# Narcotics - Hyperalgesia



## code9 (Dec 3, 2007)

About the elusive hyperalgesia that has been detected in rats. Narcotic Bowel Syndrome is different than hyperalgesia. There is confusion here.If you do a google search for : "Narcotic Bowel Syndrome" -Drossman You see only 912 entries discussing the topic, and many are repeats.(Since he is the only one discussing it in terms of short term normal use, let's filter him out)You find this definition on medscape (http://www.medscape.com/viewarticle/469586_2) :


> Narcotic bowel syndrome is a form of intestinal pseudo-obstruction *characterized by chronic opiate* use leading to ileus, vomiting, and abdominal pain.[7] The clinical manifestations of *narcotic bowel can be remedied by clonidine during the period of narcotic withdrawal*.[7]


There is also this entry from wikipedia (http://en.wikipedia.org/wiki/Opioid-induced_hyperalgesia) :


> Opioid-induced hyperalgesia[1] or opioid-induced abnormal pain sensitivity[2] is a phenomenon *associated with the long term use of opioids* such as morphine, hydrocodone, oxycodone, and methadone. Over time, individuals taking opioids can develop an increasing sensitivity to noxious stimuli, even evolving a painful response to previously non-noxious stimuli. Some studies on animals have also demonstrated this effect occurring after only a single high dose of opioids.[3] The need for dose escalation in opioid therapy may be as a result of tolerance, as a result of opioid-induced hyperalgesia, or, more likely, a combination of both. Thus patients receiving medications to relieve pain may paradoxically have more pain as a result of their medication.


Again, long term, or high dose usage. No one is talking about low-dose opiates causing hyperalgesia outside of rats.Only in Drossman's articles do you see statements like this, clearly opposed to the use of opiates (http://www.pubmedcentral.nih.gov/articlere...i?artid=2074872):


> Impressively, the United States, with 4.6% of the world's population, uses 80% of the world's opioids (25).* Although treatments with narcotics for these and other conditions should be both controlled and limited, prescriptions are actually increasing over time, and associated with this is an accelerating incidence of narcotic abuse.* From 1997 to 2002, there was greater than 400% increase in retail sales of oxycodone and methadone (25). According to the Natinal Institute on Drug Abuse (NIDA, www.drugabuse.gov/Infofacts/nationtreatns.html), there has been a 100% increase in hydrocodone associated emergency room visits over a six year span (1993-1999).


He is implying a causality, but not proving it. Then he goes on to say that to replace narcotics, in what we are guessing is NBS :


> *An antidepressant should be started prior to narcotic withdrawal and continued indefinitely. These drugs improve general well-being and abdominal pain* (66) (67;68). However, it is important to help the patient understand that full benefit may not occur for several weeks. Tricyclic antidepressants (TCA) are favored because their noradrenergic action is effective in managing pain (69) independent of its antidepressant effects (70), however the anticholinergic and antihistaminic side effects can lead to constipation and orthostasis. A secondary amine TCA (e.g., desipramine, nortriptyline) has fewer of these side effects and this is preferred over the tertiary amine agents (e.g., amitriptyline, imipramine). Lower dosages (e.g. 50 - 75 mg. desipramine) can be used for analgesic effect unless concomitant major depression is identified, which would require full dosage.. A serotonin - noradrenergic reuptake inhibitors (SNRI - e.g., duloxetine) has the advantage of providing pain benefit via its noradrenergic action, yes does not have the bowel related side effects. Selective serotonin reuptake inhibitors (SSRI). (e.g., paroxetine, fluoxetine, citalopram), are not generally recommended since their benefit in pain management is less established.


Anti-depressants do not, in fact, improve abdominal pain for everyone. They do not instill a sense of well-being in everyone. Again, it's subtle, but opiates ("narcotics") have been demonized while anti-depressants have been canonized. Yet, I see no mention of serotonin discontinuation syndrome, or any of the various worrisome side effects of playing with a neurotransmitter.*Also, this is very important : * read the first definition of NBS again :


> "Narcotic bowel syndrome is a form of intestinal pseudo-obstruction *characterized by chronic opiate* use leading to ileus, vomiting, and abdominal pain."


Now, read the definition of the same thing from Drossman's paper (http://www.pubmedcentral.nih.gov/articlere...i?artid=2074872) :


> Narcotic 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 under recognized and may be becoming more prevalent.


*Note the lack of pseudo-obstruction? The lack of reference to severe constipation (aka ileus)?*It is clear there is confusion. Drossman is hijacking a medical term and redefining it so broadly as to encompass all opiate use. Many of the people here have used opiates, whether they know it or not. Lomotil is an opiate. Motofen is an opiate. Tinctures of opium, codeine, morphine, methadone.... we do not get ileus because our goal is not to get "high." Our goal is to maintain normality, which means we cannot, by definition, get narcotic bowel syndrome. As an example, if you have severe IBS-D, and take opiates and achieve normal bowel function, without several constipation or ileus, you cannot meet the accepted definition of NBS.Drossman is redefining NBS to mean "hyperalgesia"... something which is not even fully proven beyond narcotic bowel syndrome and withdrawal.So please, do not fear opiates for the treatment of IBS. If it works for you, great! If it causes you more pain (not likely) then stop using them. But don't let this false excuse for not prescribing them go unchallenged.Question why Lomotil and Motofen are accepted opiate treatments for IBS, but codeine/morphine/oxycodone/methadone are not. It is a chronic pain condition.So why do Lomotil and Motofen not cause "hyperalgesia"? When they act as opiates, they just do not cross into the brain as efficiently as codeine and morphine?Is the answer that NBS or hyperalgesia as Drossman defines it is just sensitivity in the head? No... it's sensitivity in the abdomen, but all these drugs work the same way in the abdomen, so why is hyperalgesia not being seen in droves with all these people on Lomotil and Motofen?Perhaps it is just someone's personal opinion about the use of "narcotics" that is being pushed. Narcotics is a loaded word, and I think everyone understands that. The term is used broadly and negatively, just as it is in Drossman's paper. Opiates are the focus of this, but instead of referring to opiates and their analogs, he refers to "narcotics."But even if you subscribe to this one small subset of research that pushes hyperalgesia, ask yourself why it's not seen with Lomotil and Motofen, and only seen with other opiates. Maybe the answer is simply : it depends who is interpreting the research and their own personal beliefs.Again, do not fear opiates if they are a last resort treatment. We should push to be allowed to take whatever we need to take in order to have a decent quality of life, and not let a small group of researchers put forth ideas that harm the whole.Thank you, and I wish you all good luck.


