Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

Entourage effects of nonpsychotropic cannabinoids on visceral sensitivity in experimental colitis

Abdominal pain is the most disabling symptom of inflammatory bowel diseases, but current treatments are limited, leading patients to seek alternatives such as cannabis. Cannabis contains over 100 cannabinoids which, unlike tetrahydrocannabinol, are biologically active compounds often without psychotropic effects (ie, nonpsychotropic cannabinoids [npCBs]). These npCBs have analgesic and anti-inflammatory properties and may show potentiating effects when administered in combination, referred to as the entourage effect. Here, we investigated the analgesic effects of cannabichromene, cannabidiol (CBD), cannabidivarin, and cannabigerol (CBG), individually and in combination, using the mouse model of dextran sulfate sodium colitis-induced visceral hypersensitivity (VHS). We then explored antinociceptive targets through patch-clamp electrophysiology on dorsal root ganglia neurons and recombinant channels. We found that a single injection of 10 mg/kg of either CBD or CBG reduced both VHS and c-Fos activation in the spinal dorsal horn. Moreover, a combination of npCBs consisting of 5 mg/kg CBD with 1 mg/kg of cannabichromene, cannabidivarin, and CBG-all at subtherapeutic dosages-reduced VHS, without altering colitis. Electrophysiological recordings revealed that the antinociceptive mixture of npCBs acts through voltage-gated sodium and calcium channels, particularly Cav2.2, but not Cav3.2 and Kv channels. These results suggest that CBD, CBG, and a mixture of npCBs given at subtherapeutic doses may be beneficial in managing VHS associated with inflammatory bowel disease. SIGNIFICANCE STATEMENT: Cannabis is increasingly used as an alternative treatment for managing pain associated with chronic conditions. Nonpsychotropic cannabinoids, such as cannabidiol, interact with ionotropic and voltage-gated ion channels. In our study, we demonstrated that cannabidiol, cannabigerol, and a combination of nonpsychotropic cannabinoids, administered at subtherapeutic doses, effectively alleviated visceral hypersensitivity associated with inflammatory bowel disease.

Chronic Abdominal Pain in Patients with Inflammatory Bowel Disease in Remission: A Continuing Challenge for Clinicians

Inflammatory bowel disease (IBD) is a chronic condition that includes ulcerative colitis and Crohn's disease. It is characterized by a relapsing and remitting pattern that negatively impacts quality of life (QoL). Current goals of treatment involve symptomatic, biochemical, and endoscopic remission in a treat-to-target approach. Despite effective treatment and remission of IBD, many patients report frequent and isolated abdominal pain. A wide range of etiologies exist, including surgery-related, infections, pelvic conditions, immune-related, and systemic illnesses. Disorders of the gut-brain interaction (DGBI), frequently characterized by abdominal pain, are increasingly recognized in IBD patients, including those with quiescent disease. Various mechanisms are involved and numerous non-pharmacologic and pharmacologic therapies have been proposed. Hereby, we outline the pertinent findings of the literature on management of chronic abdominal pain, focusing on quiescent IBD.

Effects of Positive Psychological Interventions on Psychological Outcomes, Quality of Life, and Inflammation Biomarkers in Inflammatory Bowel Disease Patients: A Meta-Analysis of Randomized Controlled Trials

This meta-analysis aimed to systematically evaluate the effects of positive psychological interventions on anxiety, depression, stress, mindfulness, hope, quality of life, and disease activity, as well as inflammation biomarkers, in patients with inflammatory bowel disease. Databases such as Cochrane Library, PubMed, EBSCO, Embase, Web of Science, China Biomedical Literature Database, China Knowledge Network, and WANFANG DATA were searched by two researchers from the time of each database's creation to November 2022. A total of 14 randomized controlled trials (RCTs) with 1,191 patients were included. The results showed that positive psychological interventions were effective in reducing anxiety (standardized mean difference [SMD] = -0.81, 95% confidence interval [CI] [-1.33, -0.30], p = .002), depression (SMD = -0.86, 95% CI [-1.32, -0.41], p = .0002), and stress (SMD = -0.68, 95% CI [-1.05, -0.31], p = .0003), and significantly increased the level of hope (weighted mean difference [WMD] = 3.26, 95% CI [0.84, 5.68], p = .008), mindfulness (SMD = 0.59, 95% CI [0.30, 0.88], p < .0001), and quality of life (SMD = 0.61, 95% CI [0.09, 1.14], p = .02) of patients with inflammatory bowel disease. This suggests that positive psychological interventions can significantly improve positive psychology and reduce negative emotions in patients with inflammatory bowel disease.

Non-Intoxicating Cannabinoids in Visceral Pain

Cannabis and cannabis products are becoming increasingly popular options for symptom management of inflammatory bowel diseases, particularly abdominal pain. While anecdotal and patient reports suggest efficacy of these compounds for these conditions, clinical research has shown mixed results. To date, clinical research has focused primarily on delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is a ligand of classical cannabinoid receptors (CBRs). CBD is one of a large group of nonintoxicating cannabinoids (niCBs) that mediate their effects on both CBRs and through non-CBR mechanisms of action. Because they are not psychotropic, there is increasing interest and availability of niCBs. The numerous niCBs show potential to rectify abnormal intestinal motility as well as have anti-inflammatory and analgesic effects. The effects of niCBs are frequently not mediated by CBRs, but rather through actions on other targets, including transient receptor potential channels and voltage-gated ion channels. Additionally, evidence suggests that niCBs can be combined to increase their potency through what is termed the entourage effect. This review examines the pre-clinical data available surrounding these niCBs in treatment of abdominal pain with a focus on non-CBR mechanisms.

Building a Self-Management Toolkit for Patients with Pediatric Inflammatory Bowel Disease: Introducing the resilience 5

Transition from pediatric to adult health care is a complex process that calls for complex interventions and collaboration between health care teams and families. However, many inflammatory bowel disease (IBD) clinical care teams do not have the resources to implement rigorous transition programs for youth. This review provides a description of the Resilience5: self-efficacy, disease acceptance, self-regulation, optimism, and social support. The Resilience5 represents teachable skills to support IBD self-management, offset disease interfering behaviors, and build resilience in adolescents and young adults transitioning to adult health care systems. These skills can also be encouraged and reinforced during routine IBD clinical care.

Irritable Bowel Syndrome Is an Independent Risk Factor for Developing Opioid Use Disorder in Patients with Inflammatory Bowel Disease

BACKGROUND

Symptoms of IBS can fluctuate even when IBD is in clinical remission. Patients with IBD are at an increased risk of developing opioid addiction. The aim of the study was to determine whether IBS is an independent risk factor for developing opioid addiction and related gastrointestinal symptoms in patients with IBD.

METHODS

We identified patients with Crohn's disease (CD)+IBS and ulcerative colitis (UC) + IBS using TriNetX. The control groups consisted of patients with CD or UC alone without IBS. The main outcome was to compare the risks of receiving oral opioids and developing opioid addiction. A subgroup analysis was performed by selecting patients who were prescribed oral opioids and to compare with those not prescribed opioids. Gastrointestinal symptoms and mortality rates were compared in the cohorts.

RESULTS

Patients with concomitant IBD and IBS were more likely to be prescribed oral opioids (24.6% vs. 17.2% for CD; 20.2% vs. 12.3% for UC, p < 0.0001) and develop opioid dependence or abuse (p < 0.05). The subset of patients who were prescribed opioids are more likely to develop gastroesophageal reflux disease, ileus, constipation, nausea, and vomiting (p < 0.05).

CONCLUSIONS

IBS is an independent risk factor for IBD patients to receive opioids and develop opioid addiction.

A Missing Piece of the Puzzle: Patient and Provider Perspectives on Pain Management Needs and Opioid Prescribing in Inflammatory Bowel Disease Care

Background

Recent data have shown high rates of opioid misuse among inflammatory bowel disease (IBD) patients. We conducted a qualitative study to explore IBD patient and provider perceptions and experiences with pain management and opioid prescribing.

Methods

We conducted a focus group with IBD patients and semistructured interviews with IBD-focused physicians and nurses. We used an inductive approach for analysis and the constant comparison method to develop and refine codes and identify prominent themes. We analyzed interview and focus group data concurrently to triangulate themes.

Results

Nine patients and 10 providers participated. We grouped themes into 3 categories: (1) current practices to manage pain; (2) perceived pain management challenges; and (3) suggestions to optimize pain management. In the first category (current practices), both patients and providers reported building long-term patient-provider relationships and the importance of exploring nonpharmacologic pain management strategies. Patients reported proactively trying remedies infrequently recommended by IBD providers. In the second category (pain management challenges), patients and providers reported concerns about opioid use and having limited options to treat pain safely. Patients discussed chronic pain and having few solutions to manage it. In the third category, providers shared suggestions for improvement such as increasing use of nonpharmacologic pain management strategies and enhancing care coordination.

Conclusions

Despite some common themes between the 2 groups, we identified some pain management needs (eg, addressing chronic pain) that matter to patients but were seldom discussed by IBD providers. Addressing these areas of potential disconnect is essential to optimize pain management safety in IBD care.

The personality traits activity, self-reproach, and negative affect jointly predict clinical recurrence, depressive symptoms, and low quality of life in inflammatory bowel disease patients

BACKGROUND

The bidirectional "gut-brain axis" has been implicated in the pathogenesis of inflammatory bowel diseases (IBD). While the influence of stress and depressive symptoms on IBD is well-characterized, the role of personality remains insufficiently investigated.

METHODS

Personality was assessed in 1154 Swiss IBD cohort study (SIBDCS) patients via the NEO-Five-Factor Inventory (NEO-FFI) as well as in 2600 participants of the population-based CoLaus¦PsyCoLaus cohort study (NEO-FFI-revised). The NEO-FFI subcomponents activity, self-reproach and negative affect were associated with higher IBD disease activity and were combined to a NEO-FFI risk score. This risk score was validated and its effect on clinical IBD course and psychological endpoints was analysed in time-to-event and cumulative incidence analyses.

RESULTS

In time-to-event analyses, a high NEO-FFI risk score was predictive for the clinical endpoints of new extraintestinal manifestation [EIM, adjusted hazard ratio (aHR) = 1.64, corrected p value (q) = 0.036] and two established composite flare endpoints (aHR = 1.53-1.63, q = 0.003-0.006) as well as for the psychological endpoints depressive symptoms (aHR = 7.06, q < 0.001) and low quality of life (aHR = 3.06, q < 0.001). Furthermore, cumulative incidence analyses showed that patients at high NEO-FFI risk experienced significantly more episodes of active disease, new EIMs, one of the flare endpoints, depressive episodes and low disease-related quality of life. Personalities of IBD patients showed only minor differences from the general population sample (Pearson's r = 0.03-0.14).

CONCLUSIONS

Personality assessed by the NEO-FFI contained considerable predictive power for disease recurrence, depressive symptoms and low quality of life in IBD patients. Nevertheless, the personalities of IBD patients did not substantially differ from the general population.

Assessment of Comorbid Depression and Anxiety in Inflammatory Bowel Disease Using Adaptive Testing Technology

Background

Depression and anxiety are comorbidities of inflammatory bowel disease (IBD), and it is now recommended to screen IBD patients for these conditions. We screened patients using a novel computerized adaptive testing technology and compared the screening results to measures of disease activity.

Methods

Consecutive patients at our tertiary IBD clinic were asked to complete the validated CAT-MH™ survey (Adaptive Testing Technologies, Chicago, IL); we then reviewed disease and patient characteristics. Clinical remission status was determined based on clinical, laboratory, endoscopy and imaging results. Statistical methods included Fisher's exact test and Pearson Chi-square tests to assess association. Univariable and multivariable analyses were performed.

Results

We included 134 patients, of which 34 (25.3%) screened positive for depression and 18 (13.4%) screened positive for anxiety. We identified 19 (55.9 %) and 10 (55.5%) patients who were previously undiagnosed for depression and anxiety, respectively. Patients in clinical remission were less likely to screen positive for depression (OR 0.19; 95%CI 0.07-0.50) and for anxiety (OR 0.30; 95%CI 0.10-0.91). Compared to patients with negative CRP values, patients with positive CRP were more likely to also screen positive for depression (p=0.025) and anxiety (p=0.15).

Conclusions

We demonstrate the utility of a novel testing technology for screening patients with IBD for depression and anxiety. We found a large number of patients with previously undiagnosed anxiety or depression and a significant positive association between clinically active IBD and these mental health conditions. This work supports and informs recommendations for mental health screening in the IBD population.

Depression and Anxiety Disorders in Patients With Inflammatory Bowel Disease

Mental health is a significant yet overlooked aspect of inflammatory bowel disease (IBD) patient care, with challenges in determining optimal treatments and psychological health resources. The most common psychological conditions in patients with IBD are anxiety and depression. The increased prevalence of these mental disorders appeals to mental screening of each person diagnosed with IBD at initial consultation. There are simple and clinically viable methods available to screen for mental problems. Psychological methods may be as or even more significant as a therapeutic modality. Herein we discuss the three major areas of psychological co-morbidity in IBD: (1) the prevalence and risk factors associated with anxiety and depression disorders for patients with IBD; (2) diagnosis of psychological disorders for patients with IBD; (3) treatment with patients with IBD and mental disorders. The gastroenterologists are encouraged to screen and treat these patients with IBD and mental disorders, which may improve outcomes.

The evolution of IBD perceived engagement and care needs across the life-cycle: a scoping review

BACKGROUND

The chronic and progressive evolution of Inflammatory Bowel Diseases (IBD), with its prototypical fluctuating trend, creates a condition of psycho-social discomfort, impacting the quality of life in terms of personal, working, and interpersonal.

AIMS

In this article, we want to identify the nature and extent of the research evidence on the life experiences, the perceived engagement, the psychological, social care and welfare needs of people affected by IBD across the lifecycle.

METHODS

Following the approach set out by Arksey and O'Malley and the PRISMA extension for scoping reviews, we conducted a scoping review in March 2019 and closed the review with an update in October 2019. It was performed using electronic databases covering Health and Life Sciences, Social Sciences and Medical Sciences, such as PubMed, Medline, Embase, Scopus, Cochrane, Web of Science, PsycInfo.

RESULTS

We identified 95 peer-reviewed articles published from 2009 to 2019, that allowed to detection the main needs in children (psychological, need to be accepted, physical activity, feeding, parent style, support, social needs), adolescents (to understand, physical and psychological needs, protection, relational, gratitude, respect, and engagement) and adults (information, medical, psychological, social, work-related, practical, future-related, engagement). Although the literature confirms that the majority of the IBD units have planned provision for the different types of transitions, the quality and appropriateness of these services have not been assessed or audited for all the kinds of challenges across the life cycle.

CONCLUSIONS

The literature shows the relevance of organizing a flexible, personalized health care process across all the critical phases of the life cycle, providing adequate benchmarks for comparison in a multidisciplinary perspective and ensuring continuity between hospital and territory.

Type D personality is associated with depressive symptoms and clinical activity in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) can be exacerbated by stress and depression. Type D personality, characterised by high negative affectivity and social inhibition, represents a vulnerability towards stressors and is associated with adverse outcomes in coronary heart disease.

AIMS

To assess the prevalence of Type D personality in IBD patients and investigate potential associations with disease course.

METHODS

We tested for associations between Type D (Type D Scale-14), depressive symptoms (Hospital Anxiety and Depression Scale's depression subscore ≥11) and recurrent IBD amongst Swiss IBD cohort patients. We built regression models for cross-sectional and Cox proportional hazards models for time-to-event analyses. IBD disease course was assessed by the future occurrence of active disease (Crohn's Disease Activity Index ≥150/Modified Truelove & Witts activity index ≥10) and several IBD-relevant endpoints.

RESULTS

Amongst 2275 patients (1005 ulcerative colitis, 1270 Crohn's disease), 672 (29.5%) had Type D. Type D was a significant risk factor for future active disease (adjusted hazard ratio, aHR: 1.60, corrected P value, q = 0.007) and predicted the future presence of depressive symptoms (aHR: 3.30, P < 0.001). The combination of Type D and depressive symptoms further increased the risk for active disease (aHR: 3.98, q < 0.001). However, Type D associated depressive symptoms seemed to be the main contributor to this effect as Type D's predictive power decreased considerably in models corrected for depressive symptoms (aHR: 1.32, CI: 0.97-1.79, q = 0.292).

CONCLUSIONS

Type D personality's prevalence amongst IBD patients was comparable with its prevalence in the general population. Type D was strongly associated with depressive symptoms and showed modest independent associations with IBD prognosis.

Biosimilar Interchangeability and Emerging Treatment Strategies for Inflammatory Bowel Diseases: A Commentary

This commentary summarizes a collection of key references published within the last ten years, and identifies pharmacologic research directions to improve treatment access and success through greater biosimilar or “follow-on” biologic utilization combined with other targeted small molecule agents that possess unique pathophysiologic mechanisms for inflammatory bowel diseases (IBD) in adult and pediatric patients. Since they are not identical to the originator or reference biologic agent, all biosimilars are not generically equivalent. However, in the US and other countries, they are considered therapeutically interchangeable if the manufacturer has demonstrated no clinically meaningful differences from the reference product. Comparisons of different clinical initiation and switching scenarios are discussed with reference to interchangeability, immunogenicity, nocebo effect, cost effectiveness, and time courses for discontinuation rates.

