Is morphine (opioid analgesic) a suitable treatment option for a patient with diverticulitis and back pain?

From the Guidelines

Morphine and other opioid analgesics are generally not recommended as first-line treatment for patients with diverticulitis and back pain. For diverticulitis, opioids can worsen constipation, potentially exacerbating the condition by increasing intraluminal pressure and delaying transit time, which may complicate recovery 1. Instead, treatment should focus on antibiotics (such as ciprofloxacin 500mg twice daily with metronidazole 500mg three times daily for 7-10 days) for the infection, along with bowel rest and gradual reintroduction of fiber once symptoms improve. For back pain management in these patients, acetaminophen (up to 3000mg daily in divided doses) or NSAIDs like ibuprofen (400-600mg three times daily) are preferred if not contraindicated. Non-pharmacological approaches such as physical therapy, heat application, and gentle exercise are also important components of back pain management. If pain is severe and other options inadequate, opioids might be considered for very short-term use under close supervision, but their constipating effects must be actively managed with stool softeners and laxatives to prevent worsening of the diverticular disease.

Key considerations in managing patients with diverticulitis and back pain include:

• Avoiding opioids as first-line treatment due to their potential to worsen constipation and complicate diverticulitis recovery
• Using antibiotics and bowel rest as primary treatment for diverticulitis
• Preferring acetaminophen or NSAIDs for back pain management when not contraindicated
• Incorporating non-pharmacological approaches for back pain management
• Carefully considering the risks and benefits of short-term opioid use under close supervision when other options are inadequate

It's essential to weigh the potential benefits and harms of opioid analgesics, considering the substantial risks, including aberrant drug-related behaviors with long-term use in patients vulnerable or potentially vulnerable to abuse or addiction 1. The most recent evidence suggests that opioids should not be prescribed for chronic gastrointestinal pain because of a disorder of gut–brain interaction, and if patients are referred on opioids, these medications should be prescribed responsibly, via multidisciplinary collaboration, until they can be discontinued 1.

From the FDA Drug Label

Morphine causes a reduction in motility associated with an increase in smooth muscle tone in the antrum of the stomach duodenum Digestion of food in the small intestine is delayed and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone may be increased to the point of spasm, resulting in constipation.

Morphine may not be a suitable treatment option for a patient with diverticulitis and back pain, as it can cause a reduction in motility and increase in smooth muscle tone in the colon, potentially worsening the condition. Additionally, morphine can cause constipation, which may also exacerbate diverticulitis. 2

From the Research

Morphine as a Treatment Option for Diverticulitis and Back Pain

• Morphine is an opioid analgesic that can be used to manage pain, but its use in patients with diverticulitis is a concern due to potential complications 3, 4, 5.
• Studies have shown that opioid use, including morphine, can increase the risk of perforated colonic diverticular disease, bleeding, sepsis, obstruction, and fistula formation 3, 4, 5.
• The use of opioids, such as morphine, can also lead to constipation, which can worsen diverticulitis symptoms 6.
• However, there is no direct evidence in the provided studies that discusses the use of morphine as a treatment option for diverticulitis and back pain specifically.
• It is essential to consider alternative treatment options for managing pain in patients with diverticulitis, such as non-opioid analgesics or other therapies that do not increase the risk of complications.

Alternative Treatment Options

• Non-steroidal anti-inflammatory drugs (NSAIDs) may not be suitable for patients with diverticulitis due to the increased risk of perforation 4, 5.
• Antibiotics, such as ampicillin, gentamicin, metronidazole, piperacillin, and tazobactam, are commonly used to treat diverticulitis, especially in severe and complicated cases 7.
• Mesalazine and probiotics have also been shown to be effective in improving symptoms and preventing recurrence of diverticulitis 7.
• Calcium channel blockers may be associated with a reduced risk of diverticular complications 5.

Considerations for Opioid Use

• Patients with pre-existing opioid use may be at a higher risk of poor outcomes, including in-hospital mortality and sepsis 3.
• Opioid use can lead to constipation, which can worsen diverticulitis symptoms, and oral naloxone may be used to treat opioid-induced constipation 6.
• However, the use of oral naloxone can also lead to side effects, such as abdominal cramps and withdrawal syndrome 6.