The use of opioid drugs in management of chronic orofacial pain

The use of opioid analgesics for the management of patients with chronic pain is controversial. However, randomized and double-blind clinical trials have shown that in select groups of patients with chronic pain, the daily administration of oral opioids decreases pain levels and improves quality of life. This article provides a review of the most recent basic and clinical research supporting the rationale for the use of opioids in a select group of patients with chronic orofacial pain. Critical to the employment of this technique are proper patient evaluation and use of comprehensive management strategies. This management scheme should be reserved for patients with chronic pain that is refractory to most nonopioid therapy. The primary reason for the clinician's reluctance to initiate long-term opioid therapy for their patients with chronic pain is the potential risk of developing opioid tolerance, dependence, or addiction. In contrast to these beliefs, studies have shown a nonexistent to low risk of opioid dependence or addiction behavior with administration of scheduled oral opioids in chronic pain patients. It is essential that potential patients for this type of therapy have been carefully screened and have not had a history of drug addiction. The criteria to be evaluated when considering opioid therapy for chronic orofacial pain control include 1) inadequate pain diminution from prior nonopioid therapy, 2) negative history of substance abuse, 3) definitive determination that the pain being treated is of physiologic rather than psychologic origin, 4) a willingness to adhere to an 'opioid contract' between the doctor and patient, 5) compliance with a scheduled, rather than 'as needed' or 'breakthrough,' administration of an oral opioid, and 6) close clinical follow-up to evaluate pain relief, return to daily activities, and titration of drug levels. If these criteria are followed, administration of oral opioids may be a successful means of decreasing the patient's debilitating chronic pain to tolerable levels, enabling an improvement in the quality of life and return to function.