David Wang, MD: Bringing this all together, I’ll start with you, Rick. We really can get everyone’s opinion on this, but what advice would you give to providers or your colleagues about how to treat opioid-induced constipation moving forward at this time?
Richard Rauck, MD: I think there are several components. The first thing I’d tell them is to ask the questions. To the people at this table, it’s preaching to the choir, so to speak, the old saying. It is true still. I think from surveys we’ve done, all our colleagues aren’t asking those questions. We all have to do a better job of identifying patients in need. And I think we do have a reasonably well-structured algorithm to approach this. I think to what we’ve heard from Brett and others is you don’t need to get stuck, so to speak, in the over-the-counters [OTCs] or other nonlifestyle things for so long. If they’re not responsive to that, move more quickly in that context.
I think a little for both providers and for pharmacies, I’ve had patients come back and say, “Hey, the pharmacist told me I can’t take the over-the-counter drug with a peripherally-acting mu-opioid receptor antagonists [PAMORAs],” so there has to be education a little bit to pharmacists that these drugs are compatible. They work differently that way. Similarly, I think as we’ve already heard, we have to make sure that patients take the drugs as prescribed, that they don’t double up, that they don’t take them pro re nata [as needed] and things of that nature. Make sure the providers know how to dose. To Jeff’s point, if they do get adverse effects, at least some of them, they can back down on the dose. Most of them can back down on dose. Those types of things are important.
David Wang, MD: Would anyone else like to offer some thoughts?
Stephen Anderson, MD, FACEP: Yes, my 3 simple answers are first of all, an ounce of prevention is worth 6 pounds of cure. Second, opioid-induced constipation is not a diagnosis to jump to. It’s a diagnosis that has to be worked up to, particularly in the emergency department, and in the palliative care or cancer patient, to make sure you’re not dealing with something else like obstruction. Then finally, as we all said, a patient being on an opioid and being aware of it is important as a provider. That’s a conversation starter, not a conversation stopper.
Brett B. Snodgrass, FNP-C, CPE, FACPP, FAANP: I would add that being on opioids in and of itself is stigmatic. In this era of the opioid crisis that we talk about, maybe it’s more of a polypharmacy crisis, we have to keep the patient in the forefront and know that they’re afraid to ask many questions secondary to opioids if they are on them and on them appropriately. We have to allow the conversation to happen.
David Wang, MD: Agreed. I think I’ll leave some room for closing remarks. But this has been an extremely informative session. Before we end this discussion, I’d like to get final thoughts from each of our panelists and thank you all very much for your expertise today. Let me start with you, Dr Stephen Anderson.
Stephen Anderson, MD, FACEP: I think I already said it. Ounce versus pound. Don’t jump to the diagnosis. And use conversation starters, not conversation stoppers.
David Wang, MD: Theresa Mallick-Searle from Stanford.
Theresa Mallick-Searle, MS, NP-BC, ANP-BC: For me it’s really normalizing the discussion, giving the patient permission to ask the questions they have, educating the patient, as well as educating our colleagues about the problem, being able to diagnose the problem, and forming a prescription and treatment plan for opioid-induced constipation needs to be first and foremost while you’re writing that first opioid prescription.
David Wang, MD: Jeff, do you have any thoughts for your pharmacy-provider colleagues out there?
Jeffrey Fudin, BS, PharmD, DAIPM, FCCP, FASHP, FFSMB: Yes. I would like to give a shout-out to those pharmacists who are working in the community setting and suggest and encourage them to do an entire profile review to make sure. Even though a patient has opioid-induced constipation, look at the entire profile, see how they can take a polypharmaceutical regimen and rationalize it, how we might be able to eliminate certain drugs. Brett talked about reducing opioid doses and how people are encouraging that. If that can’t be done, I think a rational approach to that would be maybe not reducing the dose but changing to another opioid and reducing the dose for cross-tolerance, so that the analgesia is not compromised, and the patient still gets the analgesic benefit, but the opioid load is reduced. These are all things that pharmacists can be very much involved with, a simple phone call.
David Wang, MD: As we’ve seen, it certainly takes a village to take care of these patients. Make sure they’re identifying the issue, having the conversations, prescribing these new agents, these PAMORAs when the time is right. Then try to push the envelope and do better for each of them.
Theresa Mallick-Searle, MS, NP-BC, ANP-BC: I think also not feeling like you—the clinician, the emergency department doctor, the nurse practitioner in the office, the nurse practitioner in the hospital—have to work in a silo and have all the information. Feel comfortable reaching out to your colleagues to have the discussion. Use your pharmacy staff. That’s what they’re there for. They’re there to help you. They’re there to help you take care of the patient better. Ultimately, it’s the patient experience, so don’t feel fearful about reaching out to others for help.
David Wang, MD: Absolutely, I couldn’t agree more. Well, thank you all very much for your expertise and contribution to this discussion. On behalf of our panel, we thank all of you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative.
Transcript edited for clarity.