1
|
Riggott C, Fairbrass KM, Selinger CP, Gracie DJ, Ford AC. Impact of Opioid Use on the Natural History of Inflammatory Bowel Disease: Prospective Longitudinal Follow-up Study. Inflamm Bowel Dis 2024; 30:1724-1731. [PMID: 37929997 DOI: 10.1093/ibd/izad256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Opioid use is increasingly prevalent amongst patients with inflammatory bowel disease (IBD), but whether opioids have deleterious effects, or their use is merely linked with more severe disease, is unclear. We conducted a longitudinal follow-up study examining this issue. METHODS Data on demographics, gastrointestinal and psychological symptoms, quality of life, and opioid use were recorded at baseline. Data on healthcare use and adverse disease outcomes were obtained from a review of electronic medical records at 12 months. Characteristics at baseline of those using opioids and those who were not were compared, in addition to occurrence of flare, prescription of glucocorticosteroids, treatment escalation, hospitalization, or intestinal resection during the 12 months of follow-up. RESULTS Of 1029 eligible participants, 116 (11.3%) were taking opioids at baseline. Medium (odds ratio [OR], 4.67; 95% confidence interval [CI], 1.61-13.6) or high (OR, 8.03; 95% CI, 2.21-29.2) levels of somatoform symptom-reporting and use of antidepressants (OR, 2.54; 95% CI, 1.34-4.84) or glucocorticosteroids (OR, 6.63; 95% CI, 2.26-19.5; P < .01 for all analyses) were independently associated with opioid use. Following multivariate analysis, opioid users were significantly more likely to undergo intestinal resection (hazard ratio, 7.09; 95% CI, 1.63 to 30.9; P = .009), particularly when codeine or dihydrocodeine were excluded (hazard ratio, 42.9; 95% CI, 3.36 to 548; P = .004). CONCLUSIONS Opioid use in IBD is associated with psychological comorbidity and increased risk of intestinal resection, particularly in stronger formulations. Future studies should stratify the risk of individual opioids, so that robust prescribing algorithms can be developed and assess whether addressing psychological factors in routine IBD care could be an effective opioid avoidance strategy.
Collapse
Affiliation(s)
- Christy Riggott
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Keeley M Fairbrass
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Christian P Selinger
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - David J Gracie
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| |
Collapse
|
2
|
Karlovich N, McConnell R, Velayos F, Mahadevan U, Lewin S. Opioid Use and Outcomes in Patients Hospitalized With Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2024:izae216. [PMID: 39295282 DOI: 10.1093/ibd/izae216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Indexed: 09/21/2024]
Abstract
BACKGROUND Opioid use has not been shown to improve hospitalized inflammatory bowel disease patient pain scores and may prolong the length of stay (LOS). Additional clinical implications of opioid use, particularly high amounts, in the hospital setting have not yet been explored. We sought to determine how high opioid use impacts clinical outcomes in acute severe ulcerative colitis (ASUC). METHODS In this single-center study, we identified all patients hospitalized with ASUC who received intravenous corticosteroids from July 1, 2014 to December 31, 2021. Clinical outcomes including opioid exposure, cumulative intravenous corticosteroid dose, biologic rescue therapy initiation date, colectomy rate, opioid prescription at discharge, LOS, and hospitalization cost were collected. High opioid use was defined as ≥40 oral morphine equivalents (OMEs) per day. A univariable logistic regression was performed to evaluate the association of high opioid use with ASUC outcomes. RESULTS 185 eligible hospitalizations for ASUC were evaluated. 75 patients (41%) received opioids during hospitalization, and 20 patients (11%) received ≥40 OMEs/day. High opioid use was associated with a median 3-day delay in biologic rescue therapy initiation when compared with low/no opioid use (P = .02). 70% of patients with high opioid use received an opioid prescription at discharge compared with 10% of those with low/no use (P < .001). Opioid use was not associated with LOS, duration of corticosteroid therapy, colectomy rate, or hospitalization cost. CONCLUSIONS Among ASUC hospitalizations, high opioid use was associated with delayed biologic rescue therapy initiation and higher rates of opioid prescriptions at discharge.
Collapse
Affiliation(s)
- Norah Karlovich
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ryan McConnell
- Department of Gastroenterology, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - Fernando Velayos
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Uma Mahadevan
- Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Sara Lewin
- Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
3
|
Aziz S, Akhlaq A, Owings A, Gurz S, Zafar Y, Ali B, Tang SJ. Mortality Trends in Inflammatory Bowel Disease by Age, Sex, and Race in the United States from 1999 to 2020. Inflamm Bowel Dis 2024:izae184. [PMID: 39259598 DOI: 10.1093/ibd/izae184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND The prevalence and disease course of inflammatory bowel disease (IBD) have evolved over the years. It is unknown how these factors have impacted all-cause mortality. Our study assesses IBD mortality trends in the United States over 20 years by age, sex, and race. METHODS We used the Centers for Disease Control Wide-Ranging OnLine Data for Epidemiologic Research database for multiple causes of death in Crohn's disease (CD) and ulcerative colitis (UC) from 1999 to 2020. Age-adjusted mortality rates (AAMR) and crude mortality rates per 100 000 population were obtained. Joinpoint Analysis Software was used for annual percentage change (APC) overall and by age, sex, and race (White and Black). RESULTS Overall AAMR in CD and UC were 0.79 and 0.53, respectively. All-cause mortality was stable from 1999 to 2018. There was a significant rise in APC from 2018 to 2020 (CD vs. UC, +11.28 vs. +9.29). This rise was observed across both races, sexes, and ages ≥45 years in the last 2-4 years of the study. AAMR in females compared with males varied in CD (0.81 vs. 0.79) and UC (0.45 vs. 0.62). White adults had higher AAMR than Black adults in both CD (0.94 vs. 0.50) and UC (0.58 vs. 0.28). The crude mortality rate increased with age and was highest in those ≥85 years (CD vs. UC, 5.07 vs. 5.23). CONCLUSIONS All-cause mortality trends in IBD were stable until 2018 and rose between 2018 and 2020. Mortality rates were higher amongst the elderly and White adults. Females with CD and males with UC had higher mortality rates.
Collapse
Affiliation(s)
- Saleha Aziz
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Anum Akhlaq
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Anna Owings
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sana Gurz
- Department of Medicine, University of Nevada, Las Vegas, NV, USA
| | - Yousaf Zafar
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Basim Ali
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Shou-Jiang Tang
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| |
Collapse
|
4
|
Dalal RS, Lund K, Zegers FD, Friedman S, Allegretti JR, Nørgård BM. Use of Tramadol vs Traditional Opioids and Adverse Outcomes in Patients with Inflammatory Bowel Disease: A Danish Nationwide Cohort Study. Inflamm Bowel Dis 2024; 30:1121-1129. [PMID: 37523667 DOI: 10.1093/ibd/izad156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Use of traditional opioids (TOs) for pain management has been associated with adverse outcomes among patients with inflammatory bowel diseases (IBDs). It is unknown if similar associations exist for tramadol, a partial opioid agonist and serotonin and norephinephrine reuptake inhibitor. We sought to compare adverse outcomes associated with tramadol vs TOs in an IBD population. METHODS This nationwide cohort study included adults with IBD diagnosed from 1995 to 2021 in Denmark with subsequent prescriptions for tramadol or TOs. For each analgesic, 2 populations were assessed: initial users (first prescription) and persistent users (first 3 consecutive prescriptions within 365 days). Outcomes included infection, bowel obstruction/ileus, IBD surgery, and mortality within 90 days after the initial use index date (date of first prescription) and within 365 days after the persistent use index date (date of third prescription). Odds ratios adjusted for demographics, comorbidities, and IBD severity were calculated using multivariable logistic regression. RESULTS We identified 37 377 initial users and 15 237 persistent users of tramadol or TOs. Initial users of tramadol had lower adjusted odds of infection (adjusted odds ratio [OR], 0.80; 95% confidence interval [CI], 0.65-0.99), bowel obstruction/ileus (aOR, 0.74; 95% CI, 0.53-1.03), and mortality (aOR, 0.43; 95% CI, 0.35-0.55), and a higher adjusted odds of IBD-related surgery (aOR, 1.27; 95% CI, 1.02-1.60) vs initial users of TOs. Similar results were found for persistent users. CONCLUSIONS Tramadol was associated with lower odds of infection, bowel obstruction/ileus, and mortality vs TOs among patients with IBD. These associations may be impacted by residual confounding.
Collapse
Affiliation(s)
- Rahul S Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ken Lund
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Floor D Zegers
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sonia Friedman
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bente Mertz Nørgård
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
5
|
Lin VA, Hasselager RP, Fransgaard T, Gögenur I. Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study. Dis Colon Rectum 2024; 67:951-959. [PMID: 38869466 DOI: 10.1097/dcr.0000000000003258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Patients with IBD are at increased risk of persistent opioid use, wherein surgery plays an important role. OBJECTIVE Identify risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery and describe in-hospital postoperative opioid treatment. DESIGN This was a retrospective observational cohort study. ORs for persistent postoperative opioid use were calculated using preoperative and in-hospital characteristics, and in-hospital opioid use was described using oral morphine equivalents. SETTING This study was conducted at a university hospital with a dedicated IBD surgery unit. PATIENTS Patients who underwent surgery for IBD from 2017 to 2022 were included. MAIN OUTCOME MEASURES Our main outcome measure was persistent postoperative opioid use (1 or more opioid prescriptions filled 3-9 months postoperatively). RESULTS We included 384 patients, of whom 36 (9.4%) had persistent postoperative opioid use, but only 11 (2.9%) of these patients were opioid naive preoperatively. We identified World Health Organization performance status >1 (OR 8.21; 95% CI, 1.19-48.68), preoperative daily opioid use (OR 12.84; 95% CI, 4.78-35.36), psychiatric comorbidity (OR 3.89; 95% CI, 1.29-11.43) and in-hospital mean daily opioid use (per 10 oral morphine equivalent increase; OR 1.22; 95% CI, 1.12-1.34) as risk factors for persistent postoperative opioid use using multivariable regression analysis. LIMITATIONS Our observational study design and limited sample size because of it being a single-center study resulted in wide CIs. CONCLUSIONS We identified risk factors for persistent postoperative opioid use in patients undergoing surgery for IBD. Results indicate a need for optimization of pain treatment in patients with IBD both before and after surgery. These patients might benefit from additional opioid-sparing measures. See Video Abstract. FACTORES DE RIESGO EN LA ADMINISTRACION DURADERA DE OPIOIDES EN EL POSTOPERATORIO EN CASOS DE CIRUGA POR ENFERMEDAD INFLAMATORIA INTESTINAL ESTUDIO OBSERVACIONAL DE COHORTES ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de recibir opioides de manera duradera, casos donde la cirugía juega un papel importante.OBJETIVO:Identificar los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII y describir el tratamiento intra-hospitalario con los mismos.DISEÑO:Estudio observacional retrospectivo de cohortes. La relación de probabilidades (odds ratio - OR) en la adminstracion duradera de opioides post-operatorios fué calculada utilizando las características pré-operatorias y hospitalarias, donde la administración de opioides intra-hospitalarios fué descrita con la utilización de equivalentes de morfina oral.AMBIENTE:Estudio realizado en un hospital universitario con una unidad de cirugía dedicada a la EII.PACIENTES:Se incluyeron todos los pacientes sometidos a cirugía por EII entre 2017 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Nuestra principal medida de resultado fué la administración post-operatoria duradera de opioides (≥1 receta completa de opioides entre 3 y 9 meses después de la operación).RESULTADOS:Incluimos 384 pacientes, de los cuales 36 (9,4%) recibieron opioides de manera duradera en el post-operatorio, de los cuales solamente 11 pacientes (2,9%) no habían recibido opioides antes de la operación. Identificamos el estado funcional de la OMS > 1 (OR 8,21, IC 95% 1,19-48,68), el uso diario de opioides pré-operatorios (OR 12,84, IC 95% 4,78-35,36), los casos de comorbilidad psiquiátrica (OR 3,89, IC 95% 1,29-11,43) y el uso medio diario de opioides en el hospital (por cada aumento de 10 equivalentes de morfina oral) (OR 1,22, IC del 95%: 1,12-1,34 como factores de riesgo para la administración de opioides de manera duradera en el post-operatorio mediante el análisis de regresión multivariable.LIMITACIONES:Nuestro diseño de estudio observacional y el tamaño de la muestra limitada debido a que fue un estudio en un solo centro, dando como resultado intervalos de confianza muy amplios.CONCLUSIONES:Se identificaron los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII. Los resultados demuestran la necesidad de optimizar el tratamiento del dolor en pacientes con EII, tanto antes como después de la cirugía. Estos pacientes podrían beneficiarse de medidas adicionales de ahorro de opioides. (Traducción-Dr. Xavier Delgadillo).
