Brief Description of Measure:

CMS506: Safe Use of Opioids - Concurrent Prescribing
Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge

Description of Issue:

​The Safe Use of Opioids - Concurrent Prescribing measure does not currently include Schedule IV opioids in its medication list. However, recent literature related to tramadol, a Schedule IV opioid, and environmental scans of related measures indicate that including Schedule IV opioids - which include butorphanol, pentazocine, and tramadol - may align more closely with measure intent and help reduce reporting burden. We solicited feedback on the issue from our expert work group in 2020. The group noted that tramadol prescription rates are increasing and recent literature indicates that patients can develop a tolerance for tramadol, which may increase its potential for abuse. Including Schedule IV opioids would then align with the measure intent, which is to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients who have concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently. Including Schedule IV opioids would also align the measure with other related opioid measures.

Proposed Solution:

To account for the addition of Schedule IV opioids in the measure to be used in the measure, we propose updating the current Definition to:
  - Opioid: Any Schedule II, Schedule III, or Schedule IV (limited to butorphanol, pentazocine, and tramadol) opioid medication.
We also propose revising the existing grouping value set referenced within the measure logic to include Schedules II, III and IV opioid medications by creating a new extensional 'Schedule IV Opioid' medications that are generic and prescribable for butorphanol, pentazocine, and tramadol. The measure definition would be updated to account for this addition.
Current "Initial Population" definition:
   "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
     with ( ["Medication, Discharge": "Schedule II and III Opioid Medications"]
       union ["Medication, Discharge": "Schedule IV Benzodiazepines"] ) OpioidOrBenzodiazepineDischargeMedication
       such that OpioidOrBenzodiazepineDischargeMedication.authorDatetime during InpatientEncounter.relevantPeriod
Proposed "Initial Population" definition:
   "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
     with ( ["Medication, Discharge": "Schedule II, III, and IV Opioid Medications"]
       union ["Medication, Discharge": "Schedule IV Benzodiazepines"] ) OpioidOrBenzodiazepineDischargeMedication
       such that OpioidOrBenzodiazepineDischargeMedication.authorDatetime during InpatientEncounter.relevantPeriod
Current "Numerator" definition:
    ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
        where ( Count(["Medication, Discharge": "Schedule II and III Opioid Medications"] Opioids
              where Opioids.authorDatetime during InpatientEncounter.relevantPeriod)>= 2))
      union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
          with ["Medication, Discharge": "Schedule II and III Opioid Medications"] OpioidsDischarge
            such that OpioidsDischarge.authorDatetime during InpatientEncounter.relevantPeriod
          with ["Medication, Discharge": "Schedule IV Benzodiazepines"] BenzodiazepinesDischarge
            such that BenzodiazepinesDischarge.authorDatetime during InpatientEncounter.relevantPeriod)
Proposed "Numerator" definition:
    ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
        where ( Count(["Medication, Discharge": "Schedule II, III, and IV Opioid Medications"] Opioids
              where Opioids.authorDatetime during InpatientEncounter.relevantPeriod)>= 2))
      union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter
          with ["Medication, Discharge": "Schedule II and III and IV Opioid Medications"] OpioidsDischarge
            such that OpioidsDischarge.authorDatetime during InpatientEncounter.relevantPeriod
          with ["Medication, Discharge": "Schedule IV Benzodiazepines"] BenzodiazepinesDischarge
            such that BenzodiazepinesDischarge.authorDatetime during InpatientEncounter.relevantPeriod)

Rationale for Change:

​Our expert work group recommended that we include Schedule IV opioids because tramadol, a Schedule IV opioid, prescription rates are increasing and recent literature indicates that patients can develop a tolerance for tramadol, which may increase its potential for abuse. Including Schedule IV opioids would align with the measure intent, which is to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients who have concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently. Including Schedule IV opioids would also align the measure with other related opioid measures.
To include recommendations from the expert work group to include Schedule IV opioids to (1) increase alignment with intent and (2) increase alignment with related opioid measures.