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Gong Z, Xue Q, Luo Y, Yu B, Hua B, Liu Z. The interplay between the microbiota and opioid in the treatment of neuropathic pain. Front Microbiol 2024; 15:1390046. [PMID: 38919504 PMCID: PMC11197152 DOI: 10.3389/fmicb.2024.1390046] [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: 02/22/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
Neuropathic pain (NP) is characterized by its complex and multifactorial nature and limited responses to opioid therapy; NP is associated with risks of drug resistance, addiction, difficulty in treatment cessation, and psychological disorders. Emerging research on gut microbiota and their metabolites has demonstrated their effectiveness in alleviating NP and augmenting opioid-based pain management, concurrently mitigating the adverse effects of opioids. This review addresses the following key points: (1) the current advances in gut microbiota research and the challenges in using opioids to treat NP, (2) the reciprocal effects and benefits of gut microbiota on NP, and (3) the interaction between opioids with gut microbiota, as well as the benefits of gut microbiota in opioid-based treatment of NP. Through various intricate mechanisms, gut microbiota influences the onset and progression of NP, ultimately enhancing the efficacy of opioids in the management of NP. These insights pave the way for further pragmatic clinical research, ultimately enhancing the efficacy of opioid-based pain management.
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Affiliation(s)
- Zexiong Gong
- Department of Anesthesiology, Health Science Center, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Qingsheng Xue
- Department of Anesthesiology, School of Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yan Luo
- Department of Anesthesiology, School of Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Buwei Yu
- Department of Anesthesiology, School of Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Bo Hua
- Department of Anesthesiology, Health Science Center, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Zhiheng Liu
- Department of Anesthesiology, Health Science Center, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University, Shenzhen, China
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2
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Mousavi T, Nikfar S, Abdollahi M. An update on the use of pharmacotherapy for opioid-induced bowel dysfunction. Expert Opin Pharmacother 2023; 24:359-375. [PMID: 36548911 DOI: 10.1080/14656566.2022.2161883] [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: 12/24/2022]
Abstract
INTRODUCTION With the growing rate of aging and the incidence of chronic diseases, there has been an upsurge in opioid prescription and abuse worldwide. This has been associated with increased reports of opioid-related adverse events, particularly opioid-induced bowel dysfunction (OIBD), calling for a rational clinical management strategy. AREAS COVERED Through searching PubMed, Scopus, Cochrane Library, and Web of Science, English literature was gathered as of 1 January 2017. Furthermore, the USFDA, EMA, TGA, Clinicaltrials.Gov, WHO-ICTRP databases, and the latest guidelines were reviewed to extract ongoing clinical studies and provide an evidence-based expert opinion with detailed information on efficacy, safety, approval status, and pharmacokinetics of the currently used medications. EXPERT OPINION Despite the significant burden of OIBD, the clinical development of agents lags behind disease progress. Although in most places, management of opioid-induced constipation (OIC) is initiated by lifestyle modifications followed by laxatives, opioid antagonists, and secretagogue agents, there are still major conflicts among global guidelines. The fundamental reason is the lack of head-to-head clinical trials providing inter- and intragroup comparisons between PAMORAs, laxatives, and secretagogue agents. These investigations must be accompanied by further valid biopharmaceutical and economic evaluations, paving the way for rational clinical judgment in each context.
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Affiliation(s)
- Taraneh Mousavi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran, Iran.,Personalized Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (PSRC), Tehran University of Medical Sciences, Tehran, Iran
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3
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Patel D, Khodadadi A, Jadcherla A, Rengarajan A, Rogers BD, Gyawali CP. Chronic opioid users with dysphagia are indistinguishable from symptomatic nonusers on functional lumen imaging probe evaluation. Neurogastroenterol Motil 2022; 35:e14519. [PMID: 36578248 DOI: 10.1111/nmo.14519] [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: 07/13/2022] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Opioid-induced esophageal dysmotility (OIED) includes spastic esophageal motility disorders, increasingly recognized in the contemporary opioid epidemic. We assessed functional lumen imaging probe (FLIP) findings in diagnosing OIED. METHODS Symptomatic patients undergoing FLIP with no prior foregut surgery who completed validated questionnaires were identified and segregated into chronic opioid users and nonusers in this cohort study. Esophagogastric junction (EGJ) distensibility index (DI), EGJ diameter, and esophageal body contraction patterns were extracted. Symptom profiles were compared to FLIP findings between chronic opioid users and nonusers. Outcome was evaluated in a subset using the same validated questionnaires. RESULTS Over the 18-months study period, of 116 patients (median age 62 years, 70.7% female), 33 (28.4%) were chronic opioid users, with median morphine milligram equivalent of 30 mg. While presenting symptoms were similar, chronic opioid users reported higher perceptive symptoms (p = 0.008) and worse quality of life (p = 0.01) compared to nonusers. Median DI trended lower in chronic opioid users (p = 0.08), with more retrograde repetitive contractions (p < 0.001) and less absent contractility (p = 0.007), but final FLIP diagnoses were similar compared to nonusers. There was no correlation between opioid dose and FLIP metrics. In the subset with follow-up, perceptive symptoms trended higher in chronic opioid users (p = 0.08), but symptom improvement following therapy was similar in both groups. CONCLUSIONS & INFERENCES Symptomatic chronic opioid users have FLIP diagnoses that are similar to nonusers, despite higher perceptive symptoms and worse quality of life. Dominant symptoms improve both in chronic opioid users and nonusers following treatment directed by FLIP.
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Affiliation(s)
- Devan Patel
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Alexandra Khodadadi
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Aditya Jadcherla
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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4
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Balbale SN, Iroz CB, Schäfer WLA, Johnson JK, Stulberg JJ. A Missing Piece of the Puzzle: Patient and Provider Perspectives on Pain Management Needs and Opioid Prescribing in Inflammatory Bowel Disease Care. CROHN'S & COLITIS 360 2022; 4:otac033. [PMID: 36777413 PMCID: PMC9802220 DOI: 10.1093/crocol/otac033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Recent data have shown high rates of opioid misuse among inflammatory bowel disease (IBD) patients. We conducted a qualitative study to explore IBD patient and provider perceptions and experiences with pain management and opioid prescribing. Methods We conducted a focus group with IBD patients and semistructured interviews with IBD-focused physicians and nurses. We used an inductive approach for analysis and the constant comparison method to develop and refine codes and identify prominent themes. We analyzed interview and focus group data concurrently to triangulate themes. Results Nine patients and 10 providers participated. We grouped themes into 3 categories: (1) current practices to manage pain; (2) perceived pain management challenges; and (3) suggestions to optimize pain management. In the first category (current practices), both patients and providers reported building long-term patient-provider relationships and the importance of exploring nonpharmacologic pain management strategies. Patients reported proactively trying remedies infrequently recommended by IBD providers. In the second category (pain management challenges), patients and providers reported concerns about opioid use and having limited options to treat pain safely. Patients discussed chronic pain and having few solutions to manage it. In the third category, providers shared suggestions for improvement such as increasing use of nonpharmacologic pain management strategies and enhancing care coordination. Conclusions Despite some common themes between the 2 groups, we identified some pain management needs (eg, addressing chronic pain) that matter to patients but were seldom discussed by IBD providers. Addressing these areas of potential disconnect is essential to optimize pain management safety in IBD care.
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Affiliation(s)
- Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr. VA Hospital, Hines, Illinois 60141, USA
| | - Cassandra B Iroz
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Willemijn L A Schäfer
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Julie K Johnson
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jonah J Stulberg
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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5
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Tuck NL, Teo K, Kuhlmann L, Olesen SS, Johnson M, Bean DJ, Rashid U, MacCormick AD, Srikumar G, Drewes AM, Windsor JA. Pain patterns in chronic pancreatitis and chronic primary pain. Pancreatology 2022; 22:572-582. [PMID: 35562269 DOI: 10.1016/j.pan.2022.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/12/2022] [Accepted: 04/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Abdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator. AIMS This cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes. METHODS Patients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics. RESULTS Compared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent. CONCLUSIONS Within CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.
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Affiliation(s)
- N L Tuck
- The Health and Rehabilitation Research Institute, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology (AUT), Auckland, New Zealand; The Auckland Regional Pain Service (TARPS), Auckland District Health Board (ADHB), Auckland, New Zealand; The Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Waitematā District Health Board (WDHB), Auckland, New Zealand.
| | - K Teo
- Department of Surgery, School of Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - L Kuhlmann
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - S S Olesen
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - M Johnson
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - D J Bean
- The Health and Rehabilitation Research Institute, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology (AUT), Auckland, New Zealand; The Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Waitematā District Health Board (WDHB), Auckland, New Zealand
| | - U Rashid
- The Health and Rehabilitation Research Institute, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology (AUT), Auckland, New Zealand
| | - A D MacCormick
- Department of Surgery, School of Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand; Department of General Surgery, Counties Manukau District Health Board (CMDHB), Auckland, New Zealand
| | - G Srikumar
- Department of General Surgery, Counties Manukau District Health Board (CMDHB), Auckland, New Zealand
| | - A M Drewes
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - J A Windsor
- Department of Surgery, School of Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand
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Kotlińska-Lemieszek A, Żylicz Z. Less Well-Known Consequences of the Long-Term Use of Opioid Analgesics: A Comprehensive Literature Review. Drug Des Devel Ther 2022; 16:251-264. [PMID: 35082488 PMCID: PMC8784970 DOI: 10.2147/dddt.s342409] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life. OBJECTIVE To review the literature on the adverse effects of long-term opioid therapy. METHODS We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment. RESULTS Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain. CONCLUSION Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.
