Opioid Misuse in Gastroenterology and Non-Opioid Management of Abdominal Pain

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Opioids were one of the earliest classes of medications used for pain across a variety of conditions, but morbidity and mortality have been increasingly associated with their chronic use. Despite these negative consequences, chronic opioid use is increasing worldwide, with the USA and Canada having the highest rates (see figure). Chronic opioid use for non-cancer pain can have particularly negative effects in the gastrointestinal and central nervous systems, including opioid-induced constipation, narcotic bowel syndrome, worsening psychopathology and addiction.

There is no scientific evidence that the use of opioids for chronic non-cancer pain is helpful. In fact, it’s harmful in terms of increased risk of infections and early death. Alarmingly, 70% of IBD patients in hospitals are put on opioids.

 How did this misuse happen?

The medical community accepted the use of opioids for non-acute and non-cancer pain beginning in earnest back in 2001 with the Joint Commission’s Pain Standards, which aimed to address the endemic under-treatment of pain.

Now we are facing an opioid crisis, which is the result, in part, of the increased attention to pain management, combined with aggressive marketing and sophisticated delivery systems such as fentanyl patches, which took the focus away from traditional pain control methods such as antidepressants, behavioral interventions, and regional nerve blocks. Additionally, reimbursement by third-party payers also played a role in the US. Thus the traditional treatments of physical therapy, nerve blocks, psychological treatments and antidepressants (all possibly time consuming) were supplanted by quick but expensive delivery systems of opioids.

In light of the current opioid crisis, the Joint Commission is revising its standards on pain assessment and treatment.  But it is important to note that there is a misuse of opioids in gastroenterology that can be addressed with a greater understanding of non-opioid management of abdominal pain.

A recent review I co-authored with Eva Szigethy, MD, and Mitchell Knisely, MD, that summarizes the evidence of opioid misuse in gastroenterology, including the lack of evidence of a benefit from these drugs, as well as the risk of harm and negative consequences of opioid use relative to the brain-gut axis.

The review, “Opioid misuse in gastroenterology and non-opioid management of abdominal pain” was published online in Nature Reviews Gastroenterology & Hepatology. doi:10.1038/nrgastro.2017.141 

 Here are Some Key Points of the Review

  • Prescription opioid use is a global epidemic, with substantial increases in opioid-related morbidity and mortality around the world
  • There is a lack of evidence supporting the use of opioids for the management of chronic abdominal pain
  • Opioid use can have deleterious consequences on the gastrointestinal tract, including opioid-induced constipation (OIC) and narcotic bowel syndrome (NBS)
  • Many promising non-opioid pharmacological and nonpharmacological alternatives for treating abdominal pain exist; however, additional research is needed to identify best practices for treating abdominal pain in individuals with gastrointestinal disorders.
  • If opioids are prescribed, it is essential to have strategies to monitor and manage opioid misuse, continually monitor risk–benefit clinical profiles, and prevent and treat addiction


Opioids have been associated opioid induced constipation (OIC) which results from the effects of opioids on nerve receptors of the gastrointestinal tract.  It can be treated with man medications to treat constipation or more selective treatments called PAMORAs that block the effects of opioids on the nerves in the gut producing the constipation.  However,  narcotic bowel syndrome (NBS) is an underrecognized disorder that is growing in frequency due to increased use of opioids in our society. About 5% of patients on opioids end up with NBS and hyperalgesia and paradoxically have worse pain and keep going to the emergency room—and the vicious cycle continues, because they are prescribed more opioids. NBS needs to be identified and the patients taken off narcotic pain control. Rome IV added both of these disorders to their classification system, and they were not there before.

NBS is totally unrelated to OIC. You can have NBS and not be constipated or you can have OIC and not have NBS. Narcotic bowel is increased pain associated with increased use of opioids. And this is a big problem if not recognized as physicians will put patients with abdominal pain on high doses of opioids thus making the pain worse.  Some physicians without recognizing NBS are putting patients with abdominal pain on ever higher doses of opioids.

