Narcotic Bowel Syndrome Research Articles

P1073 Opioid use Before and After First Diagnosis of Crohn’s Disease: A Swedish Nationwide Cohort Study 2008-2020

Abstract Background The ongoing opioid misuse epidemic, initially sparked by over-prescription, presents challenges in managing severe pain in Crohn’s disease (CD). Despite associated negative effects, such as narcotic bowel syndrome and susceptibility to chronic use, opioids are frequently prescribed for CD patients. However, data on the evolution of opioid use before and after the initial CD diagnosis in a European context are limited. Methods This nationwide cohort study utilized the Swedish Patient Register to identify adults with a first CD diagnosis between 1 January 2008 and 31 December 2017, residing in Sweden at least two years before and three years after the diagnosis. For each CD patient, we included up to 10 reference individuals from the general population matched on birth year, sex, calendar year, and place of residence. Data on dispensed opioid prescriptions were retrieved from the National Prescribed Drug Register. Opioid use history was categorized into non-users (no dispensations), intermittent users (≥1 dispensation in 1–3 periods), and chronic users (≥1 dispensation in all periods) based on the four preceding six-month periods before the first CD diagnosis. Opioid use per six-month period was estimated from two years before to five years following CD diagnosis (corresponding index date for matched reference individuals) and coarsened exact matching was employed to account for confounding (birth year, sex, education, and history of psychiatric disorders and cancer). Results We included 12,539 incident CD patients and 116,073 matched reference individuals. During the two years before the first CD diagnosis, CD patients (and 3.9% vs 10.4% and 1.4%, respectively) were more often intermittent (22.3% vs 10.4%) or chronic (3.9% vs 1.4%) opioid users than matched reference individuals. Prior to diagnosis, opioid use per six-month period was twice as common among CD patients than in reference individuals. Following a peak in the first year after the diagnosis, the prevalence of dispensed opioids per six-month period stabilized at a three-fold level among CD patients (13.6%; 95% CI: 13.0, 14.3) compared with the reference individuals (5.5%; 95% CI: 5.4, 5.7) (Figure 1). The 6-month prevalence of opioid use five years after CD diagnosis was 7.6% (95% CI: 7.0, 8.2), 22.9% (95% CI: 21.1, 24.6), and 79.5.4% (95% CI: 73.2, 85.7) for CD patients classified as non-users, intermittent, or chronic users two years before diagnosis, respectively. Conclusion CD patients exhibited elevated opioid use two years before their initial diagnosis, which persisted at a three-fold level compared to matched reference individuals for five years post-diagnosis. This pattern persisted despite publicly-funded healthcare and modern CD therapy accessibility.

Postoperative Pain Management in Patients With Ulcerative Colitis.

Inflammatory bowel disease (IBD) is a group of chronic inflammatory disorders of the gastrointestinal tract including ulcerative colitis (UC) and Crohn's disease. Pain management can be challenging in patients with IBD because there are limitations on the use of analgesics. Use of nonsteroidal anti-inflammatory drugs is not recommended in patients with IBD because there is risk of relapse of IBD and an overall increase in disease activity. Opioids, although frequently used for treating severe acute pain, can have additional risks and complications in patients with IBD such as ileus, toxic megacolon, and narcotic bowel syndrome. Furthermore, little information is available in the literature on pain management in these patients undergoing noncolorectal surgery. This report describes 2 patients with UC in whom postoperative pain following oral and maxillofacial surgery was managed by intravenous patient-controlled analgesia with pentazocine. Apart from the development of acute dystonia in 1 case that was likely due to the use of droperidol for prevention of postoperative nausea and vomiting, postoperative pain was well controlled by pentazocine in both patients without any complications or UC exacerbations.

Disorders of gut-brain interaction and the long-term risks of opioids.