----------



## 16229 (Jan 28, 2006)

Very astute and pretty spot on. NBS is overblown. Even among regular users, only about 8% of those on opioids become addicted if they do not have a history of addiction. Taken properly under a doctor's care and that chance is even lower. I'm not the biggest advocate of daily use, there are other things to consider, but people should not be afraid to use them when they need them. The mental and physical problems incurred from long term pain can be much worse than taking the pill. It causes anxiety and panic disorder, weakened immune system, weakened cardio system, pain sufferers are much less likely to get exercise and stay in good shape. I could go on and on.And about the anti depressants, you can throw every single one of those studies in the garbage, they all need to be re-done to have any credibility. Over 50% of all these studies on anti depressants were thrown out by the drug companies/ research centers because they showed bad results. That taints the whole pool as positive studies were cherry picked. There was a big thing about this in the New York Times a couple of weeks ago if you don't know what I'm talking about.Don't forget, it is rare, but there is also seratonin syndrome. I get it and it is absolutely terrible. And anti-depressants kill your boner, I mean sex drive. That can cause another slew of problems, especially in long term relationships.I'm not saying NBS doesn't occur or isn't real, but its incidence is much lower than some would lead you to believe. And it is fully curable. It's not something you'll have for life if you do get it, it is reversable. Opiods have a much longer track record of usage than many other options available. I prefer the known vs. the unknown. I would consider anti-depressants to be almost completely unknown now as we've found out that all the research pertaining to them is absolute ####.


----------



## GilmoreGirl (Feb 26, 2017)

This is an old post but I thought I would chime in to share some personal experience.

Great breakdown of the literature - as usual with new research, there is clearly quite a confusion of terminology. I'm a biologist - it's even worse in my field....and is a giant pain!

Anyways, I have had ibs for about 8 years, I'm now 25. After LOTS of work, I had it fairly under control. I did not have D or C, just pain and gas, and lots of food intolerances. I went on a low dose of cipralex which got me out of a bit of a vicious cycle of anxiety/ibs pain, and got heavily into running and weightlifting and eating healthy with lots of protein. I was eventually able to come off of cipralex and was living medication free (except for probiotics) with about one or two attacks of pain per month. My pain 90% of the time was relieved with a bm, and gas was minimal.

This past fall, I got an anal fissure. It became chronic. While waiting for surgery, I was told to take morphine sulphate as needed - and yes it was needed. I have had to wait months for surgery, and in the meantime lost my job as a personal trainer, my boyfriend of 4 years, have had to take leave from my graduate program, and move back with my parents. I used to be fit and active and now I have lost about 30 lbs and am bedridden.

This journey would have been much easier if I did not have ibs. And the worst thing I could have done was take morphine. With ibs, i was already sensitive to the regular motions of the gut. When I started morphine, my ibs was better than ever. But in about three weeks, I had new, and more horrible pain - extreme gas, pressure in the upper and lower abdominals, heartburn, etc that would wake me up at night and last all day. I had never had ibs like this before. I decided to stop taking the morphine in case this was the cause.

I had quite severe withdrawal - flu like symptoms and diarrhea. My stomach pain got worse, then improved very slowly over the course of two months. But I am still in much more ibs pain now than I was before taking morphine. I still have diarrhea everyday and crazy amounts of gas.

Again - I did not have any of this pre-morphine. I had the odd ibs attack, but it was completely different. Pain is not relieved by a bm in this case. 
I am taking amitryptiline for the diarrhea as I cannot recover from the fissure surgery with diarrhea, and Imodium causes me the SAME stomach as morphine did (since they are both opiates, I assume).

It is now end of march, and I have my surgery next week. I am feeling like I'm starting from scratch with the ibs. The hyperaglesic effects of opiates are REAL. My gastro has ruled out everything else - I have bloodwork, stool tests, urine samples, small bowel MRI,
Colonoscopy and endoscopy, all recent.

AND I was taking a minute dose for a short period of time - normally 5 mg/day, at the most I took 15mg, for about a month and a half.

I just want people to know that there is indeed a danger in taking opiates with ibs, beyond addiction. Of course, this is just one case, but hyeraglesia makes total sense, if hypersensitivity in the gut is a causal factor in one's ibs. i never EVER had loose stools before taking morphine. In fact I'd have 2-3 formed easy formed bms in succession most mornings, not much else. Now I have severe diarrhea without amitryptiline, and with it still have moderate D. My system feels as though it has completely reset - I'm doubting it will ever return to normal.

Sorry for the long post - maybe it will help somebody who's been in a similar situation.


----------

