A Newly Defined Type of Constipation: Opioid Induced Constipation

[Brenda F. Johnson]

Defining Constipation

Constipation is usually the result of multiple other problems and should not be taken lightly. It is especially common in the elderly, the very young, and female patients. Constipation is diagnosed by several symptoms such as hard stools, straining, and several days between bowel movements. If you were thinking that constipation is only prevalent in the U.S., think again. According to the article, "How to Manage Chronic Constipation in Adults," by June Rogers MBE, Europe has up to 81% of patients with complaints of constipation. Also, in England, 12 millions prescriptions were written for laxatives in 2001.

As mentioned before, constipation affects daily living. Rogers references a study in her article done in 2011 that says constipation lowers quality of life, patients had a higher incidence of employment absenteeism, as well as being less productive at work. Below is a way that healthcare professionals rate symptoms of constipation.

Rome III criteria: At least two symptoms need to be present for the preceding 6 months (Muller-Lissner, 2009).

1. Straining at stool at least 25% of the time
2. Hard stools at least 25% of the time
3. A feeling of incomplete evacuation at least 25% of the time
4. A feeling of anal blockage at least 25% of the time
5. Manual maneuvers for rectal emptying at least 25% of the time
6. Two stools or fewer per week

There are many drugs that can cause constipation such as anticholinergics like scopolamine. Tricyclic antidepressants, phenothiazines, iron, bismuth, calcium channel blockers along with many more contribute to patients suffering from constipation.

What is Opioid Induced Constipation?

Opioids are pain relievers that mimic morphine working on the opioid receptors. Some examples are: hydrocodone, fentanyl, oxycodone, and naloxone. Opioids always causes constipation, so much so that prophylaxis should be started when the opioid is. In the article, "Management of Opioid Induced Constipation," it tells us that fiber, fluids, stool softeners are encouraged but not enough for these patients.

Treatment of OIC

The above mentioned treatments may not be enough, or even possible for some patients. One thing the physician should do is prescribe a laxative or cathartic as soon as the opioid is given. Peter Crosta tells us in his article, "All About Opioids and Opioid-Induced Constipation (OIC)," all of the types of drugs used to treat OIC:

• Emollient/lubricant cathartics - lubricates and softens stools
• Bulk cathartics - softens stools and increases bulk
• Osmotic laxatives - increases bulk and softens stool
• Stimulant cathartics - counteracts the effect of opioids by increasing motility
• Prostaglandins - (prokinetic) changes the way the intestine absorbs water and electrolytes

Another route the doctor may choose to help the patient's OIC is "rectal intervention" if the above medications have not worked. Rectal intervention is the use of enemas and rectal suppositories, rectal irrigation and manual evacuation.

There are new medications for the treatment of OIC that you may have seen on television commercials. One of those drugs that specifically targets OIC is Methylnaltrexone or Relistor. Relistor is given subcutaneously and "displaces the opioid from binding to peripheral receptors in the gut, decreasing the opioid constipating effects and inducing laxation." Because Relistor has a restricted ability to cross the blood-brain barrier, only the peripheral opioid receptors are antagonized in the gastrointestinal tract. Therefore, it does not reverse the effects of the opioid pain pill.

An oral option for OIC is the relatively new drug called Movantik. September of 2014 the FDA released a study done by the U.S. Food and Drug Administration showing patients experienced an increased number of bowel movements. Some mild side of effects of Movantik are headache, excessive gas, diarrhea, and abdominal pain. The FDA is requiring further study on the cardiac effects of this medication.

Alvimopan (Entereg) is used to decrease the development of an ileus post operatively in patients having a bowel resection, partial colectomy, and hysterectomy but does not decrease the effectiveness of morphine.

Conclusion

There are many side effects to most medications, creating the need for even more medication to treat them. For those patients taking opioids, the new medications now available allows patients to poop and still have good pain control. Have you had patients taking these medications for OIC? Please share your experiences.

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References

"All About Opioids and Opioid-Induced Constipation (OIC)." Medical News Today. 23 March, 2016. Web.

"FDA Approves Movantik for Opioid-Induced Constipation." 16 September 2014. U.S. Food and Drug Administration. 24 March, 2016. Web.

"Management of Opioid Induced Constipation." Sept. 2011, ED. 3. UWHealth Pain Care Services. 23 March, 2016. Web.

Rogers, June MBE. "How to Manage Chronic Constipation in Adults." Vol. 108:No. 41. 10 Sept. 2012. Nursing Times. 25 March 2016. Web.

[Jules A, MSN]

Tenebrae said:

A newer drug Clozapine is one of those drugs that everyone worries about agranulocytosis, when infact constipation is a much more common and potentially more harmful side effect and more recent occurence

You can't seriously be comparing the two? Clozaril has been around since the mid 70s so not so new and agranulocytosis is an acute medical emergency that has the potential to quickly kill your patient. Please don't spend time focusing on your constipated patient at the expense of the one with a plunging ANC.

This smacks of another disgraceful Harm Reduction model, instead of coming up with a highly advertised, expensive therapy which I personally suspect is targeted toward the chronic pain population, it would be make more sense to find something that is actually shown to be effective long term to treat pain, which opiates are not.

Instead of addressing the elephant in the room lets just give everyone Naloxone, something extra special to poop and ignore the underlying opiate dependence epidemic. I know this makes me sound older than dirt but our cowardly society is going to hell in a handbasket. Let's just give everyone a trophy, sigh.

