According to the NIH, up to 70 million Americans suffer from digestive conditions that end up impairing their daily functions. While many recover, others are forced to adapt their lives around certain more chronic conditions including, but not limited to, Crohn’s Disease, IBS, IBD, and Ulcerative Colitis. Considering that there are so many people affected by these conditions, it is important to understand how opioid use and opioid withdrawal interact with conditions of the gastrointestinal system.
Certain opioids have shown to be effective as treatments for IBS symptoms. This reflects a broader understanding that opioids have some function in treating dysfunction of the gastrointestinal system, like the long-standing use of opium as a treatment for dysentery (Corazziari, 1999). In current use, drugs like fentanyl have been shown to reduce pain thresholds in patients with IBS to a greater extent than with non-patients (Lembo et al., 2000). The opioid trimebutine has shown in clinical trials to be effective in treating the diarrhea associated with IBS (Corazziari, 1999). Despite these effective medical usages, the use of opioids for treating conditions of the gastrointestinal system is of course limited by the effects of opioid withdrawal (Spahn et al., 2013).
Opioid withdrawal is associated with abdominal pain and other markers of GI dysfunction, especially constipation. It seems that opioid withdrawal can inhibit bowel secretion and peristalsis, which would lead to this hallmark symptom of constipation (Holzer, 2007). Somewhat contrary to the increased pain tolerance associated with opioid use, opioid withdrawal is associated with hyperalgesia, severe sensitivity to pain. This symptom seems to arise from sensitization of the TRPV1 receptor, the same receptor bound by capsaicin, the ‘hot’ compound of peppers (Spahn et al., 2013). Paired with constipation, the experience of opioid withdrawal can become almost torturous for the individual, because the pain associated with constipation is only compounded by hyperalgesia. Medications targeting the TRPV1 receptor can make the experience more bearable, but that also would require hospitalization, meaning that treating opioid addiction on one’s own may not be feasible because of these interactions with the gut.
While certain opioids seem to be effective in treating symptoms of IBS, a recent study challenges the effectiveness of opioid use for treating or cases of IBD. In this study, chronic opioid use was associated with more complications present for individuals (Rhudy et al., 2021). These individuals often seem to require more healthcare resources to manage their condition and see worse treatment outcomes overall. From the outcomes of the study, it seems to be possible that chronic opioid use increases the susceptibility of IBD patients to symptomatic flare-ups. But it might also be the case that opioid withdrawal itself is mimicking IBD flare-ups. It is important to note that these not mild symptoms flaring up, they are severe enough to warrant hospitalization.
When these flare-ups are not caused by the IBD, doctors often end up changing treatment plans unnecessarily. This itself can be damaging to a patient’s management of their condition. These hospitalizations are also associated with steroid treatments aimed to manage the flaring up of symptoms, which can have their own issues. And of course these frequent visits to the hospital come with significant financial burdens upon the patient.
Opioids as a category include various drugs which all may interact differently with different GI conditions. Many of these conditions themselves are not completely understood, so it is important to acknowledge that opioids have some usage in treating some of these conditions, but that they also carry some significant risk. For certain GI conditions including IBD, they may end up exacerbating one’s situation and introducing further complications to one’s system. And of course, opioid withdrawal brings significant risks to the usage of these opioids where they may have useful medical applications.
References
Corazziari, E. (1999). Role of opioid ligands in the irritable bowel syndrome. Canadian Journal of Gastroenterology, 13(Suppl A), 71A-75A.
Holzer, P. (2007). Treatment of opioid-induced gut dysfunction. Expert opinion on investigational drugs, 16(2), 181-194.
Lembo, T., Naliboff, B. D., Matin, K., Munakata, J., Parker, R. A., Gracely, R. H., & Mayer, E. A. (2000). Irritable bowel syndrome patients show altered sensitivity to exogenous opioids. Pain, 87(2), 137-147.
Rhudy, C., Perry, C. L., Singleton, M., Talbert, J., & Barrett, T. A. (2021). Chronic opioid use is associated with early biologic discontinuation in inflammatory bowel disease. Alimentary pharmacology & therapeutics, 53(6), 704–711. https://doi.org/10.1111/apt.16269
Spahn, V., Fischer, O., Endres-Becker, J., Schäfer, M., Stein, C., & Zöllner, C. (2013). Opioid withdrawal increases transient receptor potential vanilloid 1 activity in a protein kinase A-dependent manner. Pain, 154(4), 598–608. https://doi.org/10.1016/j.pain.2012.12.026
On Psychology and Neuroscience 
Interesting blog, Furqan. It’s funny how a drug that can alleviate GI symptoms can also exacerbate them. Does this mean that opioids are usually only prescribed for short-term use to prevent further making GI symptoms worse? I’m a bit confused by this section: “Drugs like fentanyl have been shown to reduce pain thresholds in patients with IBS to a greater extent than with non-patients” When you say non-patients, do you mean than those without IBS?
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Thank you! On your first question, that would make sense and given the rise in abuse of prescription pain killers over the years, it would also make sense that opioids are prescribed in the short term. And on your second question, you are correct, by non-patients I meant those without IBS. I realized I made an error in that section, it should read that fentanyl has been shown to increase pain thresholds, meaning that it reduces the perception of pain.
– Furqan
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