Patients with inflammatory bowel disease (IBD) who report pain are frequently prescribed opioids during hospitalization yet do not experience significant changes in pain even with opioid consumption, according to study results published in Digestive Diseases and Sciences.
Most patients with IBD experience pain, and the majority of these IBD patients consume narcotics during hospitalization despite the risks of infection and death. The investigators of this retrospective study sought to understand pain management in patients hospitalized for IBD by measuring pain and opiate consumption for IBD-related admissions over a 3-month period.
The investigators mined data on 57 patients who were admitted at Cedars-Sinai Medical Center for IBD-related pain between July and September 2017. Patients who underwent surgery 30 days prior to the admission, were admitted for less than 24 hours, or reported no pain were excluded from analysis. All patients were asked to rate their pain using a numeric rating scale (0-10) in which nurses documented pain scores during every vital sign check and at the time of analgesic administration. Average daily pain scores and maximum daily pain scores were used to measure change in pain from admission to discharge. Inpatient opioid consumption (medication name and dosage) was extracted from electronic medical records as were baseline patient characteristics (gender, age, IBD type, prior opioid use) and healthcare utilization (readmissions, length of stay). Mixed model regression analyses were used to understand the relationship between opioid use and pain scores over time.
Of 57 patients, 51 were administered opioid medication at least once during their hospitalization. In the total cohort, the average daily pain score calculated over the entire hospitalization was 4.23±2.09, and the maximum daily pain score was 8.28±1.75. Pain scores calculated only among opioid users were similar: the average daily pain score was 4.65±2.16, and the maximum pain score was 7.53±2.56. However, pain scores among the 6 opioid nonusers were significantly lower: the average daily pain score was 2.00±1.14; P =.0136, and the maximum pain score was 4.59±2.24; P =.0044. Change in pain over time for all participants revealed less than a 1 point change in average daily pain scores (-0.96±2.03; P =.0009) and no change in maximum daily pain (-0.89±3.59; P =.0671). Change in pain among opioid users yielded similar results in which average daily pain dropped less than 1 point (-0.94±-0.29; P =.0024), and maximum daily pain did not change (-0.81±-0.47; P =.0914). Patients received on average 19.9±24.7 morphine milligram equivalents per day and 106±151 morphine milligram equivalents during the entire hospitalization; notably, opioid-naive patients received similar doses to patients who indicated opioid use before admission. Although 71% of participants were opioid-naive before admission, nearly half (47%) of the total cohort were discharged with an opioid prescription. Patient characteristics were not associated with differences in hospital utilization or pain scores.
Limitations to the study include the retrospective design, short duration, and small sample size. The investigators were further unable to elucidate potential concomitant causes of pain, including psychosocial factors common in patients with IBD like anxiety and depression. Finally, the study was conducted at a single, tertiary referral center and may be limited by bias toward complex IBD cases.
Despite a high prevalence of opioid consumption, pain related to IBD was not well controlled during hospitalization. Furthermore, nearly half of all patients treated for pain were prescribed opioids upon discharge. The investigators suggest that alternative methods for managing pain may be better utilized in this setting, especially considering that long-term opioid use is associated with poor quality of life and mortality.
Berry SK, Takakura W, Bresee C, Melmed GY. Pain in inflammatory bowel disease is not improved during hospitalization: the impact of opioids on pain and healthcare utilization [published online October 25, 2019]. Dig Dis Sci. doi: 10.1007/s10620-019-05906-x