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Affiliation(s)
- Aleksandra Kotlińska-Lemieszek
- Chair and Department of Palliative Medicine, Pharmacotherapy in Palliative Care Laboratory, Poznan University of Medical Sciences, Poznan, Poland.,Heliodor Święcicki University Hospital, Poznan, Poland
| | - Zbigniew Żylicz
- Institute of Medical Sciences, Medical College, University of Rzeszów, Rzeszów, Poland
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7
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Balbale SN, Cao L, Trivedi I, Stulberg JJ, Suda KJ, Gellad WF, Evans CT, Jordan N, Keefer LA, Lambert BL. Opioid-related emergency department visits and hospitalizations among patients with chronic gastrointestinal symptoms and disorders dually enrolled in the Department of Veterans Affairs and Medicare Part D. Am J Health Syst Pharm 2022; 79:78-93. [PMID: 34491281 PMCID: PMC8740548 DOI: 10.1093/ajhp/zxab363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We examined the prevalence of, and factors associated with, serious opioid-related adverse drug events (ORADEs) that led to an emergency department (ED) visit or hospitalization among patients with chronic gastrointestinal (GI) symptoms and disorders dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D. METHODS In this retrospective cohort study, we used linked national patient-level data (April 1, 2011, to October 31, 2014) from the VA and Centers for Medicare and Medicaid Services to identify serious ORADEs among dually enrolled veterans with a chronic GI symptom or disorder. Outcome measures included serious ORADEs, defined as an ED visit attributed to an ORADE or a hospitalization where the principal or secondary reason for admission involved an opioid. We used multiple logistic regression models to determine factors independently associated with a serious ORADE. RESULTS We identified 3,430 veterans who had a chronic GI symptom or disorder; were dually enrolled in the VA and Medicare Part D; and had a serious ORADE that led to an ED visit, hospitalization, or both. The period prevalence of having a serious ORADE was 2.4% overall and 4.4% among veterans with chronic opioid use (≥90 consecutive days). Veterans with serious ORADEs were more likely to be less than 40 years old, male, white, and to have chronic abdominal pain, functional GI disorders, chronic pancreatitis, or Crohn's disease. They were also more likely to have used opioids chronically and at higher daily doses. CONCLUSION There may be a considerable burden of serious ORADEs among patients with chronic GI symptoms and disorders. Future quality improvement efforts should target this vulnerable population.
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Affiliation(s)
- Salva N Balbale
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr VA Hospital, Hines, IL, USA
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & 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
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
- 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, Pittsburgh, PA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charlesnika T Evans
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr VA Hospital, Hines, IL, USA
| | - Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr VA Hospital, Hines, IL, USA
| | - Laurie A Keefer
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce L Lambert
- Center for Communication and Health, Northwestern University School of Communication, Chicago, IL, USA
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Lambarth A, Zarate-Lopez N, Fayaz A. Oral and parenteral anti-neuropathic agents for the management of pain and discomfort in irritable bowel syndrome: A systematic review and meta-analysis. Neurogastroenterol Motil 2022; 34:e14289. [PMID: 34755926 DOI: 10.1111/nmo.14289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a highly prevalent and economically burdensome condition; and pain is often the most unpleasant, disruptive, and difficult-to-treat symptom. Visceral hypersensitivity is a common feature driving pain in IBS, suggesting that neuropathic mechanisms may be implicated. We conducted a systematic review of available evidence to examine the role of anti-neuropathic medicines in the management of pain in IBS. METHODS We systematically searched scientific repositories for trials investigating conventional oral, and/or parenteral, pharmaceutical antineuropathic treatments in patients with IBS. We summarized key participant characteristics, outcomes related to pain (primary outcome), and selected secondary outcomes. KEY RESULTS We included 13 studies (n = 629 participants): six investigated amitriptyline, three duloxetine, three pregabalin, and one gabapentin. There was considerable methodological and statistical heterogeneity, so we performed a narrative synthesis and limited meta-analysis. Amitriptyline was most extensively studied, though only in diarrhea-predominant patients. In individual trials, amitriptyline, pregabalin and gabapentin generally appeared beneficial for pain outcomes. While duloxetine studies tended to report improvements in pain, all were un-controlled trials with high risk of bias. Meta-analysis of three studies (n = 278) yielded a pooled relative-risk of 0.50 (95%CI 0.38-0.66) for not improving with anti-neuropathic agent vs control. We did not identify any eligible studies investigating the role of parenteral anti-neuropathics. CONCLUSIONS AND INFERENCES Anti-neuropathic analgesics may improve pain in IBS, and deserve further, high-quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Investigation of amitriptyline's efficacy in non-diarrhea-predominant subtypes is currently lacking, and we recommend particular caution for its use in IBS-C.
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Affiliation(s)
- Andrew Lambarth
- University College London Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Natalia Zarate-Lopez
- University College London Hospital Gastrointestinal Physiology Unit, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
| | - Alan Fayaz
- University College Hospitals NHS Foundation Trust, Pain Education Research Centre, University College Hospitals NHS Foundation Trust: PERC@UCLH, London, UK
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9
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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.
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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
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10
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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
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Lara LF, Wastvedt S, Hodges JS, Witkowski P, Wijkstrom M, Walsh RM, Singh VK, Schwarzenberg SJ, Pruett TL, Posselt A, Naziruddin B, Nathan JD, Morgan KA, Mitchell R, Kirchner VA, Mokshagundam SL, Hatipoglu B, Gardner TB, Freeman ML, Chinnakotla S, Beilman GJ, Abu-El-Haija M, Conwell DL, Bellin MD. The Association of Smoking and Alcohol Abuse on Anxiety and Depression in Patients With Recurrent Acute or Chronic Pancreatitis Undergoing Total Pancreatectomy and Islet Autotransplantation: A Report From the Prospective Observational Study of TPIAT Cohort. Pancreas 2021; 50:852-858. [PMID: 34347725 PMCID: PMC8373657 DOI: 10.1097/mpa.0000000000001850] [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] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Smoking and alcohol use are risk factors for acute and chronic pancreatitis, and their role on anxiety, depression, and opioid use in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT) is unknown. METHODS We included adults enrolled in the Prospective Observational Study of TPIAT (POST). Measured variables included smoking (never, former, current) and alcohol abuse or dependency history (yes vs no). Using univariable and multivariable analyses, we investigated the association of smoking and alcohol dependency history with anxiety and depression, opioid use, and postsurgical outcomes. RESULTS Of 195 adults studied, 25 were current smokers and 77 former smokers, whereas 18 had a history of alcohol dependency (of whom 10 were current smokers). A diagnosis of anxiety was associated with current smoking (P = 0.005), and depression was associated with history of alcohol abuse/dependency (P = 0.0001). However, active symptoms of anxiety and depression at the time of TPIAT were not associated with smoking or alcohol status. Opioid use in the past 14 days was associated with being a former smoker (P = 0.005). CONCLUSIONS Active smoking and alcohol abuse history were associated with a diagnosis of anxiety and depression, respectively; however, at the time of TPIAT, symptom scores suggested that they were being addressed.
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Affiliation(s)
- Luis F. Lara
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH
| | - Solvejg Wastvedt
- School of Public Health, University of Minnesota Minneapolis, MN
| | - James S. Hodges
- School of Public Health, University of Minnesota Minneapolis, MN
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Vikesh K. Singh
- Department of Medicine, Division of Gastroenterology, John Hopkins Medical Institutions, Baltimore, MD
| | | | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Andrew Posselt
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Bashoo Naziruddin
- Department of Surgery, Islet Cell Processing Laboratory, Baylor Health, Dallas, TX
| | - Jaimie D. Nathan
- Division of Surgery, Cincinnati Children’s Hospital Medical Center
- Department of Surgery, University of Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Katherine A. Morgan
- Department of Surgery, Division of GI and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC
| | - Rebecca Mitchell
- School of Public Health, University of Minnesota Minneapolis, MN
| | - Varvara A. Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | | | - Betul Hatipoglu
- Department of Medicine, Division of Clinical and Molecular Endocrinology, University Hospitals, Cleveland, OH
| | - Timothy B. Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martin L. Freeman
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital
| | - Darwin L. Conwell
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Medical Center, Columbus, OH
| | - Melena D. Bellin
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN
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Abstract
Chronic pancreatitis is a clinical entity that results from the progressive inflammation and irreversible fibrosis of the pancreas resulting from the cumulative injury sustained by the pancreas over time. It is an illness with variable presentations that can severely impact quality of life, while its long-term complications such as exocrine pancreatic insufficiency (EPI), diabetes mellitus, and risk of pancreatic cancer can become life threatening. The diagnosis of chronic pancreatitis can be challenging as despite the recent advancements in imaging technology, the radiographic findings do not become prominent until late stages of disease. Thus, the physicians' clinical acumen in obtaining thorough history taking focusing on risk factors, clinical symptoms, in addition to high-quality imaging, often guide to the accurate diagnosis of chronic pancreatitis. Endoscopy also plays a pivotal role in the diagnosis and management of chronic pancreatitis. Endoscopic ultrasound (EUS) is believed to be the most sensitive modality for diagnosing chronic pancreatitis. Despite efforts, however, natural history studies have demonstrated that 61% of individuals with chronic pancreatitis will require at least one endoscopic intervention, while 31% will require a surgical procedure as part of their management strategy. Recent advancements in genomic studies have furthered our understanding of the genetic polymorphisms that are associated with the pathogenesis of chronic pancreatitis. Genetic testing offers the potential to reveal treatable pancreatitis-related disorders, and can inform decision making with regard to radical therapies for persistent or severe disease such as total pancreatectomy with islet autotransplantation (TPIAT). The management of patients suffering from chronic pancreatitis often requires a multi-disciplinary approach, addressing pertinent symptoms as well as the sequelae of chronic inflammation and fibrosis. Abdominal pain is the prevailing symptom and most common complication of chronic pancreatitis, and impairs quality of life. Although heavily dependent on a wide range of analgesia, endoscopic treatment such as endoscopic retrograde cholangiopancreatography (ERCP) and surgical intervention can offer long-lasting relief of symptoms. For EPI, treatment with pancreatic enzyme supplements offers marginal-to-moderate relief. The most feared complication of chronic pancreatitis-the development of pancreatic cancer-has no known prevention measure to date.
