C0273 - Association of Chronic Opioid Use With Dyssynergic Defecation: Dose and Exposure Effects

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Rishabh Khatri, MD

Temple University Hospital
Philadelphia, PA

Rishabh Khatri, MD¹, Jun Song, MD¹, Jay B. Patel, MD¹, Abraham Ifrah, MD, MS¹, Zubair Malik, MD¹, Henry P. Parkman, MD²
¹Temple University Hospital, Philadelphia, PA; ²Temple University Health System, Philadelphia, PA

Introduction: While opioids can be effective management for analgesia, GI side effects can limit tolerability. Chronic opioid use (OU) is associated with opioid-induced constipation (OIC) through slowing of GI transit. Studies have noted possible associations between OU and dyssynergic defecation (DD). The aim of this study was to identify chronic OU amongst patients who underwent anorectal manometry (ARM) testing to determine dose or exposure related effects on anorectal function.

Methods: We conducted a retrospective study of patients who had ARM from January 2015 to October 2021. OU was determined by pre-procedure questionnaire and medical record review. OU was considered at least one month of use at time of ARM and was standardized based on morphine milliequivalents (MMEs).

Results: Demographics are summarized in Table 1. Of 773 patients undergoing ARM, 12.7% had chronic OU. OU was associated with having DD; Type 1 DD being most common (p< 0.001). Chronic OU patients were older than patients without OU (p< 0.001). ARM in chronic OU patients was performed more often for constipation, constipation and fecal incontinence, and constipation and diarrhea when compared to patients without OU (p=0.04). Chronic OU patients were more likely to have abnormal balloon expulsion time (BET) defined as > 60 seconds (p< 0.001). Within OU, patients were divided into low and high dose of opiates for likelihood of DD findings on ARM (Figure 1). The lowest group dosing that reached significance defined low OU as 0-10 MME and high OU as ≥10 MME (p=0.005). Of the 34 low dose patients, 67.6% had DD; of the 64 high dose patients, 95.3% had DD (p=0.004). High dose OU was associated with fewer normal ARM tests and more Type I-III DD (p=0.005). Of the chronic OU, high dose patients were more likely to have abnormal defecation index (DI) defined as < 1.4 compared to low dose patients (p=0.006).

Discussion: Our data suggests a correlation between OU and ARM indications as well as OU and DD. We also found that 10 MME was the opioid dose threshold above which there is a greater association with anorectal dysfunction. Chronic OU patients suffered from constipation, were older, and had greater abnormal BET than those without OU, suggesting exposure-dependent association with OU. DI was abnormal at high dose OU compared to low dose OU, suggesting dose-dependent association with OU. Our study suggests that OIC can be associated with DD in addition to the known delayed colonic transit.

Figure: Figure 1: Presence of Dyssynergic Defecation in Low Dose Opioid Use and High Dose Opioid Use Groups
(Blue: Normal ARM, Orange: Dyssynergic Defecation on ARM) [p=0.004]

		Non-Opioid (n=675)	All Opioid (n=98)	p-Value	Low Dose (0-10 MME) Opioid (n= 34)	High Dose ( > 10 MME) Opioid (n=64)	p-Value
Gender	Male	142 (20%)	24 (24%)	0.43	7 (20.6%)	17 (26.6%)	0.62
Gender	Female	533 (80%)	74 (66%)	0.43	27 (79.4%)	47 (73.4%)	0.62
Age (mean) y		48.7 + 16.0	56.0 + 16.9	< 0.001	55.9 + 17.0	56.0 + 17.0	0.98
ARM Indication	Constipation	511 (75.6%)	78 (79.6%)	0.04	24 (70.6%)	54 (84.4%)	0.14
	Fecal Incontinence	120 (17.8%)	13 (13.3%)		8 (23.6%)	5 (7.8%)
	Constipation and Fecal incontinence	23 (3.5%)	5 (5.1%)		1 (2.9%)	4 (6.2%)
	Fecal Urgency	8 (1.2%)	0		-	-
	Incomplete Defecation	2 (0.3%)	0		-	-
	Diarrhea	10 (1.5%)	0		-	-
	Constipation and Diarrhea	1 (0.1%)	2 (2%)		1 (2.9%)	1 (1.6%)
ARM Result	Normal	281 (41.6%)	14 (14.3%)	< 0.001	11 (32.4%)	3 (4.7%)	0.005
	Type I DD	174 (25.8%)	43 (34.9%)		10 (29.4%)	33 (51.6%)
	Type II DD	33 (4.9%)	9 (9.2%)		2 (5.9%)	7 (10.9%)
	Type III DD	116 (17.2%)	18 (18.4%)		6 (17.6%)	12 (18.8%)
	Type IV DD	71 (10.5%)	14 (14.3%)		5 (14.7%)	9 (14.1%)
Defecation Index	Abnormal (< 1.4)	502 (74.3%)	80 (81.6%)	0.13	21 (61.8%)	59 (92.2%)	0.006
Defecation Index	Normal ( >1.4)	174 (25.7%)	18 (18.4%)	0.13	13 (38.2%)	5 (7.8%)	0.006
Balloon Expulsion Time	Abnormal ( >60sec)	238 (35.3%)	64 (65.3%)	< 0.001	21 (61.8%)	43 (67.2%)	0.65
Balloon Expulsion Time	Normal (< 60 sec)	436 (64.7%)	34 (34.7%)	< 0.001	13 (38.2%)	21 (32.8%)	0.65
Sensory Threshold	Low	155 (22.9%)	26 (26.5%)	0.50	11 (32.4%)	15 (23.4%)	0.33
	Normal	339 (50.1%)	43 (43.9%)		16 (47.1%)	27 (42.2%)
	High	182 (26.9%)	29 (29.6%)		7 (20.6%)	22 (34.4%)
Mean sphincter pressure (resting) mmHg		64.60 + 23.6	63.50 + 25.3	0.66	58.6 + 25.3	66.1 + 25.2	0.16
Max sphincter pressure (squeeze) mmHg		157.5 + 68.0	147.0 + 62.9	0.15	138.6 + 64.9	151.5 + 61.8	0.33

Table: Table 1: Distributions and Variables for Non-Opioid Users and Opioid Users in Patients undergoing Anorectal Manometry

Disclosures:

Rishabh Khatri indicated no relevant financial relationships.

Jun Song indicated no relevant financial relationships.

Jay Patel indicated no relevant financial relationships.

Abraham Ifrah indicated no relevant financial relationships.

Zubair Malik indicated no relevant financial relationships.

Henry Parkman indicated no relevant financial relationships.

Rishabh Khatri, MD¹, Jun Song, MD¹, Jay B. Patel, MD¹, Abraham Ifrah, MD, MS¹, Zubair Malik, MD¹, Henry P. Parkman, MD². C0273 - Association of Chronic Opioid Use With Dyssynergic Defecation: Dose and Exposure Effects, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.