# The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and Management



## Kathleen M.

Volume 5, Issue 10, Pages 1126-1139 (October 2007)ABSTRACTThe Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and ManagementView original article referenced David M.S. GrunkemeierâŽ, Joseph E. CassaraâŽ, Christine B. DaltonâŽ‡, Douglas A. DrossmanâŽ‡Corresponding Author Informationemail addressNarcotic bowel syndrome (NBS) is a subset of opioid bowel dysfunction that is characterized by chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. This syndrome is underrecognized and may be becoming more prevalent. In the United States this may be the result of increases in using narcotics for chronic nonmalignant painful disorders, and the development of maladaptive therapeutic interactions around its use. NBS can occur in patients with no prior gastrointestinal disorder who receive high dosages of narcotics after surgery or acute painful problems, and among patients with functional gastrointestinal disorders or other chronic gastrointestinal diseases who are managed by physicians who are unaware of the hyperalgesic effects of chronic opioids. The evidence for the enhanced pain perception is based on the following: (1) activation of excitatory antianalgesic pathways within a bimodal opioid regulation system, (2) descending facilitation of pain at the rostral ventral medulla and pain facilitation via dynorphin and cholecystokinin activation, and (3) glial cell activation that produces morphine tolerance and enhances opioid-induced pain. Treatment involves early recognition of the syndrome, an effective physician–patient relationship, graded withdrawal of the narcotic according to a specified withdrawal program, and the institution of medications to reduce withdrawal effects.


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## Kathleen M.

From the articleTable 1. Diagnostic Criteria for NBS*Chronic or frequently recurring abdominal pain that is treated withacute high-dose or chronic narcotics and all of the following:*The pain worsens or incompletely resolves with continued orescalating dosages of narcoticsThere is marked worsening of pain when the narcotic dose wanesand improvement when narcotics are re-instituted (soar andcrash)There is a progression of the frequency, duration, and intensity ofpain episodesThe nature and intensity of the pain is not explained by a currentor previous GI diagnosis[sup]a[/sup]_________________________________________________________[sup]a[/sup]A patient may have a structural diagnosis (eg, inflammatory boweldisease, chronic pancreatitis), but the character or activity of thedisease process is not sufficient to explain the pain.


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