Although gastroenterologists rarely initiate opioid therapy for chronic abdominal pain, it’s not unusual to inherit patients who have been prescribed opioids. That puts GIs in the position to make an important difference in their patients’ lives and the nationwide opioid epidemic, according to Eva Szigethy, MD, PhD, associate professor of psychiatry, pediatrics and medicine, and director of the Visceral Inflammation and Pain Center at the University of Pittsburgh Medical Center, PA.
“Irritable bowel syndrome, alone or in combination with other diagnoses, inflammatory bowel disease and chronic pancreatitis are the three GI populations most often managed with chronic opioid pain management, for which there’s little to no evidence,” said Dr. Szigethy, who will co-moderate Monday’s AGA Clinical Symposium Impact of America’s Opioid Epidemic on the Practice of Gastroenterology.
While there’s little upside to prescribing opioids, the downside is clear, she added.
“There’s an abundance of evidence about opioid-induced negative effects both in the brain in terms of addiction, narcotic bowel syndrome and overdose, as well as in the GI tract with constipation, gastric reflux, nausea and vomiting,” she said.
The good news, Dr. Szigethy said, is a growing body of evidence that supports non-opioid management of chronic pain. These approaches are based on a growing understanding of the neuroscience of brain-gut interactions.
Tricyclic antidepressants, duloxetine and gabapentin can all be effective pharmacologic agents for chronic pain. A variety of procedural interventions can also help, including nerve blocks and stimulation units that act on the peripheral nervous system and the brain itself. Trigger point injections may also be a viable alternative to opioids, as are wearable analgesic medication pumps.
Nonpharmacological management strategies focus on treating the whole patient, addressing the psychobehavioral problems that prolong pain and cultivating wellness.
“GIs can also be much more aware that chronic pain travels with anxiety and depression,” Dr. Szigethy said. “Screening for anxiety and depression can help deal with some of the modifiable risk factors that will improve patients’ wellbeing. We should be putting our emphasis not just on pain relief but also improving the functioning of these patients.”
Gastroenterologists often find themselves caught in the middle when it comes to managing chronic abdominal pain, she added. They are more familiar with the often-debilitating gut side effects of opioids than primary care providers and most specialists, which she said is one reason GIs so seldom initiate opioid-based therapy.
GIs may also feel pressured by patients who want a quick fix for their abdominal pain, and may even feel threatened by the specter of low patient satisfaction ratings.
“You may give the appropriate medical advice for avoiding narcotics for pain relief, but it may not be well received by patients,” Dr. Szigethy said. “What you can do is point out that what you are recommending is in line with guidelines from almost every medical organization that issues pain guidelines.
“The first strategy is preventive — avoid opioid use altogether,” she continued. “The second strategy is short-term use. Even in short-term use, frame it as a trial, not proven therapy, and never [initiate it] unless you have done an assessment of the patient’s abuse potential and have set up a treatment contract with the patient.”
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