Collapse
Affiliation(s)
- Viviane A Lin
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Køge, Køge, Denmark
| | | | | | | |
Collapse
|
6
|
Zhang D, Dong X, Li X, Yang Y, Li H, Hong Y, Yang G, Kong X, Wang X, Ma X. Moxibustion ameliorates chronic inflammatory visceral pain via spinal circRNA-miRNA-mRNA networks: a central mechanism study. Mol Brain 2024; 17:23. [PMID: 38750560 PMCID: PMC11097453 DOI: 10.1186/s13041-024-01093-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
This study aimed to unveil the central mechanism of moxibustion treating chronic inflammatory visceral pain (CIVP) from the angle of circRNA-miRNA-mRNA networks in the spinal cord. The rat CIVP model was established using a mixture of 5% (w/v) 2,4,6-trinitrobenzene sulfonic acid and 50% ethanol at a volume ratio of 2:1 via enema. Rats in the moxibustion group received herb-partitioned moxibustion at Tianshu (ST25, bilateral) and Qihai (CV6) points. The abdominal withdrawal reflex (AWR), mechanical withdrawal threshold (MWT), and thermal withdrawal latency (TWL) were adopted for pain behavior observation and pain sensitivity assessment. The circRNA, miRNA, and mRNA expression profiles were detected using the high-throughput sequencing technique. Relevant databases and bioinformatics analysis methods were used to screen for differentially expressed (DE) RNAs and build a circRNA-miRNA-mRNA (competing endogenous RNA) ceRNA regulatory network. The real-time quantitative PCR was employed to verify the sequencing result. CIVP rat models had a significantly higher AWR and lower TWL and MWT than normal rats. Between normal and model rats, there were 103 DE-circRNAs, 16 DE-miRNAs, and 397 DE-mRNAs in the spinal cord. Compared with the model group, the moxibustion group had a lower AWR and higher TWL and MWT; between these two groups, there were 118 DE-circRNAs, 15 DE-miRNAs, and 804 DE-mRNAs in the spinal cord. Two ceRNA networks were chosen to be verified. As a result, moxibustion's analgesic effect on visceral pain in CIVP rats may be associated with regulating the circRNA_02767/rno-miR-483-3p/Gfap network in the spinal cord and improving central sensitization.
Collapse
Affiliation(s)
- Dan Zhang
- Laboratory of Acupuncture-Moxibustion and Immunology, Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, 200030, China
| | - Xiaoqing Dong
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
- Department of Acupuncture and Moxibustion, Xi'an Hospital of Encephalopathy, Shaanxi University of Chinese Medicine, Shaanxi, 710032, China
| | - Xiaoying Li
- Department of Acupuncture and Moxibustion, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200071, China
| | - Yanting Yang
- Laboratory of Acupuncture-Moxibustion and Immunology, Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, 200030, China
| | - Hongna Li
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Yue Hong
- Laboratory of Acupuncture-Moxibustion and Immunology, Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, 200030, China
| | - Guang Yang
- Laboratory of Acupuncture-Moxibustion and Immunology, Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, 200030, China
| | - Xiehe Kong
- Laboratory of Acupuncture-Moxibustion and Immunology, Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, 200030, China
| | - Xuejun Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
- Eye Institute and Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, China.
| | - Xiaopeng Ma
- Laboratory of Acupuncture-Moxibustion and Immunology, Shanghai Research Institute of Acupuncture and Meridian, Shanghai University of Traditional Chinese Medicine, Shanghai, 200030, China.
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
| |
Collapse
|
7
|
Dalal RS, Nørgård BM, Zegers FD, Kjeldsen J, Friedman S, Allegretti JR, Lund K. Older Adult-Onset of Inflammatory Bowel Diseases Is Associated With Higher Utilization of Analgesics: A Nationwide Cohort Study. Am J Gastroenterol 2024; 119:323-330. [PMID: 37713526 DOI: 10.14309/ajg.0000000000002497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/25/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Patients with inflammatory bowel diseases (IBD) commonly require analgesic medications to treat pain, which may be associated with complications. We examined trends of analgesic use according to age at IBD onset. METHODS This nationwide cohort study included adults diagnosed with IBD between 1996 and 2021 in Denmark. Patients were stratified according to their age at IBD onset: 18-39 years (young adult), 40-59 years (adult), and older than 60 years (older adult). We examined the proportion of patients who received prescriptions for analgesic medications within 1 year after IBD diagnosis: strong opioids, tramadol, codeine, nonsteroidal anti-inflammatory drugs, and paracetamol. Multivariable logistic regression analysis was performed to examine the association between age at IBD onset and strong opioid prescriptions and the composite of strong opioid/tramadol/codeine prescriptions. RESULTS We identified 54,216 adults with IBD. Among them, 25,184 (46.5%) were young adults, 16,106 (29.7%) were adults, and 12,926 (23.8%) were older adults at IBD onset. Older adults most commonly received analgesic prescriptions of every class. Between 1996 and 2021, strong opioid, tramadol, and codeine prescriptions were stable, while paracetamol prescriptions increased and nonsteroidal anti-inflammatory drug prescriptions decreased. After multivariable logistic regression analysis, older adults had higher adjusted odds of receiving strong opioid prescriptions (adjusted odds ratio 1.95, 95% confidence interval 1.77-2.15) and the composite of strong opioid/tramadol/codeine prescriptions (adjusted odds ratio 1.93, 95% confidence interval 1.81-2.06) within 1 year after IBD diagnosis compared with adults. DISCUSSION In this nationwide cohort, older adults most commonly received analgesic prescriptions within 1 year after IBD diagnosis. Additional research is needed to examine the etiology and sequelae of increased analgesic prescribing to this demographic.
Collapse
Affiliation(s)
- Rahul S Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bente Mertz Nørgård
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Division of Gastroenterolgy and Hepatology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Floor D Zegers
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
- Research Unit of Medical Gastroenterology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sonia Friedman
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Division of Gastroenterolgy and Hepatology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ken Lund
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
8
|
Morris DC, Zacharek A, Zhang ZG, Chopp M. Extracellular vesicles-Mediators of opioid use disorder? Addict Biol 2023; 28:e13353. [PMID: 38017641 DOI: 10.1111/adb.13353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/27/2023] [Accepted: 10/13/2023] [Indexed: 11/30/2023]
Abstract
Opioid use disorder (OUD) is a growing health emergency in the United States leading to an epidemic of overdose deaths. OUD is recognized as an addictive brain disorder resulting in psychological, cognitive and behavioural dysfunction. These observed clinical dysfunctions are a result of cellular changes that occur in the brain. Derangements in inflammation, neurogenesis and synaptic plasticity are observed in the brains of OUD patients. The mechanisms of these derangements are unclear; however, extracellular vesicles (EVs), membrane bound particles containing protein, nucleotides and lipids are currently being investigated as agents that invoke these cellular changes. The primary function of EVs is to facilitate intercellular communication by transfer of cargo (protein, nucleotides and lipids) between cells; however, changes in this cargo have been observed in models of OUD suggesting that EVs may be agents promoting the observed cellular derangements. This review summarizes evidence that altered cargo of EVs, specifically protein and miRNA, in models of OUD promote impairments in neurons, astrocytes and microglial cells. These findings support the premise that opioids alter EVs to detrimentally affect neuro-cellular function resulting in the observed addictive, psychological and neurocognitive deficits in OUD patients.
Collapse
Affiliation(s)
- Daniel C Morris
- Department of Emergency Medicine, Michigan State University, College of Human Medicine, Henry Ford Health, Detroit, Michigan, USA
| | - Alex Zacharek
- Department of Neurological Research, Henry Ford Health, Detroit, Michigan, USA
| | - Zheng G Zhang
- Department of Neurological Research, Henry Ford Health, Detroit, Michigan, USA
| | - Michael Chopp
- Department of Neurological Research, Henry Ford Health, Detroit, Michigan, USA
- Department of Physics, Oakland University, Rochester, Michigan, USA
| |
Collapse
|
9
|
Baillie S, Norton C, Saxena S, Pollok R. Chronic abdominal pain in inflammatory bowel disease: a practical guide. Frontline Gastroenterol 2023; 15:144-153. [PMID: 38420131 PMCID: PMC10897648 DOI: 10.1136/flgastro-2023-102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/12/2023] [Indexed: 03/02/2024] Open
Abstract
Pain is common in inflammatory bowel disease (IBD), yet many patients feel their pain is not addressed by healthcare professionals. Listening to a patient's concerns about pain, assessing symptoms and acknowledging the impact these have on daily life remain crucial steps in addressing pain in IBD. While acute pain may be effectively controlled by pain medication, chronic pain is more complex and often pharmacological therapies, particularly opioids, are ineffective. Low-dose tricyclic antidepressants and psychological approaches, including cognitive-behavioural therapy, have shown some promise in offering effective pain management while lifestyle changes such as a trial of low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet in those with overlapping irritable bowel syndrome may also reduce pain. Patients benefit from a long-term, trusting relationship with their healthcare professional to allow a holistic approach combining pharmacological, psychological, lifestyle and dietary approaches to chronic pain. We present a practical review to facilitate management of chronic abdominal pain in IBD.
Collapse
Affiliation(s)
- Samantha Baillie
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sonia Saxena
- Primary Care and Public Health, Imperial College London, London, UK
| | - Richard Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
10
|
Ahmed W, Billing W, Stump TE, Strobel T, Sagi S, Fischer M, Bohm M. Opioid Legislation in Patients With Inflammatory Bowel Disease: A State-wide Retrospective Cohort Study. Inflamm Bowel Dis 2023; 29:1355-1361. [PMID: 36271877 DOI: 10.1093/ibd/izac218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Indiana State opioid prescription legislation has been shown to decrease overall opioid prescriptions. However, this effect has not been studied in specific diseases associated with chronic pain such as inflammatory bowel disease (IBD). We aimed to determine the effect of state opioid prescription legislation on opioid prescribing patterns in IBD. METHODS A retrospective cohort analysis using an interrupted time-series from December 15, 2010 to July 1, 2018, with 2 time periods separated by Title 844 of the Indiana Administrative Code, in a statewide health care system capturing the majority of the state's population including all adult patients with IBD. The primary outcome was opioid prescription rate per person-year. RESULTS In total, 9436 patients met inclusion criteria. After legislation, the total number of opioid orders per patient-year continued to increase (0.543, 95% CI, 0.528-0.558, to 0.663, 95% CI, 0.654-0.672), with fewer scripts from the emergency department (0.113, 95% CI, 0.106-0.120, to 0.092, 95% CI, 0.088-0.095) and more from outpatient providers (0.303, 95% CI, 0.292-0.314 to 0.432, 95% CI, 0.424-0.439). There were increases in biologic (0.206, 95% CI, 0.197-0.215 to 0.517, 95% CI, 0.509-0.525) and steroid (0.182, 95% CI, 0.173-0.190 to 0.237, 95% CI, 0.232-0.243) prescriptions per person-year following legislation. Factors associated with heavy opioid use included chronic steroids (odds ratio, 5.030; 95% CI, 4.176-6.054), history of IBD-related surgery (odds ratio, 2.807; 95% CI, 2.367-3.323) and current smoking (odds ratio, 2.650; 95% CI, 2.223-3.158). CONCLUSIONS Despite legislation and the increased use of disease-modifying drugs, statewide opioid prescriptions continued to increase. The increase in opiate use, high steroid use, and significant health care utilization suggests poor underlying disease control.
