Id: opioidcds-03 Url: Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy Version: 2022.1.0 Identifier: value: cdc-opioid-guidance Identifier: value: urn:oid:2.16.840.1.114222.34.3 Name: PlanDefinition_Recommendation_03_Order_Sign Title: Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy Status: active Experimental: false Type: system: http://terminology.hl7.org/CodeSystem/plan-definition-type code: eca-rule display: ECA Rule Date: 2025-08-06 Publisher: CDC / Security Risk Solutions, Inc. (SRS) Description: When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids. Logic Definitions: Library Name Name sequence OpioidCDSREC03 Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions 0 define "Chronic Pain Extended Release 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 ) and AmbulatoryOpioidPrescription.medication in Common."Extended release opioid with ambulatory misuse potential" Library Name Name sequence OpioidCDSREC03 Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential 1 define "Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" ) Library Name Name sequence OpioidCDSCommonConfig Age Less than 18 Years Is Enabled 2 // CDC 2022 General Inclusion Criteria define "Age Less than 18 Years Is Enabled": true Library Name Name sequence OpioidCDSRoutines Patient Age Less Than 18 3 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 OpioidCDSCommonConfig Sickle Cell Check Enabled 4 // Sickle Cell define "Sickle Cell Check Enabled": true Library Name Name sequence OpioidCDSCommonConfig Sickle Cell Assumed Active 5 define "Sickle Cell Assumed Active": true Library Name Name sequence OpioidCDSCommon US Core-Categorized Conditions 6 // 3. Medications indicating end of life /* or exists ( "Medications Indicating End of Life" ) */ define "US Core-Categorized Conditions": [Condition: category in "Encounter Diagnosis Condition Category"] union [Condition: category in "Problem List Condition Category"] union [Condition: category in "US Core Health Concern Condition Category"] Library Name Name sequence OpioidCDSCommon Positive Sickle Cell Condition 7 define "Positive Sickle Cell Condition": if Config."Sickle Cell Check Enabled" and not Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" and C.clinicalStatus in "Active Condition" ) else if Config."Sickle Cell Check Enabled" and Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" ) else null Library Name Name sequence OpioidCDSRoutines Condition Positive for Sickle Cell 8 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 OpioidCDSCommonConfig Active Cancer Treatment Encounters Condition Is Enabled 9 // Active Cancer Treatment define "Active Cancer Treatment Encounters Condition Is Enabled": true Library Name Name sequence OpioidCDSRoutines Encounter Period 10 // End of Opioid Naive Routine /* ** Routine #3 ** Active Cancer Treatment Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** --------------------------------------------------------------------------------------------------------------------------------- ** Two office visits within the | No | Look for a minimum of two distinct | Office Visit ** past 12 months | | 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 visits with an | No | The encounter is performed by an | Oncology specialty ** oncology specialist | | oncologist as defined in the oncology | designations (NUCC) ** present | | specialty designations using the | ** | | National Uniform Claim Committee | ** | | (NUCC) classifications | ** --------------------------------------------------------------------------------------------------------------------------------- ** Office visits including CDC | No | The encounter diagnosis (primary or | CDC malignant cancer ** malignant cancer | | secondary or co-morbidity diagnosis) | conditions ** condition | | is listed in the CDC Malignant Cancer | ** | | Conditions value set | ** ---------------------------------------------------------------------------------------------------------------------------------- ** */ define "Encounter Period": Interval[Today() - 12 months, Today()) Library Name Name sequence OpioidCDSCommon USCore Encounter Cancer Diagnoses 11 define "USCore Encounter Cancer Diagnoses": [Condition: category in "Encounter Diagnosis Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions" Library Name Name sequence OpioidCDSRoutines Encounters with Cancer Diagnosis During Encounter Period 12 // encounter-diagnosis, problem-list and health-concern Conditions // define "US Core-Categorized Cancer Diagnoses": // Common."US Core-Categorized Conditions" C // where C.code in Common."CDC malignant cancer conditions" // define "Encounters with Cancer Diagnosis During Encounter