Life Stressors in Patients with Inflammatory Bowel Disease: Comparison with a Population-Based Healthy Control Group in the Czech Republic

Background: Stress has been suggested to play a potential role in inflammatory bowel disease (IBD) pathogenesis, but studies focussing on the occurrence of specific life stress events among IBD patients are scarce. Therefore, the aim of the present study was to explore the association between various life stress events and IBD. Methods: Patients with IBD (N = 98, mean age: 38.45, 54.1% men) were compared to a group of healthy controls (N = 405, mean age: 36.45, 58.0% men) originating from a health survey conducted on a representative population sample of Czech adults. The Life Stressor Checklist-Revised (LSC-R) was used to assess the stressors. Results: IBD patients had higher odds of reporting life stressors overall (p < 0.001), life stressors before the age of 16 (p < 0.004) and a higher score in traumatic stress (p < 0.005) and interpersonal violence (p < 0.001) when compared to the control group. Gender- and diagnosis-related differences are discussed. Conclusion: Reporting life stressors experienced during childhood or adulthood is strongly associated with IBD. This should be considered in illness management, especially in a severe course of IBD.

Multidimensional Assessment of Interoceptive Abilities, Emotion Processing and the Role of Early Life Stress in Inflammatory Bowel Diseases

Perception of internal bodily sensations includes three dissociable processes: interoceptive accuracy, interoceptive sensibility, and interoceptive awareness. Interoceptive abilities play a crucial role in emotion processing and impairments of these processes have been reported in several psychiatric disorders. Studies investigating interoceptive abilities and their role in emotional experience in individuals with somatic disorders such as inflammatory bowel diseases (IBD) are sparse. Recent findings suggested an association between adverse childhood experiences (ACE) and the development of gastrointestinal disorders. The aim of the current study was to investigate the associations between the different dimensions of interoception and emotional processing in IBD while taking ACE into account. We recruited IBD patients in clinical remission (n = 35) and 35 healthy control participants (HC) matched for age, education and IQ. Interoception was measured as a three-dimensional construct. Interoceptive accuracy was assessed with the heartbeat tracking task and interoceptive sensibility with a self-report measure (Multidimensional Assessment of Interoceptive Awareness questionnaire). Emotional processing was measured using an experimental task, where participants were asked to rate the subjectively perceived valence and arousal when presented with positive, neutral and negative visual stimuli. IBD patients significantly differed in two interoceptive sensibility domains, Emotional awareness and Not-distracting. Patients reported greater awareness of the connection between bodily sensations and emotional states, while showing a stronger tendency to use distraction from unpleasant sensations compared with HC. Higher emotional awareness was linked to higher perceived intensity and arousal of negative stimuli. The strength of this relation was dependent on the severity of ACE, with severer traumatization being associated with a stronger association between emotional awareness and perceived valence and arousal. Our findings suggest that it is the subjective component of interoception, especially the one assessing interoceptive abilities within the scope of emotional experience, which affects emotional processing in IBD. This is the first study providing evidence that IBD patients did not differ in their perception of visceral signals per se but only in the subjective ability to attribute certain physical sensations to physiological manifestations of emotions. Our findings support the hypothesis that ACE affect the association between interoception and emotional processing.

Disability and quality of life before and during the COVID-19 outbreak: A cross-sectional study in inflammatory bowel disease patients

BACKGROUND/AIM

Inflammatory bowel disease (IBD) is a chronic disorder affecting patients' health-related quality of life (HRQoL) which adds to their disability. Little is known about the impact of the COVID-19 pandemic on HRQoL of IBD patients. We aimed to evaluate HRQoL in IBD patient's pre- and post-COVID-19 pandemic using the IBD-disk questionnaire and explore associations between socio demographic factors, disease types, severity and impaired HRQoL in patients with IBD.

PATIENTS AND METHODS

A cross-sectional study was conducted at a tertiary care centre in Saudi Arabia between November 2019 and March 2020 at the outpatient IBD clinics. The HRQoL of patients was assessed using the 10-item IBD-disk questionnaire.

RESULTS

A total of 59 IBD patients (40 Crohn's disease, 19 Ulcerative colitis) with a mean disease duration of 3.5 years were included. Most of the patients (77.97%) were on biologics while 35.59% were on immune modulators, 16.94% on 5-ASA, and 3.38% were on corticosteroids. There was no difference between any of the 10 IBD-disk variables pre and post-COVID-19 pandemic apart from the perception of body image, where there was a slightly more negative perception with an increase from 2.53 to 3.39 (P = 0.05) There was no significant difference in HRQoL between patients with ulcerative colitis and Crohn's disease in any of domains.

CONCLUSION

The current study showed that disability and HRQoL appears to be unaffected by the COVID-19 pandemic among our cohort, however further studies with longer follow up and larger sample size is needed.