Pain Management

Everyone experiences pain differently. Therefore, the management of IBD pain is complex and requires a personalized approach. Treatment for pain may include a combination of medications, psychological, and other approaches.

Understanding pain to manage it

If you are having pain, it is helpful to find out if your pain is from active inflammation (flare) or not. Understanding the causes of your pain will help guide your treatment. Your pain management should include a team of health care providers including your family physician (general practitionar) and gastroenterologist. You may also need a pain specialist, psychologist or counsellor, and a dietitian. Find out more later in our section on Accessing Pain Specialists

​Sources of pain

You should also collaborate with your IBD healthcare provider(s), and consider both intestinal sources of pain (e.g., gastritis, enteritis, colitis) and extra-intestinal sources of pain (e.g., mouth sores, inflammation of the joints, skin, and eyes). 

If your IBD is not active, your pain may be caused by non-inflammatory factors such as adhesions, stricture, fistulas, or functional pain (abdominal pain that may be thought of as irritable bowel syndrome-like pain). You can find out more in the section, Sources of Pain

Checking for disease activity 

To determine if your pain is due to active inflammation related to your IBD, your healthcare team may conduct a physical examination and identify inflammatory markers using blood or fecal tests, small bowel imaging, or endoscopic procedures.

Learn more about these tests in our Diagnosis and Testing section. If you have IBD inflammation, you may need a change in the medication you normally take for IBD.

Quit smoking

Cigarette smoking is associated with an increased risk of IBD and inflammation. If you have Crohn’s disease and smoke cigarettes, quitting smoking (smoking cessation) is recommended.

Other factors to consider

The approach to pain management in IBD also depends on the location of your pain, severity or intensity, type, and duration of pain. Visit our section on Talking to your Health Care Provider for tips on how to assess, track and communicate about your pain, to help determine the best pain management options for you. 

Management of chronic pain requires a holistic or multidisplinary approach. This means you need to think about your body as a whole. We need to treat sources of inflammation of course, but we also need to consider psychological and lifestyle issues that may be contributing to your pain.

Your pain management in IBD may be further complicated if you have other medical conditions. These may restrict certain treatment options or limit their effectiveness.


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Quit cigarette smoking

Smoking is discouraged in people living with IBD. It is particularly harmful to patients with Crohn’s disease, due to the direct effects of nicotine on disease activity.

Quitting smoking can help improve the health of your digestive tract and overall health. In Crohn’s disease, quitting smoking can reduce flare-up rate and disease severity. It can also help reduce the need for corticosteroids or immunosuppressive therapy.


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Medications for pain

The medications for pain are different from medications for IBD inflammation. Medications used to treat pain often target the gut-brain connection and pain pathways. Always check with your health care team before using any prescription or over-the-counter medications.

Avoid nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in IBD patients. These medications include:

  • ibuprofen (Advil, Motrin)

  • naproxen (Aleve, Naprosyn)

  • ketorolac (Toradol)

  • celecoxib (Celebrex)

  • diclofenac (Voltaren)

  • indomethacin (Indocin)

  • ketoprofen (Orudis).

Although these are used in other conditions to relieve pain (e.g., arthritis, osteoporosis), they may trigger flares in IBD patients. Speak to your IBD healthcare team if you have questions about NSAIDs use. 

Non-opioid analgesics 

Acetaminophen (Tylenol) is safe in IBD unless you have an underlying liver condition. Healthy individuals without any other contraindications (liver disease, allergies) can take up to 4000 mg/day of acetaminophen, or 3000 mg/day in older patients.

IBD patients with liver issues (non-alcoholic fatty liver disease [NAFLD], primary biliary sclerosis [PBS] or primary sclerosing cholangitis [PSC]), may need to limit their use of Tylenol.

Always check with your healthcare team before starting any medication(s) or over-the-counter products or supplements. 

Tricyclic antidepressants and SNRIs

Drugs that act on the central nervous system (CNS), such as tricyclic antidepressants and selective norepinephrine reuptake inhibitors (SNRIs), can improve changes in the gut that are associated with stress. They also help to suppress the transfer of pain signals to the brain.

Anticonvulsants

Gabapentinoids (gabapentin or pregabalin) are anticonvulsants that may block pain signals from reaching the spinal cord neurons. They also increase the release of a chemical called noradrenaline in the CNS, which helps relieve pain.

Gabapentinoids are being investigated for their potential role in the management of abdominal pain (especially visceral hypersensitivity).

Anticholinergics / antispasmodics

These drugs can help provide a bridge of pain relief while remission is being induced. They can help with pain if standard medical therapies are unable to control inflammation. They are frequently used as analgesics when there is inflammation pain causing intestinal spasms.

Opioids

Opioids relieve pain by binding to opioid receptors in your brain and spinal cord. They mimic the effects of pain-relieving chemicals that are produced naturally. They also block the ability of GI neurons to sense pain. In addition, opioids help prevent the spinal cord neurons from bringing pain signals to the brain. 

The chronic use of opioids can increase disease activity and lead to increased pain. They may also mask underlying health problems. Opioids have been linked to an increased risk of abdominal surgery in patients with Crohn's and colitis. 

In addition, chronic high-dose opioid use may contribute to underlying mood disorders. Opioids also have the potential for substance misuse. If abused, they may lead to a fatal overdose. If you are concerned about opioid use, talk to your health care provider and IBD specialist for alternative options that may work for you. 