Period": // [Encounter] Encounter // with "US Core-Categorized Cancer Diagnoses" CancerDiagnosis // such that date from Encounter.period."start".value in day of "Encounter Period" // and EndsWith(CancerDiagnosis.encounter.reference, Encounter.id) define "Encounters with Cancer Diagnosis During Encounter Period": [Encounter] Encounters where date from Encounters.period."start" in day of "Encounter Period" and exists ( Common."USCore Encounter Cancer Diagnoses" CancerDiagnoses where EndsWith(CancerDiagnoses.encounter.reference, Encounters.id) ) Library Name Name sequence OpioidCDSRoutines Number of Encounters with Cancer Diagnosis During Encounter Period 13 define "Number of Encounters with Cancer Diagnosis During Encounter Period": Count ("Encounters with Cancer Diagnosis During Encounter Period") Library Name Name sequence OpioidCDSRoutines Has Two or More Encounters with Cancer Diagnosis During Encounter Period 14 define "Has Two or More Encounters with Cancer Diagnosis During Encounter Period": "Number of Encounters with Cancer Diagnosis During Encounter Period" >= 2 Library Name Name sequence OpioidCDSCommon USCore Problem List Cancer Diagnoses 15 define "USCore Problem List Cancer Diagnoses": [Condition: category in "Problem List Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions" Library Name Name sequence OpioidCDSRoutines Has Active Cancer Diagnosis on Problem List 16 define "Has Active Cancer Diagnosis on Problem List": exists ( Common."USCore Problem List Cancer Diagnoses" CancerDiagnoses where CancerDiagnoses.category in Common."Problem List Condition Category" and exists( CancerDiagnoses.clinicalStatus.coding ClinicalStatus where ClinicalStatus.code ~ 'active' ) ) Library Name Name sequence OpioidCDSRoutines Is Active Cancer Treatment? 17 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 OpioidCDSCommonConfig End-Stage Disease Criteria Enabled 18 // CDC 2022 General Inclusion Criteria define "End-Stage Disease Criteria Enabled": true Library Name Name sequence OpioidCDSRoutines Conditions Likely Terminal for Opioid Prescribing 19 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 CDC 2022 Guideline General Inclusion Criteria 20 define "CDC 2022 Guideline General Inclusion Criteria": 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 Opioid Naive Prescription Condition Is Enabled 21 // Opioid Naive define "Opioid Naive Prescription Condition Is Enabled": true Library Name Name sequence OpioidCDSCommonConfig Can the implementing EHR support queries for past medications by date range? 22 // Subroutine 2 - Past Medications define "Can the implementing EHR support queries for past medications by date range?": true Library Name Name sequence OpioidCDSCommon Active Ambulatory Opioid Rx 23 define "Active Ambulatory Opioid Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest])) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Opioid analgesics with ambulatory misuse potential" else List<FHIR.MedicationRequest>{} Library Name Name sequence OpioidCDSRoutines Prescription/Dispense Inclusion Period 24 // End of CDC 2022 General Inclusion Criteria Routine /* ** Routine #2 ** Opioid Naive Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** ---------------------------------------------------------------------------------------------------------------------------------------- ** Opioid analgesics with | No | Look for an existing prescription (order) for | Opioid analgesics with ** ambulatory misuse potential | | opioid that is in the value set for opioid with | ambulatory misuse potential ** prescription in past 90 days | | ambulatory abuse potential authored | ** excluding the previous 24 | | within the past 90 days (excluding previous 24 | ** hours | | hours) | ** ---------------------------------------------------------------------------------------------------------------------------------------- ** Opioid analgesics with | No | Look for evidence of active medication on | Opioid analgesics with ** ambulatory misuse potential | | the medication list that is in the value set | ambulatory misuse potential ** reported in past 90 days | | for opioid with ambulatory care abuse | ** excluding previous 24 hours* | | potential | ** ---------------------------------------------------------------------------------------------------------------------------------------- ** Opioid analgesics with | No | Look for evidence of a dispensing event for | Opioid analgesics with ** ambulatory misuse potential | | medication that is in the value set for opioid | ambulatory misuse potential ** dispensing event in past 90 | | with ambulatory use potential occurring | ** days excluding previous 24 | | within