Published online Jan 21, 2019. doi: 10.4292/wjgpt.v10.i1.22
Peer-review started: October 19, 2018
First decision: November 15, 2018
Revised: December 24, 2018
Accepted: January 9, 2019
Article in press: January 9, 2019
Published online: January 21, 2019
Processing time: 94 Days and 14.7 Hours
Opioid use in the inflammatory bowel disease (IBD) population is common, given that symptoms of disease activity often include abdominal pain. While opioids may provide temporary relief, they carry long-term risks such as narcotic bowel syndrome and the potential for dependence and addiction. However, little is known about the specific rates of opioid use and misuse in the ulcerative colitis (UC) population. Functional gastrointestinal diseases often overlap with symptoms of IBD, and abdominal pain or functional symptoms in patients with UC with a concomitant diagnosis of functional gastrointestinal disorders (FGID) may be easily mistaken as a manifestation of active UC during periods of disease remission. In a previous study, we showed that rates of chronic opioid use and misuse among patients with Crohn’s disease (CD) and concomitant FGID were two-fold and three-fold higher, respectively, than in patients with CD without a diagnosis of FGID.
Identification of risk factors for opioid abuse in the IBD population, specifically in UC patients, is key in prevention of complications of these medications. Patients at risk for chronic opioid use and misuse can be identified, and prescribers can be better informed, thereby preventing many of the adverse effects – physical, mental and psychosocial – associated with long-term opioid therapy in this vulnerable population.
The purpose of this study was to characterize rates of chronic opioid use and misuse in the UC population, as these have not been studied extensively. One of the objectives of this study was to investigate whether FGID was a risk factor for chronic opioid use and misuse in UC patients, as has been demonstrated in patients with CD and FGID.
Following approval through the institutional review board, a retrospective chart review was conducted at the University of Virginia Digestive Health Center including all patients who had been evaluated for ulcerative colitis between 2006 and 2011. Patient demographics and selected variables (tobacco use, alcohol use, etc.), medical, surgical and psychiatric histories, and concomitant diagnoses of FGID (as outlined by Rome III criteria) were collected from the electronic medical record. Data on opioid use was collected from the electronic prescription monitoring program databases for the states of Virginia and West Virginia (https://virginia.pmpaware.net). Statistical analysis was conducted by a biomedical statistician and both univariate and multivariate regression analyses were performed.
This study cohort consisted of 497 patients with UC, who were seen at the University of Virginia from 2006 to 2011. Of these patients, 7.8% had a concurrent diagnosis of FGID as defined by Rome III criteria, 20.7% had concomitant psychiatric disease, and 8.7% were current tobacco users. Patients with UC and FGID were more likely to be female (P = 0.010), but no other risk factors were found to be associated with FGID in the UC cohort. A greater proportion of patients with FGID and UC were on chronic opioid therapy than patients with UC without FGID (36% vs 9%, P < 0.0001), and a greater proportion of patients with FGID and UC met criteria for opioid misuse (12.8% vs 1.3%, P < 0.001). In the multivariate logistic regression analysis, patients with FGID and UC had a 4.5-fold increased risk for chronic opioid use and 5-fold increased risk for opioid misuse in comparison to their UC counterparts without FGID. Tobacco use and anxiety also conferred higher risks for chronic narcotic use.
To our knowledge, this is the first study which assesses the rates of and risk factors for both chronic opioid use and misuse in the UC population. This study sheds light on the need for careful prescription practices among providers who have patients with UC, particularly those with concomitant diagnoses of FGID. As we hypothesized, FGID increased the risk for both chronic opioid use and misuse in our cohort of UC patients, which is a novel finding and may set the foundation for future studies. Tobacco use and anxiety also conferred an increased risk for chronic narcotic use in UC patients, as demonstrated in prior studies, but were not variables associated with FGID. While FGID did increase the risk for opioid misuse five-fold in our UC cohort, our numbers of patients meeting the definition of opioid misuse was small, and thus more associations may not have reached statistical significance.
The insights gained from this study may provide the basis for practitioners to monitor opioid use in their UC cohorts, and potentially intervene when chronic opioid use and misuse are suspected. Furthermore, this study emphasizes that PMP databases are useful tools not only in the general population, but also in specific populations such as the IBD population. While this study was conducted at a tertiary referral center in the United States and a large number of patients were included, the results may not be generalizable to the US and worldwide, as this was a single-center study and the opioid epidemic has disproportionately affected some of the geographic areas (e.g., Southwest Virginia) in which our patients reside. Future studies with a similar design and the inclusion of multiple sites may help to further define risk factors for chronic opioid use and misuse in the UC cohort. The data obtained from this study may, in the near future, also serve as a basis for quality improvement studies in which at-risk UC patients are identified and treated with alternatives for opioids in the appropriate situations.