2022 CDC Clinical Practice Guideline for Prescribing Opioids Implementation Guide
2022.1.0 - CI Build
2022 CDC Clinical Practice Guideline for Prescribing Opioids Implementation Guide
2022.1.0 - CI Build
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
| Draft as of 2025-04-24 |
<PlanDefinition xmlns="http://hl7.org/fhir">
<id value="opioidcds-02"/>
<meta>
<profile
value="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-recommendationdefinition"/>
<profile
value="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-publishableplandefinition"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table class="grid dict">
<tr>
<th scope="row"><b>Id: </b></th>
<td style="padding-left: 4px;">opioidcds-02</td>
</tr>
<tr>
<th scope="row"><b>Url: </b></th>
<td style="padding-left: 4px;"><a href="PlanDefinition-opioidcds-02.html">Recommendation #2 - Opioid Therapy Goals Discussion</a></td>
</tr>
<tr>
<th scope="row"><b>Version: </b></th>
<td style="padding-left: 4px;">2022.1.0</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>value: </b> <span>cdc-opioid-guidance</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Name: </b></th>
<td style="padding-left: 4px;">PlanDefinition_Recommendation_02_Order_Sign</td>
</tr>
<tr>
<th scope="row"><b>Title: </b></th>
<td style="padding-left: 4px;">Recommendation #2 - Opioid Therapy Goals Discussion</td>
</tr>
<tr>
<th scope="row"><b>Status: </b></th>
<td style="padding-left: 4px;">draft</td>
</tr>
<tr>
<th scope="row"><b>Experimental: </b></th>
<td style="padding-left: 4px;">true</td>
</tr>
<tr>
<th scope="row"><b>Type: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>system: </b> <span><a href="http://terminology.hl7.org/6.5.0/CodeSystem-plan-definition-type.html">http://terminology.hl7.org/CodeSystem/plan-definition-type</a></span>
</p>
<p style="margin-bottom: 5px;">
<b>code: </b> <span>eca-rule</span>
</p>
<p style="margin-bottom: 5px;">
<b>display: </b> <span>ECA Rule</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Date: </b></th>
<td style="padding-left: 4px;">2025-04-24</td>
</tr>
<tr>
<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">Centers for Disease Control and Prevention (CDC)</td>
</tr>
<tr>
<th scope="row"><b>Description: </b></th>
<td style="padding-left: 4px;">Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.</td>
</tr>
<tr>
<th scope="row"><a name="effective-data-requirements"> </a><b>Logic Definitions: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions</td>
<td>0</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">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 )</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential</td>
<td>1</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential":
exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Patient Age Less Than 18</td>
<td>2</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Patient Age Less Than 18":
if (Config."Age Less than 18 Years Is Enabled") then
AgeInYearsAt(Today()) < 18
else false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Condition Positive for Sickle Cell</td>
<td>3</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Condition Positive for Sickle Cell":
if (Config."Sickle Cell Check Enabled") then
exists(
Common."Positive Sickle Cell Condition"
)
else false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Active Cancer Treatment?</td>
<td>4</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">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"
or "Has Active Cancer Diagnosis on Problem List"
else false</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Conditions Likely Terminal for Opioid Prescribing</td>
<td>5</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Conditions Likely Terminal for Opioid Prescribing":
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</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Opioid Review Useful?</td>
<td>6</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Is Opioid Review Useful?":
not "Patient Age Less Than 18"
and not "Condition Positive for Sickle Cell"
and not "Is Active Cancer Treatment?"
and not "Conditions Likely Terminal for Opioid Prescribing"</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days</td>
<td>7</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">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</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days</td>
<td>8</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">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</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Opioid Naive?</td>
<td>9</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">// 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")</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommonConfig</td>
<td>Opioid Treatment Plan Verification Enabled</td>
<td>10</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">// Recommendation 2
define "Opioid Treatment Plan Verification Enabled":
true</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Treatment Plan Lookback Period</td>
<td>11</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Treatment Plan Lookback Period":
Interval[Today() - 90 days, Today()]</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Opioid Treatment Plan Creation or Update in Past 90 Days</td>
<td>12</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Opioid Treatment Plan Creation or Update in Past 90 Days":
[CarePlan: category in Common."Pain treatment plan"] PainTreatmentPlan
where PainTreatmentPlan.status in { 'active', 'completed' }
and (
FHIRHelpers.ToDateTime( PainTreatmentPlan.created ) during day of "Treatment Plan Lookback Period"
or PainTreatmentPlan.meta.lastUpdated during day of "Treatment Plan Lookback Period"
)
and exists(
"Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions".recorder Recorder
where Recorder ~ PainTreatmentPlan.author
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Had Opioid Treatment Plan Reviewed in Past 90 Days</td>
<td>13</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Had Opioid Treatment Plan Reviewed in Past 90 Days":
exists (
[Procedure: Common."Pain management procedure"] PainManagementProcedure
where PainManagementProcedure.performed during day of "Treatment Plan Lookback Period"
and exists (
PainManagementProcedure.performer Performer
with "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" ChronicPainScript
such that Performer.actor ~ ChronicPainScript.recorder
)
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>No Opioid Treatment Plan Created, was Edited or Reviewed in Past 90 Days?</td>
<td>14</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "No Opioid Treatment Plan Created, was Edited or Reviewed in Past 90 Days?":
Config."Opioid Treatment Plan Verification Enabled"
and not (
exists ( "Opioid Treatment Plan Creation or Update in Past 90 Days" )
or "Had Opioid Treatment Plan Reviewed in Past 90 Days"
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Inclusion Criteria</td>
<td>15</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Inclusion Criteria":
"Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
and Routines."Is Opioid Review Useful?"
