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 - User Interaction Alerts
Recommendation 1 Alert
SUMMARY: Consider Nonopioid Treatment Options for Acute Pain DETAILS: 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 provides nonopioid therapy options for common acute pain conditions. Nonopioid Pharmacological Therapy • Back pain (low back, acute) • Dental pain (acute) • Dental pain (surgical) • Kidney stone pain (acute) • Migraine pain (episodic) • Musculoskeletal pain • Postpartum pain Nonpharmacologic Treatments • Back pain (low back, acute) • Migraine pain (episodic) • Musculoskeletal pain • Postoperative pain Alert Document Record reason for opiod therapy Order Select alternative therapies from order set. Remove Will remove triggering medication order Snooze* Attempting alternative therapy. Snooze 3 months* Snooze * N/A add comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 2 Alert
SUMMARY: Maximize Nonopioid Therapies as Appropriate DETAILS: For many types of subacute and chronic pain, consider maximizing the use of nonpharmacologic and nonopioid pharmacologic therapiesas appropriate. Recommendation 2 of the 2022 CDC Clinical Prescribing Guideline provides nonopioid therapy recommendations for common subacute and chronic pain conditions. Nonpharmacologic Treatments • Back pain (chronic) • Back pain (low back, chronic) • Fibromyalgia • Headache (tension) • Knee osteoarthritis pain (chronic) • Neck pain • Temporomandibular disorder Nonopioid Pharmacological Therapy • Back pain (chronic, moderate to severe) • Fibromyalgia • Hip or knee osteoarthritis pain (chronic) • Neuropathic pain syndromes • Temporomandibular disorder Alert Document Collaborated with patient to identify treatment goals Order Select alternative therapies from order set. Remove Will remove triggering medication order Snooze* Attempting alternative therapy. Snooze 3 months* Snooze * N/A add comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 3 Alert
SUMMARY: When initiating opioid therapy, utilize immediate-release opioids DETAILS: Recommend prescribing immediate-release opioids instead of extended-release or long-acting opioids. For guidance regarding prescribing extended-release and long-acting opioids, see Recommendation 3 of the 2022 CDC Clinical Practice Guideline . Alert Document Will prescribe immediate-release opioid Snooze* Benefits outweigh risks, Snooze 3 months* Snooze * N/A add comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 4 and 5 Alert
SUMMARY : Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages DETAILS : When opioid therapy is considered appropriate, calibrate opioid dosages to lowest dose needed to achieve expected effects and optimize nonopioid therapies. For patients already receiving opioid therapy, 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 . For patients who have received opioid therapy for longer durations of time (e.g., for ≥1 year), if tapering, consider working closely with the patient to gradually taper dosages (no more than 10% per month). For more guidance regarding tapering, see Recommendation 5 of the 2022 CDC Clinical Practice Guideline . For a tapering calculator, see Agency Medical Directors' Group (AMDG) MME Calculator See MME Calculator Cautions . Alert Document Will prescribe lower dose Document Will callibrate a gradual change in dose Snooze * Benefits outweigh risks, Snooze 3 months* Snooze* Short-term benefits outweigh risks, Snooze 1 month* Snooze* N/A add comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 6 Alert
SUMMARY : When Treating for Acute Pain, Prescribe No More Opioid Than Needed DETAILS : Please verify that the opioid order quantity and duration are no more than need for the expected duration of pain severe enough to require opioids For guidance regarding prescribing opioids for acute pain, see Recommendation 6 of the 2022 CDC Clinical Practice Guideline . Alert Document - Will adjust opioid order Snooze* - Benefits of opioid therapy duration outweigh risks, Snooze 3 months* Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 7 Alert
SUMMARY : Regularly Evaluate the Benefits and Risks of Opioid Therapy DETAILS : Recommend that clinicians evaluate benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute or chronic pain or dosage escalation. Clinicians should also regularly reevaluate the benefits and risks of continued opioid therapy with patients. For additional guidance regarding opioid therapy patient consultations, see Recommendation 7 of the 2022 CDC Clinical Practice Guideline . Alert Document - Conducted benefit and risk assessment Snooze* - Conducted assessment, Snooze 3 months* Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 8 Alert
