Expert Perspectives in the Management of Opioid Induced Constipation - Episode 12
William F. Peacock, MD: How would you address the issue that OIC [opioid-induced constipation] is both common and undertreated at the same time?
Neel Mehta, MD: We’re doing part of it now. We’re spreading the word and making people aware. Certainly, the guidelines that you guys helped author, getting it out into the literature to spread it among our prescribing physicians, nurse practitioners, and physician assistant colleagues. Campaigns in direct-to-consumer have been eye-opening. The Super Bowl ad from several years back still gets talked about by patients and providers alike. It’s a topic that isn’t discussed and isn’t thought to be a major burden, but we’ve done a great job trying to highlight that. Also having frank conversations with our patients and trying to understand the adverse effects, because we’re giving them medications and we aren’t trying to discontinue the opioids. We’re trying to give them the most benefit that they can have with the least amount of adverse effects. Developing that trust and open dialogue with your patients hopefully will allow them to disclose exactly what they’re feeling.
Conar Fitton, MD: There are also some interesting new avenues to explore. When we talk to a gastroenterologist about this issue, they usually don’t have trouble diagnosing it, per se. But one thing that we see a small percentage of the time is patients who come in for a screening colonoscopy who have an incomplete preparation. They did everything appropriately, but for a variety of reasons, a small percentage of patients will have an incomplete prep.
We’re working it into our preprocedural questionnaire. Because in order to save health care dollars, most patients won’t have a doctor’s visit first if they’re relatively healthy. It’s called open access screening. We ask them a number of questions about things like cardiac history, blood thinners, something that would trigger a doctor to need to review their chart. But oftentimes, it’s just an order placed by their PCP [primary care provider], so we worked it in where we ask about constipation. If they say, “I generally only have 2 or 3 bowel movements weekly,” then we’ll say, “We’ll look through your medication list.” If they’re on opiates, we’ll say, “Maybe you’d benefit from seeing our nurse practitioner or having a visit with one of our doctors.”
That’s for health care costs reasons, to avoid having someone do all that and then possibly go under anesthesia for a procedure and then not be able to complete it, and having to redo it all again. That’s been a way, and it has been surprising how many procedures we’ve been able to improve by initiating a different therapy, something that we wouldn’t have thought of.
I want to ask Neel a question too. Have you noticed that it seems the trend over the last number of years is to funnel the opioid prescriptions to a fewer number of providers who specialize in that more? Do you think that’s going to improve recognizing these issues, because you deal with it so often? It’s a question that maybe is going to be asked at a higher percentage.
Neel Mehta, MD: To be honest, I haven’t seen that trend up here in the Northeast. The challenge comes in that many pain management providers are doing a variety of treatments, so they get a bit inundated just managing opioids. That said, we try our best to optimize things. We may tweak dosing on opioids. We may change things to better-suited regimens and introduce other multimodal therapies. While we’re doing that, we take the opportunity to talk about OIC. That’s where we hope that we’re getting more people to understand these differences. Certainly, those who are prescribing opioids will inevitably see the challenges of OIC, and hopefully they’ll educate themselves on what they can do to make things better. If you prescribe enough of these opioids, it’s going to come back to haunt you at some point.
William F. Peacock, MD: Conar, I wanted to expand on your description of having flags for patients who are going to be difficult to do a colonoscopy on. When you figure out that someone’s on opioids and may have a problem, would you give them a 3-day precolonoscopy treatment with methylnaltrexone, or would you do it the day of? How do you see that happening?
Conar Fitton, MD: I’d generally see the patient in the clinic and start them for a longer period to see if I can improve their baseline before scheduling them at all. We want to make sure they’re going to respond to that medication. It’s an interesting thought to have someone treated preprocedurally. But a colonoscopy from a screening standpoint is rarely urgent. It’s oftentimes urgent or emergent from a diagnostic bleeding or following abnormal imaging. But I’d see that person in the clinic.
Like Neel was saying, I usually have the patient get in touch with me in a shorter period of time about the efficacy, and then I usually see them about a month later. This would be someone I’d tell, “I want to make sure that when we do your procedure, we have the best chance, but it seems like you may have been suffering from this and it hasn’t been brought up or diagnosed. We’d consider this abnormal. Let’s talk about it a little.” I’d open that dialogue to say that, as we were alluding to earlier, when 4% to 5% of the population possibly have chronic pain, that’s tens of millions of people. We certainly aren’t seeing that degree of people coming to their doctor. It’s underrecognized, and that’s why it’s good that we can get together and try to get some more education out there.
I wouldn’t only do it preprocedurally. I’d see them in the normal office outpatient setting and prescribe them medication. Or maybe they haven’t tried the first-line therapy, usually people have. Then if we were going to prescribe a PAMORA [peripherally acting μ-opioid receptor antagonists], I’d do it for weeks to generally a month. As we resolve their OIC, then I’d schedule them.
William F. Peacock, MD: Whenever given the opportunity to ask a company to do a study, as the research director for emergency medicine at Baylor College of Medicine, I always do it. I’d think that would be something that would benefit from a validated protocol because other people would follow your protocol. You could call it the Fitton protocol. Then they’d get out there and do it because you published your results. That would be extremely valuable. There’s nothing worse than going to a colonoscopy, getting put to sleep, and then leaving with nothing done.
Neel Mehta, MD: That would be awful.
Conar Fitton, MD: It isn’t uncommon.
Transcript Edited for Clarity