the past 90 days (excluding previous 24 | ** hours | | hours) | ** ---------------------------------------------------------------------------------------------------------------------------------------- ** *Future consideration: Current algorithm addresses only orders (prescriptions). ** ** Note – orders use RxNorm, but medication lists and dispensed medication will ** require an NDC value set and/or local mapping of NDC to RxNorm to enable this element ** */ define "Prescription/Dispense Inclusion Period": Interval[Now() - 90 days, Now() - 24 hours] Library Name Name sequence OpioidCDSRoutines Opioid RX with Ambulatory Abuse Potential In Past 90 Days 25 define "Opioid RX with Ambulatory Abuse Potential In Past 90 Days": Common."Active Ambulatory Opioid Rx" Rx where Rx.authoredOn during day of "Prescription/Dispense Inclusion Period" Library Name Name sequence OpioidCDSRoutines Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days 26 define "Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days": if (Config."Opioid Naive Prescription Condition Is Enabled") then exists ("Opioid RX with Ambulatory Abuse Potential In Past 90 Days") else false Library Name Name sequence OpioidCDSRoutines Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days 27 // NOTE: 2020-02-05: Review direction of MedicationStatement resource (US-Core focusing on MedicationRequest i/o Statement) // NOTE: 2020-04-21: MedicationStatement a) Shouldn't be use since guidance/direction from USCore is targeting MedicationUse in R5, and b) Breaks in the publisher /* define "Reports of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days": [MedicationStatement: Common."Opioid analgesics with ambulatory misuse potential"] Statement where Statement.status in {'active', 'completed'} and Statement.effective during day of "Report Inclusion Period" */ /* define "Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days": Config."Opioid Naive Report Condition Is Enabled" and exists ("Reports of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */ define "Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days": [MedicationDispense: Common."Opioid analgesics with ambulatory misuse potential"] OpioidDispense where OpioidDispense.whenHandedOver during day of "Prescription/Dispense Inclusion Period" and OpioidDispense.status = 'completed' Library Name Name sequence OpioidCDSRoutines Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days 28 define "Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days": if (Config."Opioid Naive Prescription Condition Is Enabled") then exists ("Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days") else false Library Name Name sequence OpioidCDSRoutines Is Opioid Naive? 29 // NOTE: MedicationStatement-dependent logic comment out due to bug in Publisher not supporting MedicationStatement in AllTypes. define "Is Opioid Naive?": not ("Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days") /* and not ("Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */ and not ("Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days") Library Name Name sequence OpioidCDSREC03 Inclusion Criteria 30 define "Inclusion Criteria": "Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential" and Routines."CDC 2022 Guideline General Inclusion Criteria" and Routines."Is Opioid Naive?" Library Name Name sequence OpioidCDSCommon Conditions Indicating End of Life or With Limited Life Expectancy 31 define "Conditions Indicating End of Life or With Limited Life Expectancy": ( "US Core-Categorized Conditions" C where C.code in "Conditions likely terminal for opioid prescribing" and C.clinicalStatus in "Active Condition" ) union ( "US Core-Categorized Conditions" C where C.code in "Limited life expectancy conditions" and C.clinicalStatus in "Active Condition" ) Library Name Name sequence OpioidCDSCommonConfig Hospice Findings Exclusion Enabled 32 // OpioidCDSCommon define "Hospice Findings Exclusion Enabled": false Library Name Name sequence OpioidCDSCommon Admitted/Referred/Discharged to Hospice Care 33 define "Admitted/Referred/Discharged to Hospice Care": ( if (Config."Hospice Findings Exclusion Enabled") then [Observation: code in "Hospice Finding Codes"] O where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' }) else {} ) union ( [Encounter] E where date from E.period.start 1 year or less on or before Today() and ( if E.hospitalization.dischargeDisposition.coding is null or not exists (E.hospitalization.dischargeDisposition.coding) then false else E.hospitalization.dischargeDisposition in "Hospice Disposition" ) and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' } ) Library Name Name sequence OpioidCDSCommon End of Life Assessment 34 define "End of Life Assessment": // 1. Conditions indicating end of life or with limited life expectancy exists ( "Conditions Indicating End of Life or With Limited Life Expectancy" ) // 2. Admitted/referred/discharged to hospice care or exists ( "Admitted/Referred/Discharged to Hospice Care" ) Library Name Name sequence OpioidCDSREC03 Exclusion Criteria 35 define "Exclusion Criteria": Common."End of Life Assessment" Library Name Name sequence OpioidCDSREC03 Is Recommendation Applicable? 