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

Recommendations #4 and #5 - Lowest Effective Dose

CDC Guideline: 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Recommendation Topic: Selecting Opioids and Determining Opioid Dosages (Source)
Recommendation Description: When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. (Source)
Recommendation Category: A
Evidence Type: 3
Recommendation04-05-flow.png
Flow Diagram for Recommendation 4

  • 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 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 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 does not have conditions likely terminal for opioid prescribing present
    • Patient Morphine Milligram Equivalent (MME) greater than or equal to 50
  • Then
    • Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages:
      • Document - Will prescribe a lower dose
      • Document - Will calibrate a gradual change in dosage
      • Snooze - Benefits outweigh risks, snooze 3 months
      • Snooze - Short term benefits outweigh risks, snooze 1 month
      • Snooze - N/A add 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 Profile Path
Order for opioid analgesic with ambulatory misuse potential Yes Order for opioid analgesics with ambulatory misuse potential Opioid analgesics with ambulatory misuse potential MedicationRequest MedicationRequest.dispenseRequest.expectedSupplyDuration, MedicationRequest.medication, and MedicationRequest.category
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 MedicationRequest MedicationRequest.medication.coding.code and MedicationRequest.dosageInstruction
MME≥50? Yes MME result is ≥ 50

Effective Data Requirements

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

Resource Type Description
2022 CDC Clinical Practice Guideline Recommendation #4 and #5 PlanDefinition Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline #5
Recommendations #4 and #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) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support LogicLibraryCQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration LogicLibraryCQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines LogicLibraryCQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion LogicLibraryCQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation
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
  • 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 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 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 does not have conditions likely terminal for opioid prescribing present
    • Patient Morphine Milligram Equivalent (MME) greater than or equal to 50
  • Then
    • Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages:
      • Document - Will prescribe a lower dose
      • Document - Will calibrate a gradual change in dosage
      • Snooze - Benefits outweigh risks, snooze 3 months
      • Snooze - Short term benefits outweigh risks, snooze 1 month
      • Snooze - N/A add 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 Profile Path
Order for opioid analgesic with ambulatory misuse potential Yes Order for opioid analgesics with ambulatory misuse potential Opioid analgesics with ambulatory misuse potential MedicationRequest MedicationRequest.dispenseRequest.expectedSupplyDuration, MedicationRequest.medication, and MedicationRequest.category
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 MedicationRequest MedicationRequest.medication.coding.code and MedicationRequest.dosageInstruction
MME≥50? Yes MME result is ≥ 50

Effective Data Requirements

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

Resource Type Description
2022 CDC Clinical Practice Guideline Recommendation #4 and #5 PlanDefinition Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline #5
Recommendations #4 and #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) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support LogicLibraryCQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration LogicLibraryCQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines LogicLibraryCQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion LogicLibraryCQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation

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
CDC Guideline: 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Recommendation Topic: Selecting Opioids and Determining Opioid Dosages (Source)
Recommendation Description: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages. (Source)
Recommendation Category: B
Evidence Type: 4
Recommendation04-05-flow.png
Flow Diagram for Recommendation 5

  • 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 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 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 does not have conditions likely terminal for opioid prescribing present
    • Patient Morphine Milligram Equivalent (MME) greater than or equal to 50
  • Then
    • Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages:
      • Document - Will prescribe a lower dose
      • Document - Will calibrate a gradual change in dosage
      • Snooze - Benefits outweigh risks, snooze 3 months
      • Snooze - Short term benefits outweigh risks, snooze 1 month
      • Snooze - N/A add 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 Profile Path
Order for opioid analgesic with ambulatory misuse potential Yes Order for opioid analgesics with ambulatory misuse potential Opioid analgesics with ambulatory misuse potential MedicationRequest MedicationRequest.dispenseRequest.expectedSupplyDuration, MedicationRequest.medication, and MedicationRequest.category
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 MedicationRequest MedicationRequest.medication.coding.code and MedicationRequest.dosageInstruction
MME≥50? Yes MME result is ≥ 50

Effective Data Requirements

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

Resource Type Description
2022 CDC Clinical Practice Guideline Recommendation #4 and #5 PlanDefinition Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline #5
Recommendations #4 and #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) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support LogicLibraryCQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration LogicLibraryCQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines LogicLibraryCQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion LogicLibraryCQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation
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
  • 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 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 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 does not have conditions likely terminal for opioid prescribing present
    • Patient Morphine Milligram Equivalent (MME) greater than or equal to 50
  • Then
    • Calibrate to Lowest Opioid Dose Needed for Expected Results and Exercise Care When Changing Opioid Dosages:
      • Document - Will prescribe a lower dose
      • Document - Will calibrate a gradual change in dosage
      • Snooze - Benefits outweigh risks, snooze 3 months
      • Snooze - Short term benefits outweigh risks, snooze 1 month
      • Snooze - N/A add 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 Profile Path
Order for opioid analgesic with ambulatory misuse potential Yes Order for opioid analgesics with ambulatory misuse potential Opioid analgesics with ambulatory misuse potential MedicationRequest MedicationRequest.dispenseRequest.expectedSupplyDuration, MedicationRequest.medication, and MedicationRequest.category
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 MedicationRequest MedicationRequest.medication.coding.code and MedicationRequest.dosageInstruction
MME≥50? Yes MME result is ≥ 50

Effective Data Requirements

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

Resource Type Description
2022 CDC Clinical Practice Guideline Recommendation #4 and #5 PlanDefinition Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline #5
Recommendations #4 and #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) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support LogicLibraryCQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration LogicLibraryCQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines LogicLibraryCQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion LogicLibraryCQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation

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