Prescription opioid abuse has become a public health crisis. It is often challenging to manage affected patients as their symptoms are often viewed through a prism of complex psychosocial issues. Clinicians are often unaware of the lack of evidence regarding opioid prescribing for non-cancer pain, and these trends in prescribing have been significantly escalated by pharmaceutical companies and prescribing culture in recent years. Opioid prescribing in the context of disorders of gut-brain interaction (formerly known as functional gastrointestinal disorders) can worsen conditions such as centrally-mediated abdominal pain syndrome and narcotic bowel syndrome. Opioids should not be prescribed to these patients as the harm is significantly greater than the benefit. However, in certain patients, such as those being investigated for organic abdominal pain, a trial of opioids may be indicated. In these groups, an opioid contract should be used, in addition to risk tools to identify those most vulnerable to the negative effects of these drugs. Prevention and treatment of the long-term effects of opioids requires a multidisciplinary approach and health-care professionals should all become 'opioid aware'.

Implications of the Opioid Epidemic for the Clinical Gastroenterology Practice.

The opioid epidemic in the USA has led to a rise in opioid-related gastrointestinal (GI) side effects that are often difficult to diagnose and treat. The aim of this report is to discuss opioid pathophysiology, opioid-related GI side effects, clinical presentation, and diagnostic criteria and to review the current pharmacotherapy available. Opioid-related GI disorders are increasingly recognized and include, but are not limited to, opioid-induced esophageal dysfunction (OIED), gastroparesis, opioid-induced constipation (OIC), narcotic bowel syndrome (NBS), acute post-operative ileus, and anal sphincter dysfunction. Treatment of these conditions is challenging. OIC has the most available pharmacotherapy for treatment, including classical laxatives, peripherally acting μ-receptor antagonists (PAMORAs), novel therapies (lubiprostone, prucalopride- 5-HT agonist), and preventative therapies (PR oxycodone/naloxone). The gastrointestinal effects of opioid therapy are variable and often debilitating. While medical management for some opioid-related GI side effects exists, limiting or completely avoiding opioid use for chronic non-cancer pain will mitigate these effects most effectively.

PMS45 OPIOID USAGE AND PATIENT-REPORTED PAIN SCORES IN OSTEOARTHRITIS PATIENTS: A RETROSPECTIVE ANALYSIS OF A LARGE US ELECTRONIC HEALTH RECORD DATABASE

Osteoarthritis is a chronic degenerative disease characterized by pain, stiffness, swelling, and reduced mobility. Pain management presents a major challenge for patients, with opioid use being prevalent. However, opioids are associated with multiple complications including narcotic bowel syndrome and opiate dependency. The objective of the present study was to examine opioid usage within an osteoarthritis patient cohort stratified by type of visit and patient-reported pain scores. This retrospective study examined data from a U.S. electronic health record database (Cerner Health Facts®). Each patient visit (age ≥ 18 years) with a principal ICD9/10 diagnosis of osteoarthritis between 2012 and 2016 were included. Visit-based data for medications were examined for this cohort. ‘Opioid analgesics’ were identified as per the VA drug classification system (2016). The highest pain score per visit (Numeric Pain Scale 0-10) was used to assign a pain group (mild/moderate/severe) for every visit. The study included 1.35 million osteoarthritis visits (62% female, 38% male), with a mean (standard deviation) age of 62.1 (13.3) years. Of the total visits, 16% (N=210,681) were inpatient stays. Opioid analgesics were prescribed in 15% (N=206,024) of total visits and in 80% (N=169,106) of all inpatient stays. Pain scores were available in 15% (N=198,951) of total visits, with patients reporting severe pain in 53% (N=105,068) of those visits. Opioid analgesics were prescribed in 20% (N=7,305), 28% (N=16,029), and 43% (N=45,488) of visits with a mild, moderate, or severe pain score, respectively. This large database analysis examines patient-reported pain scores and opioid usage for osteoarthritis-related visits and provides initial insights into potentially relevant medication prescribing practices in both inpatient and non-inpatient settings. It highlights opioid use even in mild and moderate pain, especially when there are other non-opioid options indicated. Given the current opioid epidemic, there may be opportunities for improved prescribing.

258 - Peripheral Mechanism of Narcotic Bowel Syndrome: Pathophysiological Role of Opioid-Induced Fecal Retention

258 - Peripheral Mechanism of Narcotic Bowel Syndrome: Pathophysiological Role of Opioid-Induced Fecal Retention

Lead poisoning with presentation of acute abdomen and narcotic bowel syndrome in opium user woman

Lead poisoning with presentation of acute abdomen and narcotic bowel syndrome in opium user woman

Opioid misuse in gastroenterology and non-opioid management of abdominal pain.

Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates. Chronic opioid use for noncancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction. This Review summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain-gut axis. Guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders are also discussed. As chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best.

Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits.

The use of opioid medications on both an acute and chronic basis is ubiquitous in the United States. As opioid receptors densely populate the gastrointestinal tract, symptoms and side effects can be expected in these patients. In the esophagus, dysmotility may result, manifesting with dysphagia and a syndrome indistinguishable from primary achalasia. In the stomach, a marked delay in gastric emptying may occur with postprandial nausea and early satiety. Postoperatively, particularly with abdominal surgery, opioid-induced ileus may ensue. In the colon, opioid-induced constipation is common. A unique syndrome termed narcotic bowel syndrome is characterized by chronic abdominal pain often accompanied by nausea and vomiting in the absence of other identifiable causes. With the recognition of the important role of opioids on gastrointestinal function, novel drugs have been developed that use this physiology. These medications include peripheral acting opioid agonists to treat opioid-induced constipation and combination agonist and antagonists used for diarrhea-predominant irritable bowel syndrome. This review summarizes the most recent data in these areas.

A Case of Narcotic Bowel Syndrome

Narcotic bowel syndrome (NBS) is becoming increasingly recognized although it is a challenging and under-diagnosed condition. It is characterized chronic or recurrent and unresolving abdominal pain associated with escalating doses of narcotic pain medications. A 64-year-old male patient with a history of unremitting chronic abdominal pain despite extensive negative organic gastrointestinal workup, on high extremely dose opioids presented to the hospital with continued abdominal pain and new onset explosive diarrhea for seven days. On admission, he was normotensive and afebrile. Abdominal examination revealed a soft, diffusely tender to palpation, distended abdomen with normal bowel sounds. Laboratory workup showed normocytic normochromic anemia, no leukocytosis, and liver and kidney function within normal limits. KUB showed dilated loops of bowel. CT abdomen revealed distention of the entire colon, measuring up to 9.3cm at the level of the distal transverse colon without small bowel or colonic obstruction and no evidence of bowel ischemia (Figure A). Patient had positive Clostridium difficile polymerase chain reaction (PCR) for which he was treated. Repeat Clostridium difficile PCR was negative. Flexible sigmoidoscopy revealed dilated colon without pseudomembranes (Figure B). Despite treatment of CDI, patient continued to endorse abdominal pain and distention during hospitalization and on follow up. The diagnostic criteria for NBS is chronic or intermittent abdominal pain, sometimes severe, as the predominant symptoms with at least three of the following; pain worsens or dose not resolved with continued or escalating doses of narcotics; the episodes of pain have a progression of frequency, duration and intensity; when the narcotic dose wanes, a markedly intense pain is felt which improves with reinstitution of narcotic; other causes of gastrointestinal etiology for the pain have been ruled out or cannot be explained otherwise. The patient population that develops NBS is often originally prescribed opioids for intra-abdominal or extra-abdominal etiology. Over time, abdominal pain develops or worsens. The best treatment for NBS is to de-escalate opioid doses and frequency. The persistence of chronic, intermittent, crampy abdominal pain especially when symptoms worsen with effects of narcotics wear off should prompt physicians to keep narcotic bowel syndrome very high on the differential even when faced with concomitant infections.Figure 1Figure 2

Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction

Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction

Centrally Mediated Disorders of Gastrointestinal Pain

Centrally Mediated Abdominal Pain Syndrome (CAPS), formerly known as Functional Abdominal Pain Syndrome, can be distinguished from other functional GI disorders by its strong central component and relative independence from motility disturbances. CAPS is a result of central sensitization with disinhibition of pain signals rather than increased peripheral afferent excitability. A newly described condition, Narcotic Bowel Syndrome (NBS)/Opioid-Induced GI Hyperalgesia, is characterized by the paradoxical development of or increases in abdominal pain associated with continuous or increasing dosages of opioids. Patients only have relief when opioids are withdrawn. We define both conditions in the context of epidemiology, pathophysiology, clinical evaluation and treatment, emphasizing the importance of a physician-patient relationship in all aspects of care.