36 define "Is Recommendation Applicable?": "Inclusion Criteria" and not "Exclusion Criteria" Library Name Name sequence OpioidCDSCommon Is Opioid Analgesic with Ambulatory Misuse Potential? 37 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 38 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 ToString 39 define function ToString(value string): value.value Library Name Name sequence FHIRHelpers ToConcept 40 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 FHIRHelpers ToCode 41 define function ToCode(coding FHIR.Coding): if coding is null then null else System.Code { code: coding.code.value, system: coding.system.value, version: coding.version.value, display: coding.display.value } Library Name Name sequence OpioidCDSRoutines Is Subacute or Chronic Pain Prescription? 42 // 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 43 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 44 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 45 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 46 define function ToDateTime(value dateTime): value.value Library Name Name sequence OpioidCDSCommon Get Active Ambulatory Medication Requests 47 define function "Get Active Ambulatory Medication Requests" (value List<MedicationRequest>) returns List<MedicationRequest>: value Rx where Rx.status.value = 'active' and Rx.category in "Community" Library Name Name sequence FHIRHelpers ToString 48 define function ToString(value MedicationDispenseStatus): value.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: Clinicians should not treat acute pain with ER/LA opioids or initiate opioid treatment for subacute or chronic pain with extended-release and long-acting (ER/LA) opioids, and clinicians should not prescribe ER/LA opioids for intermittent or as-needed use. Copyright: © CDC 2016+. Related Artifacts: Documentation 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain Libraries: Library - Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy Actions: When Initiating Opioid Therapy, Utilize Immediate Release Opioids: Recommend prescribing immediate release opioids instead of extended-release or long-acting opioids#xD; #xD; [For guidance regarding prescribing extended release/ long-acting opioids, see Recommendation 3 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation3). When: Named Event: order-sign If: Applicability: Check whether the current order is for an extended-release opioid with ambulatory misuse potential, the patient is opioid naive and if the 2022 CDC guideline general inclusion criteria is met (Is Recommendation Applicable?) Then: : Document - Will prescribe immediate release opioid Then: : Snooze* - Benefits outweigh risks, snooze 3 months Then: : Snooze* N/A see comment, snooze 3 months Then:
Value set Opioid analgesics with ambulatory misuse potential
Value set Extended release opioid with ambulatory misuse potential
Value set Encounter Diagnosis Condition Category
Value set Problem List Condition Category
Value set US Core Health Concern Condition Category
Value set CDC malignant cancer conditions
Value set Conditions likely terminal for opioid prescribing
Value set Limited life expectancy conditions
Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions
define "Chronic Pain Extended Release 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 ) and AmbulatoryOpioidPrescription.medication in Common."Extended release opioid with ambulatory misuse potential"
Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential
define "Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential": exists( "Chronic Pain Extended Release Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )
// CDC 2022 General Inclusion Criteria define "Age Less than 18 Years Is Enabled": true
define "Patient Age Less Than 18": if (Config."Age Less than 18 Years Is Enabled") then AgeInYearsAt(Today()) < 18 else false
// Sickle Cell define "Sickle Cell Check Enabled": true
define "Sickle Cell Assumed Active": true
// 3. Medications indicating end of life /* or exists ( "Medications Indicating End of Life" ) */ define "US Core-Categorized Conditions": [Condition: category in "Encounter Diagnosis Condition Category"] union [Condition: category in "Problem List Condition Category"] union [Condition: category in "US Core Health Concern Condition Category"]
