Post written by Baha Fawwaz, MD, from Gastroenterology and Hepatology, AdventHealth, Orlando, Florida, USA.

Opioids have become one of the most widely prescribed medications in the United States. Chronic opioid use has been associated with esophageal dysmotility.

The focus of our study was to evaluate and compare the clinical outcomes of peroral endoscopic myotomy (POEM) for spastic esophageal disorders (SEDs) and esophagogastric junction outflow obstruction among chronic opioid users and nonusers.

With the opioid epidemic on the rise and its impact on esophageal motility known, there is a pressing need to investigate treatment modalities for this population. First-line treatment options for opioid-induced esophageal dysmotility include cessation of opioid use, switching to nonopioid medications, and/or seeking nonpharmacologic alternatives.

However, this strategy is infeasible for most patients. Traditionally, POEM has been shown to be successful in 85% to 90% of patients with spastic esophageal dysmotility. Yet, the clinical response to POEM in patients with chronic opioid use has not been well-established. Our goal was to evaluate the role of POEM in chronic opioid users with symptomatic SEDs.  

We conducted a multicenter propensity score matching analysis to evaluate the clinical outcomes of POEM in patients with SEDs and esophagogastric junction outflow obstruction who were opioid users (n = 64) compared with nonusers (n = 64). The results showed that the clinical response to POEM, defined as a post-POEM Eckardt score ≤3, was significantly lower among opioid users than nonusers (79.7% vs 93.8%, P = .03). Importantly, our study showed that patients using >60 morphine milligram equivalents per day had a higher likelihood of a lack of response than those using <60 morphine milligram equivalents per day.

It is conceivable that we will continue to see an increase in patients with esophageal symptoms because of the opioid epidemic. Evaluation and management of these patients can be complex and mandates a multidisciplinary approach. Conservative measures including opioid cessation and modification of analgesics should be first-line treatment. The role of POEM in these patients remains to be further elucidated and should be considered on a case-by-case basis after other less invasive alternatives have been exhausted. 

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