Opioids and the Gastrointestinal Tract - A Case of Narcotic Bowel Syndrome and Literature Review

Abstract

The worldwide use of opiates is increasing yet there is little evidence that in long-term, non-cancer patients, they have an efficacious effect on functional outcomes and quality of life measures. Although it seems paradoxical, chronic opiate use may lead to a pro-nociceptive state. Mechanisms for the development of the hyperalgesic state include activation of the opiate bimodal regulatory systems, dynorphin and spinal cord glia. A potential consequence of chronic opiate usage is the development of narcotic bowel syndrome, which is characterized by chronic or intermittent colicky abdominal pain or discomfort that worsens after the narcotic effects of opiates wear off. It is likely that this is an under-recognized diagnosis. We describe here a case of 26-year old female who had visited our institution multiple times with intractable chronic abdominal pain in the context of normal findings on haematological, biochemical, metabolic, endoscopic and radiological investigations. She had been treated with a multitude of opioid agonists with escalating doses. A diagnosis of narcotic bowel syndrome was made. On elective admission her daily analgesic requirements were 150 µg/hr fentanyl, 100 mg oramorph and 400 mg tramadol (equating to 740 mg oral morphine/24 hr). A detoxification regimen was prescribed which included rapid opiate withdrawal couple with the commencement of methadone, lorazepam, clonidine and duloxetine. She was discharged opiate free, with no abdominal pain, 14 days after admission. Clinicians must be aware of narcotic bowel syndrome, which is often erroneously labelled as a functional gastrointestinal disorder, in patients who have been on long-term opiates.

Cardiovascular phenotyping for personalized lifestyle treatments of chronic abdominal pain in Irritable Bowel Syndrome: A randomized pilot study

“…However, the outcome of such treatments is often unpredictable or not satisfactory. Opioid medications once the primary recommended treatment for many patients with chronic pain have been found to be of limited benefit in long term, and frequently unsafe leading to addiction, mortality, and other complications including the narcotic bowel syndrome . Although not proven of general benefit across all individuals, healthy lifestyle interventions, like physical activity and yoga, have been offered as safer methods to reduce disease impact and lessen chronic pain severity with few adverse events .…”

“…chronic pain have been found to be of limited benefit in long term, and frequently unsafe leading to addiction, mortality, and other complications including the narcotic bowel syndrome. [3][4][5][6] Although not proven of general benefit across all individuals, healthy lifestyle interventions, like physical activity and yoga, have been offered as safer methods to reduce disease impact and lessen chronic pain severity with few adverse events. [7][8][9][10] While attractive, physical exercise interventions as an alternative form of pain management may only be effective in subgroups of patients.…”

Pharmacology of Opioids and their Effects on Gastrointestinal Function

“…Much as opioid-induced hyperalgesia, which goes along with an increase in pain and a change from localized to diff use pain, narcotic bowel syndrome appears to result from a maladaptive plasticity of the pain matrix such that opioids cause hyperalgesia and pain rather than analgesia. Th us, unlike opioid-induced bowel dysfunction, which results from opioid ' s eff ects on gastrointestinal motility and secretion, narcotic bowel syndrome involves maladaptive alterations in the central nervous system and must not erroneously be considered a functional gastrointestinal disorder ( 77,80 ). Narcotic bowel syndrome is estimated to occur in ~ 5 % of patients on chronic opioid medication and exhibits a high degree of comorbid psychiatric illness ( 77 ).…”

“…Narcotic bowel syndrome is estimated to occur in ~ 5 % of patients on chronic opioid medication and exhibits a high degree of comorbid psychiatric illness ( 77 ). Treatment of narcotic bowel syndrome involves early diagnosis of the condition, graded withdrawal of the opioid ( ' detoxifi cation ' ), and replacement therapy ( 80,81 ).…”

Narcotic Bowel Syndrome: Is It More Common Than Before?

“…TO THE EDITOR: We read the recent article Farmer et al1 on narcotic bowel syndrome (NBS) with great interest. The authors have comprehensively described a case of NBS along with the exciting pathophysiology.…”