Gerald Sacks, MD, and Fariborz Rezai, MD, FCCP FCCM, discuss unmet needs and the future treatment landscape in managing opioid-induced constipation.
Gerald Sacks, MD: What I see as the major unmet need in the management of opioid-induced constipation [OIC] is the general unawareness that opioid-induced constipation is common and can be prevented and treated effectively using medications we have. The most common unmet need that I see is that health care professionals, physicians, nurse practitioners, and PAs [physician assistants], either don’t have the time or don’t have the knowledge base to effectively discuss opioid-induced constipation with their patients who are being prescribed opioids. I find that I spend a lot of my time educating my peer group, other health care professionals, nurse practitioners, PAs, physicians, and DOs [doctors of osteopathic medicine]. I find myself educating this group of people to better understand that when they are prescribing an opioid to treat chronic pain and sometimes even acute pain, that the patient frequently may develop opioid-induced constipation and that we have medications that effectively address and treat opioid-induced constipation. Specifically, the peripherally acting µ-opioid receptor antagonists that are designed to treat opioid-induced constipation and when taken on a daily basis, can indeed prevent the development of opioid-induced constipation. I find these medications to be highly effective. So the greatest unmet need I see is a lack of education, which also falls into a lack of time from the busy primary care practitioners and other busy health care professionals to have an in-depth discussion with the patient addressing the issue of opioid-induced constipation.
As time goes on, the general acceptance of the usage of the peripherally acting µ-opioid receptor antagonists does appear to be increasing, both by the pain management community but also by other health care professionals who are prescribing opioids to treat chronic pain. In other words, as time has gone on for the last decade or so, I have seen an increase in the educational background, in the knowledge base, of health care professionals in both understanding the concept of opioid-induced constipation and understanding that there are effective treatments for opioid-induced constipation available. I have seen an uptake— especially for patients in my hospital, but also for outpatients—in recommendations from primary care practitioners for the patient to utilize lifestyle changes: good hydration, good levels of physical activity, eating fruits and vegetables, and making sure that the patients are utilizing the over-the-counter medications when needed. Part of this is also recognizing that all of those efforts may not be successful in helping the patient maintain their baseline level of bowel function, and frequently we may need to address and treat this using a peripherally acting µ-opioid receptor antagonist.
The take-home message, I believe, is that opioid-induced constipation can be a very difficult problem for patients, but also for health care professionals to discuss with the patient. I think we should all become comfortable discussing the adverse effects of any medications we are prescribing, and also the potential adverse effects, so the patients can both address and perhaps prevent the development of opioid-induced constipation. We laugh about it because, let’s face it, we’re talking about bowel function, and many of us find this somewhat amusing. But from the patient’s point of view, I’ve had patients in which the opioid-induced constipation is dramatically affecting their life. It’s impacting their ability to interact with their family, to interact at work, and for them to even leave the house. I’ve had patients tell me that the opioid-induced constipation is so bad that they’re afraid to leave their house because they are concerned that they may have to have a bowel movement and they won’t be prepared for that. Whereas if a patient is having their opioid-induced constipation effectively treated, they can just take their medication, have their bowel movement, go on with their daily activities, and maintain a lifestyle and increased activity. In many cases, the opioids provide these patients with the opportunity to have better pain control and therefore increased functional activity. The whole goal of opioids is comfort, as well as maintenance, and increasing patients’ ability to do the things that they want to do to increase their functionality. If we can control, address, and treat opioid-induced constipation, it is 1 additional step that helps our patients maintain their healthy lifestyles.
Fariborz Rezai, MD, FCCP FCCM: I think there are quite a few unmet needs in the management of OIC. One is education. I think even in the health care world, it’s underdiagnosed or it’s diagnosed but undertreated, for a wide variety of reasons. To what I mentioned earlier, OIC or constipation in general, is something patients don’t like bringing up and physicians don’t like spending a lot of time talking about because of the nature of the diagnosis. But I think it’s something that’s worthwhile to focus on. A lot of times, I know primary care physicians will send the patients to a GI [gastrointestinal] physician, but this is something that a primary care physician can absolutely handle to the best of their ability. Obviously, if there are other, more complicated reasons they should be referred to GI. But my point is that I think more educational awareness of OIC would be beneficial for treating these patients. Other treatments that come down the pipeline may be a good option or an additional option to what we have now. That’s to be seen, but again, I think the focus is education. Once we have more education, there will be more awareness, and then there will be a better treatment.
I’m a physician and clinician who likes to be very thorough with my patients. It’s probably because I’m more of a critical care physician, where I review systems or system-by-system management. My take-home message is: focus on every diagnosis your patient has at every visit. Don’t just assume that there’s no change, because some of the slightest changes can really make a difference for your patient with long-term morbidity and even mortality. So keep that in mind.
Transcript Edited for Clarity