The Relationship Between Opioid Use and Healthcare Utilization in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Legalization of Cannabis Does Not Reduce Opioid Prescribing in Patients With Inflammatory Bowel Disease: A Difference-in-Difference Analysis

INTRODUCTION

Cannabis may provide inflammatory bowel disease (IBD) patients with an alternative to opioids for pain.

METHODS

We conducted a difference-in-difference analysis using MarketScan. Changes over time in rates of opioid prescribing were compared in states with legalized cannabis to those without.

RESULTS

We identified 6,240 patients with IBD in states with legalized cannabis and 79,272 patients with IBD in states without legalized cannabis. The rate of opioid prescribing decreased over time in both groups and were not significantly different (attributed differential = 0.34, confidence interval -13.02 to 13.70, P = 0.96).

DISCUSSION

Opioid prescribing decreased from 2009 to 2016 among patients with IBD in both states with legalized and state without legalized cannabis, similar to what has been observed nationally across a variety of diseases. Cannabis legalization was not associated with a lower rate of opioid prescribing for patients with IBD.

Moxibustion ameliorates chronic inflammatory visceral pain via spinal circRNA-miRNA-mRNA networks: a central mechanism study

This study aimed to unveil the central mechanism of moxibustion treating chronic inflammatory visceral pain (CIVP) from the angle of circRNA-miRNA-mRNA networks in the spinal cord. The rat CIVP model was established using a mixture of 5% (w/v) 2,4,6-trinitrobenzene sulfonic acid and 50% ethanol at a volume ratio of 2:1 via enema. Rats in the moxibustion group received herb-partitioned moxibustion at Tianshu (ST25, bilateral) and Qihai (CV6) points. The abdominal withdrawal reflex (AWR), mechanical withdrawal threshold (MWT), and thermal withdrawal latency (TWL) were adopted for pain behavior observation and pain sensitivity assessment. The circRNA, miRNA, and mRNA expression profiles were detected using the high-throughput sequencing technique. Relevant databases and bioinformatics analysis methods were used to screen for differentially expressed (DE) RNAs and build a circRNA-miRNA-mRNA (competing endogenous RNA) ceRNA regulatory network. The real-time quantitative PCR was employed to verify the sequencing result. CIVP rat models had a significantly higher AWR and lower TWL and MWT than normal rats. Between normal and model rats, there were 103 DE-circRNAs, 16 DE-miRNAs, and 397 DE-mRNAs in the spinal cord. Compared with the model group, the moxibustion group had a lower AWR and higher TWL and MWT; between these two groups, there were 118 DE-circRNAs, 15 DE-miRNAs, and 804 DE-mRNAs in the spinal cord. Two ceRNA networks were chosen to be verified. As a result, moxibustion's analgesic effect on visceral pain in CIVP rats may be associated with regulating the circRNA_02767/rno-miR-483-3p/Gfap network in the spinal cord and improving central sensitization.

Medication use in a cohort of adults with chronic intestinal failure: A prospective cross-sectional study

BACKGROUND

Oral drug therapy may be compromised in chronic intestinal failure (IF) because of alterations in absorption and transit. Only scarce literature is available on which medication patients with chronic IF take in daily life. The aim was to describe the medication use in these patients.

METHODS

A medication history was obtained from adults with chronic IF treated in our tertiary care IF center. Degree of polypharmacy, drug classes, Biopharmaceutics Classification System classes, route of administration, and formulation of drugs were analyzed.

RESULTS

From October 2019 until December 2020, 72 patients (35 patients with short bowel syndrome [SBS] and 37 patients without SBS) were included. Polypharmacy was seen in 85.7% of patients with SBS and 75.7% of patients without SBS. The top three drug classes were proton-pump inhibitors, vitamin D or acetaminophen, and antimotility medication or laxatives/benzodiazepines. Approximately 25% of the drugs were classified as Biopharmaceutics Classification System class I drugs. In patients with SBS (78%) and patients without SBS (74.9%), most medication was taken orally, requiring gastrointestinal absorption of the active substance to be pharmacologically active. Most of these medications (77% in patients with SBS and 80.8% in patients without SBS) were formulated as a capsule or tablet, requiring disintegration and dissolution in the gastrointestinal tract before absorption can take place.

CONCLUSION

Polypharmacy was observed in most patients with chronic IF. Most medication was taken orally in formulations requiring disintegration, dissolution, and gastrointestinal absorption, which could be compromised in chronic IF.

