Drossman Douglas, Szigethy Eva
Department of Medicine and Psychiatry, University of North Carolina Center for Functional GI and Motility Disorders, and Drossman Gastroenterology PLLC, Chapel Hill, North Carolina, USA.
1] Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA [2] Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Am J Gastroenterol Suppl. 2014 Sep 10;2(1):22-30. doi: 10.1038/ajgsup.2014.6.
The paradoxical development of chronic abdominal pain is an underrecognized side effect of opioid use. Narcotic bowel syndrome (NBS), occurring in a small proportion of chronic opioid users, consists of chronic or intermittent abdominal pain, which often increases in severity despite continued or escalating dosages of opioids prescribed to relieve pain.
A PubMed search was conducted using terms such as "narcotic bowel syndrome" and "opioid hyperalgesia" through January 2014.
Abdominal pain is the defining symptom of NBS and is thought to be mediated by central nervous system dysfunction; it should be distinguished from the peripheral side effects of opioids, such as nausea, bloating, intermittent vomiting, abdominal distension, and constipation. This latter cluster of symptoms is called opioid bowel dysfunction, although it may co-occur with NBS. Hypothesized mechanisms of the central effects of opioids on nociception in NBS include spinal cord inflammation and dysfunction in opioid receptor activity and related neuroanatomical substrates. With continued use, ∼6% of patients taking narcotics chronically will develop NBS, with profound consequences in terms of daily function. The primary management paradigm for NBS is a structured opioid withdrawal program accompanied by centrally acting adjunctive therapy comprising antidepressants, benzodiazepines, and clonidine to target pain, anxiety, and depression, and prevent withdrawal effects, in addition to peripherally acting agents such as laxatives (e.g., osmotic laxatives and chloride channel activators) to control transient constipation. Such structured withdrawal programs have been prospectively evaluated in small clinical trials and have met with considerable success in the short term.
Because rates of NBS are likely to rise, integrated intensive pharmacotherapy and psychosocial interventions are needed to help patients with NBS go off and stay off opioids. These programs will likely also reduce comorbid psychopathology and lead to adequate pain control and improved quality of life.
慢性腹痛的反常发展是阿片类药物使用未被充分认识的副作用。麻醉性肠综合征（NBS）发生于一小部分慢性阿片类药物使用者中，表现为慢性或间歇性腹痛，尽管为缓解疼痛而开具的阿片类药物剂量持续增加或不断加大，但疼痛往往会加剧。
截至2014年1月，使用“麻醉性肠综合征”和“阿片类药物痛觉过敏”等术语在PubMed上进行检索。
腹痛是NBS的典型症状，被认为是由中枢神经系统功能障碍介导的；应将其与阿片类药物的外周副作用区分开来，如恶心、腹胀、间歇性呕吐、腹部膨隆和便秘。后一组症状称为阿片类药物肠功能障碍，尽管它可能与NBS同时出现。阿片类药物对NBS伤害感受的中枢作用的假设机制包括脊髓炎症以及阿片受体活性和相关神经解剖学底物的功能障碍。持续使用的情况下，约6%长期服用麻醉药品的患者会发生NBS，对日常功能产生严重影响。NBS的主要治疗模式是有组织的阿片类药物戒断计划，同时辅以中枢作用的辅助治疗，包括使用抗抑郁药、苯二氮䓬类药物和可乐定来针对疼痛、焦虑和抑郁，并预防戒断反应，此外还使用外周作用药物如泻药（如渗透性泻药和氯通道激活剂）来控制短暂的便秘。此类有组织的戒断计划已在小型临床试验中进行了前瞻性评估，并在短期内取得了相当大的成功。
由于NBS的发生率可能会上升，需要综合强化药物治疗和心理社会干预，以帮助NBS患者停用并持续停用阿片类药物。这些计划可能还会减少共病的精神病理学问题，并实现充分的疼痛控制和生活质量改善。
