Optimal Management of Opioid Induced Constipation - Episode 5

Additional Treatment Options for OIC Management

June 17, 2021
Gerald Sacks, MD, Pain Institute of Santa Monica

,
Fariborz Rezai, MD, FCCP FCCM, Rutgers New Jersey Medical School

The role of lifestyle modifications and over-the-counter products to prevent opioid-induced constipation in patients is discussed.

Fariborz Rezai, MD, FCCP FCCM: It’s probably more important for patients on the outpatient side, but we do physical activity in the ICU [intensive care unit] setting as best as we can. We do early mobility, even on patients on the ventilator. The physical therapist, the nurse, and other health care practitioners will walk the patient around the unit. Physical activity is really key to the overall health of the body but also for having a regular bowel movement. Obviously, diet plays an important part. The appropriate balanced nutrition with appropriate vegetables, fruit, and dietary fiber helps prevent OIC [opioid-induced constipation] and other types of constipation. It doesn’t hurt for everybody—as best as they can—to be as active as they are permitted to be. Obviously, you must speak with your primary care physician regarding what you can and can’t do. It’s important to be physically active on a daily basis even if you’re not suffering from any constipation. It maintains the whole body’s homeostasis, including the bowel movements and regular bowel movements. That all comes into play. Appropriate sleep, eating a healthy balanced diet, and exercising on a regular basis all play a part in the lifestyle modification that patients should adhere to if they want to prevent any type of constipation, including OIC.

Gerald Sacks, MD: There are numerous other products. Over-the-counter medications are used to address and treat opioid-induced constipation. Whenever I have a patient taking opioids, 1 of the first things we discuss is the prevention and treatment of opioid-induced constipation. The goal is to prevent an episode of opioid-induced constipation. The last thing I want for a patient is to have to go to the emergency department for a manual disimpaction. I still remember manually disimpacting patients when I was a young physician. It’s an extremely unpleasant experience for the patient as well as the health care professional, so we try to avoid that. Certainly we try to avoid visits to the emergency department to treat constipation as well. When a patient is prescribed opioids, I initiate the discussion with the patient in terms of how to prevent the adverse effects from the opioids. I frequently will have the patient obtain a stool softener or perhaps a stool-softener-and laxative combination. Both medications are available over the counter. I frequently will have the patient utilize MiraLax, which is available over the counter. It used to be a prescription item but is now available over the counter for the prevention and treatment of opioid-induced constipation. Certainly, we have patients maintain their active and healthy lifestyle in terms of maintaining their hydration, drinking enough fluid, walking around, doing physical therapy, maintaining their physical activity level at a high level, and utilizing the opioids to treat the pain. Management of pain ensures they can do more activities, be more active, do physical therapy, and take a walk on a daily basis if that’s what they’re able to do. These over the counter medications can be helpful, but frequently patients will still—even when they’re taking a stool softener, a laxative, a suppository, or even another laxative—have opioid-induced constipation. That’s where I prescribe the peripherally acting µ-opioid receptor antagonists.

Fariborz Rezai, MD, FCCP, FCCM: Lubiprostone and linaclotide [Linzess] are used in constipation, especially for patients with irritable bowel syndrome. They’re a little less specific because they call stimulation of fluoride release or they work with the chloride channels, depending on which drug we’re talking about. But overall, they do the same thing, which is trying to increase luminol fluid. By increasing that luminol fluid, it allows the feces, the contents, to be moister to support its passage through the gut. It’s not something we really use for OIC. For OIC, we’re using something that blocks µ receptor as more of a strategic and pinpoint treatment really taking care of the ideology. This is a little more generic, where this causes more fluid in the gut. Not to mention that this also causes a lot of bloating and discomfort for the patients, so it’s not something that I use at all.

Transcript Edited for Clarity

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