[calivianya, BSN, RN]

I just really want to know who skips work for constipation. The article clearly says increased constipation = increased employee absenteeism.

I am wondering if that part of the article was tangential, I.e. people with constipation tended to have more health problems in general, or if they really found out that people were calling out because they were constipated.

I would like to see the original research on that part so I can have a good laugh.

[Tenebrae, BSN, RN]

Jules A said:

You can't seriously be comparing the two? Clozaril has been around since the mid 70s so not so new and agranulocytosis is an acute medical emergency that has the potential to quickly kill your patient. Please don't spend time focusing on your constipated patient at the expense of the one with a plunging ANC.

A more recent issue than opiate induced consitption. didn't say it was still particularly new issue.

agranulocytosis a medical emergency that can kill, no way, I didn't know that.

Interestingly enough, agranulocytosis in my country affects up to 1% of the population. Constipation related to clozapine use affects 4% of the population. ANC killed one person, complications related to clozapine constipation killed four people.

Clozapine: Fatal 'constipation' more common than fatal agranulocytosis

Death From Clozapine-Induced Constipation: Case Report and Literature Review

So the next time you are tempted to speak to me like I have no idea, please don't. I've had first hand experience working with patients with clozapine induced constipation and the complications that arise as a result. And annecdoctal evidence aside, research supports the fact that clozapine induced consitpation affects more people than agranulocytosis

[SallyTheCamel]

Farawyn said:

I never do that at work. Unless I'm sick. Yes, I'm one of those nurses.

Oh, girl. Not me. This IBS gets me "going" and I HAVE to go!

Working in home health, I know where the good bathrooms are. But there was that one time I was in the middle of BFE...

[Just and R.N]

A timely article for me. I recently took care of a patient with metastatic gastric cancer, on opiods for pain control. He had difficulty with maintaing an adequate bowel regimen due to large amounts of IV narcotics, difficulty tolerating senna and miralax, (or any PO for that matter) and possibly the physiologic effects of his disease. The only thing that worked was relistor, so yes the med does have a place. His (and my) relief when he finally had a BM was worth whatever the drug costs. Big pharma or not this was about a young dying man getting some much needed relief.

[Brenda F. Johnson, MSN]

heron said:

Do either of those drugs work better than colace and senna? Or prune juice for that matter. Frankly, they sound like very expensive solutions in search of a problem. Couldn't find it, so they made one up.

Good point, drug manufacturers are always looking for ways to charge more to the consumer. The research show that laxatives are often ineffective with these patients, these new drugs are used when other less expensive methods have not worked. They do recommend the usual increase in water, exercise if possible and increased fiber.

[Brenda F. Johnson, MSN]

emtpbill said:

Naloxone is not an opioid. While it will rip any exploring opiate off the receptor and has a higher affinity to the mu-receptor, it is not a narcotic.

You are absolutely right, it is narcan an opioid antagonist. I must have mistakenly put that in there instead of another drug. Thanks for pointing that out.

[Brenda F. Johnson, MSN]

roser13 said:

This is new?

Not trying to be sarcastic. This has always been a recognized issue.

Is this perhaps a "sponsored" article?

No, this is not a sponsored article. This has been a long time issue as you pointed out, but the new medications that target such a specific population of constipation sufferers has to have a title, and therefore "OIC"

[Brenda F. Johnson, MSN]

heron said:

The conventional low cost remedies work just fine for the small number of chronic opioid takers in my LTC. So what kind of morbidity are we really looking at that justifies a whole new drug? And what do those drugs cost, anyway.

ETA: Come to think of it, didn't see much refractory constipation on my hospice inpatient or my AIDS unit, once we got 'em on a good regimen.

I looked up the cost of Relistor (I am sure they have coupons or offers as other new drugs do) and for one vial it is $48 and for 7 vials it is $336, so yes very expensive. I am just interested in this new research and treatment because I am a GI nurse. That is the only reason I wrote this article. Yes, patients should be started immediately on laxatives, etc to prevent problems but according to the articles for some patients it is not enough.

[Brenda F. Johnson, MSN]

traumaRUs said:

I care mostly for dialysis pts and many of my pts also have cancer has a co-morbid as many chemotherapeutics have renal failure as a side effect (unfortunately).

I always start with stool softeners, colace, proceed on to miralax...etc...

Trying to be cost-conscience, I do try simple first. However, that said, these ARE newer drug on the market and knowing they are out there is important.

Thank you, the intent of my article is to notify us of new treatment, being a GI nurse, I am especially interested in things related to the bowel. I was interested, so I wrote the article, no other reason

[Brenda F. Johnson, MSN]

Libby1987 said:

Are any of these new meds developed for a population who couldn't find an effective bowel program and/or effective traditional meds and methods were contraindicated?

That is exactly who these medications are for, for the ones who traditional therapies have failed.

[Brenda F. Johnson, MSN]

Tenebrae said:

As others have said, opioids causing constipation is not new. As a nurse, if I have a patient who is on regular opiods and does not have some form of aperients charted, you can bet your bottom dollar I'll be getting the doc to chart some.

A newer drug Clozapine is one of those drugs that everyone worries about agranulocytosis, when infact constipation is a much more common and potentially more harmful side effect and more recent occurence

I guess that the title is throwing everyone for a loop. No, it is not a new concept that opioids cause constipation, however the development of these new drugs has forced a new title for a specific population