Coalescent Cyclical Vomiting: A Manifestation of Narcotic Bowel Syndrome?

This illustrative case suggests mechanisms that may contribute to disease progression and complications in adults with Cyclical Vomiting Syndrome (CVS). Symptoms initially fol- lowed a characteristic pattern in the context of marijuana use and led to repeated hospitaliza- tions. Escalating opioid use for pain control resulted in coalescence of the syndrome with more frequent and severe emetic episodes, ultimately complicated by an esophageal microperfora- tion. While analgesic therapy may play an important role in management of acute exacerba- tions, ongoing use of narcotics may contribute to the development of refractory CVS. This association of disease progression with opiates suggests that coalescent CVS should be consid- ered a foregut manifestation of narcotic bowel syndrome.

PWE-243 Narcotic bowel syndrome: a local experience of the hidden burden

Introduction The use of prescribed narcotic drugs has escalated throughout UK. There are 220,000 people within the Luton CCG catchment area and between June–November 2014, 32,956 prescriptions had been provided for strong opioid therapy. Not only is this a costly unchecked market, but much of this is taken for abdominal pain. Narcotic Bowel Syndrome (NBS) is under recognised and believed to be increasing in prevalence worldwide. NBS is a subset of opioid bowel dysfunction that is characterised by chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. We attempted to assess the demand placed on the NHS system by NBS patients. Method In 2014 we started to collect the names of patients seen in gastroenterology clinics or during hospital admission where the clinician felt the patient was suffering from NBS. This was either thought to be the main cause or contributing factor to their symptomatology. A 12 year retrospective review was then made using the hospital coding system to assess the demand made by these patients on the Luton and Dunstable University Hospital through either outpatient clinic visits and/or hospital admissions. Results A database collated the names of 41 patients with NBS. Between January 2000 and December 2014 this cohort of patients have had a total of 660 hospital admissions and 1407 outpatient appointments. In that 15 year time period, the patients had an average of 16 hospital admissions (1.1 per year) each, and 34.3 outpatient clinic appointments each (2.3 per year). During this review period 2 patients died; one 46y old male died from a definite overdose, and one 33y old died from a probable overdose. Conclusion NBS is a poorly recognised condition that places a huge demand on the NHS system with regards to time, resources and finances. Early recognition could prevent a costly and potentially fatal pathway of deterioration. Disclosure of interest None Declared.

PWE-244 The financial burden of narcotic bowel syndrome: a local experience

<h3>Introduction</h3> Narcotic drugs are widely prescribed by both GPs and hospital physicians, but little consideration is afforded to the potential longterm issues when starting patients off on these addictive therapies. has escalated throughout UK. Between June–November 2014, 32,956 prescriptions had been provided for strong opioid therapy in the Luton CCG catchment area. Not only is this a costly unchecked market, but much of this is taken for abdominal pain. Narcotic Bowel Syndrome (NBS) is under recognised and believed to be increasing in prevalence worldwide. NBS is a subset of opioid bowel dysfunction, characterised by chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. We attempted to assess some of the financial cost implications of this condition on our local district general hospital in 2014. <h3>Method</h3> In 2014 we started to collect the names of patients seen in gastroenterology clinics or during hospital admission where the clinician felt the patient was suffering from NBS. This was either thought to be the main cause or contributing factor to their symptomatology. During that year a retrospective analysis was performed reviewing the burden and cost of outpatient appointments and inpatient hospital admissions, using the hospital coding system and financial analysis. <h3>Results</h3> A database collated the names of 41 patients with NBS. From the 1st of January to the 31st of December 2014, this cohort of patients made 78 hospital admissions (1.9 per patient) with an average length of stay (LOS) of 4.1 days. This was costed at £91,310, or an average of £2,227 per patient per year. In addition to that the same 41 patients made 159 outpatient appointments (3.9 per patient), costing £15,639, or an average of £381 per patient per year. This small group of 41 patients cost a total of £106,949 in 2014 or an average of £2,608 per patient per year, in hospital inpatients admissions and outpatient appointments alone, before adding in their prescription costs. <h3>Conclusion</h3> NBS is a poorly recognised condition that places a huge demand on the NHS system with regards to time, resources and finances. The prevalence of this condition is thought to be increasing. Early recognition could prevent a costly and potentially fatal pathway of deterioration. On average the annual financial cost of hospital base care for each NBS patients is £2,608. <h3>Disclosure of interest</h3> None Declared.