Opioid Management and Alternative Strategies for GI Patients

The review noted above also discusses the guidelines for opioid management and alternative pharmacological and nonpharmacological strategies for pain management in patients with gastrointestinal disorders.

It is important to note that agents such as nonsteroidal anti-inflammatory drugs and cyclooxygenase inhibitors can trigger flares, neuromodulators such as antidepressants, antipsychotics, and anticonvulsants, which down-regulate pain at the brain level, are increasingly being used to counteract pain-related visceral hypersensitivity. Molecular agents such as antagonists to nerve growth factor and transient receptor potential vanilloid receptor subtype 1 and kappa opioid receptor agonists are also being studied.

These may eventually phase out the regular use of narcotics, but importantly, in my opinion, after 40 years of experience and research, there is absolutely no place for opioids in managing chronic abdominal or IBD pain.

Since chronic pain is complex and involves emotional and social factors, a multimodal approach targeting both pain intensity and quality of life is best. Behavioral interventions are also helpful.

This is also a societal issue. In a previous study, [access the study] we found that patients could be successfully taken off opioids in only a few days in the hospital and their pain reduced by about 1/3. Furthermore, we followed patients after taking them off narcotics and they continued to better with pain reduced by 2/3 at 3 months. However, at 3 months half the patients were put back on opioids and when this occurred their pain came back.  So they go to the ER or their physicians and get more opioids because this condition is not recognized and those patients are back to where they started.

Doctors need to know that opioid misuse is a growing phenomenon that is epidemic in proportion. They need to understand that non-cancer chronic pain should not be treated with opioids and that narcotic bowel is a separate condition.  Patients need to be treated by being taken off narcotics.

 Final Thoughts

Given the lack of evidence supporting the effectiveness of opioids for managing chronic pain, as well as the debilitating effects of those drugs on both the gastrointestinal and central nervous systems, alternative approaches to pain management in patients with gastrointestinal con-ditions must be employed. Alternatives to prescribing opioids in this population should include non-opioid pharmacological agents, behavioral interventions, strong physician–patient relationships and multidisciplinary team approaches. This Review underscores the need for additional research on non-opioid pharmacological and nonpharmacological interventions, as well as different formulations and/or delivery mechanisms of opioids for treating chronic abdominal pain in patients diagnosed with gastrointestinal disorders to reduce pain intensity, improve quality of life and avoid addiction.


University of Virginia GI Team On Their Observership with Drossman Gastroenterology as Part of Rome Foundation Visiting Scholars Program

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From left: Dr. Drossman, Jeanetta Frye, MD, Karen Finke,PA-C, both of the University of Virginia, and Megan Huff, PA-C, Drossman Gastroenterology.

I had the honor of welcoming Jeanetta Frye, MD, a Junior Faculty Gastroenterologist,  and Physician Assistant Karen Finke both of the University of Virginia for a two-week observership. They came to the Drossman Center for the Education and Practice of Biopsychosocial Care to work with me and my physician assistant Meghan Huff for two-weeks.

Their goals were to improve their skills in communication methods, clinical decision making and use of central neuromodulators and to gain first-hand experience treating patients with complex functional GI disorders using a biopsychosocial approach, the cornerstone of my practice.

This visit was part of the Rome Foundation Visiting Scholars program which also included a visit to William Whitehead PhD and Olafur Palsson Psyc. D. at the University of North Carolina Center for Functional GI and Motility Disorders.  At UNC Dr. Frye and Ms. Finke discussed their research activities and learned of the Center’s current research program.

Dr. Frye treats patients in general gastroenterology with a particular interest in FGIDs. She is an assistant professor of gastroenterology and hepatology and is board certified in both internal medicine and gastroenterology. She earned her undergraduate degree from Emory and Henry College before attending medical school and completing her residency in internal medicine at Vanderbilt University. Dr. Frye completed a fellowship in gastroenterology and hepatology at the University of Virginia, then joined the faculty of that division in 2013. 

