Narcotics Inappropriately Prescribed for Patients With IBD

[David in Seattle]

Digestive Disease Week (DDW) 2010: Abstract W1378. Presented May 5, 2010.

Although inflammatory bowel disease (IBD) can be extremely painful, narcotics are inadvisable for this condition. Even so, a sizeable proportion of patients are inappropriately prescribed these drugs, according to one of the first surveys to quantify narcotic use among patients with IBD, presented here at Digestive Disease Week 2010.

"Narcotics use is exceedingly common in patients with IBD. Why should we worry? We should worry for a lot of reasons: first, these drugs do not help noncancer patients' bowel function; second, they carry a risk of drug dependency; and third, they may actually worsen symptoms of IBD," stated Spencer D. Dorn, MD, assistant professor of medicine at the University of North Carolina in Chapel Hill.

He described a newly identified condition called narcotic bowel syndrome, in which narcotics paradoxically increase abdominal pain, particularly at higher doses.

An Internet-based survey was sent to nearly 1800 patients who had seen a physician for irritable bowel syndrome (IBS) as defined by Rome III criteria. The researchers examined demographics, clinical characteristics, clinical features (including subtype, duration, and severity), most troublesome symptom, quality of life, psychological factors (such as anxiety and depression), overall satisfaction with care, and current medications.

In all, 325 adult patients (18%) reported current use of narcotics (excluding tincture of opiate, prescribed as an antidiarrheal medication).

Dr. Dorn said that patients who used narcotics had more severe IBS and worse physical and mental health than those who did not. Significant predictors of narcotic use included poor self-rated health (P < .0001), pain as the most bothersome symptom (P < .0001), number of bothersome symptoms (P = .008), number of hospitalizations (P < .01), number of lifetime surgeries (P < .0001), current antidepressant use (P = .01), current anxiolytic use (P < .02), and current antiacid use (P = .01).

Dr. Dorn and colleagues recommend a multidisciplinary approach to the management of IBS, which emphasizes patient education, self-management over time, nonnarcotic symptom-based therapies and, in some cases, antidepressants and/or psychotherapy.

Such an approach is challenging in the current healthcare environment, he acknowledged. "Clinicians often lack the time, infrastructure, and incentives needed to provide this type of care to patients with IBD and other chronic conditions. Instead, they often take the path of least resistance. Narcotic prescriptions are a quick and easy way to get patients out of their offices, even though the long-term effects can be harmful."

Dr. Dorn told meeting attendees that this study did not quantify recreational narcotic use — only narcotic prescriptions. He also pointed out that although the United States comprises only 4% of the world's population, our country accounts for more than 80% of narcotics prescribed worldwide.

Commenting on this presentation, moderator Deborah Proctor, MD, professor of medicine and medical director of the IBD Program at Yale University in New Haven, Connecticut, said that "gastroenterologists and other doctors who treat patients with IBD should rethink prescribing narcotics. Instead, they should first try [nonsteroidal anti-inflammatory drugs], and muscle relaxants if the pain continues."

 

[GNC Crohn's Man]

Commenting on this presentation, moderator Deborah Proctor, MD, professor of medicine and medical director of the IBD Program at Yale University in New Haven, Connecticut, said that "gastroenterologists and other doctors who treat patients with IBD should rethink prescribing narcotics. Instead, they should first try [nonsteroidal anti-inflammatory drugs], and muscle relaxants if the pain continues."

I agree with everything in this article except for that last passage. Every NSAID I have ever heard about (barring Mesalamine) are very very bad for patients with Crohn's. UC I'm not 100% sure on. A good allegory would be to think of the the Narcotics as a Rabid Grizzly bear. Now think of the NSAIDs as rabid mountain lion. The grizzly bear will viciously maul and eat you. The mountain lion will have more trouble than the grizzly bear, but It will still VICIOUSLY MAUL AND EAT YOU!! Taking large doses of NSAIDs WILL cause serious gastrointestinal problems for someone with Crohn's Disease.