and Routines."Is Opioid Naive?"
and "No Opioid Treatment Plan Created, was Edited or Reviewed in Past 90 Days?"</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSREC02</td>
<td>Is Recommendation Applicable?</td>
<td>16</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define "Is Recommendation Applicable?":
"Inclusion Criteria"</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Is Opioid Analgesic with Ambulatory Misuse Potential?</td>
<td>17</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function "Is Opioid Analgesic with Ambulatory Misuse Potential?"(value List<MedicationRequest>):
("Get MedicationRequest Medication as Code"(value)) Rx
where Rx.medication in "Opioid analgesics with ambulatory misuse potential"
and Rx.category in "Community"</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>Get MedicationRequest Medication as Code</td>
<td>18</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function "Get MedicationRequest Medication as Code"(value List<MedicationRequest>):
value Rx
let Med:
if Rx.medication is Reference then singleton from (
[Medication] M
where M.id = (Last(Split((Rx.medication as FHIR.Reference).reference, '/')))
) else null
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: if Rx.medication is Reference then Med.code else Rx.medication as CodeableConcept,
subject: Rx.subject,
authoredOn: Rx.authoredOn,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>FHIRHelpers</td>
<td>ToConcept</td>
<td>19</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function ToConcept(concept FHIR.CodeableConcept):
if concept is null then
null
else
System.Concept {
codes: concept.coding C return ToCode(C),
display: concept.text.value
}</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Subacute or Chronic Pain Prescription?</td>
<td>20</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">// End of Active Cancer Treatment Routine
/*
** Routine #4
** For Subacute or Chronic Pain Routine
**
** Definition | Answer to Proceed | Details | Data (Terminology) Requirement
** -----------------------------------------------------------------------------------------------------------------------------------
** Order for opioid analgesic | Yes | Order for opioid analgesics with ambulatory | Opioid analgesics with
** with expected supply | | misuse potential with a supply duration of >= | ambulatory misuse potential
** duration >= 28 days | | 28 days |
** | | |
** | | - Subacute definition = order for opioid |
** | | analgesics with ambulatory misuse |
** | | potential with a supply duration of one to |
** | | two months. |
** | | - Chronic pain definition = order for opioid |
** | | analgesics with ambulatory misuse |
** | | potential with a supply duration of >= two |
** | | months. |
** -----------------------------------------------------------------------------------------------------------------------------------
**
*/
define function "Is Subacute or Chronic Pain Prescription?"(prescription FHIR.MedicationRequest):
"Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription)
or "Is Subacute or Chronic Pain Using Validity Period"(prescription)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Subacute or Chronic Pain Using Expected Supply Duration</td>
<td>21</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription FHIR.MedicationRequest):
(
prescription.dispenseRequest is not null
and prescription.dispenseRequest.expectedSupplyDuration is not null
and (
Common.GetDurationInDays(prescription.dispenseRequest.expectedSupplyDuration) >= 28 days
)
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSCommon</td>
<td>GetDurationInDays</td>
<td>22</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function GetDurationInDays(value FHIR.Duration):
if value is null then null
else
case
when value.code.value ~ 'a' then System.Quantity{ value: value.value.value * 365.0, unit: 'days' }
when value.code.value ~ 'mo' then System.Quantity{ value: value.value.value * 30.0, unit: 'days' }
when value.code.value ~ 'wk' then System.Quantity{ value: value.value.value * 7.0, unit: 'days' }
when value.code.value ~ 'd' then System.Quantity{ value: value.value.value, unit: 'days' }
when value.code.value ~ 'h' then System.Quantity{ value: value.value.value / 24.0, unit: 'days' }
when value.code.value ~ 'min' then System.Quantity{ value: value.value.value / 60.0 / 24.0, unit: 'days' }
when value.code.value ~ 's' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0, unit: 'days' }
when value.code.value ~ 'ms' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0 / 1000.0, unit: 'days' }
when value.code.value is null then Message(1000, true, 'Undefined', 'Error', 'Duration unit code is null')