Ms. Finke attended undergraduate school at Shenandoah University in Winchester, VA and PA school at Arcadia University near Philadelphia, PA. She has been a physician assistant in gastroenterology at UVA since 1999. In addition to seeing patients for a variety of general gastrointestional disorders and inflammatory bowel disease, she coordinates care for patients with feeding tubes, including pre- and post-procedure issues and long-term feeding tube needs.

In an effort to help illustrate the value of their experiences on learning to treating patients with functional GI disorders using a biopsychosocial approach Dr Frye and Ms. Finke share their experiences with Dr. Drossman and his care team. Their answers appear here in their own words.

As part of the Rome Foundation – Drossman Care observership, participants enjoyed dinner at a local restaurant. (From left) William Whitehead PhD, UNC Center for Functional GI and Motility Disorders and a member of the Rome Foundation Board, Megan Huff, PA-C, Drossman Gastroenterology, Karen Finke,PA-C, Jeanetta Frye, MD, both of the University of Virginia, Dr. Drossman and Magnus Simrén, MD, PhD, a visiting professor from Gothenberg, Sweden and a Rome Foundation Board member.


What are some of the main challenges you are facing?

Dr. Frye: As a gastroenterologist with a particular interest in functional GI disorders, I face many challenges in my practice.  Given the pressures of medicine today, I am unfortunately simply not able to spend enough one-on-one time with my patients.  Patients with functional GI disorders are often quite complex and require a significant amount of time to build relationships, discuss symptoms and develop treatment plans, and this is often not supported in medicine today.  In contrast, the emphasis of care is specifically focused on pursuing diagnostic tests and invasive procedures rather than building relationships and pursuing other therapeutic interventions such as psychological therapy and nutrition counseling.


Ms. Finke: As a physician assistant in an academic tertiary referral center one of the main challenges I face is having enough time to spend with patients, particularly complicated FGID patients who may have already seen multiple GI physicians. We are asked to see more and more patients with complicated issues in less time and still deliver the same high quality of care the patients deserve.
Are you seeing an increase of functional gastrointestinal disorders in your patients?

Dr. Frye: Yes.  I am definitely seeing an increase in these disorders

Ms. Finke: I think my practice has always been heavy in FGIDs and this is likely because I am at an academic tertiary referral center. I think it’s possible I see more patients who come with the diagnosis already made or who already have an idea about what their problem may be. This can be attributed to more of an awareness among primary care providers, patients having access to the internet or prior GI referrals. I think I see more patients who have already seen multiple providers with repetitive work up but no real treatment in place.

How are patients with FGIDs in typically treated in your practice?

Dr. Frye: Typically, patients with FGIDs in my practice undergo frequent testing (often at the insistence of the patient or family).  I am starting to incorporate the use of more central neuromodulators in the care of these patients, thanks to my work with Dr. Drossman.  Unfortunately, many of my patients do not have access to important interventions including psychological therapies, biofeedback and nutrition counseling.


Ms. Finke:  Most often I will use a tricyclic antidepressant (TCA), try to recommend cognitive behavioral therapy (CBT) and/or gut-directed hypnotherapy if this is available to patients based on insurance or financial resources. I find frequent follow up visits can be as important part of the treatment plan as medications by establishing a strong provider-patient relationship and providing as much education about their FGID as possible.

What prompted you to come to the Drossman Center/Drossman Gastroenterology to learn more about functional GI disorders and physician-patient communications?

Dr. Frye: I came to work with Dr. Drossman because of his reputation and my own disillusionment with my field.  As a fellow and junior faculty, I have read his work and participated in conferences where he has given outstanding lectures.  I use the Rome MDCP daily in my own practice.  I came to Dr. Drossman with a strong desire to learn the most up-to-date way to help my patients with FGIDs.
Ms. Finke: Patients with FGIDs are a big part of my patient population, but I have not felt I could offer them adequate therapy beyond TCAs and often this is inadequate. I wanted to gain a better understanding for using medications other than TCAs, improve my interview techniques so I can understand their problems and offer appropriate treatment options and patient education. The opportunity to spend time and learn from the foremost leader in FGIDs, this is a true honor.