Collapse
Affiliation(s)
- Waseem Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Wade Billing
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy E Stump
- Indiana University School of Medicine, Department of Biostatistics, Indianapolis, Indiana, USA
| | - Thomas Strobel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sashidhar Sagi
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monika Fischer
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mathew Bohm
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
11
|
Telfer L, Dalessio S, Tinsley A, Coates M. Short-Term and Long-Term Opioid Use Is Associated With Poor Outcomes in Outpatients With Inflammatory Bowel Disease. GASTRO HEP ADVANCES 2023; 2:1022-1024. [PMID: 38094225 PMCID: PMC10718513 DOI: 10.1016/j.gastha.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 12/17/2023]
Affiliation(s)
- L. Telfer
- Penn State College of Medicine, Hershey, Pennsylvania
| | - S. Dalessio
- Division of Gastroenterology & Hepatology, Penn State College of Medicine, Hershey, Pennsylvania
| | - A. Tinsley
- Division of Gastroenterology & Hepatology, Penn State College of Medicine, Hershey, Pennsylvania
| | - M. Coates
- Division of Gastroenterology & Hepatology, Penn State College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
12
|
Baillie S, Limdi JK, Bassi A, Fraser A, Parkes G, Scott G, Raine T, Lamb CA, Kennedy NA, Fumis N, Smith MA, Nicolaou A, Emms H, Wye J, Lehmann A, Carbery I, Goodhand J, Lees R, Beshyah W, Luthra P, Pollok R, Selinger C. Opioid use and associated factors in 1676 patients with inflammatory bowel disease: a multicentre quality improvement project. Frontline Gastroenterol 2023; 14:497-504. [PMID: 37854782 PMCID: PMC10579551 DOI: 10.1136/flgastro-2023-102423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/30/2023] [Indexed: 10/20/2023] Open
Abstract
Objective Despite its association with poorer outcomes, opioid use in inflammatory bowel disease (IBD) is not well characterised in the UK. We aimed to examine the extent of opioid use, the associated factors and the use of mitigation techniques such as pain-service review and opioid weaning plans among individuals with IBD. Methods Data were collected from consecutive patients attending IBD outpatient appointments at 12 UK hospitals. A predefined questionnaire was used to collect data including patient demographics, IBD history, opioid use in the past year (>2 weeks) and opioid-use mitigation techniques. Additionally, consecutive IBD-related hospital stays leading up to July 2019 were reviewed with data collected regarding opioid use at admission, discharge and follow-up as well as details of the admission indication. Results In 1352 outpatients, 12% had used opioids within the past 12 months. Over half of these individuals were taking opioids for non-IBD pain and less than half had undergone an attempted opioid wean.In 324 hospitalised patients, 27% were prescribed opioids at discharge from hospital. At 12 months postdischarge, 11% were using opioids. Factors associated with opioid use in both cohorts included female sex, Crohn's disease and previous surgery. Conclusions 1 in 10 patients with IBD attending outpatient appointments were opioid exposed in the past year while a quarter of inpatients were discharged with opioids, and 11% continued to use opioids 12 months after discharge. IBD services should aim to identify patients exposed to opioids, reduce exposure where possible and facilitate access to alternative pain management approaches.
Collapse
Affiliation(s)
- Samantha Baillie
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ash Bassi
- Department of Gastroenterology, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Aileen Fraser
- Department of Gastroenterology, University Hospitals Bristol and Weston Trust, Bristol, UK
| | - Gareth Parkes
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Glyn Scott
- Department of Gastroenterology, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter IBD Research Group, University of Exeter, Exeter, UK
| | - Natalia Fumis
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Melissa A Smith
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Andrew Nicolaou
- Pain Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Holly Emms
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - John Wye
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anouk Lehmann
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Isabel Carbery
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Goodhand
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Robert Lees
- Department of Gastroenterology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Waleed Beshyah
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Pavit Luthra
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Richard Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
13
|
Fu Y, Kurin M, Landsman M, Fass R, Song G. Irritable Bowel Syndrome Is an Independent Risk Factor for Developing Opioid Use Disorder in Patients with Inflammatory Bowel Disease. J Pers Med 2023; 13:917. [PMID: 37373905 DOI: 10.3390/jpm13060917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Yuhan Fu
- Department of Internal Medicine, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Michael Kurin
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Marc Landsman
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Ronnie Fass
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Gengqing Song
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| |
Collapse
|
14
|
Regev S, Schwartz D, Sarid O, Goren G, Slonim-Nevo V, Friger M, Sergienko R, Greenberg D, Monsonego A, Nemirovsky A, Odes S. Randomised clinical trial: Psychological intervention improves work productivity and daily activity by reducing abdominal pain and fatigue in Crohn's disease. Aliment Pharmacol Ther 2023; 57:861-871. [PMID: 36734040 DOI: 10.1111/apt.17399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/13/2022] [Accepted: 01/12/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chronic abdominal pain and fatigue are characteristics of Crohn's disease (CD) and contribute to functional impairments. AIMS To examine whether CD-tailored cognitive-behavioural and mindfulness intervention (COBMINDEX) is effective in reducing abdominal pain and fatigue in patients with CD and whether changes in abdominal pain and fatigue mediate any beneficial effects of COBMINDEX on impairments in work productivity and daily activities. METHODS This is a secondary analysis of a parallel-group multicentre randomised controlled trial. Patients with mild-to-moderate CD (n = 142) were randomised into either intervention group receiving COBMINDEX, or control group receiving treatment-as-usual for 3 months followed by COBMINDEX. Complete data were collected from 120 patients (34.0 ± 10.7 years, 62.5% female, intervention = 60, control = 60). Analysis of covariance assessed group differences in 3-month follow-up scores, controlling for baseline scores. Multiple parallel mediation analysis assessed the proposed mechanisms for the entire sample. RESULTS The intervention group demonstrated significantly lower levels of abdominal pain (F = 17.46, p < 0.001, η2 p = 0.13), fatigue (F = 7.26, p = 0.008, η2 p = 0.06) and impairments at work (F = 4.82, p = 0.032, η2 p = 0.07) and daily activities (F = 6.26, p = 0.014, η2 p = 0.05), compared with treatment-as-usual. Moreover, changes in abdominal pain and fatigue significantly mediated the beneficial effects of COBMINDEX on patients' work productivity (b = -9.90, SE = 2.86, 95% CI: -16.11 to -4.94) and daily activities (b = -9.65, SE = 1.91, 95% CI: -13.77 to 6.35), independent of changes in disease activity. CONCLUSIONS COBMINDEX is effective at reducing abdominal pain and fatigue in patients with CD, which in turn leads to improvement in functioning. Clinicians should incorporate screening for severe abdominal pain and fatigue and consider offering cognitive-behavioural and mindfulness training. CLINICALTRIALS gov, Number: NCT05085925. Ministry of Health in Israel (https://my.health.gov.il/CliniTrials/Pages/MOH_2020-02-24_008721.aspx).
Collapse
Affiliation(s)
- Shirley Regev
- Department of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Doron Schwartz
- Department of Gastroenterology and Hepatology, Soroka Medical Center, Beer-Sheva, Israel
| | - Orly Sarid
- Department of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ganit Goren
- Department of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Vered Slonim-Nevo
- Department of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Michael Friger
- Department of Public Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ruslan Sergienko
- Department of Public Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Greenberg
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alon Monsonego
- Department of Microbiology, Immunology and Genetics, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Anna Nemirovsky
- Department of Microbiology, Immunology and Genetics, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shmuel Odes
- Division of Clinical Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
15
|
Barnes A, Spizzo P, Bampton P, Andrews JM, Fraser RJ, Mukherjee S, Mountifield R. Examining the influence of inflammatory bowel disease medications on sleep quality. JGH Open 2023; 7:190-196. [PMID: 36968569 PMCID: PMC10037038 DOI: 10.1002/jgh3.12871] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/25/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023]
Abstract
Background and Aim Inflammatory bowel disease (IBD) can disrupt sleep, leading to poor sleep quality. This may in part be due to the symptoms of IBD and the influence of pro-inflammatory cytokines on sleep. This study aimed to investigate the potential influence of IBD medications on sleep quality. Methods An online survey of adults with IBD was conducted, which included measures of sleep quality, IBD activity, anxiety, depression, and physical activity. Logistic regression was used to investigate possible associations between IBD medications (corticosteroids, immunomodulators, biologics, aminosalicyate) and outcome of poor sleep. A generalized linear model was built for outcome of sleep quality score. Results There were 544 participants included in the final analysis, median age of 42, and 61% with Crohn's disease. Increased odds of poor sleep were seen in those taking opioids, medications for anxiety or depression, corticosteroids, vitamin D, methotrexate, and infliximab. A multivariate model was built incorporating demographic and IBD variables with opioids present in the final model and associated with increased odds of poor sleep. This was in addition to medications for sleep, depression, anxiety, IBD activity, and body weight. In a multivariate generalized linear model, opioids and methotrexate were associated with worse sleep quality scores. Conclusions Opioids were associated with increased odds of poor sleep independent of other factors. This provides further support for avoiding these medications in people with IBD. Infliximab was associated with increased body weight and consequently increased odds of poor sleep.
Collapse
Affiliation(s)
- Alex Barnes
- Department of GastroenterologySouthern Adelaide Local Health Network (SALHN) Flinders Medical CentreBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders UniversityBedford ParkSouth AustraliaAustralia
| | - Paul Spizzo
- Department of GastroenterologySouthern Adelaide Local Health Network (SALHN) Flinders Medical CentreBedford ParkSouth AustraliaAustralia
| | - Peter Bampton
- College of Medicine and Public HealthFlinders UniversityBedford ParkSouth AustraliaAustralia
| | - Jane M Andrews
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology(CAHLN) Royal Adelaide HospitalAdelaideSouth AustraliaAustralia
- School of Medicine, Faculty of Health & Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Robert J Fraser
- Department of GastroenterologySouthern Adelaide Local Health Network (SALHN) Flinders Medical CentreBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders UniversityBedford ParkSouth AustraliaAustralia
| | - Sutapa Mukherjee
- College of Medicine and Public HealthFlinders UniversityBedford ParkSouth AustraliaAustralia
- Department of Respiratory and Sleep MedicineSouthern Adelaide Local Health Network (SALHN) Flinders Medical CentreBedford ParkSouth AustraliaAustralia
| | - Réme Mountifield
- Department of GastroenterologySouthern Adelaide Local Health Network (SALHN) Flinders Medical CentreBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders UniversityBedford ParkSouth AustraliaAustralia
| |
Collapse
|
16
|
Zhang Z, Zhang WH, Lu YX, Lu BX, Wang YB, Cui LY, Cheng H, Yuan ZY, Zhang J, Gao DP, Gong JF, Ji Q. Intraoperative Low-Dose S-Ketamine Reduces Depressive Symptoms in Patients with Crohn's Disease Undergoing Bowel Resection: A Randomized Controlled Trial. J Clin Med 2023; 12:jcm12031152. [PMID: 36769799 PMCID: PMC9917783 DOI: 10.3390/jcm12031152] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
Background: Patients with Crohn's disease (CD) undergoing bowel resection often suffer from depression and acute pain, which severely impairs their recovery. We aimed to investigate the effects of S-ketamine preconditioning on postoperative depression in patients with CD undergoing a bowel resection with mild to moderate depression and to observe whether it can relieve postoperative pain and anti-inflammation. Methods: A total of 124 adult patients were randomized into one of the two groups. Patients in the S-ketamine group received a 0.25 mg/kg S-ketamine intravenous drip under general anesthesia induction, followed by a continuous infusion of S-ketamine with 0.12 mg/kg/h for more than 30 min through target-controlled infusion. Patients in the placebo group received 0.9% saline at an identical volume and rate. The primary outcome measure was the 17-item Hamilton depression Scale (HAMD-17). The secondary outcomes were scores on the following questionnaires: a nine-item patient health questionnaire (PHQ-9); a quality of recovery (QoR-15) form; and a numeric rating scale (NRS). Additional secondary outcomes included the levels of C-reactive protein (CRP) and interleukin 6 (IL-6) on postoperative days (PODs) 1, 3, and 5, the length of hospital stay, and opioid use throughout the hospital stay. Results: The scores of PHQ-9 and HAMD-17 in the S-ketamine group were lower than those in the placebo group on postoperative days (PODs) 1, 2, and 7 (p < 0.05). The scores of QoR-15 in the S-ketamine group were higher than those in the placebo group on postoperative days (PODs) 3 and 5 (p < 0.05). The NRS scores of PACU, postoperative days 1 and 2 in the S-ketamine group were lower than those in the placebo group (p < 0.05). There was no significant difference in the CRP and IL-6 levels on postoperative days (PODs) 1, 3, and 5, postoperative complications, and hospital stay between the two groups (p > 0.05). Conclusions: The trial indicated that the intraoperative administration of low-dose S-ketamine could alleviate mild-to-moderate depressive symptoms and postoperative pain in patients with Crohn's disease undergoing bowel resection without worsening their safety.
