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Transcript of Narcotic Bowel Syndrome Douglas A. Drossman, M.D. Co-Director UNC Center for Functional GI &...
Narcotic Bowel Syndrome
Narcotic Bowel Syndrome
Douglas A. Drossman, M.D.Co-Director
UNC Center for Functional GI & Motility DisordersChapel Hill, NC, USA
Douglas A. Drossman, M.D.Co-Director
UNC Center for Functional GI & Motility DisordersChapel Hill, NC, USA
Adverse Effects of Opioids on the BowelAdverse Effects of Opioids on the Bowel
Opioid bowel dysfunction (OBD)–Constipation, nausea, vomiting, bloating, ileus,
and sometimes pain
Narcotic bowel syndrome (NBS)–Abdominal pain is the predominant symptom
–Progressive and paradoxical increase in pain despite continued or escalating dosages of narcotics prescribed to relieve the pain
–Underrecognized
Opioid bowel dysfunction (OBD)–Constipation, nausea, vomiting, bloating, ileus,
and sometimes pain
Narcotic bowel syndrome (NBS)–Abdominal pain is the predominant symptom
–Progressive and paradoxical increase in pain despite continued or escalating dosages of narcotics prescribed to relieve the pain
–Underrecognized
Pappagallo. Am J Surg 2001;182:11S–18S Grunkenmeier et al. Clin Gastro Hep 2007;5:1126-1139Mehendale, Yuan. Dig Dis 2006;24:105–112Pappagallo. Am J Surg 2001;182:11S–18S Grunkenmeier et al. Clin Gastro Hep 2007;5:1126-1139Mehendale, Yuan. Dig Dis 2006;24:105–112 21242124
Narcotic Bowel SyndromeNarcotic Bowel Syndrome
A Case of Narcotic Bowel Syndrome Successfully Treated with ClonidineVoishim Wong, George Sobala, and Monty LosowskyPostgrad Med Journal 1994; 70:138
A Case of Narcotic Bowel Syndrome Successfully Treated with ClonidineVoishim Wong, George Sobala, and Monty LosowskyPostgrad Med Journal 1994; 70:138
Editorial: The Narcotic Bowel SyndromeM. Rogers and J. Cerda, J Clin Gastroenterol, 1989; 11(2):132
Editorial: The Narcotic Bowel SyndromeM. Rogers and J. Cerda, J Clin Gastroenterol, 1989; 11(2):132
Narcotic Bowel Treated with ClonidineJohn E. Sandgren, Mark S. McPhee, and Norton J. GreenbergerAnn of Int Med 1984; 101:331
Narcotic Bowel Treated with ClonidineJohn E. Sandgren, Mark S. McPhee, and Norton J. GreenbergerAnn of Int Med 1984; 101:331
19871987
Narcotic Bowel SyndromeNarcotic Bowel Syndrome
Grunkemeier, DMS et al., Clin Gastroenterology and Hepatology 2007; 5:1126Grunkemeier, DMS et al., Clin Gastroenterology and Hepatology 2007; 5:1126
The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and Management*
David M. S. Grunkemeier, Joseph E. Cassara, Christine B. Dalton, and Douglas A. Drossman
The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and Management*
David M. S. Grunkemeier, Joseph E. Cassara, Christine B. Dalton, and Douglas A. Drossman
19881988
* “Seminal paper” for 2007 – American College of Physicians
* “Seminal paper” for 2007 – American College of Physicians
Typical Clinical Presentation for NBSTypical Clinical Presentation for NBS Patient presents with chronic or recurrent abdominal
pain which is treated with narcotics
Narcotics may have relieved 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 alter motility and aggravate pain
Can occur with in patients FGID, organic disease or otherwise health subjects (e.g., post operative)
Patient presents with chronic or recurrent abdominal pain which is treated with narcotics
Narcotics may have relieved 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 alter motility and aggravate pain
Can occur with in patients FGID, organic disease or otherwise health subjects (e.g., post operative)
Grunkenmeier et al. Clin Gastro Hep 2007; 5:1126Grunkenmeier et al. Clin Gastro Hep 2007; 5:112621252125
Case 1: NBD Developing in FBDCase 1: NBD Developing in FBD 42 yo woman with h/o IBS for > 20yrs but worsening lower
abdominal pain x 3 yrs
PCP was prescribing oxycodone (10 mg tid) for pain and clonazepam and paroxetine for anxiety and depression
Pain seemed different from her more typical IBS symptoms: more persistent and not relieved by defecation
Pain associated with abdominal bloating, nausea, vomiting, and depressive symptoms
Twice tried to stop narcotics but was unsuccessful due to increasing pain
Was placed on outpatient detoxification and 1 year later she remained off narcotics with only mild IBS symptoms
42 yo woman with h/o IBS for > 20yrs but worsening lower abdominal pain x 3 yrs
PCP was prescribing oxycodone (10 mg tid) for pain and clonazepam and paroxetine for anxiety and depression
Pain seemed different from her more typical IBS symptoms: more persistent and not relieved by defecation
Pain associated with abdominal bloating, nausea, vomiting, and depressive symptoms
Twice tried to stop narcotics but was unsuccessful due to increasing pain
Was placed on outpatient detoxification and 1 year later she remained off narcotics with only mild IBS symptoms
Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21262126
Functional Pain Disorders Particularly Vulnerable to Being Treated with Narcotics
Functional Pain Disorders Particularly Vulnerable to Being Treated with Narcotics
Abdominal pain is a key feature and associated with:– Pain is a strong predictor of health care seeking
– 43% of patients admitted for abdominal pain are discharged from hospitals with no specific explanation for their pain
Perception of no other treatment options Narcotics are more likely prescribed when symptoms
are severe and patient demands pain relief
Abdominal pain is a key feature and associated with:– Pain is a strong predictor of health care seeking
– 43% of patients admitted for abdominal pain are discharged from hospitals with no specific explanation for their pain
Perception of no other treatment options Narcotics are more likely prescribed when symptoms
are severe and patient demands pain relief
Spiegel et al. Arch Intern Med 2004;164:1773-1780Lembo A et al. CGH 2005;3:717–725Spiegel et al. Arch Intern Med 2004;164:1773-1780Lembo A et al. CGH 2005;3:717–725
Grunkemeier D.M.S. et al. CGH 2007, 5:1126Gray DW et al. Br J Surg 1987;74:239–242Grunkemeier D.M.S. et al. CGH 2007, 5:1126Gray DW et al. Br J Surg 1987;74:239–242
21272127
Case 2: NBS with Crohn’s DiseaseCase 2: NBS with Crohn’s Disease
20 yo woman with a 16 mo h/o narcotic use (methadone 260 mg/d) for low back pain
Admitted with obstipation; methadone tapered to 230 mg/d and enemas given
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
20 yo woman with a 16 mo h/o narcotic use (methadone 260 mg/d) for low back pain
Admitted with obstipation; methadone tapered to 230 mg/d and enemas given
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; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21282128
Case 2: NBD with Crohn’s DiseaseCase 2: NBD with Crohn’s Disease Narcotics reinstituted for pain presumed due to Crohn’s
disease and pain got worse
The GI service was consulted and determined that although the patient had Crohn’s disease, the pain pattern was related clinically to NBS
Corticosteroids and 5-ASA were started and methadone was tapered gradually over 11 days
Pain improved with withdrawal of narcotics
Patient continued to use narcotics worsening pain that improved with withdrawal of narcotics (unrelated to CD activity)
Narcotics reinstituted for pain presumed due to Crohn’s disease and pain got worse
The GI service was consulted and determined that although the patient had Crohn’s disease, the pain pattern was related clinically to NBS
Corticosteroids and 5-ASA were started and methadone was tapered gradually over 11 days
Pain improved with withdrawal of narcotics
Patient continued to use narcotics worsening pain that improved with withdrawal of narcotics (unrelated to CD activity)
Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21292129
NBS Can Occur in Organic GI disorders
The pain is attributed to an underlying disease
The physician feels justified to use narcotics even when disease activity is not sufficient to explain pain
Assessment of disease activity relative to the patient’s pain behavior is needed
The pain is attributed to an underlying disease
The physician feels justified to use narcotics even when disease activity is not sufficient to explain pain
Assessment of disease activity relative to the patient’s pain behavior is needed
Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21302130
Case 3: NBD Developing PostoperativelyCase 3: NBD Developing Postoperatively 40 yo lawyer admitted with severe abdominal pain, n/v fever No history of previous GI symptoms Severe RLQ tenderness and leukocytosis surgery normal Postoperatively given 40 mg/day of IV Morphine Sulphate 2 weeks later increasing pain and obstipation; x-ray showed
partial small bowel obstruction 2nd surgery 6 cm. small bowel resected due to adhesions and SBO 1 wk laterperitonitis from anastamotic perforation3rd surgery Continued in hospital for 2 months on 406080 mg/day IV
morphine sulfate for severe pain n/v with “pseudo-obstruction GI consult diagnosed NBS and patient detoxified over 6 days Patient dischargedcontinued abdominal pain, bloating for 1 yr No difficulties over subsequent 10 years
40 yo lawyer admitted with severe abdominal pain, n/v fever No history of previous GI symptoms Severe RLQ tenderness and leukocytosis surgery normal Postoperatively given 40 mg/day of IV Morphine Sulphate 2 weeks later increasing pain and obstipation; x-ray showed
partial small bowel obstruction 2nd surgery 6 cm. small bowel resected due to adhesions and SBO 1 wk laterperitonitis from anastamotic perforation3rd surgery Continued in hospital for 2 months on 406080 mg/day IV
morphine sulfate for severe pain n/v with “pseudo-obstruction GI consult diagnosed NBS and patient detoxified over 6 days Patient dischargedcontinued abdominal pain, bloating for 1 yr No difficulties over subsequent 10 yearsGrunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21312131
NBS Can Occur in Otherwise Healthy PersonsNBS Can Occur in Otherwise Healthy Persons
Can occur postoperatively from high dosages of IV narcotics
Narcotics are justified because the pain and N/V is attributed to surgical injury and postoperative ileus
Surgery visceral hypersensitivity enhanced pain
Increased narcotics ileus pseudoobstruction
NBS develops
Can occur postoperatively from high dosages of IV narcotics
Narcotics are justified because the pain and N/V is attributed to surgical injury and postoperative ileus
Surgery visceral hypersensitivity enhanced pain
Increased narcotics ileus pseudoobstruction
NBS develops
Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21322132
Challenges for Physicians Challenges for Physicians
Physicians are ambivalent about prescribing narcotics for non-malignant chronic pain
Patient’s requests for pain relief difficult dialog about narcotic use. This can interfere with discussion of other treatment options
The physician may then feel unwilling or unable to manage the clinical condition negative interaction
Patient may feel hopeless and angry at the physician when the request for narcotics is rejected
Physicians are ambivalent about prescribing narcotics for non-malignant chronic pain
Patient’s requests for pain relief difficult dialog about narcotic use. This can interfere with discussion of other treatment options
The physician may then feel unwilling or unable to manage the clinical condition negative interaction
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; 5:1126Drossman DA. Am J Gastroenterol 1997; 92:1418Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Drossman DA. Am J Gastroenterol 1997; 92:1418
21332133
Challenges for Physicians (cont.)Challenges for Physicians (cont.)
Nonverbal communication of pain most predictive of narcotic prescribing
Time constraints for clinical visit increases diagnostic testing reduces effective communication and information gathering improper-decision making
Patients may be discharged from ER or released from clinic with narcotic Rx for pain without a diagnosis or treatment plan or follow-up
PCP must deal with lack of diagnosis and pressure to prescribe narcotics
Nonverbal communication of pain most predictive of narcotic prescribing
Time constraints for clinical visit increases diagnostic testing reduces effective communication and information gathering improper-decision making
Patients may be discharged from ER or released from clinic with narcotic Rx for pain without a diagnosis or treatment plan or follow-up
PCP must deal with lack of diagnosis and pressure to prescribe narcotics
Turk DC et al. Clin J Pain 1997; 13:330Drossman DA. Gastroenterology 2004; 126:952Turk DC et al. Clin J Pain 1997; 13:330Drossman DA. Gastroenterology 2004; 126:952 21342134
PainPain
Narcotic Bowel Syndrome
Narcotic Bowel Syndrome
Maladaptive Therapeutic Interaction
Maladaptive Therapeutic Interaction
NarcoticsNarcoticsNarcoticsNarcotics
Patient Frustration
Patient Frustration
“Negative” evaluations“Negative” evaluations
Increased Healthcare Utilization
Increased Healthcare Utilization
Emergency Room VisitsEmergency Room Visits
Healthcare / Societal
Pressures
Healthcare / Societal
Pressures
Physician FrustrationPhysician
Frustration
“Furor Medicus”
“Furor Medicus”
Vicious Cycleof Patient - Physician
Interactions
Vicious Cycleof Patient - Physician
Interactions
Narcotic Bowel SyndromeNarcotic Bowel Syndrome
1888b1888b
Narcotic Prescribing in the Health Care Setting The USA (4.6% of world population) prescribes 80% of world’s opioids.
19972002: >400% increase in retail sales of oxycodone and methadone
19931999: 100% increase in hydrocodone associated ED visits
Prescribing has shifted from acute severe pain or palliative care of malignancies to prolonged use in chronic nonmalignant pain (e.g. IBD, FGIDs)
Pain treatment centers shifted to narcotic treatments for non-malignant pain emphasizes “quick fix” over multidisciplinary pain treatment
There is no scientific evidence for long-term benefit of narcotics in non-malignant pain
Greater sensitivity of bowel in FGIDs more side effects from narcotics
These changing practice patterns are enabled by 3rd party payers due to greater cost benefit with shorter visits and expensive delivery systems
The net effect is increased annual health care expenditures
The USA (4.6% of world population) prescribes 80% of world’s opioids.
19972002: >400% increase in retail sales of oxycodone and methadone
19931999: 100% increase in hydrocodone associated ED visits
Prescribing has shifted from acute severe pain or palliative care of malignancies to prolonged use in chronic nonmalignant pain (e.g. IBD, FGIDs)
Pain treatment centers shifted to narcotic treatments for non-malignant pain emphasizes “quick fix” over multidisciplinary pain treatment
There is no scientific evidence for long-term benefit of narcotics in non-malignant pain
Greater sensitivity of bowel in FGIDs more side effects from narcotics
These changing practice patterns are enabled by 3rd party payers due to greater cost benefit with shorter visits and expensive delivery systems
The net effect is increased annual health care expenditures
Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007; 5:1126 21352135
Retail Sales of Opioid Medications 1997-2002
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
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):1Trescot et al. Pain Physician 2006; 9(1):121362136
Opiate Prescriptions in Ambulatory Visits NHAMCS 1994-2005
Choung et al. in preparationChoung et al. in preparation
%Ambullatory
visits
%Ambullatory
visits
11
22
77
1994 - 1995
1994 - 1995
44
66
88
55
33
00
1996 - 1997
1996 - 1997
1998 - 1999
1998 - 1999
2000 - 2001
2000 - 2001
2002 - 2003
2002 - 2003
2004 - 2005
2004 - 2005
21382138
Drug Abuse Related Emergency Department VisitsDrug Abuse Related Emergency Department Visits
US Department of Health and Human Services. April 2004Trescot et al. Pain Physician. 2006 Jan; 9(1):1-39US Department of Health and Human Services. April 2004Trescot et al. Pain Physician. 2006 Jan; 9(1):1-39
100,000100,000
1995199500
19961996 19981998 19991999 20002000 20022002
110,000110,000
80,00080,000
60,00060,000
40,00040,000
20,00020,000
19971997 20012001
Narcotic analgesicsBenzodiazepinesNarcotic analgesicsBenzodiazepines
VisitsVisits
21402140
Bimodal (Excitatory/Inhibitory) Opioid Modulation in Dorsal Horn– Activation of opioid receptors generally considered to inhibit
afferent neurons reduced signaling (via Gi/Go protein receptor)
– Newly identified Gs protein excitatory receptor hyperalgesia
–Gs excitatory receptor activates with low dose opioids (1-10ηmol/L) or and acutely is inhibited with high dose opioids (>1μmol/L)
–Gi/Go inhibitory receptor activates with high dose opioids but is inhibited with chronic opioid use
– Chronic opioid usehyperalgesia due to Gi/Go inhibition and Gs activation
– Low dose narcotic antagonists (e.g. Suboxone–buprenorphine/naloxone) analgesia with lower dosages by blocking Gs protein excitatory activation
Bimodal (Excitatory/Inhibitory) Opioid Modulation in Dorsal Horn– Activation of opioid receptors generally considered to inhibit
afferent neurons reduced signaling (via Gi/Go protein receptor)
– Newly identified Gs protein excitatory receptor hyperalgesia
–Gs excitatory receptor activates with low dose opioids (1-10ηmol/L) or and acutely is inhibited with high dose opioids (>1μmol/L)
–Gi/Go inhibitory receptor activates with high dose opioids but is inhibited with chronic opioid use
– Chronic opioid usehyperalgesia due to Gi/Go inhibition and Gs activation
– Low dose narcotic antagonists (e.g. Suboxone–buprenorphine/naloxone) analgesia with lower dosages by blocking Gs protein excitatory activation
Grunkemeier D.M.S. et al. CGH 2007; 5:1126Grunkemeier D.M.S. et al. CGH 2007; 5:1126Crain SM et al. Pain 2000; 84:121Crain SM et al. Brain Res 1992; 575:Crain SM et al. Pain 2000; 84:121Crain SM et al. Brain Res 1992; 575:
Potential Physiological Mechanisms for NBSPotential Physiological Mechanisms for NBS
21412141
aa
HyperalgesiaHyperalgesia
Gs
bb cc
Low-dose opioid1-10 nM
Low-dose opioid1-10 nM
High-dose opioid>1 M
High-dose opioid>1 M
Chronic opioid use
Chronic opioid use
Low-dose masks inhibitory effects
Low-dose masks inhibitory effects
High-dose masks excitatory effects
High-dose masks excitatory effects
Sensitized excitatory receptor
Sensitized excitatory receptor
Tolerance to
inhibitory receptor
Tolerance to
inhibitory receptor
AnalgesiaAnalgesia HyperalgesiaHyperalgesia
GsGo
Gi
GoGo GoGoGsGs
GiGiGiGi
InhibitoryInhibitoryExcitatoryExcitatory
InhibitoryInhibitoryExcitatoryExcitatory InhibitoryInhibitory ExcitatoryExcitatory
18901890
Potential Physiological Mechanisms for NBSPotential Physiological Mechanisms for NBS Bimodal (Excitatory/Inhibitory) Opioid Modulation in Dorsal Horn Descending Pain Facilitation at RVM and via Dynorphin and CCK
Activation– Cingulate and prefrontal cortex and rostral ventral medulla (RVM)
and PAG modulate incoming pain signals at the level of the spinal cord
– These areas can produce antinociception via descending inhibitory pathways
– RVM in particular can activate descending tracts to enhance nociception at the spinal cord
– Dynorphin (endogenous opioid) is found in inflammatory conditions, with nerve injury or in opiate induced pain states increases excitatory neurotransmitters from primary afferent neurons
– Cholecystokinin (CCK) and CCK receptors in CNS overlap with distribution of opioid peptides and can facilitate descending pain pathways
Bimodal (Excitatory/Inhibitory) Opioid Modulation in Dorsal Horn Descending Pain Facilitation at RVM and via Dynorphin and CCK
Activation– Cingulate and prefrontal cortex and rostral ventral medulla (RVM)
and PAG modulate incoming pain signals at the level of the spinal cord
– These areas can produce antinociception via descending inhibitory pathways
– RVM in particular can activate descending tracts to enhance nociception at the spinal cord
– Dynorphin (endogenous opioid) is found in inflammatory conditions, with nerve injury or in opiate induced pain states increases excitatory neurotransmitters from primary afferent neurons
– Cholecystokinin (CCK) and CCK receptors in CNS overlap with distribution of opioid peptides and can facilitate descending pain pathways