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13
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Mansour J, Zulfiqar M, Umer A, Zurcher KS, Heeger A, Menias CO. Abdominal Imaging Manifestations of Recreational Drug Use. Radiographics 2020; 40:1895-1915. [PMID: 33064622 DOI: 10.1148/rg.2020200048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Recreational drug use is a burgeoning health issue worldwide, with a variety of presenting symptoms and complications. These complications can be secondary to the toxic effects of the drug itself, drug impurities, and nonsterile injection. The abdominal radiologist is likely to encounter patients who use drugs recreationally and may be responsible for recognizing and reporting these acute conditions, which in some cases can be life threatening. Because these patients often present with an altered mental state and may deny or withhold information on drug use, the underlying cause may be difficult to determine. The most commonly used drugs worldwide include cocaine, cannabinoids, opioids, and amphetamines and their derivatives. Complications of use of these drugs that can be seen at abdominopelvic CT can involve multiple organ systems, including the soft tissue and gastrointestinal, genitourinary, vascular, and musculoskeletal systems. A diverse range of abdominal complications associated with these drugs can be seen at imaging, including disseminated infections, gastrointestinal ischemia, and visceral infarction. Radiologists should be familiar with the imaging findings of these complications to accurately diagnose these entities and help guide workup and patient treatment. ©RSNA, 2020.
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Affiliation(s)
- Joseph Mansour
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Maria Zulfiqar
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Affan Umer
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Kenneth S Zurcher
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Allen Heeger
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
| | - Christine O Menias
- From the Department of Radiology, Saint Louis University Hospital, 3635 Vista Ave, 2nd Floor, Deslodge Tower, St Louis, MO 63103-2097 (J.M., A.U.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.M., M.Z.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (K.S.Z., C.O.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (A.H.)
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Kassam AF, Kim Y, Cortez AR, Dhar VK, Wima K, Shah SA. The impact of opioid use on human and health care costs in surgical patients. Surg Open Sci 2020; 2:92-95. [PMID: 32754712 PMCID: PMC7391897 DOI: 10.1016/j.sopen.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 12/02/2022] Open
Abstract
Background Preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear. Methods A single-center retrospective analysis was performed on surgical patients admitted with intestinal obstruction (2010–2014). Patients were grouped into active opioid and nonopioid user cohorts. Active opioid use was defined as having an opioid prescription overlapping the date of admission. Chronic opioid use was defined by duration of use ≥ 90 days. Admission or intervention due to opioid-related illness was determined through consensus decision of 2 independent, blinded clinicians. Primary end point was the effect of active opioid use on hospital resource utilization. Results During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 55 (18.6%) of these patients, with a median length of opioid use of 164 days (interquartile range 54–344 days). Average length of use was 164 days, with the majority of active users (n = 42, 76.4%) meeting criteria for chronic use. A subgroup analysis of active users demonstrated that opioid-related conditions were responsible for 10 admissions (18.2%) and 2 readmissions (3.6%). Among active users requiring surgical intervention, 3 procedures (21.4%) were due to opioid-related illnesses. Median hospital length of stay was 2 days longer (8 vs 6 days) and hospital costs were greater ($12,241 vs $8489) among active users (P < .05 each). Conclusion Active opioid users are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and health care spending.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Mischel RA, Muchhala KH, Dewey WL, Akbarali HI. The "Culture" of Pain Control: A Review of Opioid-Induced Dysbiosis (OID) in Antinociceptive Tolerance. THE JOURNAL OF PAIN 2020; 21:751-762. [PMID: 31841668 PMCID: PMC7286790 DOI: 10.1016/j.jpain.2019.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022]
Abstract
It is increasingly recognized that chronic opioid use leads to maladaptive changes in the composition and localization of gut bacteria. Recently, this "opioid-induced dysbiosis" (OID) has been linked to antinociceptive tolerance development in preclinical models and may therefore identify promising targets for new opioid-sparing strategies. Such developments are critical to curb dose escalations in the clinical setting and combat the ongoing opioid epidemic. In this article, we review the existing literature that pertains to OID, including the current evidence regarding its qualitative nature, influence on antinociceptive tolerance, and future prospects. PERSPECTIVE: This article reviews the current literature on OID of gut bacteria, including its qualitative nature, influence on antinociceptive tolerance, and future prospects. This work may help identify targets for new opioid-sparing strategies.
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Affiliation(s)
- Ryan A Mischel
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia
| | - Karan H Muchhala
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia
| | - William L Dewey
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia
| | - Hamid I Akbarali
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia.
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Charilaou P, Mohapatra S, Joshi T, Devani K, Gadiparthi C, Pitchumoni CS, Broder A. Opioid use disorder in admissions for acute exacerbations of chronic pancreatitis and 30-day readmission risk: A nationwide matched analysis. Pancreatology 2020; 20:35-43. [PMID: 31759905 DOI: 10.1016/j.pan.2019.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/24/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014. METHODS This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses. RESULTS 189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16-1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases' aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289). CONCLUSION OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.
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Affiliation(s)
- Paris Charilaou
- Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, NJ, USA.
| | - Sonmoon Mohapatra
- Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, NJ, USA
| | - Tejas Joshi
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Kalpit Devani
- East Tennessee State University/ James H. Quillen College of Medicine, Johnson City, TN, USA
| | | | | | - Arkady Broder
- Saint Peter's University Hospital/Rutgers-RWJ Medical School, New Brunswick, NJ, USA
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17
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Davydov DM, Shahabi L, Naliboff B. Cardiovascular phenotyping for personalized lifestyle treatments of chronic abdominal pain in Irritable Bowel Syndrome: A randomized pilot study. Neurogastroenterol Motil 2019; 31:e13710. [PMID: 31429514 PMCID: PMC6861616 DOI: 10.1111/nmo.13710] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/30/2019] [Accepted: 08/08/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Different physical exercise interventions for pain and other related symptoms largely follow non-personalized guidelines and show a high degree of variability in outcome. These interventions are considered to have different pathways toward improvement in autonomic regulation of energy metabolism. The current pilot study was conducted to assess the predictive value of individual cardiovascular (CV) activity markers at rest to predict clinical outcomes for two popular exercise-based interventions (walking and yoga) in patients with Irritable Bowel Syndrome (IBS). METHODS Twenty-seven adult participants with IBS were randomly assigned to a 16-biweekly Iyengar yoga or walking program. They completed pre- and post-treatment assessments on IBS symptom severity, affective and somatic complaints, and various measures of resting autonomic function including blood pressure (BP), heart rate and its variability, baroreceptor sensitivity (BRS) to activations and inhibitions with gains of brady- and tachycardiac baro-responses, and BP start points for these spontaneous baroreflexes. RESULTS Pretreatment BRS was differentially related to clinical response for the treatment groups. Specifically, a significant decrease in pain severity was found in response to yoga for those participants who had lower resting BRS to activations, but decreased pain severity was associated with higher resting BRS for those in the walking group. The effect was not related to affective symptom relief. Other CV measures showed similar associations with clinical outcomes for both groups. CONCLUSIONS The data suggest therefore that CV based phenotypes may be useful in personalizing clinical interventions for IBS. They may also point to autonomic mechanisms that are targets for such interventions.
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Affiliation(s)
- Dmitry M. Davydov
- Laboratory of Neuroimmunopathology, Institute of General Pathology and Pathophysiology, Russian Academy of Sciences, 8 Baltiyskaia ul., Moscow, 125315, Russia
| | - Leila Shahabi
- Departments of Medicine, Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095
| | - Bruce Naliboff
- Departments of Medicine, Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90095
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Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Abdominal Pain in Patients with Gastroparesis: Associations with Gastroparesis Symptoms, Etiology of Gastroparesis, Gastric Emptying, Somatization, and Quality of Life. Dig Dis Sci 2019; 64:2242-2255. [PMID: 30852767 PMCID: PMC6656584 DOI: 10.1007/s10620-019-05522-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/06/2019] [Indexed: 12/30/2022]
Abstract
UNLABELLED Abdominal pain can be an important symptom in some patients with gastroparesis (Gp). AIMS (1) To describe characteristics of abdominal pain in Gp; (2) describe Gp patients reporting abdominal pain. METHODS Patients with idiopathic gastroparesis (IG) and diabetic gastroparesis (DG) were studied with gastric emptying scintigraphy, water load test, wireless motility capsule, and questionnaires assessing symptoms [Patient Assessment of Upper GI Symptoms (PAGI-SYM) including Gastroparesis Cardinal Symptom Index (GCSI)], quality of life (PAGI-QOL, SF-36), psychological state [Beck Depression Inventory (BDI), State-Trait Anxiety Index (STAI), PHQ-15 somatization scale]. RESULTS In total, 346 Gp patients included 212 IG and 134 DG. Ninety percentage of Gp patients reported abdominal pain (89% DG and 91% IG). Pain was primarily in upper or central midline abdomen, described as cramping or sickening. Upper abdominal pain was severe or very severe on PAGI-SYM by 116/346 (34%) patients, more often by females than by males, but similarly in IG and DG. Increased upper abdominal pain severity was associated with increased severity of the nine GCSI symptoms, depression on BDI, anxiety on STAI, somatization on PHQ-15, the use of opiate medications, decreased SF-36 physical component, and PAGI-QOL, but not related to severity of delayed gastric emptying or water load ingestion. Using logistic regression, severe/very severe upper abdominal pain associated with increased GCSI scores, opiate medication use, and PHQ-15 somatic symptom scores. CONCLUSIONS Abdominal pain is common in patients with Gp, both IG and DG. Severe/very severe upper abdominal pain occurred in 34% of Gp patients and associated with other Gp symptoms, somatization, and opiate medication use. ClinicalTrials.gov Identifier: NCT01696747.
