2022 CDC Clinical Practice Guideline for Prescribing Opioids Implementation Guide, published by Centers for Disease Control and Prevention (CDC). This guide is not an authorized publication; it is the continuous build for version 2022.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/opioid-cds-r4/ and changes regularly. See the Directory of published versions

2022 CDC Clinical Practice Guideline - Documentation

This section contains documentation for implementers from both the clinical and technical perspectives. The process documentation describes the assumptions and decisions made, as well as a functional description of the recommendations.

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

Clinical Sites

• Colorado University of Colorado School of Medicine(“Colorado”)
• Duke Health (“Duke”)
• Medical University of South Carolina (“MUSC”)
• University of Washington Medical Center (“UW”)
• Yale New Haven Health (“Yale”)

Pilot Testing Reports

Guideline Recommendation	Clinical Site	Test Period	Hook Tested	Functionality Validated	Functionality Not Validated	Comments
2016 Recommendation 4	Yale	2020	patient-view	Alert when a patient is initiating therapy for chronic pain and an extended release opioid was prescribed instead of an immediate release opioid.
2016 Recommendation 10	Yale	2020	patient-view	When a patient was prescribed opioids for chronic pain, and there has not been a urine toxicology screen conducted over the past year, the service issues an alert recommending that a screen be conducted.
2016 Recommendation 11	Yale	2020	patient-view	Alert when opioids are co-prescribed with benzodiazepines.
2016 Recommendation 12	Yale	2020	patient-view	Alert is triggered when a patient has been diagnosed with opioid use disorder (OUD) in the past 90 days and there is no record of the patient receiving OUD treatment.
2016 Recommendation 10	Duke	2020	patient-view	Alert when opioids are co-prescribed with benzodiazepines.
2016 Recommendation 11	Duke	2020	patient-view	Alert when opioids are co-prescribed with benzodiazepines.
2016 Recommendation 10	Yale	2021	order-sign	When signing an order for opioids for chronic pain, the service will alert when there has not been a urine toxicology screen conducted over the past year.
2016 Recommendation 10	Yale	2021	order-sign (with suggestion cards)	Alert recommending a urine toxicology screen includes a functionality that creates a test order when the alert is accepted.
2016 Recommendation 10	Duke	2021	patient-view/order-sign/order-select	When a patient was prescribed opioids for chronic pain, and there has not been a urine toxicology screen conducted over the past year, the service issues an alert recommending that a screen be conducted, If the patient did have a toxicology test in the past year and tested positive for cocaine or Phencyclidine (PCP) an alert was issued.		Duke tested the service with three different hooks. They learned that the order-select hook was not appropriate for the evaluation because only the medication selected was provided to the service when that hook is triggered. The service required additional ordering information, such as the duration of the order, the quantity, and the frequency of the medication. When Duke configured their electronic health record system (EHR) to create a urine toxicology screen order (as opposed to using a suggestion card), it resulted in a loop when the user accepted the alert. Accepting the alert resulted in an order-sign event that triggered the clinical decision support (CDS) service. The only way to break the alert loop was to decline the recommendation. This was not an issue at Yale.
Draft 2022 Recommendation 10	MUSC	2022	order-sign	Validated a base use case of a patient who has not had a toxicology screen in the past year. Also validated alerts for positive results for cocaine, PCP, and opiates.
Draft 2022 Recommendation 11	MUSC	2022	order-select	Validate co-prescribing alert both for patients with a pending benzodiazepine order and an existing opioid order, and for patients with a pending opioid order and an existing benzodiazepine order.		Recommendation 11 is an example of an evaluation that fits well with an order-select implementation because the medication selected is the only order information that needs to be known by the service.
Draft 2022 Recommendation 8	Colorado	2022	order-sign	The morphine milligram equivalent (MME) calculation was disabled in the version of Recommendation 8, which was integration tested. The test case that was validated was co-prescribing with a benzodiazepine. This produced an alert recommending that naloxone be offered to the patient.	Integration testing was conducted for one use case: co-prescribing with a benzodiazepine. Other recommendation conditions, such as history of substance use disorder and an average daily morphine milligram equivalent (MME) of MME>=50 were not validated. An MME calculation was not conducted as part of this testing.
Draft 2022 Recommendation 11	MUSC	2022	order-select	Validate co-prescribing alert both for patients with a pending benzodiazepine order and an existing opioid order, and for patients with a pending opioid order and an existing benzodiazepine order.		Recommendation 11 is an example of an evaluation that fits well with an order-select implementation because the medication selected is the only order information that needs to be known by the service.
Draft 2022 Recommendation 10	Colorado	2022	order-sign	Validated base use case of a patient who has not had a urine toxicology screen in the past year. The focus of this implementation was on documenting performance with response times of under a second.	Enhanced functionality around unexpected test results was not tested.
2022 Recommendation 10	UW	2023	order-sign	Validated unexpected test result alerts for methadone and alcohol—validated suppression of alert for positive methadone result when methadone was ordered for a patient. Confirmed alert recommending a urine toxicology screen when the patient did not have a screen in the past twelve months.
2022 Recommendation 10	Yale	2023	order-sign	Validated unexpeted postive test result alerts for Cocaine, PCP, Opiates, Fentanyl, Synthetic Opioids, Amphetamines, and Tetrahydrocannabinol (THC).
2022 Recommendation 11	UW	2023	order-select	Validated alerts for co-prescribing opioids and benzodiazepines with a variety of ordering scenarios.
2022 Recommendation 10	MUSC	2024	order-sign	Validated enhanced alert displays and functionality, along with evaluations for unexpected positive, expected positive, expected negative, and unexpected negative urine toxicology results for a variety of substances (for specific substances, see Recommendation 10 in this implementation guide). Refined performance to meet production expectations. Implemented suggestion cards that can create urine toxicology test orders.		Service performance and functionality are considered by MUSC to be at production level.
2022 Recommendation 10	Yale	2024	order-sign	Validated enhanced alert displays and functionality, along with evaluations for unexpected positive, expected positive, expected negative, and unexpected negative urine toxicology results for a variety of substances (for specific substances, see Recommendation 10 in this implementation guide). Refined performance to meet production expectations.		Service performance and functionality are considered by Yale to be at production level.
2022 Recommendation 10	Yale	2025	order-sign (run-ahead execution with order-select)	Conducted stress and edge case testing, introduced customized acknowledgment reasons, introduced service into production testing, and established run-ahead service that leverages both order-select and order-sign hooks. Also added suggestion functionality for the urine toxicology screen alert that allows the user to select among toxicology test options within the alert, and create test orders by accepting the alert		In response to testing in production, run-ahead execution was established to improve performance.
2022 Recommendation 10	MUSC	2025	order-sign	Conducted a variety of tests with a clinician, added suggestion functionality for the urine toxicology screen alert that allows the user to select among toxicology test options within the alert, and create test orders by accepting the alert. Enabled the service for testers in production.	This site choose not to provide users with customized acknowledgment reasons.