Practice Pointers for Managing Opioid-induced Constipation

In “Managing Opioid-Induced Constipation in Ambulatory-Care Patients,” Clyde R. Goodheart, MD, MBA, MS, and Stewart B. Leavitt, MA, PhD, write "Constipation is a frequent side effect of opioids since these agents decrease peristaltic activity in the gastrointestinal (GI) tract. Because of the mechanisms involved in opioid-induced constipation, some treatments that may be applicable for common, functional constipation are inappropriate for ambulatory-care patients prescribed opioid analgesics.”

They go on to discuss the key differences between opioid-induced constipation (OIC) and functional constipation, and the ways in which those differences can affect clinical decision making. They also discuss the role of opioid receptors and differential opioid effects in OIC; patient assessment and treatment; myths and facts about non-pharmacologic treatment of OIC; and the use of opioid receptor antagonists and other agents in the treatment of OIC.

These “practice pointers” offer a brief summary of key points made by the authors:

• Constipation during opioid therapy is common, if not inevitable, and may be different from ordinary functional constipation.

• Clinicians should anticipate the constipating side effects of opioid analgesics and discuss them with patients before starting opioid therapy.

• Many patients with prior constipation rely on self-management and OTC remedies, and they may not mention these to healthcare providers when starting opioid therapy.

• Given the high variability among patients, characterizing a person as constipated based only on the number of bowel movements per day or week is inappropriate.

• Prevention is the best approach to managing constipation, and an appropriate regimen should be tailored for each patient’s needs when beginning opioid therapy.

• Because treating constipation is based mostly on clinical or personal experience, common myths and misconceptions exist among clinicians and patients.

• Available evidence does not suggest that opioid-induced constipation can be managed merely by increasing intake of fluids or dietary fiber, unless the patient is dehydrated or consuming a fiber-deficient diet.

• In patients with mild constipation and little physical activity, moderate increases in activity level, as tolerated, can be beneficial.

• Bulk-forming laxatives are not appropriate in opioid-induced constipation, because peristalsis is inhibited in these patients.

• Effective treatment and management of opioid-induced constipation usually requires laxatives; most commonly, a combination stool softener and stimulant.

Source: “Managing Opioid-Induced Constipation in Ambulatory-Care Patients,” available at Pain Treatment Topics.