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Narcotic Bowel Syndrome

Narcotic Bowel Syndrome. A Case of Narcotic Bowel Syndrome Successfully Treated with Clonidine Voishim Wong, George Sobala, and Monty Losowsky Postgrad Med Journal 1994; 70:138. Editorial: The Narcotic Bowel Syndrome M. Rogers and J. Cerda, J Clin Gastroenterol, 1989; 11(2):132.

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Narcotic Bowel Syndrome

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  1. Narcotic Bowel Syndrome A Case of Narcotic Bowel Syndrome Successfully Treated with Clonidine Voishim Wong, George Sobala, and Monty Losowsky Postgrad Med Journal 1994; 70:138 Editorial: The Narcotic Bowel Syndrome M. Rogers and J. Cerda, J Clin Gastroenterol, 1989; 11(2):132 Narcotic Bowel Treated with Clonidine John E. Sandgren, Mark S. McPhee, and Norton J. Greenberger Ann of Int Med 1984; 101:331

  2. Narcotic Bowel Syndrome The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and Management David M. S. Grunkemeier, Joseph E. Cassara, Christine B. Dalton, and Douglas A. Drossman Grunkemeier, DMS et al., Clin Gastroenterology and Hepatology 2007; 5:1126

  3. Opioid related bowel dysfunction • Opioid bowel dysfunction • constipation, nausea, bloating, ileus, and sometimes pain • Narcotic bowel syndrome (NBS) • abdominal pain is the predominant symptom • progressive and paradoxical increase despite continued or escalating dosages of narcotics prescribed to relieve the pain • Under recognized Pappagallo. Am J Surg 2001;182:11S–18S Mehendale, Yuan. Dig Dis 2006;24:105–112 Grunkemeier et al. Clin Gastro Hep 2007;5:1126-1139

  4. Chronic Narcotics for Non-Malignant Pain Control • 1980’s low-dose narcotics introduced as part of multi-component pain management program for nonmalignant pain • Shift toward costly, rapidly absorbed narcotics without clear benefit • Chronic pain patients have significant impairment on multiple QOL measures, including physical, psychological and social well being • Encouraging passivity • Enabled by 3rd party payers JAMA. 1995;274(23):1881-2

  5. Opioids in Chronic pain • Inadequate treatment of pain - lack of knowledge about pain management - inadequate understanding of addiction - fear of investigation by federal, state, local agencies Trescot et al. Pain Physician 2006;9(1):1-39 Fleming et al. Mo Med 2002 ;99(10):560-5.

  6. Opioid Use in Chronic pain • As many as 90% of patients – receive opioids for chronic pain management Ballantyne et al. N Engl J Med. 2003;349(20):1943-53 Chou et al. J Pain Symptom Manage. 2003;26(5):1026-48 • The frequency of overall opioid use among patients with back pain – 68% Luo et al. Spine. 2004;29(8):884-90 • Medicaid patients more likely to receive prescription opioids (73% Medicaid vs. 40% commercial insurance) Trescot et al. Pain Physician. 2006;9(1):1-39

  7. Opioids & Pain-Related Visits in Emergency Department • Pain-related visits: 42% Emergency Department visits • Opioids prescribing for pain-related visits increased from 23% in 1993 to 37% in 2005 • Overall, white patients with pain were more likely to receive an opioids than black, Hispanic, or Asian patients. Pletcher et al. JAMA. 2008;299(1):70-8.

  8. ER Pain-related Visits at which an Opioid was Prescribed, by Race and Survey Year NHAMCS 1993-2005 Pletcher et al. JAMA. 2008;299(1):70-8.

  9. Retail Sales of Opioid Medications 1997-2002 1997 2002 % change Morphine 5,922,872 10,264,264 73.3 Hydrocodone 8,669,311 18,822,618 117.1 Oxycodone 4,449,562 22,376,891 402.9 Methadone 518,737 2,649,559 410.8 Trescot et al. Pain Physician 2006;9(1):1-39

  10. Annual Numbers of New Non-Medical Users of Pain Relievers: 1965-2002 Substance Abuse and Mental Health Services Administration (2004) Trescot et al. Pain Physician. 2006 Jan;9(1):1-39

  11. Non-Medical Use of Prescription Drugs • Opioids, CNS depressants and stimulants - Abuse and addiction of these controlled prescription have been sharply rising • Between 1992 and 2003, while the US population increased 14%, the number of people using controlled prescription drugs jumped 94% Bollinger et al. The National Center on Addition and Substance Abuse at Columbia University (CASA), July 2005.

