Proposed 2022 CDC Clinical Practice Guideline for Prescribing Opioids
2022-04-13 2022-04-13 2022-04-13 2022-04-13 2022-04-13 2022-04-13 2022-04-13 2022-04-13 2022-04-13 2022-04-13
CDC-2022-0024-5098 CDC-2022-0024-5101 CDC-2022-0024-5109 CDC-2022-0024-5106 CDC-2022-0024-5107 CDC-2022-0024-5132 CDC-2022-0024-5129 CDC-2022-0024-5265 CDC-2022-0024-5263 CDC-2022-0024-5274
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https://api.regulations.gov/v4/comments/CDC-2022-0024-5098 https://api.regulations.gov/v4/comments/CDC-2022-0024-5101 https://api.regulations.gov/v4/comments/CDC-2022-0024-5109 https://api.regulations.gov/v4/comments/CDC-2022-0024-5106 https://api.regulations.gov/v4/comments/CDC-2022-0024-5107 https://api.regulations.gov/v4/comments/CDC-2022-0024-5132 https://api.regulations.gov/v4/comments/CDC-2022-0024-5129 https://api.regulations.gov/v4/comments/CDC-2022-0024-5265 https://api.regulations.gov/v4/comments/CDC-2022-0024-5263 https://api.regulations.gov/v4/comments/CDC-2022-0024-5274
Anonymous Koa Monica Peter Marisa Anonymous Elizabeth Nika Keith Anonymous
Anonymous Kai Turner Liepmann md faafp Harford Anonymous Galicia-pigg M. Brown Anonymous
I am begging you to change these guidelines.  Thanks to a NY Times article on 3/13/22, The Other Victims of the Opioid Crisis, I finally had the information I needed to ask the right questions about why I cannot get the relief from chronic pain that would enable me to live my life.  I do not remember the date but have a clear memory of the day my pain management doctor said he could not give me the level of medication I needed because of this guideline.  He said the government apparently only understood black and white.  And, yes, this was a period of time that it was scandalous that there were doctors who opened offices just to hand out opioid prescriptions.  Just a few months before my husband were in my hospital room talking to my spine surgeon after my 7th spinal fusion about the problem.  None of us foresaw the horrible swing of the pendulum.  I hope you caught that it was the 7th fusion.  Except for vertebrae C3, which is filled with stenosis, my entire spine has been surgically or auto-fused.  I assume that whoever reading this knows what these means in terms of pressure on nerves and blood vessels coming from the spine.I was in my early 30s (now 75) when told I had arthritis in my lower spine.  For years doctors tested me for rheumatoid arthritis because my osteoarthritis is so extensive and bilateral.  My first orthopedic surgery was my carpal tunnels in my early 40s.  In my 50s, the surgeries alternated between my knees (4 replacements) and my spine.  When my spine has been opened, if the surgery was near a previous one where bone material had filled in, the earlier hardware was removed to prevent a possible infection site.  One of those was attacked again by arthritis and was done again.  About a year ago I would sometimes get shooting pains in my feet. At my next appointment with my spine surgeon (every 3 months), I was told that when I bent my back L3 and L4 were sliding over the nerves to my feet.  Fortunately my surgeon is not only highly skilled but very conservative, so there was no immediate scheduling of a surgery that would have involved removing the hardware from the last fusion at T10 through L2, replacing it and continuing the fusion down through my pelvis (both sides of my sacrum are eroded by arthritis; after years of steroid shots, it became too painful to get in position for the shots).  Within 6 months L3  4 self- fused. Good.  The good news was that there would be no surgery.  The bad news is that the nerve is under constant pressure which means constant pain.  Unfortunately I do not tolerate the medications used for nerve pain.  From what I have read on the web from NIH, Mayo, and Cleveland, the treatment that remains is opioids.For the last 3-4 years, I have been taking a generic hydrocodone 10mg-acetaminophen 325 and used a Fentanyl 25 mcg duragesic patch. I dont think the patch does much of anything except for maybe the middle 24 hrs.  I also take one 100mg of Celebrex per day.The pain in my feet is most intense when I try to sleep.  Before I try to sleep I take a Tizanidine tablet and a Zolpidem tablet.  At most I sleep for 2 hrs. before pain awakens me; sometimes I can fall asleep for another hour or two.  Pain takes away any desire to eat; I make myself do it to keep glucose levels even (insulin resistant).  As often as not I am in tears which is not the person I am.  I havent seen my family in months because I dont want my beloved grandchildren to see me in this condition.  I dont go anywhere and I dont do anything because it means more movement and more pain.  