Collapse
Affiliation(s)
- Zhen Zhang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Wen-Hao Zhang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Yin-Xiao Lu
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Bo-Xuan Lu
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Yi-Bo Wang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Li-Ying Cui
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Hao Cheng
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Zhen-Yu Yuan
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Jie Zhang
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Da-Peng Gao
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Jian-Feng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
| | - Qing Ji
- Department of Anesthesiology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210016, China
- Correspondence:
| |
Collapse
|
17
|
Management of Pelvic Pain in Patients with Crohn's Disease-Current Overview. J Clin Med 2023; 12:jcm12020526. [PMID: 36675454 PMCID: PMC9862261 DOI: 10.3390/jcm12020526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Crohn's disease (CD) is a subtype of chronic inflammatory bowel diseases (IBD) with characteristic skip lesions and transmural inflammation that may affect the entire gastrointestinal tract from the mouth to the anus. Persistent pain is one of the main symptoms of CD. This pain has multifactorial pathogenesis, but most often arises from intestinal inflammation itself, as well as from gut distention or partial intestinal obstruction. Some current evidence also suggests sensitization of sensory pathways, as well as modulation of those signals by the central nervous system, which highlights the impact of biopsychosocial factors. To date, most studies have focused only on the pain located in the abdomen, while pelvic pain has rarely been explored, despite it being a common symptom. The aim of this study is to provide an abbreviated summary of the current state of knowledge on the origins and treatment of pelvic pain in CD.
Collapse
|
18
|
Dalavaye N, Erridge S, Nicholas M, Pillai M, Bapir L, Holvey C, Coomber R, Rucker JJ, Hoare J, Sodergren MH. The effect of medical cannabis in inflammatory bowel disease: analysis from the UK Medical Cannabis Registry. Expert Rev Gastroenterol Hepatol 2023; 17:85-98. [PMID: 36562418 DOI: 10.1080/17474124.2022.2161046] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Cannabis-based medicinal products (CBMPs) have shown promising preclinical activity in inflammatory bowel disease (IBD). However, clinical trials have not demonstrated effects on inflammation. This study aims to analyze changes in health-related quality of life (HRQoL) and adverse events in IBD patients prescribed CBMPs. METHODS A case series from the UK Medical Cannabis Registry was performed. Primary outcomes included changes from baseline in the Short Inflammatory Bowel Disease Questionnaire (SIBDQ), Generalized Anxiety Disorder-7 (GAD-7), Single-Item Sleep Quality Scale (SQS), and EQ-5D-5L Index score at 1 and 3 months. Statistical significance was defined using p < 0.050. RESULTS Seventy-six patients with Crohn's disease (n = 51; 67.11%) and ulcerative colitis (n = 25; 32.89%) were included. The median baseline SIBDQ score improved at 1 and 3 months. EQ-5D-5L index values, GAD-7, and SQS also improved after 3 months (p < 0.050). Sixteen (21.05%) patients reported adverse events with the majority being classified as mild to moderate in severity. CONCLUSION Patients treated with CBMPs for refractory symptoms of Crohn's disease and ulcerative colitis demonstrated a short-term improvement in IBD-specific and general HRQoL. Prior cannabis consumers reported greater improvement compared to cannabis-naïve individuals.
Collapse
Affiliation(s)
- Nishaanth Dalavaye
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon Erridge
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK.,Sapphire Medical Clinics, London, UK
| | - Martha Nicholas
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Manaswini Pillai
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lara Bapir
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Ross Coomber
- Sapphire Medical Clinics, London, UK.,St. George's Hospital NHS Trust, London, UK
| | - James J Rucker
- Sapphire Medical Clinics, London, UK.,Department of Psychological Medicine, Kings College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Jonathan Hoare
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK.,Sapphire Medical Clinics, London, UK
| | - Mikael H Sodergren
- Imperial College Medical Cannabis Research Group, Department of Surgery and Cancer, Imperial College London, London, UK.,Sapphire Medical Clinics, London, UK
| |
Collapse
|
19
|
Wang D, Li S, Ma X, Chen X, Tian X, Li X, Chen L, Kang Q, Wang X, Jin P, Lu X, Fu Y, Li J, Sheng J. Immunomodulatory effects of fentanyl and morphine on DSS- and TNBS-induced colitis. Immunopharmacol Immunotoxicol 2022; 44:1044-1057. [PMID: 35848944 DOI: 10.1080/08923973.2022.2102993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Opioid prescription for inflammatory bowel disease (IBD)-related pain is on the rise. However, the use of strong opioids can result in severe complications, and even death, in IBD patients. This study aimed to define the role of fentanyl and morphine, two representative strong opioids, in the pathogenesis of dextran sodium sulfate (DSS)- and 2,4,6-trinitrobenzenesulfonic acid solution (TNBS)-induced colitis. METHOD DSS and TNBS models were induced in C57BL/6J and Balb/c mice, respectively. Disease activity index (DAI), histopathology, enzyme-linked immunosorbent assay (ELISA), multiplex ELISA, and flow cytometry were performed to evaluate the effects of fentanyl and morphine. RESULT Fentanyl exacerbated DSS- and TNBS-induced colitis, while morphine exhibited no significant immunomodulatory effect. Fentanyl and morphine had no obvious effects on the serum levels of adrenocorticotropic hormone (ACTH), glucocorticoid (GC), and prostaglandin E2 (PGE-2) in DSS and TNBS models. Fentanyl elevated the proportions of Th1 cells, μ-opioid receptor (MOR) + Th1 cells, and MOR + macrophages in the colonic mucosa of DSS-treated mice, and enhanced the proportions of Th1 cells, macrophages, MOR + Th1 cells, and MOR + macrophages in the colonic mucosa of TNBS-treated mice. We found that fentanyl upregulated the levels of inflammatory cytokines/chemokines in MOR + macrophages of the colonic lamina propria mononuclear cells (LPMCs) from DSS-treated mice, whereas it had no effect on the expression of most inflammatory cytokines/chemokines in MOR + macrophages in the colonic LPMCs from TNBS-treated mice. CONCLUSION Our findings suggest that fentanyl exacerbates murine colitis via Th1 cell- and macrophage-mediated mechanisms, while morphine exhibits no significant immunomodulatory effect.
Collapse
Affiliation(s)
- Dezhi Wang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Shanshan Li
- Department of Laboratory, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xianzong Ma
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China.,Chinese PLA General Hospital, Beijing, China
| | - Xi Chen
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xiaoran Tian
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xuhang Li
- Department of Medicine/GI Division, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Linxiao Chen
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Qian Kang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xin Wang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Peng Jin
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xiaojuan Lu
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Yanxia Fu
- Department of Biochemistry and Molecular Biology, Capital Medical University, Beijing, China
| | - Jianghua Li
- State Key Laboratory of Membrane Biology, School of Medicine, Tsinghua University, Beijing, China
| | - Jianqiu Sheng
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China.,Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
20
|
Cohen-Mekelburg S, Tony Van M, Wallace B, Berinstein J, Yu X, Lewis J, Hou J, Dominitz JA, Waljee AK. The Association Between Nonsteroidal Anti-Inflammatory Drug Use and Inflammatory Bowel Disease Exacerbations: A True Association or Residual Bias? Am J Gastroenterol 2022; 117:1851-1857. [PMID: 35970816 PMCID: PMC9714642 DOI: 10.14309/ajg.0000000000001932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/07/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Studies suggest that nonsteroidal anti-inflammatory drugs (NSAID) may contribute to inflammatory bowel disease (IBD) exacerbations. We examined whether variation in the likelihood of IBD exacerbations is attributable to NSAID. METHODS In a cohort of patients with IBD (2004-2015), we used 3 analytic methods to examine the likelihood of an exacerbation after an NSAID exposure. First, we matched patients by propensity for NSAID use and examined the association between NSAID exposure and IBD exacerbation using an adjusted Cox proportional hazards model. To assess for residual confounding, we estimated a previous event rate ratio and used a self-controlled case series analysis to further explore the relationship between NSAID and IBD exacerbations. RESULTS We identified 15,705 (44.8%) and 19,326 (55.2%) IBD patients with and without an NSAID exposure, respectively. Findings from the Cox proportional hazards model suggested an association between NSAID and IBD exacerbation (hazard ratio 1.24; 95% confidence interval 1.16-1.33). However, the likelihood of an IBD exacerbation in the NSAID-exposed arm preceding NSAID exposure was similar (hazard ratio 1.30; 95% confidence interval 1.21-1.39). A self-controlled case series analysis of 3,968 patients who had both an NSAID exposure and IBD exacerbation demonstrated similar exacerbation rates in the 1 year preceding exposure, 2-6 weeks postexposure, and 6 weeks to 6 months postexposure, but a higher incidence in 0-2 weeks postexposure, suggesting potential confounding by reverse causality. DISCUSSION While we see an association between NSAID and IBD exacerbations using traditional methods, further analysis suggests this may be secondary to residual bias. These findings may reassure patients and clinicians considering NSAID as a nonopioid pain management option.
Collapse
Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - M.S. Tony Van
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Beth Wallace
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Division of Rheumatology, University of Michigan Medicine, Ann Arbor, MI
| | - Jeff Berinstein
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI
| | - Xianshi Yu
- Department of Statistics, University of Michigan, Ann Arbor, MI
| | - James Lewis
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Jason Hou
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
- VA Houston Healthcare System, Houston, TX
| | - Jason A. Dominitz
- VA Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, University of Michigan Medicine, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| |
Collapse
|
21
|
Chang HC, Gau SY. Inflammatory Bowel Disease and Incident Acute Arterial Events. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00927-2. [PMID: 36220548 DOI: 10.1016/j.cgh.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Hui-Chin Chang
- Library, Chung Shan Medical University Hospital, Taichung, Taiwan; Evidence-based Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Shuo-Yan Gau
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| |
Collapse
|
22
|
Rabinowitz LG, Zylberberg HM, Yang J, Gold SL, Chesner J, Ji J, Hu L, Dubinsky M. De Novo Ostomy Placement Is Associated with Increased Outpatient Opioid Use In Patients with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:4033-4042. [PMID: 34613501 DOI: 10.1007/s10620-021-07257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/13/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND/AIMS Opioid use is associated with poor outcomes in patients with inflammatory bowel disease (IBD). We aimed to identify novel factors associated with increased outpatient opioid (OPRx) use following IBD-related hospitalization. METHODS This was a retrospective cohort study of IBD patients ≥ 18 years old, hospitalized during 2018. The primary outcome was receiving ≥ 1(OPRx) in the year following index hospitalization (IH), excluding prescriptions written within 2 weeks of discharge. Secondary outcomes included having 1-2 vs ≥ 3 OPRx and rates of healthcare utilization. Univariate and multivariate analyses tested associations with OPRx. RESULTS Of 526 patients analyzed, 209 (40%) received at least 1 OPRx; with a median of 2 [1-3] OPRx. Presence or placement of ostomy at IH, exposure to opioids during IH, ulcerative colitis (UC), mental health comorbidities, admission for surgery and managed on the surgical service, and IBD surgery within 1 year prior to IH were associated with ≥ 1 OPRx on univariate analysis. On multivariable analysis, UC, ostomy placement during IH, anxiety, and inpatient opioid exposure were independently associated with ≥ 1 OPRx. A majority (> 70%) of both inpatient and outpatient opioid prescriptions were written by surgeons. Patients requiring ≥ 3 OPRx had the highest rates of unplanned IBD surgery (56% p = 0.04), all-cause repeat hospitalization (81%, p = 0.003), and IBD-related repeat hospitalization (77%, p = 0.007) in the year following IH. CONCLUSIONS A multimodal approach to pain management for IBD patients, as well as increased recognition that any patient with a de novo ostomy is at particular risk of opioid use, is needed.
Collapse
Affiliation(s)
- Loren G Rabinowitz
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Haley M Zylberberg
- Division of Gastroenterology, Department of Medicine, New York Presbyterian Hospital-Columbia University, New York, NY, USA
| | - Jeong Yang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephanie Lauren Gold
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jaclyn Chesner
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiayi Ji
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Liangyuan Hu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center, Icahn School of Medicine Mount Sinai, New York, NY, USA
| |
Collapse
|
23
|
Wils P, Caron B, D’Amico F, Danese S, Peyrin-Biroulet L. Abdominal Pain in Inflammatory Bowel Diseases: A Clinical Challenge. J Clin Med 2022; 11:4269. [PMID: 35893357 PMCID: PMC9331632 DOI: 10.3390/jcm11154269] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 02/01/2023] Open
Abstract
Up to 60% of inflammatory bowel disease (IBD) patients experience abdominal pain in their lifetime regardless of disease activity. Pain negatively affects different areas of daily life and particularly impacts the quality of life of IBD patients. This review provides a comprehensive overview of the multifactorial etiology implicated in the chronic abdominal pain of IBD patients including peripheral sensitization by inflammation, coexistent irritable bowel syndrome, visceral hypersensitivity, alteration of the brain-gut axis, and the multiple factors contributing to pain persistence. Despite the optimal management of intestinal inflammation, chronic abdominal pain can persist, and pharmacological and non-pharmacological approaches are necessary. Integrating psychological support in care models in IBD could decrease disease burden and health care costs. Consequently, a multidisciplinary approach similar to that used for other chronic pain conditions should be recommended.
Collapse
Affiliation(s)
- Pauline Wils
- Department of Gastroenterology, Claude Huriez Hospital, University of Lille, F-59000 Lille, France
| | - Bénédicte Caron
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, F-54000 Nancy, France; (B.C.); (L.P.-B.)
- Department of Gastroenterology, University of Lorraine, Inserm, NGERE, F-54000 Nancy, France
| | - Ferdinando D’Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.D.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.D.); (S.D.)
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, F-54000 Nancy, France; (B.C.); (L.P.-B.)
- Department of Gastroenterology, University of Lorraine, Inserm, NGERE, F-54000 Nancy, France
| |
Collapse
|
24
|
Bierle DM, Wight EC, Ganesh R, Himes CP, Sundsted KK, Jacob AK, Mohabbat AB. Preoperative Evaluation and Management of Patients With Select Chronic Gastrointestinal, Liver, and Renal Diseases. Mayo Clin Proc 2022; 97:1380-1395. [PMID: 35787866 DOI: 10.1016/j.mayocp.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/22/2021] [Accepted: 03/29/2022] [Indexed: 11/28/2022]
Abstract
Patients with chronic gastrointestinal, hepatic, and renal disease are frequently encountered in clinical practice. This is due in part to the rising prevalence of risk factors associated with these conditions. These patients are increasingly being considered for surgical intervention and are at higher risk for multiple perioperative complications. Many are able to safely undergo surgery but require unique considerations to ensure optimal perioperative care. In this review, we highlight relevant perioperative physiology and outline our approach to the evaluation and management of patients with select chronic gastrointestinal, hepatic, and renal diseases. A comprehensive preoperative evaluation with a multidisciplinary approach is often beneficial, and specialist involvement should be considered. Intraoperative and postoperative plans should be individualized based on the unique medical and surgical characteristics of each patient.
Collapse
Affiliation(s)
- Dennis M Bierle
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Elizabeth C Wight
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Karna K Sundsted
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arya B Mohabbat
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
25
|
Chugh R, Gaidos JKJ. Fertility and Pregnancy in Crohn's Disease. Gastroenterol Clin North Am 2022; 51:381-399. [PMID: 35595421 DOI: 10.1016/j.gtc.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The prevalence of inflammatory bowel disease is continuing to increase worldwide and is more commonly diagnosed in women of reproductive age. Individuals with Crohn's disease may have inaccurate perceptions regarding the rate of infertility, heritability, and the safety of taking therapies for Crohn's disease during pregnancy, all of which greatly affect their decisions surrounding family planning. Given this area of need for both patients and providers, in this article, we have included the latest evidence on the impact of Crohn's disease on fertility, heritability, pregnancy outcomes, and the safety of medications for Crohn's disease during pregnancy and lactation.
Collapse
Affiliation(s)
- Rishika Chugh
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Gastroenterology, Department of Medicine, University of California San Francisco, 1701 Divisadero, San Francisco, CA 94115, USA
| | - Jill K J Gaidos
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Section of Digestive Diseases, Yale Inflammatory Bowel Disease Program, 40 Temple Street, Suite 1C, New Haven, CT 06510, USA.
| |
Collapse
|
26
|
Young E, Jones E, Thomas M, Lawrence M, Andrews J. Poor engagement and adherence predict neoplasia in inflammatory bowel disease: a case-control study. Intern Med J 2022; 53:731-737. [PMID: 35353446 DOI: 10.1111/imj.15760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 01/23/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Colorectal adenocarcinoma is an important and preventable complication of inflammatory bowel disease. A previous case series suggested mental health issues and poor engagement in care as novel risk factors. AIMS We sought to confirm the role of patient engagement in care in the development of neoplasia using a case-control methodology. METHODS Patients in a single referral centre from 2007 to 2017 with colorectal adenocarcinoma, high-grade dysplasia or multifocal low-grade dysplasia were included as neoplasia cases. Each case was assigned up to three matched controls (matched for age, gender, underlying disease, inflammatory bowel disease type & phenotype and disease duration). Novel and known risk factors were compared between groups. RESULTS Thirty-two cases with 88 matched controls were included. Patients with neoplasia were more likely to have poor adherence to, or engagement with care (OR 4.79). They were also more likely to have chronic use of opioids (3.86) and long-term prednisolone (OR 2.97). Of note, no difference was found in measures of socioeconomic disadvantage, reflecting equitable access to healthcare in the public institution where the care was studied. As previously shown, patients with neoplasia had multiple markers of increased cumulative burden of inflammation, including more IBD-related hospital admissions, elevated inflammatory markers and severe inflammation at colonoscopy. CONCLUSIONS This study confirms poor adherence or engagement with care as a new risk factor for colorectal adenocarcinoma in patients with inflammatory bowel disease; identifying a vulnerable group whom clinicians should endeavour to engage in order to avoid this catastrophic complication. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Edward Young
- Royal Adelaide Hospital Department of Gastroenterology and Hepatology IBD Service.,University of Adelaide
| | - Esther Jones
- Royal Adelaide Hospital Department of Gastroenterology and Hepatology IBD Service.,University of Adelaide
| | | | | | - Jane Andrews
- Royal Adelaide Hospital Department of Gastroenterology and Hepatology IBD Service.,University of Adelaide
| |
Collapse
|
27
|
Cheatham SM, Muchhala KH, Koseli E, Jacob JC, Komla E, Negus SS, Akbarali HI. Morphine Exacerbates Experimental Colitis-Induced Depression of Nesting in Mice. FRONTIERS IN PAIN RESEARCH 2022; 2:738499. [PMID: 35295474 PMCID: PMC8915634 DOI: 10.3389/fpain.2021.738499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are excellent analgesics, but recent clinical evidence suggests that these drugs might worsen disease severity in Crohn's disease patients, limiting their clinical utility for treating Inflammatory Bowel Disease (IBD). One indicator of change in well-being from conditions such as IBD is behavioral depression and disruption to activities of daily living. Preclinical measures of behavioral depression can provide an indicator of changes in quality of life and subsequent modification by candidate analgesics. In mice, nesting is an adaptive unconditioned behavior that is susceptible to disruption by noxious stimuli, and some types of pain related nesting depression are responsive to opioid and NSAID analgesics. Here we show that a 2, 4, 6-trinitrobenzene sulfonic acid (TNBS) model of experimental colitis depresses nesting behavior in mice, and we evaluated effects of morphine, an opioid, and ketoprofen, a NSAID, on TNBS-induced nesting depression. In Swiss Webster mice, TNBS significantly reduced nesting that peaked on Day 3 and recovered in a time-dependent manner with complete recovery by Day 7. In the absence of colonic inflammation, daily treatment with morphine (1-10 mg/kg) did not decrease nesting except at 10mg/kg/day. However, in TNBS-treated mice 3.2 mg/kg/day morphine significantly exacerbated TNBS-induced nesting depression and delayed recovery. While 3.2 mg/kg/day morphine alone did not alter locomotor activity and TNBS-induced depression of locomotion recovered, the combination of TNBS and 3.2 mg/kg/day morphine significantly attenuated locomotion and prevented recovery. Daily treatment with 3.2 or 10 mg/kg ketoprofen in TNBS-treated mice did not prevent depression of nesting. These data suggest that opioid analgesics but not NSAIDS worsen colonic inflammation-induced behavioral depression. Furthermore, these findings highlight the importance of evaluating analgesic effects in models of colonic inflammation induced depression of behavior.
Collapse
Affiliation(s)
- Stanley M Cheatham
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Karan H Muchhala
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Eda Koseli
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Joanna C Jacob
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Essie Komla
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - S Stevens Negus
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| | - Hamid I Akbarali
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States
| |
Collapse
|
28
|
Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | | |
Collapse
|
29
|
Survival Impact of Long-Term Tramadol Use on Breast Cancer for Patients with Chronic Pain: A Propensity Score-Matched Population-Based Cohort Study. J Pers Med 2022; 12:jpm12030384. [PMID: 35330383 PMCID: PMC8951340 DOI: 10.3390/jpm12030384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/01/2023] Open
Abstract
Purpose: The impact of tramadol analgesic use before breast cancer diagnosis on survival in patients with chronic pain is unclear. Therefore, we designed a propensity score-matched population-based cohort study to compare the breast cancer-related survival of patients with chronic pain who received long-term tramadol analgesic treatment with that of those who did not receive such treatment. Patients and Methods: We included patients with chronic pain and categorized them into two groups according to their analgesic use, comparing their breast cancer-related survival; patients with breast cancer and chronic pain who were prescribed ≥180 defined daily doses (DDDs) of tramadol analgesics per year >3 months before breast cancer diagnosis comprised the case group, and those who were prescribed non-tramadol analgesics before breast cancer diagnosis comprised the control group. Patients in both groups were matched at a ratio of 1:5. Results: The matching process yielded a final cohort of 624 patients (104 and 520 in the case and control groups, respectively) who were eligible for further analysis. According to both univariate and multivariate Cox regression analyses, the adjusted hazard ratio for all-cause death in the case group compared with in the control group was 3.45 (95% confidence interval = 2.36−5.04; p < 0.001). Conclusion: Long-term tramadol analgesic use prior to breast cancer diagnosis might be associated with poor overall survival in patients with chronic pain compared with such patients that did not receive long-term tramadol analgesic treatment.
Collapse
|
30
|
Sheehan JL, Jacob J, Berinstein EM, Greene-Higgs L, Steiner CA, Berry SK, Shannon C, Cohen-Mekelburg SA, Higgins PDR, Berinstein JA. The Relationship Between Opioid Use and Healthcare Utilization in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2022; 28:1904-1914. [PMID: 35230420 PMCID: PMC9924039 DOI: 10.1093/ibd/izac021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain is commonly experienced by patients with inflammatory bowel disease (IBD). Unfortunately, pain management is a challenge in IBD care, as currently available analgesics are associated with adverse events. Our understanding of the impact of opioid use on healthcare utilization among IBD patients remains limited. METHODS A systematic search was completed using PubMed, Embase, the Cochrane Library, and Scopus through May of 2020. The exposure of interest was any opioid medication prescribed by a healthcare provider. Outcomes included readmissions rate, hospitalization, hospital length of stay, healthcare costs, emergency department visits, outpatient visits, IBD-related surgeries, and IBD-related medication utilization. Meta-analysis was conducted on study outcomes reported in at least 4 studies using random-effects models to estimate pooled relative risk (RR) and 95% confidence interval (CI). RESULTS We identified 1969 articles, of which 30 met inclusion criteria. Meta-analysis showed an association between opioid use and longer length of stay (mean difference, 2.25 days; 95% CI, 1.29-3.22), higher likelihood of prior IBD-related surgery (RR, 1.72; 95% CI, 1.32-2.25), and higher rates of biologic use (RR, 1.38; 95% CI, 1.13-1.68) but no difference in 30-day readmissions (RR, 1.17; 95% CI, 0.86-1.61), immunomodulator use (RR, 1.13; 95% CI, 0.89-1.44), or corticosteroid use (RR, 1.36; 95% CI, 0.88-2.10) in patients with IBD. On systematic review, opioid use was associated with increased hospitalizations, healthcare costs, emergency department visits, outpatient visits, and polypharmacy. DISCUSSION Opioids use among patients with IBD is associated with increased healthcare utilization. Nonopioid alternatives are needed to reduce burden on the healthcare system and improve patient outcomes.