  12. Drug abuse related emergency department visitsinvolving narcotic analgesics and benzodiazepines US Department of Health and Human Services. April 2004. Trescot et al. Pain Physician. 2006 Jan;9(1):1-39

  13. The US with 4.6% of the world’s population uses 80% of the worlds opioids! Trescot et al. Pain Physician. 2006 Jan;9(1):1-39

  14. NBS – Diagnostic Features • Chronic or intermittent colicky abdominal pain that worsens when the narcotic wears off • Pain is dominant, but bloating, anorexia, N/V, distension and constipation are common (opioid bowel) • Clinical evaluation: ileus or pseudo-obstruction with retained fecal material • Worse with eating; sitophobia; decreased meals can lead to mild weight loss and • May occur with healthy post-surgical patients given high dosages for long period of time • May be more problematic in patients with chronic GI disorders, particularly FGIDs • A proportion of these patients may be narcotic seeking

  15. Diagnostic Criteria: Narcotic Bowel Syndrome Chronic or frequently recurring abdominal pain treated with acute high dose or chronic narcotics and: • The pain worsens or incompletely resolves with continued or escalating dosages of narcotics • There is marked worsening of pain when the narcotic dose wanes and improvement when narcotics are reinstituted (“Soar and Crash”) • There is a progression of the frequency, duration and intensity of the pain episodes • The nature and intensity of the pain is not explained by a current or previous GI diagnosis* *A patient may have a structural diagnosis (e.g., IBD, chronic pancreatitis, but the character or activity of the disease process is not sufficient to explain the pain Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126

  16. Patient 1 • 42 yo woman with h/o 3CS’s & adhesion lysis, IBS for > 20yrs but worsening, new lower abdominal pain x 3 yrs • Pain was persistent, not relieved by defecation and seemed different from her more typical IBS symptoms • Pain associated with abdominal bloating, nausea, vomiting, and depressive symptoms • PCP has been prescribing oxycodone (10 mg tid) for pain and clonazepam and paroxetine for anxiety and depression • Twice tried to stop narcotics but was unsuccessful due to increasing pain Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126

  17. Functional pain disorders particularly vulnerable to being treated with narcotics • Abdominal pain is a key feature and associated with: •  illness severity, health care visits and costs, psychosocial distress •  coping, daily function and HRQOL • Strong predictor of health care seeking • 43% of patients admitted for abdominal pain are discharged from hospitals with no specific explanation for their pain • No other treatment options • Up to 30% of FGID experience severe daily symptoms • Narcotics are more likely prescribed when symptoms are severe and patient demands pain relief Spiegel et al. Arch Intern Med 2004;164:1773-1780 Spiegel et al. Am J Gastroenterol 2008 (in press) Lembo A et al. CGH 2005;3:717–725 Grunkemeier D.M.S. et al. CGH 2007, 5:1126 Gray DW et al. Br J Surg 1987;74:239–242

  18. Development of NBS • Patient presents with chronic or recurrent abdominal pain which is treated with narcotics • Narcotics may relieve pain initially but then tachyphylaxis occurs • Pain worsens when the narcotic effect wears off • Shorter pain-free periods result in increasing narcotic doses • Increasing doses further adversely affect motility and enhance visceral pain sensation Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126

  19. Patient case 2 • 20 yo woman with a 16 mo h/o narcotic use (methadone 260 mg/d) for low back pain • Admitted with RLQ pain constipation; methadone tapered to 230 mg/d and enemas given • W/U showed 6 cm ovarian teratoma, resected, post op pain continued. D/C’d on prior methadone dose. • 3 days later, patient returned with N/V, RLQ pain • Studies: • CT scan: short segment of TI thickening and retained fecal material • Colonoscopy: congested TI without obstruction; biopsies showed mild chronic active ileitis • SBFT:20 cm of thickened, non-obstructing TI Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126