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20
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Thapa N, Kappus M, Hurt R, Diamond S. Implications of the Opioid Epidemic for the Clinical Gastroenterology Practice. Curr Gastroenterol Rep 2019; 21:44. [PMID: 31346779 DOI: 10.1007/s11894-019-0712-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW The opioid epidemic in the USA has led to a rise in opioid-related gastrointestinal (GI) side effects that are often difficult to diagnose and treat. The aim of this report is to discuss opioid pathophysiology, opioid-related GI side effects, clinical presentation, and diagnostic criteria and to review the current pharmacotherapy available. RECENT FINDINGS Opioid-related GI disorders are increasingly recognized and include, but are not limited to, opioid-induced esophageal dysfunction (OIED), gastroparesis, opioid-induced constipation (OIC), narcotic bowel syndrome (NBS), acute post-operative ileus, and anal sphincter dysfunction. Treatment of these conditions is challenging. OIC has the most available pharmacotherapy for treatment, including classical laxatives, peripherally acting μ-receptor antagonists (PAMORAs), novel therapies (lubiprostone, prucalopride- 5-HT agonist), and preventative therapies (PR oxycodone/naloxone). The gastrointestinal effects of opioid therapy are variable and often debilitating. While medical management for some opioid-related GI side effects exists, limiting or completely avoiding opioid use for chronic non-cancer pain will mitigate these effects most effectively.
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Affiliation(s)
- Namisha Thapa
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Matthew Kappus
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ryan Hurt
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Diamond
- Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L-461, Portland, OR, 97239, USA.
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Abstract
Scientific research into the effects and mechanisms of acupuncture for gastrointestinal diseases including inflammatory bowel disease has been rapidly growing in the past several decades. In this review, we discuss the history, theory, and methodology of acupuncture and review potentially beneficial mechanisms of action of acupuncture for managing inflammatory bowel disease. Acupuncture has been shown to decrease disease activity and inflammation via increase of vagal activity in inflammatory bowel disease. Acupuncture has demonstrated beneficial roles in the regulation of gut dysbiosis, intestinal barrier function, visceral hypersensitivity, gut motor dysfunction, depression/anxiety, and pain, all of which are factors that can significantly impact quality of life in patients with inflammatory bowel disease. A number of clinical trials have been performed to investigate the therapeutic effects of acupuncture in ulcerative colitis and Crohn's disease. Although the data from these trials are promising, more studies are needed given the heterogeneous and multifactorial aspects of inflammatory bowel disease. There is also an important need to standardize acupuncture methodology, study designs, and outcome measurements.
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Affiliation(s)
- Gengqing Song
- Department of Gastroenterology, Hepatology & Nutrition, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
| | - Claudio Fiocchi
- Department of Gastroenterology, Hepatology & Nutrition, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology & Nutrition, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
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Siddiqui MT, Bilal M, Schorr-Lesnick B, Lebovics E, Dworkin B. Opioid use disorder is associated with increased mortality and morbidity in patients with gastroparesis. Ann Gastroenterol 2019; 32:370-377. [PMID: 31263359 PMCID: PMC6595927 DOI: 10.20524/aog.2019.0389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Opioid use disorder (OUD) epidemic has been declared a nationwide public health emergency by the Department of Health and Human Services. There are limited data regarding OUD in patients with gastroparesis. This study aimed to evaluate the impact of OUD on the outcomes in patients hospitalized with gastroparesis and to delineate the trends associated with OUD and gastroparesis using a nationally representative sample. Methods We used the National (Nationwide) Inpatient Sample database from 2005-2014 to identify patients hospitalized with a primary diagnosis of gastroparesis (ICD 9 Code: 536.3) and a concurrent diagnosis of OUD. We used Pearson chi-square analysis to compare demographics, the independent samples t-test to assess differences in length of stay and cost of care, and multivariate regression analysis to adjust for confounders. Results Between 2005 and 2014, a total of 145,700 patients with a primary diagnosis of gastroparesis were hospitalized in the United States, of whom 4519 (3.1%) had a concurrent diagnosis of OUD. The prevalence of OUD in gastroparesis doubled from 2.1% in 2005 to 4.3% in 2014. After adjusting for confounders, patients with OUD had greater in-hospital mortality (adjusted odds ratio 2.7, 95% confidence interval: 2.1-3.5). Patients with OUD also had significantly longer hospital stays and higher costs. Independent predictors of OUD in patients with gastroparesis were younger age, female sex, alcohol use, depression, and Medicaid insurance. Conclusion OUD in patients with gastroparesis is associated with greater mortality and healthcare resource utilization.
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Affiliation(s)
- Mohamed Tausif Siddiqui
- Department of Internal Medicine, New York Medical College, Valhalla, NY (Mohamed Tausif Siddiqui)
| | - Mohammad Bilal
- Department of Gastroenterology, University of Texas Medical Branch, Galveston, TX (Mohammad Bilal)
| | - Beth Schorr-Lesnick
- Department of Gastroenterology, New York Medical College, Valhalla, NY (Beth Schorr-Lesnick, Edward Lebovics, Brad Dworkin), USA
| | - Edward Lebovics
- Department of Gastroenterology, New York Medical College, Valhalla, NY (Beth Schorr-Lesnick, Edward Lebovics, Brad Dworkin), USA
| | - Brad Dworkin
- Department of Gastroenterology, New York Medical College, Valhalla, NY (Beth Schorr-Lesnick, Edward Lebovics, Brad Dworkin), USA
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Zou WB, Ru N, Wu H, Hu LH, Ren X, Jin G, Wang Z, Du YQ, Cao YN, Zhang L, Chang XY, Zhang RC, Li XB, Shen Y, Li P, Li ZS, Liao Z. Guidelines for the diagnosis and treatment of chronic pancreatitis in China (2018 edition). Hepatobiliary Pancreat Dis Int 2019; 18:103-109. [PMID: 30922816 DOI: 10.1016/j.hbpd.2019.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/02/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China
| | - Nan Ru
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Hao Wu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Xu Ren
- Department of Gastroenterology, Heilongjiang Provincial Hospital, Harbin 150030, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yi-Qi Du
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Ya-Nan Cao
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Lei Zhang
- Department of Radiology, Shanghai First People's Hospital, Shanghai 200080, China
| | - Xiao-Yan Chang
- Department of Pathology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Rong-Chun Zhang
- Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiao-Bin Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yan Shen
- Department of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Peng Li
- Department of Digestive Endoscopy, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China.
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China.
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Mantzouranis G, Fafliora E, Saridi M, Tatsioni A, Glanztounis G, Albani E, Katsanos KH, Christodoulou DK. Alcohol and narcotics use in inflammatory bowel disease. Ann Gastroenterol 2018; 31:649-658. [PMID: 30386114 PMCID: PMC6191867 DOI: 10.20524/aog.2018.0302] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/03/2018] [Indexed: 02/07/2023] Open
Abstract
The aim of this study was to evaluate alcohol consumption and narcotics use among patients with inflammatory bowel diseases (IBD). A comprehensive literature search was conducted in Medline using relevant keywords. The references of the retrieved articles were also searched to identify additional articles. Only English-language studies that provided evidence on alcohol consumption and/or narcotics use among non-hospitalized IBD patients were included in the present review. Twelve studies were included that examined the use of alcohol among IBD patients. The prevalence of alcohol consumption among IBD patients appeared to be similar to that of the general population. The majority of the studies reported worsening of IBD symptoms among patients who consumed alcoholic beverages. Four studies were identified that evaluated narcotics use as analgesia among IBD patients. Narcotics use was prevalent among IBD patients and correlated with a longer disease duration and comorbid mental illnesses. The available evidence suggests that alcohol consumption may have a deleterious effect on IBD symptoms. Furthermore, a considerable proportion of IBD patients are reported to use a narcotic as analgesia and this was correlated with their mental health status. Further studies are needed to address these important facets of IBD.
