Expert Perspectives in the Management of Opioid Induced Constipation - Episode 3
William F. Peacock, MD: In regard to the disease burden and management consideration, the first thing to consider is the patient’s perspective and their quality of life. What do you guys think about that? Are they miserable or is this just an annoyance?
Conar Fitton, MD: When you look at the data, it’s impressive how significantly it affects their quality of life, especially when you look at the studies about how frequently these patients are having either spontaneous bowel movements or what we consider complete evacuations or complete spontaneous bowel movements. The constipation is severe. The more moderate to severe patients are averaging anywhere between 1 to 1.5 bowel movements a week.
The issue is that they have that sense that they have to go due to the effects of the opioids increasing sphincter tone. They plan their whole days around this. It’s unbelievable. They can sit in the bathroom for hours. They don’t want to go somewhere because maybe they’ve taken a significant amount of osmotic and stimulant laxatives, and then they have accidents and overflow diarrhea. I’ve had patients who haven’t been out of the house for months. It’s quite sad. Like you said, they don’t want to talk about it because it’s considered an embarrassing topic for them, and their family and friends may not have to do it. Maybe they’ll try to decrease their opioid dose, which doesn’t usually work, as Neel can talk about.
The quality-of-life impacts are significant. If it’s a question that doesn’t get asked, we’re missing a lot of the patients. Like you said, in the emergency department, that diagnosis isn’t all that challenging most of the time. By the time someone gets to my office, the diagnosis usually isn’t very challenging. But unless you ask those questions in a certain type of manner, they may not volunteer that information. Those are the patients who may get the most significant benefit from treatment.
Neel Mehta, MD: Yes. Conar hit on that well. There are a lot of patients suffering. Some of them have resigned to accepting the fact that 1 bowel movement a week is normal. That’s all they remember, especially those who have suffered for a long period of time. Most people who don’t have constipation would be horrified to know that they only go once a week. Clearly, we’ve got a population that’s suffering in silence and accepting it.
The second aspect of that is the memorable patients who stand out your mind. I was very early into practice. I hadn’t done a good job of educating on bowel regimen for 1 older patient. She called me and said that she hadn’t gone in almost 10 days. Luckily, she wasn’t throwing up or had an outright obstruction, but it was just as bad of an emergency as acute sciatica, which we get frequent calls for. Clearly, this is impactful. The burden is that they have all these needs that need to be addressed, and they’re unsure of what to treat first. These conditions are often linked together and they aren’t realizing it.
William F. Peacock, MD: Yes. If you haven’t gone to the bathroom for 10 days, that’s going to be miserable. We think of this as being abdominal discomfort. It is also the whole systemic perspective. When you’re nauseated, you don’t want to eat, and you don’t eat because you don’t feel good. Then you get yourself dehydrated because you aren’t taking anything by mouth. Then they’re in the hospital for a reason that looks different from what the precipitating event was. It’s easy when they have abdominal pain and they tell you they’re taking narcotics. It’s a lot harder when they’re there with dehydration because they laid at their house and didn’t feel well enough to maintain their own sanity.
Conar Fitton, MD: Yes. And unlike a lot of the other adverse effects we see from opiates, constipation is the 1 that patients don’t develop tolerance to. Patients can develop tolerance to somnolence and nausea in the absence of any obstructive process, or those symptoms will generally improve over time, but constipation doesn’t. By the time patients get to our office for OIC [opioid-induced constipation], they’ve tried an average of between 4 and 5 over-the-counter or sometimes even prescription medications.
The mechanism of OIC is so unique that once I have that explanation and talk to people about it, they say, “No wonder the other medications are oftentimes not efficacious.” It isn’t affecting the actual mechanism like these peripherally acting opioid receptor antagonists do. We’ll talk about those. But like Neel was saying, the cost is huge. The impact on patients’ lives is huge. Through education, hopefully we’ll be able to intervene a little earlier.
William F. Peacock, MD: Yes. Patients trying other methods to relieve the symptoms is a challenge. I’ve had patients who use their bowel preparation, polyethylene glycol. Their doctor prescribed it and said, “Use this to clean yourself out,” and they did. The challenge with that is you drink a gallon of what’s essentially liquid plastic. You have no liquid in, so you become dehydrated even though you’re drinking all this stuff. Then they come in with a syncopal episode. I’ve seen that multiple times in older patients. This whole problem then spins out control into a whole bunch of different things.
Conar Fitton, MD: They’re on a number of medications and maybe on diuretics. You see electrolyte abnormalities associated with it. There are cardiac patients. They’re on a number of other medicines. Maybe they just had orthopedic surgery and aren’t mobile. Not all of them, but so many of them can be avoided.
Neel Mehta, MD: It’s very stressful for them. Their chance of causing other health problems just with those episodes of constant constipation is very high.
Transcript Edited for Clarity