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Opioid misuse in gastroenterology and non-opioid management of abdominal pain

Key Points

  • Prescription opioid use is a global epidemic, with substantial increases in opioid-related morbidity and mortality around the world

  • There is a lack of evidence supporting the use of opioids for the management of chronic abdominal pain

  • Opioid use can have deleterious consequences on the gastrointestinal tract, including opioid-induced constipation and narcotic bowel syndrome

  • Many promising non-opioid pharmacological and nonpharmacological alternatives for treating abdominal pain exist; however, additional research is needed to identify best practices for treating abdominal pain in individuals with gastrointestinal disorders

  • If opioids are prescribed, it is essential to have strategies to monitor and manage opioid misuse, continually monitor risk–benefit clinical profiles, and prevent and treat addiction

Abstract

Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates. Chronic opioid use for noncancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction. This Review summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain–gut axis. Guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders are also discussed. As chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best.

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Figure 1: Trends in total opioid consumption by country between 1994 and 2014.
Figure 2: Summary of opioid-induced effects within the gastrointestinal system.
Figure 3: Putative mechanisms for narcotic bowel syndrome and other models of opioid-induced hyperalgesia.

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Acknowledgements

M.K. is supported by NIH Award Number T32NR009759.

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Correspondence to Eva Szigethy.

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E.S. is a consultant for AbbVie and has received royalties from American Psychiatric Association Publishing, grant support from the NIH, the Crohn's & Colitis Foundation and the Bruce and Cynthia Sherman Foundation, and honoraria for educational talks for Imedex and the American Academy of Child and Adolescent Psychiatry. D.D. is President of the Rome Foundation and has been on advisory boards for Allergan, AstraZeneca, Ironwood and Shionogi in the past year.

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Szigethy, E., Knisely, M. & Drossman, D. Opioid misuse in gastroenterology and non-opioid management of abdominal pain. Nat Rev Gastroenterol Hepatol 15, 168–180 (2018). https://doi.org/10.1038/nrgastro.2017.141

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