Recommendation #10 - Urine Drug Testing

Description

Presents 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.

Creation Date
Version
0.1.0
Unique Identifier
cdc-opioid-guidance
Status
Experimental
True

Artifact Creation and Usage

Contributors

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.

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights

No copyright restrictions apply.

Implementation Details
Engineering Details

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

 

Repository Information
Knowledge Level
1. NARRATIVE 2. SEMI-STRUCTURED 3. STRUCTURED 4. EXECUTABLE

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Purpose

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.

Intended Population

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.

Usage

For use by primary care providers delivering care in an outpatient setting.

Cautions

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.***

Supporting Evidence
References

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.

Recommendation

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.

Strength of Recommendation

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.

Quality of Evidence

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.

Decision Notes
Artifact Decision Notes

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

Artifact Representation
Triggers

Type: Named event

Event: Provider prescribes an opioid medication

 

Inclusions

Patient is >=18 years of age

AND prescription of opioid medication 

Exclusions

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

Interventions and Actions

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.

 

 

Testing Experience
Pilot Experience

The artifact is currently being pilot tested at two academic medical centers.