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LAS VEGAS – To appropriately manage patients on opioids who develop constipation, one of the most important distinctions to make is whether the condition was caused by the pain treatment or was just exacerbated by it, according to Darren M. Brenner, MD.
Because of the rampant use of opioids, the answer to that question is increasingly relevant to clinical practice, said Dr. Brenner, associate professor of medicine (gastroenterology and hepatology) and surgery at Northwestern University, Chicago.
Dr. Brenner described a concise algorithm (Curr Gastroenterol Rep. 2017 Mar;19[3]:12) for discerning these patient groups; he codeveloped the algorithm with meeting cochair Brooks D. Cash, MD, chief of the division of gastroenterology, hepatology, and nutrition at the University of Texas, Houston.
Step 1 in the algorithm is simply to ask patients whether they are constipated. “You should ask all of your patients who are on opioids if they have this problem,” Dr. Brenner said. “A significant percentage of individuals using opioids will develop constipation.”
According to the results of studies that Dr. Brenner summarized, up to 80% of patients taking opioids for chronic, noncancer pain will develop opioid-induced constipation, and more than 90% of opioid-taking patients with advanced illness will need laxatives.
Given this prevalence, clinicians might want to be skeptical when patients on opioids reply “no” when asked whether they are constipated.
“From my own clinical experience, you will miss a third of your population that has constipation,” Dr. Brenner said, noting that some patients will instead think of their condition in terms of incomplete evacuation or decreased stool frequency.
Step 2 of the algorithm, therefore, is to assess for signs and symptoms of functional constipation in all patients, regardless of whether they report the condition.
The recently published Rome IV diagnostic criteria included a new category for opioid-induced constipation. According to the new definition, opioid-induced constipation must include new or worsening symptoms, such as fewer than three solid bowel movements per week, and straining, blockage sensation, or manual maneuvers on at least 25% of bowel movements, among other symptoms listed in the report.
If patients do have constipation meeting these criteria, then step 3 of the algorithm is to determine whether the symptoms were present prior to taking opioids.
If onset of constipation is related to the start of opioid treatment, options may include prescribing peripherally acting mu-opioid receptor antagonists (PAMORAs). By contrast, onset unrelated to the start of opioids, also known as opioid-exacerbated constipation, may require treatment according to the underlying cause. For example, slow-transit constipation may respond to laxatives, while evacuation disorders may be treated with surgery, biofeedback, or physical therapy.
The hardest group to identify, according to Dr. Brenner, is individuals whose symptoms were so minor that they didn’t even realize they had constipation symptoms prior to opioids.
Because treatment protocols for opioid-induced and opioid-exacerbated constipation are so different, “we must tease these people out,” Dr. Brenner said.
Global Academy and this news organization are owned by the same parent company.
Dr. Brenner reported disclosures related to Allergan, Daiichi Sankyo, Ironwood Pharmaceuticals, Prius Medical, Salix Pharmaceuticals, Synergy Pharmaceuticals, Shionogi, and others.
LAS VEGAS – To appropriately manage patients on opioids who develop constipation, one of the most important distinctions to make is whether the condition was caused by the pain treatment or was just exacerbated by it, according to Darren M. Brenner, MD.
Because of the rampant use of opioids, the answer to that question is increasingly relevant to clinical practice, said Dr. Brenner, associate professor of medicine (gastroenterology and hepatology) and surgery at Northwestern University, Chicago.
Dr. Brenner described a concise algorithm (Curr Gastroenterol Rep. 2017 Mar;19[3]:12) for discerning these patient groups; he codeveloped the algorithm with meeting cochair Brooks D. Cash, MD, chief of the division of gastroenterology, hepatology, and nutrition at the University of Texas, Houston.
Step 1 in the algorithm is simply to ask patients whether they are constipated. “You should ask all of your patients who are on opioids if they have this problem,” Dr. Brenner said. “A significant percentage of individuals using opioids will develop constipation.”
According to the results of studies that Dr. Brenner summarized, up to 80% of patients taking opioids for chronic, noncancer pain will develop opioid-induced constipation, and more than 90% of opioid-taking patients with advanced illness will need laxatives.
Given this prevalence, clinicians might want to be skeptical when patients on opioids reply “no” when asked whether they are constipated.
“From my own clinical experience, you will miss a third of your population that has constipation,” Dr. Brenner said, noting that some patients will instead think of their condition in terms of incomplete evacuation or decreased stool frequency.
Step 2 of the algorithm, therefore, is to assess for signs and symptoms of functional constipation in all patients, regardless of whether they report the condition.