else Message(1000, true, 'Undefined', 'Error', 'Unsupported duration unit code: ' + value.code.value)
end</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>OpioidCDSRoutines</td>
<td>Is Subacute or Chronic Pain Using Validity Period</td>
<td>23</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function "Is Subacute or Chronic Pain Using Validity Period"(prescription FHIR.MedicationRequest):
(
prescription.dispenseRequest is not null
and prescription.dispenseRequest.validityPeriod is not null
and (
days between prescription.dispenseRequest.validityPeriod.start and prescription.dispenseRequest.validityPeriod.end >= 28
)
)</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>FHIRHelpers</td>
<td>ToDateTime</td>
<td>24</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function ToDateTime(value dateTime): value.value</code></pre>
<br/><br/>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
<tr>
<td>FHIRHelpers</td>
<td>ToString</td>
<td>25</td>
</tr>
</table>
<pre style="max-width: 990px;"><code class="language-cql">define function ToString(value CarePlanStatus): value.value</code></pre>
<br/><br/>
</td>
</tr>
<tr>
<th scope="row"><b>Knowledge Capability: </b></th>
<td style="padding-left: 4px;">
shareable computable executable publishable
</td>
</tr>
<tr>
<th scope="row"><b>Use Context: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>code</b></th><th><b>value</b></th><th><b>display</b></th></tr>
<tr>
<td>focus</td>
<td>182888003</td>
<td>Medication requested (situation)</td>
</tr>
<tr>
<td>focus</td>
<td>82423001</td>
<td>Chronic pain (finding)</td>
</tr>
<tr>
<td>focus</td>
<td/>
<td/>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Purpose: </b></th>
<td style="padding-left: 4px;"><div><p>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.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Usage: </b></th>
<td style="padding-left: 4px;">Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.</td>
</tr>
<tr>
<th scope="row"><b>Copyright: </b></th>
<td style="padding-left: 4px;"><div><p>© CDC 2016+.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Related Artifacts: </b></th>
<td style="padding-left: 4px;">
<p><b>Documentation</b></p>
<ul>
<li>
<a href="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"> 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain</a>
</li>
</ul>
</td>
</tr>
<tr>
<th scope="row"><b>Libraries: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><td><a href="Library-OpioidCDSREC02.html">Library - Recommendation #2 - Opioid Therapy Goals Discussion</a></td></tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Actions: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<td>
<b> Maximize Nonopioid Therapies as Appropriate:</b> For many types of subacute and chronic pain, consider maximizing the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate.
[Recommendation 2 of the CDC 2022 Clinical Prescribing Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation2) provides nonopioid therapy recommendations for common subacute and acute pain conditions.
**Nonopioid Pharmacological Therapy**
- [Back pain (chronic, moderate to severe)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=For%20moderate%20to%20severe%20chronic%20back%20pain%20or%20hip%20or%20knee%20osteoarthritis%20pain%2C%20a%20nonopioid%20strategy%20starting%20with%20acetaminophen%20or%20NSAIDs%20results%20in%20improved%20pain%20intensity%20with%20fewer%20side%20effects%20compared%20with%20a%20strategy%20starting%20with%20opioids%20(74))
- [Fibromyalgia](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=In%20patients%20with%20fibromyalgia%2C%20multiple,effectiveness%20is%20limited%20(8).)
- [Hip or knee osteoarthritis pain (chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=or%20hip%20or%20knee%20osteoarthritis%20pain%2C%20a%20nonopioid%20strategy%20starting%20with%20acetaminophen%20or%20NSAIDs%20results%20in%20improved%20pain%20intensity%20with%20fewer%20side%20effects%20compared%20with%20a%20strategy%20starting%20with%20opioids%20(74).)
- [Neuropathic pain syndromes](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Tricyclic%20antidepressants%2C%20SNRI%20antidepressants%2C%20selected%20anticonvulsants%2C%20or%20transdermal%20lidocaine%20are%20recommended%20for%20neuropathic%20pain%20syndromes%20(e.g.%2C%20diabetic%20neuropathy%20or%20postherpetic%20neuralgia)%20(156).)
- [Temporomandibular disorder](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=For%20temporomandibular%20disorder%20pain%20that%20is%20not%20sufficiently%20improved%20with%20nonpharmacologic%20interventions%2C%20NSAIDs%20can%20be%20effective%20(179%2C180).)
