Editorial: Toward Safer Pain Management in IBD—Lessons From Prescription Patterns. Authors' Reply

Abstract

We welcome the editorial in response to our work on pain and sedative medication use in inflammatory bowel disease (IBD) [1, 2]. Chronic pain remains one of the most challenging and under-managed aspects of living with IBD, despite therapeutic advances in inflammation control over the past decade.

The need for effective, safer alternatives to opioids is clear. Neuromodulators including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs)—have been increasingly used in clinical practice to target the central pain mechanisms of the gut-brain axis [3]. These agents offer a plausible pharmacological alternative in IBD based on their success in other chronic pain syndromes, such as irritable bowel syndrome (IBS), fibromyalgia, and neuropathic pain.

However, the current evidence base for the use of neuromodulators in IBD-specific pain remains limited and mixed [4]. Intermittent and continuous neuromodulator use is associated with similar or higher rates of corticosteroid use, respectively, which may be attributable to a more severe disease phenotype in individuals requiring neuromodulator prescriptions [5]. TCAs may modestly improve global well-being in individuals with inactive or mild disease, and their established efficacy in IBS may have relevance for patients with IBD-IBS overlap [3, 4] In a cohort study, neuromodulator use in IBD was associated with higher corticosteroid use, and more frequent emergency department visits and hospitalisations, although not IBD-related complications [6]. Notably, neuromodulator use was also linked to a reduced risk of surgery. In a systematic review and meta-analysis of 11 studies, neuromodulators significantly improved depressive symptoms and quality of life in individuals with IBD compared to placebo [7]. While SNRIs may improve anxiety-related symptoms, their impact on pain in this population has not been formally studied.

Pain symptoms persist even in endoscopic remission, and patients consistently rate pain and fatigue among their most burdensome symptoms. Improving symptom control is essential to holistic care and aligns with the broader goals of treat-to-target strategies, which now extend beyond inflammation alone [8]. Alongside developing new advanced therapies for treating inflammation, a well-designed randomised controlled trial of neuromodulators for IBD-related pain should be a research priority, given the potential for neuromodulators to reduce opioid reliance and improve quality of life.

A further consideration is the potential role of psychological interventions in managing pain and related symptoms in IBD. These approaches have shown potential in recent IBD studies, for example self-directed cognitive behavioural therapy in a sub-population with coexistent IBS in the recently conducted IBD BOOST RCT and resilience training using the “Gaining Resilience Through Transitions” program [9, 10]. These may offer an effective alternative, or adjunct to, neuromodulators.

In conclusion, while neuromodulators hold promise as a strategy for managing chronic pain in IBD, we currently lack definitive evidence to support their widespread use. A pragmatic, multicentre RCT is warranted to inform clinical guidelines and reduce reliance on opioids and sedatives. Without such data, we risk continuing to overlook a major unmet need in the care of people with IBD.

Samantha Baillie: conceptualization, writing – original draft. Jonathan Blackwell: conceptualization, writing – review and editing. Richard Pollok: writing – review and editing, conceptualization.

This article is linked to Baillie et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70247 and https://doi.org/10.1111/apt.70263.