  20. Patient 2 • Narcotics reinstituted for pain presumed due to Crohn’s disease and pain got worse • The GI service determined that although the patient had Crohn’s disease, the pain pattern was related clinically with NBS • Corticosteroid and 5-ASA were started and methadone was tapered gradually over 11 days successfully • 6 months reported no functional limitations, no back pain • 1 yr relapsed, stopped IBD meds, restarted narcotics & had wt loss, iron def anemia. Tapered over 4 days, w/in 1 month regained wt, ↑ hgb. • History of repeated use of narcotics with worsening pain and improvement in pain with withdrawal of narcotics Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126

  21. NBS also prevalent in organic GI disorders • Because the pain can be attributed to an underlying disease, the physician may feel justified to use narcotics even when the disease activity is not sufficient to explain pain • Careful assessment of disease activity relative to the patient’s pain behavior is needed • It should be recognized that with functional and organic GI conditions, patients can have visceral hypersensitivity and central factors which may amplify visceral perception Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126

  22. “Whoa – way too much information !”

  23. Patient 3 • 20 yo woman, h/o UC, s/p IPAA 1 yr ago • Admitted with severe midepigastric abdominal pain, no change in BM’s • CT free fluid in RUQ and mod stool in J-pouch→ Narcotics for pain control & txfr UNC for further care

  24. On SRG svc, morphine increased to 90mg/day due to lack of response • EGD neg, pouch endoscopy with multiple 3-4mm erosions, ? Crohn’s • VCE attempted but retained in stomach with food due to poor motility • MRI/MRCP normal, pelvic U/S small ovarian cysts • On 2nd week, exlap due to continued pain, nausea, vomiting. Negative • Postop pain continued → 360mg/day morphine. • Refused psychiatry → txfr Med Svc →GI consult with successful 5 day detox.

  25. Just before d/c, found to be sequestering syringes under bed and manipulating IV bag • Wanted return to narcotics due to pain • Would only leave hospital if PICC left in, but ultimately did leave • Went to PCP next day→narcotics. • Hospitalized at outside hospital, s/o AMA when docs wouldn’t give narcotics • Another hospital for ? Bowel obstruction→ narcotics • Several months later, UNC IBD clinic denied narcotics but UTOX positive

  26. In summary, pain though due to complication of IPAA, but found due to NBS • Detoxification complicated by drug seeking behavior and ultimately doctor peregrination → narcotic restriction and treatment impossible

  27. Contribution of Physician-Patient Behaviors • Nonverbal communication of pain behaviors more predictive of the prescribing of narcotics than clinical evidence of disease • Time constraints for patient-physician interaction and increasing use of diagnostic tests reduce patient-centered care, effective communication, gathering of relevant information, and proper-decision making • Patient is discharged without a diagnosis or appropriate treatment plan but with narcotics for pain Turk DC et al. Clin J Pain 1997;13:330-336 Drossman DA. Gastroenterology 2004;126:952-953

  28. Contribution of Physician-Patient Behaviors • PCP must then deal with lack of diagnosis and prescribing of narcotics • Ambivalence or conflict about prescribing narcotics • Dialog about narcotic use may interfere with adequate discussion of other treatment options • Physician may be unwilling or unable to manage the clinical condition • Patient may feel hopeless and angry at the physician when the request for narcotics is rejected Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126 Drossman DA. Am J Gastroenterol 1997;92:1418-1423

  29. Narcotic Bowel Syndrome Pain Narcotics Narcotics Vicious Cycle of Patient - Physician Interactions Maladaptive Therapeutic Interaction Narcotic Bowel Syndrome Physician Frustration Patient Frustration “Negative” evaluations “Furor Medicus” Healthcare / Societal Pressures Increased Healthcare Utilization Emergency Room Visits

  30. Summary • NBS is a clinical condition that is a subset of opioid bowel dysfunction • Main feature is chronic or recurrent abdominal pain which worsens or incompletely resolves with continued or escalating dosages of narcotics • NBS can occur with FGID or organic diseases • Limitations in health care system affecting patient-physician communication, gathering of relevant information, proper decision-making and lack of recognition of NBS and knowledge of alternative treatments for pain contribute to increasing narcotic use

  31. Narcotic Withdrawal Protocol Physician – Patient Relationship -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21 Day of taper

  32. Clinician-Patient Process and Techniques • Accept the pain as real (validate) and treatable (hope) • “I can see the pain has really affected your life” • “We can work together on this”

  33. Clinician-Patient Process and Techniques • Accept the pain as real and treatable • Elicit the patient’s concerns and expectations • “What are your biggest worries or concerns about being on narcotics (and going off narcotics)?” • “What do you expect will happen when you stop narcotics?”