Moving on. Tylenol is not a NSAID. Taking large amounts of it just kills your liver. Mesalamine is a NSAID, but it is not for pain. It used for treatment of UC and Crohn's. http://www.medicinenet.com/mesalamine/article.htm

 

[David in Seattle]

I agree with everything in this article except for that last passage. Every NSAID

I was surprised about the NSAID thing, too. Technically the 5 ASA's are NSAIDS, being salicylates, but they really act more locally, topically, even, in IBD, and aren't generally thought of in the same way, so I'm going to assume they are referring to systemic oral drugs like Naproxen, Ibuprofen, and COX-2 inhibitors. I also think the use of so called "muscle relaxants" (like cyclobenzaprine) is questionable. Again, dicyclomine (Bentyl) could be thought of as a "muscle relaxant", but it's really more of an antispasmodic. It's almost like they got confused over terminology. Odd.

 

[GNC Crohn's Man]

The reporter probably misquoted her. Either that or she doesn't know what she is talking about.

Professor of medicine and medical director of the IBD Program at Yale University

I hope she knows what she's talking about if she is the IBD program director for an Ivy League school.

 

[Rebecca85]

How do they know that the narcotics cause the more severe symptoms? Surely it makes more sense that people with more severe symptoms are more likely to be prescribed narcotics??? In fact if you read the study carefully it says that pain predicted narcotic use (as you would expect). Surely if the pain was due to narcotic misuse it would be narcotic use predicting pain! And as for the nsaids, i am new to this crohn's business and even I know to avoid them especially in a flare!

Rebecca.

 

[David in Seattle]

How do they know that the narcotics cause the more severe symptoms? Surely it makes more sense that people with more severe symptoms are more likely to be prescribed narcotics???

Wondered that myself, Rebecca.

 

[D Bergy]

Dr. Dorn told meeting attendees that this study did not quantify recreational narcotic use — only narcotic prescriptions. He also pointed out that although the United States comprises only 4% of the world's population, our country accounts for more than 80% of narcotics prescribed worldwide.

Hey, that makes us number one in narcotic consumption. Who says the US is not a leader in anything nowadays? And who got my share of the narcotics?

Dan

 

[David in Seattle]

Hey, that makes us number one in narcotic consumption. Who says the US is not a leader in anything nowadays? And who got my share of the narcotics?

Dan

:ylol2: :ylol2: :ylol2:

 

[saidinstouch]

Hey, that makes us number one in narcotic consumption. Who says the US is not a leader in anything nowadays? And who got my share of the narcotics?

Dan

I think I did since September with the hell my stomach has put me through

 

[Lisa]

Intersesting......also, I've never been prescribed narcotic painkillers for my Crohns'.....even while in the hospital...or with my fistulas.......I guess my Dr's just let me suffer.....hmmmm.......

 

[semicolon306]

I think this depends on the person and how they deal with pain. Currently I am taken Dilaudid PRN 4mg with my crohns. I have found that this is the only thing that works for me. In fact with a partial obstruction I take this immediately and it tends to help. All my 15 doctors are unsure why it works, since with most people it can cause slowing of the bowels and constipation. I also have a very rear condition with crohns and a fistula that has connected to my spine and made friends with it.

I think all medications have their place, you just have to use them when needed and not abuse them. Let me tell you honestly I get nauseous on the medication, but it is the only thing to relieve the pain. I have been under care of over 20 years, just now it started to get worse. Soon to be removed, so hoping that helps with the pain.

I sort of think some of these studies do not take into account we are all different and you need to take it case by case, same as diets.

 

[Lisa]

I am one of those who has a high tolerance for pain....probably because of dealing with the Crohns'.....you forget what it feels like to NOT be in pain after a while!.......

Unfortunately I can't take dilaudid.......somewhat allergic to it! At least I found out while in the hospital once lol....that whole feeling fluid in your lungs and breaking out in hives is NOT FUN!

I have to be literally on the floor curled up in pain to go to the ER.....lol....then again, I worked in EMS and we are some of the worst when it comes to getting rtreatment! hehe.....

 

[semicolon306]

Same here, work in EMS. Only good thing is knowing the nurses to get in quicker, LOL.