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Affiliation(s)
- George Mantzouranis
- Department of Gastroenterology, University of Ioannina, Medical School (George Mantzouranis, Eleftheria Fafliora, Athina Tatsioni, George Glantzounis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Eleftheria Fafliora
- Department of Gastroenterology, University of Ioannina, Medical School (George Mantzouranis, Eleftheria Fafliora, Athina Tatsioni, George Glantzounis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Maria Saridi
- Department of Social Sciences, University of Peloponnese, Corinth, Academic Tutor at Hellenic Open University (Maria Saridi), Greece
- Correspondence to: Maria Saridi, PhD, Research Fellow, Faculty of Social Sciences, University of Peloponnese, Corinth, Greece, Academic Tutor at Hellenic Open University, Greece, Sina 33, 20131 Corinth, Greece, e-mail:
| | - Athina Tatsioni
- Department of Gastroenterology, University of Ioannina, Medical School (George Mantzouranis, Eleftheria Fafliora, Athina Tatsioni, George Glantzounis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - George Glanztounis
- Department of Gastroenterology, University of Ioannina, Medical School (George Mantzouranis, Eleftheria Fafliora, Athina Tatsioni, George Glantzounis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Eleni Albani
- Department of Nursing, TEI of Western Greece (Eleni Albani), Greece
| | - Konstantinos H. Katsanos
- Department of Gastroenterology, University of Ioannina, Medical School (George Mantzouranis, Eleftheria Fafliora, Athina Tatsioni, George Glantzounis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology, University of Ioannina, Medical School (George Mantzouranis, Eleftheria Fafliora, Athina Tatsioni, George Glantzounis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
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Shada A, Nielsen A, Marowski S, Helm M, Funk LM, Kastenmeier A, Lidor A, Gould JC. Wisconsin's Enterra Therapy Experience: A multi-institutional review of gastric electrical stimulation for medically refractory gastroparesis. Surgery 2018; 164:760-765. [PMID: 30072246 DOI: 10.1016/j.surg.2018.04.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/04/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastric electrical stimulation is a treatment for symptoms of diabetic or idiopathic gastroparesis refractory to medical management. We sought to evaluate the outcomes of gastric electrical stimulation in the state of Wisconsin during a more than 10-year period. METHODS Data were collected prospectively from patients undergoing implantation of the gastric electrical stimulation to initiate gastric electrical stimulation therapy at two Wisconsin institutions from 2005-2017. The Gastroparesis Cardinal Symptom Index was administered during clinical encounters and over the phone preoperatively and postoperatively. RESULTS A total of 119 patients received gastric electrical stimulation therapy (64 diabetic and 55 idiopathic). All devices were placed laparoscopically. Mean follow-up was 34.1 ± 27.2 months in diabetic and 44.7 ± 26.2 months in idiopathic patients. A total of 18 patients died during the study interval (15.1%). No mortalities were device-related. Diabetics had the greatest rate of mortality (25%; mean interval of 17 ± 3 months post implantation). GCSI scores improved, and prokinetic and narcotic medication use decreased significantly at ≥1 year. Satisfaction scores were high. CONCLUSION Gastric electrical stimulation therapy led to the improvement of symptoms of gastroparesis and a better quality of life. Patients were able to decrease the use of prokinetic and narcotic medications and achieve long-term satisfaction. Diabetic patients who develop symptomatic gastroparesis have a high mortality rate over time.
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Affiliation(s)
- Amber Shada
- Department of Surgery, Division of General Surgery, University of Wisconsin, Madison
| | - Alex Nielsen
- Department of Surgery, Division of General Surgery, Medical College of Wisconsin, Milwaukee; and
| | - Sarah Marowski
- Department of Surgery, Division of General Surgery, University of Wisconsin, Madison
| | - Melissa Helm
- Department of Surgery, Division of General Surgery, Medical College of Wisconsin, Milwaukee; and
| | - Luke M Funk
- Department of Surgery, Division of General Surgery, University of Wisconsin, Madison;; William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Andrew Kastenmeier
- Department of Surgery, Division of General Surgery, Medical College of Wisconsin, Milwaukee; and
| | - Anne Lidor
- Department of Surgery, Division of General Surgery, University of Wisconsin, Madison
| | - Jon C Gould
- Department of Surgery, Division of General Surgery, Medical College of Wisconsin, Milwaukee; and.
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Pain in pancreatic ductal adenocarcinoma: A multidisciplinary, International guideline for optimized management. Pancreatology 2018; 18:446-457. [PMID: 29706482 DOI: 10.1016/j.pan.2018.04.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
Abdominal pain is an important symptom in most patients with pancreatic ductal adenocarcinoma (PDAC). Adequate control of pain is often unsatisfactory due to limited treatment options and significant variation in local practice, emphasizing the need for a multidisciplinary approach. This review contends that improvement in the management of PDAC pain will result from a synthesis of best practice and evidence around the world in a multidisciplinary way. To improve clinical utility and evaluation, the evidence was rated according to the GRADE guidelines by a group of international experts. An algorithm is presented, which brings together all currently available treatment options. Pain is best treated early on with analgesics with most patients requiring opioids, but neurolytic procedures are often required later in the disease course. Celiac plexus neurolysis offers medium term relief in a substantial number of patients, but other procedures such as splanchnicectomy are also available. Palliative chemotherapy also provides pain relief as a collateral benefit. It is stressed that the assessment of pain must take into account the broader context of other physical and psychological symptoms. Adjunctive treatments for pain, depression and anxiety as well as radiotherapy, endoscopic therapy and neuromodulation may be required in selected patients. There are few comparative studies to help define which combination and order of these treatment options should be applied. New pain therapies are emerging and could for example target neural transmitters. However, until better methods are available, management of pain should be individualized in a multidisciplinary setting to ensure optimal care.
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27
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Nee J, Rangan V, Lembo A. Reduction in pain: Is it worth the gain? The effect of opioids on the GI tract. Neurogastroenterol Motil 2018; 30:e13367. [PMID: 29700963 DOI: 10.1111/nmo.13367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 03/30/2018] [Indexed: 02/08/2023]
Abstract
The use of opioid medications for acute and chronic pain has increased significantly in the past 20 years in the United States. Given the high density of opioid receptors in the gastrointestinal tract, side effects are common in these patients including constipation, dysphagia, bloating, nausea, and vomiting. These side effects, which are experienced by most patients who take opioids, can lead to significant impairment in quality of life. Unlike other side effects from opioids, gastrointestinal side effects do not diminish with continued use, often leading patients to reduce or discontinue their opioid treatment to relieve these side effects. Therefore, physicians must be aware and anticipate potential side effects in patients receiving opioids to ensure appropriate pain management.
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Affiliation(s)
- J Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - V Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - A Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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28
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Keefer L, Palsson OS, Pandolfino JE. Best Practice Update: Incorporating Psychogastroenterology Into Management of Digestive Disorders. Gastroenterology 2018; 154:1249-1257. [PMID: 29410117 DOI: 10.1053/j.gastro.2018.01.045] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/13/2022]
Abstract
Chronic digestive diseases, including irritable bowel syndrome, gastroesophageal reflux disease, and inflammatory bowel diseases, cannot be disentangled from their psychological context-the substantial burden of these diseases is co-determined by symptom and disease severity and the ability of patients to cope with their symptoms without significant interruption to daily life. The growing field of psychogastroenterology focuses on the application of scientifically based psychological principles and techniques to the alleviation of digestive symptoms. In this Clinical Practice Update, we describe the structure and efficacy of 2 major classes of psychotherapy-cognitive behavior therapy and gut-directed hypnotherapy. We focus on the impact of these brain-gut psychotherapies on gastrointestinal symptoms, as well as their ability to facilitate improved coping, resilience, and self-regulation. The importance of the gastroenterologist in the promotion of integrated psychological care cannot be overstated, and recommendations are provided on how to address psychological issues and make an effective referral for brain-gut psychotherapy in routine practice.
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Affiliation(s)
- Laurie Keefer
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | | | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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29
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Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018; 154:1140-1171.e1. [PMID: 29274869 DOI: 10.1053/j.gastro.2017.11.279] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Central neuromodulators (antidepressants, antipsychotics, and other central nervous system-targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut-brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations. METHODS The working team summarized the literature on the pharmacology of central neuromodulators and their effects on gastrointestinal sensorimotor function and conducted an evidence-based review on their use for treating FGID syndromes. Because of the paucity of data for FGIDs, we included data for non-gastrointestinal painful disorders and specific symptoms of pain, nausea, and vomiting. This information was combined into a final document comprising a synthesis of available evidence and recommendations for clinical use guided by the research and clinical experience of the experts on the committee. RESULTS The evidence-based review on neuromodulators in FGID, restricted by the limited available controlled trials, was integrated with open-label studies and case series, along with the experience of experts to create recommendations using a consensus (Delphi) approach. Due to the diversity of conditions and complexity of treatment options, specific recommendations were generated for different FGIDs. However, some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship. CONCLUSIONS Based on systematic and selectively focused review and the consensus of a multidisciplinary panel, we have provided summary information and guidelines for the use of central neuromodulators in the treatment of chronic gastrointestinal symptoms and FGIDs. Further studies are needed to confirm and refine these recommendations.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, North Carolina.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans Törnblom
- Departments of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Szigethy E, Knisely M, Drossman D. Opioid misuse in gastroenterology and non-opioid management of abdominal pain. Nat Rev Gastroenterol Hepatol 2018; 15:168-180. [PMID: 29139482 PMCID: PMC6421506 DOI: 10.1038/nrgastro.2017.141] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates. Chronic opioid use for noncancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction. This Review summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain-gut axis. Guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders are also discussed. As chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best.
