Is narcotic addiction more prevalent in IBD patients?

A major clinical problem in patients with inflammatory bowel disease (IBD) is abdominal pain. Narcotics are frequently prescribed for relief of pain and control of other symptoms, such as diarrhea. It has been suggested by others1 that narcotic addiction in IBD may encompass different but related entities. These include drug abuse, defined as a pathological condition manifested by intoxication or inability to decrease drug use, persisting for at least 1 month, leading to impaired social or occupational functioning, and drug dependence, a generally more severe disorder with physiological tolerance and/or withdrawal symptoms.1 Both of these may occur in patients with IBD. Kaplan and Korelitz1 originally estimated that about 5% of patients from a large IBD private practice were drug-dependent, most commonly on oral narcotics. It was believed that frequency of drug dependence was probably higher in hospitalized patients, including as many as 30% of IBD patients referred specifically for psychiatric evaluation. Drug dependence seemed more common in Crohn's disease (CD) than ulcerative colitis (UC) and there were several hypothetical risk factors that were identified. These included: chronic pain, diarrhea, and malaise; increased exposure to narcotics and tranquilizers; and the psychological effects of a chronic illness initiated early in life. A more recent study utilizing another comparable large clinical practice experience of a single clinician that evaluated the long-term outlook of CD, diagnosed early in life, noted the death from a suicidal drug overdose (i.e., about 0.5%).2 Later studies sought to further determine the specific prevalence of narcotic use and the risk factors contributing to this risk in patients with IBD. These investigations have been very limited. An Australian study reported in 20013 noted that about 5.1% of patients with CD were prescribed narcotics on a chronic basis. Most had abdominal cramping pain that could be attributed to stricture development in the terminal ileum. In agreement with earlier studies, the patients that relied chronically on narcotics were also more likely to have a concurrent psychiatric disorder. In a recent American study, Cross et al4 retrospectively analyzed 291 patients with CD seen over a 5-year period in a tertiary care setting. Narcotic use was defined in 13.1%. Narcotic users were more likely to be females, with higher rates of disability and a longer duration of disease. In addition, narcotic users were more likely to consume other medications and had a higher prevalence of neuropsychiatric drug use. Using the Harvey–Bradshaw index, narcotic users had higher measurements of disease activity. In addition, their quality of life was estimated to be substantially diminished. Using multivariate analysis, active disease, polypharmacy use of more than 5 drugs, and smoking were associated with chronic narcotic use. Additional studies seem warranted. Patients with IBD, particularly CD, who require chronic and ongoing use of narcotics may reflect a specific subgroup that are more difficult to manage. It has been suggested that these patients be thoroughly evaluated to identify any untreated active disease, including exclusion of intermittent small bowel obstruction from subtle strictures.4 Smoking cessation should be encouraged so that disease activity might be reduced. An evaluation of all medications being used, including over-the-counter preparations, should be done with the objective of withdrawal of any that might not be essential to management. Finally, there should be a high index of suspicion for an associated psychiatric disorder and/or drug-seeking behavior. It has also been recommended that a pain management specialist be consulted4 with only a single physician providing narcotic prescriptions.1 A cautious approach has been advised in prolonged use of high-dose opioids in CD.5 Future research should focus on investigating the mechanisms of chronic pain syndromes in patients with IBD.

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