**Nonpharmacologic Treatments**
- [Back pain (chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20recommend%20appropriate%20noninvasive%20nonpharmacologic%20approaches%20to%20help%20manage%20chronic%20pain%2C%20such%20as%20exercise%20(e.g.%2C%20aerobic%2C%20aquatic%2C%20or%20resistance%20exercises)%20or%20exercise%20therapy%20(a%20prominent%20modality%20in%20physical%20therapy)%20for%20back%20pain)
- [Back pain (low back, chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=loss%20for%20knee%20osteoarthritis%3B%20manual%20therapies%20for%20hip%20osteoarthritis%3B-,psychological%20therapy%2C%20spinal%20manipulation%2C%20low%2Dlevel%20laser%20therapy%2C%20massage%2C%20mindfulness%2Dbased%20stress%20reduction%2C%20yoga%2C%20acupuncture%2C%20and%20multidisciplinary%20rehabilitation%20for%20low%20back%20pain,-%3B%20mind%2Dbody%20practices%20(e.g.%2C%20yoga%2C%20tai%20chi%2C%20or)
- [Fibromyalgia](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=massage%2C%20and%20acupuncture%20for%20neck%20pain%3B%20cognitive-,behavioral%20therapy%2C%20myofascial%20release%20massage%2C%20mindfulness%20practices%2C%20tai%20chi%2C%20qigong%2C%20acupuncture%2C%20and%20multidisciplinary%20rehabilitation%20for%20fibromyalgia,-%3B%20and%20spinal%20manipulation%20for%20tension%20headache%20()
- [Headache (tension)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=and%20spinal%20manipulation%20for%20tension%20headache.)
- [Knee osteoarthritis pain (chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Many%20noninvasive%20nonpharmacologic,for%20hip%20osteoarthritis%3B)
- [Neck pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=mind%2Dbody%20practices%20(e.g.%2C%20yoga%2C%20tai%20chi%2C%20or%20qigong)%2C%20massage%2C%20and%20acupuncture%20for%20neck%20pain%3B)
- [Temporomandibular disorder](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=For%20temporomandibular%20disorder%20pain%2C%20patient%20education%20and%20self%2Dcare%20can%20be%20effective%2C%20as%20can%20occlusal%20splints%20for%20some%20patients%20and%20biobehavioral%20therapy%20for%20prevention%20of%20disabling%20symptoms%20(172%2C173).)<br/>
<b>When:</b> <i>Named Event:</i> order-sign<br/>
<b>If:</b> <i>Applicability:</i> Check whether the current order is for an opioid with ambulatory misuse potential, a pain treatment plan has been established or edited within the past 90 days, a pain management procedure occurred within the past 90 days, the patient is opioid naive and if an opioid review is appropriate for the patient <i>(Is Recommendation Applicable?)</i><br/>
<b>Then:</b>
<table class="grid-dict">
<tr>
<td>
<b> :</b> Document - Collaborated with patient to identify treatment goals<br/>
<b>Then:</b>
</td>
</tr>
<tr>
<td>
<b> :</b> Snooze* - Attempting alternate therapy, snooze 3 months<br/>
<b>Then:</b>
</td>
</tr>
<tr>
<td>
<b> :</b> Order - Select alternative therapies from order select<br/>
<b>Then:</b>
</td>
</tr>
<tr>
<td>
<b> :</b> Snooze* - N/A see comment, snooze 3 months<br/>
<b>Then:</b>
</td>
</tr>
<tr>
<td>
<b> :</b> Remove - Will remove triggering medication order<br/>
<b>Then:</b>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</text>
<contained>
<Library>
<id value="effective-data-requirements"/>
<name value="EffectiveDataRequirements"/>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/library-type"/>
<code value="module-definition"/>
</coding>
</type>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Common"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommon|2022.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library FHIRHelpers"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/FHIRHelpers|4.0.1"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Routines"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSRoutines|2022.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Config"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSCommonConfig|2022.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Opioid analgesics with ambulatory misuse potential"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-analgesics-with-ambulatory-misuse-potential"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Community"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/medicationrequest-category-community"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Pain treatment plan"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/pain-treatment-plan"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Pain management procedure"/>
<resource
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/pain-management-procedure"/>
</relatedArtifact>
<parameter>
<name value="ContextPrescriptions"/>
<use value="in"/>
<min value="0"/>
<max value="*"/>
<type value="MedicationRequest"/>
</parameter>
<parameter>
<name value="Is Recommendation Applicable?"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<dataRequirement>
<type value="CarePlan"/>
<profile value="http://hl7.org/fhir/StructureDefinition/CarePlan"/>
<mustSupport value="category"/>
<mustSupport value="status"/>
<mustSupport value="created"/>
<mustSupport value="meta"/>
<mustSupport value="meta.lastUpdated"/>
<mustSupport value="author"/>
<codeFilter>
<path value="category"/>
<valueSet
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/pain-treatment-plan"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="performer"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://fhir.org/guides/cdc/opioid-cds/ValueSet/pain-management-procedure"/>
</codeFilter>
</dataRequirement>
</Library>
</contained>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="shareable"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="computable"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="executable"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-knowledgeCapability">
<valueCode value="publishable"/>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString
value="Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions"/>
</extension>
<extension url="statement">
<valueString
value="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>