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Affiliation(s)
- Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, 3708 Fifth Avenue, Pittsburgh, Pennsylvania 15213, USA
| | - Mitchell Knisely
- School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, Pennsylvania 15261, USA
| | - Douglas Drossman
- Center for Functional GI & Motility Disorders, University of North Carolina, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, North Carolina 27599, USA
- Drossman Gastroenterology PLLC, 901 Kings Mill Road, Chapel Hill, North Carolina 27517, USA
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31
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Sayuk GS, Kanuri N, Gyawali CP, Gott BM, Nix BD, Rosenheck RA. Opioid medication use in patients with gastrointestinal diagnoses vs unexplained gastrointestinal symptoms in the US Veterans Health Administration. Aliment Pharmacol Ther 2018; 47:784-791. [PMID: 29327358 DOI: 10.1111/apt.14503] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/05/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND While opioid prescriptions have increased alarmingly in the United States (US), their use for unexplained chronic gastrointestinal (GI) pain (eg, irritable bowel syndrome) carries an especially high risk for adverse effects and questionable benefit. AIM To compare opioid use among US veterans with structural GI diagnoses (SGID) and those with unexplained GI symptoms or functional GI diagnoses (FGID), a group for whom opioids have no accepted role. METHODS Veterans Health Administration (VHA) administrative data from fiscal year 2012 were used to identify veterans with diagnostic codes recorded for SGID and FGID. This cohort study examined VHA pharmacy data to compare groups receiving ≥ 1 opioid prescription during the year and number of prescriptions filled. Bivariate and multiple logistic regression analyses adjusted for potential confounding factors (demographics, medical diagnoses, social factors) and identified potential mediators (service use, psychiatric comorbidity) of opioid use in these groups. RESULTS A greater proportion of veterans with FGID received an opioid prescription during fiscal year 2012 (36.0% of 272 431) compared to only 28.9% of 1 223 744 in the SGID group (Relative Risk [RR] = 1.25). In multivariate logistic regression, personality disorders and drug abuse (OR 1.23 for each group), recent homelessness (OR 1.22), psychotropic medication fills (OR 1.55) and emergency department encounters (OR 1.21) were independently associated with opioid prescription use. CONCLUSIONS Despite the potential for adverse consequences, opioids more often are prescribed for veterans with chronic, unexplained GI symptoms compared to those with structural diagnoses. Psychiatric comorbidities and frequent healthcare encounters mediate some of the opioid use risk.
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Affiliation(s)
- G S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.,Gastroenterology Section, John Cochran Veterans Affairs Medical Center, St. Louis, MO, USA
| | - N Kanuri
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - B M Gott
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - B D Nix
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - R A Rosenheck
- Department of Veterans Affairs, New England Mental Illness Research, Education, and Clinical Center, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Jehangir A, Parkman HP. Chronic opioids in gastroparesis: Relationship with gastrointestinal symptoms, healthcare utilization and employment. World J Gastroenterol 2017; 23:7310-7320. [PMID: 29142478 PMCID: PMC5677192 DOI: 10.3748/wjg.v23.i40.7310] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/08/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the relationship of chronic scheduled opioid use on symptoms, healthcare utilization and employment in gastroparesis (Gp) patients. METHODS Patients referred to our tertiary care academic center from May 2016 to July 2017, with established diagnosis or symptoms suggestive of Gp filled out the Patient Assessment of Upper GI Symptoms, abdominal pain and demographics questionnaires, and underwent gastric emptying and blood tests. They were asked about taking pain medicines and the types, doses, and duration. We used Mann Whitney U test, Analysis of Variance, Student's t test and χ2 tests where appropriate for data analyses. RESULTS Of 223 patients with delayed gastric emptying, 158 (70.9%) patients were not taking opioids (GpNO), 22 (9.9%) were taking opioids only as needed, while 43 (19.3%) were on chronic (> 1 mo) scheduled opioids (GpCO), of which 18 were taking opioids for reasons that included gastroparesis and/or stomach pain. Median morphine equivalent use was 60 mg per day. GpCO reported higher severities of many gastrointestinal symptoms compared to GpNO including nausea (mean ± SE of mean of 4.09 ± 0.12 vs 3.41 ± 0.12, P = 0.011), retching (2.86 ± 0.25 vs 1.98 ± 0.14, P = 0.003), vomiting (2.93 ± 0.24 vs 2.07 ± 0.15, P = 0.011), early satiety (4.17 ± 0.19 vs 3.57 ± 0.12, P = 0.004), post-prandial fullness (4.14 ± 0.18 vs 3.63 ± 0.11, P = 0.022), loss of appetite (3.64 ± 0.21 vs 3.04 ± 0.13, P = 0.039), upper abdominal pain (3.86 ± 0.20 vs 2.93 ± 0.13, P = 0.001), upper abdominal discomfort (3.74 ± 0.19 vs 3.09 ± 0.13, P = 0.031), heartburn during day (2.55 ± 0.27 vs 1.89 ± 0.13, P = 0.032), heartburn on lying down (2.76 ± 0.28 vs 1.94 ± 0.14, P = 0.008), chest discomfort during day (2.42 ± 0.20 vs 1.83 ± 0.12, P = 0.018), chest discomfort at night (2.40 ± 0.23 vs 1.61 ± 0.13, P = 0.003), regurgitation/reflux during day (2.77 ± 0.25 vs 2.18 ± 0.13, P = 0.040) and bitter/acid/sour taste in the mouth (2.79 ± 0.27 vs 2.11 ± 0.14, P = 0.028). GpCO had a longer duration of nausea per day (median of 7 h vs 4 h for GpNO, P = 0.037), and a higher number of vomiting episodes per day (median of 3 vs 2 for GpNO, P = 0.002). Their abdominal pain more frequently woke them up at night (78.1% vs 57.3%, P = 0.031). They had a lower employment rate (33.3% vs 54.2%, P = 0.016) and amongst those who were employed less number of working hours per week (median of 23 vs 40, P = 0.005). They reported higher number of hospitalizations in the last 1 year (mean ± SE of mean of 2.90 ± 0.77 vs 1.26 ± 0.23, P = 0.047). CONCLUSION GpCO had a higher severity of many gastrointestinal symptoms, compared to GpNO. Hospitalization rates were more than 2-fold higher in GpCO than GpNO. GpCO also had lower employment rate and working hours, when compared to GpNO.
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Affiliation(s)
- Asad Jehangir
- Department of Internal Medicine, Reading Health System, Spruce St/6th Ave, West Reading, PA 19611, United States
- Department of Gastroenterology, Temple University Hospital, Philadelphia, PA 19140, United States
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Hospital, Philadelphia, PA 19140, United States
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Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol 2017; 15:1338-1349. [PMID: 28529168 PMCID: PMC5565678 DOI: 10.1016/j.cgh.2017.05.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023]
Abstract
The use of opioid medications on both an acute and chronic basis is ubiquitous in the United States. As opioid receptors densely populate the gastrointestinal tract, symptoms and side effects can be expected in these patients. In the esophagus, dysmotility may result, manifesting with dysphagia and a syndrome indistinguishable from primary achalasia. In the stomach, a marked delay in gastric emptying may occur with postprandial nausea and early satiety. Postoperatively, particularly with abdominal surgery, opioid-induced ileus may ensue. In the colon, opioid-induced constipation is common. A unique syndrome termed narcotic bowel syndrome is characterized by chronic abdominal pain often accompanied by nausea and vomiting in the absence of other identifiable causes. With the recognition of the important role of opioids on gastrointestinal function, novel drugs have been developed that use this physiology. These medications include peripheral acting opioid agonists to treat opioid-induced constipation and combination agonist and antagonists used for diarrhea-predominant irritable bowel syndrome. This review summarizes the most recent data in these areas.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Anthony Lembo
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David A Katzka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE OF REVIEW Chronic abdominal pain is a complex medical condition. The causes of chronic abdominal pain are extremely diverse ranging from chronic pancreatitis, Crohn's disease, to chronic pain with no clear etiology. Treatment of chronic abdominal pain remains a challenge in our clinical practice. While current interventions with celiac plexus blocks and pain medications provide some relief for these patients, but these treatments are typically less efficacious and limited by various adverse effects. Opioid medications are commonly used to manage chronic pain syndromes that are refectory to other pain management interventions. The potential problems related to opioids include misuse, abuse, constipation, nausea pruritus, et al. Moreover, according to the recent centers for disease (CDC) control report, opioid abuse has reached epidemic proportions in the USA (LJ P. Centers for Disease Control and Prevention. 2016) and accounted for 28,000 deaths in 2014. Rudd et al. (MMWR Morb Mortal Wkly Rep 64(50-51):1378-82, 2016) Given this current situation, it is apparent that a careful review of clinical evidences supporting the use of opioid medications is necessary to guide our treatment approaches in the management of complex chronic abdominal pain patients. This review is set out to analyze efficacy of opioid medications for chronic abdominal pain. RECENT FINDINGS The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline, and EMbase. The search terms used included Opioid, Oxycodone, Buprenorphine, Morphine, Fentanyl, Oxymorphone, Hydromorphone, chronic abdominal pain, Crohn's disease, and pancreatitis. All studies were considered eligible for inclusion if they were clinical studies evaluating the efficacy of opioid medications for chronic abdominal pain. Two studies were found according to these criteria. Chronic abdominal pain is a challenging medical condition in our daily practice. This condition often requires opioid medications when other treatments fail. This review provided very limited clinical evidence to support long-term opioid use for chronic abdominal pain. Given recent CDC report of opioid epidemic, it is prudent to use the best medical practice with appropriate evaluation of psychological comorbidities, urine drug screening, prescription drug monitor, and opioid treatment agreements to minimize adverse side effects related to opioids. Furthermore, well-designed clinical trials are needed to evaluate the effectiveness of long-term use of opioid medications, and more clinical research on which opioid medication is more effective for chronic abdominal pain.
