Today we are joined by gastroenterologist Dr. Gil Melmed. He discusses the high prevalence of pain in patients with IBD, especially among those hospitalized with acute pain. He also highlights the risks associated with opioid use and advocates for a proactive pain management approach while describing a proactive pain bundle implemented at Cedar-Sinai, which includes acetaminophen, gabapentin, and NSAIDs, aiming to minimize opioid use.

My name is Gil Melmed. I’m a gastroenterologist and inflammatory bowel disease specialist. I direct the clinical Inflammatory Bowel Disease Program at Cedar-Sinai, where I oversee the clinical research program, and I’m also the associate director of the division of gastroenterology and hepatology.

So the prevalence of pain in IBD itself is quite high, and this is even in patients not in the hospital. Patients with inflammatory bowel disease suffer from chronic symptoms that can include pain, particularly people with Crohn’s disease, certainly people with ulcerative colitis as well, particularly when the disease is active. But pain is a pretty common feature of Crohn’s disease and is included in all of the disease activity assessment scales that we use for Crohn’s disease. So when somebody’s in the hospital, we’re talking about acute pain on top of chronic pain. And in that regard, patients with IBD represent probably the group within gastroenterology, which is the highest in need of addressing pain, particularly as it’s in the hospital.

When patients are admitted, they’re often admitted for symptoms of a bowel obstruction or disease flare. And these are all characterized in addition to other symptoms by significant abdominal pain. I don’t know that opioid use in this population is associated with different kinds of outcomes than it is in the general population, but they may be exacerbated. So in the general population, we certainly understand the consequences of opioid use as relating to potential overdoses of opioids. That in and of themselves can lead to respiratory depression, and that’s usually the cause of death or things that happen while somebody’s using opioids in the sense of compromised neurological function and an aspiration that it can occur. But we’re not even talking about that. There’s dependency that can occur with a need for increasing doses of opioids over time that can then lead to accidental overdoses. But even just routine, a single dose of opioids can also have significant effects.

For example, in the gut with slowing down of the gut motility constipation. And in somebody with, let’s say a bowel obstruction or partial bowel obstruction with a lot of abdominal pain, that represents a real dilemma. For example, somebody with Crohn’s disease presenting in that way, because we’re already concerned about the inability of contents to pass through the intestinal tract due to mechanical obstruction and exacerbating that gut motility through these of opioids can add significantly. So in that sense, opioids are desired by the patient or desired by the healthcare team as a way of alleviating pain. But at the same time, it can also exacerbate pain because it can worsen that overall inability of the gut to function normally in allowing its contents to pass through. So in that sense, it can be a double-edged sword and can actually lead to worsening of the situation it’s trying to treat.

The gastroenterologist is often looked to direct the care of patients with inflammatory bowel disease given the complexities of IBD care, and this may extend beyond the medications or the guidance around the specifics of treatment of the disease activity and really broaden towards the overall holistic care of the patient. And in this regard, gastroenterologists may be looked at for guidance by the general medical team or the surgical team for all things medical and should therefore prompt gastroenterologists to really understand and be aware of pain. Its manifestations and most appropriate ways to address it in our IBD patients. I think this is going to require an understanding of what the current pain protocols are in a given health system or in a given hospital. There may not be standardized protocols shared across all systems, although I do think that many systems are looking to adjust the traditional ways of treating pain, which have historically relied upon sliding scales of pain that lead to escalating doses of opioids in order to address greater severity of pain.

So for example, historically we might’ve asked the patient, where are you on a pain scale? And for the lower end of the pain scale, they might get a lower dose of an opioid and a higher end of a pain scale. They might get a higher dose of an opioid or a chronically or around the clock administered opioid. And so the way pain scales might be adjusted is to start to think about proactive ways of addressing pain rather than reactively responding to the patient’s needs using a scale. Now, I think that proactive approaches anticipate that certain groups of patients are going to have pain and therefore getting them on something in a proactive way before the pain manifests is a real change in the paradigm of how we think about pain. I think we still need to be able to respond to pain. We still need to be able to give patients something over and above whatever it might be even proactively that they may be receiving.

And to also behoove us to think more broadly beyond the use of traditional pain medications beyond the use of opioids. In order to address both that proactive and that reactive way of treating pain, we developed a proactive protocol at our institution that looks to minimize the use of opioids and treating pain. So for our protocol for milder pain, we would administer acetaminophen around the clock. And for patients who cannot take oral medications to utilize parenterally administered acetaminophen, we also look to use gabapentin in and around the clock fashion and maybe even NSAIDs. Historically, we don’t think about NSAIDs for patients with IBD due to potential risks of exacerbation of IBD. But in the short term, there actually is very little data to suggest that NSAIDs are harmful.

I think that to incorporate a proactive pain bundle in a hospital setting really requires having the tools to do it. So incorporating a bundle, for example, into an electronic medical record as part of admission orders, it’s educating those that might be writing the admission orders. And depending on the hospital, if it’s a teaching hospital, having the residents or the training or the house staff involved in training them appropriately to utilize these bundles for these patients, it may require the approval of a pain bundle by, for example, a pharmacy and therapeutics committee at a hospital in order to get buy-in from the relevant stakeholders that would need to approve such a bundle.

And so I think that understanding what one’s particular environment requires in order to institute such a bundle is going to be critically important to its implementation. We conducted a randomized trial of our proactive pain bundle, as I alluded to that incorporated proactive use of acetaminophen, gabapentin, and other modalities proactively such as Celecoxib in our IBD patients with minimizing opioids only for those that were the most severe or for breakthrough pain and randomized patients to receive that pain bundle or the traditional utilization of a reactive sliding scale for pain control. And what we found was that patients who received the pain bundle overall did not report any worse pain than those that received the traditional sliding scale. And in fact, in many cases, reported improved pain when we measured pain on the numeric rating scale for pain on each hospital day. In addition, our patients assigned to receive the proactive pain bundle were less likely to receive opioids overall, received much fewer opioids, even though they could access opioids for breakthrough pain or for severe pain. And also were less likely to be prescribed opioids

Upon another very important consideration because patients who are prescribed opioids in the hospital for pain and then are leaving the hospital are often leaving with a prescription for opioids that ends up getting refilled. So for those particular outcomes, we demonstrated that being having a proactive opioid sparing pain bundle with opioids only for severe or breakthrough pain was associated with as good as or better outcomes than using the traditional model without the need for opioids or with minimizing the use of opioids. And so as a result, we feel that utilization of such a bundle, at least in our healthcare, such as ours, should be considered standard of care for patients with inflammatory bowel disease. And we’d love to be able to influence guidelines and spread the results of our findings to other similar institutions and other similar hospitals taking care of this patient population so that we can influence overall outcomes more broadly.