Opioid Risk Assessment

When to Use This Skill

Use when a clinician needs to evaluate opioid prescribing safety including total daily MME calculation, concurrent CNS depressant screening, ORT scoring, and CDC guideline compliance.

Clinical Workflow

1. Use fhir_read to retrieve Patient demographics (age, gender for ORT scoring)
2. Use fhir_search to pull all active MedicationRequest resources; classify as opioids, benzodiazepines, gabapentinoids, muscle relaxants, Z-drugs, naloxone
3. Calculate total daily MME for each opioid using dose x frequency x MME conversion factor (see references/mme-conversion-table.md)
4. Evaluate against CDC 2022 thresholds: <20 lower risk, 20-49 moderate, 50-89 caution, >=90 high risk
5. Use fhir_search to pull Condition resources for ORT scoring: substance use history, psychiatric diagnoses
6. Apply Opioid Risk Tool scoring (gender-specific criteria)
7. Use fhir_search to check for recent urine drug screen (LOINC 19295-5) and pain assessments (LOINC 72514-3)
8. Assess naloxone co-prescription status; recommend if MME >= 50 or concurrent CNS depressants

FHIR Resources

• MedicationRequest -- Active opioid and concurrent prescriptions with dosing details
• MedicationDispense -- Fill history for pattern analysis
• Patient -- Age and gender for ORT scoring
• Condition -- Psychiatric diagnoses, substance use history for ORT
• Observation -- Urine drug screen results, pain scores

FHIR Query Examples

Pull Active Medications

fhir_search(resourceType="MedicationRequest", queryParams="patient=[patient-id]&status=active&_count=100")

Pull Substance Use History

fhir_search(resourceType="Condition", queryParams="patient=[patient-id]&_count=100")

Pull Urine Drug Screen

fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&code=19295-5,3426-4&_sort=-date&_count=5")

Clinical Guidelines

• CDC 2022 Clinical Practice Guideline for Prescribing Opioids for Pain
• FDA REMS for extended-release/long-acting opioids
• PDMP (Prescription Drug Monitoring Program) check recommended before each opioid prescription

Interpretation Guide

• Total daily MME thresholds: <50 standard monitoring, 50-89 prescribe naloxone and reassess, >=90 avoid or taper
• Concurrent benzodiazepine + opioid = FDA Boxed Warning for respiratory depression
• ORT scores: 0-3 low risk, 4-7 moderate risk, >=8 high risk (scores differ by gender)
• UDS consistency: presence of prescribed opioid confirms adherence; absence suggests diversion; non-prescribed substances flag polysubstance risk
• Include CAGE-AID screening questions for clinician to administer

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges