03/20/12. Recognize the right of patients to appropriate assessment and management of pain

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1 Narcotic Bowel Syndrome Alvin Zfass M.D. M.D. Professor of Medicine Toufic Kachaamy M.D. GI Fellow Chronic Pain 110 million Americans suffer from chronic pain according to the NIH Cost of untreated t or undertreated t d pain is estimated to over 60 Billion annually from lost productivity Increase healthcare utilization and poor quality of life Pain control culture JCAHO HHS NIH Third party payers Patients Efficiency 1

2 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) On January 1, 2001, pain management standards went into effect for Joint Commission accredited ambulatory care facilities, hospitals and other health care facilities JCAHO Pain management standards Recognize the right of patients to appropriate assessment and management of pain Screen patients for pain during their initial assessment and, when clinically required, during ongoing, periodic reassessments Educate patients suffering from pain and their families about pain management If a patient is experiencing pain, appropriate care should be made available Narcotics Culture In San Francisco, oxycodone emergency department visits increased 110% from 2001 to % increase in Narcotic prescriptions between 1997 and 2006 USA Less than 5% of the world population More than 80% of prescribed narcotics 2

3 Narcotic effect on the GI tract Decreased peristalsis Relaxation of longitudinal muscle Increased tone of circular muscle Decreased secretion Pain modulation Overall effect: nausea, constipation, bloating and reflux Opioid bowel dysfunction The presence of constipation, bloating, abdominal distension, i GERD, nausea, and vomiting in a patient on opioids. Narcotic bowel syndrome (NBS) Chronic or frequently occurring abdominal pain which h worsens with continued or escalating doses of narcotics 3

4 Narcotic Bowel syndrome First described in 1984 Five patients with chronic abdominal pain on narcotics with resolution by withdrawal of narcotics Under recognized Poorly understood. Narcotic bowel syndrome treated with clonidine. Resolution of abdominal pain and intestinal pseudo-obstruction. Ann Intern Med Sep;101(3):331-4 Sandgren JE Diagnostic Criteria Patients treated with narcotics >2 weeks The pain worsens with escalating doses of narcotics Acutely pain improves and can even resolve with narcotics Chronically pain episodes worsens The pain is not explained by another underlying disease Clinical Gastroenterology and Hepatology. Volume 5, Issue 10, October 2007, Pages The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and Management. Douglas A. Drossman Prevalence 2,913 patients surveyed from Olmsted county 117 were taking narcotics Half had some form of abdominal pain 5 met criteria for NBS Am J Gastroenterol 2009; 104: published online 14 April 2009 Opioid Bowel Dysfunction and Narcotic Bowel Syndrome: A Population-Based Study Rok Seon Choung MD 4

5 Prevalence of NBS in patients on chronic narcotics for non cancer pain Patients on chronic narcotics Opioid bowel 50 60% Narcotic bowel syndrome 6% Neurogastroenterol Motil Apr;22(4):424-30, e96. Opioid-induced induced bowel disorders and narcotic bowel syndrome in patients with chronic non cancer pain. Tuteja AK Pain is usually Colicky Clinical Features Worsens with food so might lead to weight loss Exam is usually negative Labs are normal Imaging can be abnormal including pseudo-obstructionobstruction Patients with prior functional GI pain can recognize a different kind of pain Narcotic effect on abdominal pain Acutely : pain relief Chronically: can to lead to hyperalgesia Glial cell activation altering the cytokine milieu Decrease in analgesic effect Increase in the anti-opioid regulatory mechanisms in the brain and spinal cord 5

6 Can we predict who will develop NBS? Not enough data Long term opioid therapy for non cancer pain Evidence shows that it is ineffective 60% of patients self discontinue it after few months because of side effects or lack of efficacy Patients on it more than 90 days are usually on it long term Long term use occurs in patients with psychiatric comorbidities and substance abuse problems Management Multidisciplinary and resource intensive Establishing a good physician-patient patient relationship Gradual withdrawal of narcotics Treat underlying comorbidities 6

7 Patient physician relationship Accept the pain as real Explain the physiologic basis of pain Explain the plan Set realistic expectations Identify the patient who is motivated to get off narcotics Focus on quality of life and functional status Narcotic withdrawal Inpatient detox programs if needed Detox protocol are very helpful Avoid and treat withdrawal symptoms Clonidine: Alpha-2 adrenergic agonist Treatment of comorbidities Benzodiazepine For anxiety and narcotic withdrawal Antidepressants (TCAs, Duloxetine) Treat depression Help with pain modulation Treatment of Opioid bowel symptoms 7

8 Summary Narcotic Bowel syndrome is likely on the rise Diagnosis is difficult and requires a high index of suspicion Treatment is resource intensive and difficult Prevention is key 8

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