Recommendation #4 - Opioid Release Rate When Starting Opioid Therapy 

Description

Provides a recommendation to prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids when starting opioid therapy for chronic pain

Creation Date
Version
0.1
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.
Repository Information
Approval Date
Publication Date
Last Review Date
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 receiving an opioid medication for acute pain, active cancer treatment, palliative care and end-of-life care.
This artifact has not undergone clinical testing. 
EHR expectations: Have availability to snooze if benefits outweigh risks or if not applicable
Assumptions: Count only ambulatory prescriptions

Supporting Evidence
Source Description

Derived from the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.

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. 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

When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids

Strength of Recommendation
Category A recommendation: Applies to all persons; most patients should receive the recommended course of action.
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.
Artifact Representation
Triggers
Trigger context Primary care/ambulatory care
Trigger event Prescription of extended release/long acting opioid with ambulatory care abuse potential
Inclusions

Prescribed an extended release opioid
AND has had an encounter in the past 12 months
AND has NOT had a prescription for opioids with abuse potential in the past 90 days (excluding today)
Exclusions
Diagnosis of metastatic cancer
OR diagnosis of pancreatic cancer
OR liquid form of opioid medication
OR referral to hospice (procedure)
OR admission to hospice (procedure) 
OR urgent admission to hospice (procedure) 
OR discharge to healthcare facility for hospice care (procedure) 
OR full care by hospice (finding)
OR transition from self-care to hospice (finding) 
OR transition from acute care to hospice (finding) 
OR transition from long-term care to hospice (finding)
OR transition from long-term care to hospice (finding) 
OR dying care (regime/therapy) 
Interventions and Actions
Intervention DISPLAY "Recommend use of immediate-release opioids instead of extended release/long acting opioids when starting a patient on opioids"
Intervention DISPLAY links to opioid guidance (e.g.,  https://jamanetwork.com/journals/jama/fullarticle/2503508)
Action SELECT one of the following:
1) Will prescribe immediate release
2) Risk of overdose carefully considered and outweighed by benefit; snooze 3 months
3) N/A - see comment ( will be reviewed by medical director); snooze 3 months
Testing Experience
Pilot Experience

This artifact has not been tested in a clinical environment.