On the bad hand, knowing what is going to happen, LOL

 

[Lydia]

I am allergic to codeine and my GI will not prescibe anything stronger for fear of dependancy. It sucks because sometimes I am in a lot of pain. Not lately though.

 

[David in Seattle]

I am allergic to codeine and my GI will not prescibe anything stronger for fear of dependancy. It sucks because sometimes I am in a lot of pain. Not lately though.

You can become as addicted to codeine as any other opioid if you take enough of it. Codeine is demethylated to morphine in the liver, so it's just as potentially addicting as the more potent morphine.

You might ask your doctor about Tramadol, a mixed agonist/antagonist opioid which has similar strength to codeine. Again, you can also get addicted to Tramadol, but a lot of doctors feel a little more at ease prescribing it, mostly the result of advertising. I would not imagine there'd be any cross-allergic reaction, since it isn't chemically similar to the natural opiates, codeine and morphine. Actually, given the benefit some get from naltrexone (a much more potent full opioid antagonist), Tramadol might be especially appropriate to IBD pain. An interesting possibility. I have taken Tramadol, as well as codeine for my condition, with only the slightest relief, but I'm still not clearly diagnosed with IBD.

Another possible opioid of moderate strenght for you given your allergy might be Demerol (meperidine), also not chemically related to the natural opiates.

 

[CrohnsHobo]

I was taking Percocet regularly for about six months. About the only way I made it through the last half of last year.

 

[juggys69]

Digestive Disease Week (DDW) 2010: Abstract W1378. Presented May 5, 2010.

Although inflammatory bowel disease (IBD) can be extremely painful, narcotics are inadvisable for this condition. Even so, a sizeable proportion of patients are inappropriately prescribed these drugs, according to one of the first surveys to quantify narcotic use among patients with IBD, presented here at Digestive Disease Week 2010.

"Narcotics use is exceedingly common in patients with IBD. Why should we worry? We should worry for a lot of reasons: first, these drugs do not help noncancer patients' bowel function; second, they carry a risk of drug dependency; and third, they may actually worsen symptoms of IBD," stated Spencer D. Dorn, MD, assistant professor of medicine at the University of North Carolina in Chapel Hill.

He described a newly identified condition called narcotic bowel syndrome, in which narcotics paradoxically increase abdominal pain, particularly at higher doses.

An Internet-based survey was sent to nearly 1800 patients who had seen a physician for irritable bowel syndrome (IBS) as defined by Rome III criteria. The researchers examined demographics, clinical characteristics, clinical features (including subtype, duration, and severity), most troublesome symptom, quality of life, psychological factors (such as anxiety and depression), overall satisfaction with care, and current medications.

In all, 325 adult patients (18%) reported current use of narcotics (excluding tincture of opiate, prescribed as an antidiarrheal medication).

Dr. Dorn said that patients who used narcotics had more severe IBS and worse physical and mental health than those who did not. Significant predictors of narcotic use included poor self-rated health (P < .0001), pain as the most bothersome symptom (P < .0001), number of bothersome symptoms (P = .008), number of hospitalizations (P < .01), number of lifetime surgeries (P < .0001), current antidepressant use (P = .01), current anxiolytic use (P < .02), and current antiacid use (P = .01).

Dr. Dorn and colleagues recommend a multidisciplinary approach to the management of IBS, which emphasizes patient education, self-management over time, nonnarcotic symptom-based therapies and, in some cases, antidepressants and/or psychotherapy.

Such an approach is challenging in the current healthcare environment, he acknowledged. "Clinicians often lack the time, infrastructure, and incentives needed to provide this type of care to patients with IBD and other chronic conditions. Instead, they often take the path of least resistance. Narcotic prescriptions are a quick and easy way to get patients out of their offices, even though the long-term effects can be harmful."

Dr. Dorn told meeting attendees that this study did not quantify recreational narcotic use — only narcotic prescriptions. He also pointed out that although the United States comprises only 4% of the world's population, our country accounts for more than 80% of narcotics prescribed worldwide.

