A Newly Defined Type of Constipation: Opioid Induced Constipation

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    Americans suffer from many bowel issues with constipation being on the top of the list. We can blame our diet, inactivity, not enough fluids, mechanical problems, and pain medication but whatever the reason, constipation all to often affects our daily living. There is a relatively new terminology describing a very specific type of constipation called Opioid induced constipation. OIC is a result of taking opioids for chronic pain relief

    A Newly Defined Type of Constipation: Opioid Induced Constipation

    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 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.
    Last edit by tnbutterfly on Jun 15, '18
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    42 Comments

  3. by   heron
    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.
  4. by   emtpbill
    Quote from Brenda F. Johnson
    Defining 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.
    .

    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.
  5. by   roser13
    This is new?

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

    Is this perhaps a "sponsored" article?
    Last edit by roser13 on Apr 12, '16
  6. by   heron
    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.
    Last edit by heron on Apr 12, '16
  7. by   Barnstormin' PMHNP
    I agree with all of the above posters.
  8. by   nutella
    It has been long known that narcotic pain medication also causes constipation. In fact, I have known patients with terrible diarrhea who got prescribed medication containing a narcotic to help with that (opium).
    Constipation is a side effect that will not get better and it is an issue with chronic but also acute pain relief. Anybody who takes narcotics should be on a bowel regimen. From working in hospice and palliative care, I can tell you that all patients, even if on pain medication only short term, need to take medication to help with bowels.Colace, while a stool softener, will not do much to get the bowels going. But you also do not prescribe all the new EXPENSIVE medications when we have in fact medications (most of the over the counter) that are just fine if given in the right dose. Cheaper and also very effective is Senna - but 1 or even 1 pill twice a day might not be enough. If 1 pill twice a day is not enough, some people have to take 2 in am and 1 in pm or 2 twice a day. There is also Miralax, there is lactulose, bisacodyl p.o. . Heck - even milk of mag or mag citrate. Of course if you wait too long to initiate bowel protocols or people are not taking them - you might find yourself with an order for a bisacodyl sup or enemas.
    In my personal opinion, there is no reason to give expensive newer medication or subq injections that have much more side effects.
    It is a huge market for bowel meds but most people who get the low cost bowelmeds upon initiation of narcotics plus teaching do just fine....
  9. by   KatieMI
    The effect itself was known from Avicenna time. Every ER, I guess, has a set of frequent fliers coming once in a while either for pain pills script, or for symptoms directly related to constipation these pills induced. The special drugs, like Relistor, are pretty new, though.

    I think that, while it is really cool that we know more about mechanisms and that these drugs may potentially be very useful for certain populations like onco patients who depend on opioids and have contraindications to traditional laxatives, most "typical consumers" of opioids should be treated traditionally. It is way cheaper and doesn't let at least some of them settle comfortably in their "routine" which quite often leads to abuse in the end.

    Do not like pain, gas, and that Miralax? Well, let's sit and think about what to do with your low back with as little of these "good pills" as possible, because the pills cause it all. I know you need one the days you work... how about PT the rest of the week?
  10. by   tnbutterfly
    Quote from roser13
    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.
  11. by   traumaRUs
    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.
  12. by   heron
    Well, color me skeptical. Just sayin'.
  13. by   Hollybobs
    Quote from nutella
    It has been long known that narcotic pain medication also causes constipation. In fact, I have known patients with terrible diarrhea who got prescribed medication containing a narcotic to help with that (opium).
    Constipation is a side effect that will not get better and it is an issue with chronic but also acute pain relief. Anybody who takes narcotics should be on a bowel regimen. From working in hospice and palliative care, I can tell you that all patients, even if on pain medication only short term, need to take medication to help with bowels.Colace, while a stool softener, will not do much to get the bowels going. But you also do not prescribe all the new EXPENSIVE medications when we have in fact medications (most of the over the counter) that are just fine if given in the right dose. Cheaper and also very effective is Senna - but 1 or even 1 pill twice a day might not be enough. If 1 pill twice a day is not enough, some people have to take 2 in am and 1 in pm or 2 twice a day. There is also Miralax, there is lactulose, bisacodyl p.o. . Heck - even milk of mag or mag citrate. Of course if you wait too long to initiate bowel protocols or people are not taking them - you might find yourself with an order for a bisacodyl sup or enemas.
    In my personal opinion, there is no reason to give expensive newer medication or subq injections that have much more side effects.
    It is a huge market for bowel meds but most people who get the low cost bowelmeds upon initiation of narcotics plus teaching do just fine....
    ^^^. Yup.
  14. by   loriangel14
    Since when is it "news" that opioids cause constipation?

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