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Diagnosis and treatment of narcotic bowel syndrome

Nature Reviews Gastroenterology & Hepatology volume 11, pages 410–418 (2014)Cite this article

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Key Points

  • Narcotic bowel syndrome (NBS) is characterized by incompletely controlled abdominal pain that cannot be explained by another known or previous diagnosis in patients receiving steady or increasing doses of opioids

  • Many patients with NBS have substantial psychiatric comorbidity; potential substance abuse disorders should be assessed and considered in any treatment plan

  • NBS affects ∼5% of patients who are chronically taking opioids

  • The mechanisms of NBS are distinct from the effects of opioids on gastrointestinal motility and are mediated through multiple mechanisms of plasticity in the central nervous system

  • No therapy has proven durable in the majority of patients with NBS; opioid detoxification is promising, but ∼50% of patients relapse within 3 months

  • Future research must focus on the prevention of recidivism in long-term care, including psychosocial interventions when needed

Abstract

With increased prescription of opioids has come increased recognition of adverse consequences, including narcotic bowel syndrome (NBS). Characterized by incompletely controlled abdominal pain despite continued or increasing doses of opioids, NBS is estimated to occur in 4.2–6.4% of patients chronically taking opioids. Patients with NBS have a high degree of comorbid psychiatric illness, catastrophizing and disability; comorbid substance abuse must also be considered among this population. NBS should be distinguished from opioid-induced bowel disorder, which results from the effects of opioids on gastrointestinal motility and secretion. By contrast, the mechanisms of NBS are probably centrally mediated and include glial cell activation, bimodal opioid modulation in the dorsal horn, descending facilitation of pain and the glutaminergic system. Few treatments have been rigorously studied. A trial of opioid detoxification resulted in complete detoxification for the vast majority of patients with reduction in pain symptoms; however, despite improvement in pain, approximately half of patients returned to opioid use within 3 months. Improved strategies are needed to identify patients who will respond to detoxification and remain off opioids. Comorbid psychiatric and substance abuse disorders are barriers to durable response after detoxification and should be actively sought out and treated accordingly. An effective patient–physician relationship is essential.

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Figure 1: The relationship among NBS, OBD and OIC.

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Authors and Affiliations

  1. Division of Gastroenterology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, 48109, MI, USA

    Jacob E. Kurlander

  2. UNC Center for Functional GI and Motility Disorders and Drossman Gastroenterology PLLC, 901 Kings Mill Road, Chapel Hill, 27517, NC, USA

    Douglas A. Drossman

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Both authors contributed equally to all aspects of the manuscript.

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Correspondence to Douglas A. Drossman.

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D.A.D. acts as a consultant for AstraZeneca, Furiex Pharmaceuticals, Ironwood Pharmaceuticals and Takeda, and sits on an Advisory Board for Synergy Pharmaceuticals. J.E.K. declares no competing interests.

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Kurlander, J., Drossman, D. Diagnosis and treatment of narcotic bowel syndrome. Nat Rev Gastroenterol Hepatol 11, 410–418 (2014). https://doi.org/10.1038/nrgastro.2014.53

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