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Managing the Pain

All treatment for IBS begins with education to understand the nature of the condition, including why and how symptoms arise. IBS is a brain-gut disorder. For people with IBS that is mild, the treatment is at the level of the gut. But, when more severe chronic pain is present, the treatment also needs to be at the level of the brain.

The primary activity of the newer medications for IBS that have been developed over the past decade is at the level of the gut, not of the brain. Their principal effect is to address the bowel irregularity of IBS and is more limited in their effect on chronic pain in IBS.

The relationship between the doctor and the patient is important. The right relationship with the patient is created when the person is heard, validated, and valued by the provider. This is the interpersonal level that can strengthen positive beliefs, which help with pain management.

It is important for people with chronic IBS pain to find a healthcare provider that listens to them, is respectful, and addresses their expressed needs.

The provider must understand and address how the pain is impacting the person’s daily life. He or she needs to offer guidance, not only to help make treatment decisions but also to help identify related factors that the person can influence and control on their own.

This includes a process of education, explaining the close relationship between the brain and the gut, and the factors that influence pain intensity and reduction. Individuals then can understand why they are having pain and how they can most effectively manage and improve long-term.

Can the chronic pain state be reversed?

Chronic pain can be turned around and reversed if done with the proper treatment interventions. This often includes the use of central acting agents, or neuromodulators, and psychological approaches, along with self-management steps that individuals can take on their own. Combining therapies together can be more effective than using just one approach.

While still theoretical, it’s been shown in practice that even the structural changes involving nerve cells can be reversed. Although chronic severe pain can reduce the number of brain cells, studies using brain imaging have shown that various interventions can result in neurogenesis, the regrowth of nerve cells.

How can chronic pain in IBS be managed?

When pain is chronic it takes time for it to go away. Because pain is an emotional experience, taking steps to improve emotions can lead to reduction of the harmful effects of the pain even when it is still present.

Maintaining an active role in life, engaging in physical activity, and addressing emotional and social health are important to help promote a sense of well-being, which counters negative expectations.

Psychological approachesPsychological approaches harness the mind’s own ability to affect pain sensations by sending signals, thoughts or nerve impulses, which close the pain gate.

There are many of these techniques, ranging from hypnosis to relaxation therapies to meditation to cognitive-behavioral therapy. They can help ease symptoms and restore a sense of control over the disorder.

Medications – Anticholinergic agents taken before meals may provide short-term reduction of abdominal pain after meals. The newer gut-targeted medications treat multiple symptoms, including pain, in IBS with diarrhea (IBS-D) and IBS with constipation (IBS-C).

When the above mentioned medications do not adequately treat the pain, centrally targeted medications may be tried. They can be used in addition to other IBS medications and are prescribed to provide long-term relief of severe chronic pain.

Central acting or targeted medications are agents that can block signals from the brain. They modify nerve activity in order to restore function or relieve symptoms that have a basis in brain activity and may help influence recovery through neurogenesis.

Antidepressants are a type of central acting agents. Usually in doses lower than used to treat depression they decrease intestinal and central hypersensitivity, help the brain control the pain better, and also act on motility and secretion in the gut.

Other existing agents appear to have similar effects. At the present time, the descriptive terms used are changing from ‘antidepressants’ to ‘central neuromodulators’ in order to be consistent with their true effects on influencing, or modulating, brain-gut pathways rather than for their original intent to treat psychiatric disease.

How quickly does a central agent have effect on the pain?

There are two levels to taking one of these agents. At the first level the medication increases the brain’s ability to down-regulate nerve signals through the gate control mechanism, closing the gate to reduce pain. Within four to six weeks the pain is generally 30–50% better.

The second level is the neurogenesis, and that can take six months to a year or more. This is important to help prevent the pain from coming back, or relapsing.

The two effects are the physiologic effect of the pain control through the gating mechanism, and the neuroplastic effect through the brain to regrow those nerves that have been damaged by the chronic pain.

Are opioids useful for treating chronic pain in IBS?

There is no evidence that opioids, narcotics, have any long-term benefit. Yet, there is an epidemic of opioid use. Furthermore, opioids slow down the gut causing constipation, gastroparesis, nausea, and vomiting, particularly in those with IBS.

In addition, about 5–6% of people who go on opioids develop a condition called narcotic bowel syndrome, also called opioid induced central hyperalgesia. It was identified in 2007, but is not always recognized. Typically, the person who has chronic pain is given opioids, the pain gets worse, and more opioids are given.

What the opioids are doing in people with narcotic bowel syndrome is activating the spinal cord mechanisms to amplify and increase the signaling to the brain. Discontinuing the opioids while substituting effective alternatives is the only way the condition can be treated. This requires the doctor and patient working closely together.

Opioids are not a treatment for chronic pain in IBS. Not only is this because of the risk for getting narcotic bowel syndrome, but it deflects from proper treatment where there is clear benefit. There is no evidence for long-term benefit of opioids.

What kind of healthcare provider best treats IBS pain?

A gastroenterologist who works in neurogastroenterology addressing the brain-gut axis, or a primary care practitioner who knows how to work with chronic pain is usually best trained to treat IBS pain. They may work with a multi-disciplinary team of therapists trained in treating chronic visceral pain.

Good pain clinicians are likely going to use the right treatment. They need to be familiar with neurogastroenterology and how to use centrally targeted approaches to manage the chronic visceral pain in IBS. Be on the alert for pain management clinics that use opioids as treatment.

I have chronic abdominal pain from IBS. What things can I do on my own to manage my pain?

In managing chronic IBS pain there is benefit from taking an active role, and working in partnership with a knowledgeable healthcare provider.

Here is a Ten Step Plan of self-management things you can do to help reach your treatment goals:

1 – Acceptance

  • Accept that the pain is there
  • Learn all you can about your condition and it’s management; knowledge is therapeutic

2 – Get Involved

  • Take an active role in your care
  • Develop with your provider a partnership in the care
  • Understand your provider’s recommendations and maintain an open dialogue

3 – Set Priorities

  • Look beyond your symptoms to the things important in your life
  • Do what is important
  • Eliminate or reduce what is not important

4 – Set Realistic Goals

  • Set goals within your power to accomplish
  • Break a larger goal into small manageable steps
  • Take the time to enjoy the success of reaching your goals

5 – Know Your Rights with your Healthcare Provider

  • To be treated with respect
  • To ask questions and voice your opinions
  • To disagree as well as agree
  • To say no without guilt

6 – Recognize and Accept Emotions

  • Mind and body are connected
  • Strong emotion affects pain
  • By acknowledging and dealing with your emotions you can reduce stress and decrease the pain

7 - Relaxation

  • Stress lowers pain threshold and increases symptoms
  • Relaxation helps reclaim control over your body and reduces pain
  • Examples of relaxation options to consider (taught or guided by an expert):
    • Deep breathing exercises
    • Progressive relaxation
    • Gut-directed hypnosis
    • Yoga
    • Meditation

8 – Exercise

  • Diverts attention from your symptoms
  • Increases your sense of control in life
  • Helps you feel better about yourself

9 – Refocus

  • With these steps your symptoms are no longer the center of your life
  • Focus on abilities not disabilities
  • You will then see you can live a more normal life

10 – Reach Out

  • Share your thoughts and feelings with your provider
  • Talk and interact with family and friends in healthy ways
  • Support others and seek support from them as well

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