Neuropathic pain The treatment for neuropathic pain without an underlying treatable cause is largely pharmacological, with surgical options typically reserved for those who cannot tolerate or who obtain no relief from pharmacological treatment. Classical trigeminal neuralgia is typically treated with anticonvulsants such as carbamazepine and oxcarbazepine as first-line drugs and gabapentin and pregabalin as second-line drugs, although evidence supporting these choices is slim (Khan, et al., 2017). To date, there is insufficient evidence to support or refute the use of other anticonvulsants such as lamotrigine and topiramate. The effectiveness of a medication which is not an anticonvulsant such as the muscle relaxant Baclofen can be increased when it is combined with medications such as phenytoin or carbamazepine for the treatment of trigeminal neuralgia (Trigeminal Neuralgia, 2021). Other types of episodic paroxysmal neuralgias are treated with the same medications. Treatment for continuous orofacial neuropathic pain is largely derived from data on diabetic neuropathy and postherpetic neuralgic pains. There is dependable support for the use of tricyclic antidepressants, gabapentin, pregabalin, tramadol, and topical 5% lidocaine (Maarbjerg, et al., 2017; Fornasan, 2017; Highsmith, 2019; Mu, Weinberg, Moulin, & Clarke, 2017). In rare cases, opioid medications are prescribed for chronic orofacial pain. When prescribing opioids for nonterminal pain such as trigeminal neuropathic pain, long-acting medications such as methadone or time-released versions of medications such as oxycodone and morphine are preferred to maintain a steady state of the medication in the bloodstream. Use of such medications to treat chronic pain requires close monitoring of the patient and careful documentation. A written agreement outlining the responsibilities of the patient and the “do’s and don’t’s” associated with the prescription of such medications is highly recommended. Consultation with a physician should be considered because the long-term risks of use should be weighed against a person’s medical history, current pain state, and the potential benefits of treatment. To obtain the most current information available, readers are encouraged to regularly check product information provided by the manufacturer of each drug and available from such sources as the U.S. Food and Drug Administration website (https://www. fda.gov). Dental practitioners should prescribe only medications for which they can take full responsibility. Medication misuse and addiction Recently, there has been a close focus in the United States on the abuse of prescription medications, particularly the misuse of narcotic pain medications. The Centers for Disease Control and Prevention (CDC) has stated that prescription drug abuse is the nation’s fastest-growing drug problem; the CDC has even classified prescription drug abuse as an epidemic (Office of National Drug Control Policy, n.d.). Government data show that one third of teenagers who use a drug recreationally for the first time are engaging in the nonmedical use of a prescription drug (Office of National Drug Control Policy, n.d.). There was a steady increase in dispensing opioid medications in the United States which began in 2006 and which peaked in 2012 with 255 million prescriptions for opioid medications or 81.3 prescriptions per 100 persons. However, between 2012 and2019 the dispensing rate of opioid medications declined to 153 million or 46.7 opioid prescriptions per 100 persons (Centers for Disease Control and Prevention, 2020). This increased availability of narcotic medications was likely a factor in their abuse (World Health Organization, 2020). Hydrocodone, oxycodone, and codeine combination products being the most common drugs of abuse (Centers for Disease Control and Prevention, 2020). Between 1999 and 2019 three waves of opioid overdose medications claimed the lives of about 500,000 people. The first such wave began in the 1990 ’s and involved prescription opioid medications and methadone; the second began in 2010 with a rapid increase in overdose deaths from heroin and the third wave began in 2013 and involved a significant increase in overdose
deaths from synthetic opioids, particularly fentanyl (Centers for Disease Control and Prevention, 2021). Clearly, prescription opioid abuse is a serious problem in the United States and elsewhere. However, most individuals who abuse prescription medications are not the patients themselves. It is estimated that among those who abuse opioid medications, about 1% took them from a family member for whom a legitimate prescription for an opioid medication was made (Reinberg, 2017). It is mandatory that prescribed opioid medications are kept in a secured location and that the initial number of pills are recorded and those used should be deducted from the initial count with discrepancies investigated immediately. Those in the 18 to 25 age range represent the greatest past-year nonmedical use of opioids with the greatest use of prescription medications among those 26 years of age or older (Phillips, 2017). The overwhelming majority of individuals who are legitimately prescribed opioid medications for pain will not develop true addiction. Although definitions of the term addiction have varied, according to a large-scale meta-analysis of all published studies, only a small percentage of individuals prescribed opioid medications for pain can be categorized as having true addiction as defined below (National Institute of Drug Abuse, 2021). When assessing opioid misuse, it is important to understand the differences among three related concepts: physical dependence, tolerance, and addiction: ● Physical dependence : Is a state of biological adaptation in which the human body has adjusted to a drug and negative effects are encountered when the drug is abruptly stopped or reduced. However, dependence is different from addiction, most importantly because opioid medications will almost always create physical dependence when used over long periods of time. The human body will adjust to the presence of opioids, but pain and other withdrawal symptoms will emerge when opioids are stopped abruptly (World Health Organization, 2020). ● Tolerance : Means that an individual requires higher doses of the same drug to obtain the same effects (in this case, pain relief) (National Institute on Drug Abuse, 2020). Larger doses of medications are required because the hepatic enzymes of the cytochrome P-450 system which metabolize drugs become more active (Lynch, 2019). Although dose-escalation of opioids is a difficult clinical problem, it is not unusual for people with chronic pain to require increased dosages over time. Like dependence, however, tolerance is not synonymous with true addiction. ● Addiction : Is a chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development. True addiction is much more than just physical dependence or tolerance. The American Chronic Pain Association (2013); (American Psychiatric Association, 2013) characterizes addiction by four key elements, known as the “4 C’s”: compulsive use, loss of control, craving, and continued use despite consequences: 1. Compulsive use might include preoccupation with taking the drug, stockpiling the drug, or “doctor shopping” to obtain more of the drug. 2. Loss of control involves the inability to exercise restraint with respect to the desired quantity, frequency of use, or taking higher dosages than prescribed. 3. Craving the psychological drug effects includes a strong desire for the euphoric feeling experienced when taking the drug (i.e., feeling “high”) rather than for physical pain relief. 4. Use of the drug is continued despite its adverse effects or awareness of the negative consequences, which may include family conflict, financial or legal problems, and difficulties with employers, declining health, and other consequences.
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