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Affiliation(s)
- Dajie Wang
- Jefferson Pain Center, Thomas Jefferson University Hospital, 834 Chestnut St. T150, Philadelphia, PA, 19107, USA.
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Beckers AB, Keszthelyi D, Fikree A, Vork L, Masclee A, Farmer AD, Aziz Q. Gastrointestinal disorders in joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type: A review for the gastroenterologist. Neurogastroenterol Motil 2017; 29. [PMID: 28086259 DOI: 10.1111/nmo.13013] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/23/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Joint hypermobility syndrome (JHS)/Ehlers-Danlos syndrome hypermobility type (EDS-HT) is the most common hereditary non-inflammatory disorder of connective tissue, characterized by a wide range of symptoms, mainly joint hyperextensibility and musculoskeletal symptoms. A majority of patients also experiences gastrointestinal (GI) symptoms. Furthermore, JHS/EDS-HT has specifically been shown to be highly prevalent in patients with functional GI disorders, such as functional dyspepsia and irritable bowel syndrome. PURPOSE The aim of this review was to examine the nature of GI symptoms and their underlying pathophysiology in JHS/EDS-HT. In addition, we consider the clinical implications of the diagnosis and treatment of JHS/EDS-HT for practicing clinicians in gastroenterology. Observations summarized in this review may furthermore represent the first step toward the identification of a new pathophysiological basis for a substantial subgroup of patients with functional GI disorders.
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Affiliation(s)
- A B Beckers
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - D Keszthelyi
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Fikree
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - L Vork
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Masclee
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A D Farmer
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK
| | - Q Aziz
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Drewes AM, Bouwense SAW, Campbell CM, Ceyhan GO, Delhaye M, Demir IE, Garg PK, van Goor H, Halloran C, Isaji S, Neoptolemos JP, Olesen SS, Palermo T, Pasricha PJ, Sheel A, Shimosegawa T, Szigethy E, Whitcomb DC, Yadav D. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 2017; 17:720-731. [PMID: 28734722 DOI: 10.1016/j.pan.2017.07.006] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/26/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.
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Affiliation(s)
- Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark.
| | - Stefan A W Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Myriam Delhaye
- Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Japan
| | - John P Neoptolemos
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
| | - Tonya Palermo
- Seattle Children's Hospital Research Institute, Washington School of Medicine, USA
| | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrea Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Tooru Shimosegawa
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Eva Szigethy
- Visceral Inflammation and Pain Center, Division of Gastroenterology, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
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White Paper AGA: The Impact of Mental and Psychosocial Factors on the Care of Patients With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2017; 15:986-997. [PMID: 28300693 DOI: 10.1016/j.cgh.2017.02.037] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/09/2017] [Accepted: 02/27/2017] [Indexed: 02/07/2023]
Abstract
Patients with chronic medically complex disorders like inflammatory bowel diseases (BD) often have mental health and psychosocial comorbid conditions. There is growing recognition that factors other than disease pathophysiology impact patients' health and wellbeing. Provision of care that encompasses medical care plus psychosocial, environmental and behavioral interventions to improve health has been termed "whole person care" and may result in achieving highest health value. There now are multiple methods to survey patients and stratify their psychosocial, mental health and environmental risk. Such survey methods are applicable to all types of IBD programs including those at academic medical centers, independent health systems and those based within independent community practice. Once a practice determines that a patient has psychosocial needs, a variety of resources are available for referral or co-management as outlined in this paper. Included in this white paper are examples of psychosocial care that is integrated into IBD practices plus innovative methods that provide remote patient management.
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Affiliation(s)
- Alexander C Ford
- From the Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, and the Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom (A.C.F.); the Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.E.L.); the Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia (N.J.T.); the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (N.J.T.); and Karolinska Institute, Stockholm (N.J.T.)
| | - Brian E Lacy
- From the Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, and the Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom (A.C.F.); the Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.E.L.); the Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia (N.J.T.); the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (N.J.T.); and Karolinska Institute, Stockholm (N.J.T.)
| | - Nicholas J Talley
- From the Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, and the Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, United Kingdom (A.C.F.); the Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.E.L.); the Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia (N.J.T.); the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (N.J.T.); and Karolinska Institute, Stockholm (N.J.T.)
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Abstract
BACKGROUND AND AIMS Patients with Crohn's disease (CD) are often prescribed opioids chronically to manage pain associated with their disease. However, little evidence exists to support this practice. Here, we examine newly diagnosed patients with CD with and without chronic opioid use (COU) and sought to identify predictors and consequences of COU. METHODS A nationally representative administrative health care claims that data set identified newly diagnosed patients with CD. Their data were examined during the periods 6 months before and 2 years after diagnosis. Multivariable logistic regression was used to assess predictors of COU at diagnosis. RESULTS The final study cohort consisted of 47,164 patients with CD. Of them, 3.8% were identified with new COU. Chronic opioid users were more likely women, older, and likely who had more surgeries, endoscopies, admissions, and medication usage compared with other patients. Features detected before CD diagnosis that correlated with COU after diagnosis included previous opioid use (odds ratio [OR] = 6.6), chronic pain (OR = 1.36), arthritis (OR = 1.95), and mental disorders (OR = 1.58). Interestingly, emergency department visits before CD Dx increased the risk of COU (OR = 1.11), whereas endoscopy reduced COU risk (OR = 0.88). CONCLUSIONS This study presents a nationally representative assessment of COU in newly diagnosed patients with CD. The results may be used to determine the impact of COU in this population and to alert clinicians to those patients with CD at high risk of COU. Chronic opioids are consistently associated with indicators of more severe disease; however, additional research is needed to determine whether COU drives disease severity or vice versa.
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Farmer AD, Gallagher J, Bruckner-Holt C, Aziz Q. Narcotic bowel syndrome. Lancet Gastroenterol Hepatol 2017; 2:361-368. [DOI: 10.1016/s2468-1253(16)30217-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 02/06/2023]
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Click B, Anderson AM, Binion DG. Predicting Costs of Care for Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2017; 15:393-395. [PMID: 27923719 PMCID: PMC5316305 DOI: 10.1016/j.cgh.2016.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Benjamin Click
- Division of Gastroenterology, Hepatology, and Nutrition, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alyce M. Anderson
- Division of Gastroenterology, Hepatology, and Nutrition, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David G. Binion
- Division of Gastroenterology, Hepatology, and Nutrition, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Regueiro M, Greer JB, Szigethy E. Etiology and Treatment of Pain and Psychosocial Issues in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:430-439.e4. [PMID: 27816599 DOI: 10.1053/j.gastro.2016.10.036] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/07/2016] [Accepted: 10/27/2016] [Indexed: 12/15/2022]
Abstract
There is increasing evidence that brain-gut interactions are altered during development of inflammatory bowel diseases (IBDs). Understanding the relationship between the neurobiology, psychological symptoms, and social ramifications of IBD can guide comprehensive care for the whole patient. The most common psychological conditions in patients with IBD are chronic abdominal pain, anxiety, and depression. We review the evidence-based data and rates of these conditions and their respective relationship to IBD and the diagnostic approaches to identify patients with these conditions. Different treatment options for pain and psychosocial conditions are discussed, and new models of team-based IBD care are introduced. Providing the health care provider with tools to diagnose and manage psychological conditions in patients with Crohn's disease or ulcerative colitis is necessary for their total care and should be part of quality-improvement initiatives.
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Affiliation(s)
- Miguel Regueiro
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julia B Greer
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eva Szigethy
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Chen L, Ilham SJ, Feng B. Pharmacological Approach for Managing Pain in Irritable Bowel Syndrome: A Review Article. Anesth Pain Med 2017; 7:e42747. [PMID: 28824858 PMCID: PMC5556397 DOI: 10.5812/aapm.42747] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/02/2016] [Accepted: 12/24/2016] [Indexed: 12/13/2022] Open
Abstract
Context Visceral pain is a leading symptom for patients with irritable bowel syndrome (IBS) that affects 10% - 20 % of the world population. Conventional pharmacological treatments to manage IBS-related visceral pain is unsatisfactory. Recently, medications have emerged to treat IBS patients by targeting the gastrointestinal (GI) tract and peripheral nerves to alleviate visceral pain while avoiding adverse effects on the central nervous system (CNS). Several investigational drugs for IBS also target the periphery with minimal CNS effects. Evidence of Acquisition In this paper, reputable internet databases from 1960 - 2016 were searched including Pubmed and ClinicalTrials.org, and 97 original articles analyzed. Search was performed based on the following keywords and combinations: irritable bowel syndrome, clinical trial, pain, visceral pain, narcotics, opioid, chloride channel, neuropathy, primary afferent, intestine, microbiota, gut barrier, inflammation, diarrhea, constipation, serotonin, visceral hypersensitivity, nociceptor, sensitization, hyperalgesia. Results Certain conventional pain managing drugs do not effectively improve IBS symptoms, including NSAIDs, acetaminophen, aspirin, and various narcotics. Anxiolytic and antidepressant drugs (Benzodiazepines, TCAs, SSRI and SNRI) can attenuate pain in IBS patients with relevant comorbidities. Clonidine, gabapentin and pregabalin can moderately improve IBS symptoms. Lubiprostone relieves constipation predominant IBS (IBS-C) while loperamide improves diarrhea predominant IBS (IBS-D). Alosetron, granisetron and ondansetron can generally treat pain in IBS-D patients, of which alosetron needs to be used with caution due to cardiovascular toxicity. The optimal drugs for managing pain in IBS-D and IBS-C appear to be eluxadoline and linaclotide, respectively, both of which target peripheral GI tract. Conclusions Conventional pain managing drugs are in general not suitable for treating IBS pain. Medications that target the GI tract and peripheral nerves have better therapeutic profiles by limiting adverse CNS effects.