<extension url="displaySequence">
<valueInteger value="0"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString
value="Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"/>
</extension>
<extension url="statement">
<valueString
value="define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential":
exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )"/>
</extension>
<extension url="displaySequence">
<valueInteger value="1"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Patient Age Less Than 18"/>
</extension>
<extension url="statement">
<valueString
value="define "Patient Age Less Than 18":
if (Config."Age Less than 18 Years Is Enabled") then
AgeInYearsAt(Today()) < 18
else false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="2"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Condition Positive for Sickle Cell"/>
</extension>
<extension url="statement">
<valueString
value="define "Condition Positive for Sickle Cell":
if (Config."Sickle Cell Check Enabled") then
exists(
Common."Positive Sickle Cell Condition"
)
else false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="3"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Active Cancer Treatment?"/>
</extension>
<extension url="statement">
<valueString
value="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"
or "Has Active Cancer Diagnosis on Problem List"
else false"/>
</extension>
<extension url="displaySequence">
<valueInteger value="4"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Conditions Likely Terminal for Opioid Prescribing"/>
</extension>
<extension url="statement">
<valueString
value="define "Conditions Likely Terminal for Opioid Prescribing":
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>
<extension url="displaySequence">
<valueInteger value="5"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Opioid Review Useful?"/>
</extension>
<extension url="statement">
<valueString
value="define "Is Opioid Review Useful?":
not "Patient Age Less Than 18"
and not "Condition Positive for Sickle Cell"
and not "Is Active Cancer Treatment?"
and not "Conditions Likely Terminal for Opioid Prescribing""/>
</extension>
<extension url="displaySequence">
<valueInteger value="6"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString
value="Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days"/>
</extension>
<extension url="statement">
<valueString
value="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"/>
</extension>
<extension url="displaySequence">
<valueInteger value="7"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString
value="Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days"/>
</extension>
<extension url="statement">
<valueString
value="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"/>
</extension>
<extension url="displaySequence">
<valueInteger value="8"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Opioid Naive?"/>
</extension>
<extension url="statement">
<valueString
value="// 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")"/>
</extension>
<extension url="displaySequence">
<valueInteger value="9"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommonConfig"/>
</extension>
<extension url="name">
<valueString value="Opioid Treatment Plan Verification Enabled"/>
</extension>
<extension url="statement">
<valueString
value="// Recommendation 2
define "Opioid Treatment Plan Verification Enabled":
true"/>
</extension>
<extension url="displaySequence">
<valueInteger value="10"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString value="Treatment Plan Lookback Period"/>
</extension>
<extension url="statement">
<valueString
value="define "Treatment Plan Lookback Period":
Interval[Today() - 90 days, Today()]"/>
</extension>
<extension url="displaySequence">
<valueInteger value="11"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString
value="Opioid Treatment Plan Creation or Update in Past 90 Days"/>
</extension>
<extension url="statement">
<valueString
value="define "Opioid Treatment Plan Creation or Update in Past 90 Days":
[CarePlan: category in Common."Pain treatment plan"] PainTreatmentPlan
where PainTreatmentPlan.status in { 'active', 'completed' }
and (
FHIRHelpers.ToDateTime( PainTreatmentPlan.created ) during day of "Treatment Plan Lookback Period"
or PainTreatmentPlan.meta.lastUpdated during day of "Treatment Plan Lookback Period"
)
and exists(
"Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions".recorder Recorder
where Recorder ~ PainTreatmentPlan.author
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="12"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString
value="Had Opioid Treatment Plan Reviewed in Past 90 Days"/>
</extension>
<extension url="statement">
<valueString
value="define "Had Opioid Treatment Plan Reviewed in Past 90 Days":
exists (
[Procedure: Common."Pain management procedure"] PainManagementProcedure
where PainManagementProcedure.performed during day of "Treatment Plan Lookback Period"
and exists (
PainManagementProcedure.performer Performer
with "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" ChronicPainScript
such that Performer.actor ~ ChronicPainScript.recorder
)
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="13"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString
value="No Opioid Treatment Plan Created, was Edited or Reviewed in Past 90 Days?"/>
</extension>
<extension url="statement">
<valueString
value="define "No Opioid Treatment Plan Created, was Edited or Reviewed in Past 90 Days?":
Config."Opioid Treatment Plan Verification Enabled"
and not (
exists ( "Opioid Treatment Plan Creation or Update in Past 90 Days" )
or "Had Opioid Treatment Plan Reviewed in Past 90 Days"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="14"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString value="Inclusion Criteria"/>
</extension>
<extension url="statement">
<valueString
value="define "Inclusion Criteria":
"Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
and Routines."Is Opioid Review Useful?"
