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.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
No evidence of current naloxone medications?	Yes	Find evidence of naloxone medication prescription (an active medication order for naloxone)	Naloxone medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.authoredOn
Currently receiving benzodiazepine or other central nervous system depressant medications?	Yes	Find evidence of benzodiazepine prescription (an active medication order for benzodiazepine or other central nervous system depressant medications)	Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, MedicationRequest.category, and MedicationRequest.authoredOn
MME (morphine milligram equivalents > 50)	Yes	Determine MME from existing active prescriptions (recommendation 4 & 5), or future scope; dispensed medications, or patient-reported medications		MedicationRequest	MedicationRequest.medication, MedicationRequest.category, MedicationRequest.authoredOn, and MedicationRequest.dosageInstruction
History of conditions documenting substance use disorder?	Yes	Find evidence of conditions documenting substance use in the problem list or past medical history, including history of overdose	Conditions documenting substance misuse disorder	Condition Procedure	Condition.code, Condition.category, and Procedure.code
Diagnosis with a sleep-disordered breathing condition?	Yes	Find documentation of an active sleep-disordered breathing condition	Conditions documenting sleep-disordered breathing	TBD	TBD

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 #8	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #8
Recommendation #8 - risk factors for opioid-related harms before and during opioid therapy	Library	Defines the data requirements to support evaluation of recommendation #8
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

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) 1 patch per 10 days for 30 days. This will trigger the message "Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present." Consider offering naloxone given following risk factor(s) for opioid overdose: Average MME (54.000000 'mg/d') >= 50 mg/day.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days 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
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days for 30 days. Patient has also been prescribed Temazepam 20 MG Oral Tablet (RXNorm 104693) 1 tablet per 1 day for 30 days. This will trigger the message “Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present. Consider offering naloxone given following risk factor(s) for opioid overdose: concurrent use of benzodiazepine.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days for 30 days. Patient has also been prescribed Naloxone Hydrochloride 0.02 MG/ML Injectable Solution (RXNorm 1191212) 1ml per 1 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
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days for 30 days. This will trigger the message "Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present" Consider offering naloxone given following risk factor(s) for opioid overdose: history of alcohol or drug abuse.	Request JSON	Response JSON

• When
• Order for opioid analgesics with ambulatory misuse potential:
• 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 is not currently prescribed naloxone medications
• Factors that increase risk for opioid overdose are present:
• Currently receiving benzodiazepine or other central nervous system depressant medications, or
• High opioid dosages (MME/day >= 50), or
• History of substance use disorder, or
• Diagnosed with sleep-disordered breathing condition
• Then
• Incorporate Risk Mitigation Strategies Into Opioid Therapy:
• Order - Order naxalone
• Document - Risk mitigation strategy implemented, snooze 3 months
• Snooze - 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	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.medication, and MedicationRequest.category
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
No evidence of current naloxone medications?	Yes	Find evidence of naloxone medication prescription (an active medication order for naloxone)	Naloxone medications	MedicationRequest	MedicationRequest.medication, and MedicationRequest.authoredOn
Currently receiving benzodiazepine or other central nervous system depressant medications?	Yes	Find evidence of benzodiazepine prescription (an active medication order for benzodiazepine or other central nervous system depressant medications)	Benzodiazepine or other central nervous system depressant medications	MedicationRequest	MedicationRequest.medication, MedicationRequest.category, and MedicationRequest.authoredOn
MME (morphine milligram equivalents > 50)	Yes	Determine MME from existing active prescriptions (recommendation 4 & 5), or future scope; dispensed medications, or patient-reported medications		MedicationRequest	MedicationRequest.medication, MedicationRequest.category, MedicationRequest.authoredOn, and MedicationRequest.dosageInstruction
History of conditions documenting substance use disorder?	Yes	Find evidence of conditions documenting substance use in the problem list or past medical history, including history of overdose	Conditions documenting substance misuse disorder	Condition Procedure	Condition.code, Condition.category, and Procedure.code
Diagnosis with a sleep-disordered breathing condition?	Yes	Find documentation of an active sleep-disordered breathing condition	Conditions documenting sleep-disordered breathing	TBD	TBD

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 #8	PlanDefinition	Event-Condition-Action rule that implements behavior for 2022 CDC Clinical Practice Guideline Recommendation #8
Recommendation #8 - risk factors for opioid-related harms before and during opioid therapy	Library	Defines the data requirements to support evaluation of recommendation #8
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

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) 1 patch per 10 days for 30 days. This will trigger the message "Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present." Consider offering naloxone given following risk factor(s) for opioid overdose: Average MME (54.000000 'mg/d') >= 50 mg/day.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days 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
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days for 30 days. Patient has also been prescribed Temazepam 20 MG Oral Tablet (RXNorm 104693) 1 tablet per 1 day for 30 days. This will trigger the message “Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present. Consider offering naloxone given following risk factor(s) for opioid overdose: concurrent use of benzodiazepine.	Request JSON	Response JSON
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days for 30 days. Patient has also been prescribed Naloxone Hydrochloride 0.02 MG/ML Injectable Solution (RXNorm 1191212) 1ml per 1 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
Patient is 18 or older. Patient has been prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RXNorm 197696) 1 patch per 12 days for 30 days. This will trigger the message "Incorporate into the management plan strategies to mitigate risk; including considering offering naloxone when factors that increase risk for opioid overdose are present" Consider offering naloxone given following risk factor(s) for opioid overdose: history of alcohol or drug abuse.	Request JSON	Response JSON