Commenting on this presentation, moderator Deborah Proctor, MD, professor of medicine and medical director of the IBD Program at Yale University in New Haven, Connecticut, said that "gastroenterologists and other doctors who treat patients with IBD should rethink prescribing narcotics. Instead, they should first try [nonsteroidal anti-inflammatory drugs], and muscle relaxants if the pain continues."

Yeah...... Let me tell you something, if you're a doctor, its people like you that have turned my life into a living hell.....

About seven years ago, I got put out of work because of chronic sciatica, nothing to do with whats here right ? Maybe, but probably wrong. Just a little later I got an infection ( I was prescribed vic's for the previous issue, never took them, never even filled it ) epididymitis, which I was given vics again, this time I did take them, as well as the antibiotics. I also had had "stomach" issues for years, which I had always just waved off. These, for whatever reason also came much more to the for front when I got first laid up, with a "back" issue.

As it turns out, the vic's were my salvation when confronted with all three issues. Now, later, I got an infection again, ER checked me out, had me come back in after the antibiotic treatment was done. Turns out I have chronic prostatitis as well, and this is what causes me to get these infections so frequently now. I have the "unknown" cause kind, its not viral, its been seven years now and no steroids or antibiotic treatment has worked.

Through the course of this, I lost my coverage, I was never big on going to doctors before these issues anyways. I can count on my fingers the time I had since I was 18 until this all started when I was 37. I have had stomach issues since my teens, I just always waved them off.

Well, I am now waiting for disability and on was on GPA, which wouldn't cover my getting tested for Crohns or IBS ( or really anything besides a primary and scripts for that matter, as I would later find out ) which is what my primary doctor is 99& sure I have a severe case of one of them. She snuck me on some of the steroid and other treatments to see if they would help, no joy. The only thing that gave me any relief was the vic's. So we worked out a schedule with them that worked for me, which on paper is 8 a day. In reality, some days I took very little, on bad days I could take up to 12 though. In comes the FDA and PROP people like you, which cut what I could take in a month by a third.

My primary then wrote my scipt as must last 30 days and was going to send me to a pain clinic so I could get the amount I was already taking. Me, thinking I was smart went and looked up stuff online, and saw she could write me three scripts in 90 days time, so I ignored her and took them as normal, figuring I would be in a pain clinic soon enough.

Turns out GPA didn't cover that either. This got me in hot water with my primary for not listening, and added a danger of addiction note to my medical records......... She had offered to send me to a pain clinic in the past to get on Schedule two, also mentioned MJ was becoming legal as an option...... I turned down both, this was before the R.I. laws changed, does that sound like an addict or someone wanting to get high ? I turned down an offer to get on oxy.............

During this, over a year ago, GPA was phased out, so I couldn't get back on that, but my Obamacare app kept hanging up in the works............ No doctor at all................. No meds, no nothing, even though because I utsmarted" myself, I wasn't on vics anymore..........

Wound up in the hospital for kidney stones ( this just to top my hell off I guess, although I knew they were and are still coming as I had already been told my kidneys were calcified years earlier, just took awhile and I think I have passed a couple before, just not this severe/size ). There a navigator did what my case worker and myself had failed to do all these months, actually get my med app through. They had kept "losing" my paper work before this. This time she faxed it in, and verified with one of them they received it. Even with this, they "lost" it again, but this time she was there to raise holy hell over it since she had verified it with them and she is a navigator that works for Kent, but not them.


Now, for the past year + my life has been a living hell, I would literally rather die than know I have to face life with this pain forever. My coverage this time does cover specialists, so I will hopefully finally know what my stomach/abdomen issues are. My other two issues are for life though. I have changed primary's because I lost my transportation, so with my old ones notation, that won't look good I assume.

Now, listen to me, I don't want to be on schedule two drugs, still, to this day. I don't want to be "doped" up. I don't want to be on MJ, even though its legal, I don't want to be high, I just want the pain gone, or more accurately, a sense of relief from it. Vic's at my old dosage do all of that. But because of people like you I am fearful this still won't happen. My God, we put dogs to sleep when in misery, why can't we with us as well if you wish to offer no relief, just suffering ? Its people like you that have turned my life into a living hell. Just realise this please when you wake up and look in a mirror. I am not an addict, I can't even imagine being "high" on vic's, they make me drowsy sometimes, that is all. I can deal with being "drowsy" sometimes. I don't want to be "high" which is all the other options offer. Vic's bad side effects ? Believe it or not, they help with my passing "mud", they actually in my case regulate me instead of constipate.