What do you think practically you could do differently in your practice now that you have had this immersion experience with Dr. Drossman?

 Dr. Frye: Working with Dr. Drossman has been a career-changing experience.  I just will not be able to express how much this has reinvigorated my desire to improve my care of patients with FGIDs.  His mentorship has been unbelievable.  I am so excited to continue to work with him and continue my education in the management of FGIDs.  I am now energized to improve my use of therapeutic options with patients – particularly with the use of central neuromodulators and psychological therapies.  I am working to use the techniques he teaches (regarding the patient interview) on a daily basis.  I am also thrilled to take this back to my institution and share with my trainees.
Ms. Finke: I have been able to change my interview techniques by asking different questions, such as questions about quality of life, impact on their life, their hopes/expectations. I will ask more detailed trauma/abuse history, listen more actively, less documenting during an initial visit. I will involve the patient more in developing their treatment plan so they feel more in control. I anticipate using other antidepressants and atypical antipsychotics when TCAs fail or are inappropriate and can better educate patients about why we use them and how they work. I left feeling more confident in managing my FGID patients.


Any advice or insight you would like to share with other physicians? 

Ms. Finke: Listening to the patient, validating their concerns and developing a treatment plan together is an excellent base for improving their quality of life in patients, even before medications are prescribed. This immersion experience was invaluable and change how I will manage my FGID patients moving forward.

Clinicians and investigators can allocate time to visit DrossmanCare for one week up to a year.  For further information please contact

This visit was also sponsored by the Rome Foundation Visiting Scholars Program.  The Foundation endorses observorships to approved academic or clinical practice programs.  For further information please contact


Join Us for Live Webcast: What’s New in the Rome IV Criteria – Friday, Jan. 19, 8:00 am EST

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Join us on Friday, January 19, 2018 8:00 am EST for live webcast covering the latest in Rome IV, diagnosing and treatment of IBS, functional constipation and esophageal disorders, as well as case based learning with the Multidimensional Clinical Profile (MDCP) and algorithms from the Rome Clinical Interactive Decision-Making Toolkit.

Who should attend?

GI physicians, Primary Care Physicians, NPs, PAs, GI fellows and anyone interested in learning more about diagnosis and treatment of IBS, Functional Constipation and Esophageal disorders.

Douglas Drossman, MD, MACG, Lin Chang, MD and Williiam Chey, MD, FACG

How to Access the Webcast on Friday January 19, 2018 at 8:00 am EST

Access Webcast via this link
Password:  2018TownHall

Rome Foundation Review Provides Guidance for Use of Gut-Brain Modulators for Functional GI Disorders

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Douglas A. Drossman, MD, MACG, President of the Rome Foundation and Drossman Gastroenterology offers insight on new research published online in Gastroenterology, Neuromodulators for Functional GI Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report.  Central neuromodulators (antidepressants, antipsychotics and other CNS targeted medications) are increasingly used for treatment of functional GI disorders (FGIDs), now recognized as Disorders of Gut-Brain Interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations

  1. What’s new and/or what are the research highlights?

Drossman: This is the first and most comprehensive review of the use of central neuromodulators for painful functional gastrointestinal disorders (FGIDs) like irritable bowel syndrome (IBS), centrally mediated abdominal pain and other painful symptoms.  It is the culmination of an 18-month project (a Rome Working Team) where we did an evidenced-based review of the literature and consensus of experts to come up with recommendations.  One key point is that we are changing the use of antiquated terminology of “antidepressants” and “antipsychotics” which were developed originally to treat psychiatric disorders, and replacing with the term neuromodulators.  The new term reflects better our understanding that these are disorders of gut-brain interaction (Rome IV).