Collapse
Affiliation(s)
- Jessica L Sheehan
- Address correspondence to: Jessica L. Sheehan, MD, MS, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA ()
| | - Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliot M Berinstein
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | | | - Calen A Steiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Sameer K Berry
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Shirley A Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | | | | |
Collapse
|
31
|
Wynne J, Kozuch P. Medical marijuana for inflammatory bowel disease: the highs and lows. Scand J Gastroenterol 2022; 57:197-205. [PMID: 34919496 DOI: 10.1080/00365521.2021.1998604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Increased interest in cannabis as a potential treatment and/or adjuvant therapy for inflammatory bowel disease (IBD) has been driven by patients with refractory disease seeking relief as well those who desire alternatives to conventional therapies. Available data have shown a potential role of cannabis as a supportive medication, particularly in pain reduction; however, it remains unknown whether cannabis has any impact on the underlying inflammatory process of IBD. The purpose of this review article is to summarize the available literature concerning the use of cannabis for the treatment of IBD and highlight potential areas for future study.
Collapse
Affiliation(s)
- Joshua Wynne
- Internal Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Patricia Kozuch
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| |
Collapse
|
32
|
Malik TA, Farraye FA. Routine Management of Hospitalized Patients with Ulcerative Colitis. MANAGEMENT OF INPATIENT INFLAMMATORY BOWEL DISEASE 2022:11-30. [DOI: 10.1007/978-1-0716-1987-2_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
33
|
Balbale SN, Cao L, Trivedi I, Stulberg JJ, Suda KJ, Gellad WF, Evans CT, Lambert BL, Jordan N, Keefer LA. High-Dose Opioid Use Among Veterans with Unexplained Gastrointestinal Symptoms Versus Structural Gastrointestinal Diagnoses. Dig Dis Sci 2021; 66:3938-3950. [PMID: 33385263 PMCID: PMC8245587 DOI: 10.1007/s10620-020-06742-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND In a cohort of Veterans dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D, we sought to describe high-dose daily opioid use among Veterans with unexplained gastrointestinal (GI) symptoms and structural GI diagnoses and examine factors associated with high-dose use. METHODS We used linked national patient-level data from the VA and Centers for Medicare and Medicaid Services (CMS). We grouped patients into 3 subsets: those with unexplained GI symptoms (e.g., chronic abdominal pain); structural GI diagnoses (e.g., chronic pancreatitis); and those with a concurrent unexplained GI symptom and structural GI diagnosis. High-dose daily opioid use levels were examined as a binary variable [≥ 100 morphine milligram equivalents (MME)/day] and as an ordinal variable (50-99 MME/day, 100-119 MME/day, or ≥ 120 MME/day). RESULTS We identified 141,805 chronic GI patients dually enrolled in VA and Part D. High-dose opioid use was present in 11% of Veterans with unexplained GI symptoms, 10% of Veterans with structural GI diagnoses, and 15% of Veterans in the concurrent GI group. Compared to Veterans with only an unexplained GI symptom or structural diagnosis, concurrent GI patients were more likely to have higher daily opioid doses, more opioid days ≥ 100 MME, and higher risk of chronic use. Factors associated with high-dose use included opioid receipt from both VA and Part D, younger age, and benzodiazepine use. CONCLUSIONS A significant subset of chronic GI patients in the VA are high-dose opioid users. Efforts are needed to reduce high-dose use among Veterans with concurrent GI symptoms and diagnoses.
Collapse
Affiliation(s)
- Salva N Balbale
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA.
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Itishree Trivedi
- Division of Gastroenterology and Hepatology, University of Illinois At Chicago, Chicago, IL, USA
| | - Jonah J Stulberg
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Surgical Outcomes and Quality Improvement Center (SOQIC), Division of Gastrointestinal Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charlesnika T Evans
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce L Lambert
- Center for Communication and Health, Northwestern University School of Communication, Chicago, IL, USA
| | - Neil Jordan
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Laurie A Keefer
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| |
Collapse
|
34
|
Bakshi N, Hart AL, Lee MC, Williams ACDC, Lackner JM, Norton C, Croft P. Chronic pain in patients with inflammatory bowel disease. Pain 2021; 162:2466-2471. [PMID: 34534174 PMCID: PMC8442739 DOI: 10.1097/j.pain.0000000000002304] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/19/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Nikul Bakshi
- Research Department, Crohn's and Colitis UK, Hatfield, United Kingdom
| | | | - Michael C. Lee
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Amanda C de C. Williams
- Research Department of Clinical, Educational and Health Psychology, University College London, and Pain Management Centre, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jeffrey M. Lackner
- Division of Behavioral Medicine, Department of Medicine, University at Buffalo, SUNY, Buffalo, NY, United States
| | - Christine Norton
- Division of Care for Long-Term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, United Kingdom
| | - Peter Croft
- Primary Care Centre Versus Arthritis and Centre for Prognosis Research, Keele University, Keele, United Kingdom
| |
Collapse
|
35
|
Chhibba T, Guizzetti L, Seow CH, Lu C, Novak KL, Ananthakrishnan AN, Bernstein CN, Kaplan GG, Panaccione R, Ma C. Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis. Clin Gastroenterol Hepatol 2021; 19:2064-2071.e1. [PMID: 32683099 DOI: 10.1016/j.cgh.2020.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. METHODS We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. RESULTS We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. CONCLUSIONS More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.
Collapse
Affiliation(s)
- Tarun Chhibba
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Leonardo Guizzetti
- Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada.
| |
Collapse
|
36
|
Abstract
New data suggest that incidence and prevalence of inflammatory bowel diseases [IBD] are still increasing worldwide, and approximately 0.2% of the European population suffer from IBD at the present time. Medical therapy and disease management have evolved significantly in recent decades, with an emphasis on tight objective monitoring of disease progression and a treat-to-target approach in Europe and also worldwide, aiming to prevent early bowel damage and disability. Surgery rate declined over time in Europe, with 10-30% of CD and 5-10% of UC patients requiring a surgery within 5 years. The health economic burden associated with IBD is high in Europe. Direct health care costs [approximately €3500 in CD and €2000 in UC per patient per year] have shifted from hospitalisation and surgery towards drug-related expenditures with the increasing use of biologic therapy and other novel agents, and substantial indirect costs arise from work productivity loss [approximately €1900 per patient yearly]. The aim of this paper is to provide an updated review of the burden of IBD in Europe by discussing current data on epidemiology, disease course, risk for surgery, hospitalisation, and mortality and cancer risks, as well as the economic aspects, patient disability, and work impairment, by discussing the latest population-based studies from the region.
Collapse
Affiliation(s)
- Mirabella Zhao
- Gastro Unit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
| | - Lóránt Gönczi
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Peter L Lakatos
- First Department of Medicine, Semmelweis University, Budapest, Hungary.,McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - Johan Burisch
- Gastro Unit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
| |
Collapse
|
37
|
Zhang Y, Yan Y, Meng J, Girotra M, Ramakrishnan S, Roy S. Immune modulation mediated by extracellular vesicles of intestinal organoids is disrupted by opioids. Mucosal Immunol 2021; 14:887-898. [PMID: 33854193 PMCID: PMC8225561 DOI: 10.1038/s41385-021-00392-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 02/02/2021] [Accepted: 02/11/2021] [Indexed: 02/06/2023]
Abstract
Extracellular vesicles (EVs) are effective mediators of intercellular communications between enterocytes and immune cells. The current study showed that EVs isolated from mouse and human intestinal organoids modulated inflammatory responses of various immune cells including mouse bone-marrow derived-macrophages, dendritic cells, microglia cells, and human monocytes. EVs suppressed LPS-elicited cytokine production in these cells while morphine abolished EVs' immune modulatory effects. Microarray analysis showed that various microRNAs, especially Let-7, contributed to EV-mediated immune modulation. Using murine models, we showed that injection of EVs derived from intestinal organoids reduced endotoxin-induced systemic inflammation and alleviated the symptoms of DSS-induced colitis. EVs derived from morphine-treated organoids failed to suppress the immune response in both these models. Our study suggests that EVs derived from intestinal crypt cells play crucial roles in maintaining host homeostasis and opioid use is a risk factor for exacerbating inflammation in patients with inflammatory diseases such as sepsis and colitis.
Collapse
Affiliation(s)
- Yue Zhang
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Yan Yan
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jingjing Meng
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Mohit Girotra
- Division of Gastroenterology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sundaram Ramakrishnan
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sabita Roy
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA.
| |
Collapse
|
38
|
Kaimakliotis P, Ramadugu A, Kang J, McGorisk T, Polick A, Votta-Velis E, Trivedi I. Targeted housestaff intervention reduces opioid use without worsening patient-reported pain scores and improves outcomes among patients with IBD: the "IBD pain ladder". Int J Colorectal Dis 2021; 36:1193-1200. [PMID: 33486534 DOI: 10.1007/s00384-021-03852-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). With the goal of reducing inpatient opioid use among patients with IBD admitted to our inpatient gastroenterology (GI) service, we designed and implemented a standardized, educational intervention providing analgesic decision support to internal medicine and emergency medicine housestaff at our institution. METHODS Pre-intervention data was collected from patients admitted during a 9-month period prior to intervention. Post-intervention patients were identified prospectively. The primary outcome was reduction in aggregate inpatient opioid use in oral morphine equivalents per patient. RESULTS A total of 68 patients with 81 hospitalizations were analyzed. There was no statistically significant difference in baseline admission characteristics between the two groups. Our primary outcome was achieved with a statistically significant reduction in opioid use during hospitalization (43.4 mg vs 7.7 mg; p < 0.01). Secondary outcomes achieved included reduction in new opioid prescriptions upon discharge, reduced hospital length of stay, and reduced 90-day readmission rates. There was no significant difference between patients' pain scores between the two groups. CONCLUSION We believe this intervention, aimed at housestaff education, provides a roadmap for pain management decision-making in this patient population. It is a readily reproducible strategy that can be widely applied to improve inpatient IBD patient care. Importantly, patient experience and pain scores were unchanged despite lower use of inpatient opioid analgesia, highlighting successful opioid-sparing analgesics in most inpatients with IBD.
Collapse
Affiliation(s)
- Pavlos Kaimakliotis
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA.
| | - Ajit Ramadugu
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Jennifer Kang
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Timothy McGorisk
- Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, IL, USA
| | - Anne Polick
- Department of Internal Medicine, University of Illinois Chicago, Chicago, IL, USA
| | | | - Itishree Trivedi
- Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, IL, USA
| |
Collapse
|
39
|
Häuser W, Morlion B, Vowles KE, Bannister K, Buchser E, Casale R, Chenot J, Chumbley G, Drewes AM, Dom G, Jutila L, O'Brien T, Pogatzki‐Zahn E, Rakusa M, Suarez–Serrano C, Tölle T, Krčevski Škvarč N. European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain. Eur J Pain 2021; 25:949-968. [PMID: 33655607 PMCID: PMC8248186 DOI: 10.1002/ejp.1736] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC). METHODS The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment. RESULTS The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation. CONCLUSIONS Opioids remain a treatment option for some selected patients with CNCP under careful surveillance. SIGNIFICANCE In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.