Grunkemeier D.M.S. et al. CGH 2007; 5:1126 Porreca F et al. Trends Neurosci 2002; 25:319 Vanderah TW et al. J Neurosci 2000; 20:7074 Heinricher MM et al. J Neurophysiol 2004; 92:1982Grunkemeier D.M.S. et al. CGH 2007; 5:1126 Porreca F et al. Trends Neurosci 2002; 25:319 Vanderah TW et al. J Neurosci 2000; 20:7074 Heinricher MM et al. J Neurophysiol 2004; 92:1982
21422142
Glia of Brain and Spinal CordMicrogliaMicroglia AstrocytesAstrocytes
22842284
Grunkemeier D.M.S. et al. CGH 2007, 5:1126 Watkins LR et al. Trends Neurosci 2005;28:661 Hutchinson MR et al. Sci World J 2007;7:98Grunkemeier D.M.S. et al. CGH 2007, 5:1126 Watkins LR et al. Trends Neurosci 2005;28:661 Hutchinson MR et al. Sci World J 2007;7:98
Potential Physiological Mechanisms for NBSPotential Physiological Mechanisms for NBS Bimodal (Excitatory/Inhibitory) Opioid Modulation in Dorsal Horn Descending Pain Facilitation at RVM and via Dynorphin and CCK
Activation Effects of Glial Cell Activation on Pain and Facilitation by
Opioids
-Glial cells (astrocytes and microglia) in dorsal horn can amplify pathologic pain and produce hyperalgesia
- Infection/chronic inflammation activates glial cells releases inflammatory cytokines enhances neuronal excitability
-Chronic narcotics bind to glia via μ receptors release of proinflammatory cytokines
– Opiates can also activate dynorphin release glial cell activation
Bimodal (Excitatory/Inhibitory) Opioid Modulation in Dorsal Horn Descending Pain Facilitation at RVM and via Dynorphin and CCK
Activation Effects of Glial Cell Activation on Pain and Facilitation by
Opioids
-Glial cells (astrocytes and microglia) in dorsal horn can amplify pathologic pain and produce hyperalgesia
- Infection/chronic inflammation activates glial cells releases inflammatory cytokines enhances neuronal excitability
-Chronic narcotics bind to glia via μ receptors release of proinflammatory cytokines
– Opiates can also activate dynorphin release glial cell activation
21432143
Effects of Opioids on Glia and PainEffects of Opioids on Glia and Pain
Hutchinson M et al. Scientific World J 2007; 7:98Hutchinson M et al. Scientific World J 2007; 7:98
Opioids acutely activate neuronal receptors analgesia
Chronic opioid use “activates” glia via toll-like receptors (TLR4, TLR2)
TLR dependent glial activation produces pro-inflammatory cytokines (IL-1, IL-6, TNFα) and other inflammatory mediators
Inflammatory cytokines increase neuronal excitability, produce neuropathic pain, reduce opioid analgesia and chronically, lead to opioid induced hyperalgesia.
Opioids acutely activate neuronal receptors analgesia
Chronic opioid use “activates” glia via toll-like receptors (TLR4, TLR2)
TLR dependent glial activation produces pro-inflammatory cytokines (IL-1, IL-6, TNFα) and other inflammatory mediators
Inflammatory cytokines increase neuronal excitability, produce neuropathic pain, reduce opioid analgesia and chronically, lead to opioid induced hyperalgesia.
22852285
TLR4
Opioids: Neuronal Analgesia and Glial Activation
AnalgesiaAnalgesia
IL-1IL-1IL-1IL-1
IL-1IL-1
IL-1IL-1
IL-1IL-1IL-1IL-1
IL-1IL-1
IL-1IL-1
IL-1IL-1
IL-1IL-1ANALGESIAANALGESIAHutchinson M et al. Scientific World J 2007;7:98Hutchinson M et al. Scientific World J 2007;7:98 22862286
Opioids acutely activate neuronal receptors analgesia
Chronic opioid use “activates” glia via toll-like receptors (TLR4, TLR2)
TLR dependent glial activation produces pro-inflammatory cytokines (IL-1, IL-6, TNFα) and other inflammatory mediators
Inflammatory cytokines increase neuronal excitability, produce neuropathic pain, reduce opioid analgesia and chronically, lead to opioid induced hyperalgesia.
Low dose opioid antagonists (e.g., naloxone) can block TLR activation of glia and enhance opioid analgesia
Future pain treatment may reduce detrimental (i.e., glial inflammatory) effects while preserving beneficial (neuronal opioid receptor analgesic) effects
Opioids acutely activate neuronal receptors analgesia
Chronic opioid use “activates” glia via toll-like receptors (TLR4, TLR2)
TLR dependent glial activation produces pro-inflammatory cytokines (IL-1, IL-6, TNFα) and other inflammatory mediators
Inflammatory cytokines increase neuronal excitability, produce neuropathic pain, reduce opioid analgesia and chronically, lead to opioid induced hyperalgesia.