In that context, we are treating a dysfunctional brain-gut axis with these medications, often in doses lower than for treating major psychiatric disorders.  Some of the major findings are that tricyclic antidepressants (TCAs) and SNRIs do work for pain.  However, if a single medication does not work or has side effects, we employ the concept of augmentation (combining two or more treatments) to help those that don’t initially respond.  Also, patients are kept on them for a year or more for relapse prevention.  It is a way to provide ample time to reverse the dysfunctional circuitry causing the FGID problem in the first place, and it may reverse the neurodegeneration that occurs over time. Finally, if there are frequent side effects or a failure to respond we recommend doing pharmacogenomic testing, a new method to evaluate how patients genetically metabolize these medications.  Also, it’s important to realize that the ways in which we employ these treatments for FGIDs is different from how psychiatrists treat psychiatric disorders.  In fact, psychiatrists are not well versed in these methods.

  1. What do physicians need to know?

Drossman: This is a paradigm shift.  We are looking to re-educate clinicians to understand the value of these medications for GI pain, nausea, and bowel dysfunction in cases, particularly where traditional GI drugs don’t work.  Physicians are not aware of many of the newer methods for managing the FGIDs and feel poorly trained in the use of these medications.  The Rome Foundation is looking to increase this understanding.  This Rome Working Team report will be out in March in Gastroenterology currently online for access to those who have a journal subscription.

In addition, we will be holding a major symposium at DDW on Saturday June 2nd at the Washington convention center from 2-3:30 “Central Neuromodulators for Chronic GI Pain and FGIDs (DGBI) – A Rome Foundation Working Team Report”.  The speakers will be me, Alex Ford and Jan Tack.  In addition, on Sunday at DDW (June 3) there will be a breakfast session “Using Neuromodulators for Disorders of Brain Gut Interactions: A Primer for Clinicians” with myself and Harley Sobin, MD.  For this session, we will do some practical case based guidelines. Thus, we are beginning to see a major change in the acceptance and value of these treatments.

  1. What’s important for patients to know?

Drossman: They can be helped!  Additionally, patients should know that the Rome Foundation is reducing the sense of stigma by avoiding unnecessary attributions relating these treatments to psychiatric disorders.  We believe there will be a big difference in acceptance and benefit to patients over the next few years as more and more physicians use them with a proper understanding of how they can benefit these chronic gastrointestinal symptoms.  With regard to DrossmanCare – we have been taking care of hundreds of patients over the years in this manner and helping patients with the most refractory symptoms who have been to other medical centers without benefit.  In our practice [see below citation], the combination of good communication skills to help patients understand the physiological value of these medications coupled with our knowledge of selecting the best medications or combinations of medications to treat these FGIDs make a difference to help those that have previously failed treatment.  I left UNC in part out of a commitment to improve patients suffering from these disorders using these methods and now we see it happen.

Related Resources

“Central Neuromodulators for Chronic GI Pain and FGIDs (DGBI) – A Rome Foundation Working Team Report”, Gastroenterology. 2017 Dec 21. pii: S0016-5085(17)36718-5. doi: 10.1053/j.gastro.2017.11.279

Beyond Tricyclics: New Ideas for Treating Patients With Painful and Refractory Functional Gastrointestinal Symptoms, The American Journal of Gastroenterology(2009) 104, 2897–2902 (2009) doi:10.1038/ajg.2009.341


Meghan Huff Joins Drossman Gastroenterology as Physician Assistant

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Meghan Huff

Meghan Huff  PA-C has joined Drossman Gastroenterology  and has already has become an integral part of the practice by enhancing its patient centered philosophy.  She participates in all clinic visits and coordinates medication prescriptions and pre-authorizations and communicates with patients through phone calls and messages to optimize their care in a timely fashion.

