Id: opioidcds-09 Url: Recommendation #9 - Consider Patient's History of Controlled Substance Prescriptions Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Name: PlanDefinition_Recommendation_09_Order_Sign Title: Recommendation #9 - Consider Patient's History of Controlled Substance Prescriptions Status: draft Experimental: true Type: system: http://terminology.hl7.org/CodeSystem/plan-definition-type code: eca-rule display: ECA Rule Date: 2025-07-01 Publisher: Centers for Disease Control and Prevention (CDC) Description: When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose. Logic Definitions: Library Name Name sequence OpioidCDSREC09 Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions 0 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 ) Library Name Name sequence OpioidCDSREC09 Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential 1 define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" ) Library Name Name sequence OpioidCDSRoutines Patient Age Less Than 18 2 define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false Library Name Name sequence OpioidCDSRoutines Condition Positive for Sickle Cell 3 define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false Library Name Name sequence OpioidCDSRoutines Is Active Cancer Treatment? 4 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 Library Name Name sequence OpioidCDSRoutines Conditions Likely Terminal for Opioid Prescribing 5 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 Library Name Name sequence OpioidCDSRoutines Is Opioid Review Useful? 6 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" Library Name Name sequence OpioidCDSCommonConfig PDMP Data Not Reviewed in Past 90 Days Criteria Enabled 7 // Recommendation 9 define "PDMP Data Not Reviewed in Past 90 Days Criteria Enabled": true Library Name Name sequence OpioidCDSREC09 Look Back 90 Days 8 define "Look Back 90 Days": Interval[Today() - 90 days, Today()] Library Name Name sequence OpioidCDSREC09 PDMP Data Not Reviewed in Past 90 Days 9 define "PDMP Data Not Reviewed in Past 90 Days": Config."PDMP Data Not Reviewed in Past 90 Days Criteria Enabled" and not ( exists ( [Procedure: Common."PDMP review procedure"] P where P.status ~ 'completed' and P.performed during "Look Back 90 Days" ) or exists ( [Observation: Common."PDMP data reviewed finding"] O where O.status in { 'final', 'amended' } and ( if O.effective is FHIR.Period then (O.effective as FHIR.Period) during day of "Look Back 90 Days" else if O.effective is FHIR.dateTime then date from O.effective in day of "Look Back 90 Days" else false ) ) ) Library Name Name sequence OpioidCDSREC09 Inclusion Criteria 10 define "Inclusion Criteria": "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and Routines."Is Opioid Review Useful?" and "PDMP Data Not Reviewed in Past 90 Days" Library Name Name sequence OpioidCDSREC09 Exclusion Criteria 11 define "Exclusion Criteria": false Library Name Name sequence OpioidCDSREC09 Is Recommendation Applicable? 12 define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria" Library Name Name sequence OpioidCDSCommon Is Opioid Analgesic with Ambulatory Misuse Potential? 13 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" Library Name Name sequence OpioidCDSCommon Get MedicationRequest Medication as Code 14 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 } Library Name Name sequence FHIRHelpers ToConcept 15 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 } Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Prescription? 16 // 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) Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Using Expected Supply Duration 17 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 ) ) Library Name Name sequence OpioidCDSCommon GetDurationInDays 18 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 Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Using Validity Period 19 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 ) ) Library Name Name sequence FHIRHelpers ToDateTime 20 define function ToDateTime(value dateTime): value.value Library Name Name sequence FHIRHelpers ToString 21 define function ToString(value ProcedureStatus): value.value Library Name Name sequence FHIRHelpers ToInterval 22 define function ToInterval(period FHIR.Period): if period is null then null else if period."start" is null then Interval(period."start".value, period."end".value] else Interval[period."start".value, period."end".value] Knowledge Capability: shareable computable executable publishable Use Context: code value display focus 182888003 Medication requested (situation) focus 82423001 Chronic pain (finding) focus 274663001 Acute pain (finding) focus Purpose: 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: At a minimum, during long-term opioid therapy, PDMP data should be reviewed before an initial opioid prescription and then every 3 months or more frequently. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain Libraries: Library - Recommendation #9 - Consider Patient's History of Controlled Substance Prescriptions Actions: Before Ordering Opioids, Review PDMP Data: Review PDMP data for this patient before completing an opioid order.#xD; #xD; For guidance about utilizing PDMP information to improve patient safety, see [Recommendation 9 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20take,see%20Recommendation%2010).).#xD; #xD; [CDC advises not to dismiss patients from your practice on the basis of PDMP information](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20not%20dismiss,Recommendations%208%20and%2012%5D).) When: Named Event: order-sign If: Applicability: Check whether the current order is for an opioid with ambulatory misuse potential, if an opioid review is appropriate or there exists evidence of a prescription drug monitoring program (PDMP) review procedure or finding occurred in the past 90 days. (Is Recommendation Applicable?) Then: : Access Data - Launch app to review PDMP data Then: : Document - PDMP data reviewed, snooze 3 months Then: : Snooze* - N/A see comment, snooze 3 months Then:
Value set Opioid analgesics with ambulatory misuse potential
Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
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 )
Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential
define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )
define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false
define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false
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
Conditions Likely Terminal for Opioid Prescribing
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
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"
PDMP Data Not Reviewed in Past 90 Days Criteria Enabled
// Recommendation 9 define "PDMP Data Not Reviewed in Past 90 Days Criteria Enabled": true
define "Look Back 90 Days": Interval[Today() - 90 days, Today()]
define "PDMP Data Not Reviewed in Past 90 Days": Config."PDMP Data Not Reviewed in Past 90 Days Criteria Enabled" and not ( exists ( [Procedure: Common."PDMP review procedure"] P where P.status ~ 'completed' and P.performed during "Look Back 90 Days" ) or exists ( [Observation: Common."PDMP data reviewed finding"] O where O.status in { 'final', 'amended' } and ( if O.effective is FHIR.Period then (O.effective as FHIR.Period) during day of "Look Back 90 Days" else if O.effective is FHIR.dateTime then date from O.effective in day of "Look Back 90 Days" else false ) ) )
define "Inclusion Criteria": "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential" and Routines."Is Opioid Review Useful?" and "PDMP Data Not Reviewed in Past 90 Days"
define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria"
Is Opioid Analgesic with Ambulatory Misuse Potential?
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"
Get MedicationRequest Medication as Code
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 }
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 }
Is Subacute or Chronic Pain Prescription?
// 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)
Is Subacute or Chronic Pain Using Expected Supply Duration
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 ) )
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
Is Subacute or Chronic Pain Using Validity Period
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 ) )
define function ToDateTime(value dateTime): value.value
define function ToString(value ProcedureStatus): value.value
define function ToInterval(period FHIR.Period): if period is null then null else if period."start" is null then Interval(period."start".value, period."end".value] else Interval[period."start".value, period."end".value]
Recommendation #9 - Consider Patient's History of Controlled Substance Prescriptions
Centers for Disease Control and Prevention (CDC)
When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
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.
At a minimum, during long-term opioid therapy, PDMP data should be reviewed before an initial opioid prescription and then every 3 months or more frequently.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Before Ordering Opioids, Review PDMP Data
Review PDMP data for this patient before completing an opioid order. For guidance about utilizing PDMP information to improve patient safety, see [Recommendation 9 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20take,see%20Recommendation%2010).). [CDC advises not to dismiss patients from your practice on the basis of PDMP information](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#:~:text=Clinicians%20should%20not%20dismiss,Recommendations%208%20and%2012%5D).)
Check whether the current order is for an opioid with ambulatory misuse potential, if an opioid review is appropriate or there exists evidence of a prescription drug monitoring program (PDMP) review procedure or finding occurred in the past 90 days.
Access Data - Launch app to review PDMP data
Document - PDMP data reviewed, snooze 3 months
Snooze* - N/A see comment, snooze 3 months