In symptomatic adults undergoing high-resolution manometry, long-term opioid use was linked to esophageal dysmotility
The results of a recent meta-analysis highlight the need for clinicians to widen their perspective on the risks of opioids to include both upper and lower GI motility disorders, an ACP Journal Club commentary said.
Chronic opioid use is associated with esophageal dysmotility, according to a meta-analysis of nine retrospective studies that compared manometry in 1,749 patients on long-term opioids with 8,543 not on opioids. Opioid use was associated with significantly higher risk of esophageal spasm, esophagogastric junction outflow obstruction, and type III achalasia. Basal lower esophageal sphincter pressure, integrated relaxation pressure, and distal contractile integral all differed significantly in opioid users versus nonusers. Opioid use was associated with a lower risk of ineffective esophageal motility.
The meta-analysis results were published online July 19 by the American Journal of Gastroenterology. The following commentary by James Kim, MD, MBA, was published in the ACP Journal Club section of the December Annals of Internal Medicine.
The review and meta-analysis by Niu and colleagues remind us of the extensive effects of opioids on the GI system. Although the review included only 9 studies (245 were initially screened), it has a very specific focus on esophageal dysmotility. Results of Egger and Begg tests suggest a lack of publication bias for both primary and secondary study outcomes.
The traditional clinical focus with opioid use in pain management has been on opioid-related motility changes that result in constipation. An entire pharmacologic industry is devoted to easing opioid-related constipation. However, the presence of opioid receptors throughout the gut should widen the perspective to both upper and lower GI motility disorders. Upper GI dysmotility associated with long-term opioid use has typically not been recognized as an important side effect. As most patients taking long-term opioids have several comorbid conditions that require treatment with multiple medications, upper GI symptoms may be attributed to those medications or their potential interactions.
Niu and colleagues' results are specific to the type of upper GI disorders manifested by opioid effects. They point to an association between long-term opioid use and type III achalasia (but not types I and II), esophagogastric junction outflow obstruction, and distal esophageal spasm. The tendency of opioids to cause spasticity in the upper GI tract is interesting. The effect in the lower GI tract is inhibition of motility.
The specific diagnosis of the upper GI condition is not as important as awareness that long-term opioid use may cause important upper GI symptoms and associated morbidity. This underscores the need to carefully consider the risks and benefits of opioid therapy. The Canadian opioid use guidelines for chronic noncancer pain state that nonopioid therapy and nonpharmacologic interventions be used in place of opioids (recommendation 1) and that opioids, if used, should be used at the lowest effective dose (recommendation 9). Implementing these recommendations is a start for reducing opioid-induced side effects.