Books have been a mainstay of my life, but pain even keeps me from reading.  I want my life back.My pain management doctor will not increase my dosage.  I dont know if this is really his choice or the policy of the much-vaunted health service for which he works.While you change this guideline, I am also begging you to change who is allowed to do the prescribing.  It is beyond belief that anyone would think that an anesthesiologist should prescribe these medications rather than a primary care physician who would know the patient best or even a specialist such as an endocrinologist, rheumatologist who the patient sees regularly.Unlike the man in The NY Times article, suicide is not an option for my beliefs about life, but that doesnt mean I havent thought about the relief it might bring.  I am begging you to give me and the thousand like me our lives back. As a patient and advocate for adequate analgesia for the chronic disease and disability communities, I have witnessed and experienced the barriers to pain management and healthcare caused by CDC 2016 Guidelines. The harms patients suffer include experiencing severely increased high impact pain, forced tapers, patient abandonment, mental health crises, and suicide. Patients have lost access to adequate and appropriate pain care. CDC Guidelines also facilitate patient loss of access to the general healthcare system including primary care and mental healthcare. Healthcare providers now make decisions not based on their best clinical judgement, but through a lens of liability, fear, and stigmatization. This expanded clinical guideline will significantly increase the harms to all patients in all clinical settings in need of appropriate pain management. As evidenced by the harmful outcomes of the 2016 Guidelines and lack of any action to reverse these harms, terms such as unintended consequences and wide misapplication are now moot. Patients and providers are aware any issuance of federal guidance will be interpreted as standard of care, mandate, policy, and law, as federal guidance is designed to accomplish. This underscores the lack of forethought and understanding CDC demonstrates in its guidance issuance effects on providers and patient populations.   CDC Injury Prevention Center does not have the professional experience, expertise, or stakeholder input necessary to develop guidance on the appropriate treatment of pain in all clinical settings. The influence of special interest groups is obvious in the failure to address serious conflicts of interest of authors and blatant violations of the Federal Advisory Committee Act. The updated guidelines make painfully evident CDC Injury Prevention Center is insufficient and unqualified to provide guidance on treatment of acute, subacute, or chronic pain through the exclusion of new relevant evidence, data, and research, continued use of the scientifically invalidated metric of Morphine Milligram Equivalent (MME), as well as exclusion of input from stakeholders who possess the expertise and experience to contribute to best practice guidance for pain treatment including the crucial tool of appropriate opioid prescribing. The harms to patients caused by the 2016 Guidelines are still occurring in vast numbers of patients. The 2022 updated Guidelines do not address reversal of these harms and will further cause increased harms to expanded patient populations without any viable plan to track patient outcomes from implementation. As a patient with lived experience, a disabled person, and an advocate for pro-patient care, to prevent continued and increased patient harms, it is imperative CDC withdrawal and rescind both the 2016 Guidelines and the 2022 updated Guidelines immediately. Thank you for your time,[name redacted], Ambassador, Chronic Disease Coalition You need to let doctors prescribe medicine as they see fit. If someone has an injury,  there is often no way of knowing whether pain will be acute or chronic. I used to have chronic pain. At the time, my  hospital was discouraging opioid use. That led to me not getting the proper pain treatment. My primary doctor kept trying to get me to stop taking Percocet even though I was in constant pain. Evevtually the Percocet didnt work as well. And you know what? My doctor refused to up my dose. She was worried that I would become a junkie in 10 years. I promised her that I would commit suicide long before that happened. I had to double my dose of Percocet and take it once every other day just to get four hours of relief in a 48 hour period. I researched pain treatments to try. Massage therapy? Tried it. It didnt fix my pain. Trigger point therapy? I tried both the pressure kind (worked a little at first, but eventually not) and the injection kind. An