2016 CDC Guideline Recommendation #6 - Prescribe Lowest Effective Dose and Duration - 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 #6 - Prescribe Lowest Effective Dose and Duration

Recommendation #6:

Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed (recommendation category: A, evidence type: 4).

Contents

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

Functional Description

When

Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting
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

Prescription is for treating acute pain.
Prescription is for more than 7 days or for an extended release opioid

Then

Recommend limiting therapy to no more than 3 days with an absolute maximum of 7 days and limit to immediate release opioids. Potential actions include:

Change order to ≤ 7 days
Document reason for not limiting therapy; snooze 3 months
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	Data (Terminology) Requirement
Order for opioid analgesics with with ambulatory misuse potential?	Yes	Trigger based on a new prescription (order) for opioids in the relevant value set - ideally the prescription should be selected prior to being committed to the system	Opioid analgesics with ambulatory misuse potential
For acute pain?	Yes	See For Acute Pain sub-routine
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Order for extended release opioid analgesics with ambulatory misuse potential?	Yes	Determine if the new prescription (order) Extended release opioid for analgesics with ambulatory misuse potential	Extended release opioid analgesics with ambulatory misuse potential
Order for opioid analgesics with ambulatory misuse potential for > 7 days?	Yes	Determine if the new prescription (order) has an intended duration of > 7 days	Opioid analgesics with ambulatory misuse potential

Effective Data Requirements

For Acute Pain

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
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

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

Content

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

Resource	Type	Description
2016 CDC Guideline Recommendation #6	PlanDefinition	Event-Condition-Action rule that implements behavior for 2016 CDC Guideline Recommendation #6
Recommendation #6 - Prescribe Lowest Effective Dose and Duration	Library	Defines the data requirements to support evaluation of recommendation #6
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 oxyCODONE HCl 10 MG 12HR Extended Release Oral Tablet (RXNorm 1049502). Patients "Dosage Instructions" are 1 Tablet per day for 5 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed oxyCODONE HCl 10 MG 12HR Extended Release Oral Tablet (RXNorm 1049502).Patients "Dosage Instructions" are 1 Tablet per day for 27 days. The patient will be included and the following message will be triggered - "Recommend limit therapy to ≤ 3 days to maximum of ≤ 7 days and to limit to immediate release opioids".	Request JSON	Response JSON

Description

CDS Hooks Request

Expected Response

Patient is 18 or older. Patient has been prescribed oxyCODONE HCl 10 MG 12HR Extended Release Oral Tablet (RXNorm 1049502). Patients "Dosage Instructions" are 1 Tablet per day for 5 days. The patient will be excluded and no message will be triggered - an empty set of cards will be returned.

Request JSON

Response JSON

Patient is 18 or older. Patient has been prescribed oxyCODONE HCl 10 MG 12HR Extended Release Oral Tablet (RXNorm 1049502).Patients "Dosage Instructions" are 1 Tablet per day for 27 days. The patient will be included and the following message will be triggered - "Recommend limit therapy to ≤ 3 days to maximum of ≤ 7 days and to limit to immediate release opioids".

Request JSON

Response JSON