Recommendation #5 - Lowest Effective Dose

Description

Presents a Centers for Disease Control and Prevention (CDC) recommendation that when opioids are started, providers should prescribe the lowest effective dosage.

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.
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 receiving 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. 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 opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to >90 MME per day.

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 3 evidence: Observational studies or randomized clinical trials with notable 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 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) Calculation of daily dosage

3) Determining opioid usage (i.e., active medications)

4) 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 for >=80 days in previous 90 days

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

ACTION                  CALCULATE morphine milligram equivalence (MME) for opioid being prescribed AND all other active opioid prescriptions

 

INTERVENTION     DISPLAY notification to provider:

                              1) If morphine milligram equivalent (MME) >=50 and <90 (Recommendation category: A; evidence type: 3):
                              RECOMMENDATION: High risk for opioid overdose - consider tapering to <50 MME per day
                              RATIONALE: Providers should start opioids at the lowest effective dosage, use caution when increasing opioid dosages, and increase dosage by
                              the smallest practical amount. Before increasing total opioid dosage to >=50 MME per day, providers should reassess whether opioids are
                              meeting the patient’s treatment goals. If a patient’s opioid dosage for all sources of opioids combined is >=50 MME per day, providers should
                              implement additional precautions, including increased frequency of follow-up and consider offering naloxone.

                              2) If morphine milligram equivalent (MME) >=90 (Recommendation category: A; evidence type: 3):
                              RECOMMENDATION: High risk for opioid overdose - taper now to <50 MME per day
                              RATIONALE: Providers should avoid increasing opioid dosages >=90 MME per day or should carefully justify a decision to increase dosage to 
                              >=90 MME per day based on individualized assessment of benefits and risks and weighing factors such as diagnosis, incremental benefits for pain
                              and function relative to harms as dosages approach 90MME per day, other treatments and effectiveness, and recommendations based on
                              consultation with pain specialists. If patients do not experience improvement in pain and function at >=90 MME per day, or if there are escalating 
                              dosage requirements, providers should discuss other approaches to pain management with the patient, consider working with patients to taper
                              opioids to a lower dosage or to taper and discontinue opioids,and consider consulting a pain specialist. Established patients already prescribed high
                              dosages of opioids (>=90MME/day), including patients transferring from other providers, should be offered the opportunity to reevaluate their
                              continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. For patients who
                              agree to taper opioids to lower dosages, providers should collaborate with the patient on a tapering plan.

                              3) If Does Not Meet Inclusion Criteria:
                              RECOMMENDATION: No recommendation provided, as patient does not meet inclusion criteria
                              RATIONALE: The recommendation applies to adults aged >=18 years with chronic pain prescribed >=50 MME per day of opioid medications for
                              >=80 days in the previous 90 days

                              4) If Excluded:
                              RECOMMENDATION: No recommendation provided, as patient meets exclusion criteria
                              RATIONALE: The recommendation does not apply to children aged <18 years and patients receiving active cancer treatment, palliative care and 
                              end-of-life care 

 

INTERVENTION    DISPLAY notification to provider:
                               TABLE: Morphine milligram equivalence (MME) calculation and results
                               RATIONALE: Provide sufficient information to understand how the equivalence was calculated and source of the data used in the calculation

 

INTERVENTION    DISPLAY link to morphine milligram equivalence (MME) table: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

 

INTERVENTION    DISPLAY link to relevant recommendation statement available at CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
                                             

INTERVENTION    DISPLAY link to reference information: https://jamanetwork.com/journals/jama/fullarticle/2503508
 

ACTION                 DOCUMENT provider response

                               1) Will reduce dosage

                               2) Risk of opioid overdose carefully considered and outweighed by benefit; re-evaluate in 3 months

                               3) Acute pain; re-evaluate in 1 month

                               4) N/A - see comment (will be reviewed by medical director); re-evaluate in 3 months

 

INTERVENTION    DISPLAY link to patient opioid education materials relevant to care plan:
                               Prescription Opioids: What You Need to Know: https://www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf
                               Promoting Safer and More Effective Pain Management: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-Patients-a.pdf
                               Preventing an Opioid Overdose: https://www.cdc.gov/drugoverdose/pdf/patients/Preventing-an-Opioid-Overdose-Tip-Card-a.pdf

 

Testing Experience
Pilot Experience

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