The recently published Rome IV diagnostic criteria included a new category for opioid-induced constipation. According to the new definition, opioid-induced constipation must include new or worsening symptoms, such as fewer than three solid bowel movements per week, and straining, blockage sensation, or manual maneuvers on at least 25% of bowel movements, among other symptoms listed in the report.
If patients do have constipation meeting these criteria, then step 3 of the algorithm is to determine whether the symptoms were present prior to taking opioids.
If onset of constipation is related to the start of opioid treatment, options may include prescribing peripherally acting mu-opioid receptor antagonists (PAMORAs). By contrast, onset unrelated to the start of opioids, also known as opioid-exacerbated constipation, may require treatment according to the underlying cause. For example, slow-transit constipation may respond to laxatives, while evacuation disorders may be treated with surgery, biofeedback, or physical therapy.
The hardest group to identify, according to Dr. Brenner, is individuals whose symptoms were so minor that they didn’t even realize they had constipation symptoms prior to opioids.
Because treatment protocols for opioid-induced and opioid-exacerbated constipation are so different, “we must tease these people out,” Dr. Brenner said.
Global Academy and this news organization are owned by the same parent company.
Dr. Brenner reported disclosures related to Allergan, Daiichi Sankyo, Ironwood Pharmaceuticals, Prius Medical, Salix Pharmaceuticals, Synergy Pharmaceuticals, Shionogi, and others.
LAS VEGAS – To appropriately manage patients on opioids who develop constipation, one of the most important distinctions to make is whether the condition was caused by the pain treatment or was just exacerbated by it, according to Darren M. Brenner, MD.
Because of the rampant use of opioids, the answer to that question is increasingly relevant to clinical practice, said Dr. Brenner, associate professor of medicine (gastroenterology and hepatology) and surgery at Northwestern University, Chicago.
Dr. Brenner described a concise algorithm (Curr Gastroenterol Rep. 2017 Mar;19[3]:12) for discerning these patient groups; he codeveloped the algorithm with meeting cochair Brooks D. Cash, MD, chief of the division of gastroenterology, hepatology, and nutrition at the University of Texas, Houston.
Step 1 in the algorithm is simply to ask patients whether they are constipated. “You should ask all of your patients who are on opioids if they have this problem,” Dr. Brenner said. “A significant percentage of individuals using opioids will develop constipation.”
According to the results of studies that Dr. Brenner summarized, up to 80% of patients taking opioids for chronic, noncancer pain will develop opioid-induced constipation, and more than 90% of opioid-taking patients with advanced illness will need laxatives.
Given this prevalence, clinicians might want to be skeptical when patients on opioids reply “no” when asked whether they are constipated.
“From my own clinical experience, you will miss a third of your population that has constipation,” Dr. Brenner said, noting that some patients will instead think of their condition in terms of incomplete evacuation or decreased stool frequency.
Step 2 of the algorithm, therefore, is to assess for signs and symptoms of functional constipation in all patients, regardless of whether they report the condition.
The recently published Rome IV diagnostic criteria included a new category for opioid-induced constipation. According to the new definition, opioid-induced constipation must include new or worsening symptoms, such as fewer than three solid bowel movements per week, and straining, blockage sensation, or manual maneuvers on at least 25% of bowel movements, among other symptoms listed in the report.
If patients do have constipation meeting these criteria, then step 3 of the algorithm is to determine whether the symptoms were present prior to taking opioids.
If onset of constipation is related to the start of opioid treatment, options may include prescribing peripherally acting mu-opioid receptor antagonists (PAMORAs). By contrast, onset unrelated to the start of opioids, also known as opioid-exacerbated constipation, may require treatment according to the underlying cause. For example, slow-transit constipation may respond to laxatives, while evacuation disorders may be treated with surgery, biofeedback, or physical therapy.
The hardest group to identify, according to Dr. Brenner, is individuals whose symptoms were so minor that they didn’t even realize they had constipation symptoms prior to opioids.
Because treatment protocols for opioid-induced and opioid-exacerbated constipation are so different, “we must tease these people out,” Dr. Brenner said.
Global Academy and this news organization are owned by the same parent company.
Dr. Brenner reported disclosures related to Allergan, Daiichi Sankyo, Ironwood Pharmaceuticals, Prius Medical, Salix Pharmaceuticals, Synergy Pharmaceuticals, Shionogi, and others.
EXPERT ANALYSIS FROM PERSPECTIVES IN DIGESTIVE DISEASES