What is Narcotic Bowel Syndrome?

It’s estimated that between 25% and 45% of adults experience long-term pain. This ongoing pain can lead to a reduced quality of life, loss of productive time, and a constant need for pain medication. The costs of managing this pain are high due to frequent emergency room visits, repeated hospital admissions, and a range of expensive treatments and procedures. Right now, one of the most commonly used types of medication to manage moderate to severe pain are opioids, which are used for both cancer and non-cancer related pain. Over the past 30 years, the use of opioids has grown significantly, and it’s thought that about 2% to 3% of US adults are currently using opioids for long-term non-cancer pain. Every year, almost 250 million opioid prescriptions are written out by healthcare workers.

In the last 20 years, healthcare workers have been frequently prescribing opioids to manage pain. But this widespread use of opioids has also led to a range of side effects. Some of the more common side effects include constipation, itching, slowed breathing, and sleepiness.

Healthcare workers are familiar with these side effects, but a lesser-known side effect of opioids is something called narcotic bowel syndrome (NBS). The most common gastrointestinal issue caused by opioids is opioid-induced constipation, causing nausea, upset stomach, stomach cramps, bloating, and constipation. NBS, however, causes frequent or long-lasting stomach pain related to regular opioid use. This pain often gets worse with increased doses of opioids or with the extended use of opioids.

What Causes Narcotic Bowel Syndrome?

Narcotic bowel syndrome (NBS) is not completely understood, but it’s seen in about 6% of persons who take opioids for a long time. This condition can significantly impact the quality of life and may result in frequent trips to the emergency room and repeated hospital stays. The way to manage NBS is by slowly stopping the opioid intake and simultaneously preventing any withdrawal symptoms and pain. This can be done through the use of antidepressants, clonidine, and benzodiazepines. Plus, many patients may need laxatives and new drugs that block the effects of opioids to help manage constipation. Along with the medical treatment, psychological therapy can be beneficial to prevent the recurrence of the syndrome.

It’s not unusual for NBS to be mistaken for other gastrointestinal problems.

Diagnosing NBS can be challenging. It’s important to manage the pain properly, acknowledging how this condition affects the person’s quality of life. The wrong treatment might involve increasing the painkiller dosage, performing unnecessary invasive diagnostic procedures, or consulting with a surgeon. However, many patients are often wrongly treated with drugs to reduce stomach acid, laxatives, and by changing their diet.

Risk Factors and Frequency for Narcotic Bowel Syndrome

Narcotic bowel syndrome (NBS) has been known in the medical world for many years, but it is often missed or overlooked by healthcare workers, likely due to a lack of familiarity with the condition. The exact number of people affected by NBS is unclear, but it is thought that about 4% to 6% of those who use opioids long-term can develop the syndrome. In the United States, it’s estimated that around 150,000 people may have NBS. However, this is likely an underestimate, as a true diagnosis can not always be confirmed. The rate could be much higher, especially among those suffering from long-lasting pain that isn’t related to cancer.

Current estimates suggest that 1 out of every 20 people who use opioids long-term could develop NBS. For this reason, it’s crucial that all healthcare professionals who prescribe or administer opioids are well-informed about the syndrome, so they can recognize it and take the right action in a timely manner.

There are no specific groups of people who are more likely to get NBS, though some smaller studies suggest that the following groups might be more often affected:

People who are well-educated
Females
Individuals who are unemployed or have been disabled for long periods due to health problems
People with moderate to severe pain
Those with moderate to severe mental health issues, such as depression, anxiety, impulsivity, mood swings, or anger

Further research into NBS indicates that if a person has both NBS and a psychiatric condition, it can make the bowel syndrome worse. As a result, anyone diagnosed with NBS should also visit a mental health professional to be evaluated thoroughly.

Signs and Symptoms of Narcotic Bowel Syndrome

Narcotic Bowel Syndrome (NBS) is often missed because it presents as a strange type of abdominal pain that actually worsens with opioid use. This misunderstood condition can lead to an increasing reliance on opioids, which unfortunately, intensifies the abdominal pain. While the hallmark of NBS is this amplifying pain, it shouldn’t be confused with the typical side effects of opioids. These usual side effects can include: nausea, vomiting, bloating, abdominal cramps, and constipation, and they may happen alongside NBS symptoms.

Nausea
Vomiting
Bloating
Abdominal cramps
Constipation

Testing for Narcotic Bowel Syndrome

NBS, or Narcotic Bowel Syndrome, is diagnosed through observing symptoms, and isn’t generally identified by standard lab or imaging tests. This condition is often overlooked due to a lack of knowledge about it. The key to diagnosing it is linking long-term opioid use with worsening stomach pain.

There are a few specific signs that can indicate NBS:

* A pattern of increasing pain that gets worse even though higher doses of opioids are being used
* Stomach pain that feels like it’s cramping or burning
* Pain that’s accompanied by feelings of sickness, throwing up, a bloated stomach, or constipation
* Eating can make symptoms worse, and early weight loss and loss of appetite may be noticeable
* Usage of opioids for at least 3 months
* Taking a daily opioid dose equivalent to 50 to 75 mg of morphine
* Stomach pain occurring within 14 to 28 days after starting the opioid

The pain can also vary depending on the amount of the dosage. Often, the diagnosis of NBS is delayed because the symptoms aren’t specific and many people aren’t familiar with the condition.

