Hospitalized patients with inflammatory bowel disease treated using a novel pain management protocol that employs scheduled nonopioid medications adjusted based on pain severity used less opioids in a recent study.
The study also found that the protocol—developed by researchers at Cedars-Sinai, in Los Angeles—was more effective at controlling pain than standard care with opioids (Sci Rep 2023;13[1]:22396).
Pain is a major symptom in most hospitalized IBD patients, and it’s routinely treated with opioids. But these drugs have significant risks, including misuse, overdose, inadvertent diversion, as well as infection, hospital readmission, and even death.
“Despite these risks, patients with IBD receive opioids more often than [those with] any other chronic GI condition,” said Sameer Berry, MD, the lead study investigator, who is now a clinical assistant professor in the Department of Medicine at the NYU Grossman School of Medicine, in New York City. “While many hospitalized patients with IBD will require opioid medication for pain control, we must explore nonopioid analgesic options to help mitigate associated risks and improve long-term pain control in our patients.”
After conducting a literature review on pain management and researching analgesic protocols used in other conditions similar to IBD, Dr. Berry and his co-investigators developed the Proactive Analgesic Inpatient Narcotic-Sparing (P.A.I.N.-Sparing) protocol. The approach relies on scheduled nonopioid pain medications tailored to the severity of a patient’s pain (Figure). However, patients have the option to request opioid medication for uncontrolled breakthrough pain.
To test the efficacy of the P.A.I.N.-Sparing protocol, they randomized 33 patients with IBD to be treated with the P.A.I.N. protocol or usual care with opioids.
Both groups reported significant reductions in pain from admission to discharge, but those in the intervention group tended to have lower pain scores (3.02±0.90 vs. 4.29±0.81; P=0.059) and used significantly less opioids (average daily morphine milligram equivalents, 11.8±15.3 vs. 30.9±42.2; P=0.027).
With regard to mobility, patients treated under the protocol also had a significantly higher step count by day 4 in the hospital (2,330±1,709 vs. 1,050±1,214; P=0.014).
These findings are significant, said Gil Melmed, MD, the senior investigator of the study and director of inflammatory bowel disease clinical research at Cedars-Sinai. They demonstrate that “a proactive pain control bundle for hospitalized patients with IBD can improve pain and lead to overall better outcomes, including physical activity in the hospital, and at the same time reduces the use of opioids, which are associated with so much potential for harm.”
Anita Afzali, MD, a professor of clinical medicine in the Division of Digestive Diseases at the University of Cincinnati College of Medicine, agreed, saying the research “provides a helpful guide to proactively manage pain for patients hospitalized with IBD.
Dr. Afzali, who was not involved in the study. told Gastroenterology & Endoscopy News that “the P.A.I.N.-sparing protocol applied in this study demonstrates a useful and methodical approach to assess, evaluate and manage pain control from hospital admission to discharge.”
Of note, the intervention protocol included only pharmacologic interventions, but the researchers said that nonpharmacologic strategies currently being studied, including biofeedback and virtual reality, also could be incorporated into a proactive approach to relieve pain and discomfort in hospitalized IBD patients.
—Ashley Welch
Drs. Afzali and Berry reported no relevant financial disclosures. Dr. Melmed reported financial relationships with AbbVie, Arena, Boehringer-Ingelheim, BMS, Dieta, Ferring, Fresenius Kabi, Gilead, Janssen, Merck, Oshi Health, Pfizer, Prometheus Labs, Samsung Bioepis, Takeda, Techlab, Viatris and Venkata.
This article is from the April 2024 print issue.