Before you diagnose an esophageal motility disorder ask about opiate use!

Review by Prof. Eamonn Quigley (USA)

Study Summary 

For a variety of reasons, the use of opiates has proliferated around the world, and, in some countries, this has emerged as a major public health problem. While the latter is largely related to opiates sourced illegally there is also a significant problem with over-prescribing of opiates. In addition, some individuals, such as those with cancer pain have recourse to opiates for entirely appropriate reasons. This systematic review and meta-analysis based on nine studies explored the impact of chronic opiate use on the results of high-resolution esophageal manometry (HRM), performed for symptoms suggestive of esophageal dysmotility, and compared findings among 1,749 individuals on opiates with 8,543 who were not. The findings were striking and revealed a significant association between opiate use and diffuse esophageal spasm (odds ratio 4.84), esophago-gastric junction outflow obstruction (OR 5.13) and type III achalasia (OR 4.15). No association was evident between opiate use and types I and II achalasia; ineffective esophageal motility was, indeed, less common among those on opiates. 

Commentary 

Clinicians are aware of the impacts of opiates on gastric and colonic motility leading to gastroparesis and constipation, respectively. This study, along with others, now demands that we add esophageal dysmotility, including such very significant entities as diffuse esophageal spasm and type III achalasia, to the list of opiate-related gastrointestinal complications. The most striking association was with a clinically challenging and relatively new entity, esophago-gastric junction outflow obstruction (EGJOO). A failure to incriminate opiate use in the pathogenesis of these important esophageal motor patterns could result in recourse to invasive and inappropriate interventions, including surgery. While often a somewhat sensitive area to explore, opiate use must be asked about and defined when faced with a patient with esophageal symptoms and the above listed HRM findings in a context where opiate use is possible. It is much better to ask an awkward question than to recommend a potentially disastrous therapy.

Citation

Niu C, Zhang J, Bapaye J, et al. Systematic review with meta-analysis: chronic opioid use is associated with esophageal dysmotility in symptomatic patients. Am J Gastroenterol 2023;18:2123-32. 

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