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.

---

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.

[Brenda F. Johnson, MSN]

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.

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.

Oh, no - I actually completely agree with you. There is too many addicted to pain meds people out there, but if I wrote that in my article I would be crucified. So I left that part out, as a GI nurse, I just focused on new medications to treat them.

[Brenda F. Johnson, MSN]

calivianya said:

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.

www.nursingtimes.net volume 108 no 41.

[JBudd, MSN]

Speaking as one of the people who have suffered from OIC, despite the regimin with my chemo..... let me tell you the constipation pain was worse than the post mastectomies pain. I really wish I had gone to the ER for the med, I vaguely remembered an inservice on it but I was too sick to think clearly. The laxative, stool softener, enemas and sitz did NOTHING on that day.

So it is all very well to sit and armchair quarterback about a manufactured need for an expensive drug but there was a need and it was met. And no, I'm not an addict, and quit using the pain meds etc. when I no longer needed them; never developed a dependence. Just constipation.

[Brenda F. Johnson, MSN]

JBudd said:

Speaking as one of the people who have suffered from OIC, despite the regimin with my chemo..... let me tell you the constipation pain was worse than the post mastectomies pain. I really wish I had gone to the ER for the med, I vaguely remembered an inservice on it but I was too sick to think clearly. The laxative, stool softener, enemas and sitz did NOTHING on that day.

So it is all very well to sit and armchair quarterback about a manufactured need for an expensive drug but there was a need and it was met. And no, I'm not an addict, and quit using the pain meds etc. when I no longer needed them; never developed a dependence. Just constipation.

I am sorry you had to have first hand experience with OIC. But thank you so much for your input!

[jifferte, BSN, MSN, RN]

JBudd said:

Speaking as one of the people who have suffered from OIC, despite the regimin with my chemo..... let me tell you the constipation pain was worse than the post mastectomies pain. I really wish I had gone to the ER for the med, I vaguely remembered an inservice on it but I was too sick to think clearly. The laxative, stool softener, enemas and sitz did NOTHING on that day.

So it is all very well to sit and armchair quarterback about a manufactured need for an expensive drug but there was a need and it was met. And no, I'm not an addict, and quit using the pain meds etc. when I no longer needed them; never developed a dependence. Just constipation.

I'm so sorry that you had to experience this. Hope you are doing well.

[Kiminindy, BSN, RN]

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.

I have had cancer twice. I appreciate the article for what it is, informative. All patients are not the same as you have pointed out. The typical medications used for constipation do not always work on all people.

[jdub6]

Although I agree that senna plus usually works just fine if you give enough, I have heard that most laxatives actually can cause permanent motility problems if taken chronically (not sure I've ever seen that in a pt but I've read and heard about it many times). People who use large amounts of laxatives for long periods of time, like those with eating disorders who abuse laxatives, can actually end up dependant on them just for normal bowel function and often have lifetime issues with constipation even with laxative use (again this is something I haven't seen much but have heard lots).

I would assume those who use laxatives with opioids long term would have the same problem (I think there are a few,like maybe miralax, that don't do this but they are not always effective, I was always told that anything that increases motility can cause dependence). I wonder if these new meds don't have this problem? I could see if the cost comes down a bit but remains more expensive than senna and bisacodyl, that one could still justify it if it meant avoiding lifelong motility issues?

[gettingbsn2msn, MSN, RN]

My problem with this drug is how it is advertised on TV. The man in the commercial is working on a construction site. He is obviously presented as using opioids. Does anyone see the irony in this. We have an opioid epidemic in this country. I am an NP and received the letter from the surgeon general office about NOT writing scripts for opioids (generic letter). However when average Joe sees this on TV he or she expects that they can see their PCP and easily get a script for narcotics. Oh, and if they get a little constipation they can take another drug. They make it appear so easy. Of course they use a very handsome man in the ad that appears to be in perfect health and shape. Such irony!!!!