Polysubstance use in inflammatory bowel disease is associated with increased risk of emergency department visits: a longitudinal study

Background

Polysubstance use (PSU), the simultaneous use of 2 or more substances of abuse, is common in inflammatory bowel disease (IBD). Preliminary studies suggest it may be associated with poor outcomes. This prospective study evaluated the impact of PSU on disease activity and healthcare resource utilization in IBD.

Methods

This study was conducted in a tertiary IBD center between October 29, 2015, and December 31, 2019. Participants were assessed over 2 time points (index and follow-up outpatient appointments) separated by a minimum of 6 months. Demographics, endoscopic disease activity, and surveys assessing symptoms, healthcare resource utilization and substance use (tobacco, alcohol, marijuana, cocaine, methamphetamine, heroin, opioid, or benzodiazepine) were abstracted. We identified PSU during the index appointment and computed descriptive statistics and contingency table analyses, and multivariate logistic regression models at follow up to evaluate outcomes.

Results

162 consecutively enrolled IBD patients were included. Seventy-five patients (46%) were polysubstance users at the index appointment. The most common cohorts were utilizing tobacco and alcohol (n=40) or tobacco and opioids (n=13). On bivariate and multivariate analyses, PSU during the index visit was positively associated with emergency department (ED) visits (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.24-5.07; P=0.01) and negatively associated with extraintestinal manifestations (OR 0.37, 95%CI 0.18-0.74; P=0.005). Age, sex, disease activity, disease subtype and IBD-related symptoms were not associated with PSU.

Conclusions

IBD patients exhibiting PSU had increased risk of future ED visits. This study highlights the risks of PSU and reinforces the importance of appropriate substance use screening.

Risk of Attempted Suicide Among Patients With IBD: A Nationwide Longitudinal Follow-up Study

BACKGROUND

Evidence suggests that IBD is related to an increased risk of depressive disorder and suicide.

OBJECTIVES

Whether IBD is an independent risk factor for suicide remains unclear.

DESIGN

A matched cohort study design.

SETTINGS

Taiwan National Health Insurance Research Database.

PATIENTS

A total of 3625 adults with IBD aged ≥20 years and 36,250 matched controls were selected between 1997 and 2013 and followed-up to the end of 2013.

MAIN OUTCOME MEASURES

Any suicide attempt was identified during the study period. Stratified Cox regression analysis was conducted on each matched pair to investigate the attempted suicide risk between the IBD and control groups.

RESULTS

The hazard ratio for any suicide attempt among the patients with IBD was 4.61 (95% CI, 3.29-6.48) compared with controls matched exactly for depressive disorder. No significant difference in suicide attempts was noted between patients with ulcerative colitis (HR, 4.12; 95% CI, 2.69-6.32) and patients with Crohn's disease (HR, 5.78; 95% CI, 3.27-10.22).

LIMITATIONS

The incidence of any suicide attempt may be underestimated.

CONCLUSION

IBD was an independent risk factor for attempted suicide. However, further studies are required to elucidate the definite pathomechanisms between IBD and suicide.

RIESGO DE INTENTO DE SUICIDIO ENTRE PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL UN ESTUDIO DE SEGUIMIENTO LONGITUDINAL A NIVEL NACIONAL

ANTECEDENTES: La evidencia sugiere que la enfermedad inflamatoria intestinal (EII) está relacionada con un mayor riesgo de trastornos depresivos y de suicidios.OBJETIVOS: Sin embargo, aún no está claro si la EII es un factor de riesgo independiente para llegar al suicidio.DISEÑO: Estudio de cohortes de tipo pareado.AJUSTES: Investigación en la base de datos del seguro nacional de salud de Taiwán.PACIENTES: Se seleccionaron un total de 3.625 adultos con EII de ≥20 años y 36.250 controes emparejados entre 1997 y 2013, se les dio un seguimiento hasta finales de 2013.PRINCIPALES MEDIDAS DE RESULTADO: Se identificó cualquier intento de suicidio durante el período del estudio. Se realizó un análisis de regresión de Cox estratificado en cada dupla apareada dentro la investigación del riesgo de intento de suicidio comparado entre los grupos de EII y el grupo control.RESULTADOS: El cociente de riesgo instantáneo (HR) para cualquier intento de suicidio entre los pacientes con EII fue de 4,61 (el intervalo de confianza [IC] del 95 %: 3,29-6,48) en comparación con los controles apareados exactamente en casos de trastorno depresivo. No se observaron diferencias significativas en los intentos de suicidio entre los pacientes con colitis ulcerosa (HR: 4,12, IC 95 %: 2,69-6,32) y enfermedad de Crohn (HR: 5,78, IC 95 %: 3,27-10,22).LIMITACIONES: La incidencia de cualquier intento de suicidio puede estar subestimada.CONCLUSIÓN: La EII fué un factor de riesgo independiente para el intento de suicidio. Sin embargo, se requieren más estudios para dilucidar los mecanismos patogénicos definitivos entre la EII y el suicidio. (Traducción-Dr. Xavier Delgadillo ).

