Email UpdatesProvides a notification to consider Naloxone when factors that increase the risk for opioid overdose (such as history or overdose, history of substance use disorder, higher opioid dosages [>= 50 MME/day], or concurrent benzodiazepine use) are present
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.
| Functional description and logic files available at: http://build.fhir.org/ig/cqframework/opioid-cds/recommendation-08.html |
| Opioid value sets available at: http://build.fhir.org/ig/cqframework/opioid-cds/terminology.html |
| Test data is available at: http://build.fhir.org/ig/cqframework/opioid-cds/test.html |
| For clinical informaticists interested in how the behavior for the artifacts was determined, refer to the Process Documentation. |
| For an overview of how the artifacts are represented in the FHIR Clinical Reasoning resources, refer to the Integration Documentation. |
| For a detailed description of how to implement the functionality with CDS Hooks calling into a FHIR Clinical Reasoning server, refer to the Implementation Documentation. |
| For a detailed description of how to implement the functionality with a Java-based CDS Hooks service, refer to the Service Documentation. |
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 receiving an opioid medication for acute pain, active cancer treatment, palliative care and end-of-life care.
This artifact has not undergone clinical testing.
Assumptions: Count only ambulatory prescriptions
Derived from the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
| 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. |
Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
| 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. |
| 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. |
| Trigger context | Primary care/ambulatory care |
| Trigger event | Prescription of opioid with ambulatory care abuse potential |
Average MME >= 50
OR on a benzodiazepine medication
OR History of alcohol abuse or drug abuse
| On Naloxone |
| OR 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) |
| Intervention | DISPLAY "Consider offering naloxone given following risk factor(s) for opioid overdose: (average MME >= 50/day), (concurrent use of benzodiazepine), (history of alcohol or drug abuse)". Reference: CDC Recommendation #8 |
| Intervention | DISPLAY links to opioid guidance (e.g., https://jamanetwork.com/journals/jama/fullarticle/2503508) |
| Action | SELECT one of the following: 1) Will offer Naloxone 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 |
This artifact has not been tested in a clinical environment.