BACKGROUND Eleven percent of American adults have chronic low back pain- and many of these individuals have severe, disabling, refractory pain. Many texts recommend against using opioids for these patients without citing original research. METHODS A MEDLINE literature search was conducted for original research on the use of opioids for chronic noncancer pain. Additional references were also sought from review articles and book chapters. Based on this research and the authors' clinical experience, recommendations were formulated for implementing chronic opioid analgesic therapy (COAT) for patients with chronic low back pain. RESULTS No controlled studies were found. Case series reports on a total of 566 patients suggest that COAT is safe and effective for many patients with recalcitrant chronic low back pain. Preexisting substance use disorders, personality disorders, certain medical conditions, and certain occupational factors are relative contraindications to COAT. Methods to prevent and monitor for drug problems among COAT recipients include contracts, family interviews, and drug testing. Pain and overall function are the key monitoring parameters. Once patients attain some relief, an exercise regimen should be initiated. Other nonpharmacologic treatments and nonopioids are also recommended. CONCLUSIONS Physicians are encouraged to consider COAT for selected patients with severe chronic low back pain who respond inadequately to other treatments.