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 - Subroutines

For Acute Pain

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Order for opioid analgesics with ambulatory misuse potential of duration < 28 days	Yes	Look for an existing prescription (order) for opioid analgesics with ambulatory misuse potential of duration < 28 days	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, MedicationRequest.category, and MedicationRequest.dispenseRequest.expectedSupplyDuration

For more information see the acute pain documentation

For Subacute or Chronic Pain

• Order for opioid analgesic with an expected supply duration of 28 days or longer or
• Order in the past 90 days for opioid analgesic with therapy type of "continuous" or
• Order for opioid analgesic for 28 of the past 90 days including today and
• An active or pending order for opioid analgesic

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Order for opioid analgesic with expected supply duration ≥ 28 days, or	Yes	Order for opioid analgesics with ambulatory misuse potential with a supply duration ≥ 28 days • Subacute definition = order for opioid analgesic with ambulatory misuse potential with a supply duration of one to two months • Chronic pain definition = order for opioid analgesic with ambulatory misuse potential with a supply duration of ≥ two months	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication and MedicationRequest.dispenseRequest.expectedSupplyDuration or MedicationRequest.dispenseRequest.validityPeriod or MedicationRequest.dosageInstruction.timing.repeat.boundsPeriod
A present or past order in the last 90 days for opioid analgesic with ambulatory misuse potential with courseOfTherapyType of continuous, or	Yes	• Note that courseOfTherapyType is an element of the US Core MedicationRequest resource. In some EHRs, users can populate this element by setting a flag indicating that order is part of long-term care.	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication and MedicationRequest.authoredOn or MedicationRequest.dosageInstruction.timing.event and MedicationRequest.courseOfTherapyType
Order for opioid analgesic with ambulatory misuse potential prescribed for 28 of the past 90 days from today, and an active or pending order for opioid analgesics with ambulatory misuse potential	Yes	• Reviews active and past medications for an indication of recent treatment for chronic pain.	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication and MedicationRequest.dispenseRequest.expectedSupplyDuration or MedicationRequest.dispenseRequest.validityPeriod or MedicationRequest.dosageInstruction.timing.repeat.boundsPeriod and MedicationRequest.status

For more information see the subacute and/or chronic pain documentation

Opioid Review Useful

• Patient is 18 or over
• Patient does not have evidence of sickle cell disease
• Patient does not have findings indicating limited life expectancy
• Patient does not have orders for therapies indicating end of life care
• Patient is not undergoing active cancer treatment:
• Patient problem list includes CDC malignant cancer condition, or
• Patient has had at least 2 office visits within the past 12 months with a CDC malignant cancer condition diagnosis
• Patient does not have conditions likely terminal for opioid prescribing present

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Age < 18 years?	No	Calculate age from date of birth; exclude patients with age less than 18 years at the time of the prescription	Date of birth	Patient	Patient.birthDate
Evidence of sickle cell disease?	No	Look for patients with a diagnosis or problem list entry indicating sickle cell disease	Sickle cell disease condition	Condition	Condition.category, Condition.code, and Condition.clinicalStatus
Limited life expectancy conditions present?	No	Look for documented findings consistent with those listed in the limited life expectancy value set (terminal illness, bad prognosis, pre-terminal)	Limited life expectancy conditions	Condition	Condition.category and Condition.code
Order for therapies indicating end of life care in past 90 days?	No	Look for patients with an existing order for therapies indicating end of life care written within past 90 days	Therapies indicating end of life care	ServiceRequest	ServiceRequest.status, ServiceRequest.intent, ServiceRequest.authoredOn, and ServiceRequest.code
Active cancer treatment?	No	See Active Cancer Treatment sub-routine
Conditions Likely Terminal for opioid prescribing present?	No	Look for patients with active conditions in the value set end-of-life-conditions	Conditions likely terminal for opioid prescribing	Condition	Condition.category, Condition.code, and Condition.clinicalStatus

Active Cancer Treatment

• Patient problem list includes CDC malignant cancer condition, or
• Patient has had at least 2 office visits within the past 12 months with a CDC malignant cancer condition diagnosis

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Patient problem list includes CDC malignant cancer condition?	No	• An active CDC malignant cancer condition entry is present within the Patient's problem list	CDC malignant cancer conditions	Condition	Condition.category and Condition.code
Two office visits within the past 12 months?	No	Look for a minimum of two distinct encounters within 12 months of the date of the current visit for which each of the following is true: • the encounter diagnosis (primary or secondary or co-morbidity diagnosis) is listed in the CDC Malignant Cancer Conditions value set	Office Visit	Encounter	Encounter.class and Encounter.period.start
Office visits including CDC malignant cancer condition?	No	• The encounter diagnosis (primary or secondary or co-morbidity diagnosis) is listed in the CDC Malignant Cancer Conditions value set	CDC malignant cancer conditions	Condition and Encounter	Condition.category, Condition.code, and Encounter.diagnosis

Opioid Naive

• No indication of opioid use in the past 90 days from a prescription, self report (for future implementation), or a dispensing event (for future implementation)