As far as tests go:

Blood Test:
Regular blood tests, like a white cell count, are typically normal for people with NBS.

Imaging:
Although imaging isn’t needed for diagnosing NBS, abdominal x-rays might be done to eliminate other conditions like bowel obstruction, a punctured internal organ, or kidney stones. For patients diagnosed with NBS, x-rays could show partial bowel obstruction or lack of movement in the bowel. Some patients might have a build-up of feces in the intestines due to constipation caused by opioids.

Treatment Options for Narcotic Bowel Syndrome

Before starting treatment, remember that Narcotic Bowel Syndrome (NBS) is a condition where high levels of pain are caused by opioid medications. This can lead to situations where the patient pursues more pain medication from different places, making the pain worse. This can lead to more hospital visits, more lengthy stays, returning to the hospital due to unbearable pain, and potentially needless surgeries. Sometimes health professionals may not realise the patient has NBS, so they might continue prescribing opioids, leading to worsening pain.

Building a trusting relationship with the patient is crucial, as they may then be more likely to admit to using high doses of opioids or using them frequently. Health professionals should be understanding and compassionate, addressing all the patient’s concerns and expectations. It’s important to listen to and appreciate the patient’s concerns to create a more successful treatment outcome.

Treatment for NBS usually involves reducing or stopping the opioid medication, and sometimes using antidepressants. The mentality behind treating NBS is to gradually taper off the opioids while managing withdrawal symptoms and handling the pain through other methods. One suggested method involves prescribing a long-acting opioid medication, like methadone, for pain relief, alongside drugs to prevent withdrawal symptoms like clonidine, lorazepam, and duloxetine.

Antidepressants are commonly used to treat NBS, and these have also been successful in treating pain linked to irritable bowel syndrome. The antidepressant should be started before tapering or discontinuing the opioid medication and should be continued indefinitely. Rexent studies suggest that both milnacipran and duloxetine can help reduce the need for opioids for pain management.

Medium and long-acting benzodiazepines like clonazepam or lorazepam can help manage the opioid withdrawal phase, thanks to their calming and anti-anxiety properties. Clonidine has also been used to help manage NBS, as it can ease withdrawal symptoms like muscle pain, restlessness, and chills.

For patients who aren’t responding to these treatments, mood stabilisers or atypical antipsychotics may be suggested. Pregabalin, for example, has been shown to lower the need for opioids in patients recovering from surgery.

In addition to drug therapy, patients with NBS often benefit from behavioural interventions. Positive relationships between the healthcare provider and the patient can help prevent opioid dependency and decrease the need for pain medications. Strategies such as cognitive behaviour therapy and hypnosis have shown promising results in reducing pain.

Patients must also be managed for constipation, a side effect of opioids. Health professionals should prescribe a laxative at the same time as the opioid medication to prevent constipation and improve overall quality of life.

Narcotic bowel syndrome (NBS) can be tough to diagnose, because its symptoms often mimic those of opioid-induced constipation and many other gastrointestinal conditions. The primary symptom that sets NBS apart is that abdominal pain gets worse with continued or increased use of opioids.

When diagnosing NBS, physicians may consider the possibility of several gastrointestinal conditions including:

IBS: Stomach pain, gas, bloating, altered bowel habits, mucus in stools.
Gastritis: Burning pain in the middle part of the stomach, feeling sick, vomiting, loss of appetite, bloating, burping, and weight loss.
Chronic pancreatitis: Persistent or intermittent stomach pains that may radiate to your back, bulky smelly stools, greasy stools, and weight loss.
Biliary colic: Intermittent pain, nausea and vomiting, often worsened with fatty foods.
Gallstones: Pain in the upper right side of the abdomen, nausea, vomiting, pain relief with opioids.
Peptic ulcer disease: Stomach pain that is worse on an empty stomach and relief with a meal, dark-colored stools. Other conditions like partial bowel obstruction, mesenteric ischemia, kidney stones, ovarian cysts, endometriosis, and uterine fibroids (leiomyoma) could also be considered.

If NBS is suspected, it’s important to ask the patients about their history of using opioids chronically or in high doses. Another key question to ask is whether the intensity of pain increases with higher doses of opioids.

Acute opioid withdrawal should also be investigated, as it can manifest as increased sensitivity to pain, runny nose, yawning, restlessness, stomach cramps, sweating and diarrhea.

NBS is usually underdiagnosed, partly because opioids can affect the digestive system in various ways, making it tricky to pinpoint the cause of the abdominal pain. And, in part because not much has been widely published about the condition, many healthcare professionals aren’t fully aware of it.

Lastly, because there are so many causes of abdominal pain, it can take a lot of time to find out the real cause. Also, in most cases, the cause of the pain doesn’t require surgery, so patients are usually sent home and often don’t return for a follow-up.

Preventing Narcotic Bowel Syndrome

There are various approaches to managing pain using opiate drugs, but these methods haven’t been widely approved for patients with NBS. Researchers are considering the potential use of drugs that block opiate receptors in the peripheral system. However, these are still in the experimental stage, with clinical trials needed to prove their effectiveness. Current research is also focusing on developing new anti-inflammatory drugs. One of these is ketotifen, which helps stabilize mast cells, and others are aimed at impacting astrocytes and microglia cells.