We asked Meghan  to share a little more about herself in the following Q&A:

1. Tell us a little about your background. What have you done before coming to work with Dr Drossman? 
 Meghan: I graduated from Seton Hall University Physician Assistant Program with my Master’s in Physician Assistant studies in May 2015. After graduating I worked for a private Pediatrician’s practice for 18 months in Danbury CT. My husband and I recently moved to Chapel Hill in July. Prior to PA school, I received my Bachelor of Science degree from the University of Notre Dame and worked as a CNA to fulfill my clinical hour requirements.  
2. What inspired you to become a PA? And why gastroenterology? 
  Meghan:  I was inspired to become a PA while on a medical mission trip to the Dominican Republic. While serving such an underserved population, I learned how a PA could work with doctors to treat patients of all ages and in all specialties. I was drawn to being part of the healthcare team and liked the fact that a PA has a lot of flexibility to work in any field. I decided to work in gastroenterology because disorders of the GI tract affect a wide range of patients and require a trusting relationship between patients and providers to achieve treatment goals.
3. What is it like working with Dr. Drossman and his patients?  What are some of the rewards and some of the challenges? 

 Meghan: Working with Dr. Drossman and his patients is an incredible opportunity. Chronic issues of pain and irregular digestion impact every aspect of a patient’s life. Being able to improve the every day life of a person is hugely rewarding. It is also of course very challenging to  gain the trust of patients who have seen many doctors previously and either not been taken seriously or not gotten proper care.

Meghan Huff and Dr. Douglas Drossman

4. What is different about how he conducts his practice? 
 Meghan:  Dr. Drossman listens to every patient with such compassion and he tries to ensure that each patient is able to say everything they want and need to say. By committing to working with each patient to achieve his or her treatment goals, Dr. Drossman not only involves his patients in his or her own care but he is truly invested in working to get each patient where he or she wants to be.
5. What inspires you to go to work everyday? 
 Meghan:  Every day is different and some days are really hard but some days, I get to go to work and hear a patient say his or her pain is gone. That is really awesome.
6. Share some of the things you enjoy doing in your free time? 
 Meghan:  I enjoy hiking, walking the trails around my neighborhood and swimming. Generally, I like to do outdoor activities with friends. I also really like watching TV/Movies and sports with my husband, particularly football.
7. If you could offer some words of wisdom for GI patients, what would you tell them? 

 Meghan:  Be your own advocate and find a doctor who takes the time to really listen to your symptoms and your history. 


Drossman Care Says Farewell to Amy Rodriguez PA-C as She Embarks on New Journey

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Amy Rodriguez PA-C joined Drossman Gastroenterology in October 2016 and will soon be leaving to embark on a new journey in life.

She was an integral part of the practice by enhancing its patient centered philosophy.  She participates in all clinic visits and coordinates medication prescriptions and pre-authorizations and communicates with patients through phone calls and messages to optimize their care in a timely fashion.

Amy graduated in May 2006 from the United States Military Academy at West Point where she was on the Black Knight Parachute Team.  Following graduation, she spent six years on active duty as a Paratrooper at Fort Bragg, North Carolina with two deployment tours to Iraq and one to Haiti as a Medical Service Corps officer.  She then decided to provide service in the healthcare field and attended the University of North Carolina at Chapel Hill for her PA school prerequisites and worked as a medical assistant at the Central Dermatology Center prior to attending Wake Forest Physician Assistant School, where she graduated in May 2016.  She and her graduate school partner were recognized for their research skills by receiving the Kitty Bowman Research Award

We would all like to say farewell from the DrossmanCare team, it has been a pleasure having you as part of our staff the last several months. Despite our sadness, we certainly wish Amy only the best and thank her for the hard work she has put in at Drossman Gastroenterology. Thank you Amy!

Rome Foundation’s Dr. Laurie Keefer, Featured in NBC News on Efficacy of Hypnosis for GI Disorders

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Dr. Laurie Keefer

Hypnosis is a well-recognized treatment for functional gastrointestinal disorders (FGIDs) including IBS with proven scientific benefit. Recently the news media has taken great interest in this treatment as shown in this NBC News feature that highlights Laurie Keefer, PhD from Mount Sinai Medical Center in New York. Dr. Keefer is a nationally recognized clinical psychologist who treats GI disorders including FGIDs with hypnosis. She is also a leading member of the Rome Foundation

In this video, Dr. Keefer explains why gastroenterologists are turning to psychologists for help with their patients who don’t get relief from medication. Hypnotherapy can be an effective treatment for heartburn and other stomach conditions. It’s a powerful alternative treatment, backed with scientific evidence, that is increasingly being offered at the nation’s leading medical centers.

