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In the United States alone, more than 240 million opioid prescriptions are dispensed every year and roughly 3% of all Americans are prescribed an opioid regimen for chronic non-cancer pain relief.
A common adverse side effect of opioid medications is opioid-induced constipation, or OIC, which occurs in 40% to 90% of patients taking opioids. If you are taking opioids, your doctor should evaluate you for any signs of OIC.
To more deeply understand OIC, we must first take a look at what opioids are, and how they can cause constipation. Constipation occurs when bowel movements become less frequent and more difficult to pass.
Opioid (or narcotic) pain medications— best known colloquially as “painkillers”, are a class of drugs commonly prescribed for their pain-reducing—or analgesic—qualities, and include substances like oxycodone, hydrocodone, codeine, and morphine. You might recognize these drugs by their brand names: Oxycontin, Vicodin, Percocet, among others. These medications have been used as a means of providing pain relief for many years. They are also are used for medical, as well as nonmedical, purposes, including:
Pain relief—With respect to pain relief, opioids are used to treat:
Anesthesia—Opioids are typically used as anesthetic regimens that aid in surgical procedures.
Cough suppression—Opioids (such as codeine), combined with other agents, may suppress cough, and some are used for this clinical purpose, especially if a dry and non-productive cough presents.
Diarrhea suppression—Opioids typically cause constipation, and as such, they are sometimes utilized in the treatment of diarrhea
Addiction treatment —Certain types of opioids, methadone in particular, are used to help opiate or narcotic addicts wean off stronger opioids like heroin to help prevent severe withdrawal symptoms.
Severe Anxiety—In very rare cases, opioids may be used to treat severe anxiety.
The vast majority of patients receiving long-term opioid pain medication are in advanced stages of their disease. Despite their analgesic benefits, opioids can cause a number of side effects, the most commonly occurring of which is opioid-induced constipation, or OIC. Patients develop a tolerance for many of the other side effects of opioids, such as respiratory depression. However, patients generally do not develop a tolerance to OIC. Altogether, studies indicate that as many as 81% of patients who are prescribed opioids experience OIC.
Opioids affect a specific set of receptors in the central nervous system, or CNS, and they may also function in the gastrointestinal, or GI, tract. More specifically, opioids bind to mu receptors in both the CNS and GI tract. In the CNS, this results in pain relief. In the GI tract, however, this tends to inhibit the normal functioning of the GI system, particularly the intestines and colon, resulting in severe constipation.
Opioids are effective pain relievers, but often have the side effect of constipation, which can be severe, especially with long-term use. Opioid pain medications affect the GI system in a number of ways, including:
Taking opioid-based substances—legal or illicit—puts you at risk for OIC. Along with opioid use, you may be at higher risk for OIC based on the following factors:
Other factors that may impact OIC include:
Your doctor will gather your medical history to check for standard problems associated with constipation, like:
Be prepared for a physical assessment that may necessitate oral, abdominal, and anorectal examination. Opioid-induced constipation is a clinical condition characterized by slowed gastrointestinal movement, and occurs in 90% of all patients that take opioids for advanced cancer pain. This condition is characterized by a number of symptoms, which include:
The symptoms of OIC can be very similar to those of opioid bowel disorder (OBD), which can pose a challenge when making a diagnostic assessment.
Common physical symptoms of OIC include:
Other symptoms of OIC include:
Cessation of opioid use may quickly alleviate OIC symptoms; however; this is not a recommended approach for treatment. Recent advances in the understanding of the etiology of OIC have brought forth the development of targeted pharmacologic regimens that prove effective at both alleviating OIC symptoms while also maintaining the analgesic or pain relieving, effects of the opioid medications. Recently conducted studies indicate that as many as 81% of patients who are prescribed opioids experience OIC.
Opioid medications are extremely effective for the treatment and management of pain, however their frequent use results in opioid-induced constipation, or OIC. Treatment options for OIC range from simple diet changes to stool softeners and laxatives to the use of specialized medication that specifically treats constipation that occurs due to long-term use of opiate medication.
Talk to your doctor about whether the following lifestyle changes might help with your OIC. Lifestyle changes that may prove beneficial include increasing:
Changes in lifestyle, however, may not be possible for many patients, and may ultimately prove ineffective in treating OIC. If there is a concurrent underlying disease or medicine that is causing constipation, the disease may need to be treated separately or another treatment regimen may have to be considered.
Constipation is the most frequently cited side effect for long-term opioid therapy. Screening for OIC should begin with a thorough personal history of bowel habits prior to using opioids. A rectal examination may prove useful in screening for OIC, but is not always necessary. Opioid-induced constipation should be monitored often, daily in some cases. A patient should work with their doctor to develop protocols to address specific lengths of time in which he or she has been without a bowel movement. Impaction must be ruled out before starting treatment for constipation.
It’s important to remember that only those who take opioid medications are at risk for OIC. In other words, this condition is not necessarily preventable in the way that other conditions may be.
OIC symptoms usually require medical treatment with a therapeutic regimen that accompanies the opioid painkillers that are causing the constipation. Withholding opioid treatment is ill advised because it results in a decrease in the patient’s quality of life.
For the treatment of OIC, doctors may recommend:
Constipation is a known side effect of opioid analgesics and should be addressed before opioid therapy begins. As opioid-induced constipation can be severe and adversely impact quality of life and compliance with therapy, prophylaxis with laxatives is considered to be the best approach. A British Pain Society survey conducted in March 2009 showed that nearly half of all general practitioners (GP) (44%) surveyed believe that the negative impact of such side effects is the key factor in patient non-compliance with prescribed opioid treatments.
Concurrent management on initiation of opioids frequently includes recommending certain lifestyle or dietary adjustments (as listed above) and initiating a scheduled regimen of laxatives. Laxative and cathartic therapy may be needed throughout opioid therapy and beyond. Effective management requires a composite of strategies, including behavioral and lifestyle changes (diet, activity, and fluid intake, as appropriate).
However medications used to manage opioid-induced constipation, such as laxatives, do not address the underlying opioid receptor-mediated cause of constipation and are often ineffective. Therefore, pharmacotherapeutic intervention may be necessary.
Methylnaltrexone (available as Relistor) helps restore bowel function in patients who have advanced illness and receive opioids for pain relief. Methylnaltrexone is delivered via subcutaneous injection and is designed to displace the opioid from binding to peripheral receptors in the gut, decreasing the opioid’s constipating effects and inducing laxation. Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist (PAMORA) that decreases the constipating effects of opioids in the GI tract without affecting pain relief.
Additionally, lubiprostone (available as Amitiza) is a chloride channel activator that is utilized in the treatment of OIC in adults with chronic, non-cancer pain.
There are a number of complementary and alternative therapies that can help with opioid-induced constipation, among them:
It’s important to remember that your OIC is caused by a medication that, if prescribed and taken properly, will exponentially increase your overall quality-of-life by decreasing your pain and getting you back to a more functional place. And OIC should not cause you embarrassment. Speak with your doctor right away if you should experience OIC symptoms.
Speak with your physician if you are experiencing these symptoms while taking opioid medication:
Fewer than 3 bowel movements per week, with at least 25% of those bowel movements associated with one (or more) of the following conditions:
If you are experiencing discomfort and you think you may have opioid-induced constipation, call the doctor that prescribed your medication. You might also want to call a gastroenterologist.
Due to the nature of this condition, you may likely be reluctant to speak with your doctor about your OIC; however, it is imperative that you do. Some questions that may help initiate the conversation include:
For more information on opioid-induced constipation, see:
Medical News Today
Practical Pain Management
ACP Online
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