anesthesiologist injected a steroid and lidocaine near one of my nerves. The 20 minutes of relief was amazing! I thought I found a fix. But the steroid irritated the nerve. I have never been in so much pain in my life! Percocet did nothing for that pain. I spent a day and night crying and wishing I was dead. I wanted to go to a hospital for help, but was afraid that I would be accused of doctor shopping and would no longer be allowed to have any Percocet. You would think that by the way my doctor acted, that I was on a lot of Percocet. Nope. I got 10 mg/day. Other women with a similar issue were on 3 times that amount. To get further help with pain management, I wanted to try physical therapy. I made an appointment. The therapist told me I wouldnt get drugs from her. Who hoes to a physical therapist for drugs? Then she wanted to know about pain and drug use in my family members. Crazy right? I was there to find out if there was something I could physically try to get rid of my pain, but here this therapist was trying to see if Im doctor shopping and if Ive got drug addicts in my family.  She didnt recommended no physical therapy. Instead, I was told to do enjoyable things like spend time with friends. I told her I was in too much pain to enjoy friends plus the shear act of pretending to not be in pain when with friends was mentally and emotionally exhausting. I was told to relax with a hot bath or learn meditation. Thats when I knew something was was wrong in this hospital. I could tell the hospital had given directives to discourage pain medicine use. I was right. About a year later. I found an article about Group Health that stated the insurance carrier/hospital told doctors to encourage their patients to stop taking prescription pain medicine. I tried meditation for pain management. Hated it. I found that the hospital had an online group meeting to help with chronic illness. Listening to people worried about losing their jobs or marriages made my depression sooooo much worse. Plus, the class gave the same crappy advice that the physical therapist gave. I dropped the class. At some point I tried a salve I bought on the internet. Didnt work. I bought a tens unit. Didnt work. I was pissed. I tried so hard to find non opioid ways to deal with my pain, but there was no help. The one thing that did help, I  couldnt get a higher dose of. At the time, I had a coworker who had a bad fall. She got strong meds, physical therapy, AND water therapy. I couldnt wait to switch insurance companies.  I finally understood why people called Group Health Group Death.My situation was made worse because I was the one trying to find alternative treatments. My doctors insisted nothing could be done without more medicine which they would give me. I was suicidal. I mean neither my gynecologist or primary doctor recommended that I seek treatment elsewhere. In fact, I was told that if I doctor shopped, my pain management treatment would end. Once I switched insurance, what a difference! I was in so much pain that I couldnt wait to see my new doctor. I went to an urgent clinic to see if I could get muscle relaxers to help. I told the doctor everything that I had tried. I even told him how badly the trigger point injection was. I forgot to mention in my previous stated here that, on top of the excruciating pain. I urinated like a horse for days which caused severe leg cramps for weeks. You wouldnt think trying to stop pain would cause me to be in even more pain. That doctor got me on a non opioid and my new doctor added a different non opioid to that. He also told me Group Health didnt have a pain specialist, so they were limited in what they could prescribe. I should have been sent to a specialist!My new doctor recommended physical therapy. My new physical therapist was very familiar with my problem and gave me exercises that were very helpful. My pain decreased significantly. Still, it took over two years before I wasnt in pain 24/7.  The CDC guidelines are based on noble motives-to improve health care, protect doctors from malicious prosecution,  and patients from side effects of opioid prescriptions.Unfortunately, they fail at all three, because the goals are impossible in our current legal and social environment.The great hollowing out of the middle class, driven by federal tax policy, has increased deaths of despair starting at least in 1979. Physician prescribing certainly hasnt increased deaths from alcohol or suicide. Neither was it the cause of increased use of drugs of all sorts.The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 19992015  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607670/Why Deaths of Despair Are Increasing in the US and Not Other Industrial Nations