and Routines."Is Opioid Naive?"
and "No Opioid Treatment Plan Created, was Edited or Reviewed in Past 90 Days?""/>
</extension>
<extension url="displaySequence">
<valueInteger value="15"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSREC02"/>
</extension>
<extension url="name">
<valueString value="Is Recommendation Applicable?"/>
</extension>
<extension url="statement">
<valueString
value="define "Is Recommendation Applicable?":
"Inclusion Criteria""/>
</extension>
<extension url="displaySequence">
<valueInteger value="16"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString
value="Is Opioid Analgesic with Ambulatory Misuse Potential?"/>
</extension>
<extension url="statement">
<valueString
value="define function "Is Opioid Analgesic with Ambulatory Misuse Potential?"(value List<MedicationRequest>):
("Get MedicationRequest Medication as Code"(value)) Rx
where Rx.medication in "Opioid analgesics with ambulatory misuse potential"
and Rx.category in "Community""/>
</extension>
<extension url="displaySequence">
<valueInteger value="17"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="Get MedicationRequest Medication as Code"/>
</extension>
<extension url="statement">
<valueString
value="define function "Get MedicationRequest Medication as Code"(value List<MedicationRequest>):
value Rx
let Med:
if Rx.medication is Reference then singleton from (
[Medication] M
where M.id = (Last(Split((Rx.medication as FHIR.Reference).reference, '/')))
) else null
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: if Rx.medication is Reference then Med.code else Rx.medication as CodeableConcept,
subject: Rx.subject,
authoredOn: Rx.authoredOn,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="18"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToConcept"/>
</extension>
<extension url="statement">
<valueString
value="define function ToConcept(concept FHIR.CodeableConcept):
if concept is null then
null
else
System.Concept {
codes: concept.coding C return ToCode(C),
display: concept.text.value
}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="19"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Subacute or Chronic Pain Prescription?"/>
</extension>
<extension url="statement">
<valueString
value="// End of Active Cancer Treatment Routine
/*
** Routine #4
** For Subacute or Chronic Pain Routine
**
** Definition | Answer to Proceed | Details | Data (Terminology) Requirement
** -----------------------------------------------------------------------------------------------------------------------------------
** Order for opioid analgesic | Yes | Order for opioid analgesics with ambulatory | Opioid analgesics with
** with expected supply | | misuse potential with a supply duration of >= | ambulatory misuse potential
** duration >= 28 days | | 28 days |
** | | |
** | | - Subacute definition = order for opioid |
** | | analgesics with ambulatory misuse |
** | | potential with a supply duration of one to |
** | | two months. |
** | | - Chronic pain definition = order for opioid |
** | | analgesics with ambulatory misuse |
** | | potential with a supply duration of >= two |
** | | months. |
** -----------------------------------------------------------------------------------------------------------------------------------
**
*/
define function "Is Subacute or Chronic Pain Prescription?"(prescription FHIR.MedicationRequest):
"Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription)
or "Is Subacute or Chronic Pain Using Validity Period"(prescription)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="20"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString
value="Is Subacute or Chronic Pain Using Expected Supply Duration"/>
</extension>
<extension url="statement">
<valueString
value="define function "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription FHIR.MedicationRequest):
(
prescription.dispenseRequest is not null
and prescription.dispenseRequest.expectedSupplyDuration is not null
and (
Common.GetDurationInDays(prescription.dispenseRequest.expectedSupplyDuration) >= 28 days
)
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="21"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSCommon"/>
</extension>
<extension url="name">
<valueString value="GetDurationInDays"/>
</extension>
<extension url="statement">
<valueString
value="define function GetDurationInDays(value FHIR.Duration):
if value is null then null
else
case
when value.code.value ~ 'a' then System.Quantity{ value: value.value.value * 365.0, unit: 'days' }
when value.code.value ~ 'mo' then System.Quantity{ value: value.value.value * 30.0, unit: 'days' }
when value.code.value ~ 'wk' then System.Quantity{ value: value.value.value * 7.0, unit: 'days' }
when value.code.value ~ 'd' then System.Quantity{ value: value.value.value, unit: 'days' }
when value.code.value ~ 'h' then System.Quantity{ value: value.value.value / 24.0, unit: 'days' }
when value.code.value ~ 'min' then System.Quantity{ value: value.value.value / 60.0 / 24.0, unit: 'days' }
when value.code.value ~ 's' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0, unit: 'days' }
when value.code.value ~ 'ms' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0 / 1000.0, unit: 'days' }
when value.code.value is null then Message(1000, true, 'Undefined', 'Error', 'Duration unit code is null')
else Message(1000, true, 'Undefined', 'Error', 'Unsupported duration unit code: ' + value.code.value)
