Recurrent abdominal pain and vomiting
3. What is the cornerstone of treatment for narcotic bowel syndrome?
- Establishing a therapeutic relationship
- Detoxification
- Supportive management with intravenous fluids, antiemetics, and stool-softeners
- Medical management with a short-acting narcotic, clonidine, lorazepam, and desipramine
MANAGEMENT OF NARCOTIC BOWEL SYNDROME
An effective therapeutic relationship with the patient is the cornerstone of treatment and should be established before starting detoxification.17 The physician must first learn to accept that the patient’s condition is real and must show genuine empathy as well as provide information about the pathophysiologic basis of the condition, the rationale for withholding narcotics, and the detrimental role narcotics play in the vicious circle of pain.
Detoxification involves gradually withdrawing the narcotic and substituting a nonnarcotic such as an antidepressant for pain control, as well as prescribing a drug such as a benzodiazepine or clonidine to prevent withdrawal symptoms and a laxative to prevent constipation.17,24 The physician must reassure the patient that he or she will not be abandoned in pain and that all medications will be continuously adjusted as needed to keep him or her comfortable throughout the detoxification process.17,24 The physician must continuously gauge the patient’s willingness to continue with treatment and must also be readily available to address the patient’s concerns in a timely manner.17,24 Involving family members and friends may provide additional support to the patient. Referral to a functional gastrointestinal motility program, a pain specialist, and a psychologist may also be considered.17,24 Follow-up care is essential, even after the withdrawal program has ended.17,24
BACK TO THE PATIENT
After successfully establishing a therapeutic relationship and discussing the treatment plan with our patient, we started him on the same dosage of narcotic that he had been receiving, calculated in intravenous morphine equivalents to achieve maximal comfort, and then decreased the dosage by 10% to 33% daily until he was completely off narcotics. An antidepressant and a benzodiazepine were given simultaneously with narcotic tapering. Oral clonidine (0.1–0.4 mg/day) was given after the narcotic dosage was reduced to about half, and polyethylene glycol was given as needed for constipation. The total duration of detoxification was 7 days.
The patient was referred to a psychologist for cognitive-behavioral and relaxation therapy, as well as for encouragement and support. At 6 months, he had had no recurrence of symptoms.
TAKE-HOME MESSAGE
In the United States, the number of patients taking a narcotic for nonmalignant pain is increasing, 25 and physicians should be more aware of complications such as narcotic bowel syndrome.
Narcotic bowel syndrome should be suspected in any patient with prolonged narcotic use presenting with multiple recurrent episodes of abdominal pain after other causes are ruled out.
Establishing a good therapeutic relationship with the patient is the cornerstone of successful treatment. Patients who understand their condition and are willing to be treated tend to have better outcomes.
Supportive treatment, symptom relief, and emotional support during detoxification increase compliance.
