Recommendation #7 - Opioid Therapy Risk Assessment

Description

Provides a recommendation to conduct an opioid therapy risk assessment to evaluate the benefits and harms of opioid therapy that aligns with CDC Recommendation #7.

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: If not able to document/retrieve above procedure, then use EHR snoozing functionality to allow "Have assessed/will assess. Snooze 3 months".
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

Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue 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 opioid with ambulatory care abuse potential
Inclusions

Opioid prescription for at least 7 of the past 10 days AND at least 1 encounter in past 12 months (excluding today)
OR Opioid Rx for at least 21 of 30 days for each of the past 3 months
AND No assessment of risk for opioid use  within past 90 days (noted as Procedure)

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 "Patients on opioid therapy should be evaluated for benefits and harms within 1 to 4 weeks of starting opioid therapy and every 3 months or more subsequently".
Action SUGGEST risk assessment [Assessment of risk for opioid abuse (procedure) SCTID: 454281000124100 OR High risk drug monitoring (regime/therapy): SCTID: 268525008]
Intervention DISPLAY links to opioid guidance (e.g.,  https://jamanetwork.com/journals/jama/fullarticle/2503508)
Action SELECT one of the following:
1) Will schedule assessment of risk for opioid use
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.