define "Positive Sickle Cell Condition": if Config."Sickle Cell Check Enabled" and not Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" and C.clinicalStatus in "Active Condition" ) else if Config."Sickle Cell Check Enabled" and Config."Sickle Cell Assumed Active" then ( "US Core-Categorized Conditions" C where C.code in "Sickle Cell Diseases" ) else null
define "Condition Positive for Sickle Cell": if (Config."Sickle Cell Check Enabled") then exists( Common."Positive Sickle Cell Condition" ) else false
Active Cancer Treatment Encounters Condition Is Enabled
// Active Cancer Treatment define "Active Cancer Treatment Encounters Condition Is Enabled": true
// End of Opioid Naive Routine /* ** Routine #3 ** Active Cancer Treatment Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** --------------------------------------------------------------------------------------------------------------------------------- ** Two office visits within the | No | Look for a minimum of two distinct | Office Visit ** past 12 months | | 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 visits with an | No | The encounter is performed by an | Oncology specialty ** oncology specialist | | oncologist as defined in the oncology | designations (NUCC) ** present | | specialty designations using the | ** | | National Uniform Claim Committee | ** | | (NUCC) classifications | ** --------------------------------------------------------------------------------------------------------------------------------- ** Office visits including CDC | No | The encounter diagnosis (primary or | CDC malignant cancer ** malignant cancer | | secondary or co-morbidity diagnosis) | conditions ** condition | | is listed in the CDC Malignant Cancer | ** | | Conditions value set | ** ---------------------------------------------------------------------------------------------------------------------------------- ** */ define "Encounter Period": Interval[Today() - 12 months, Today())
define "USCore Encounter Cancer Diagnoses": [Condition: category in "Encounter Diagnosis Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions"
Encounters with Cancer Diagnosis During Encounter Period
// encounter-diagnosis, problem-list and health-concern Conditions // define "US Core-Categorized Cancer Diagnoses": // Common."US Core-Categorized Conditions" C // where C.code in Common."CDC malignant cancer conditions" // define "Encounters with Cancer Diagnosis During Encounter Period": // [Encounter] Encounter // with "US Core-Categorized Cancer Diagnoses" CancerDiagnosis // such that date from Encounter.period."start".value in day of "Encounter Period" // and EndsWith(CancerDiagnosis.encounter.reference, Encounter.id) define "Encounters with Cancer Diagnosis During Encounter Period": [Encounter] Encounters where date from Encounters.period."start" in day of "Encounter Period" and exists ( Common."USCore Encounter Cancer Diagnoses" CancerDiagnoses where EndsWith(CancerDiagnoses.encounter.reference, Encounters.id) )
Number of Encounters with Cancer Diagnosis During Encounter Period
define "Number of Encounters with Cancer Diagnosis During Encounter Period": Count ("Encounters with Cancer Diagnosis During Encounter Period")
Has Two or More Encounters with Cancer Diagnosis During Encounter Period
define "Has Two or More Encounters with Cancer Diagnosis During Encounter Period": "Number of Encounters with Cancer Diagnosis During Encounter Period" >= 2
define "USCore Problem List Cancer Diagnoses": [Condition: category in "Problem List Condition Category"] CancerDiagnoses where CancerDiagnoses.code in "CDC malignant cancer conditions"
Has Active Cancer Diagnosis on Problem List
define "Has Active Cancer Diagnosis on Problem List": exists ( Common."USCore Problem List Cancer Diagnoses" CancerDiagnoses where CancerDiagnoses.category in Common."Problem List Condition Category" and exists( CancerDiagnoses.clinicalStatus.coding ClinicalStatus where ClinicalStatus.code ~ 'active' ) )
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
// CDC 2022 General Inclusion Criteria define "End-Stage Disease Criteria Enabled": true
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
CDC 2022 Guideline General Inclusion Criteria
define "CDC 2022 Guideline General Inclusion Criteria": 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"
Opioid Naive Prescription Condition Is Enabled
// Opioid Naive define "Opioid Naive Prescription Condition Is Enabled": true
Can the implementing EHR support queries for past medications by date range?
