2016 CDC Guideline Recommendation #5 - Lowest Effective Dose - Opioid Prescribing Support Implementation Guide v2016.4.0

Opioid Prescribing Support Implementation Guide
2016.4.0 - CI Build

Opioid Prescribing Support 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 2016.4.0 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

2016 CDC Guideline Recommendation #5 - Lowest Effective Dose

Recommendation #5:

When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to >90 MME/day (recommendation category: A, evidence type: 3).

Contents

Functional Description
For Chronic Pain
Opioid Review Useful
Opioid Naive
Content
Example Data/Requests

Functional Description

When

Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting
Prescription is for treating chronic pain.
Opioid review is useful for this patient:

Patient is 18 or over
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 has had at least 2 office visits within the past 12 months with an oncology specialist present, or
Patient has had at least 2 office visits within the past 12 months with a CDC malignant cancer condition diagnosis

Patient Morphine Milligram Equivalent (MME) greater than or equal to 50

Then

Recommend to consider tapering dosage when MME is greater than or equal to 50 and less than 90 or taper dosage now when MME is greater than or equal to 90:

Will reduce dosage
Benefits outweigh risks, snooze 3 months
Active pain, snooze 1 month
N/A - see comment, snooze 3 months

The following table describes the flowchart decisions and sub-routines for the recommendation
Definition	Answer to Proceed	Details
Opioid order for chronic pain?	Yes	See For Chronic Pain sub-routine
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Calculate MME for prescription + active opioids	N/A	Current calculation uses known order (prescription) data. Note - for as needed (PRN) medication, the daily dose assumes the maximum dose the patient may take any given day if a range is present. Ideally, dispensed data could be used to determine the medication dispensed to the patient
MME≥50?	Yes	MME result is ≥ 50
MME≥90?	Yes	MME result is ≥ 90

Effective Data Requirements

For Chronic Pain

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
Order for opioid analgesic with expected supply duration ≥ 28 days	Yes	Order for opioid analgesics with ambulatory misuse potential with a supply duration of ≥ 28 days	Opioid analgesics with ambulatory misuse potential

Opioid Review Useful

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
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
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
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
Active cancer treatment?	No	See Active Cancer Treatment sub-routine	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

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
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
Office visits with an oncology specialist present?	No	• The encounter is performed by an oncologist as defined in the oncology specialty designations using the National Uniform Claim Committee (NUCC) classifications	Oncology specialty designations (NUCC)
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

Opioid Naive

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
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
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
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

Content

The following artifacts formalize the description of the logic and behavior defined by this recommendation.

Resource	Type	Description
2016 CDC Guideline Recommendation #5	PlanDefinition	Event-Condition-Action rule that implements behavior for 2016 CDC Guideline Recommendation #5
Recommendation #5 - lowest effective dosage	Library	CQL Library that provides logic for evaluating whether a prescription exceeds the MME of 50 mg/day
Opioid Terminology Management Knowledge-base Data (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support Logic	Library	CQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration Logic	Library	CQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines Logic	Library	CQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion Logic	Library	CQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation

Example Data/Requests

Description	CDS Hooks Request	Expected Response
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) one patch per day for 30 days. This will trigger the message "High risk for opioid overdose - taper now" It will then link to the "MME Conversation Tables" "https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf"	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed Morphine Sulfate 10 MG (RXNorm 892495) one tablet per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON

Description

CDS Hooks Request

Expected Response

Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) one patch per day for 30 days. This will trigger the message "High risk for opioid overdose - taper now" It will then link to the "MME Conversation Tables" "https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf"

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed Morphine Sulfate 10 MG (RXNorm 892495) one tablet per day for 30 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.

Request JSON

Response JSON