Chronic Opioid Use Is Associated With Early Biologic Discontinuation in Inflammatory Bowel Disease

Christian Rhudy; Courtney L. Perry; Michael Singleton; Jeffery Talbert; Terrence A. Barrett

Disclosures

Aliment Pharmacol Ther. 2021;53(6):704-711. 

In This Article

Background

Chronic opioid use for non-cancer-related illness has been increasingly scrutinised in recent years. While the total number of opioid prescriptions is decreasing in the United States, the average number of prescriptions per year remains at 51.4 per 100 citizens.[1] This implies that a large number of prescriptions continue to be provided for non-cancer-related conditions. This problem is not limited to the United States, as emerging literature over the past few years from Europe reports increased rates of opioid prescriptions for non-cancer-related pain.[2,3] Data suggest that chronic opioid use impairs clinical care with worse disease outcomes and increases all-cause mortality.[4]

Inflammatory bowel disease (IBD) is a chronic illness with a relapsing and remitting course. Disease flares are accompanied by symptoms such as abdominal pain, nausea/vomiting and diarrhoea. These symptoms are often severe enough to prompt emergency room visits, during which patients are likely to receive opioids as our group has shown previously.[5] This phenomenon has also been documented outside the US, as prior studies reported Canadian patients with chronic opioid use and IBD had more emergency department visits and decreased quality of life as compared to patients without chronic opioid use.[6,7] Furthermore, previous studies have found chronic opioid use in IBD is associated with worse surgical outcomes, longer hospital stays and increased mortality.[8,9] Many predictors of chronic opioid use are associated with poorer outcomes in IBD such as smoking, depression and therapeutic non-compliance.[5,10] We suspect that chronic opioid use may further interfere with productive therapy by enhancing patient behaviours that compromise effective clinical management.

In recent years, IBD therapeutic management has placed increasing emphasis on rapid escalation of therapy in response to disease biomarkers to improve outcomes.[11] Thus, clinicians are often hypervigilant in modifying therapeutic regimens in response to perceived disease flares. While 'tight control' improves disease management in the vast majority of IBD patients, we suspect that it potentiates an unintended negative impact in patients who regularly receive opioids. IBD patients receiving chronic opioids are susceptible to both IBD flares and the clinical manifestations of opioid withdrawal.[12] There is similarity between symptoms of opioid withdrawal and IBD flares including abdominal pain, nausea, diarrhoea and malaise, which falsely mimics disease recurrence and complicates disease management. In the interest of maintaining 'tight control' of IBD, we suspect that providers abandon biologic therapies and label patients with chronic opioid use as 'primary non-responders'.[13] Currently, there are no studies investigating the impact of the recent shift in IBD management to obtain 'tight control' on patients with chronic opioid use. We hypothesise that this group may have rapid therapeutic cycling, which quickly leaves patients without treatment options. This study is designed to determine if chronic opioid use is associated with early discontinuation of biologic therapies independent of disease severity.

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