Id: opioidcds-11-patient-view Url: Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines (patient-view) Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_11_Patient_View Title: Recommendation #11 - Concurrent Use of Opioids and Benzodiazepines (patient-view) 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: Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. Logic Definitions: Library Name Name sequence OpioidCDSCommon Active Ambulatory Benzodiazepine or CNS Depressant Rx 0 define &quot;Active Ambulatory Benzodiazepine or CNS Depressant Rx&quot;: if Config.&quot;Can the implementing EHR support queries for past medications by date range?&quot; then ( &quot;Get MedicationRequest Medication as Code&quot;(&quot;Active Medication List&quot;) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in &quot;Benzodiazepine medications&quot; or Rx.medication in &quot;CNS Depressant Medications&quot; else List&lt;FHIR.MedicationRequest&gt;{} Library Name Name sequence OpioidCDSCommon Active Ambulatory Opioid Rx 1 define &quot;Active Ambulatory Opioid Rx&quot;: if Config.&quot;Can the implementing EHR support queries for past medications by date range?&quot; then ( &quot;Get MedicationRequest Medication as Code&quot;(&quot;Get Active Ambulatory Medication Requests&quot;([MedicationRequest])) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in &quot;Opioid analgesics with ambulatory misuse potential&quot; else List&lt;FHIR.MedicationRequest&gt;{} 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 OpioidCDSREC11PatientView Inclusion Criteria 9 define &quot;Inclusion Criteria&quot;: ( exists (Common.&quot;Active Ambulatory Benzodiazepine or CNS Depressant Rx&quot;) and exists (Common.&quot;Active Ambulatory Opioid Rx&quot;) ) and Routines.&quot;Is Opioid Review Useful?&quot; Library Name Name sequence OpioidCDSCommon Conditions Indicating End of Life or With Limited Life Expectancy 10 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 11 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 12 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 OpioidCDSREC11PatientView Exclusion Criteria 13 define &quot;Exclusion Criteria&quot;: Common.&quot;End of Life Assessment&quot; Library Name Name sequence OpioidCDSREC11PatientView 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 82423001 Chronic pain (finding) 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 use particular caution when prescribing opioid pain medication and benzodiazepines concurrently. In addition, clinicians should consider whether benefits outweigh risks for concurrent use of opioids with other central nervous system depressants. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain Libraries: Library - Recommendation #11 Patient View - Concurrent Use of Opioids and Benzodiazepines Actions: Use Particular Caution When Prescribing Opioid Pain Medication and Benzodiazepines or Other CNS Depressants Concurrently: Consider whether the benefits outweigh the risks of concurrently prescribing opioids and benzodiazepines, or other central nervous system depressant medications.#xD; #xD; When co-prescribing risks outweigh benefits, consult [Recommendation 11 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=evidence%20type%3A%203).-,Implementation%20Considerations,-Although%20in%20some) for further guidance.#xD; #xD; [For patients being treated for opioid use disorder who are also taking benzodiazepines or other medications that depress the central nervous system, the CDC recommends not withholding buprenorphine or methadone](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=gabapentin%20and%20pregabalin).-,Buprenorphine%20or%20methadone%20for%20opioid%20use%20disorder%20should%20not%20be%20withheld%20from%20patients%20taking%20benzodiazepines%20or%20other%20medications%20that%20depress%20the%20central%20nervous%20system.,-Clinicians%20should%20check).#xD; #xD; If the decision is made to taper benzodiazepine medications, [the CDC recommends tapering benzodiazepines gradually prior to discontinuation](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20taper%20benzodiazepines%20gradually%20before%20discontinuation%20because%20abrupt%20withdrawal%20can%20be%20associated%20with%20rebound%20anxiety%2C%20hallucinations%2C%20seizures%2C%20delirium%20tremens%2C%20and%2C%20rarely%2C%20death.%20The%20rate%20of%20tapering%20should%20be%20individualized). When: Named Event: patient-view If: Applicability: Check whether the patient is using opioids concurrently with benzodiazepines or other central nervous system depressants and if an opioid review is appropriate. (Is Recommendation Applicable?) Then: : Document - Will modify prescription Then: : Snooze* - Benefits outweigh risks, snooze 3 months Then: : Snooze* - N/A see comments, snooze 3 months Then:
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
Active Ambulatory Benzodiazepine or CNS Depressant Rx
define "Active Ambulatory Benzodiazepine or CNS Depressant Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Active Medication List") ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Benzodiazepine medications" or Rx.medication in "CNS Depressant Medications" else List<FHIR.MedicationRequest>{}
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>{}
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"
define "Inclusion Criteria": ( exists (Common."Active Ambulatory Benzodiazepine or CNS Depressant Rx") and exists (Common."Active Ambulatory Opioid Rx") ) and Routines."Is Opioid Review Useful?"
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 #11 - Concurrent Use of Opioids and Benzodiazepines (patient-view)
Centers for Disease Control and Prevention (CDC)
Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
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 use particular caution when prescribing opioid pain medication and benzodiazepines concurrently. In addition, clinicians should consider whether benefits outweigh risks for concurrent use of opioids with other central nervous system depressants.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Use Particular Caution When Prescribing Opioid Pain Medication and Benzodiazepines or Other CNS Depressants Concurrently
Consider whether the benefits outweigh the risks of concurrently prescribing opioids and benzodiazepines, or other central nervous system depressant medications. When co-prescribing risks outweigh benefits, consult [Recommendation 11 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=evidence%20type%3A%203).-,Implementation%20Considerations,-Although%20in%20some) for further guidance. [For patients being treated for opioid use disorder who are also taking benzodiazepines or other medications that depress the central nervous system, the CDC recommends not withholding buprenorphine or methadone](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=gabapentin%20and%20pregabalin).-,Buprenorphine%20or%20methadone%20for%20opioid%20use%20disorder%20should%20not%20be%20withheld%20from%20patients%20taking%20benzodiazepines%20or%20other%20medications%20that%20depress%20the%20central%20nervous%20system.,-Clinicians%20should%20check). If the decision is made to taper benzodiazepine medications, [the CDC recommends tapering benzodiazepines gradually prior to discontinuation](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20taper%20benzodiazepines%20gradually%20before%20discontinuation%20because%20abrupt%20withdrawal%20can%20be%20associated%20with%20rebound%20anxiety%2C%20hallucinations%2C%20seizures%2C%20delirium%20tremens%2C%20and%2C%20rarely%2C%20death.%20The%20rate%20of%20tapering%20should%20be%20individualized).
Check whether the patient is using opioids concurrently with benzodiazepines or other central nervous system depressants and if an opioid review is appropriate.
Snooze* - Benefits outweigh risks, snooze 3 months
Snooze* - N/A see comments, snooze 3 months