Low dose opioid antagonists (e.g., naloxone) can block TLR activation of glia and enhance opioid analgesia
Future pain treatment may reduce detrimental (i.e., glial inflammatory) effects while preserving beneficial (neuronal opioid receptor analgesic) effects
Effects of Opioids on Glia and PainEffects of Opioids on Glia and Pain
Hutchinson M et al. Scientific World J 2007; 7:98Hutchinson M et al. Scientific World J 2007; 7:98 22872287
ANALGESIAANALGESIA
Potential Benefit of Opioid Antagonists
IL-1IL-1
IL-1IL-1
IL-1
Hutchinson M et al. Scientific World J 2007;7:98Hutchinson M et al. Scientific World J 2007;7:98 22882288
IL-1
TLR4
Dorsal horn
glial cell
Dorsal horn
glial cell
Neuron-to-glia chemokineFractalkine
Neuron-to-glia chemokineFractalkine
Sensory afferent neuronATP, NO, SP, CGRP
Sensory afferent neuronATP, NO, SP, CGRP
Immune / infectious challenges
Virus, bacteria, trauma
Immune / infectious challenges
Virus, bacteria, traumaCNS signalsCNS signals
Chronic opiod usePro-inflammatory cytokine,
dynorphin release
Chronic opiod usePro-inflammatory cytokine,
dynorphin release
Other glial cells
Other glial cells
Proinflammatory cytokines, PG, NO excitatory amino acidsProinflammatory cytokines, PG, NO excitatory amino acids
Enhanced painEnhanced pain
Neuron excitability upregulates NMDA releaseNeuron excitability upregulates NMDA release
18891889
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*
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*
Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126Grunkemeier D.M.S. et al. Clin Gastro and Hepatology 2007, 5:1126
Chronic or frequently recurring abdominal pain treated with acute high dose or chronic narcotics and:
Diagnostic Criteria: Narcotic Bowel SyndromeDiagnostic Criteria: Narcotic Bowel Syndrome
* 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* 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
21442144
PainPain
Narcotic Bowel Syndrome
Narcotic Bowel Syndrome
Maladaptive Therapeutic Interaction
Maladaptive Therapeutic Interaction
NarcoticsNarcoticsNarcoticsNarcotics
Patient Frustration
Patient Frustration
“Negative” evaluations“Negative” evaluations
Increased Healthcare Utilization
Increased Healthcare Utilization
Emergency Room VisitsEmergency Room Visits
Healthcare / Societal
Pressures
Healthcare / Societal
Pressures
Physician FrustrationPhysician
Frustration
“Furor Medicus”
“Furor Medicus”
NBS treatment, Narcotics withdrawal
NBS treatment, Narcotics withdrawal
Vicious Cycleof Patient - Physician
Interactions
Vicious Cycleof Patient - Physician
Interactions
Narcotic Bowel SyndromeNarcotic Bowel Syndrome
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Narcotic Withdrawal ProtocolNarcotic Withdrawal Protocol
Physician – Patient RelationshipPhysician – Patient Relationship
-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21Day of taperDay of taper
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Accept the pain as real (validate) and treatable
“I can see the pain has really affected your life”
“We can work together on this”
Accept the pain as real (validate) and treatable
“I can see the pain has really affected your life”
“We can work together on this”
Clinician-Patient Process and TechniquesClinician-Patient Process and Techniques
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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?”
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?”
Clinician-Patient Process and TechniquesClinician-Patient Process and Techniques
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Clinician-Patient Process and TechniquesClinician-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)”
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)” 21472147
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
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
Clinician-Patient Process and TechniquesClinician-Patient Process and Techniques
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Clinician-Patient Process and TechniquesClinician-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 Clinical setting
Outpatient Patient must be highly motivated
Withdrawal can take days to weeks
Inpatient• If complicated by nausea, vomiting, ileus or pseudo-
obstruction
• Limited motivation or social support
• Requires monitoring
• Withdrawal can occur over several days
Accept the pain as real and treatable Elicit the patient’s concerns and expectations Provide information through a dialog Present the withdrawal program Clinical setting
Outpatient Patient must be highly motivated
Withdrawal can take days to weeks
Inpatient• If complicated by nausea, vomiting, ileus or pseudo-
obstruction
• Limited motivation or social support
• Requires monitoring
• Withdrawal can occur over several days 22102210
Clinician-Patient Process and TechniquesClinician-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 Clinical setting Gauge the patient’s response
Willingness to go through the program Degree of participation
Keep a log? Be aware of: “Whatever you say doc”
Assess 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?”
Accept the pain as real and treatable Elicit the patient’s concerns and expectations Provide information through a dialog Present the withdrawal program Clinical setting Gauge the patient’s response
Willingness to go through the program Degree of participation
Keep a log? Be aware of: “Whatever you say doc”
Assess 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?”
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Narcotic Withdrawal ProtocolNarcotic 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
Accept pain as real and treatable Elicit patients concerns/expectations Provide information through a dialog Present the withdrawal program Gauge the patient’s response
Physician – Patient RelationshipPhysician – Patient Relationship
PEG 3350 17g PO BIDPEG 3350 17g PO BID
TCA or SNRITCA or SNRI
-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21Day of taperDay of taper
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Tricyclics (e.g., Desipramine, Nortriptyline, Amitriptyline)Pain benefitSide effects (sedation, constipation) reduce adherence20 amines (desipramine/nortriptyline) have fewer side effects
SNRIs (e.g., Duloxetine, Venlafaxine, Desvenlafaxine)Pain benefitNausea side effectsSpecific effects
Duloxetine first to be marketed for “pain with depression”Venlafaxine requires higher dosage (e.g., 225 mg.) for pain benefit
SSRIs (e.g., Paroxetine, Citalopram, Escitalopram)Anxiolysis (social phobia, agoraphobia, OCD)+/- pain benefit (but augments TCA effect via anxiolysis)Side effects (anxiety, diarrhea) Specific effects
Tricyclics (e.g., Desipramine, Nortriptyline, Amitriptyline)Pain benefitSide effects (sedation, constipation) reduce adherence20 amines (desipramine/nortriptyline) have fewer side effects
SNRIs (e.g., Duloxetine, Venlafaxine, Desvenlafaxine)Pain benefitNausea side effectsSpecific effects
Duloxetine first to be marketed for “pain with depression”Venlafaxine requires higher dosage (e.g., 225 mg.) for pain benefit
SSRIs (e.g., Paroxetine, Citalopram, Escitalopram)Anxiolysis (social phobia, agoraphobia, OCD)+/- pain benefit (but augments TCA effect via anxiolysis)Side effects (anxiety, diarrhea) Specific effects
Antidepressants
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Narcotic Withdrawal ProtocolNarcotic Withdrawal Protocol
Physician – Patient RelationshipPhysician – Patient Relationship
PEG 3350 17g PO BIDPEG 3350 17g PO BID
TCA or SNRITCA or SNRI
Lorazepam 1mg PO q 6hrs. Lorazepam 1mg PO q 6hrs.
-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21Day of taperDay of taper
Morphine equiv. Dose (mg)Morphine equiv. Dose (mg) 220 200 180 160 140 120 100 80 60 40 20 0220 200 180 160 140 120 100 80 60 40 20 0
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Accept pain as real and treatable Elicit patients concerns/expectations Provide information through a dialog Present the withdrawal program Gauge the patient’s response
Accept pain as real and treatable Elicit patients concerns/expectations Provide information through a dialog Present the withdrawal program Gauge the patient’s response
Start medium acting benzodiazepine (e.g., lorazepam) Involve psychologist to help with withdrawal program 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)
Start medium acting benzodiazepine (e.g., lorazepam) Involve psychologist to help with withdrawal program 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)
Narcotic Withdrawal
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Narcotic Withdrawal ProtocolNarcotic Withdrawal Protocol
Accept pain as real and treatableElicit patients concerns/expectationsProvide information through a dialogPresent the withdrawal programGauge the patient’s response
Accept pain as real and treatableElicit patients concerns/expectationsProvide information through a dialogPresent the withdrawal programGauge the patient’s response
Physician – Patient RelationshipPhysician – Patient Relationship
PEG 3350 17g PO BIDPEG 3350 17g PO BID
TCA or SNRITCA or SNRI
Lorazepam 1mg PO q 6hrs. Lorazepam 1mg PO q 6hrs.
Clonidine 0.1mg PO q 6 hrs.Clonidine 0.1mg PO q 6 hrs.
-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21-3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 . . . 21Day of taperDay of taper
Morphine equiv. Dose (mg)Morphine equiv. Dose (mg) 220 200 180 160 140 120 100 80 60 40 20 0220 200 180 160 140 120 100 80 60 40 20 0
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Clonidine α2-adrenergic against 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 Azaprione with anti-anxiety effects acting on non BZD GABA receptors Has 5HT1 and 5HT2 effects May augment the effect of the antidepressant
Quetiapine Atypical antipsychotic in high doses with complex effects Dopamine (D1, D2) and Serotonin (5HT1a, 5HT2) antagonism and some α2-
adrenergic effect Benefits include – sleep, anti-anxiety, analgesia augmentation
Clonidine α2-adrenergic against 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 Azaprione with anti-anxiety effects acting on non BZD GABA receptors Has 5HT1 and 5HT2 effects May augment the effect of the antidepressant
Quetiapine Atypical antipsychotic in high doses with complex effects Dopamine (D1, D2) and Serotonin (5HT1a, 5HT2) antagonism and some α2-
adrenergic effect Benefits include – sleep, anti-anxiety, analgesia augmentation
Centrally Acting Augmentation
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“If I don’t think it’s going to work, will it still work?”“If I don’t think it’s going to work, will it still work?” 20212021
When Will Program Work?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
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
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Interferences With Successful OutcomeInterferences 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”)
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”)
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Seeks additional help elsewhereMay 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
Seeks additional help elsewhereMay 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
Interferences With Successful OutcomeInterferences With Successful Outcome
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Case 4: Unsuccessful TreatmentCase 4: Unsuccessful Treatment 26 yo medical student sent by father (prominent academic physician) for
detoxification 2 year history of pain beginning acutely as sharp and severe in RLQ followed by N/V
which has progressed in frequency and severity Extensive evaluation with HIDA, MRI/MRCP, ERCP, CT, Liver bx all normal Diagnosed with cyclic vomiting syndrome and Rx with amitriptyline with 8 mo relief Pain recurred while on taking night call began taking fentanyl patch
improvement gradual increase in dosing for relief now self medicates 2 mg. dilaudid SQ q4 hrs.
Currently with severe constipation (BM q2-3 wks), pain relieved only 1-2 hrs on narcotic, n/v
Psychologist consulted to help with detoxification program Psychosocial
– Lost control of life because of frequent hospitalizations
– Engaged for 2 yrs and fiance lives out of state
– Current problem has delayed wedding and he has contemplated dropping out of school
– Brother developed appendicitis and quit medicine soon after graduation – “Best choice he ever made”; Father upset
– Denies stress related to symptoms or in his life; illness is “positive” – brings him closer to mother and fiance
26 yo medical student sent by father (prominent academic physician) for detoxification
2 year history of pain beginning acutely as sharp and severe in RLQ followed by N/V which has progressed in frequency and severity
Extensive evaluation with HIDA, MRI/MRCP, ERCP, CT, Liver bx all normal Diagnosed with cyclic vomiting syndrome and Rx with amitriptyline with 8 mo relief Pain recurred while on taking night call began taking fentanyl patch
improvement gradual increase in dosing for relief now self medicates 2 mg. dilaudid SQ q4 hrs.
