Question

Case Study: Opioid-induced Constipation

You work in a pediatric surgical practice. You notice that children are frequently seen post-discharge for complaints of abdominal distress and constipation. You suspect opioid-induced constipation. Your practice has no related practice policies.

Questions: What can you discover about opioid-induced constipation in your own practice and in general? Should your practice have a related policy? If not, why not? If so, what should the policy be?

Data

Data from your practice 2009-present

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Answer 1

Opioids are among the most commonly prescribed analgesics for chronic pain and postoperative pain

Constipation is the most common gastrointestinal complaint among patients receiving opioids.

Constipation can be caused because of decreased peristalsis as a side-effect of opioids so that that the gastrointestinal contents are not moving.

Types of Assessments for constipation:

Rome III Criteria, Bowel Function Index, Bowel Function Diary.

-Assess bowel function routinely.

-Prevention of constipation should be instituted with increased intake of fluids to minimize constipating effects.

The Rome III criteria for Functional Constipation requires ≥ 2 of the following in at least 25 % of bowel movements: straining, lumpy or hard stools, the sensation of incomplete evacuation, the sensation of anorectal obstruction, manual maneuvers to facilitate defecation, and/or < 3 bowel movements/week. In addition, loose stools should rarely present without laxatives and the criteria must be fulfilled for the last 12 weeks, although the 12-week requirement may be inappropriate in patients who are taking short-term opioids.

The Bowel Function Index is a simple, 3-item, clinician-administered questionnaire designed to evaluate opioid-induced constipation. Each of the three items (ease of defecation, feeling of incomplete bowel evacuation, and personal judgment of constipation) are evaluated on a 0 – 100 numerical rating scale, where 0 corresponds to no problems and 100 to most severe problems.

Most recently, Camilleri et al.published a validation of a bowel function diary (BF diary) that includes patient-reported outcomes associated with opioid-induced constipation. The BF diary includes three electronically implemented modules: *Module 1 consists of 4 items to which patients responded after recording each bowel movement and time of occurrence, either immediately after each defecation or as part of the daily evening report. Module items include the time at which the bowel movement occurred, the extent of straining, the extent of emptying, pain associated with the bowel movement, and shape/consistency of the stool (based on the Bristol Stool form scale).

*Module 2 includes five items to which patients responded once daily during the evening based on symptoms they experienced in the past 24 h, including the inability to have a bowel movement, bloating, abdominal pain, gas, and lack of appetite.

Module 3 includes a list of constipation treatment options (extra fiber, stool softener, laxative, enema, suppository, “ something else”, and none of these) and patients indicated all such treatments used in the past 24 h to relieve constipation.

The physical exam should include a digital rectal examination, including assessment of the anal sphincter and pelvic floor relaxation on straining.

Opiates often result in constipation at lower doses than those required for analgesia, and therefore a small reduction in opioid dosing is generally not effective for managing opioid-induced constipation.

The conventional management of opioid-induced constipation, including nonpharmacologic management, opioid rotation, non-constipating opioids, fiber-rich food, stool softeners, and laxatives.

*Opioid rotation: Opioids vary in their propensity to cause constipation; likewise, individuals vary in terms of the opioid dose required for pain relief and their liability for side effects. Opioid rotation — defined simply as the process of switching opioids — can be used to reduce constipation while maintaining or improving analgesia.

Constipation is common among patients treated with opioids. Affected patients should be evaluated with a focused history and physical exam, and sometimes with select diagnostic tests. Firstline treatment includes opioid rotation, low-cost and low-risk approaches such as lifestyle modifications, stool softeners, laxatives, and fiber.