The CDC has officially released the draft CDC Clinical Practice Guideline for Prescribing Opioids—United States, 2022. The docket is now open for public comment, and it will remain open until April 11, 2022.
- Federal Register Notice
- Full Docket, including links to the proposed guideline, the overview of public engagement work that went into the development of the guideline, the GRADE tables of evidence, and the Opioid Working Group report.
Some Major Changes From the 2016 Guideline
First, we want to acknowledge the important and positive changes that we are seeing in this version. While we are still reviewing the full guideline, and all updates contained within, a few major changes from the 2016 guideline have become immediately apparent, which you can see below. We welcome feedback from you about these issues as well as any other celebrations or concerns you may have.
- Applies to additional clinicians: While the 2016 guideline was intended only for primary care physicians, the 2022 version is intended to provide recommendations for physicians, nurse practitioners, physician assistants, and oral health practitioners.
- Promotes integrated pain management: The draft states, “As clinicians may work within team-based care, the recommendations refer to and promote integrated pain management and collaborative working relationships with, for example, behavioral health specialists, such as social workers or psychologists, and pharmacists.” Further, the draft states that “medications should ideally be combined with nonpharmacologic therapy to provide greater benefits to patients in improving pain and function” and that multimodal therapies and multidisciplinary biopsychosocial rehabilitation-combining approaches can reduce long-term pain and disability.
- Calls for improved payment of multimodal treatments: The draft states that health systems and payers should work to ensure that multimodal pain treatments are available, accessible, and reimbursed. The CDC calls on public and private payers to support a broader array of nonpharmacologic interventions, stating that “reimbursement is often cited as a principal barrier to why these nonpharmacologic treatments are not more widely used.”
- Emphasis on joint decision making: Unlike the 2016 guideline, the 2022 draft emphasizes the importance of the clinician and patient jointly determining treatment goals and how opioid effectiveness will be evaluated.
- Removal of arbitrary dosage ceilings: In a drastic departure from the 2016 guideline, the 2022 draft has removed recommendations related to arbitrary dosage ceilings. Mentions of specific dosages are now presented in a much more narrative form, alongside specific evidence and considerations, but without explicit warnings not to exceed certain dosages. The guideline does, however, caution clinicians to be aware of rules related to MME thresholds established on a state-by-state basis.
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Explicitly voluntary and not be used as mandatory limits: The draft says, “Of utmost importance, this clinical practice guideline provides voluntary clinical practice recommendations for clinicians that should not be used as inflexible standards of care. The clinical practice guideline recommendations are also not intended to be implemented as absolute limits of policy or practice across populations by organizations, healthcare systems, or government entities.”
AACIPM Takes Action
As always, AACIPM is actively working to connect the dots to expedite access to person-centered pain care, engaging stakeholders around this important opportunity for public comment (as we have done recently with efforts related to AHRQ and CMS).
AACIPM facilitated a call on Friday, February 18th, 1:00-2:00PM EST, with multi-stakeholder leaders, many involved in our ongoing efforts, to discuss this draft and the possibility of submitting a group response. On this call, each stakeholder group was be invited to share their reactions to the draft and any concerns they may have. AACIPM’s goal is to identify areas of consensus and opportunity across leaders representing people with pain, policymakers, healthcare providers, payors, purchasers, academia, patient/caregiver advocates and more.
If you are a leader of a an organization or policy group and would like to learn more about this, please contact Amy Goldstein, Director, AACIPM.
I am a chronic pain patient, caused by a herniated disc which herniated multiple times, now have nerve damage (Sciatica) three back surgeries, stenosis, adjacent segment disease, went through steroid injections, PT, Spinal Cord Stimulator now removed, Was on 90 mg of opioids, 60 mgs of morphine, and 30 mg of Vicodin for break through pain, and I was stable for 15 years, and never needed an increase. My pain doctor because of the CDC guidelines decided I needed to be forcefully tapered because he said it wasn’t really helping me, (which is was) now I am at 35 mg of opioids daily, and in severe pain every hour of every day, my quality of life is poor, I can’t exercise like I did before because it just hurts too much. I don’t understand why I am being punished and can’t have relief for my pain? I have tried everything before being on opioids, and opioids are the only treatment that gave me enough relief to have quality of life. I am so afraid with the new CDC guidelines that the doctors will still be afraid to treat pain patients. If the doctors do give enough opioids the pharmacies are afraid to fill them. Will the DEA still arrest doctors for helping and prescribing opioids to Chronic pain patients? Doctors went many years to school and I feel like they can’t practice medicine anymore without harassment. Please take away all MME on Opioids because everyone is an individual, one size doesn’t fit all, and it should be the doctors choice not the CDC. I do appreciate they are asking for chronic pain patients opinions.
Thank you for taking some time to listen to patients. Hopefully it will be done with an empathetic ear and an understanding that it is the ‘well intentioned policies’ that has created the opioid epidemic. Without acknowledgement of this simple truth, no amount of input from the public can move the needle. Thank you again for listening.
