Editorial: Toward Safer Pain Management in IBD—Lessons From Prescription Patterns

Abstract

Pain is reported by roughly two-thirds of patients with inflammatory bowel disease (IBD) [1]. Chronic pain impairs quality of life and psychosocial wellbeing, and increases pain medication use [2]. Acetaminophen/paracetamol, NSAIDs and opioids are commonly used in practice but are associated with adverse effects and outcomes [3]. Despite this, data on the prevalence and scope of pain medication use in IBD remain limited. This editorial discusses the timely and relevant study by Baillie et al. [4] which explored trends in pain and sedative medication use in IBD in the UK.

Using Clinical Practice Research Datalink-GOLD, the authors filled a much-needed gap in our understanding, particularly in Europe, of global prescription and co-prescription patterns of benzodiazepines, Z drugs (non-benzodiazepine hypnotics acting at the benzodiazepine receptors, commonly prescribed for sleep difficulties) and gabapentinoids for pain management in IBD and identified risk factors for harm. They examined prescriptions of 4901 patients over a 5-year follow-up period, focusing on opioid potency and chronicity, and the use of benzodiazepines and Z drugs. Between 2010 and 2019, chronic prescription of strong and weak opioids, gabapentin and Z drugs increased, while benzodiazepine prescriptions declined. Co-prescriptions, especially with gabapentinoids, also increased. Chronic prescribing of strong opioids was most common in Crohn's disease. Older age of diagnosis, female sex, current smoking, anxiety/depression and fibromyalgia prior to diagnosis were significantly associated with long-term and co-prescribing patterns.

While the longitudinal follow-up and large sample size are key strengths of the study, the lack of data on indications for prescription and co-prescription limits interpretation. While concerns around dependence and overdose with co-prescriptions are valid, the benefits of reducing opioid use through cautious gabapentinoid co-prescriptions should not be overlooked [5, 6]. Furthermore, there is no data on the use of adjuvant therapies such as neuromodulators, antispasmodics, or lifestyle interventions often used in North America to reduce chronic opioid use [2, 7].

Pain management in IBD is challenging due to its relapsing–remitting course often leading to persistent chronic pain [7]. Effective pain management (Table 1) requires an understanding of its underlying mechanisms. Distinguishing visceral pain from gut inflammation versus centrally-mediated neuropathic or functional pain is essential. It is also important to consider common co-existing painful conditions such as irritable bowel syndrome and psychosocial drivers of pain [8, 9].

While the decline in chronic benzodiazepine prescription is encouraging, the increase in the chronic prescriptions of opioids, gabapentinoids and Z drugs is concerning due to risks of dependence, paradoxical worsening of pain and harmful adverse effects from co-prescriptions. In this context, early use of neuromodulators may offer a safer and more effective approach to managing chronic pain in IBD—especially when accompanied by anxiety, depression and functional disorders [10]. Therefore, effective care involves not merely the absence of pain medication, but a culture of proactively assessing and addressing pain and its risk factors early through patient-centric discussions, self-management strategies and referral to psychosocial care [2, 7]. Overall, a deeper understanding of pain coupled with integrated care models with screening and early referral to psychosocial care can be instrumental for effective pain management and improved outcomes.

Shabari Shenoy: conceptualization, writing – review and editing, writing – original draft. Laurie Keefer: conceptualization, writing – review and editing.

L.K. reports research grants from Ardelyx and the Leona M. and Harry B. Helmsley Charitable Trust, is a consultant for AbbVie, Eli Lilly, Pfizer and Janssen, and is an equity owner/co-founder/consultant for Trellus Health. S.S. declares no conflicts of interest.

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.70304.