Approaches to Care in Patients with Opioid-Induced Constipation

William F. Peacock, MD: Let me ask both of you. When you see a patient who you’ve diagnosed with opioid-induced constipation, the first time you’re seeing them, they aren’t miserable. They’re uncomfortable, but you aren’t concerned about hospitalizing them or something of that nature. What would be your first strategy? What would be your first-line treatment?

Neel Mehta, MD: I try to get a good history of what they’ve tried. Many of them have had intermittent trials of over-to-counter laxatives or stimulants. It’s reasonable to maximize those if they aren’t too uncomfortable, but I also use that time to educate, to say, “There’s a chance that this may not work for you. We may need a prescription second-line therapy. We can prescribe that now, so you have it, or you check in with me in a couple of days to go to something like that.” It’s reasonable to try 1 or 2 classes of laxatives or stimulants.

Conar Fitton, MD: By the time people get to me, they’re ready. We see them when they’re more than ready. It’s pretty rare that I’ve seen people who haven’t gone to Walgreens and emptied the shelves into their basket. We frequently use PAMORAs [peripherally acting μ-opioid receptor antagonists]. It’s usually what they’re getting when they leave. It can take a little while to go over their medications to see what else may be contributing. From a GI [gastrointestinal] perspective, we want to rule out any other organic pathology that can happen, whether it’s obstruction from something else or is contributing.

The first history and physical usually takes a little longer because other things can happen. With certain medications, you want to make sure that there isn’t any mechanical obstruction. But so often, people have been to the ED [emergency department]. I’ve looked at their imaging. We can rule it out and make sure they leave with the correct treatment, with a short-term follow-up and a plan to say, “This is what we’re going to use. I’d like to discontinue your other laxatives, but if by day 3”—I like to write out a plan for them because the data for how much the physician’s guidance sinks in is very shocking. I like to leave with a specific plan, and I like to write it out. That way, through the messaging systems with the hospital and electronic medical records, it’s easy to check back in and try to prevent them from overburdening the ED.

William F. Peacock, MD: Yes. As you said, what patients remember is absolutely shocking. You’ll tell them 10 things, they’ll remember 2, and they’ll get 1 of them wrong. It’s unbelievable. We do everything in writing. We hand constipation and obstipation instructions to the patients. Every now and then, I find them in the parking lot. They didn’t even make it home. But you have to make your best shot at it. That’s the way we’ve addressed it. We do the whole over-the-counter routine and add anything new that we can. In terms of dietary and lifestyle modifications, we give them those instructions, put it all in a written format, and say, “Here you go. Call your doctor in a couple of days. Let’s see how things go.”

Neel Mehta, MD: Yes. The other challenge we face is that you have to successfully document those conservative measures to get some of the second-line therapies approved. Sometimes going back and getting details from the patients is what it takes for my medical assistants to get these approvals on the phone.

William F. Peacock, MD: Yes. The preapproval stuff is a nightmare that I don’t have and emergency medicine doesn’t have. I talk to my friends who are in the inpatient or outpatient world, and it’s a huge time drain and impediment to giving the therapy they want to give. It’s unbelievable.

Conar Fitton, MD: Yes, it’s unbelievable.

Neel Mehta, MD: And it changes. We could talk for 3 hours about that process. You learn a system, get it down, and the next thing you know, it’s different and there are all sorts of different rules that you have to apply.

William F. Peacock, MD: Yes. The challenge is I’m not convinced that they’re with good medical intent, as opposed to good financial intent, which aren’t the same.

Neel Mehta, MD: That’s unfortunately a sad truth.

Transcript Edited for Clarity