Photo Credit: Jacob Wackerhausen

Gil Melmed, MD, shares how a proactive pain management protocol curbed opioid prescriptions and utilization among hospitalized patients with IBD.

Patients with inflammatory bowel disease (IBD) who are admitted to the hospital often have unique pain management needs, as opioids can exacerbate possible bowel obstructions. In a study published in Scientific Reports, gastroenterologist Gil Melmed, MD, and colleagues found that a proactive pain protocol helped curb opioid prescribing and utilization in patients with IBD.

Dr. Melmed spoke with Physician’s Weekly (PW) about the challenges of managing pain in this patient population and his study.

PW: What are the prevalence and challenges of managing pain in hospitalized patients with IBD?

Dr. Melmed: Pain is a common feature of Crohn’s disease and is included in all the Crohn’s disease activity assessment scales. Patients with IBD likely represent the population within gastroenterology that is most in need of pain management, especially when admitted to the hospital. Patients are often admitted due to symptoms of a bowel obstruction or disease flare, which are characterized by significant abdominal pain.

What are common complications of opioid use within this patient population?

I do not think opioid use in this population is associated with different kinds of outcomes versus the general population, but the outcomes may be exacerbated.

A patient in need of increasing opioid doses over time can develop a dependency, which can then lead to accidental overdoses. Even a single dose of opioids can have significant effects.

In a patient with Crohn’s disease presenting with a bowel obstruction, we’re already concerned about content’s inability to pass by the intestinal tract due to mechanical obstruction. The patient or healthcare team may desire opioids to alleviate pain, but those opioids can also exacerbate pain because they can worsen the gut’s inability to function. In that sense, opioids can worsen the situation they’re intended to treat.

What is the gastroenterologist’s role in IBD pain management?

Gastroenterologists often direct the care of patients with IBD. This may extend beyond medications or the specifics of treating disease activity and broaden towards overall, holistic care. In this regard, the general medical or surgical teams may look to gastroenterologists for guidance on all things medical.

How might pain management protocols be adjusted for patients with IBD?

Many systems want to adjust traditional pain management, which historically has relied upon sliding scales and escalating opioid doses. Patients on the lower end of the pain scale get a lower opioid dose; on a higher end of the pain scale, they might get a higher dose or around-the-clock administration.

Start thinking about proactive ways to address pain rather than using a scale to respond to the patient’s needs reactively. Proactive approaches anticipate starting their pain management proactively before the pain manifests and is a fundamental change in the paradigm.

What are the potential barriers to implementing a proactive protocol?

We developed a proactive protocol at our institution that looks to minimize the use of opioids for treating pain. In our protocol, for milder pain, we would administer acetaminophen around the clock. For patients who cannot take oral medications or use parenterally administered acetaminophen, we consider gabapentin and potentially NSAIDs around the clock.

Historically, we haven’t considered NSAIDs for patients with IBD due to potential risks for IBD exacerbation. However, there are little data to suggest NSAIDs are harmful in the short term. Some data suggest that up to 2 weeks of S(+)-ibuprofen (SIB) may be appropriate for patients with IBD without increasing risk for disease exacerbation, so we incorporate SIB into our proactive regimen depending on a patient’s pain severity. We reserve opioids for the most severe pain or pain that’s a breakthrough beyond the proactive protocol.

Can you discuss your recent research? How might your findings impact guidelines for pain management in patients with IBD?

We conducted a randomized trial of our proactive pain bundle. We randomly assigned patients to receive either the pain bundle or traditional utilization of a reactive sliding scale for pain control. We found that patients who received the pain bundle did not report worse pain than those who received the traditional sliding scale.

Patients who are prescribed opioids in the hospital often leave with a prescription that ends up being refilled. Patients assigned to receive the proactive pain bundle were less likely to receive opioids and received much fewer opioids, even though they could access opioids for breakthrough or severe pain. These patients were less likely to be prescribed opioids upon discharge.

This bundle should be considered the standard of care for patients with IBD and influence guidelines to share our findings with similar institutions taking care of this patient population and improving outcomes.