Chronic Abdominal Pain: Reduce Opioid Use, Increase Multidisciplinary Care

When a patient with chronic abdominal pain (CAP) is referred to a Cleveland Clinic pain physician such as Bruce Vrooman, MD, management is infused with interdisciplinary collaboration from the start.

“The first step is a thorough workup in conjunction with a gastroenterologist — and sometimes a colorectal or general surgeon — to determine whether an acute process is taking place,” says Dr. Vrooman, a board-certified pain management specialist and anesthesiologist in the Department of Pain Management.

Depending on the workup findings, Dr. Vrooman and colleagues identify potential diagnostic and therapeutic interventions, which typically start conservatively — and again with collaboration across specialties. “We often focus on lifestyle modifications, biofeedback, cognitive behavioral therapy, stress reduction and similar approaches, which are done in association with psychologists in Cleveland Clinic’s Neurological Center for Pain,” he says.

Giving Chronic Abdominal Pain Its Due

This multidisciplinary approach to CAP has become so well established at Cleveland Clinic that the relevant players — the Department of Pain Management, the Digestive Disease Institute and the Neurological Center for Pain (within the Neurological Institute) — are in the process of formalizing it with the creation of a Chronic Abdominal Pain Clinic this year. The collaboration has also translated to development of a novel Cleveland Clinic care path that tackles the important issue of chronic opioid therapy in patients with CAP.

The launch of the Chronic Abdominal Pain Clinic not only will give patients and referring physicians a point around which to coordinate related care, it also recognizes the complexity of a condition whose causes may be known or unknown and which often vexes patients and clinicians alike.

Targeted Nerve Blocks and Stimulation Modalities

In those more vexing cases, Dr. Vrooman says, initial conservative measures may require supplementation with medication management and/or minimally invasive procedures such as nerve blocks. The latter often include differential epidural nerve blocks, an injection along the abdominal wall, or blocks for visceral pain such as celiac plexus or splanchnic nerve blocks.

“There also may be a role for neurostimulation — either peripheral nerve stimulation or spinal cord stimulation — for various abdominal pain conditions,” notes Dr. Vrooman, who is involved in several clinical trials evaluating these treatments.

“Studies have demonstrated that neurostimulation is an effective therapy for conditions such as chronic pancreatitis and visceral hyperalgesia,” he says. “This is an area of medicine that combines technology and minimally invasive procedures under the overarching goal of reducing pain and improving functionality.”

Special Challenges from Opioids…

Special challenges are posed by burgeoning numbers of patients who are prescribed opioids for CAP, with varying degrees of efficacy. “Often outside physicians will place patients on escalating opioid doses without a corresponding reduction in pain,” Dr. Vrooman says. “There is little to no evidence-based literature behind chronic opioid therapy for CAP, yet it frequently is prescribed with little to no positive effect.”

Patients with CAP on opioid therapy can experience opioid-induced hyperalgesia and sensitization, and they have increased emergency room and hospital admissions and longer hospital stays compared with those not on opioids. “The result is a major healthcare problem,” Dr. Vrooman notes.

…and a Care Path to Address Them

Cleveland Clinic is countering that problem with its new Chronic Abdominal Pain Care Path, a joint effort among the Department of Pain Management, the Digestive Disease Institute and the Neurological Center for Pain modeled on other recent Cleveland Clinic care paths.

The care path, which focuses largely on decreasing chronic opioid use, “standardizes our approach to reducing the deleterious effects of opioid therapy in CAP,” Dr. Vrooman explains. “It has the goal of simultaneously improving pain, functionality and overall health while also coordinating patients’ multidisciplinary care.”

Development of the care path and new clinic coincides with enhanced efforts to make specialized care for CAP accessible at Cleveland Clinic as widely and quickly as possible, particularly in situations where opioids might otherwise be prescribed or when patients are already on inappropriate opioid therapy.

“While it might sometimes seem easier to prescribe opioids for a patient with CAP, we make a concerted effort to evaluate alternatives with fewer risks and side effects,” Dr. Vrooman says. “It takes time to listen and evaluate a patient thoroughly to determine the best treatment plan, but it’s worth the effort.”