COMMENTARY

Impact of Opioid Epidemic on IBD: Patients Are at Risk

Digestive Disease Week (DDW) 2018

William F. Balistreri, MD

Disclosures

August 06, 2018

Prescription opioid addiction is clearly an American epidemic with devastating consequences. According to data from the Centers for Disease Control and Prevention, 40% of opioid overdose deaths in 2016 were related to a prescription opioid.[1] Gomes and colleagues[2] recently reported the sobering statistic that the percentage of all deaths attributable to opioids increased 292% between 2001 and 2016. The burden was particularly high among those aged 24-35 years; in 2016, 20% of deaths in this age group involved opioids.

The current opioid crisis has had an impact on gastrointestinal diseases, and several presentations at this year's Digestive Disease Week focused specifically on opioid use in patients with inflammatory bowel disease (IBD). In view of their chronic relapsing-remitting pain and diminished quality of life, these patients often are prescribed opioids and may be at risk for opioid use disorder (OUD).

How Common Is Chronic Opioid Use in IBD?

Opioids are commonly prescribed for the management of pain in patients with IBD, despite concerns regarding the efficacy of these agents in relieving chronic pain and the known risk for adverse effects. Studies[3,4] have described the prevalence of chronic opioid use to be approximately 5%-6% among patients with IBD, with adolescents and young adults at particular risk for continued opioid use.

Wren and colleagues[5] evaluated the prevalence of chronic opioid use and associated healthcare utilization among adolescents and young adults with IBD in the United States in an analysis of a large administrative data set. Chronic opioid therapy (COT), defined as having at least two opioid drug claims on distinct dates within 1 year, was reported in 18% of the population. In year two, 31% continued to receive opioids; in year three, 11%; and in year four, 5%. Individuals receiving COT for 4 years were significantly more likely to take corticosteroids, have comorbid pain, have psychiatric diagnoses, visit the emergency department, and be hospitalized compared with those receiving COT for a shorter duration and those who did not receive opioids. This study highlights that a subset of adolescents and young adults with IBD are at particular risk for continued opioid use, associated comorbidities, and increased healthcare utilization.

Landsman and colleagues[6] also characterized trends in opioid use in patients with IBD over the past 15 years using the Explorys database, which contains over 40 million unique patient records from hospitals across the United States. They documented that despite advances in treatment for IBD, chronic pain remains a significant issue and that chronic opioid use has increased. They reported that of 276,340 patients with a diagnosis of IBD, the percentage of chronic opioid users rose from 14% in 2002 to 26% in 2016. Of note, over the same period, chronic opioid use among privately insured patients increased, whereas there was a decline among Medicare patients.

Lin and colleagues[7] estimated the rates of opioid use in patients before and after their diagnosis of IBD and further explored the relationship between opioid use and healthcare resource utilization. The generalized estimating equation was used to estimate the percentage of patients with opioid-related claims over the initial 3 years after a diagnosis of IBD. In the Crohn disease (CD) cohort, they found that 27% of opioid users versus 12% of nonusers had CD-related emergency department visits, and 35% of opioid users versus 16% of nonusers had CD-related inpatient hospitalizations during year one. In the ulcerative colitis (UC) cohort, 15% of opioid users versus 6% of nonusers had UC-related emergency department visits, and 26% of opioid users versus 11% of nonusers had UC-related inpatient hospitalizations during year one.

Increasing opioid-related diagnoses among hospitalized patients with IBD are associated with increased length of stay and greater healthcare utilization.

Cohen-Mekelburg and colleagues[8] reviewed approximately 2,500,000 adult discharges with any diagnosis of IBD and found that 2.2% of IBD-related inpatient stays also had an OUD-related diagnosis, with an average annual increase in OUD-related IBD inpatient discharges of 8.8% from 2005 to 2014. Characteristics associated with OUD also could be used to identify at-risk patients. In their multivariable analysis, a diagnosis of CD, having a public payer, and the presence of psychiatric comorbidities were associated with a higher likelihood of an OUD-related diagnosis. The investigators emphasized the importance of screening for OUD in the IBD population and referral to evidence-based treatment/behavioral interventions to improve outcomes and reduce costs.

Michailidis and colleagues[9] sought to quantify opioid use within an IBD outpatient clinic at the University of Kentucky and its impact on healthcare utilization. They retrospectively reviewed all patients with IBD who had received at least one outpatient opioid analgesic prescription. Of 740 distinct patients, 24% were prescribed opioids at least once and 10% fulfilled the definition of OUD. Chronic users had higher composite utilization scores than patients who were not chronic users. In addition, patients receiving opioids on a chronic basis were significantly more likely to obtain them from more than four prescribers and pharmacies and to be diagnosed with psychiatric disease than patients who were not chronic users. Furthermore, patients who were chronic users had more than twice the average number of emergency department visits and CT or MRI scans.

These observations raise concern regarding the discontinuity of care and the potential for high radiation exposure. The investigators suggest that providers be aware of these red flags when prescribing long-term analgesics. They urge the addition of addiction and pain specialists to the IBD clinic to minimize OUD because of the high risk for chronic opioid use. They also recommend offering alternative options for analgesia.

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