  34. Clinician-Patient Process and Techniques • Accept the pain as real and treatable • Elicit the patient’s concerns and expectations • Provide information through a dialog: • Address the patient’s stated concerns and expectations • Provide a physiologic basis for the pain • “Pain in the body is experienced in the brain where it can turn ‘pain volume’ up or down depending on the circumstances (give examples)” • Discuss the effects of narcotics on pain and GI function • “Narcotics slow the bowels producing the constipation, bloating and vomiting you are having; they also sensitize the nerves to turn up the ‘pain volume’ thus making the pain worse” • Explain the rationale for and process of withdrawal • “It is likely you will be better and certainly no worse when you are off the narcotics. We will be substituting other pain control methods while we gradually taper the narcotics (so you won’t be abandoned in pain)”

  35. Clinician-Patient Process and Techniques • Accept the pain as real and treatable • Elicit the patient’s concerns and expectations • Provide information through a dialog • Present the withdrawal program • Use illustrations or graphics • Involve a responsible family member • Indicate that someone will be available to address possible side effects or flare-ups

  36. Clinician-Patient Process and Techniques • Accept the pain as real and treatable • Elicit the patient’s concerns and expectations • Provide information through a dialog • Present the withdrawal program • Gauge the patient’s response • Willingness to go through the program • Degree of participation • Keep a log? • “Whatever you say doc” • Non-verbal behaviors and “meta-language” • Address challenging questions • “How do you know you’re still not missing something?” • “What if I get a bad attack?” • “What if these other medicines make me sick?”

  37. Narcotic Withdrawal Protocol • Accept pain as real and treatable • Elicit patients concerns/expectations • Provide information through a dialog • Present the withdrawal program • Gauge the patient’s response TCA or SNRI PEG 3350 17g PO BID Physician – Patient Relationship -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21 Day of taper

  38. Antidepressant Receptor Site Effects NE 5HT Histamine Ach TCAs (25-150 mg) Amitriptyline (3o) +++ +++++++ ++++ Doxepin (3o) ++ +++++++ ++ Desipramine (2o) +++ ++++ + Nortriptyline (2o) +++ +++ ++ SSRIs (1-2 pills) Citalopram nil++++nil nil Escitalopram nil ++++ nil nil Fluoxetine nil++++nil nil Paroxetine nil++++nil nil Sertraline nil++++nil nil SNRI’s (variable) Venlafaxine ++ ++nil nil Duloxetine +++ +++nil nil

  39. Antidepressants • Tricyclics (e.g., Desipramine, Nortriptyline, Amitriptyline) • Pain benefit • Anticholinergic and Histaminic side effects + constipation • Side effects affect adherance • Specific effects • Desipramine/Nortriptyline fewer side effects • SNRIs (e.g., Duloxetine, Venlafaxine) • Pain benefit • Nausea side effects • Duloxetine first to be marketed for “pain with depression” • Venlafaxine requires higher dosage (225 mg.) for pain benefit • SSRIs (e.g., Paroxetine, Citalopram, Escitalopram, Fluoxetine) • Anxiolysis benefit • Can augment TCA effect on pain via anxiolysis • Anxiety is initial side effect + diarrhea • Helpful for social phobia, agoraphobia, OCD (higher dosages)

  40. Antidepressant Treatment TCA SSRI SNRI Potentialpain (pain) pain benefits depression depression,panic, depression anxiety, OCD Adverse events Risk from overdose moderate minimal minimal Efficacy for IBS good not studied good? Dose Adjustment yes not usual varies Cost / month $5-30 $40-80 $60-100 Nausea, Agitation, Dizziness, Sleep disturbance, Fatigue Liver dysfunction Sedation, Hypotension, Constipation, Dry mouth/eyes, Arrhythmias, Weight gain, Sex dysfunction Insomnia, Agitation, Diarrhea, Night sweats, Headache Weight loss, Sex dysfunction