Deaths of Despair Rise Steeply in the US vs Western Europe, Canada, Australia, and Japan https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2788767#ysc210003f1 Deaths of Despair article w graphs How Working-Class Life Is Killing Americans, in Charts https://www.nytimes.com/interactive/2020/03/06/opinion/working-class-death-rate.html  Opioid/Overdose Crisis as a Dialectics of Pain, Despair, and One-Sided Struggle - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676222/Americas 1% Has Taken $50 Trillion From the Bottom 90%  https://time.com/5888024/50-trillion-income-inequality-america/ Deaths from overdoses of all sorts have been increasing smoothly since 1979.https://science.sciencemag.org/content/361/6408/eaau1184/tab-figures-data Actions based on misunderstanding the problem cannot solve the problem.In fact, the physicians task is simply impossible. Prescribing opioids comes with a high risk of felony prosecution; even if the prescribing is perfect, that is irrelevant if prosecutors show anomalies in the business or operations side of the practice. And we know that no one prescribes perfectly 100% of the time. When the price for this is 20 years in prison, doctors simply refuse to prescribe.The problem is the 1970 CSA that criminalizes use and possession of medications. The US prohibited use and sale of alcohol for 13 years, then wisely decided this was bad policy. Weve had drug prohibition for 50 years, and all thats done is waste money, kill Americans and put minority men in jail.The best CDC could do would be to recognize the epidemic of deaths of despair its causes, and advocate social policy to reverse them.The least CDC could do would be to not make the situation worse by prescribing bleeding and purging.  Thank you for the opportunity to comment on the proposed CDC Guideline for Prescribing Opioids for Chronic Pain. While the proposed guidelines are an improvement from the 2016 guidelines, they do not represent a significant enough change to allow patients with legitimate chronic pain disorders who depend on opioid therapy to reduce their pain and improve their quality of life. It is understandable that the CDC is hoping to reduce drug overdose deaths. However, while opioid prescriptions have decreased by over 40% in the last decade (likely caused in part by the 2016 guidelines), annual drug overdose deaths in the U.S. have increased. The problem is clearly not with the prescribing of opioidsillicit street drugs are primarily driving the increase. There is therefore no reason to unfairly target chronic pain patients who are trying to treat their pain with the medical recommendations of their doctors. We do know that as legal prescriptions have decreased, suffering, disability, and suicide among those who suffer with chronic pain have risen steadily. The CDCs 2016 guidelines have unfortunately led to extremely harmful unintended consequences for patients with chronic pain. Many states adopted laws and regulations that limited opioid prescribing. Similarly, many health insurances based policies on those guidelines.  Many doctors have stopped prescribing opioids at all or minimize what they will prescribe, despite patients documented needs, because it is seen as such a huge risk to their license. Some doctors will not take on new patients who have been prescribed opioids. Many pharmacies will not fill patients prescriptions due to the increasing regulatory burden.  As a result of this, patients with chronic pain who have legitimately and safely taken opioids to control their pain for years now have to jump through herculean obstacles to obtain their prescriptions.The proposed guidelines do not balance discussing the known risks of opioids with the benefits of continuing opioids for chronic pain when a patient has failed other treatment options. The guidelines also do not take into account the incredible harms of poorly managed chronic pain, which include physical distress, mental agony, inability to hold a steady job, disability, and suicide. The guidelines must include strong language discouraging physicians from abandoning patients who depend on opioids for their pain. Additionally, citing specific doses can be interpreted (as it was in the 2016 guidelines) as giving a hard ceiling. Physicians need to be trusted to use their judgement to decide which medications are safe and beneficial for their patients, and at what doses.These guidelines matter deeply to me because I have a close friend in her early 40s who suffers from chronic pain and who currently spends the majority of her productive hours simply trying to obtain the medications that her doctor feels are most beneficial and safe for her. She has tried multiple other treatment methods to