October 1st, 2010
The New Epidemic: Narcotic Bowel and Abdominal Pain
I remember clearly when “pain” became a vital sign. As I suspect most medical professionals felt, chronic pain was a serious and disabling symptom that was poorly treated for the most part. The last decade of expanding research into mechanisms and treatments of chronic pain has brought enormous relief to the millions that suffer from this symptom.
However, it has also resulted in a growing and devastating new problem and that is visceral hyperalgesia (abdominal pain) from chronic narcotics used to treat pain. Whereas most health care professionals know that narcotics can cause alteration in bowel function (constipation from slowed colonic transit, nausea and vomiting from delayed gastric emptying, etc.), I suspect most are not aware that narcotic bowel from chronic narcotic use also includes abdominal pain arising from narcotic induced visceral hypersensitivity.
It has been said that the most common reason for consultation to a GI doctor is for IBS, but in my practice, the most common consult is now for abdominal pain that is secondary to chronic narcotic use. This is the new GI epidemic in the U.S. in my opinion.
Have you been seeing these patients as well? What are you telling them and the referring provider? Let us know what you think.
2 Responses to “The New Epidemic: Narcotic Bowel and Abdominal Pain”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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I believe there are two sides to the pain epidemic. Having worked with cancer patients with advanced metastatic disease, I certainly understand the physicians who believe that in this group pf patients, pain should be a vital sign and its palliation should take priority.
However I have also worked with the patients who possibly may have visceral hyperalgesia, in retrospect most of whom were diabetic patients. In this group, pain control is difficult to deal with, and they tend to return over and over again for the same symptoms,, usually EGD and colonoscopy negative. Another subgroup are the sickle cell patients, some of whom start out doing well on non narcotic analgesia, however needing narcotics or switching to a provider who considers this as a first option, they tend to get this chronic (usually)abdominal pain only relieved and sometimes worsened by narcotics. The last two subgroups are usually difficult to manage, and a number of them become narcotic dependent.
Narcotics have both inhibitory and excitatory pathways in the gut, the latter thought to be the mechanism of NBS – thus, short-lived analgesia followed by rebound pain from stimulation of the pro-pain pathway. One potential treatment other than tapering off narcotics, is a narcotic combined with 1/10 the usual dosage of a narcotic antagonist. Much improved analgesia plus no reversal. DDW 2010 also had an abstract(Jill Smith, Penn State) that there were unexplained and beneficial immune modulation from this combo in a small group of Crohn’s patients showing benefit. It would be fascinating to see followup investigation.