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Opioid-Induced Constipation

What Is Opioid-Induced Constipation

In the United States alone, more than 240 million opioid prescriptions are dispensed every year and roughly 3% of all Americans are prescribed an opioid regimen for chronic non-cancer pain relief.

A common adverse side effect of opioid medications is opioid-induced constipation, or OIC, which occurs in 40% to 90% of patients taking opioids. If you are taking opioids, your doctor should evaluate you for any signs of OIC.

To more deeply understand OIC, we must first take a look at what opioids are, and how they can cause constipation. Constipation occurs when bowel movements become less frequent and more difficult to pass.

Opioid (or narcotic) pain medications— best known colloquially as “painkillers”, are a class of drugs commonly prescribed for their pain-reducing—or analgesic—qualities, and include substances like oxycodone, hydrocodone, codeine, and morphine. You might recognize these drugs by their brand names: Oxycontin, Vicodin, Percocet, among others. These medications have been used as a means of providing pain relief for many years. They are also are used for medical, as well as nonmedical, purposes, including:

Pain relief—With respect to pain relief, opioids are used to treat:

Acute pain post-surgery—one of the most common clinical uses for opioids is to treat post-surgical acute pain
Cancer pain—often used to relieve pain caused by cancer, especially in advanced or end stages. This is also referred to as palliative care, since these medications may be the only way to relieve terminal pain in patients at the end of their lives. About 70% of patients with advanced cancer commonly complain of pain.
Injury or trauma—pain associated with injury or trauma is another common clinical use for opioids
Pain arising from chronic disease—pain associated with severe, chronic, debilitating diseases, like complex regional pain syndrome may be treated with opioids.

Anesthesia—Opioids are typically used as anesthetic regimens that aid in surgical procedures.

Cough suppression—Opioids (such as codeine), combined with other agents, may suppress cough, and some are used for this clinical purpose, especially if a dry and non-productive cough presents.

Diarrhea suppression—Opioids typically cause constipation, and as such, they are sometimes utilized in the treatment of diarrhea

Addiction treatment —Certain types of opioids, methadone in particular, are used to help opiate or narcotic addicts wean off stronger opioids like heroin to help prevent severe withdrawal symptoms.

Severe Anxiety—In very rare cases, opioids may be used to treat severe anxiety.

The vast majority of patients receiving long-term opioid pain medication are in advanced stages of their disease. Despite their analgesic benefits, opioids can cause a number of side effects, the most commonly occurring of which is opioid-induced constipation, or OIC. Patients develop a tolerance for many of the other side effects of opioids, such as respiratory depression. However, patients generally do not develop a tolerance to OIC. Altogether, studies indicate that as many as 81% of patients who are prescribed opioids experience OIC.

What Causes Opioid-Induced Constipation

Risk Factors For Opioid-Induced Constipation

Diagnosing Opioid-Induced Constipation

Symptoms of Opioid-Induced Constipation

Prognosis

Living With Opioid-Induced Constipation

Screening

Prevention

Common Treatment

OIC symptoms usually require medical treatment with a therapeutic regimen that accompanies the opioid painkillers that are causing the constipation. Withholding opioid treatment is ill advised because it results in a decrease in the patient’s quality of life.

For the treatment of OIC, doctors may recommend:

Osmotic laxatives – which increase the amount of water in the gut, increasing bulk and softening stools.
Emollient or lubricant cathartics – that soften and lubricate stools.
Bulk cathartics – which increase bulk and soften stools.
Stimulant cathartics – which directly counteract the effect of the opioid medications by increasing intestinal motility, helping the gut to push the stools along.
Prostaglandins or prokinetic drugs – which change the way the intestines absorb water and electrolytes, and they increase the weight and frequency of stools while reducing transit time.
Other medicines that block the effects of opioids on the bowel to alleviate OIC symptoms
Rectal intervention, as deemed appropriate by the physicians

Constipation is a known side effect of opioid analgesics and should be addressed before opioid therapy begins. As opioid-induced constipation can be severe and adversely impact quality of life and compliance with therapy, prophylaxis with laxatives is considered to be the best approach. A British Pain Society survey conducted in March 2009 showed that nearly half of all general practitioners (GP) (44%) surveyed believe that the negative impact of such side effects is the key factor in patient non-compliance with prescribed opioid treatments.

Concurrent management on initiation of opioids frequently includes recommending certain lifestyle or dietary adjustments (as listed above) and initiating a scheduled regimen of laxatives. Laxative and cathartic therapy may be needed throughout opioid therapy and beyond. Effective management requires a composite of strategies, including behavioral and lifestyle changes (diet, activity, and fluid intake, as appropriate).

However medications used to manage opioid-induced constipation, such as laxatives, do not address the underlying opioid receptor-mediated cause of constipation and are often ineffective. Therefore, pharmacotherapeutic intervention may be necessary.

Methylnaltrexone (available as Relistor) helps restore bowel function in patients who have advanced illness and receive opioids for pain relief. Methylnaltrexone is delivered via subcutaneous injection and is designed to displace the opioid from binding to peripheral receptors in the gut, decreasing the opioid’s constipating effects and inducing laxation. Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist (PAMORA) that decreases the constipating effects of opioids in the GI tract without affecting pain relief.

Additionally, lubiprostone (available as Amitiza) is a chloride channel activator that is utilized in the treatment of OIC in adults with chronic, non-cancer pain.