculator/TaperDoseCalculator.html) [For more guidance regarding tapering, please see Recommendation 5 of the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation5).) **MME Calculator Cautions** 1) All doses are in mg/day except for fentanyl, which is mcg/hr. 2) Equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics. 3) 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 medica…
priority:
  v: urgent
documentation:
  type:
    v: documentation
  label:
    v: Recommendation 4
  url:
    v: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation4:~:text=risks%20to%20patients-,(recommendation%20category%3A%20A%3B%20evidence%20type%3A%203).,-Implementation%20Considerations
    l: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
  document:
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/cqf-strengthOfRecommendation
        l: cqf-strengthOfRecommendation
      value: CodeableConcept
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/cqf-qualityOfEvidence
        l: cqf-qualityOfEvidence
      value: CodeableConcept
    url:
      v: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation4:~:text=risks%20to%20patients-,(recommendation%20category%3A%20A%3B%20evidence%20type%3A%203).,-Implementation%20Considerations
      l: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
documentation:
  type:
    v: documentation
  label:
    v: Recommendation 5
  url:
    v: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation5:~:text=from%20higher%20dosages-,(recommendation%20category%3A%20B%3B%20evidence%20type%3A%204).,-Implementation%20Considerations
    l: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
  document:
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/cqf-strengthOfRecommendation
        l: cqf-strengthOfRecommendation
      value: CodeableConcept
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/cqf-qualityOfEvidence
        l: cqf-qualityOfEvidence
      value: CodeableConcept
    url:
      v: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation5:~:text=from%20higher%20dosages-,(recommendation%20category%3A%20B%3B%20evidence%20type%3A%204).,-Implementation%20Considerations
      l: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
trigger:
  type:
    v: named-event
  name:
    v: order-sign
condition:
  kind:
    v: applicability
  expression:
    description:
      v: Check whether the current order is for an opioid with ambulatory misuse potential, the calculated MME result for the order and other active opioid medications for the patient is greater than or equal to 50 and if an opioid review is appropriate for the patient
    language:
      v: text/cql.identifier
    expression:
      v: Is Recommendation Applicable?
grouping behavior:
  v: visual-group
selection behavior:
  v: any
action:
  description:
    v: Document - Will prescribe a lower dose
action:
  description:
    v: Document - Will calibrate a gradual change in dosage
action:
  description:
    v: Snooze* - Benefits outweigh risks, snooze 3 months
action:
  description:
    v: Snooze* - Short term benefits outweigh risks, snooze 1 month
action:
  description:
    v: Snooze* - N/A add comment, snooze 3 months

system:
  v: http://terminology.hl7.org/CodeSystem/recommendation-strength
  l: recommendation-strength
code:
  v: strong
display:
  v: Strong

system:
  v: http://terminology.hl7.org/CodeSystem/evidence-quality
  l: evidence-quality
code:
  v: low
display:
  v: Low quality

system:
  v: http://terminology.hl7.org/CodeSystem/recommendation-strength
  l: recommendation-strength
code:
  v: weak
display:
  v: Weak

system:
  v: http://terminology.hl7.org/CodeSystem/evidence-quality
  l: evidence-quality
code:
  v: very-low
display:
  v: Very low quality