Collapse
Affiliation(s)
- Winfried Häuser
- Department Internal Medicine 1Klinikum SaarbrückenSaarbrückenGermany
- Department of Psychosomatic Medicine and PsychotherapyTechnische Universität MünchenMunichGermany
| | - Bart Morlion
- Center for Algology & Pain ManagementUniversity Hospitals LeuvenLeuvenBelgium
| | | | - Kirsty Bannister
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Eric Buchser
- Pain Management and Neuromodulation Centre EHC HospitalMorgesSwitzerland
| | - Roberto Casale
- Neurorehabilitation UnitDepartment of RehabilitationHABILITABergamoItaly
| | - Jean‐François Chenot
- Department of General PracticeInstitute for Community MedicineUniversity Medicine GreifswaldGermany
| | - Gillian Chumbley
- Imperial College Healthcare NHS TrustCharing Cross HospitalLondonUK
| | - Asbjørn Mohr Drewes
- Mech‐SenseDepartment of Gastroenterology & HepatologyAalborg University HospitalDenmark
| | - Geert Dom
- Collaborative Antwerp Psychiatric Research Institute (CAPRI)Antwerp UniversityAntwerpenBelgium
| | | | - Tony O'Brien
- College of Medicine & HealthUniversity College CorkCorkRepublic of Ireland
| | - Esther Pogatzki‐Zahn
- Department of Anaesthesiology, Intensive Care and Pain MedicineUniversity Hospital Münster UKMMunsterGermany
| | - Martin Rakusa
- Department of NeurologyUniversity Medical CentreMariborSlovenia
| | | | - Thomas Tölle
- Department of NeurologyTechhnische Universität MünchenMünchenGermany
| | - Nevenka Krčevski Škvarč
- Department of Anesthesiology, Intensive Care and Pain TreatmentFaculty of Medicine of University MariborMariborSlovenia
| |
Collapse
|
40
|
Niccum B, Moninuola O, Miller K, Khalili H. Opioid Use Among Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2021; 19:895-907.e4. [PMID: 32835841 DOI: 10.1016/j.cgh.2020.08.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/04/2020] [Accepted: 08/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite reported adverse effects of opioids in patients with inflammatory bowel disease (IBD), the burden of opioid use in this population appears to be high. We performed a systematic review and meta-analysis of prior studies to determine the prevalence of opioid use among patients with IBD as well as risk factors and outcomes associated with opioid use in this population. METHODS We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Library through November of 2019. Primary outcomes included the prevalence of opioid use and demographic and clinical variables associated with opioid use in patients with IBD. Quality was assessed using the Newcastle-Ottawa scale. We used random-effect meta-analysis to estimate pooled relative risks (RRs) and 95% CIs. RESULTS Of 780 citations identified, 31 were included in our study. The prevalence of opioid use was 21% (95% CI, 13%-30%) in the outpatient setting. Likewise, 62% (95% CI, 25%-92%) of patients received opioids while hospitalized for IBD. Opioid use was associated with female sex (RR 1.20; 95% CI 1.03-1.40), depression (1.99; 95% CI 1.80-2.19), substance abuse (4.67; 95% CI 2.87-7.60), prior gastrointestinal surgery (2.33; 95% CI 1.66-3.26), biologic use (1.36; 95% CI 1.06-1.74), and steroid use (1.41; 95% CI 1.04-1.91). Based on the systematic review, opioid use also appeared to be associated with increased IBD activity, healthcare use, infection, and mortality. CONCLUSION In a systematic review and meta-analysis, we found that 21% of outpatients with IBD (and 62% of hospitalized patients) are opioid users; use is associated with more severe IBD and increased healthcare use. Further studies are required to determine whether opioids are the cause or an effect of these associations. Nonetheless, urgent interventions are needed to reduce opioid use, improve disease-related outcomes and reduce healthcare costs.
Collapse
Affiliation(s)
- Blake Niccum
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Oluwatoba Moninuola
- Department of Internal Medicine, Saint Peter's University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kaia Miller
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
41
|
Szigethy EM, Murphy SM, Ehrlich OG, Heller CA, Engel-Nitz NM, Meadows P, Allen JI. Opioid Use Associated With Higher Costs Among Patients With Inflammatory Bowel Disease. CROHN'S & COLITIS 360 2021; 3:otab021. [PMID: 36778940 PMCID: PMC9802349 DOI: 10.1093/crocol/otab021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Indexed: 11/12/2022] Open
Abstract
Background Opioid use by patients with inflammatory bowel disease (IBD) has been associated with poorer health outcomes. This study describes socioeconomic characteristics; health utilization trends; and costs of patients with IBD and either no opioid prescriptions, or in 1 of 3 opioid duration categories based on Center for Disease Control guidelines: acute (0-30 days), moderate (31-90 days), or chronic (>90 days). We utilized the Cost of IBD Care Optum research database results for this study. Methods The Optum Research Database from years 2007 to 2016 including IBD patients with commercial or Medicare Advantage insurance in the United States was used. Additional inclusion criteria included continuous enrollment with medical and pharmacy benefit coverage for at least 24 months (12 months before and 12 months after the index date of IBD diagnosis). The association between costs and patient characteristics were assessed across a no opioid use group during this period and the 3 opioid duration groups. Results Among 51,178 IBD patients, 33,229 (64.93%) were part of the no opioid use group, while 13,635 (26.64%) were in acute, 1698 (3.32%) were in moderate, and 2616 (5.11%) were in chronic use groups, as determined by pharmacy claims data. Patients in the chronic group were more likely to be white (75.38%) compared to all the other groups (no opioid use, acute, and moderate), have attained less education (only high school diploma), have had lower incomes, and have had Medicare instead of commercial insurance. Patients across all opioid prescription groups were more likely to have had diagnoses associated with pain in the prior year, with rates increasing by the length of opioid prescription (63.68%, 80.17%, and 86.11% for acute, moderate, and chronic groups). Compared to the no-use group, the acute group had more ambulatory (outpatient) visits, while the chronic group had fewer. Emergency department visits and inpatient hospitalizations were higher in all 3 opioid groups compared to the no opioid use group. Ambulatory, emergency department, inpatient, and total (medical + pharmacy) costs were higher in all 3 opioid groups, compared to the no opioid use group, even after adjusting for demographic and clinical patient characteristics. Conclusions Among patients with IBD, increasing opioid use was associated with higher healthcare resource utilization and, concomitantly, higher healthcare costs during this period.
Collapse
Affiliation(s)
- Eva M Szigethy
- Department of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Address correspondence to: Eva M. Szigethy, MD, PhD, Department of Psychiatry and Medicine, University of Pittsburgh Medical Center, 3708 Fifth Avenue, Suite 401, Pittsburgh, Pennsylvania 15213, USA ()
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Orna G Ehrlich
- Research Department, Crohn’s & Colitis Foundation, New York, New York, USA
| | - Caren A Heller
- Research Department, Crohn’s & Colitis Foundation, New York, New York, USA
| | - Nicole M Engel-Nitz
- Health Economics and Outcomes Research Department, Optum, Eden Prairie, Minnesota, USA
| | - Perry Meadows
- Department of Government Programs, Medical Director, Government Programs, Geisinger Health Plan, Danville, Pennsylvania, USA
| | - John I Allen
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
42
|
Rhudy C, Perry CL, Singleton M, Talbert J, Barrett TA. Chronic opioid use is associated with early biologic discontinuation in inflammatory bowel disease. Aliment Pharmacol Ther 2021; 53:704-711. [PMID: 33497484 PMCID: PMC7897267 DOI: 10.1111/apt.16269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/02/2020] [Accepted: 01/05/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic opioid use is associated with poorer clinical outcomes in inflammatory bowel disease. AIMS To investigate an association between chronic opioid use and persistence with biologic agents in management of inflammatory bowel disease. METHODS A total of 16 624 patients diagnosed with inflammatory bowel disease and receiving a first-time biologic prescription from 2011 to 2016 were identified retrospectively from the Truven MarketScan Database. A cohort of 1768 patients were identified as chronic opioid users utilising outpatient prescription claims. Utilisation patterns of biologic therapies were assessed from inpatient administration and outpatient claims data, including persistence calculations. Information on healthcare utilisation and common comorbidities was also collected. A Cox regression model was constructed to assess the hazard of chronic opioid use on early discontinuation of biologic therapy controlling for disease severity. RESULTS A mean 1.5 different biologic agents were utilised by inflammatory bowel disease patients with chronic opioid use (vs 1.37 in the comparator group; P < 0.0001). A lower proportion of the chronic opioid use cohort persisted on biologic therapies to the end of the study period (16.2% vs 33.5% P < 0.0001). Inflammatory bowel disease patients with chronic opioid use utilised more healthcare resources and had a higher rate of comorbidities than the reference cohort. Patients with chronic opioid use were 23% more likely (hazard ratio 1.23; 95% CI [1.16-1.31]) to be non-persistent with biologic therapy while accounting for relevant markers of disease acuity. CONCLUSIONS Chronic opioid use is associated with increased hazard of biologic discontinuation in inflammatory bowel disease. Symptoms of opioid withdrawal may mimic IBD flares thereby leading providers to inappropriately switch biologic therapies and compromise disease control.
Collapse
Affiliation(s)
- Christian Rhudy
- University of Kentucky College of Pharmacy, Institute for Pharmaceutical Outcomes and Policy, Lexington, Kentucky
| | - Courtney L. Perry
- University of Kentucky College of Medicine, Department of Digestive Diseases and Nutrition, Lexington, Kentucky
| | - Michael Singleton
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, Kentucky
| | - Jeffery Talbert
- University of Kentucky College of Medicine, Division of Biomedical Informatics, Lexington, Kentucky
| | - Terrence A. Barrett
- University of Kentucky College of Medicine, Department of Digestive Diseases and Nutrition, Lexington, Kentucky
| |
Collapse
|
43
|
Abstract
In traditional medicine, Cannabis sativa has been prescribed for a variety of diseases. Today, the plant is largely known for its recreational purpose, but it may find a way back to what it was originally known for: a herbal remedy. Most of the plant's ingredients, such as Δ-tetrahydrocannabinol, cannabidiol, cannabigerol, and others, have demonstrated beneficial effects in preclinical models of intestinal inflammation. Endogenous cannabinoids (endocannabinoids) have shown a regulatory role in inflammation and mucosal permeability of the gastrointestinal tract where they likely interact with the gut microbiome. Anecdotal reports suggest that in humans, Cannabis exerts antinociceptive, anti-inflammatory, and antidiarrheal properties. Despite these reports, strong evidence on beneficial effects of Cannabis in human gastrointestinal diseases is lacking. Clinical trials with Cannabis in patients suffering from inflammatory bowel disease (IBD) have shown improvement in quality of life but failed to provide evidence for a reduction of inflammation markers. Within the endogenous opioid system, mu opioid receptors may be involved in anti-inflammation of the gut. Opioids are frequently used to treat abdominal pain in IBD; however, heavy opioid use in IBD is associated with opioid dependency and higher mortality. This review highlights latest advances in the potential treatment of IBD using Cannabis/cannabinoids or opioids.
Collapse
|
44
|
A Role for Primary Care Pharmacists in the Management of Inflammatory Bowel Disease? Lessons from Chronic Disease: A Systematic Review. PHARMACY 2020; 8:pharmacy8040204. [PMID: 33147771 PMCID: PMC7712000 DOI: 10.3390/pharmacy8040204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background and aims: Chronic disease, particularly inflammatory bowel disease (IBD), requires a multifaceted approach to managing patients, but it is apparent that primary care pharmacists are being underutilized. To demonstrate the benefits of pharmacist interventions in primary care, a systematic review was conducted of interventions in asthma and type 2 diabetes where pharmacists have a defined role in chronic disease management. We also explored potential opportunities for primary care pharmacists to deliver tailored care to patients with inflammatory bowel disease. Methods: The search strategy retrieved original research articles from seven databases; eligible articles were assessed for inclusion. Quality appraisal was performed independently by two reviewers. Results: Thirty-seven included studies were grouped into four categories of interventions: education/counseling (43%), medication management (34%), monitoring/follow-up (17%), and screening/risk prevention (6%). Education plus counseling was reported as the main intervention delivered by pharmacists. Three measurable outcomes were identified: clinical, humanistic (e.g., quality of life), and economic. Clinical outcomes (63%) were reported more commonly than humanistic (26%) and economic (11%) outcomes. Pharmacist interventions led to statistically significant improvements in control of disease, severity, and medication adherence, as well as improvements in overall patient satisfaction, quality of life among patients with asthma and type 2 diabetes. Conclusion: As one of the most accessible sources of primary health care, pharmacists are well-placed to minimize the impact of chronic diseases on patients and communities. Evidence suggests there are opportunities for primary care pharmacists to play a more active role in the management of chronic diseases such as IBD.
