Opioid Induced Constipation

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What is OIC?

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Opioid induced constipation (OIC) is one of the most common side effects of the use of opioids.  Opioids are prescription analgesics, or pain relievers, that decrease the way your brain perceives pain. They can be prescribed to treat pain resulting from a variety of conditions, including chronic back pain, chronic neck pain, spondylosis (or spinal osteoarthritis).Side effects may occur with all medications, but the following can result from taking opioids:

  • Constipation
  • Lightheadedness
  • Sleepiness
  • Nausea
  • Vomiting.

OIC is a different condition than functional constipation, and it’s important to know the difference.

It is estimated that more than 40% of patients taking prescription opioids develop OIC.

OIC occurs when the use of opioids reduces the gastrointestinal tract’s motility, making bowel movements difficult. This can result in straining, having hard or lumpy stools or the sensation of incomplete evacuation.

OIC is not your everyday constipation

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OIC is one of the most common side effects of opioid use and is not expected to go away over time. It can cause fecal impaction, overflow diarrhea, and pseudo-obstruction. If left untreated, it can be difficult to manage and may become unresponsive to common treatment regimens. Both functional constipation and OIC share symptoms like bloating, hard stools, distended stomach, inability to pass stool completely and stomach content retention, but OIC has additional symptoms that include:

  • Acid reflux
  • Vomiting
  • Nausea
  • Cramping

It is the comorbidity of chronic illness and constipation that sets it apart from regular constipation. OIC directly impacts pain management and adherence to treatment. In a study of patients treated with oral opioids and laxatives, approximately one third of patients reported changing their dosing regimen in response to the side effects of opioid medication. These alterations in the opioid regimen resulted in increased pain among 92% of patients.

OIC is also associated with decreases in quality of life. For example, 86% of patients who altered their opioid dosing regimen to manage their GI side effects reported an increase in pain that had a moderate to high impact on quality of life and activities of daily living.

Talk about it with your doctor

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Your doctor is there to help you, but no one knows what you are going through as well as you do. You can make the most of each healthcare provider visit by preparing to describe your situation as thoroughly and accurately as possible.Changes in lifestyle may not be possible for many patients and may be ineffective in treating OIC. If there is a concurrent underlying disease or medicine that is causing constipation, the disease may need to be treated separately or another treatment regimen may have to be considered, as in the case of chronic illness.

OIC treatment usually requires additional medicines to be prescribed along with the opioid painkillers that are causing the constipation. Withholding opioid treatment is ill-advised because it may decrease a patient’s quality of life. Often, laxatives and/or cathartics are prescribed at the same time as opioid painkillers so that treatment for constipation begins immediately. While a cathartic accelerates defecation, a laxative eases defecation, usually by softening the stool. Some medications are considered to be both laxatives and cathartics.

For the treatment of OIC, you may ask your doctor about the following options:

  • Osmotic laxatives – increase the amount of water in the gut, increasing bulk and softening stools.
  • Emollient or lubricant cathartics – soften and lubricate stools.
  • Bulk cathartics – increase bulk and soften stools.
  • Stimulant cathartics – directly counteract the effect of the opioid medications by increasing intestinal motility, helping the gut to push the stools along.
  • Prostaglandins or prokinetic drugs – change the way the intestines absorb water and electrolytes; they also increase the weight and frequency of stools while reducing transit time.
  • Recent medicines block the effects of opioids on the bowel to reverse opioid-induced constipation.

Although the treatments listed above are usually successful in treating OIC, sometimes a physician will recommend rectal intervention. Rectal interventions are indicated if the appropriate oral measures have been ineffective. Rectal intervention means the following treatments:

  • Suppositories
  • Enemas (micro or large volume)
  • Rectal irrigation (sometimes known as colonic irrigation)
  • Manual evacuation

The first choice, rectal intervention for uncomplicated constipation is glycerine suppositories. If suppositories are ineffective, then a stimulant enema might be administered. Oral and rectal stimulant laxatives should be avoided if there is a possible or proven bowel obstruction.

Once you are in the healthcare provider’s office, you may find it embarrassing or difficult to discuss your bathroom habits, but that is normal. Just try to remember that your healthcare provider is a professional, who has similar conversations with many other patients.

Be sure to advocate for yourself and ensure that your concerns are being properly addressed. You may find it helpful to write down each of your symptoms that may include constipation (having less than 3 bowel movements a week), straining when having a bowel movement, gas pain, abdominal pain or discomfort, bloating, hard or lumpy stool or the feeling of incomplete emptying after a bowel movement.

Next, chronicle how many times per week you experience the symptom and how long you have been experiencing the symptom. Do the symptoms disrupt your daily activities and do you find yourself planning around them? Lastly, be sure to note if anything seems to triggers them. For example, do symptoms get worse when you eat certain foods or are under a lot of stress?

Does OIC impact our community?

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OIC affects the chronic pain community. Some studies have shown that only 61% of the doctors treating patients knew that their patients were constipated and 25% didn’t know that their patients were taking laxatives.

Clearly, there’s a communication problem between doctors and patients when it comes to OIC. So one of the biggest issues – besides the obvious issue of constipation itself – is that patients are either too embarrassed to bring it up with their physicians or physicians aren’t asking patients about it.

If the physician isn’t asking about constipation, the patient may not feel empowered enough to bring that up with the provider suggesting that they may want to prioritize their pain medication refill or pain medication treatment over the constipation issue. The patient may also feel that they can manage their constipation on their own.

Over-the-counter laxatives, as well as increased intake of fluid and dietary fiber, may relieve OIC. But even when those treatments fail, many doctors remain in the dark about what their patients are going through or that OIC might be interfering with pain management.

There is a constant struggle for chronic pain sufferers to control their pain and not let it control them.

In order to deal with pain, patients take the needed medications. However, the side effects can be brutal, even affecting peoples sleep patterns, impairing performance at work, and limiting ability to leave the house.