Should opioid use be limited in patients with chronic opioid use and recurrent small bowel obstructions?

Opioid Management in Patients with Chronic Opioid Use and Recurrent Small Bowel Obstructions

Opioids should be limited or avoided in patients with chronic opioid use and recurrent small bowel obstructions due to their detrimental effects on intestinal motility and potential to worsen obstruction. 1 Opioids inhibit intestinal motility, which can exacerbate small bowel obstruction and lead to narcotic bowel syndrome, characterized by chronic, worsening abdominal pain despite continued or escalating doses of narcotics.

Pathophysiology and Complications

• Opioids bind to mu receptors in the colon causing constipation, which affects up to 80% of patients taking chronic opioid therapy 1
• In patients with recurrent small bowel obstructions, opioids can:
  • Further inhibit intestinal motility, worsening obstruction
  • Invalidate tests of small bowel motility
  • Increase risk of line infections in patients on long-term parenteral nutrition
  • Lead to narcotic bowel syndrome with hyperalgesic effects 1
  • Cause opioid-induced bowel dysfunction (OBD) with symptoms including constipation, abdominal cramping, bloating, and gastroesophageal reflux 2

Management Approach

1. Opioid Reduction Strategy

• Implement gradual supervised opioid withdrawal with involvement of pain specialists 1
• Replace opioids with neuropathic pain medications 1
• Consider patient-controlled analgesia with methadone at low doses and flexible intervals if pain control is necessary 3

2. Management of Opioid-Induced Constipation

If opioids cannot be completely avoided, manage constipation with:

• First-line: Osmotic laxatives (17-34 g/day) and stimulant laxatives (5-15 mg/day) 1
• Second-line: Peripherally acting mu opioid receptor antagonists (PAMORAs):
  • Naloxegol (0.2 mg/day)
  • Naldemedine (12.5-25 mg/day)
  • Methylnaltrexone (12 mg/day SubQ; 450 mg/day oral) 1

3. Dietary and Lifestyle Modifications

• Low residue diet or liquid diet to reduce obstructive episodes 1
• Avoid gas-producing foods 4
• Eat slowly, chew thoroughly, and plan smaller, more frequent meals 4
• Establish regular toileting schedule 4

4. Prokinetic Therapy

• Consider prokinetics like prucalopride to improve intestinal motility and prevent recurrence 4
• Avoid medications that worsen gastric motility (anticholinergics, long-term PPIs) 4

Special Considerations

Diagnostic Approach During Obstruction Episodes

• Obtain abdominal CT scan during episodes of severe pain to identify transition points between dilated and normal-sized bowel 1
• Consider contrast follow-through studies or MRI scans when appropriate 1

Surgical Considerations

• Surgery should be avoided when possible in patients with chronic intestinal dysmotility 1
• Nutritional status should be optimized before any surgical procedure 1
• Judicious palliative surgical intervention may improve symptoms in selected cases 1

Monitoring and Follow-up

• Monitor for nutritional deficiencies (iron, B12, fat-soluble vitamins) 4
• Assess for symptoms of narcotic bowel syndrome (chronic, worsening abdominal pain despite continued opioid use) 1
• Evaluate for small intestinal bacterial overgrowth (SIBO), which can complicate dysmotility 4

Pitfalls to Avoid

• Avoid abrupt discontinuation of opioids in chronic users
• Do not use cyclizine (antihistamine/anticholinergic) as it can worsen dysmotility 1
• Antimotility agents may worsen diarrhea in cases with bowel dilatation by encouraging bacterial overgrowth 4
• Avoid multiple laparotomies as they may result in secondary dysmotility 1

By limiting opioid use and implementing appropriate management strategies, patients with chronic opioid use and recurrent small bowel obstructions can experience improved bowel function, reduced pain, and better quality of life.