// Subroutine 2 - Past Medications define "Can the implementing EHR support queries for past medications by date range?": true
define "Active Ambulatory Opioid Rx": if Config."Can the implementing EHR support queries for past medications by date range?" then ( "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest])) ) Rx where date from Rx.authoredOn 2 years or less on or before Today() and Rx.medication in "Opioid analgesics with ambulatory misuse potential" else List<FHIR.MedicationRequest>{}
// End of CDC 2022 General Inclusion Criteria Routine /* ** Routine #2 ** Opioid Naive Routine ** ** Definition | Answer to Proceed | Details | Data (Terminology) Requirement ** ---------------------------------------------------------------------------------------------------------------------------------------- ** Opioid analgesics with | No | Look for an existing prescription (order) for | Opioid analgesics with ** ambulatory misuse potential | | opioid that is in the value set for opioid with | ambulatory misuse potential ** prescription in past 90 days | | ambulatory abuse potential authored | ** excluding the previous 24 | | within the past 90 days (excluding previous 24 | ** hours | | hours) | ** ---------------------------------------------------------------------------------------------------------------------------------------- ** Opioid analgesics with | No | Look for evidence of active medication on | Opioid analgesics with ** ambulatory misuse potential | | the medication list that is in the value set | ambulatory misuse potential ** reported in past 90 days | | for opioid with ambulatory care abuse | ** excluding previous 24 hours* | | potential | ** ---------------------------------------------------------------------------------------------------------------------------------------- ** Opioid analgesics with | No | Look for evidence of a dispensing event for | Opioid analgesics with ** ambulatory misuse potential | | medication that is in the value set for opioid | ambulatory misuse potential ** dispensing event in past 90 | | with ambulatory use potential occurring | ** days excluding previous 24 | | within the past 90 days (excluding previous 24 | ** hours | | hours) | ** ---------------------------------------------------------------------------------------------------------------------------------------- ** *Future consideration: Current algorithm addresses only orders (prescriptions). ** ** Note – orders use RxNorm, but medication lists and dispensed medication will ** require an NDC value set and/or local mapping of NDC to RxNorm to enable this element ** */ define "Prescription/Dispense Inclusion Period": Interval[Now() - 90 days, Now() - 24 hours]
Opioid RX with Ambulatory Abuse Potential In Past 90 Days
define "Opioid RX with Ambulatory Abuse Potential In Past 90 Days": Common."Active Ambulatory Opioid Rx" Rx where Rx.authoredOn during day of "Prescription/Dispense Inclusion Period"
Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days
define "Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days": if (Config."Opioid Naive Prescription Condition Is Enabled") then exists ("Opioid RX with Ambulatory Abuse Potential In Past 90 Days") else false
Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days
// NOTE: 2020-02-05: Review direction of MedicationStatement resource (US-Core focusing on MedicationRequest i/o Statement) // NOTE: 2020-04-21: MedicationStatement a) Shouldn't be use since guidance/direction from USCore is targeting MedicationUse in R5, and b) Breaks in the publisher /* define "Reports of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days": [MedicationStatement: Common."Opioid analgesics with ambulatory misuse potential"] Statement where Statement.status in {'active', 'completed'} and Statement.effective during day of "Report Inclusion Period" */ /* define "Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days": Config."Opioid Naive Report Condition Is Enabled" and exists ("Reports of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */ define "Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days": [MedicationDispense: Common."Opioid analgesics with ambulatory misuse potential"] OpioidDispense where OpioidDispense.whenHandedOver during day of "Prescription/Dispense Inclusion Period" and OpioidDispense.status = 'completed'
Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days
define "Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days": if (Config."Opioid Naive Prescription Condition Is Enabled") then exists ("Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days") else false
// NOTE: MedicationStatement-dependent logic comment out due to bug in Publisher not supporting MedicationStatement in AllTypes. define "Is Opioid Naive?": not ("Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days") /* and not ("Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */ and not ("Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days")
define "Inclusion Criteria": "Patient Is Being Prescribed Extended Release Opioid Analgesic with Ambulatory Misuse Potential" and Routines."CDC 2022 Guideline General Inclusion Criteria" and Routines."Is Opioid Naive?"