Before you try to say something like, "You talk like an addict", realize this, its been over a year, I haven't had one, just a life of suffering and hell. When I was put in the hospital again, the ER gave me a one day supply, and told me to get a script from my primary. Took two weeks for that wonderful lady at Kent to get my coverage through, so yeah....... Also lost my transportation, so I am now at Coventry CCAP, since my 65 year old mother can drive me there...... And they are waiting om my records from my old primary, even though most of this is documented at Kent and R.I. hospital through the past seven years, which is how my first primary started treating me to begin with, things they have instant access to.

All of this for them to "maybe" send me to a pain clinic just to get a schedule three because of people like you, and I fear even that not happening since CCAP are PROP supporters.

Realize this, people like you with your views are literally putting at least hundreds of us through endless and pointless misery because of your views. I hope you feel proud of yourself when you look in the mirror every morning.

Just put people like me out of our misery if you can't see the truth, thats all we ask, a painless way out rather then you condemn us to living hell, is that really to much ? Since the other option which is just doing something about our pain seems so wrong to you. You don't have our pain, walk a mile, more accurately a year or two in our shoes, then sing your song. I hope you feel good about yourself when you look in the mirror.......

 

[juggys69]

And yes, I realize how old this post is, but you know what ? its one of the first that come up when you google stuff, and I do feel slightly better getting that off my chest.

 

[juggys69]

I think this depends on the person and how they deal with pain. Currently I am taken Dilaudid PRN 4mg with my crohns. I have found that this is the only thing that works for me. In fact with a partial obstruction I take this immediately and it tends to help. All my 15 doctors are unsure why it works, since with most people it can cause slowing of the bowels and constipation. I also have a very rear condition with crohns and a fistula that has connected to my spine and made friends with it.

I think all medications have their place, you just have to use them when needed and not abuse them. Let me tell you honestly I get nauseous on the medication, but it is the only thing to relieve the pain. I have been under care of over 20 years, just now it started to get worse. Soon to be removed, so hoping that helps with the pain.

I sort of think some of these studies do not take into account we are all different and you need to take it case by case, same as diets.

I hope people like you still are around, that comment about my crohns has made friends with my spine, hrmmm. Sound like anything I said ? My primary told me that my chronic prostate issues could actually be the cause of all three issues in the long run, which sounds far fetched to me.

What you said sounds nearer to the mark. Especially since as I said, I've had stomach issues since I was a teen. One of those handful of times after I was 18 that I actually went to a doctor was for that actually. They said I had massive blockages and gave me some fizzy drinks that you can buy OTC, which actually worked. They said I had "gastritise", which I took to mean they had no clue, Crohns wasn't even on the radar back then. Had multiple flare ups over the years between, but the first experience had so shamed me in my own eyes that I never went back for that again. No matter how painful it got, I just bought the OTC fizzeys, and maybe drank some to ease the pain. Passed blood in my mud a few times, got scared of the fizzys as a result and never bought them either. Just drank some two dogs, which for whatever reason pretty much did the same thing, but no blood.

This was the norm right up until I was first hospitalized with the "back" issue. I would go somewhat normally, then I would pass mud worse and worse until a day would come when it felt like I passed all my insides, and then I would feel better, and so the cycle restarted it self. I guess I should have seen a doctor back then about it again and insisted they find out what was going on while I had my coverage that I paid for and rarely used. :rosette2:oo:

 

[juggys69]

@ David, sorry I let my angst out on you, this thread came up as one of the first in google when I was looking around and it just rubbed me the wrong way. Getting much more the feeling that you're actually a patient rather than a doctor.

I still feel as I said, just I get the idea my angst may have been off target, I do apologize if thats the case. I still feel better having ranted though.