David Wang, MD: Considering all the different treatment options available, Jeff, what do you recommend should be our goals of treatment for using the variety of medications?
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: For most guidelines and most people who practically think this through, the first line of therapy would be over-the-counter [OTC medication]. And I think a lot of patients first seek out a pharmacist or self-treat, and they may go to some kind of community variety store and pick up something like Senokot or docusate. And that’s fine if it works.
But 1 of the things we want to try to avoid is the anxiety that’s associated with this and the constant thinking about what’s going to happen: am I going to get stuck out of the house? Or the pain associated with it: did this come first? I think we want to decrease the anxiety. We certainly want to decrease the discomfort. And a big thing is that we don’t really want to chase after the constipation. With the idea that the patient is on chronic opioid therapy, we want to prevent it to the extent that we’re able. If OTC laxatives work, that’s fine. But if they don’t work, I think we need to look for the next step, which could be a PAMORA [peripherally acting mu opioid receptor antagonist] in order to basically lessen the burden on the patients.
Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP: I would wonder, when will the guidelines change? Why don’t we use what we know works, rather than go through all the steps? We know we can have some benefit from it, but we’re still seeing people follow guidelines, which we’re told to do. But the guidelines make a PAMORA basically a third- or fourth-line therapy.
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: I’m glad you brought that up. In 2015, the American Academy of Pain Medicine put out consensus guidelines on how to treat opioid-induced constipation [OIC]. And you’re right, they were third line. But in those guidelines, they actually looked at the Bowel Function Index, which is also a guideline. It’s a 3-question questionnaire in which the patients rate various parameters on a scale of 0 to 100, 0 being the least problematic and 100 being the most problematic. In those guidelines, you really didn’t have to go through all these other therapies. If you reached 30 or greater, you are a candidate for PAMORA. And I think most guidelines agree with that.
David Wang, MD: Until the guidelines change, certainly we’re still in this predicament. Sometimes prevention is the best treatment. Rick, I might ask you, what are things we can do telling patients about to even prevent getting to this place?
Richard Rauck, MD: I think there are some prophylactic things that we shouldn’t forget about. While we want to think they can’t be effective, it’s been my experience that they can. For instance, just drinking more fluids, trying to hydrate yourself better, can offset some of the constipation effects for people with either idiopathic constipation or opioid-induced constipation. It’s not always an all-or-none phenomenon. I think that’s 1 of the simplest things. I live in the Southeast, where people tend to get dehydrated, particularly in the summer, and where you have the highest incidence with kidney stones as well. But similarly, the dehydration does affect them that way when it comes to constipation.
Another area is—and this is difficult with some of our chronic pain patients—if we can get them to be more active, right? Activity can help in a lot of ways. We want our pain patients to be active anyway, right? We think that’s good for them for a lot of reasons. I try to piggyback on the fact that it not only might help strengthen them, help some core things, and help somewhat with their product things, but it may also help with the constipation.
Thirdly, before you even go to OTC, just change your own diet. Increasing fiber in your diet, increasing bulk that way, can help. We’re not exactly a country that always does a really good job in our diet of foods; they can help just with our gut. I think there are things we can do, and I think they can surprise all of us with their efficacy. But a lot of times they fail as well, particularly with OIC.
Stephen Anderson, MD, FACEP: You’re spot on that this a catch-22 and a vicious circle. It’s an at-risk population for nausea that doesn’t want to take as much in. It’s 1 that doesn’t get up and move as much, possibly because of their pain, and also 1 that doesn’t want to go far from the restroom because of the embarrassment.
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: It’s interesting. You put up fiber, right? And so I’ve got to tell you, I have a lot of patients who come in and they say to me, “I’ve read that it’s good to increase fiber, so I’ve been taking cilium.” And 1 of the big issues is that if these patients don’t drink a whole lot of water and they use cilium, it will make opioid-induced constipation worse, because it’s like mixing cement. If you take this powder and you don’t put enough water in it, it’s a problem. And so I actually try to stay away from the cilium unless I know that the patient is going to flush fluids.
Theresa Mallick-Searle, MS, NP-BC, ANP-BC: That’s a really important distinction to make when you’re looking at this because I think often, clinicians tend to put together OIC with idiopathic constipation. It’s really important to differentiate between those 2 diagnoses, because the treatments can be different.
Richard Rauck, MD: Yes, Theresa, I think that’s a great point. Because to be honest, in the studies when we sometimes look at the results and they’re not as impactful as we think they should be, I’ve heard gastroenterologists tell me part of that is because it’s just the underlying incidence of idiopathic constipation. These drugs, as we know—at least the true PAMORAs—will not reverse idiopathic constipation. It stands to reason that some of our patients with OIC also suffer from idiopathic constipation. We’ve got to keep those 2 diagnoses in our head and realize that they can coexist as well.
Theresa Mallick-Searle, MS, NP-BC, ANP-BC: Absolutely.
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: To piggyback on that, 1 of the things I see a whole lot, particularly in the pain community that’s taking opioids on a regular basis, is that they may have skeletal muscle pain. They may have a neuropathic pain and/or a sleeping disorder. It’s not uncommon to have a patient who truly has opioid-induced constipation, but on top of that they’re on cyclobenzaprine for skeletal muscle, which has a tremendous amount of anticholinergic properties. On top of that, they’re on a TCA [tricyclic antidepressant] like amitriptyline, which chemically is identical to cyclobenzaprine, except for a single double bond in the middle ring. It’s basically doubling up on the drug, right?
Theresa Mallick-Searle, MS, NP-BC, ANP-BC: Absolutely, yes.
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: They may have a patient who has urinary frequency. And so they’re on a drug for that. A lot of times we have patients with opioid-induced constipation, and if we can eliminate or reduce all these other drugs that are causing constipation by another mechanism, that could be really helpful too.
Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP: And maybe that goes back to the guidelines.
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: Right.
Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP: Maybe that says, “Are we going to try to reduce other things?” We’re going to try to treat the other type of constipation as opposed to figuring out if it’s an opioid-induced constipation. We’ll go down the checklist and treat other types of constipation before we get there.
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: Right. Of course, there’s an overlap too. There are patients who truly have OIC.
Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP: Absolutely.
Stephen Anderson, MD, FACEP: To continue on this whole thing, the big push in emergency medicine right now is what’s called the ALTO movement—alternative to opioids—which is adding all these other things to try to stay away from the opiates. That’s well and good if it keeps you away from the opioids, but just adding more things on top of the opioids is not the right answer.
Transcript edited for clarity.