I have been taking 20mg of Oxycontin ER, twice per day for over 22 years. Never 3 per day and never 1. I am dependent on this medication to survive no differently than a diabetic depends on insulin or people with renal failure are dependent on dialysis. This is a dependency, not an addiction. Over these 22 years I have seen many changes to the rules and guidelines for prescribing these types of medications. Doctors have at times become so fearful of losing licenses and by default, careers, a high percentage of Doctors made the patient’s needs secondary thus forcing otherwise law abiding citizens to the streets for substitutes and then no one is managing the patients dosing. The media have lumped heroin addicts into the same category as pain patients on opioids thus exacerbating the public perceptions and the subsequent policies created by governing agencies. People like myself are not addicts. We typically choose to live at pain level 4-6 by using Opioids instead of simply existing in a wheel chair or bedridden at a pain level 10. The most stressful time for us is when our doctors retire. Personally, when my family doctor retired, I had to interview 9 doctors over a 2 month period before I could find one will to work with me for a lifetime of full body health to include prescribing my NEEDED medications. God willing I die before this one retires. 15 years ago, I could take a hand written script on the road with me to Seattle to visit my daughter and get my script filled at any local CVS in the Seattle area. Try doing that now. I had to plan every vacation or out of town adventure around my 30 day supply for the next 5 years and now a 90 day supply, thank heavens for that. I am now reaching retirement status and God forbid I want to go to Europe for 6 months with my wife. Over the past 22 years on this medication I have successfully run my business with dignity and in top 1 percentile nationally for my industry and I have employed an average 25 people during this period. Without my needed medication my life would have been spent in a wheel chair and in a bed with a trapeze overhead, or possibly not at all. I am OK spending my life productively living everyday at a pain level 4 or 5 or 6 but at least I have and have had a productive life functioning at a tremendously high level. My complaint is never the pain. It is the pain in the butt of navigating doctors appointments, pharmacies, being viewed as no better than homeless addict by a pharmacy clerk. I don’t believe my condition or the cause of my pain is of importance. What is of importance is that I hope to live long enough to say I have been taking 20 mg of Oxycontin twice per day for 50 years and bounce a new generation or 2 on my knee. Oh yeah, and that my current doctor doesn’t retire, or move or fall ill himself. Let the good doctors be better doctors and stop punishing patients for bad doctor’s and heroin addict’s choices. Stop forcing mothers and aunts and sisters and brothers to the streets for medications.
Thank you for listening. I am happy to discuss, visit, testify or simply help to inform, in or at any venue. My experience of this matter is long and storied.
I am 63yo female…I have chronic back pain along with a laundry list of health issues, for over 30 years. I am a colon cancer survivor when I was 27yo. I’ve had 3 leg surgeries in 4 yrs. and have now lost the use of my right leg from my knee down. I wear a brace 24/7 just so I can walk. My PCP has prescribed Vicodin and have increased my quantity to 60 pills a month and that was 4-5 yr.’s ago…I was told to take Tylenol in between the 2 pills a day to take the edge off…. I now need 2 new knees and my pain level has increased, but because of the guidelines and the hassle to get a few more pills a month to help my quality of life. I sit in my apartment and don’t venture out much because by the time I get home I can’t move. I AM NOT A PILL HEAD…I AM NOT AN ADDICT; I just need to be able to enjoy my life. Because of the people that abuse opioids, everyone that needs the medication to live a good pain free life is bunched up in the same category. Now I’m told I have to sign the same contract 4x’s a year instead on once…I now have to go for a drug test 4X’s a year. I also was told that I can no longer smoke marijuana, which is legal in my state because I’m on Vicodin. The marijuana actually does help. My PCP is afraid to help me anymore because of her being labeled as a Dr. that’s easy on prescribing medication needed to help the patients that need it. Don’t punish the few that need the opioids to live a productive life.
The 2016 CDC guidelines have had minimal impact on overdose numbers but has had a massive impact on chronic pain patients. Long term pain patients are not drug seekers, drug abusers or drug diverters. Their pain medication is the same as medication to treat hypertension or diabetes. It is what allows an individual to continue to have a job and to remain active in their community, church or social circles. The lack of quality of life that chronic pain patients have had to endure related to the 2016 CDC guidelines with the recommended, and many times forced reduction of pain medications, and/or swapping to medications recommended by the CDC regardless of their efficacy has been shameful. Dogs and cats receive better pain management than human beings do.
The CDC and the federal government’s punitive actions against legitimate prescribing physicians who fear that their licenses will be investigated or revoked has created an environment of patient abandonment. Once let go from a prescribing physician a patient needs to search, sometimes for months, to find a physician who will help them and does not immediately suspect them of being a drug seeker. The stigma and ostracism associated with chronic pain and the manner in which many physicians, their staff, pharmacists, pharmacy technicians, and multiple other healthcare professionals treat these patients is nothing short of unethical. It is particularly disturbing to be judged for requiring a necessary medication for a medical condition when the diagnosis is a rare or a chronic disease process that is not immediately identified by external symptoms or assistive devices such as canes or wheelchairs.
Your scorced earth policy with its “one size fits all” manner of pain treatment and guidleines is untenable. The 2016 guidelines did nothing to prevent overdoses but did plenty to negatively impact the social, emotional, phsycological and phsiological care of every chronic pain patient. Pain patients have tried every available avenue of alternative treatment including yoga, massage, TENS, physical therapy, biofeedback, medical marijuana and accupuncture just to name a few. The majority of which are NOT covered by insurance and are paid out of pocket. Many chronic pain sufferers would be thrilled to have even modest relief from their pain with any of those modalities, but it does not usually happen, and pain medications supplement those treatments. And, many patients have had serious side effects from NSAIDs, such as severe GI bleeding.
Chronic pain patients are required to have strict pain managemnt agreements that include mandatory and safety-proven guideines such as regularly scheduled office visits, mandatory drug urine or blood testing and frequent monitoring of medication refills. Please give legitimate, licensed physicians who are pain experts, the ability to effectively treat their patients without the fear of retribution and the ability to offer alternative treatments only IF it works for the patient, not because the CDC mandates it.
I am a 53 year old black man with sickle cell Anemia I have been taking opioids for almost 30 years and wrote a letter in 2015 when I first heard about the removal of opioids and we were promised that it would not effect people who really needed it but later found out that it certainly did and now we know all that has happened. I truly hope that the new guidelines will allow people to live comfortable and with some quality of life ?