Proactive pain management in patients with IBD, using a bundle with acetaminophen, gabapentin, and NSAIDs, reduces opioid use and maintains effective pain control.
The prevalence of pain in IBD itself is quite high, and this is even in patients not in the hospital. Patients with inflammatory bowel disease suffer from chronic symptoms that can include pain, particularly people with Crohn’s disease, certainly people with ulcerative colitis as well, particularly when the disease is active. But pain is a pretty common feature of Crohn’s disease and is included in all the disease activity assessment scales that we use for Crohn’s disease. When somebody’s in the hospital, we’re talking about acute pain on top of chronic pain. And in that regard, patients with IBD represent probably the group within gastroenterology, which is the highest in need of addressing pain, particularly as it’s in the hospital.
When patients are admitted, they’re often admitted for symptoms of a bowel obstruction or disease flare. And these are all characterized in addition to other symptoms by significant abdominal pain. I don’t know that opioid use in this population is associated with different kinds of outcomes than it is in the general population, but they may be exacerbated. So in the general population, we certainly understand the consequences of opioid use as relating to potential overdoses of opioids. That in and of themselves can lead to respiratory depression, and that’s usually the cause of death or things that happen while somebody’s using opioids in the sense of compromised neurological function and an aspiration that it can occur. But we’re not even talking about that. There’s dependency that can occur with a need for increasing doses of opioids over time that can then lead to accidental overdoses. But even just routine, a single dose of opioids can also have significant effects.
For example, in the gut with slowing down of the gut motility constipation. And in somebody with, let’s say a bowel obstruction or partial bowel obstruction with a lot of abdominal pain, that represents a real dilemma. For example, somebody with Crohn’s disease presenting in that way, because we’re already concerned about the inability of contents to pass through the intestinal tract due to mechanical obstruction and exacerbating that gut motility through these of opioids can add significantly. So in that sense, opioids are desired by the patient or desired by the healthcare team as a way of alleviating pain. But at the same time, it can also exacerbate pain because it can worsen that overall inability of the gut to function normally in allowing its contents to pass through. So in that sense, it can be a double-edged sword and can actually lead to worsening of the situation it’s trying to treat.
The gastroenterologist is often looked to direct the care of patients with inflammatory bowel disease given the complexities of IBD care, and this may extend beyond the medications or the guidance around the specifics of treatment of the disease activity and really broaden towards the overall holistic care of the patient. And in this regard, gastroenterologists may be looked at for guidance by the general medical team or the surgical team for all things medical and should therefore prompt gastroenterologists to really understand and be aware of pain. Its manifestations and most appropriate ways to address it in our IBD patients. I think this is going to require an understanding of what the current pain protocols are in a given health system or in a given hospital. There may not be standardized protocols shared across all systems, although I do think that many systems are looking to adjust the traditional ways of treating pain, which have historically relied upon sliding scales of pain that lead to escalating doses of opioids in order to address greater severity of pain.
So for example, historically we might’ve asked the patient, where are you on a pain scale? And for the lower end of the pain scale, they might get a lower dose of an opioid and a higher end of a pain scale. They might get a higher dose of an opioid or a chronically or around the clock administered opioid. And so the way pain scales might be adjusted is to start to think about proactive ways of addressing pain rather than reactively responding to the patient’s needs using a scale. Now, I think that proactive approaches anticipate that certain groups of patients are going to have pain and therefore getting them on something in a proactive way before the pain manifests is a real change in the paradigm of how we think about pain. I think we still need to be able to respond to pain. We still need to be able to give patients something over and above whatever…
Read More: A Proactive Pain Management Protocol in Crohn’s Disease