Read the full NBC News article and watch the video

As a key member of the Rome Foundation, Dr. Keefer serves as a member of two Rome IV committees of the Rome IV book :  “Central Disorders of Gastrointestinal Pain” [Co-Chair] and “Biopsychosocial Aspects of Functional GI Disorders.  She also leads the Rome Foundation’s Psychogastroenterology Standing Committee which focuses on increasing the availability of GI-trained mental health professionals around the world.

Dr. Keefer is well known for her training of therapists in the implementation of evidence-based behavior therapies for GI diseases with an emphasis on gut-directed hypnotherapy and cognitive behavior therapy and is a sought-after lecturer on these topics.  She is also a member of Council for the American Neurogastroenterology and Motility Society.

In her current role at Icahn School of Medicine at Mount Sinai in New York City, Dr. Keefer oversees Psychobehavioral Research for the Division of Gastroenterology and also Co-Directs a patient-centered subspecialty medical home within the Susan and Leonard Feinstein IBD Clinical Center called GRITT-IBDTM [Gaining Resilience Through Transitions] which focuses on reducing negative outcomes for patients with inflammatory bowel disease by enhancing resilience with behavioral tools.  She remains committed to the development of self-management tools that leverage the strong brain-gut connection in order to improve outcomes for patients with chronic digestive diseases.

Rome Foundation Links Mind-Gut in Treating Chronic Digestive Disorders

The Rome Foundation has recognized the value of linking mind and gut in treatment of chronic digestive disorders and is now supporting the development of a Rome Psychogastroenterology Group (see information I’ve attached that you can expand upon about the group here).

The goal of this group is to connect mental health providers interested in treating patients with GI disorders, including FGIDs with the Rome Foundation and treating gastroenterologists.

This program will have dual benefits:

  1. To encourage mental health providers to go into this GI subspecialty and to gain knowledge from training programs provided by this group
  2. To become a resource for patients with FGIDS being treated by gastroenterologists as part of Rome Foundation’s educational initiative.

Mental Health Providers interested in Treating Patients with GI Disorders, please contact Dr. Laurie Keefer

Related Resources

Efficacy, Tolerability, and Safety of Hypnosis in Adult Irritable Bowel Syndrome: Systematic Review and Meta-Analysis, Psychosomatic Medicine 76:389Y398 (2014)

Long-Term Success of GUT-Directed Group Hypnosis for Patients With Refractory Irritable Bowel Syndrome: A Randomized Controlled Trial, The American Journal of Gastroenterology, Am J Gastroenterol  advance online publication, 19 February 2013;  doi: 10.1038/ajg.2013.19

Understanding and Managing Pain in Irritable Bowel Syndrome (IBS) – Tips and Insight

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This is an excerpt from a recent article I authored for the IFFGD. It appears here with permission.

Read full article 

Pain, by definition, is the dominant symptom experienced by patients with irritable bowel syndrome (IBS). Three out of 4 people with IBS report continuous or frequent abdominal pain, with pain the primary factor that makes their IBS severe. Importantly, and unlike chronic pain in general, IBS pain is often associated with alterations in bowel movements (diarrhea, constipation, or both).

The standard general definition for pain is, an unpleasant sensory and emotional experience that’s associated with actual or perceived damage to the body. Pain that is shortlived is termed acute, while pain that lasts 6 months or longer is termed chronic. Chronic pain may be constant or recurring frequently for extended periods of time.