Medical cannabis

In recent studies on the use of cannabis in people living with IBD, pain is the top reason why people choose to use cannabis for symptom management. Patients may be more likely to use cannabis for symptom management if they have a history of abdominal surgery, chronic abdominal pain, and a poorer quality of life.

In these studies, people living with IBD report meaningul improvements in pain relief, in addition to other symptoms like nausea, appetite, and sleep.

Our current knowledge of the how cannabis acts to reduce IBD pain is poorly understood. There is no long-term safety data for cannabis use and there are risks involved. Immunosuppressed patients may be at risk for infections secondary to contaminants found in cannabis.

Patients interested in taking cannabis should speak to their health care provider and obtain a prescription to obtain medical cannabis from a licensed producer. This helps ensure consistency and quality control of cannabis products as well as screening of contaminants. 

To learn more about cannabis use to manage symptoms of IBD, visit our section Cannabis and IBD.


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Psychological and cognitive therapies

Psychological approaches can help improve how you adapt to pain and improve your mental wellness. All patients with IBD should have mental health assessments done, and treatment provided as needed. If you are feeling suicidal, please do not hesitate to seek help and contact your health care provider immediately.

Mindfulness-based therapies

Mindfulness-based therapies are a type of CBT that involves meditation and breathing exercises. Mindfulness meditation emphasizes the need to ‘live in the now.’ It uses a judgment-free response to your feelings, thoughts, and behaviours. Mindfulness techniques are useful in treating anxiety, depression, and chronic pain.

Watch the video below to learn more from an expert psychologist about the use of mindfulness to manage pain and well-being in IBD: 

Yoga and breathing exercises

Yoga and slow, deep breathing can help you relax. You can take classes in yoga or relaxation techniques, or use videos or books.

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) includes acceptance and mindfulness procedures, along with commitment and behaviour change strategies, to help reduce stress. 

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) emphasizes the relationship between thoughts, feelings, and behaviours. The aim of CBT is to train you how to evaluate your negative thoughts, and understand how they impact your behaviour and emotions. CBT can help you learn how to change this type of thinking. 

Biofeedback

Biofeedback reduces muscle tension and slows the heart rate through the help of a feedback machine. It can help you relax and cope more easily with stress. One study has shown biofeedback, in conjunction with education, relaxation techniques, and training in cognitive coping techniques, helped reduce symptoms (including pain) in patients with IBD. It also helped them cope better with their disease. 

Hypnotherapy

Hypnotherapy is guided hypnosis or a trance-like state of focus and concentration. This is achieved with the help of a clinical hypnotherapist. There are some reports that hypnotherapy may improve abdominal pain in IBD and irritable bowel syndrome (IBS), including pain intensity and frequency. 

Apps to help you manage pain 

Digital applications and tools can be helpful for managing pain, anxiety, depression, and stress. Here are some suggestions from our experts: 

  • Moodgym helps you learn and practice skills to prevent and manage symptoms of depression and anxiety.

  • Headspace offers information about meditation and how it can help with stress, anxiety, and other issues.

  • Calm.com provides 100+ guided meditations covering anxiety, focus, stress, sleep, relationships, and more.


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Exercise and physical activity

Physical exercise plays an important role in the management and prevention of IBD. Some studies show regular exercise may help reduce stress and symptoms of IBD. This can improve physical functioning and well-being of patients with IBD.

Studies have shown stress causes more illness in patients who get a low amount of physical activity. Exercise has a positive effect on disease control. In fact, people with physically demanding jobs tend to have a lower risk of IBD. Therefore, it is a great idea to exercise on a regular basis when you have IBD.

Talk to your healthcare team about incorporating physical exercise into your daily activities. 

For more information, please visit our Exercise and Lifestyle section.

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Diet and nutrition

Certain foods can aggravate IBD symptoms including abdominal pain, bloating, cramping or discomfort. Try downloading MyGut app or use a food diary to keep track of what you are eating, how you are feeling, and what happens when you eliminate certain foods. Also, try eating small meals more frequently and drinking lots of water. 

There is no proven IBD diet. Here are a few dietary therapies that some patients report improve symptoms of IBD:

  • Exclusive enteral nutrition (EEN): This is a completely liquid diet containing all the macro- and micronutrients a patient with IBD needs. There are different types of EEN diets. The EEN diet has been shown to induce and maintain remission. It seems to reduce patients’ abdominal symptoms and inflammation but it is a difficult diet to tolerate.

  • Mediterranean diet as an anti-inflammatory diet: This diet is based on the traditional cuisine of the Mediterranean countries. It is typically high in vegetables, fruits, whole grains, beans, nuts, seeds, and olive oil. The Mediterranean diet has been shown to promote a healthy microbiota (balance of organisms in the gut) and reduce inflammation.

Visit our section on Diet and Nutrition, to learn more about how diet can be modified to help manage IBD.


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Transcutaneous Electrical Nerve Stimulation (TENS)

In transcutaneous electrical nerve stimulation (TENS), adhesive electrodes are placed on your skin. They deliver electricity to block pain signals in that area.

TENS may be helpful in treating issues related to IBD such as fecal incontinence or ileus, which is a build-up in the intestines that could lead to a blockage.


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Therapeutic endoscopy

A stricture (narrowing of a part of the intestine) can cause pain and has the potential for blockage. One way to treat strictures is by using a therapeutic endoscopy procedure called endoscopic balloon dilatation.


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Surgery

Depending on the nature, location, and length of a stricture, surgical intervention may be required. Adhesions are bands of scar tissue that form after surgery. Surgery is the only way to break adhesions that cause pain.


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