end"/>
</extension>
<extension url="displaySequence">
<valueInteger value="22"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="OpioidCDSRoutines"/>
</extension>
<extension url="name">
<valueString value="Is Subacute or Chronic Pain Using Validity Period"/>
</extension>
<extension url="statement">
<valueString
value="define function "Is Subacute or Chronic Pain Using Validity Period"(prescription FHIR.MedicationRequest):
(
prescription.dispenseRequest is not null
and prescription.dispenseRequest.validityPeriod is not null
and (
days between prescription.dispenseRequest.validityPeriod.start and prescription.dispenseRequest.validityPeriod.end >= 28
)
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="23"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToDateTime"/>
</extension>
<extension url="statement">
<valueString
value="define function ToDateTime(value dateTime): value.value"/>
</extension>
<extension url="displaySequence">
<valueInteger value="24"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToString"/>
</extension>
<extension url="statement">
<valueString
value="define function ToString(value CarePlanStatus): value.value"/>
</extension>
<extension url="displaySequence">
<valueInteger value="25"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements" id="effective-data-requirements">
<valueCanonical value="#effective-data-requirements"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-softwaresystem">
<valueReference>🔗
<reference value="Device/cqf-tooling"/>
</valueReference>
</extension>
<url
value="http://fhir.org/guides/cdc/opioid-cds/PlanDefinition/opioidcds-02"/>
<identifier>
<use value="official"/>
<value value="cdc-opioid-guidance"/>
</identifier>
<version value="2022.1.0"/>
<name value="PlanDefinition_Recommendation_02_Order_Sign"/>
<title value="Recommendation #2 - Opioid Therapy Goals Discussion"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/plan-definition-type"/>
<code value="eca-rule"/>
<display value="ECA Rule"/>
</coding>
</type>
<status value="draft"/>
<experimental value="true"/>
<date value="2025-04-24"/>
<publisher value="Centers for Disease Control and Prevention (CDC)"/>
<contact>
<telecom>
<system value="url"/>
<value value="https://www.cdc.gov"/>
</telecom>
</contact>
<description
value="Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks."/>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="focus"/>
<display value="Clinical Focus"/>
</code>
<valueCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="182888003"/>
<display value="Medication requested (situation)"/>
</coding>
</valueCodeableConcept>
</useContext>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="focus"/>
<display value="Clinical Focus"/>
</code>
<valueCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="82423001"/>
<display value="Chronic pain (finding)"/>
</coding>
</valueCodeableConcept>
</useContext>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="focus"/>
<display value="Clinical Focus"/>
</code>
<valueCodeableConcept>
<text value="Subacute pain"/>
</valueCodeableConcept>
</useContext>
<purpose
value="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
value="Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks."/>
<copyright value="© CDC 2016+."/>
<topic>
<text value="Opioid Prescribing"/>
</topic>
<author>
<name value="Kensaku Kawamoto, MD, PhD, MHS"/>
</author>
<author>
<name value="Bryn Rhodes"/>
</author>
<author>
<name value="Floyd Eisenberg, MD, MPH"/>
</author>
<author>
<name value="Robert McClure, MD, MPH"/>
</author>
<relatedArtifact>
<type value="documentation"/>
<display
value="2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain"/>
<url value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"/>
<document>
<url value="https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm"/>
</document>
</relatedArtifact>
<library
value="http://fhir.org/guides/cdc/opioid-cds/Library/OpioidCDSREC02"/>
<action>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-strengthOfRecommendation">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/recommendation-strength"/>
<code value="strong"/>
<display value="Strong"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-qualityOfEvidence">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/evidence-quality"/>
<code value="moderate"/>
<display value="Moderate quality"/>
</coding>
</valueCodeableConcept>
</extension>
<title value="Maximize Nonopioid Therapies as Appropriate"/>
<description
value="For many types of subacute and chronic pain, consider maximizing the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate.
[Recommendation 2 of the CDC 2022 Clinical Prescribing Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation2) provides nonopioid therapy recommendations for common subacute and acute pain conditions.
**Nonopioid Pharmacological Therapy**
- [Back pain (chronic, moderate to severe)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=For%20moderate%20to%20severe%20chronic%20back%20pain%20or%20hip%20or%20knee%20osteoarthritis%20pain%2C%20a%20nonopioid%20strategy%20starting%20with%20acetaminophen%20or%20NSAIDs%20results%20in%20improved%20pain%20intensity%20with%20fewer%20side%20effects%20compared%20with%20a%20strategy%20starting%20with%20opioids%20(74))
- [Fibromyalgia](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=In%20patients%20with%20fibromyalgia%2C%20multiple,effectiveness%20is%20limited%20(8).)
