Transitioning Therapies for Patients With Opioid-Induced Constipation

William F. Peacock, MD: How often do you have to fail certain levels of management before you’re allowed to increase the prescription intensity? Is that an impediment to moving things along?

Conar Fitton, MD: It can be. I’ve noticed that in the outpatient setting. One way I haven’t had to need that all the time is when we’re transitioning patients from being on it as an inpatient to being on it as an outpatient. I found that to be quite a bit easier, depending on the options available in the physician’s or nurse practitioner’s facility. But I’ve found that to be one of the most efficacious ways to get it done. When they have been on it, have benefited from it, and are going to need it, that’s been easier to approve, especially quickly.

As an outpatient, as Neel was saying, it’s part of my note of documenting what they’ve failed, because it’s very rare that they haven’t failed enough to get that through. All the over-the-counter treatments are so widely available, and a lot of times people are taking them at baseline. They’re increasing soluble fiber. They have docusate at home. They have senna at home, so they’ve tried it. The documentation is key. Then we can get it done quickly.

Neel Mehta, MD: Yes. The current state of affairs is that you have to list the names, and generally that’s sufficient to get them approved if they haven’t met benefit from those. As insurance companies tend to be a little algorithmic, my fear is that things that are happening in my world in pain management may come to this area too. For example, with back pain, physical therapy used to just be a question. “Did you do physical therapy?” Now it’s, “Was it within the past 6 weeks? Was it doctor guided? How many days did they go? What specific exercises? Show me the prescription. Show me the report from the physical therapist.” That’s just 1 part of getting treatment for back pain. Hopefully we don’t come to a point where we have pill counts of Colace to verify that they took it.

Conar Fitton, MD: I don’t think anything would surprise us at this point.

William F. Peacock, MD: Electronic medical record.

Neel Mehta, MD: As people escalate their therapies and start to find success, they stop everything once they’ve achieved the bowel movements, and then they inevitably come back with the same problem.

Conar Fitton, MD: That happens over and over. People want to take things PRN as needed. There’s a movement toward fewer medications, and certain people are generally against it. But that’s the whole thing. We run into that the most with our patients with inflammatory bowel disease. They start feeling great, and there it goes. It can be something where you tell them, “If you had an orthopedic injury, we think you’re going to be on pain medicines for X period of time. One prescription may do it.” But Neel is seeing patients who have chronic back pain and are benefiting from opiates. In that situation, it’s going to be consistent. Once they see the benefit from it, you have to explain to them over and over, “This is why it’s working, and this is part of your regimen, so please keep taking it.” It happens all the time.

William F. Peacock, MD: The new and better you.

Transcript Edited for Clarity