Opiate Use in Hospitalized Patients with IBD Can Be Significantly Reduced Using a Proactive Pain Protocol: Results of a Randomized Controlled Trial

ABSTRACT

INTRODUCTION: Hospitalized patients with inflammatory bowel disease (IBD) are often treated with high doses of opioids, which can lead to opioid dependence, decreased quality of life, and increased mortality. We developed an evidence-based inpatient pain protocol for adults with inflammatory bowel disease (IBD) comprised of scheduled acetaminophen, celecoxib, gabapentin, and as-needed lorazepam (Table 1). In this study, we compared this proactive pain protocol to usual care in a randomized control trial. METHODS: Hospitalized, nonpregnant adults with IBD with abdominal pain and without recent surgery were randomized to the proactive pain protocol or to a standard-of-care reactive pain regimen (as-needed acetaminophen and opioids). Outcomes included daily pain (assessed by numeric rating scores, 0-10), average daily morphine milligram equivalents (MME), length of stay (LOS), need for surgery during admission, and 30-day readmission rates. Intended sample size was 166 subjects, but enrollment was halted early due to lower than expected recruitment and COVID-19 research restrictions. Subjects were analyzed per-protocol. RESULTS: Thirty-three subjects were enrolled;1 withdrew consent and was excluded from analysis. Seventeen were randomized to the proactive protocol and 15 to the reactive regimen (control group). One subject in the control group received the proactive protocol. Baseline demographics, race, type of IBD, CRP, and reason for admission were similar between the two groups. There was a significant decrease in pain over time in both groups (22.8 ± 2.8 points, P < 0.0001). Overall, those receiving the proactive protocol had numerically lower pain scores over the course of hospitalization (3.02 ± 0.90 vs 4.29 ± 0.81, P = 0.059) (Figure 1) and consumed fewer daily MME than controls (13.94 ± 5.96 vs 37.26 ± 10.51, P = 0.02) (Figure 2). There were no differences in LOS (7.3 ± 6.6 vs 7.1 ± 3.5, P = 0.66), surgery during admission (11.1% vs 21.4%, P = 0.63), and readmission (11.1% vs 14.3%, P . 0.99) between the two groups. One subject had emesis after taking celecoxib which stopped after discontinuation;no other adverse events were noted. CONCLUSION: A proactive pain protocol reduces the use of opioids and may also improve overall pain control compared with a standard, reactive pain regimen in hospitalized patients with IBD. Proactive pain control with scheduled non-opioid pain medications should be considered for patients hospitalized with IBD to reduce reliance on opioids.