manage her pain, such as numerous non-opioid medications, procedures, injections, implanted spinal stimulators, complementary/ alternative medication modalities, mind-body strategies, etc. Her doctor agrees with her current treatment plan and has been prescribing opioids to her safely for many years. She is at low risk for overdose and would never dream of selling or giving away her medications. She does not get high from her medicationsshe simply has a reduction in pain that allows her to function on a daily basis. Most months out of the year, the red tape is so incredibly obstructive that she ends up running out of her needed medication, leading to dangerous sudden tapering, extreme pain, and inability to function. If her current doctor were to retire, it would be virtually impossible for her to find another doctor willing to take her on as a new patient and continue the medications that she has safely used to attain a minimum quality of life. My friend, like thousands of other chronic pain patients around the country, is depending on the CDC to take back much of the harmful language from the 2016 guidance. The CDC needs to replace the prior language with more appropriate statements that respect the benefits that many chronic pain patients receive from taking opioids and that acknowledges the incredible harms that come from limiting dosing, suggesting medically unnecessary tapers and making it incredibly difficult for patients to obtain the medication that their doctor has decided is best for them. One set of proposed changes that takes the needs of chronic pain patients into account was written by [name redacted], PhD and [name redacted], MD (https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/commentary-how-fill-holes-cdc-opioid-prescribing-guideline-revisi). These proposed revisions should be strongly considered by the CDC. 6 years ago CDC issued Guidelines for opiod prescription and use. They have been a foreseeable disaster. Illegal fentanyl heroin cocaine meth are killing more Americans then ever. People with injuries surgery child birth are denied or get limited safe pain relief medication. ChronicPainPatients have their opiod prescription canceled or severely limited. Some seek Illegal drugs which have unknown ingredients, quality  amounts.The CDC Guidelines should be totally rescinded. If not, then substantially limited. I have MS, congential spinal stenosis, degenerative disc disease, and need a knee replacement I cant get until next year. Because of all my issues I developed drop foot. The drop foot causes me to fall a lot. I never get pain meds even though I fractured my knee and footand had had bulging discs from my many falls. I basically sit on the couch most of the day because trying to do things or stand longer than 15 min I feel like my back is going to break. I have never abused my medication so I should not be treated like I have. These guidelines have poisoned the entire healthcare industry. Doctors and nurses are not treating pain even while patients lie in hospital. Pharmacists are making decisions about whether you deserve to fill the prescription or decide not to give you the full prescription. Its absolutely Ridiculous. My brother had multiple surgeries in a short period of time to clean out staph infection that has spread to bone throughout his body including 2 operations on his spine. He spent weeks lying in bed in agony. They were stingy with the morphine and oxy. They didnt try other options finally at week 5 he got Dilaudid which helped so much. He was actually able to carry a conversation and not be groaning in pain. He should have been given more medication. He should have gotten other medications tried. Instead he was in agony for weeks. Not only are these measures not a step in the right direction the intention behind these guidelines is positioning all aspects of healthcare.  I have been a chronic pain patient for 12 years. My pain was being controlled by pain medication up until 2018 when I was force cutoff of 385 MME with no taper. I went from working full time to not being able to get out of bed.  