番茄社区

Concerned by the increase in opioid use for patients with varying types of chronic pain, a team of gastroenterologists undertook a study to find out if these agents were also being overprescribed for patients with unexplained gastrointestinal pain, or functional gastrointestinal diagnoses (FGID). In such patients, opioid use is of questionable benefit and also associated with serious adverse effects.¹

Opioid use greater in FGID than SGID

Investigators used Veterans Health Administration (VHA) administrative data from fiscal year 2012 to compare opioid prescriptions for patients with a structural GI diagnosis (SGID) to those with a functional GI diagnosis (FGID).¹

They found that 36% of 272,431 patients with FGID received an opioid prescription compared to 28.9% of 1,223, 744 of patients with SGID (relative risk [RR]=1.25).¹ In fact, patients with FGID were 40% more likely (unadjusted) to receive an opioid prescription than those with SGID. During the study year, patients treated with opioids received an average of 6.8 opioid prescriptions.

鈥淭his mirrors the dramatic increase I鈥檝e seen in our clinic over the past decade,鈥� said Gregory S. Sayuk, MD, MPH, lead author and associate professor of medicine and psychiatry, Washington University School of Medicine, St. Louis. 鈥淭en years ago, I could count on both hands the number of people with functional GI diagnoses who were taking opioids. Now 1 in 3 of the people who come to our clinic with this diagnosis already have an opiate prescription.鈥�

Paradoxical pain worsening in patients with FGID

In addition to the limited evidence of effectiveness for the use of opioids for any type of nonmalignant chronic pain, Dr. Sayuk has additional concerns when these agents are given to patients with a functional GI diagnosis. 鈥淲ith regard to abdominal pain, there is a strong potential for opioids to paradoxically worsen the pain. Opioids can cause a narcotic bowel syndrome with increased pain sensitivity even in individuals who don鈥檛 have a functional GI disorder. In patients with a functional GI diagnosis, such as irritable bowel syndrome (IBS) with constipation, the opioid will further exacerbate the constipation and cause more pain. I tell patients with IBS, 鈥榓s far as your gut is concerned, taking an opioid is like taking a handful of loperamide.鈥� It is kind of a double hit for an individual with a functional GI disorder.鈥�

番茄社区 asked Dr. Sayuk if he had any evidence that these results from a predominantly male VA clinic could be generalized to other populations. 鈥淲e have looked at this in our academic practice as well, and the results (in press) are almost identical.鈥� 

 Dr. Sayuk said his team expected to see increasing use in all practice settings, 鈥淏ut in the VA it was surprising because providers are all acutely aware that they are being monitored on a system level for opioid use.鈥�

Reimbursement drives opioid overuse

Why are clinicians prescribing opioids for patients with FGID? Dr. Sayuk blames the health care system in the United States that limits the amount of time a provider can spend with a patient. 鈥淥ther approaches to pain management are generally more time-consuming. With our reimbursement system, in order to keep the lights on, the provider has to squeeze in a many office visits as possible in a day because reimbursement is often just $25 or $30 for a return patient visit. Compare this to reimbursement for a procedure, like a colonoscopy. The system rewards procedures not time spent with the patient to maximize health and minimize inappropriate drug use.鈥�

Dr. Sayuk compares this to other countries with different reimbursement systems and far lower levels of opioid use. 鈥淢y colleagues in Europe and Latin America say they don鈥檛 have this same problem because they understood from the beginning that opioids were not the right approach, and they utilized nonpharmacologic strategies early on.鈥�

Multidisciplinary pain management for patients with FGID

What does Dr. Sayuk recommend for pain management in patients with FGID?

鈥淲e utilize a multidisciplinary approach, often getting patents involved in other programs, such psychotherapy, hypnotherapy, relaxation therapy, yoga, and acupuncture.鈥� When drugs are necessary we often use antidepressants, such as tricyclics and serotonin and norepinephrine reuptake inhibitors.鈥�

In a recent systematic scoping review, promising strategies to identify and reduce opioid misuse in patients with gastrointestinal disorders included prescription drug monitoring and self-management interventions.² Dr. Sayuk urges clinicians to be especially wary of opioid use in higher risk patients. 鈥淚n our study, we found that psychiatric comorbidity, psychotropic prescriptions and emergency room encounters were independently associated with opioid prescriptions and could be 鈥榙rivers鈥� of opioid use. It is important for clinicians to recognize these higher risk patients and develop strategies to manage their pain without potentially harmful opioids.鈥�

Published: March 01, 2018