Dain Schroeder received his first opioid prescription for Crohn’s disease from a probably benevolent, but possibly misguided gastroenterologist. With that first order for hydrocodone, Mr. Schroeder started down a path of increasingly potent narcotics, emotional challenges, painful opioid withdrawals and stigma that came from within the health care system.
After years of struggling with prescription narcotics, Mr. Schroeder has some strong thoughts for providers who are tempted to treat the pain of inflammatory bowel disease (IBD) with opioids.
“The medical system has failed me in so many ways that it’s almost an embarrassment,” said Mr. Schroeder, a 26-year-old freelance journalist in Quincy, Wash.
Mr. Schroeder’s story (sidebar) is not uncommon, given that as many as 20% of outpatients with IBD use prescription opioids on an ongoing basis (Inflamm Bowel Dis 2014;20:2234-2238). That number is particularly high, as there is no evidence that long-term opioids are effective for treating chronic abdominal pain, said Eva Szigethy, MD, PhD, associate professor of psychiatry, pediatrics and medicine and director of the Visceral Inflammation and Pain Center in the Division of Gastroenterology at the University of Pittsburgh.
“What we do know is that the risks of opioid use quickly outweigh any benefits, and that long-term opioid use can actually aggravate the very pain it is intended to treat,” Dr. Szigethy said. As many as 10% of chronic opioid users can develop narcotic bowel syndrome, a condition of increased sensitivity to pain caused by changes in how opioids interact with their receptors.
“These central effects are different from the known peripheral side effects of opioids, such as slowed motility, which leads to painful constipation and distention, and can co-occur with narcotic bowel syndrome,” she said (Am J Gastroenterol 2014;2:22-30).
According to Dr. Szigethy, long-term use of opioids is accompanied by other potential harms, including an undesirable cycle of requiring stronger and stronger opioids, more adverse effects (e.g., nausea, sedation, urinary retention and pruritus) and greater functional impairment—not to mention the risk for overdose (Figure).
Although the proportion of IBD patients using opioids who develop addiction is unknown, certain subgroups of patients may be at relatively higher risk for abuse or dependence, such as those with a diagnosis of Crohn’s disease and comorbid irritable bowel syndrome, men and patients with a history of substance abuse, psychiatric diagnoses or trauma.
“Clinicians should watch for signs of abuse and drug-seeking in all patients,” she emphasized. “Those include using more than one pharmacy, running out of medication early, visiting more than one emergency room and reacting angrily if their opioid prescription is not renewed when they ask for it.”
Dr. Szigethy added an important caveat, noting that these behaviors might also be signs of physical tolerance, not necessarily abuse.
“Tolerance can lead patients to require higher and higher doses, and possibly more frequent prescriptions,” she explained.
Don’t Create a Problem
In the community setting, chronic use of opioids by patients with IBD is a “significant problem in a significant minority of patients,” said Alan Buchman, MD, MSPH, a gastroenterologist and colorectal surgeon at the University of Illinois at Chicago. The challenge of inappropriate opioid use for managing IBD pain “is not so much with the patients, but the physicians who prescribe these medications,” he said.
“My approach is to neither create a problem nor to continue it, so I don’t write prescriptions for narcotics other than tincture of opium or codeine to control diarrhea in Crohn’s disease patients with short bowel or, rarely, Tylenol #3 if I know there is very significant disease and inflammation,” Dr. Buchman said. “And I let surgeons manage postoperative pain.”
Although one might expect pain medicine clinicians to be better opioid stewards, Dr. Buchman noted that, in his experience, they have been sources of pain medication “rather than providers in a multidisciplinary approach to managing pain that includes behavioral therapists, physical exercise therapists and psychiatrists, if necessary [Table]. Instead of pain medicine doctors, I seek out addiction specialists for opioid-dependent patients, which, in my opinion, is often really what they need. And I ask that there only be one physician prescribing opioids.”
Opioid overuse can also complicate the management of IBD, Dr. Buchman added, because opioid-related abdominal pain from bowel distention and pseudo-obstruction may seem like an IBD obstruction caused by Crohn’s disease.
“When that happens, patients are at risk of overly aggressive treatment for active IBD, when in fact their IBD is inactive,” he explained.
As for Mr. Schroeder, reflecting on his own experience with receiving opioids, he wondered whether he was glad that he was ever administered these drugs.
“That’s a tough question,” he said. “I think it’s a wonderful thing that opioids exist, but for someone with Crohn’s, it’s important to weigh the risks versus the rewards incredibly carefully before taking that first pill. Two months of oral hydrocodone can lead to two years on transdermal fentanyl.”
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