My quality of life is next to nothing now compared to when I was properly medicated. Please help me and millions of others in ridding the 2016 opioid prescribing guidelines. Please do not put a MME cap on our medications. This will only continue to dissuade Drs. from being comfortable enough to prescribe the medication I need to survive and work as a functional member of society. I deserve a quality of life which has been taken from me and my family.Thank you. DONT FORGET THE CURSE!!!!!!! I have been living with severe chronic pain for decades. This pain has negatively impacted every facet of my life. I have tried countless treatments for pain, including: OTC medication, prescription medication (non-pain medications, non-opioid pain medications, and opioids), injections, physical therapy, minimally invasive procedures, and major surgeries. The ONLY treatment that has given me relief and afforded me an acceptable quality of life is a combination of one long-acting and one short-acting opioid. Now, my insurance company, FEP BC BS, is taking me off opioids completely. This is  against my will and over the strong objections of my long-time physicians. FEP BC BS is using the CDCs strict 2016 opioid guidelines to justify their decision. The CDCs follow-up clarification statement on these guidelines has been ignored. This has caused great harm to me and to many others. The CDC must issue new, flexible guidelines that INCLUDE the clarifications, thereby making it more difficult for insurance companies to cherry-pick the official advice. I am physically dependent on, NOT addicted to or abusing, opioids. I have been on these two opioids for at least five years. I am a responsible and compliant pain management patient. I adhere to the strict terms of my patient contract and I have never given my physicians cause for concern. My condition has not changed. My behavior has not changed. What has changed is FEP BC BS opioid policy. This new policy is based on the CDC 2016 opioid guidelines and it completely dismisses the CDC, FDA, and HHS clarification statements that were issued later, in response to serious concerns over misapplication of the guidelines. FEP BC BS is misapplying the guidelines in the exact ways they have been explicitly told not to. For example:-FEP BC BS has instituted a rigid MME/day allotment and refuses to consider a prescribers informed opinion or a patients individual situation. The CDCs clarification paper states POLICIES THAT MANDATE HARD LIMITS CONFLICT WITH THE GUIDELINES EMPHASIS ON INDIVIDUALIZED ASSESSMENT OF THE BENEFITS AND RISKS OF OPIOIDS GIVEN THE SPECIFIC CIRCUMSTANCES AND UNIQUE NEEDS OF EACH PATIENT. -FEP BC BS has rejected explicit safety warnings from the CDC, such as, SERIOUS HARM IN PATIENTS WHO ARE PHYSICALLY DEPENDENT ON OPIOID PAIN MEDICINES SUDDENLY HAVING THESE MEDICINES DISCONTINUED OR THE DOSE RAPIDLY DECREASED. THESE INCLUDE SERIOUS WITHDRAWAL SYMPTOMS, UNCONTROLLED PAIN, PSYCHOLOGICAL DISTRESS, AND SUICIDE. The FDA agrees, stating, SHOULD NOT ABRUPTLY DISCONTINUE OPIOIDS IN A PATIENT WHO IS PHYSICALLY DEPENDENT.-FEP BC BS ignores the CDCs assertion that, THE RECOMMENDATION STATEMENT DOES NOT SUGGEST DISCONTINUATION OF OPIOIDS ALREADY PRESCRIBED AT HIGHER DOSAGES. This insurance company has inappropriately seized total control of my treatment. They have taken on the role of doctor and regulator. They have imposed hard limits. They have not considered my specific situation. They have not listened to my physicians. They have not listened to me. They have not listened to the CDC, FDA, or HHS. They have rapidly decreased my medications by a weekly 50% (a far cry from HHS advice to, WHEN tapering or discontinuation is appropriate, decrease opioids by no more than 10% per month). FEP has done this though I am physically dependent on these medications and have been for years, and despite the extreme physical and psychological effects I have and will continue to experience.Since their drastic cuts, I have been unable to sleep and have suffered with intense anxiety and panic attacks (at one point, I thought I was having a heart attack). I have headaches, joint and muscle pain, nausea, diarrhea, exhaustion, irritability, and more. I cannot complete necessary tasks. I feel worthless. And I know none of this is going to get better. It is only going to get worse. I have no more appeals and my only recourse is to take my insurance company to court. This will cost $30,000. I feel powerless, desperate, and hopeless. The life that awaits me is one of agonizing, daily pain and scant functionality. It is not a life worth living and I dont know what Im going to do. The CDC MUST incorporate these clarifications into the new guidelines, otherwise their sound, patient-centered advice will continue to be ignored and people with pain will continue to suffer. While the 2016 guidelines were created with good intent, they led to dramatic overcorrections and knee-jerk reactions that have resulted in serious negative repercussions. Pain is not being adequately treated and is often completely ignored. Doctors, nurses, pharmacists, and insurance companies feel free to openly engage in patient-profiling and discrimination. People in pain are resorting to desperate measures as their options for relief dwindle to nothing. Please take steps to fix these and other unintended consequences. 