Avoiding narcotics in Crohn's disease

Prevalence of chronic narcotic use among children with inflammatory bowel disease

BACKGROUND & AIMS

Narcotic analgesics are not recommended for long-term management of pain for patients with inflammatory bowel disease (IBD), particularly pediatric patients. We compared chronic use of narcotics among children with IBD and the general population and investigated factors associated with narcotic use in the pediatric IBD population.

METHODS

This cross-sectional study included children (younger than 18 years old) with continuous enrollment in a large administrative claims database from 2010 through 2011 (n = 4,911,286). Children with IBD were identified through diagnosis codes and dispensation of IBD medication (n = 4344); they were matched for age, sex, and region with 5 children without IBD (n = 21,720). Chronic narcotic use was defined as ≥3 dispensements of narcotics. We estimated prevalence odds ratios (PORs) and 95% confidence intervals (CIs), comparing narcotic use on the basis of IBD status and evaluating variables associated with narcotic use by patients with IBD by using conditional and unconditional logistic regression.

RESULTS

The prevalence of chronic narcotic use was 5.6% among children with IBD vs 2.3% in the general population (POR, 2.6; 95% CI, 2.2-3.0). Compared with the general population, POR for chronic narcotic use was significantly higher for pediatric IBD patients with psychological impairment (POR, 6.8; 95% CI, 4.3-10.6) than those without (POR, 2.3; 95% CI, 1.9-2.7). Older age, increased healthcare utilization, fracture, and psychological impairment were strongly associated with chronic use of narcotics among children with IBD.

CONCLUSIONS

Chronic narcotic use is common in pediatric IBD patients, particularly among those with anxiety and depression. Increased awareness of psychological comorbidity, screening, and treatment may reduce symptoms that lead to narcotic use and its complications.

Clinical markers of Crohn's disease severity and their association with opiate use

BACKGROUND

The safety of opiate use for patients with Crohn's disease (CD) has long been a concern. The recent Crohn's therapy, resource, evaluation, and assessment tool (TREAT) registry update has added to these concerns by demonstrating an association of opiate use with an increased risk of infection and death in CD. While the association is clear, the relationship of opiates to these negative outcomes is not. It is unknown whether opiates are a contributing factor to these negative outcomes or if their use is merely a marker of more severe disease. We hypothesized that opiate use is not harmful in CD but is a marker of disease severity and would be associated with commonly accepted clinical markers of severe CD such as early age at CD onset, disease duration, small intestinal involvement, a history of fistula or stricture, and lower quality of life (QOL) scores.

METHODS

Data on CD history including pain medication usage were obtained from an interviewer directed survey of patients admitted to two tertiary care hospitals over a 2-year period. CD as the primary admitting diagnosis was not required. Active opiate use was defined by usage within the past month prior to admission.

RESULTS

A total of 133 patients were approached to participate, of whom 108 consented to the survey, and 51 were active opiate users. Opiate using CD patients were more commonly smokers (22% vs. 3.45%, P < 0.010), had fistulas (40% vs. 22.4%, P < 0.048) and had a poorer quality of life score by short form inflammatory bowel disease questionnaire (mean 3.80 vs. 4.34, P < 0.036) than non-opiate users. No difference was found between opiate users and non-users for age of diagnosis, disease duration, or a history of strictures.

CONCLUSIONS

The study findings demonstrate that opiate use in CD is associated with markers of disease severity including fistulas, smoking, and lower QOL scores. The findings suggest that opiates may not be directly harmful to patients with CD, but may merely be another marker of disease severity. However, given opiates unproven benefits for long term CD pain control and risk of dependence, caution should still be exercised in their use.