Collapse
|
45
|
Gordon KS, Manhapra A, Crystal S, Dziura J, Edelman EJ, Skanderson M, Kerns RD, Justice AC, Tate J, Becker WC. All-cause mortality among males living with and without HIV initiating long-term opioid therapy, and its association with opioid dose, opioid interruption and other factors. Drug Alcohol Depend 2020; 216:108291. [PMID: 33011662 PMCID: PMC7644145 DOI: 10.1016/j.drugalcdep.2020.108291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the relationship between long-term opioid therapy (LTOT) dose and overdose is well-established, LTOT's association with all-cause mortality is less understood, especially among people living with HIV (PLWH). There is also limited information regarding the association of LTOT cessation or interruption with mortality. METHODS Among PLWH and matched uninfected male veterans in care, we identified those who initiated LTOT. Using time-updated cox regression, we examined the association between all-cause mortality, unnatural death, and overdose, and opioid use categorized as 1-20 (reference group), 21-50, 51-90, and ≥ 91 mg morphine equivalent daily dose (MEDD). RESULTS There were 22,996 patients on LTOT, 6,578 (29 %) PLWH and 16,418 (71 %) uninfected. Among 5,222 (23 %) deaths, 12 % were unnatural deaths and 6 % overdoses. MEDD was associated with risk of all 3 outcomes; compared to patients on 1-20 mg MEDD, adjusted risk for all-cause mortality monotonically increased (Hazard Ratios (HR) [95 % CI] for 21-50 mg MEDD = 1.36 [1.21, 1.52], 51-90 mg MEDD = 2.06 [1.82, 2.35], and ≥ 91 mg MEDD = 3.03 [2.71, 3.39]). Similar results were seen in models stratified by HIV. LTOT interruption was also associated with all-cause, unnatural, and overdose mortality (HR [95 % CI] 2.30 [2.09, 2.53], 1.47 [1.13, 1.91] and 1.52 [1.04, 2.23], respectively). CONCLUSIONS Among PLWH and uninfected patients on LTOT we observed a strong dose-response relationship with all 3 mortality outcomes. Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all-cause mortality in addition to unnatural and overdose fatalities.
Collapse
Affiliation(s)
- K S Gordon
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.
| | - A Manhapra
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States; Integrative Pain Recovery Service, Hampton VA Medical Center, Hampton, VA, United States; Departments of Physical Medicine & Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, VA, United States
| | - S Crystal
- Rutgers University, New Brunswick, NJ, United States
| | - J Dziura
- Yale School of Public Health, New Haven, CT, United States
| | - E J Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - M Skanderson
- VA Connecticut Healthcare System, West Haven, CT, United States
| | - R D Kerns
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States; Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - A C Justice
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States; Yale School of Public Health, New Haven, CT, United States
| | - J Tate
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - W C Becker
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
46
|
Reja M, Hajela N, Makar M, Marino D, Bhurwal A, Rustgi V. One-year risk of opioid use disorder after index hospitalization for inflammatory bowel disease. Int J Colorectal Dis 2020; 35:2081-2087. [PMID: 32681379 DOI: 10.1007/s00384-020-03691-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients with inflammatory bowel disease are commonly prescribed opiates for pain. We sought to determine the incidence of opiate use disorder after inflammatory bowel disease (IBD) admission over a 1-year period as well as its impact on mortality and hospital resource utilization. METHODS The Nationwide Readmission Database 2016 was used to identify adult patients with a principal diagnosis of IBD who were subsequently readmitted with a primary diagnosis of opioid use disorder. The primary outcome was 1-year readmission rate for opiate use disorder. Predictors were analyzed using multivariate logistic regression. Secondary outcomes were mortality rate, length of stay, and total hospital costs and charges. RESULTS Among the 6340 index hospitalizations for IBD, 4.7% (6.0% Crohn's and 2.6% ulcerative colitis) were readmitted within 1 year for opiate use disorder. Readmission hospitalizations were associated with additional mortality (0.32%) and hospital utilization (length of stay 4.80 days, mean total costs $9503, and mean total charges $38,288). Ulcerative colitis had significantly higher mortality and hospital utilization costs compared with Crohn's disease. In multivariable analysis, odds of readmission were associated with female sex (OR 1.51, CI 1.19-1.92), private insurance (OR 0.20, CI 0.11-0.37), Charlson Comorbidity Index (OR 0.20, CI 0.11-0.37), anxiety (OR 1.65, CI 1.02-2.63), and depression (OR 2.07, CI 1.28-3.34). On stratification analysis, psychiatric comorbidities were associated with both Crohn's and ulcerative colitis. CONCLUSION Patients with IBD were often readmitted for opiate use disorder and sustained significant mortality and hospital costs. Psychiatric comorbidities, gender, and insurance status impacted the odds of readmission and represent targets for intervention.
Collapse
Affiliation(s)
- Mishal Reja
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA.
| | - Nitya Hajela
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA
| | - Michael Makar
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA
| | - Daniel Marino
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Abhishek Bhurwal
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Vinod Rustgi
- Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, USA
| |
Collapse
|
47
|
Tchoe HJ, Jeong S, Won DY, Nam JH, Joung KI, Shin JY. Increased risk of death with codeine use in the elderly over 85 years old and patients with respiratory disease: A case-control study using retrospective insurance claims database. Medicine (Baltimore) 2020; 99:e22155. [PMID: 32957338 PMCID: PMC7505312 DOI: 10.1097/md.0000000000022155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022] Open
Abstract
To investigate the risk of mortality associated with exposure to codeine, considering various risk groups, using population-based national insurance claims data.National sample cohort data from the National Health Insurance Service of South Korea (2002-2013) was used in this case-control study. Cases were defined as patients with a death record between January 1, 2002 and December 31, 2013. Each case was matched to 10 controls based on age, sex, baseline comorbidities, and year of death. Definition of exposure was codeine prescription in 30 days prior to death and sensitivity analyses were performed for 15 and 60-day exposures. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were estimated using conditional logistic regression adjusting for benzodiazepine, other opioids, anesthetics, hypnotics, CYP2D6 inducer, CYP3A4 inducer, and the Charlson comorbidity index.A total of 19,341 cases and 185,700 matched controls were included. The overall risk associated with codeine use and mortality risk was not significant (aOR 1.08, 95% CI 1.00-1.16). Sensitivity analyses with different exposure time window also presented similar insignificant results. However, in the subgroup analyses, codeine use was associated with an increased risk of mortality in the >85-year-old age group (aOR 2.38, 95% CI 1.26-4.48) and patients with respiratory disease (aOR 1.29, 95% CI 1.17-1.42).Although no statistically significant association was found in codeine exposure and mortality risk between cases and controls, we demonstrated that the elderly over 85 years old and patients with respiratory disease are associated with a higher risk with codeine exposure. Therefore, a more cautious practice of codeine prescription in these groups might be needed.
Collapse
Affiliation(s)
- Ha jin Tchoe
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Sohyun Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
- Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston, MA 02131, USA
| | - Dae Yeon Won
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Jin Hyun Nam
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Kyung-In Joung
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| |
Collapse
|
48
|
Sultan K, Swaminath A. From Bad to Worse: The Relationship Between Opioid Use and Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:1188-1189. [PMID: 32614051 DOI: 10.1093/ecco-jcc/jjaa059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Keith Sultan
- Zucker School of Medicine at Hofstra/Northwell, Division of Gastroenterology, North Shore University Hospital, Manhasset, and Long Island Jewish Medical Center, Queens, NY, USA
| | - Arun Swaminath
- Zucker School of Medicine at Hofstra/Northwell, Division of Gastroenterology, Lenox Hill Hospital, New York, NY, USA
| |
Collapse
|
49
|
Dalal RS, Palchaudhuri S, Snider CK, Lewis JD, Mehta SJ, Lichtenstein GR. Exposure to Intravenous Opioids Is Associated With Future Exposure to Opioids in Hospitalized Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:2269-2278.e3. [PMID: 31887450 DOI: 10.1016/j.cgh.2019.12.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/25/2019] [Accepted: 12/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Opioid use is associated with increased mortality in patients with inflammatory bowel diseases (IBD). Hospitalized patients with IBD often receive high-potency intravenous opioids (IVOPIs). It is not known whether exposure to IVOPIs affects post-discharge opioid use or complications. We investigated the association between inpatient administration of IVOPIs and a post-discharge opioid prescription (OPIRx) in patients with IBD. METHODS We performed a retrospective cohort study of 862 adults with IBD hospitalized at a large urban academic health system from March 1, 2017 through April 10, 2018. We collected clinical data from the electronic health records and used multivariable mixed-effect logistic regression to assess the association between inpatient opioid exposure and OPIRx-within 12 months while adjusting for confounders. IV and non-IVOPI exposures were evaluated as binary variables. IVOPI exposure was also evaluated as a continuous variable in IV morphine mg equivalents/length of stay (IVMMEs/day). RESULTS Multivariable mixed-effect logistic regression demonstrated a significant association between IVOPIs and OPIRx (IV vs no IVOPIs odds ratio [OR], 3.3; 95% CI, 1.7-6.4 and IVMMEs/day OR, 1.1; 95% CI, 1.0-1.1). Subgroup analysis of patients with IBD flares (n = 621) identified a significant association between IVOPIs and OPIRx (IV vs no IVOPIs OR, 5.4; 95% CI, 2.6-11.0). Among patients who did not receive IVOPIs, there was a significant association between oral/transdermal opioids and OPIRx (non-IVOPIs vs no opioids OR, 4.2; 95% CI, 1.0-16.8). CONCLUSIONS Inpatient IV and non-IV opioid use are associated with post-discharge opioid exposure in patients with IBD, with a dose-dependent effect. Alternative analgesics should be considered for hospitalized patients with IBD, to minimize risk of future opioid use.
Collapse
Affiliation(s)
- Rahul S Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sonali Palchaudhuri
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher K Snider
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shivan J Mehta
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary R Lichtenstein
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
50
|
A Multimodal Intervention Using Nonopioid Analgesics Is Associated With Reduced Intravenous Opioid Exposure Among Hospitalized Patients With Inflammatory Bowel Diseases. Am J Gastroenterol 2020; 115:1474-1485. [PMID: 32796178 DOI: 10.14309/ajg.0000000000000806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Opioid use in patients with inflammatory bowel disease (IBD) is associated with increased mortality. Previous interventions targeting reduced intravenous opioid (IVOPI) exposure for all patients admitted to a general medical unit have decreased total opioid use without compromising pain control. We therefore performed a prospective evaluation of a multimodal intervention encouraging the use of nonopioid alternatives to reduce IVOPI exposure among patients with IBD hospitalized at our institution. METHODS This was a prospective evaluation of a multimodal intervention to reduce IVOPI use among patients with IBD aged ≥18 years admitted to a general medical unit at a large urban academic medical center from January 1, 2019, to June 30, 2019. Intravenous and total (all routes) opioid exposures were measured as proportions and intravenous morphine milligram equivalents/patient day and compared with preintervention (January 1, 2018, to December 31, 2018) data. Hospital length of stay (LOS), 30-day readmission rates (RRs), and pain scores (1-10 scale) were also assessed. RESULTS Our study involved 345 patients with IBD with similar baseline characteristics in preintervention (n = 241) and intervention (n = 104) periods. Between study periods, we observed a significant reduction in the proportion of patients receiving IVOPIs (43.6% vs 30.8%, P = 0.03) and total opioid dose exposure (15.6 vs 8.5 intravenous morphine mg equivalents/d, P = 0.02). We observed similar mean pain scores (3.9 vs 3.7, P = 0.55) and significantly reduced mean LOS (7.2 vs 5.3 days, P = 0.03) and 30-day RRs (21.6% vs 11.5%, P = 0.03). DISCUSSION A multimodal intervention was associated with reduced opioid exposure, LOS, and 30-day RRs for hospitalized patients with IBD. Additional research is needed to determine long-term benefits of reduced opioid exposure in this population.
Collapse
|