- [Hip or knee osteoarthritis pain (chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=or%20hip%20or%20knee%20osteoarthritis%20pain%2C%20a%20nonopioid%20strategy%20starting%20with%20acetaminophen%20or%20NSAIDs%20results%20in%20improved%20pain%20intensity%20with%20fewer%20side%20effects%20compared%20with%20a%20strategy%20starting%20with%20opioids%20(74).)
- [Neuropathic pain syndromes](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Tricyclic%20antidepressants%2C%20SNRI%20antidepressants%2C%20selected%20anticonvulsants%2C%20or%20transdermal%20lidocaine%20are%20recommended%20for%20neuropathic%20pain%20syndromes%20(e.g.%2C%20diabetic%20neuropathy%20or%20postherpetic%20neuralgia)%20(156).)
- [Temporomandibular disorder](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=For%20temporomandibular%20disorder%20pain%20that%20is%20not%20sufficiently%20improved%20with%20nonpharmacologic%20interventions%2C%20NSAIDs%20can%20be%20effective%20(179%2C180).)
**Nonpharmacologic Treatments**
- [Back pain (chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20recommend%20appropriate%20noninvasive%20nonpharmacologic%20approaches%20to%20help%20manage%20chronic%20pain%2C%20such%20as%20exercise%20(e.g.%2C%20aerobic%2C%20aquatic%2C%20or%20resistance%20exercises)%20or%20exercise%20therapy%20(a%20prominent%20modality%20in%20physical%20therapy)%20for%20back%20pain)
- [Back pain (low back, chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=loss%20for%20knee%20osteoarthritis%3B%20manual%20therapies%20for%20hip%20osteoarthritis%3B-,psychological%20therapy%2C%20spinal%20manipulation%2C%20low%2Dlevel%20laser%20therapy%2C%20massage%2C%20mindfulness%2Dbased%20stress%20reduction%2C%20yoga%2C%20acupuncture%2C%20and%20multidisciplinary%20rehabilitation%20for%20low%20back%20pain,-%3B%20mind%2Dbody%20practices%20(e.g.%2C%20yoga%2C%20tai%20chi%2C%20or)
- [Fibromyalgia](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=massage%2C%20and%20acupuncture%20for%20neck%20pain%3B%20cognitive-,behavioral%20therapy%2C%20myofascial%20release%20massage%2C%20mindfulness%20practices%2C%20tai%20chi%2C%20qigong%2C%20acupuncture%2C%20and%20multidisciplinary%20rehabilitation%20for%20fibromyalgia,-%3B%20and%20spinal%20manipulation%20for%20tension%20headache%20()
- [Headache (tension)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=and%20spinal%20manipulation%20for%20tension%20headache.)
- [Knee osteoarthritis pain (chronic)](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Many%20noninvasive%20nonpharmacologic,for%20hip%20osteoarthritis%3B)
- [Neck pain](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=mind%2Dbody%20practices%20(e.g.%2C%20yoga%2C%20tai%20chi%2C%20or%20qigong)%2C%20massage%2C%20and%20acupuncture%20for%20neck%20pain%3B)
- [Temporomandibular disorder](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=For%20temporomandibular%20disorder%20pain%2C%20patient%20education%20and%20self%2Dcare%20can%20be%20effective%2C%20as%20can%20occlusal%20splints%20for%20some%20patients%20and%20biobehavioral%20therapy%20for%20prevention%20of%20disabling%20symptoms%20(172%2C173).)"/>
<priority value="urgent"/>
<trigger>
<type value="named-event"/>
<name value="order-sign"/>
</trigger>
<condition>
<kind value="applicability"/>
<expression>
<description
value="Check whether the current order is for an opioid with ambulatory misuse potential, a pain treatment plan has been established or edited within the past 90 days, a pain management procedure occurred within the past 90 days, the patient is opioid naive and if an opioid review is appropriate for the patient"/>
<language value="text/cql.identifier"/>
<expression value="Is Recommendation Applicable?"/>
</expression>
</condition>
<groupingBehavior value="visual-group"/>
<selectionBehavior value="any"/>
<action>
<description
value="Document - Collaborated with patient to identify treatment goals"/>
</action>
<action>
<description
value="Snooze* - Attempting alternate therapy, snooze 3 months"/>
</action>
<action>
<description
value="Order - Select alternative therapies from order select"/>
</action>
<action>
<description value="Snooze* - N/A see comment, snooze 3 months"/>
</action>
<action>
<description value="Remove - Will remove triggering medication order"/>
</action>
</action>
</PlanDefinition>