OC-050 Panenteric capsule endoscopy: whole gut visualisation without intubation

Introduction Capsule endoscopy (CE) is a well-tolerated, first line small bowel (SB) investigative modality. A specifically adapted version is available to image the colon, thus providing an option for non-invasive, single visit imaging of the entire gastrointestinal tract. This study evaluates a novel panenteric protocol utilised to investigate patients with symptoms which could originate from the SB, large bowel or both sites. Method Retrospective, single centre, involving consecutive patients attending for panenteric CE between July 2008 and December 2014. PillCam SB (Given Imaging, Israel) or MiroCam (Intromedic, Korea) and PillCam Colon 2 (Given Imaging) were used. All patients with known inflammatory bowel disease (IBD) successfully passed a PillCam Patency device prior. Patient demographics, procedural data, final diagnosis and outcomes were collected. Results 108 procedures were performed, mean age 41.5 years (range 16–95), 72 female, median follow up 27 months (range 2–79). 41 patients had known IBD (37 Crohn’s, 4 ulcerative colitis (UC)) and were undergoing disease re-assessment after 12 months of anti-TNF therapy (12), or due to relapse in symptoms (29). The remaining 67 patients had suspected IBD with predominant symptoms of diarrhoea (33), abdominal pain (15), iron deficiency anaemia (8), weight loss (6) and gastrointestinal bleeding (5). 51 patients refused colonoscopy, 37 chose CE over colonoscopy, 17 had an incomplete colonoscopy and 3 were unfit for colonoscopy. Panenteric capsule endoscopy completion rate (CECR) was 60.1% (65/108), SB CECR 86.1% (93/108) and colon CECR 71.3% (77/108). Colon CE bowel preparation was graded as good or excellent in 61.8%. 2 patients were excluded due to prolonged gastric retention of the colon capsule, 1 subsequently diagnosed with narcotic bowel syndrome. No complications were encountered. In the IBD group, 25 patients (61.0%) had evidence of active disease, leading to medication alterations in 21, surgery in 1 and conservative management in 3. Of the 16 patients in whom mucosal healing had been achieved, medication regimens were downgraded in 10 patients. In the suspected IBD group, this was identified in 13.4% (7 Crohns, 2 UC). Clinically relevant alternative findings included colon polyps (16), diverticular disease (9 colonic, 1 SB), angioectasia (6 SB, 1 colonic), and a small bowel carcinoid (1). The remaining 24 patients were diagnosed with functional bowel disorders and discharged. Of all the 34 patients with IBD identified, 22 had ileitis alone, 5 had ileocolonic disease and 7 had colonic disease alone. Conclusion Panenteric capsule endoscopy is feasible and can be performed safely in patients known to have IBD. It can be used to guide management without resorting to conventional endoscopy and identifies pathology in all areas of the GI tract. Disclosure of interest None Declared.

(467) Complete relief of chronic abdominal pain after rapid detoxification of oral and intravenous opiates: a case report

Chronic abdominal pain can be one of the most frustrating diagnoses to treat for the pain physician. Patients tend to have varied success with interventional procedures and are often started on chronic opiates. This can very easily lead to complications such as narcotic bowel syndrome or opioid induced hyperalgesia stemming from central sensitization and hyperalgesia. We present the case of a 27 year-old female that had chronic abdominal pain since 2010 from autoimmune hepatitis, primary sclerosing cholangitis and gastroparesis.

Pain management in patients with inflammatory bowel disease: translational approaches from bench to bedside.

