From the AGA Journals

Opioids linked to mortality in IBD

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Does opioid use in IBD result in increased mortality? 

Balancing control of pain and prevention of opioid-related morbidity and mortality remains a major challenge for health care providers, particularly in IBD. This study by Burr et al. highlights the potential dangers of opiate use among patients with IBD with the finding that opioid prescriptions at least three times per year were associated with a two- to threefold increase in mortality. Another important observation from this study was that the prevalence of opioid use among IBD patients increased from 10% to 30% during 1990-2013. One would like to believe that, with better treatment modalities for IBD, fewer patients would require chronic opioid medications over time; however, this observation suggests that there has been a shift in the perception and acceptance of opioids for IBD patients.

Studying opioid use among IBD patients remains challenging as even well-controlled retrospective studies are unable to fully separate whether opioid use is merely associated with more aggressive IBD courses and hence worse outcomes, or whether opioid use directly results in increased mortality. As clinicians, we are left with the difficult balance of addressing true symptoms of pain with the potential harm from opioids; we often counsel against the use of nonsteroidal anti-inflammatory medications in IBD, and yet there is growing concern about use of opioids in this same population. Further research is needed to address patients with pain not directly tied to inflammation or complications of IBD, as well as nonmedical, behavioral approaches to pain management.

Dr. Jason K. Hou

Jason K. Hou, MD, MS, is an investigator in the clinical epidemiology and outcomes program, Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center, Houston; assistant professor, department of medicine, section of gastroenterology & hepatology, Baylor College of Medicine, Houston; and codirector of Inflammatory Bowel Disease Center at the VA Medical Center at Baylor. He has no conflicts of interest.



Among patients with inflammatory bowel disease (IBD), opioid prescriptions tripled during a recent 20-year period, and heavy use of strong opioids was a significant predictor of all-cause mortality, according to a large cohort study reported in the April issue of Clinical Gastroenterology and Hepatology.

Because this study was retrospective, it could not establish causality, said Nicholas E. Burr, MD, of the University of Leeds (England) and his associates. But “[de]signing and conducting a large-scale randomized controlled trial may not be feasible,” they wrote. “Despite the limitations of observational data, population data sets may be the best method to investigate a potential effect.”

A woman holds opioid pills. Liderina/Thinkstock

The gastrointestinal side effects of many analgesics complicate pain management for patients with IBD, who not only live with chronic abdominal pain but also can develop arthropathy-related musculoskeletal pain, chronic widespread pain, and fibromyalgia. In addition to the risk of narcotic bowel associated with opioid use in IBD, opioids can mask flares in IBD or can cause toxic dilatation if administered during acute flares, the researchers noted. Because few studies had examined opioid use in IBD, the investigators retrospectively studied 3,517 individuals with Crohn’s disease and 5,349 patients with ulcerative colitis from ResearchOne, a primary care electronic health records database that covers about 10% of patients in England. The data set excluded patients with indeterminate colitis or who underwent colectomy for ulcerative colitis.

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