Pain Ladder

The concept of using a pain ladder originated from World Health Organization guidelines for patients with chronic cancer pain [51]. It provides a simple algorithm to limit the prescription of opioids until the use of all alternative analgesics has been exhausted. A stepwise approach beginning with NSAIDs followed by the use of weak, moderate, and finally strong opioids is generally recommended. The use of adjunct medications is further encouraged as they can be associated with a significant reduction in pain with the number needed to treat (NNT) for a 50% reduction in pain ranging from 3 to 10 [52].

Is There an Opioid Benefit?

Opioids have been shown to achieve a meaningful reduction in pain (30% or greater) in approximately 50% of patients in chronic non-cancer pain for up to 12 weeks [53]. Many patients ultimately discontinue medication as a result of inadequate pain relief or side effects. There is no evidence to support or refute the use of opioids in temporomandibular joint pain and guidelines only reflect expert opinion. Equally important is the goal of improving activities of daily living and quality of life with opioids although there is no evidence to support the use of opioids to improve these outcomes. The limited evidence supporting opioids in the non-cancer chronic pain should not be a reason to withhold them from patients with TMJ pain who may benefit although further studies are clearly needed to clarify the exact role of opioids. Many clinicians choose to prescribe short-acting opioids based in part on a lack of experience with long-acting agents. Short-acting opioids do provide the ability to better control pain that fluctuates throughout the day despite the need for more frequent dosing, issues with patient compliance, and increased risk for ADRB. However, long-acting opioids provide better plasma levels, improved compliance, and reduced ADRB, particularly with abuse- deterrent formulations [54].

The use of opioids to improve function and quality of life in chronic non-cancer pain is less clear [54, 55]. There is some evidence that failure to return to work correlates with opioids in a dose-dependent manner. Functional improvements appear to be better with NSAIDs and weak opioids such as tramadol.

The use of long-term opioids in patients with chronic TMJ pain remains controversial as it does in most chronic non-cancer pain states. A lack of evidence to support chronic opioids should not serve as a reason to withhold them although any long-term prescribing beyond 4 weeks should be weighed carefully balancing the patient analgesic requirement and the potential for ADRB and opioid misuse.

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