The chronic pain in IBS can be felt anywhere in the abdomen, though is most often reported in the lower abdomen. It may be worsened soon after eating, and relieved or at times worsened after a bowel movement. It is not always predictable and may change over time. People with IBS use different descriptors to explain how the pain feels; some examples include cramping, stabbing, aching, sharp or throbbing. IBS is a long-term condition that is challenging both to patients and healthcare providers. It affects 10–15% of adults. Less than half of those see a doctor for their symptoms. Yet patients with IBS consume more overall health care than those without IBS.

The primary reason people with IBS see a clinician is for relief of abdominal pain. Standard diagnostic test results are normal in people with IBS; diagnosis is based on certain symptoms that meet defined (Rome IV) criteria. How can IBS be so painful when nothing irregular shows up on tests? The answer is that IBS is a condition where the symptoms relate to alterations in normal gastrointestinal function; that is, dysregulation of brain and gut affecting both pain signals and motility (movement of the bowels). The aim of this publication is to explain this relationship between the brain and the gut in order to help those affected understand why and how pain in IBS occurs, and how it can be confidently managed.

Ten Steps for Self-Management – What 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: You have the right 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 and 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. Interact with family and friends in healthy ways. Support others and seek support from them as well.

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About The International Foundation for Functional Gastrointestinal Disorders (IFFGD)
The International Foundation for Functional Gastrointestinal Disorders(IFFGD) is a nonprofit education and research organization. Our mission is
to inform, assist, and support people affected by gastrointestinal (GI) disorders. Visit our websites at and or
phone 414-964-1799.

Opinions expressed are an author’s own and not necessarily those of the International Foundation for Functional Gastrointestinal Disorders (IFFGD). IFFGD does not guarantee or endorse any product in this publication nor any claim made by an author and disclaims all liability relating thereto. This article is in no way intended to replace the knowledge or diagnosis of your doctor. We advise seeing a physician whenever a health problem arises requiring an expert’s care.

What Do Patients Want? Honesty, Respect, Effective Communications

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I encourage you to watch the video and put into practice the tips and insights gleaned.

For related information on effective patient-provider relationships please see my previous posts:

Now Available Webinar Recording Achieving Effective Patient-Provider Communication with Dr. Drossman

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One of the greatest problems that emerges with continually decreasing amounts of time that clinicians can spend with patients include the inability to:

1) obtain sufficient high quality information about the illness and

2) have quality time to establish an effective patient-provider relationship.

This can result in inaccurate diagnoses and treatments as well as patient and physician dissatisfaction with each other and the very process of care.

This webinar is specifically designed for patients and features Douglas A. Drossman, MD, MACG, and one of his patients, Katie Errico, who recently published her health journey in The American Journal of Gastroenterology.

Dr. Drossman and Katie will discuss her case as an example of effective patient-provider communication and provide guidance, tips and insights on what you can do to better understand your symptoms and how best to communicate with your doctor on how they are impacting your quality of life so you can effectively work together to achieve symptom relief.


1. To learn methods that help to optimize a visit to a physician

2. To learn ways to self manage chronic pain and functional GI symptoms

3. To understand how effective communication improves the patient-provider relationship through presentation of a case history


About Katie Errico:

I am a 31 year old special education teacher, tennis enthusiast and lover of dogs.  I am also a type one diabetic, diagnosed at 22, and looking back have had symptoms of IBS since my early teen years.  However, I did not know this until I met Dr. Drossman just after my 29th birthday, who also discovered that I have functional dyspepsia, atrophic gastritis and pernicious anemia.  I’m not going to lie, this was no easy road to travel and I still hit some bumps every now and again, but I can honestly say for the first time in a long time, I’m really enjoying my life 

Related Resources

Katie: A Patient’s Perspective Katie Errico Am J Gastroenterol 2017; 112:528–529; doi: 10.1038/ajg.2017.26; published online 21 February 2017

Katie: The Physician’s Perspective of a Young Woman’s Illness Experience Douglas A. Drossman , MD 1 Am J Gastroenterol 2017; 112:525–527; doi: 10.1038/ajg.2017.23; published online 21 February 2017

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