April 8, 2022
Rochelle P. Walensky, MD, MPH
DirectorCenters for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30329
Re: Docket No: CDC-2022-0024

Dear Director Walensky:

On behalf of the American Association of Oral and Maxillofacial Surgeons (AAOMS), theprofessional association that represents more than 9,000 oral and maxillofacial surgeons(OMSs) in the United States, I would like to thank you and your colleagues at the Centers
for Disease Control and Prevention (CDC) for your work to draft an updated and expanded
voluntary guideline that provides evidence-based recommendations for clinicians whoprescribe opioids for outpatients 18 years of age and older with acute pain (duration lessthan one month), subacute pain (duration of one to three months) or chronic pain
(duration of three months or more). AAOMS appreciates the opportunity to review andoffer comments on the guideline.

Oral and maxillofacial surgery is the surgical specialty of dentistry. As such, management ofour patients’ pain following invasive procedures is an important aspect of providing thebest quality patient care. As lawful prescribers, we know, when used appropriately,prescription opiates enable individuals with pain to lead productive lives and recover more
comfortably from surgical procedures; however, dentists, including OMSs, have aresponsibility to ensure we do not exacerbate a growing public health risk while ensuring
our patients receive the relief they need following complex dental procedures.
AAOMS and its members are very aware of the risks associated with exposure to opioids.
AAOMS is constantly addressing the opioid epidemic with education of our membership,
which has resulted in a significant reduction in OMS opioid prescribing patterns
throughout the country. Because many of our patients are undergoing their first surgery
and first experience with post operative pain, OMSs are committed to using the mosteffective means of managing pain with the least amount of harm.

Guideline approach
AAOMS supports the CDC’s nuanced approach presented in the guideline. One of the mainconcerns among stakeholders with the 2016 guideline was the fact that therecommendations in that document were adopted as standards to which prescribers were
held accountable by healthcare systems, insurers and government entities. Statelegislatures and regulatory boards, for example, established arbitrary prescribing
thresholds for acute pain management that often did not take into account the nature orseverity of the procedure or the patient’s pain tolerance.
AAOMS is pleased to see that the CDC recognized the unintended negative impacts of the2016 guideline and that the updated draft guideline, beginning on line 33, specificallywarns against the recommendations being used as “absolute limits of policy or practiceacross populations by organizations, healthcare systems, or government entities."

The draft guideline also notes, starting on line 83, that it “provides recommendations onlyand is intended to be flexible, not supplant, clinical judgement and individualized, personcentered decision-making.” AAOMS firmly believes that the practitioner-patient
relationship must be upheld, allowing for practitioner judgment in the management of apatient’s pain – including drug types, dosages and treatment durations. Pain management
decisions should be individualized and only determined after a careful assessment of thelevel of risk to – and condition of – the patient. AAOMS appreciates the CDC’s recognition of
the important relationship between the provider and patient in the draft updated guideline.
AAOMS also is pleased to see the above concepts – provider judgement; flexibility to meeteach patients’ unique needs; and avoiding the misapplication of the practice guideline
beyond its intended use – reiterated in the five guiding principles starting on line 5830 ofthe guideline. Like the Box 1 Recommendations that immediately precede them, theguiding principles will be an area of the guideline mostly likely to be referenced byclinicians, insurers and policymakers; therefore, including those concepts in the guiding
principles is important.

Prescribing decisions
AAOMS supports the guideline’s recommendations related to how prescribers should
determine whether or not to initiate opioids as well as determine the selection, dosage andduration of opioids. The guideline’s recommendations are in line with AAOMS’s own
prescribing recommendations1, which advise OMSs to use non-opioids as first-line
analgesic therapy. When opioids are indicated for acute breakthrough pain, AAOMS
recommends short-acting opioid analgesics, starting with the lowest possible effective doseand the shortest duration possible.

1 Opioid Prescribing: Acute and Postoperative Pain Management. American Association of Oral andMaxillofacial Surgeons. AAOMS.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf

Pediatric Patients
AAOMS understands that the guideline only addresses patients who are over the age of 18.
Many OMS patients, however, are younger than age 18 and need access to appropriate pain
management following dental surgical procedures. Lines 386 through 395 of the guidelinebriefly discuss pediatric patients and reference a set of guidelines related to pediatricpatients undergoing surgical procedures that were developed by an outside entity. AAOMS,
however, supports the addition of a Box 1 Recommendation related to the pediatric patient
population – particularly with regard to acute pain – to provide an additional resource forprescribers involved in managing the pain of pediatric patients.
Changes to Box 1 Recommendations
Finally, AAOMS suggests the following amendments to the Box 1 Recommendations toprovide additional perspective for stakeholders, who may only look at the Box
Recommendations, rather than examine the entire guideline.
••

Box 1 Recommendation #1 - Include discussion of the risks and realistic
benefits of opioid therapy for acute pain. Box Recommendation 2 advises
clinicians to discuss “the known risks and realistic benefits of opioid therapy” withpatients suffering from subacute and chronic pain. AAOMS believes that such
conversations between a prescriber and patient suffering from acute pain are also
beneficial, and therefore, Recommendation 1 should contain this same advice.
AAOMS furthers supports informing patients that daily use of opioids can result inphysiological opioid dependence in as little as three days. While such language isalready noted elsewhere in this document, it is important that it also be included in
the Box Recommendations for clinicians to easily refer to.

Box 1 Recommendation #4 – Include a definition of “dosage above levels likely
to yield diminishing returns.” Supporting material in the guideline defines suchdosage as 50 MME/day or higher. AAOMS supports adding this definition as an
example to Recommendation 4 to ensure stakeholders understand the context of
this statement.

Thank you in advance for consideration of AAOMS’s comments to the draft updated
guideline. The specialty believes the draft updated guideline is a significant improvement
over the 2016 guideline and appreciates the time and attention spent by the CDC and otherstakeholders involved in writing this important resource. Please contact Jeanne Tuerk,AAOMS Director of Government Affairs, at 800-822-6637, ext. 4321, or jtuerk@aaoms.org
with questions.
Sincerely,J. David Johnson Jr., DDSAAOMS President