Optimal Management of Opioid Induced Constipation - Episode 6
Gerald Sacks, MD, and Fariborz Rezai, MD, FCCP, FCCM, share their personal experience in approaching and openly communicating the management of opioid-induced constipation with patients.
Gerald Sacks, MD: Many practitioners are reluctant to discuss opioid-induced constipation with their patients because of their own personal uncomfortableness in discussing the topic. I have no problem discussing all GI [gastrointestinal]–related activities, and GI doctors have no issue or problem discussing this part of the body and normal gastrointestinal functions. But I do find that frequently many patients, as well as many health care professionals, are reluctant to address and treat opioid-induced constipation. Primarily this is because of a general uncomfortableness in thinking about and discussing normal bowel function. Indeed, when I ask patients who are taking 6 or 8 opioid pills per day, whom have been suffering with opioid-induced constipation for months or years, about whether their health care professional has ever brought up the subject of opioid-induced constipation and discussed the treatment of opioid-induced constipation, frequently the answer is no. It’s never been brought up or discussed. In other words, our primary care practitioners are so busy addressing diabetes, hypertension, chronic pain, and all issues associated with the opioids, that frequently they may not have the time to discuss the treatment of opioid-induced constipation.
As a pain management practitioner, I feel it’s my obligation to discuss and treat any adverse effects that may be caused by medications that I’m prescribing. So I look at the medications that I’m prescribing and then consider the potential adverse effects of those medications. Therefore, I need to have a discussion with every patient who is on opioids about their bowel function. That includes discussion about how frequently they’re going to the bathroom, whether they’re having success in the bathroom, whether they feel they’re straining, whether they feel it’s very uncomfortable, how often they go to the bathroom, and the quality and quantity of their stool. What we try to do is have the patient return to their baseline level of bowel function by utilizing medications and lifestyle enhancements so that they’re able to maintain their baseline level of bowel function to maintain their level of activity.
Most of the patients coming into my office are actually already taking opioids. Indeed, 100% of my patients are referred by other physicians, so those patients are frequently sent to me for management and treatment of their chronic pain. Part of that is management and treatment of their opioid usage. It’s rare that I have a patient come in, referred by a primary care practitioner or an orthopedic surgeon or a spine surgeon, who has had the topic of opioid-induced constipation discussed with them in any detail. Some of my primary care colleagues are comfortable and familiar with treating opioid-induced constipation with over the counter medications and, sometimes, with peripherally acting µ-opioid receptor antagonists. However, it’s not common for orthopedic surgeons, spine surgeons, and other referring sources—podiatrists, neurologists, etc—to send a patient to me who is taking opioids and is also concomitantly taking a peripherally acting µ-opioid receptor antagonist. It’s up to me to educate the patient and sometimes also to educate the practitioner—whether it’s an orthopedic surgeon, a spine surgeon, a neurologist, an endocrinologist, a primary care practitioner—in the appropriate treatment of opioid-induced constipation using over-the-counter medications, lifestyle changes, increased hydration, increased intake of fruit and vegetables, and also the appropriate usage of peripherally acting µ-opioid receptor antagonists.
In my practice, I try to make the discussion about opioid-induced constipation a normal part of each patient’s visit. When a patient comes in and I’m discussing their chronic pain, we ask about the quality of the pain, the intensity of the pain, how often it occurs, and what they’re doing to decrease their pain, whether it’s pharmacologically, using physical therapy modalities, or lifestyle changes. Part of that discussion is on any adverse effects, either potential or actual, that are occurring from the medications being prescribed. Part of that discussion sometimes is an in-depth analysis of the adverse effects that the patients are having from their opioids. The most common adverse effect that my patients on opioids have is opioid-induced constipation. This can be addressed and treated effectively using peripherally acting µ-opioid receptor antagonists.
Fariborz Rezai, MD, FCCP, FCCM: Constipation is something that, depending on the patient, some patients love talking about. But you’re right: The majority of patients are a little private about their bowel movements. They don’t want to talk about constipation. As a good health care practitioner, our job is to really look at the system-based system. When you’re at the GI, you’re asking those questions for your patient. But you don’t want to just say, “How are your bowel movements?” That’s not the right way to ask the question. Say, “How often do you have a bowel movement? What’s the consistency?” Try to narrow down all the little nuances with that. Try to understand: Does a patient have constipation? Do they not? What’s the etiology? Because if you ask the patient, “Are you constipated?” they may say no. In their mind, they’ve had 1 bowel movement a week, and they feel that’s normal. It’s important to decipher how often and what type of bowel movements they’re having because you, as the clinician, have to make that decision. Are they constipated? Are they not? What type of constipation? It’s very important how you phrase that question. Make the patient comfortable. You’re the physician. You’re the clinician. You’re treating the patient. It’s part of the review system. It’s part of the physical examination. You really need to ask the question in a thoughtful manner so you can get the appropriate answer from your patient.
Transcript Edited for Clarity