Addressing Opioid-Induced Constipation With Patients

Fariborz Rezai, MD, FCCP FCCM: The question is: OIC [opioid-induced constipation] is a common diagnosis and it’s often undertreated, and why is that? I think most people realize that opioids cause constipation. I think that’s a no-brainer. The public knows that; clinicians know that. But I think the misunderstanding is that it’s not treatable. That’s key: focus on the diagnosis. The patient has OIC. For whatever reason, they’re on opioids as part of their disease process that’s being treated by a health care practitioner. The issue here is the OIC they’re suffering from. It’s important to go over the review systems, but really focus on the treatment plan: lifestyle modification, diet, staying active, and also what type of bowel regimens they’re on. Is something like methylnaltrexone beneficial to them? Would that work? If we’ve tried other approaches and they haven’t worked, then it’s key to start something like methylnaltrexone to inhibit the opioid effect on the gut. Again, when do you start this? Well, it’s probably appropriate to have those discussions from day 1 because even if the patient is not suffering from constipation at that point, they may suffer from it at some point, and that’s key. It’s better to be proactive than having a patient who’s been constipated, or having OIC, possibly for a couple of years. Then it’s more difficult.

I have advice for providers who treat patients with OIC. Obviously, you are seeing the patient for multiple reasons, but if you’re treating them for OIC, if it’s part of the differential, if it’s part of their diagnosis, I think you have to spend a fair amount of time to really judge: how is their OIC? Is it improving? Is it not improving? Do a good examination, get a good history. How often are their bowel movements? What type of bowel movements? What is the stool consistency? I think those are all important to determine where your patient stands. Because obviously, the treatment they get will depend on if they’re getting better, or worse, or stagnant. Again, just because you treat OIC once doesn’t mean it’s gone. That diagnosis is like any other diagnosis, such as AFib [atrial fibrillation] or hypertension. That diagnosis stays with the patient, at least for the foreseeable future. I think a good clinician will evaluate that diagnosis at every visit and determine what is the appropriate treatment at that time.

Transcript Edited for Clarity