Email UpdatesPresents a Centers for Disease Control and Prevention (CDC) recommendation when prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Artifact Creation and Usage
The implementation guide was developed as part of the Clinical Quality Framework Initiative, a public-private partnership sponsored by the Centers for Medicare & Medicaid Services (CMS) and the U.S. Office of the National Coordinator for Health Information Technology (ONC) to identify, develop, and harmonize standards for clinical decision support and electronic clinical quality measurement.
The project is a joint effort by the Centers for Disease Control and Prevention (CDC) and ONC focused on improving processes for the development of standardized, shareable, computable decision support artifacts using the CDC Opioid Prescribing Guideline as a model case.
Contributors include Kensaku Kawamoto, MD, PhD, MHS, Bryn Rhodes, Floyd Eisenberg, MD, MPH and Robert McClure, MD, MPH.
Please contact Greg White gw@securityrs.com for additional information.
No copyright restrictions apply.
Logic files available at link: http://build.fhir.org/ig/cqframework/opioid-cds/index.html
See section 1.4.0 Content Index; links to the logic and behavior defined by the implementation guide.
Technical files available at link: http://build.fhir.org/ig/cqframework/opioid-cds/profiles.html
Documentation files available at link: http://build.fhir.org/ig/cqframework/opioid-cds/documentation.html
Structured code that is interpretable by a computer (includes data elements, value sets, logic)
The CDC Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.
For use in adults aged 18 years and older prescribed opioid medications for chronic pain (i.e., pain conditions that typically last >3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care and end-of-life care.
For use by primary care providers delivering care in an outpatient setting.
The recommendation does not apply to children aged <18 years or to adults prescribed an opioid medication for acute pain, active cancer treatment, palliative care and end-of-life care.
***The CDS is in development and being piloted in a clinical environment. Updates are expected following pilot testing.***
Guideline:
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65(1):1-49. doi: 10.15585/mmwr.rr6501e1. Accessed February 15, 2018 at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Grading of recommendations:
Ahmed F. US Advisory Committee on Immunization Practices handbook for developing evidence-based recommendations [version 1.2]. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/acip/recs/grade/downloads/handbook.pdf (http://www.cdc.gov/vaccines/acip/recs/grade/downloads/handbook.pdf). Accessed February 14, 2017.
Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-926.
The CDC recommends when prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Category B recommendation: Individual decision making needed; different choices will be appropriate for different patients. Providers help patients arrive at a decision consistent with patient values and preferences and specific clinical situations.
Reference: CDC Advisory Committee on Immunization Practices Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.
Type 4 evidence: Clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations.
Evidence characterized as low quality using GRADE methodology.
Reference: CDC Advisory Committee on Immunization Practices Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.
See the following for details: http://build.fhir.org/ig/cqframework/opioid-cds/process-documentation.html
Decision notes for the following issues are available at the link: http://build.fhir.org/ig/cqframework/opioid-cds/process-documentation.html
1) Opioid determination (i.e., what constitutes an opioid)
2) Determining opioid usage (i.e., active medications)
3) Information to assist with non-medication terminology
Type: Named event
Event: Provider prescribes an opioid medication
Patient is >=18 years of age
AND prescription of opioid medication
Diagnosis of metastatic cancer
OR diagnosis of pancreatic cancer
OR liquid form of opioid medication
OR referral to hospice (procedure) SCTID : 306205009
OR admission to hospice (procedure) SCTID: 305336008
OR urgent admission to hospice (procedure) SCTID: 183919006
OR discharge to healthcare facility for hospice care (procedure) SCTID: 428371000124100
OR full care by hospice (finding) SCTID: 170935008
OR transition from self-care to hospice (finding) SCTID: 448451000124101
OR transition from acute care to hospice (finding) SCTID: 1891000124102
OR transition from long-term care to hospice (finding) SCTID: 1951000124104
OR transition from long-term care to hospice (finding) SCTID: 1951000124104
OR dying care (regime/therapy) SCTID: 385736008
INTERVENTION DISPLAY notification to provider:
1) If no urine drug test in <12 months (Recommendation category: B; evidence type: 4):
RECOMMENDATION: Urine drug screening results not available within last 12 months. Patient should have a urine drug test
performed.
RATIONALE: Providers should use urine drug testing to assess for prescribed opioids as well as other controlled substances and illicit drugs that
increase risk for overdose when combined with opioids, including nonprescribed opioids, benzodiazepines, and heroin.
ACTION DOCUMENT provider response:
1) Will perform urine drug screening
2) N/A - opioid not for chronic pain management; re-evaluate in 3 months
INTERVENTION DISPLAY notification to provider:
1) If urine drug test in <12 months but negative for opioids (Recommendation category: B; evidence type: 4):
RECOMMENDATION: Urine drug screening results are inconsistent with patient's medication regimen.
RATIONALE: Before ordering urine drug testing, providers should explain to patients that testing is intended to improve their safety, should
explain expected results (e.g., presence of prescribed medication and absence of drugs, including illicit drugs, not reported by the patient),
and should ask patients whether there might be unexpected results.
2) If urine drug test in <12 months and positive for drugs not reported by the patient (Recommendation category: B; evidence type: 4):
RECOMMENDATION: Urine drug screening results are inconsistent with patient's medication regimen.
RATIONALE: Before ordering urine drug testing, providers should explain to patients that testing is intended to improve their safety, should
explain expected results (e.g., presence of prescribed medication and absence of drugs, including illicit drugs, not reported by the patient),
and should ask patients whether there might be unexpected results.
The artifact is currently being pilot tested at two academic medical centers.