A big part of a pediatric gastroenterologist’s daily practice is trying to help patients with recurrent abdominal pain. The goals are to determine the reason for the pain and then to offer the best therapy. In many cases, these goals can be quite difficult. With regard to diagnosis, the majority of patients have ‘functional’ pain and the diagnosis is in part a diagnosis of exclusion, trying to rule out other potential etiologies. With regard to treatment, this is also difficult.
Narcotics are not often given for pediatric abdominal pain, but are used under certain circumstances. These medications can have unintended consequences. One consequence of frequent narcotic usage is that individuals may tolerate pain more poorly after receiving narcotics. A useful review of narcotic overuse was published in the New England Journal of Medicine in 2010. (NEJM 2010; 363: 1981).
“Deaths from unintentional drug overdoses in the United States have been rising steeply since the early 1990s …and are the second-leading cause of accidental death, with 27,658 such deaths recorded in 2007.” 11,499 of the deaths in 2007 were due to unintentional narcotic overdose. In comparison, in the same year, there were about 6,000 deaths from cocaine & 2,000 deaths from heroin.
Besides the number of deaths, the other alarming factor has been a sharp rise (10-fold since 1990) in the usage of narcotics in the past two decades. One of the factors driving this increase has been a compassionate interest in relieving pain. The availability of these drugs throughout the country even in remote regions allows these abusable drugs to be more accessible than illicit drugs like cocaine and heroin. While the availability of these medications may increase the rates of suicide, most opioid-overdose deaths are tragic accidents. Often, laboratory tests identify one or more substances in addition to the opioid, indicating that the depressant effects of alcohol or other drugs were additive in causing death.
With regard to gastroenterology/pediatric gastroenterology, another important aspect of narcotics use is the association of increased mortality risk with inflammatory bowel disease. This has been shown by analyzing a registry for infliximab (IFX) (Lichtenstein G, DDW 2010, abstracts#T1039 & T1040.). In the TREAT registry with 6273 patients (3334 treated with IFX), the only risk factors for increased mortality/increased infections were steroids and narcotics. This study also showed that IFX did not increase mortality, serious infections, malignancy or lymphoma in this cohort.
Clin Gastro & Hep 2008; 6: 978. Refractory abdominal pain review. ‘Narcotics over time increase frequency, duration and intensity of pain.’ Practical recommendations:
treat constipation, withdraw narcotics, consider mental health (CBT/hypnosis/psychotherapy/stress mgt), and possible TCA or SNRI therapy.