Management of Opioid-Induced Chronic Constipation - Episode 4
David Wang, MD: Going back to what you were saying, Rick, is this idea of an ounce of prevention being worth a pound of cure. Just as important as recommending things is starting the dialogue with patients. Steve, from what you’ve seen in your practice, when do practitioners really discuss OIC [opioid-induced constipation] with their patients?
Richard Rauck, MD: Well, the emergency department is a skewed venue. It’s when people are in with miserable pain, I’ve just done an exhaustive work-up, and I really haven’t found much else. That usually brings me back to looking over their medications as part of that work-up. And that’s when I always have that conversation. I can tell you that I was trained quite awhile ago, where they talked to me initially about anytime someone over age 60 gets puts on an opiate, you should have that conversation right away. I’m finding now that that age, there’s no cutoff—60 is not a magic number.
I start that conversation now quickly when I start opiates that I think might be used longer than 2 days with people in the emergency department, because I think it’s important.
David Wang, MD: Can I ask you a follow-up? I’m sure you’ve seen many patients who had an opioid on their list, medical list, who maybe started recently. How many of them have a concurrent laxative or agent of some kind?
Stephen Anderson, MD, FACEP: My guess is that in the emergency department early on, not many that will reveal it to me. It’s certainly not 1 of those cases where, when they do, what’s called a med reconciliation comes up. You really have to ask specifically, and then you find, just as we heard, that a lot of them have already been aisle 5 shopping to try to find solutions themselves.
Richard Rauck, MD: Let me add a little bit, David. I work more in a chronic outpatient setting, and I always tell the fellows that for any of our patients, many of whom come to us on opioids, you need to make sure you’ve had that conversation. It doesn’t have to be a lengthy in-depth conversation, in my opinion. I think that’s where people make the mistake. I understand we’re all busy practitioners and we have a lot of work to do, but you usually can get to the heart of this with patients in 1 or 2 questions.
I also tell my colleagues, or the fellows, when they’re going out into their own practices, make sure you put it the questionnaire somewhere. It’s not reliable for all patients, but certainly some will circle if constipation is a problem and sometimes if they’re too embarrassed that way.
I also think you ought to certainly have that conversation when you start an opioid in a patient, right? Don’t wait till they come back, or they’re not going to talk about it. None of the drugs we’re going to talk about that are approved for OIC have a prevention indication for OIC. But that doesn’t mean we shouldn’t as clinicians talk to patients about OIC when they first get an opioid, so they are at least aware. Also so that they’re not surprised by it. In fact, you should say, “Look, if you do develop it—which is pretty doggone common, maybe as much as 80% or 90% of the people on opioids—there are treatments for it, and you don’t have to just stop the drug if you get that adverse effect.”
Stephen Anderson, MD, FACEP: There’s a tape that I roll out of my brain every time I prescribe an opioid, and I didn’t necessarily do it 10 years ago. But now if I prescribe it, I talk a little about the risk of addiction, the risk of other things, and I mention the complications. As you said, it’s 1 or 2 extra sentences, and it’s worth it.
Theresa Mallick-Searle, MS, NP-BC, ANP-BC: It’s interesting because we’ve been talking about opioid-induced constipation and the importance of educating our patients, talking to our patients, and talking to our colleagues for decades. And to fall back on a comment that Brett made about how even now, prescribing opioids requires so much more education when you start a patient about addiction, about safety in the household, and all that. I think the OIC question and comments are getting pushed farther and farther down. It’s just about reminding ourselves what we need to do. Normalize it: make the condition part of normal discussion.
Stephen Anderson, MD, FACEP: We’re going to come back and say over and over again to remove the stigma, because that’s really important.
David Wang, MD: Normalizing it is so important. We’ve heard that it can be a sensitive topic. People can feel anxious about this. We’ve also heard that constipation is almost a nebulous term for the public. Even with our criteria, there are so many elements of it. I’m curious, Brett, in your practice, how do you address a patient who may be embarrassed to talk about this or doesn’t even know how to begin talking about this with you?
Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP: Well, you said embarrassed and that’s always interesting. It’s not a sexy topic, and that’s what I’ve said from day 1: it’s not erectile dysfunction. Whoever thought we would have these conversations very openly to providers, and men would be OK to have these conversations? But you talk about constipation, and men drop their head. And it’s men more than women who drop their head and don’t want to have the conversation. It will take a visit or 2 after you continue asking that question for them to say, “Yes, this is a problem.” I think it’s a reluctance in the population, not just men.
But again, it’s not a topic everybody wants to talk about. Sometimes during the first conversation people say, “Oh, I’m just fine.” But in all reality, it’s not. There’s a reluctance. I think it’s just that ongoing dialogue—at every visit we’re going to talk about this, along with everything else. It’s putting in an order saying, “Yes, this is important.” We know it’s the most common adverse effect. We know respiratory depression and concern for overdose are the least common and most serious. It’s just making certain that it’s a dialogue that you’re going to continually have, and then that comfort level builds to have the conversation.
David Wang, MD: Absolutely, finding your own words to be comfortable with it. But the most important thing is just having the courage and foresight to even plan and engage in that conversation, not waiting for your patients to take initiative with you.
Transcript edited for clarity.