Managing chronic orofacial pain: Preventing harm, combating a crisis

By Sarah Marshall

In 2015, an estimated 12.5 million people misused prescription opioids in the U.S., and more than 33,000 died from overdosing on opioids.  About 11 percent of these prescriptions are written by dentists, and as prescribers of these potentially addictive medications, oral health care providers play a fundamental role in combating the national opioid crisis as well as preventing these drugs from becoming harmful to patients.

Navy Capt. (Dr.) Steve Hargitai, an associate professor in the Uniformed Services University of the Health Sciences Postgraduate Dental College, addressed this important topic during the annual Association of Military Surgeons of the U.S. (AMSUS) meeting Nov. 27 through Dec. 1. The meeting was an opportunity for hundreds of health care providers, worldwide, to collaborate, network, and discuss various topics relevant to the Military Health System.

As prescribers of opioids, oral health care providers play a fundamental role in combating the national opioid crisis, as well as preventing these drugs from becoming harmful to patients. Navy Capt. (Dr.) Steve Hargitai, an associate professor at the USU Postgraduate Dental College, addressed this important topic during the annual AMSUS meeting earlier this month. (Image credit: SSgt Joseph Pagán)

Hargitai, who is also chairman of the Orofacial Pain Center at the Naval Postgraduate Dental School, explained that while trying to minimize the number of opioids prescribed, there are still patients who benefit from them for chronic pain relief, for example, if they’re experiencing facial nerve damage, which can lead to continuous pain, or if they have recalcitrant temporomandibular joint (TMJ) pain.  Therefore, it’s important for providers to recognize who’s at risk for opioid-related abuse, overdose or death, he said. Individuals who currently have a substance use disorder, or who are taking benzodiazepines, used to treat seizures, anxiety, panic disorder, and sleep disorders are most at risk.  He added that patients with severe obstructive sleep apnea are also at risk for opioid-related harm.

Additionally, patients with chronic orofacial pain (pain in the head, neck or jaw) typically experience this type of chronic pain along with other medical concerns, he said, such as other body pain, or behavioral health issues. It’s essential to know whether they’re taking medications for those issues and to be aware of any potential complications from adverse drug interactions, Hargitai added.

When prescribing opioids for chronic orofacial pain, Hargitai said providers should also understand who may be prone to developing chronic pain in order to help stay on top of it. Those with poor sleep patterns, other body pains, or a history of depression or anxiety may be at a greater risk for developing chronic pain, he said.

X-Rays on display during a corrective facial surgery in the
hospital at Royal Air Force Lakenheath, England. (Image credit:
U.S. Air Force Senior Airman Erin O’Shea/Released) 

“In medicine and dentistry, providers should also always be vigilant in safeguarding patients on opioids with close monitoring and frequent follow-up,” he said.  During follow-up appointments, providers should be sure to check the effectiveness of the opioids when they’re prescribed for chronic pain, asking the patient how much relief the medication is providing and for how long, and if the patients have experienced any adverse side effects.

Hargitai also recommends that, for post-operative pain, it may be beneficial to only prescribe a three-day course of opioids, instead of prescribing for long-term use. It may also be effective to start a patient at a very low dose of opioids, he said, then slowly and gradually increase the dosage, over time, as needed.

Alternatively, he encourages providers to start off by prescribing other pain management strategies, if possible, avoiding opioids altogether.  Other strategies that have been known to be successful for patients with chronic orofacial pain include acupuncture or battlefield acupuncture, a unique auricular (ear) acupuncture procedure that uses small, stud-shaped needles inserted into points on the outer ear, stimulating nerves that modify pain signals in the brain.

Ultimately, doctors should be sure to identify the best candidates for opioid therapy, he said, and then find what works best for each individual patient with chronic pain, allowing them to return to a good quality of life.