  41. Narcotic Withdrawal Protocol Accept pain as real and treatable Elicit patients concerns/expectations Provide information through a dialog Present the withdrawal program Gauge the patient’s response Lorazepam 1mg PO q 6hrs. TCA or SNRI 220 200 180 160 140 120 100 80 60 40 20 0 Morphine equiv. Dose (mg) PEG 3350 17g PO BID Physician – Patient Relationship -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21 Day of taper

  42. Narcotic Withdrawal • Clinical setting • Inpatient • If complicated by nausea, vomiting, ileus or pseudo-obstruction • Limited motivation or social support • Requires monitoring • Withdrawal can occur over several days • Outpatient • Patient is highly motivated • Withdrawal can take days to weeks • Start medium acting benzodiazepine (e.g., lorazepam) • Narcotic tapering • Start with maximal daily dose of medium to long acting narcotic (more frequent dosing needed for short acting opiates) • Standardize all narcotics to one dose (morphine equivalents) • Non-contingently reduce 10-33% each day (e.g., off on 4th day with 33% reduction qd) • NO prn or breakthrough dosing)

  43. Narcotic Withdrawal Protocol Accept pain as real and treatable Elicit patients concerns/expectations Provide information through a dialog Present the withdrawal program Gauge the patient’s response Clonidine 0.1mg PO q 6 hrs. Lorazepam 1mg PO q 6hrs. TCA or SNRI 220 200 180 160 140 120 100 80 60 40 20 0 Morphine equiv. Dose (mg) PEG 3350 17g PO BID Physician – Patient Relationship -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21 Day of taper

  44. Centrally Acting Augmentation • Clonidine • α2-adrenergic agonist with central (anxiety reduction) and peripheral (pain reduction via bowel compliance) effects • Helps reduce diarrhea • Prevents adrenergic effects of narcotic withdrawal • Mirtazepine • Serotonergic and noradrenergic drug with 5HT2 and 5HT3 effects – can have pain benefit • Use with nausea, anorexia, weight loss, diarrhea • Some sedation • Buspirone • Azapirone with anti-anxiety effects acting on non BZD GABA receptors • Has 5HT1 and 5HT2 effects • May augment the effect of the antidepressant

  45. When Will Program Work? • The patient • Has no history of drug seeking behavior or other substance use • Recognizes the adverse effects of the narcotics • Understands there are other treatment options for pain relief • Is motivated at start and throughout treatment (no “bargaining”) • The physician • Believes in and communicates commitment to the patient and the treatment plan • Is comfortable in coordinating the treatment (medications, availability) • Will personally follow up or set up resources (psychologist, primary care doc, PA or FNP) to do so • The treatment interaction is collaborative • Health care resources are available • Psychologist • Primary care clinician

  46. Interferences With Successful Outcome • Negotiation (“Just one more day”) • Determine if it relates to anxiety about treatment failure, ambivalence, lack of desire to continue or malingering • Explore and discuss patient concerns • May not have been previously addressed • May fear being abandoned in the care • Provide solutions • Continue discussions • Reduce time between dosing maintaining daily dosage • Adjust or add other medications (.e.g. Ketorolac) • Rapidly tapers or abruptly withdraws narcotics • Patient may not have understood protocol • Trying to prove he/she can do it or to “get it over with” • Sabotage(“See it does not work”)

  47. Interferences With Successful Outcome • Seeks additional help elsewhere • May be due to lack of trust with diagnosis • Risk of seeing physicians who again prescribe narcotics • Provide solutions • Encourage patient to work with one treating physician • Identify and communicate with other physicians involved • Copy records to other physicians • Be vigilant to drug seeking behaviors

  48. Narcotic Bowel Syndrome Pain Narcotics Narcotics Vicious Cycle of Patient - Physician Interactions Maladaptive Therapeutic Interaction Narcotic Bowel Syndrome Physician Frustration Patient Frustration “Negative” evaluations “Furor Medicus” NBS treatment, Narcotics withdrawal Healthcare / Societal Pressures Increased Healthcare Utilization Emergency Room Visits

  49. Narcotics & the Gastroenterologist: Take Home Points • Increasing use of narcotics for chronic non-malignant pain • Need to be aware of nonverbal pain behavior and pain out of proportion to clinical findings • Consider narcotic bowel syndrome in patients with escalating abdominal pain who use opioids

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