Abdominal pain is a common symptom in patients with inflammatory bowel disease (IBD) that negatively affects quality of life and can lead to increased health-seeking behavior. Although abdominal pain has been traditionally attributed to inflammation, there is growing literature demonstrating the existence of functional abdominal pain in patients with IBD, of which there are a variety of potential causes. Thus, when approaching a patient with IBD who has abdominal pain, in addition to IBD-related complications (e.g., inflammation/stricture), it is important to screen for related contributors, including peripheral factors (visceral hypersensitivity, bacterial overgrowth, and bowel dysmotility) and centrally mediated neurobiological and psychosocial underpinnings. These central factors include psychological symptoms/diagnoses, sleep disturbance, and stress. Opioid-induced hyperalgesia (e.g., narcotic bowel syndrome) is also growing in recognition as a potential central source of abdominal pain. This review draws from clinical studies and animal models of colitis and abdominal pain to consider how knowledge of these potential etiologies can be used to individualize treatment of abdominal pain in patients with IBD, including consideration of potential novel treatment modalities for the future. Accurate assessment of the source(s) of pain in patients with IBD can help guide appropriate diagnostic workup and use of disease-modifying therapy.

Predictors of Sleep Disturbance Amongst Adult IBD Patients

Introduction: Sleep disturbances are common among patients with inflammatory bowel disease (IBD). Our objectives are to (1) determine the rates of sleep disturbance in our adult IBD patients using the Pittsburgh sleep quality index (PSQI), (2) assess the structure of the PSQI in this population to evaluate if certain items cluster together, and (3) evaluate predictors of sleep disturbance. Methods: This was a prospective observational study of IBD patients seen over a 3-year period in our IBD center. Demographic information, IBD phenotype, disease activity [Harvey Bradshaw index (HBI) for Crohn’s disease (CD) and ulcerative colitis activity index (UCAI) for UC], and quality of life (SIBDQ) were collected. Medication use including IBD medications, narcotics, and antidepressants was documented. Sleep quality was assessed using the PSQI and sleep disturbance was defined as a total PSQI score >5. Factor analysis was performed on the subscales of the PSQI. Multivariable linear regression was used to assess which clinical variables are most important in the prediction of poor sleep. Results: A total of 671 adult IBD patients were included: mean age 44.1 years (SD 14.2), 46.3% male, and the majority with CD (62.4%). Nineteen percent of patients were on narcotics and 31% on prednisone. The mean PSQI score was 6.8 (4.3) with 61% of subjects having a score consistent with a sleep disturbance. Mean SIBDQ score was 50.8 (12.9), mean HBI for CD patients was 4.5 (4.3) and mean UCAI for UC patients was 4.1 (4.8). Factor analysis of PSQI demonstrated a 2-factor solution. The first factor, termed “insomnia” included sleep efficiency, duration, latency, and subjective quality while the second factor termed “fatigue” consisted of daytime dysfunction and sleep disturbance (awakenings). For total PSQI score, 41.5% of the total variance was accounted for by age, quality of life and IBD activity (p=0.004) with only quality of life making a significant contribution. The “insomnia” factor showed a significant association with age and quality of life while the “fatigue” factor was significantly predicted by disease activity. Patients on narcotics had poorer sleep than those not on narcotics but steroid treatment for IBD did not significantly impact sleep disturbance. Conclusion: Sleep disturbance is a complex behavior. It is common in IBD and is associated with narcotic use, active disease, and poor quality of life. Further study is required to understand the impact of poor sleep hygiene on inflammation and response to IBD treatment. Disclosure - Eva Szigethy, MD - Research grant from Crohn and Colitis Foundation of America (CCFA) and honorarium from GI health foundation to write a review on narcotic bowel syndrome. Jana G. Hashash, MD, Claudia Rivers, MD, Ada Youk, PhD, Wai Kan Chiu, PhD, Laci Altman, Greg Thorkelson, MD, David G. Binion, MD, and Miguel D. Regueiro, MD, FACG - have no financial disclosures.

Narcotic bowel syndrome and opioid-induced constipation.

Prescription opioid use for chronic non-cancer pain has reached epidemic levels in the USA. With this increased use is the recognition of serious opioid-related gastrointestinal complications such as narcotic bowel syndrome (NBS) and opioid-induced constipation (OIC). NBS consists of a paradoxical worsening of abdominal pain with escalating doses of opioids and is likely mediated by the central nervous system. Therapy requires an intensive multidisciplinary approach to detoxification. OIC is the most common gastrointestinal side effect of opioids. Several novel therapeutics are available to treat OIC that fails to respond to laxative therapy. This review will summarize recent findings on the pathophysiology and treatment approaches to NBS and OIC with a focus on controversies about diagnosis and intervention.