Sabita Roy, PhD, a microbiologist, and Maria Abreu, MD, a gastroenterologist, both at the University of Miami Health System, wanted to find out if opioids make IBD inflammation worse or if people with worse inflammation simply need more opioids to make it through their day. Drs. Roy and Abreu induced IBD in a group of mice and brought them to identical stages of symptom severity. Then they gave some of the mice doses of opioid painkillers and observed how their symptoms developed. The results were clear. Mice that received the medication developed much worse IBD symptoms compared with those that did not get opiods. “This is obviously a very important clinical issue,” Abreu says. “Yes, pain is a major part of the disease, but we don’t want to be making the disease worse by treating the pain.” Roy adds, “In fact, [opioids] have a number of deleterious effects on the digestive system.” One of the effects she highlights is how opioids can change the microbiome. The drugs throw off the delicate balance of bacteria in the gut by stimulating the growth of harmful microbial communities. Even in healthy people, that can cause problems. For people with IBD, it could be dangerous: A surge in harmful bacteria may stimulate an inflammatory response from the immune system. If it grows severe enough, the resultant flare-up could require hospitalization. Opioids can also damage the lining of the gastrointestinal tract. This can result in a little-understood condition called leaky gut syndrome, which can severely aggravate the symptoms of IBD. For now, the researchers can’t say for certain if these mechanisms are behind the worsening symptoms in their mice. But their research shows that people with IBD — and their care providers — should approach opioids with caution.
If Not Opioids, Then What?
The researchers have some recommendations for pain relief for people with IBD, as well as some direction for future research. First, they point out that not all opioids are the same. While all opioids can be harmful in high doses, morphine-related drugs cause more problems than those related to codeine. “This is a very important observation, especially for hospital settings,” Abreu says. “Our first line of defense there is hydromorphone," which is often referred to as Dilaudid, a morphine-derived painkiller. It is short acting and wears off quickly. “So,” Abreu continues, “patients need another dose pretty soon, and every dose actually makes the underlying problem worse. It’s a vicious cycle.” Outside the hospital setting, Abreu recommends sticking to the absolute minimum dose of opioids required to function. Roy, in turn, suggests that people with IBD who are taking opioids might benefit from ingesting probiotic foods or supplements because they promote the growth of healthy gut bacteria, countering the imbalance induced by opioids. Finally, both researchers broached the subject of alternative pain relief. “More patients should consider therapies like acupuncture,” Abreu says. “It may increase our natural threshold for pain.” These findings may worry people with IBD who are in need of pain relief. When they experience a bad flare-up, opioids are often the only comfort available. “The fact is there’s nothing better for pain management,” Roy says. “No other class of drugs provides even close to the same level of relief. But going forward, we as researchers need to find out how to get the benefits of opioids without the negatives.”
