Recommendation #8: Naloxone Consideration

Description

Provides 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

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. 
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

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. 

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

   Average MME >= 50
   OR on a benzodiazepine medication
   OR History of alcohol abuse or drug abuse 

Exclusions
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) 
Interventions and Actions
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
Testing Experience
Pilot Experience

This artifact has not been tested in a clinical environment.