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Affiliation(s)
- Longtu Chen
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA
| | - Sheikh J. Ilham
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA
| | - Bin Feng
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA
- Corresponding author: Bin Feng, Ph.D., Department of Biomedical Engineering, University of Connecticut, 260 Glenbrook Road, Unit 3247, Storrs, CT 06269-3247, USA. Tel: +1-8604866435, Fax: +1-8604862500, E-mail:
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Abstract
OPINION STATEMENT The use of opioids for the treatment of chronic non-cancer pain is growing at an alarming rate. Opioid-induced bowel dysfunction (OBD) is a common adverse effect of long-term opioid treatment manifesting as constipation, nausea, and vomiting. These effects are primarily mediated by peripheral μ-opioid receptors with resultant altered GI motility and function. As a result, patients may present with opioid-induced constipation (OIC), opioid-induced nausea and vomiting (OINV), and/or narcotic bowel syndrome (NBS). This often leads to decreased quality of life and in many cases, discontinuation of opioid therapy. There is limited evidence to support the use of traditional anti-emetics and laxatives in the treatment of OBD. Tapering the dose of opioids, switching to transdermal application, opioid rotation, or dual-action opioids, such as tapentadol, may be helpful in the treatment of OBD. Novel agents, such as peripherally acting μ-opioid receptor antagonists which target the cause of OIC, show promise in the treatment of OBD and should be considered when conventional laxatives fail. This chapter will review the pathophysiology of OBD, including OINV and OIC, and treatment options available.
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Thompson JS, Langenfeld SJ, Hewlett A, Chiruvella A, Crawford C, Armijo P, Oleynikov D. Surgical treatment of gastrointestinal motility disorders. Curr Probl Surg 2016; 53:503-549. [PMID: 27765162 DOI: 10.1067/j.cpsurg.2016.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE.
| | - Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Alexander Hewlett
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | - Dmitry Oleynikov
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
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Hobbs PM, Johnson WG, Graham DY. Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes. World J Gastrointest Pharmacol Ther 2016; 7:370-386. [PMID: 27602238 PMCID: PMC4986390 DOI: 10.4292/wjgpt.v7.i3.370] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
One of the most challenging issues arising in patients with chronic pancreatitis is the management of abdominal pain. Many competing theories exist to explain pancreatic pain including ductal hypertension from strictures and stones, increased interstitial pressure from glandular fibrosis, pancreatic neuritis, and ischemia. This clinical problem is superimposed on a background of reduced enzyme secretion and altered feedback mechanisms. Throughout history, investigators have used these theories to devise methods to combat chronic pancreatic pain including: Lifestyle measures, antioxidants, analgesics, administration of exogenous pancreatic enzymes, endoscopic drainage procedures, and surgical drainage and resection procedures. While the value of each modality has been debated over the years, pancreatic enzyme therapy remains a viable option. Enzyme therapy restores active enzymes to the small bowel and targets the altered feedback mechanism that lead to increased pancreatic ductal and tissue pressures, ischemia, and pain. Here, we review the mechanisms and treatments for chronic pancreatic pain with a specific focus on pancreatic enzyme replacement therapy. We also discuss different approaches to overcoming a lack of clinical response update ideas for studies needed to improve the clinical use of pancreatic enzymes to ameliorate pancreatic pain.
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Olesen AE, Farmer AD, Olesen SS, Aziz Q, Drewes AM. Management of chronic visceral pain. Pain Manag 2016; 6:469-86. [PMID: 27256577 DOI: 10.2217/pmt-2015-0011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite marked differences in underlying pathophysiology, the current management of visceral pain largely follows the guidelines derived from the somatic pain literature. The effective management of patients with chronic visceral pain should be multifaceted, including both pharmacological and psychological interventions, thereby providing a mechanism-orientated approach to treatment. Patients can frequently become disenfranchised, and subsequently disengaged, with healthcare providers leading to repeated consultations. Thus, a key aspect of management is to break this cycle by validating patients' symptoms, adopting an empathic approach and taking time to educate patients. To optimize treatment and outcomes in chronic visceral pain we need to move away from approaches exclusively based on dealing with peripheral nociceptive input toward more holistic strategies, taking into account alterations in central pain processing.
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Affiliation(s)
- Anne E Olesen
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design & Pharmacology, Faculty of Health & Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Adam D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,University Hospitals of North Midlands, Stoke on Trent, UK
| | - Søren S Olesen
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Qasim Aziz
- University Hospitals of North Midlands, Stoke on Trent, UK
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Drewes AM, Munkholm P, Simrén M, Breivik H, Kongsgaard UE, Hatlebakk JG, Agreus L, Friedrichsen M, Christrup LL. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group. Scand J Pain 2016; 11:111-122. [DOI: 10.1016/j.sjpain.2015.12.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/12/2015] [Indexed: 02/07/2023]
Abstract
Abstract
Background and aims
Opioid-induced bowel dysfunction (OIBD) is an increasing problem due to the common use of opioids for pain worldwide. It manifests with different symptoms, such as dry mouth, gastro-oesophageal reflux, vomiting, bloating, abdominal pain, anorexia, hard stools, constipation and incomplete evacuation. Opioid-induced constipation (OIC) is one of its many symptoms and probably the most prevalent. The current review describes the pathophysiology, clinical implications and treatment of OIBD.
Methods
The Nordic Working Group was formed to provide input for Scandinavian specialists in multiple, relevant areas. Seven main topics with associated statements were defined. The working plan provided a structured format for systematic reviews and included instructions on how to evaluate the level of evidence according to the GRADE guidelines. The quality of evidence supporting the different statements was rated as high, moderate or low. At a second meeting, the group discussed and voted on each section with recommendations (weak and strong) for the statements.
Results
The literature review supported the fact that opioid receptors are expressed throughout the gastrointestinal tract. When blocked by exogenous opioids, there are changes in motility, secretion and absorption of fluids, and sphincter function that are reflected in clinical symptoms. The group supported a recent consensus statement for OIC, which takes into account the change in bowel habits for at least one week rather than focusing on the frequency of bowel movements. Many patients with pain receive opioid therapy and concomitant constipation is associated with increased morbidity and utilization of healthcare resources. Opioid treatment for acute postoperative pain will prolong the postoperative ileus and should also be considered in this context. There are no available tools to assess OIBD, but many rating scales have been developed to assess constipation, and a few specifically address OIC. A clinical treatment strategy for OIBD/OIC was proposed and presented in a flowchart. First-line treatment of OIC is conventional laxatives, lifestyle changes, tapering the opioid dosage and alternative analgesics. Whilst opioid rotation may also improve symptoms, these remain unalleviated in a substantial proportion of patients. Should conventional treatment fail, mechanism-based treatment with opioid antagonists should be considered, and they show advantages over laxatives. It should not be overlooked that many reasons for constipation other than OIBD exist, which should be taken into consideration in the individual patient.
Conclusion and implications
It is the belief of this Nordic Working Group that increased awareness of adverse effects and OIBD, particularly OIC, will lead to better pain treatment in patients on opioid therapy. Subsequently, optimised therapy will improve quality of life and, from a socio-economic perspective, may also reduce costs associated with hospitalisation, sick leave and early retirement in these patients.
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Affiliation(s)
- Asbjørn M. Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Hobrovej Denmark
| | - Pia Munkholm
- NOH (Nordsjællands Hospital) Gastroenterology , Hillerød Denmark
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition , Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Göteborg Sweden
| | - Harald Breivik
- Department of Pain Management and Research , Oslo University Hospital and University of Oslo , Rikshospitalet Norway
| | - Ulf E. Kongsgaard
- Department of Anaesthesiology, Division of Emergencies and Critical Care , Oslo University Hospital, Norway and Medical Faculty, University of Oslo , Rikshospitalet Norway
| | - Jan G. Hatlebakk
- Department of Clinical Medicine , Haukeland University Hospital , Bergen , Norway
| | - Lars Agreus
- Division of Family Medicine , Karolinska Institute , Stockholm , Sweden
| | - Maria Friedrichsen
- Department of Social and Welfare Studies , Faculty of Medicine and Health Sciences , Norrköping , Sweden
| | - Lona L. Christrup
- Department of Drug Design and Pharmacology , Faculty of Health Sciences, University of Copenhagen , københavn Denmark
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Anderson MA, Akshintala V, Albers KM, Amann ST, Belfer I, Brand R, Chari S, Cote G, Davis BM, Frulloni L, Gelrud A, Guda N, Humar A, Liddle RA, Slivka A, Gupta RS, Szigethy E, Talluri J, Wassef W, Wilcox CM, Windsor J, Yadav D, Whitcomb DC. Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group. Pancreatology 2016; 16:83-94. [PMID: 26620965 PMCID: PMC4761301 DOI: 10.1016/j.pan.2015.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.
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Affiliation(s)
| | | | - Kathryn M Albers
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Chari
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg Cote
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Brian M Davis
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nalini Guda
- Department of Gastroenterology, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jyothsna Talluri
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wahid Wassef
- Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA.
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