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Opioid analgesics with ambulatory misuse potential prescription in past 90 days excluding the last 24 hours?	No	Look for an existing prescription (order) for opioid that is in the value set for opioid with ambulatory misuse potential authored within the past 90 days (excluding the last 24 hours)	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, MedicationRequest.category, and MedicationRequest.authoredOn
Opioid analgesics with ambulatory misuse potential reported as being taken excluding the last 24 hours?*	No	Look for evidence of active medication on the medication list that is in the value set for opioid with ambulatory care misuse potential (excluding the last 24 hours)	Opioid analgesics with ambulatory misuse potential	MedicationStatement	MedicationStatement.medication, MedicationStatement.status, and MedicationStatement.effective
Opioid analgesics with ambulatory misuse potential dispensing event in past 90 days excluding the last 24 hours?*	No	Look for evidence of a dispensing event for medication that is in the value set for opioid with ambulatory use potential occurring within the past 90 days (excluding the last 24 hours)	Opioid analgesics with ambulatory misuse potential	MedicationDispense	MedicationDispense.medication, MedicationDispense.status, and MedicationDispense.whenHandedOver
* Future consideration: Current algorithm addresses only orders (prescriptions). 1 - Implement one global configuration point to set all past medication queries at each particular site: “Can the implementing EHR support queries for past medications by date range? Yes or No”. An evaluation to determine if a patient is opioid naive is not possible when a EHR system does not support queries for past medications by date range. 2 - orders use RxNorm, but medication lists and dispensed medication will require an NDC value set and/or local mapping of NDC to RxNorm to enable this element

Recommendation-specific Subroutines

Recommendation 9 PDMP Review in Past 90 Days

• PDMP review procedure has been performed in the past 90 days or
• PDMP data has been reviewed in the past 90 days

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
PDMP review procedure in past 90 days?	No	Look for evidence of a prescription drug monitoring program (PDMP) review procedure (may need to modify time interval for review based on local practice / regulation) [Evidence for the PDMP review procedure may potentially originate in a PDMP Smart App that provides the code once PDMP review procedure has been completed]	PDMP review procedure	Procedure	Procedure.code, Procedure.status, and Procedure.performed
PDMP data reviewed finding in past 90 days?	No	Documentation (i.e., a finding that PDMP review has occurred) in last 90 days (may need to modify time interval for review based on local practice / regulation)	PDMP data reviewed finding	Observation	Observation.status, Observation.code, and Observation.effective

Recommendation 10 Urine Toxicology Screening

• Opioid urine toxicology screening in past year, or
• Nonopioid urine toxicology screening in past year

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Opioid urine toxicology screening in past year?	Yes	An opioid urine toxicology screening test performed within the past year	Opioid urine toxicology screening	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status
Nonopioid urine toxicology screening in past year?	Yes	A nonopioid urine toxicology screening test performed within the past year	Non-opioid urine toxicology screening	Observation	Observation.category, Observation.code, Observation.effective, and Observation.status

Recommendation 10 Possible Unexpected Results

• Positive result for a substance of potential interest in the past year or
• Negative result for a prescribable substance in the past year and
• An order for that substance exists in the 30 days prior to the test or
• Positive result for a prescribable\n substance in the past year and
• No order for that substance exists\n in the 30 days prior to the test

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Positive result for a substance of potential interest in the past year?	Yes	Urine toxicology screen result contains a substance of potential interest	Cocaine urine toxicology test result Heroin urine toxicology test result Phencyclidine (PCP) urine toxicology test result	Observation	Observation.category, Observation.code, and Observation.value
Possible unexpected negative result for prescribable substance?	Yes	Negative result for a prescribable substance in the past year and an order for that substance exists in the 30 days prior to the test	Amphetamine urine toxicology test result Barbiturate urine toxicology test result Benzodiazepine urine toxicology test result Buprenorphine urine toxicology test result Fentanyl urine toxicology test result Methadone urine toxicology test result Opiate urine toxicology test result Oxycodone urine toxicology test result Amphetamine medication Barbiturate medication Benzodiazepine medication Buprenorphine medication Fentanyl medication Methadone medication Opiate medication Oxycodone medication	Observation MedicationRequest	Observation.category, Observation.code, and Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication
Possible unexpected positive result for prescribable substance?	Yes	Positive result for a prescribable substance in the past year and no order for that substance exists in the 30 days prior to the test	Amphetamine urine toxicology test result Barbiturate urine toxicology test result Benzodiazepine urine toxicology test result Buprenorphine urine toxicology test result Fentanyl urine toxicology test result Methadone urine toxicology test result Opiate urine toxicology test result Oxycodone urine toxicology test result Amphetamine medication Barbiturate medication Benzodiazepine medication Buprenorphine medication Fentanyl medication Methadone medication Opiate medication Oxycodone medication	Observation MedicationRequest	Observation.category, Observation.code, and Observation.value, MedicationRequest.status, MedicationRequest.authoredOn, and MedicationRequest.medication

Recommendation 11 Opioid Analgesic or Benzodiazepine or CNS Depressant Order

• Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting or
• Provider is prescribing a benzodiazepine or
• Provider is prescribing a central nervous system depressant medication

The following table describes the flowchart decisions and sub-routines for the recommendation

Definition	Answer to Proceed	Details	Data (Terminology) Requirement	Profile	Path
Order for opioid analgesics with ambulatory misuse potential?	Yes	Trigger based on a new prescription (order) for opioid analgesics with ambulatory misuse potential - ideally the prescription should be selected prior to being committed to the system	Opioid analgesics with ambulatory misuse potential	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Order for benzodiazepine medications?	Yes	Trigger based on a new prescription (order) for benzodiazepines in the relevant value sets - ideally the prescription should be selected prior to being committed to the system	Benzodiazepine medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category
Order for central nervous system depressant medications?	Yes	Trigger based on a new prescription (order) for central nervous system depressant in the relevant value sets - ideally the prescription should be selected prior to being committed to the system	CNS depressant medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.category