Conditions Indicating End of Life or With Limited Life Expectancy
define "Conditions Indicating End of Life or With Limited Life Expectancy": ( "US Core-Categorized Conditions" C where C.code in "Conditions likely terminal for opioid prescribing" and C.clinicalStatus in "Active Condition" ) union ( "US Core-Categorized Conditions" C where C.code in "Limited life expectancy conditions" and C.clinicalStatus in "Active Condition" )
// OpioidCDSCommon define "Hospice Findings Exclusion Enabled": false
Admitted/Referred/Discharged to Hospice Care
define "Admitted/Referred/Discharged to Hospice Care": ( if (Config."Hospice Findings Exclusion Enabled") then [Observation: code in "Hospice Finding Codes"] O where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' }) else {} ) union ( [Encounter] E where date from E.period.start 1 year or less on or before Today() and ( if E.hospitalization.dischargeDisposition.coding is null or not exists (E.hospitalization.dischargeDisposition.coding) then false else E.hospitalization.dischargeDisposition in "Hospice Disposition" ) and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' } )
define "End of Life Assessment": // 1. Conditions indicating end of life or with limited life expectancy exists ( "Conditions Indicating End of Life or With Limited Life Expectancy" ) // 2. Admitted/referred/discharged to hospice care or exists ( "Admitted/Referred/Discharged to Hospice Care" )
define "Exclusion Criteria": Common."End of Life Assessment"
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 ToString(value string): value.value
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 }
define function ToCode(coding FHIR.Coding): if coding is null then null else System.Code { code: coding.code.value, system: coding.system.value, version: coding.version.value, display: coding.display.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
Get Active Ambulatory Medication Requests
define function "Get Active Ambulatory Medication Requests" (value List<MedicationRequest>) returns List<MedicationRequest>: value Rx where Rx.status.value = 'active' and Rx.category in "Community"
define function ToString(value MedicationDispenseStatus): value.value
Recommendation #3 - Opioid Immediate Release Form When Starting Opioid Therapy
CDC / Security Risk Solutions, Inc. (SRS)
When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
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.
Clinicians should not treat acute pain with ER/LA opioids or initiate opioid treatment for subacute or chronic pain with extended-release and long-acting (ER/LA) opioids, and clinicians should not prescribe ER/LA opioids for intermittent or as-needed use.
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
When Initiating Opioid Therapy, Utilize Immediate Release Opioids
Recommend prescribing immediate release opioids instead of extended-release or long-acting opioids [For guidance regarding prescribing extended release/ long-acting opioids, see Recommendation 3 of the 2022 CDC Clinical Practice Guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation3).
Check whether the current order is for an extended-release opioid with ambulatory misuse potential, the patient is opioid naive and if the 2022 CDC guideline general inclusion criteria is met
Document - Will prescribe immediate release opioid
Snooze* - Benefits outweigh risks, snooze 3 months
Snooze* N/A see comment, snooze 3 months