Opioid use and associated factors in 1676 patients with inflammatory bowel disease: a multicentre quality improvement project

Objective

Despite its association with poorer outcomes, opioid use in inflammatory bowel disease (IBD) is not well characterised in the UK. We aimed to examine the extent of opioid use, the associated factors and the use of mitigation techniques such as pain-service review and opioid weaning plans among individuals with IBD.

Methods

Data were collected from consecutive patients attending IBD outpatient appointments at 12 UK hospitals. A predefined questionnaire was used to collect data including patient demographics, IBD history, opioid use in the past year (>2 weeks) and opioid-use mitigation techniques. Additionally, consecutive IBD-related hospital stays leading up to July 2019 were reviewed with data collected regarding opioid use at admission, discharge and follow-up as well as details of the admission indication.

Results

In 1352 outpatients, 12% had used opioids within the past 12 months. Over half of these individuals were taking opioids for non-IBD pain and less than half had undergone an attempted opioid wean.In 324 hospitalised patients, 27% were prescribed opioids at discharge from hospital. At 12 months postdischarge, 11% were using opioids. Factors associated with opioid use in both cohorts included female sex, Crohn's disease and previous surgery.

Conclusions

1 in 10 patients with IBD attending outpatient appointments were opioid exposed in the past year while a quarter of inpatients were discharged with opioids, and 11% continued to use opioids 12 months after discharge. IBD services should aim to identify patients exposed to opioids, reduce exposure where possible and facilitate access to alternative pain management approaches.

Intraoperative Low-Dose S-Ketamine Reduces Depressive Symptoms in Patients with Crohn's Disease Undergoing Bowel Resection: A Randomized Controlled Trial

Background: Patients with Crohn's disease (CD) undergoing bowel resection often suffer from depression and acute pain, which severely impairs their recovery. We aimed to investigate the effects of S-ketamine preconditioning on postoperative depression in patients with CD undergoing a bowel resection with mild to moderate depression and to observe whether it can relieve postoperative pain and anti-inflammation. Methods: A total of 124 adult patients were randomized into one of the two groups. Patients in the S-ketamine group received a 0.25 mg/kg S-ketamine intravenous drip under general anesthesia induction, followed by a continuous infusion of S-ketamine with 0.12 mg/kg/h for more than 30 min through target-controlled infusion. Patients in the placebo group received 0.9% saline at an identical volume and rate. The primary outcome measure was the 17-item Hamilton depression Scale (HAMD-17). The secondary outcomes were scores on the following questionnaires: a nine-item patient health questionnaire (PHQ-9); a quality of recovery (QoR-15) form; and a numeric rating scale (NRS). Additional secondary outcomes included the levels of C-reactive protein (CRP) and interleukin 6 (IL-6) on postoperative days (PODs) 1, 3, and 5, the length of hospital stay, and opioid use throughout the hospital stay. Results: The scores of PHQ-9 and HAMD-17 in the S-ketamine group were lower than those in the placebo group on postoperative days (PODs) 1, 2, and 7 (p < 0.05). The scores of QoR-15 in the S-ketamine group were higher than those in the placebo group on postoperative days (PODs) 3 and 5 (p < 0.05). The NRS scores of PACU, postoperative days 1 and 2 in the S-ketamine group were lower than those in the placebo group (p < 0.05). There was no significant difference in the CRP and IL-6 levels on postoperative days (PODs) 1, 3, and 5, postoperative complications, and hospital stay between the two groups (p > 0.05). Conclusions: The trial indicated that the intraoperative administration of low-dose S-ketamine could alleviate mild-to-moderate depressive symptoms and postoperative pain in patients with Crohn's disease undergoing bowel resection without worsening their safety.