SUMMARY : Discuss Risks and Offer Naloxone DETAILS : Recommend incorporating strategies to mitigate opioid therapy risks, including offering naloxone For guidance regarding assessing opioid therapy risks, see Recommendation 8 of the 2022 CDC Clinical Practice Guideline . For more information about prescribing naloxone, see https://prescribetoprevent.org MME Calculator Cautions Alert Order - Naloxone ordered Document - Verified patient is on Naloxone an has been educated on use, Snooze 3 months* Document - Naloxone discussed but declined, Snooze 3 months* Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 9 Alert
SUMMARY : Before Ordering Opioids, Review PDMP Data DETAILS : Review PDMP data for this patient before completing opioid order. For guidance about utilizing PDMP information to improve patient safety, see Recommendation 9 of the 2022 CDC Clinical Practice Guideline . Alert Access Data - Launch app to review PDMP data Document - PDMP data reviewed, Snooze 3 months* Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 10 UDS Alert
SUMMARY : Consider the benefits and risks of conducting a Urine Toxicology Screen DETAILS : Consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and non-prescribed controlled substances. For guidance regarding utilizing toxicology tests for prescribing opioids see Recommendation 10 of the 2022 CDC Clinical Practice Guideline . UDS Alert Document - Ordered toxicology screen Document - Risks outweigh benefits Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 10 Possible Unexpected Results Alert
SUMMARY : Patient may have possible unexpected toxicology test results DETAILS (example): Patient may have possible unexpected toxicology test results in the past year including: - Possible unexpected substance found: - opiate [Presence] in urine by screen method on 2024-10-16 - Possible unexpected substance found: - benzoylecgonine [Presence] in urine by screen method on 2024-07-15 - Possible unexpected negative result found: - dextroamphetamine Sulfate 20 MG Oral Tablet on 2024 -10-16 Note on false positives and unexpected negative results... An unexpectedly negative test may be due to time since last dose, diversion, intermittent use, aberrant drug use behavior, or other factors, including a false negative result. Clinicians should interpret this result in the context of the overall treatment plan. Positive results may be a false positives or could represent occasional use or possible substance use disorder. For a review regarding interpreting possible false positive urine toxicology results, see http://pubmed.ncbi.nlm.nih.gov/24986836 . It is unknown if the findings reported in this article can be extrapolated to other laboratory analyzers that were not used in the referenced studies. For guidance regarding evaluating and addressing unexpected toxicology tests results, see Recommendation 10 of the 2022 CDC Clinical Practice Guideline Possible Unexpected Results Alert Document - Will repeat urine drug screen more frequently Document - will consult with patient regarding possible unexpected test results Document - Will assess patient for substance abuse disorder Snooze* - Patient's test results were expected, Snooze for 3 months* Snooze* - N/A Snooze for 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 11 Alert
SUMMARY : Use Particular Caution When Prescribing Opioid Pain Medication and Benzodiazepines or Other CNS Depressants Concurrently DETAILS : 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 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. [ 1 ] If the decision is made to taper benzodiazepine medications, the CDC recommends tapering benzodiazepines gradually prior to discontinuation. [ 2 ] Alert Document - Will modify prescription Snooze* - Benefits outweigh risks, Snooze 3 months* Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
Recommendation 12 Alert
SUMMARY : Offer Evidence-based Medications to Treat Patients with Opioid Use Disorder DETAILS : For patients diagnosed with opioid use disorder, consider opioid agonist or partial agonist treatment with methadone or buprenorphine maintenance therapy. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks of resuming drug use, overdose, and overdose death. For guidance regarding diagnosing and treating opioid use disorder, see Recommendation 12 of the 2022 CDC Clinical Practice Guideline . CDC recommends against releasing patients from care due to diagnosis of opioid use disorder. [ 1 ] MME conversion factors should not be applied to dosage decisions related to the management of opioid use disorder. [ 2 ] 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. [ 3 ] Consult the FDA approved product labeling for specific guidance on medications. Alert Snooze* - Patient already provided medication elsewhere to treat opioid use disorder, Snooze 3 months* Snooze* - Patient declined medication therapy, Snooze 3 months* Document - Will order medication to treat opioid use disorder Refer - Will refer patient to SUD specialist Snooze* - N/A see comment, Snooze 3 months* *Snooze duration referenced in the alert response is an example and is intended to be patient specific. User Interaction EHR Configured Alert Response Options Examples