Currently with severe constipation (BM q2-3 wks), pain relieved only 1-2 hrs on narcotic, n/v
Psychologist consulted to help with detoxification program Psychosocial
– Lost control of life because of frequent hospitalizations
– Engaged for 2 yrs and fiance lives out of state
– Current problem has delayed wedding and he has contemplated dropping out of school
– Brother developed appendicitis and quit medicine soon after graduation – “Best choice he ever made”; Father upset
– Denies stress related to symptoms or in his life; illness is “positive” – brings him closer to mother and fiance 21532153
Admitted for detoxification program with taper to occur by 25% daily While patient acknowledged desire to go off narcotics, he repeatedly asked
what he will get if pain recurs. On 1st day before when getting full narcotic dosing he asked for delay in taper
because he ate fried chicken the night before During taper he requested to leave hospital to go to his hotel room Later mother noted narcotics stashed in his room Patient’s mother reported that he told her he would go back on narcotics at
home if he has pain One night before completion of taper patient reported increased pain and
demanded to go back on narcotics and to slow down taper This was refused and narcotics completely tapered off That night prior to discharge the patient signed out against medical advice A follow up appointment was given in 6 weeks but patient did not return 6 months later the patient contacted Dr. Drossman stating he now felt he was
ready to come off narcotics. Inpatient detoxification rescheduled
Admitted for detoxification program with taper to occur by 25% daily While patient acknowledged desire to go off narcotics, he repeatedly asked
what he will get if pain recurs. On 1st day before when getting full narcotic dosing he asked for delay in taper
because he ate fried chicken the night before During taper he requested to leave hospital to go to his hotel room Later mother noted narcotics stashed in his room Patient’s mother reported that he told her he would go back on narcotics at
home if he has pain One night before completion of taper patient reported increased pain and
demanded to go back on narcotics and to slow down taper This was refused and narcotics completely tapered off That night prior to discharge the patient signed out against medical advice A follow up appointment was given in 6 weeks but patient did not return 6 months later the patient contacted Dr. Drossman stating he now felt he was
ready to come off narcotics. Inpatient detoxification rescheduled
Case 4: Unsuccessful Treatment, Con’t.Case 4: Unsuccessful Treatment, Con’t.
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Case 4: Unsuccessful Treatment (cont.)Case 4: Unsuccessful Treatment (cont.) Rehospitalized for detoxification 10/08
Psychosocial / Clinical data– Claimed that had bowel obstructions from adhesions after leaving UNC – records obtained
and not documented – laparoscopy showed some adhesions but no obstruction
– Patient said engagement was off, mother said he is still seeing her
– Mother closely involved in care
– Psychologist saw patient and saw little motivation for detox – refused several visits
Protocol instituted with more delayed detox program – 15% reduction daily
On 2nd day patient stated it was too fast and asked for 10% reduction – refused
By 4th day patient said he was having pain and asked for “just one shot”
Patient noted to house staff that after discharge he would go to ER to get pain shot if he had pain
Narcotics tapered off by 6th day
That evening he went down to basement of hospital to find the ER to get a pain shot. was escorted back but that evening and later found to be very sedated
Patient discharged the next morning
Rehospitalized for detoxification 10/08
Psychosocial / Clinical data– Claimed that had bowel obstructions from adhesions after leaving UNC – records obtained
and not documented – laparoscopy showed some adhesions but no obstruction
– Patient said engagement was off, mother said he is still seeing her
– Mother closely involved in care
– Psychologist saw patient and saw little motivation for detox – refused several visits
Protocol instituted with more delayed detox program – 15% reduction daily
On 2nd day patient stated it was too fast and asked for 10% reduction – refused
By 4th day patient said he was having pain and asked for “just one shot”
Patient noted to house staff that after discharge he would go to ER to get pain shot if he had pain
Narcotics tapered off by 6th day
That evening he went down to basement of hospital to find the ER to get a pain shot. was escorted back but that evening and later found to be very sedated
Patient discharged the next morning 21612161
Summary – Narcotic Bowel SyndromeSummary – Narcotic Bowel Syndrome NBS is a subset of opioid bowel dysfunction
Chronic or recurrent abdominal pain which worsens or incompletely resolves with continued or escalating dosages of narcotics
Can occur in patients with FGID or organic diseases
Limitations in health care: use of narcotics for non-malignant pain, poor communication, improper decision-making and lack of recognition of NBS, contribute to escalating narcotic use
Treatment involves a protocol driven detoxification that requires a motivated patient and clinical team
NBS is a subset of opioid bowel dysfunction
Chronic or recurrent abdominal pain which worsens or incompletely resolves with continued or escalating dosages of narcotics
Can occur in patients with FGID or organic diseases
Limitations in health care: use of narcotics for non-malignant pain, poor communication, improper decision-making and lack of recognition of NBS, contribute to escalating narcotic use
Treatment involves a protocol driven detoxification that requires a motivated patient and clinical team
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“It sort of makes you stop and think, doesn’t it?”“It sort of makes you stop and think, doesn’t it?”