Expert Perspectives in the Management of Opioid Induced Constipation - Episode 2
William F. Peacock, MD; Conar Fitton, MD; and Neel Mehta, MD, explore the importance of early intervention and the overall challenges of ensuring that patients receive appropriate care for opioid-induced constipation.
William F. Peacock, MD: The 3 of us are specialists in our own world. I don’t think most patients see specialists up front. It’s down the food chain when they’ve been sick for a while, and their internist is at their wit’s end, and says, “I don’t know what to do. Go see a gastroenterologist,” or something like that. There may be a larger segment of patients who are under the radar and completely missed by any therapies.
Conar Fitton, MD: Absolutely. A lot of times, we like to think that it’s always going to come down to the person who’s prescribing them. Because a lot of times, in smaller areas, they may not have access to specialized care, and it’s coming down to the primary care providers. But it’s something that when we see it on their medication list, we try to bring it up in a way that’s nonthreatening. “This is common. It’s very treatable. We have great therapies for this. This is what we can try.”
The fact is that it’s a very multifactorial thing too. Constipation is very common in the general population, especially as the average life expectancy is increasing. Patients are on a number of medications already. Certain types of injuries that require opioids decrease patients’ mobility. Through education, hopefully we can intervene earlier, because it severely affects patients’ quality of life.
William F. Peacock, MD: Yes. We don’t have an oncologist on board today, but that’s another population of physicians that deals with this in at least half of their patients because of the nature of that disease. The biggest challenge in my world is that I’m starting to learn that patients don’t want to talk about this. It’s fairly subtle, like Neel said, with the narcotic concerns. This is somewhat hidden at the patient level. When they come to the ED [emergency department], it isn’t hidden at all. By that time, they’re throwing up or absolutely miserable and they know it’s coming from their belly. They may not know it’s from the opioid, but they know the source of it. I don’t think it’s as difficult a diagnosis as for somebody in the larger world. You went through the Rome criteria. I don’t think most emergency doctors are familiar with that because it’s a specialist-defined parameter, and by the time we see them, they’re miserable.
Conar Fitton, MD: If you were familiar with it, I’d have no job, so I like to be the one who’s familiar with it.
William F. Peacock, MD: Excellent. We’re making sure you have a job.
Neel Mehta, MD: Yes. Primary care has come around, and they’ve learned a lot about this, but there are a lot of them. The opportunity remains in how we can help them be successful. Not all of these patients have to necessarily come see a specialist for this treatment, which is what our job is: to disseminate the information.
Conar Fitton, MD: One of the things that I’ve tried to do, especially since we do both inpatient and outpatient, is try to identify the patients who may be developing signs or symptoms in the hospital and transition them to realizing that maybe this will be something that they should go home with to prevent that fecal impaction, where they come to the ED [emergency department] and we’re recognizing it when it’s costly to the health care system. They may get a complication from it. We’ve even seen reports of bowel perforations. We’re trying to intervene for patients who have longer hospital stays, if you look at the total knee and total hip data. We’ll talk about things like that. But we try to get ahead of it a little, recognizing earlier who’s going to be at risk and who’s developing it within the first week or 2.
William F. Peacock, MD: Yes. The costs are a big deal. When somebody comes to my department, it’s always 4:00 in the morning and they’re uncomfortable. Frequently, they’ll get an enema. I hate that, the nurse hates it, and the patient hates it. We all hate it. It doesn’t work very well. Sometimes it does—about 25% of the time. Then they feel great and go home, but we haven’t solved the problem. The other 75% of the time, these people get hospitalized, with a large health care dollars expense. Getting ahead of it and preventing it is worth a lot of pain and suffering that’s otherwise down the road.
Neel Mehta, MD: Yes. And if you add to that the number of other treatments that people try on their own without any guidance—think about all the diet changes and supplements and things that they’re throwing at it. Some of those things aren’t cheap. Certainly, there are a lot of health care dollars being spent by payers or by patients, with unfortunately poor results.
William F. Peacock, MD: Every ED doctor has a story. I had a 75-year-old man who came in seizing. He also had fasciculations, which is very unusual. We decided it had to be some kind of nicotine stimulant. We gave him physostigmine, which is always scary to do, and it stopped. He went to the ICU [intensive care unit] and woke up the next day and said he had been constipated. He had given himself an enema with 4 cigarettes, which is so much nicotine poison. He almost died. He came within inches of it. But he was desperate. He had to do something. This guy ended up with a 3-day ICU stay from trying to cure his constipation. We subsequently published that in emergency medicine literature, because it’s a huge problem for patients. They don’t want to come to the hospital. They hate it. Going to the ED is the last place you want to go to go to the bathroom. By the time they’re there, they’ve tried a few things, and some of them are dangerous.
Transcript Edited for Clarity