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10 Articles in Volume 17, Issue #10
A Guest Editorial on Counterfeit Pain Medication: The Other Epidemic
A Model to Incorporate Functional Medicine into Chronic Pain Care
Chronic Pain and Substance-Related Disorders
Getting at the Root of Opioid-Induced Constipation (OIC) with an Osteopathic Approach
Inside FDA's Guidance on Generic Abuse-Deterrent Opioids
Neural Pathway Pain — A Call for More Accurate Diagnoses
Pain Care in a Natural Disaster
Pharmacological Interventions in Sport-Related Concussion
The Internet of Medical Things
What Type of Withdrawal Symptoms from Tramadol Might a Patient Experience?

Getting at the Root of Opioid-Induced Constipation (OIC) with an Osteopathic Approach

Due to OIC’s unique pathophysiology, standard treatments may be ineffective. Addressing potential underlying causes may remove symptomatic roadblocks.

Given the rise of opioid use for pain treatment as well as palliative care, healthcare providers have witnessed a parallel rise of opioid-induced constipation, affecting up to 40-70% of chronic users. While not as immediately life-threatening, opioid-induced constipation (OIC) poses risks for analgesic discontinuation, physical sequelae, and altered quality of life.1

Adverse effects associated with opioids are frequent, and may affect numerous organ systems. Within the gastrointestinal (GI) tract—nausea, vomiting, reflux, bloating, and constipation are reported, for example, with constipation being the most frequent.2 The economic burden (defined as resource utilization and cost) of OIC is significantly higher than in patients who take opioids but do not develop OIC.3

Opioid-induced constipation is a difficult condition to treat, and may have a significant psychosocial impact on those affected.4 Unlike other adverse side effects of opioids, accommodation does not occur and thus, OIC typically does not improve or resolve over time. Further compounding the situation, the pathophysiology of OIC is quite different from functional or idiopathic constipation. Therefore, conventional treatments used for functional constipation often fail to provide adequate symptom relief.5-8

The desired opioid effect for pain control occurs in the central nervous system. However, opioids also bind peripheral mu opioid receptors within the GI tract with the end effect being reduced myenteric plexus activity and relaxation of the peristaltic effect of the GI tract.9 This effect may occur even with standard pain management doses of opioids that do not constitute overuse or reflect abuse.

As the prevalence of chronic pain rises, and the use of opioid medications continues,3 healthcare providers must be well-versed in the appropriate use of opioids, as well as in the prevention and management of opioid-induced constipation.

Diagnosing Opioid-Induced Constipation

Current methods for diagnosing opioid-induced constipation include both objective and subjective criteria as described below. While methods of diagnosis may vary among disciplines, a frequently used assessment typically examines a patient’s history with regard to:

  • current or recent opioid use
  • defecation frequency (most often fewer than three spontaneous bowel movements per week)
  • at least two of the following symptoms occurring 25% of the time or more: straining, hard or lumpy stool, incomplete evacuation, and infrequent bowel movements.

Unfortunately, these criteria may not identify all patients experiencing OIC, and many patients may not address the problem with their caregiver.10,11 Therefore, it is crucial that clinicians have regular discussions on bowel habits with patients receiving opioid medications in order to identify those with OIC.

Pharmacologic Treatment Options

Traditional treatments of idiopathic or functional constipation, such as stool softeners and laxative agents, along with behavioral modifications, may be considered first-line treatments for constipation due to their convenience, low cost, and favorable risk profile. However, because the mechanism for opioid-induced constipation differs from that of idiopathic or functional constipation, many of these first-line treatments may not be effective, leaving patients with refractory constipation.5,6

Newer OIC therapies include a class designated by the US Food and Drug Administration as peripherally acting mu opioid receptor antagonists (PAMORA). Three approved drugs in this class include: subcutaneous methylnaltrexone, naloxegol, and naldemedine. While these medications tested better than placebo in various studies, not all patients responded positively.12-13 Some patients also reported adverse reactions, ranging from GI related effects to increased body temperature and dizziness.9

Given the limited and varying effects of pharmacologic agents produced thus far, and the knowledge that most patients taking chronic opioids have varying levels of polypharmacy, other more effective treatments may be considered.

 

Osteopathic Approaches

Osteopathic physicians (DOs) have long subscribed to a philosophy of holistic treatment of any medical problem from five perspectives:

  • behavioral
  • biomechanical
  • metabolic
  • neurologic
  • respiratory-circulatory.

When considering these perspectives, pain practitioners and patients may be better able to fully assess the problem and understand what factors might be contributing to OIC. By putting forth an in-depth and personalized approach, the physician may aim to address not just the symptomatology of OIC, but also what may be propagating its manifestation.

Within the domain of osteopathy are manual techniques termed osteopathic manipulative treatments (OMT), which supplement these five components of care. The benefit of using the multiperspective approach is that a practitioner not trained in OMT may still utilize these viewpoints when treating patients. Below is an osteopathic approach to diagnosing and treating OIC (technique procedures are not elaborated in this article).

Behavioral

To reduce or eliminate opioid use, behavioral health or habits may be addressed in patients with OIC as a definitive way to “cure” OIC. However, this may not be a viable option for many patients who require opioids for chronic pain or palliation. However, limiting or reducing opioid use without sacrificing appropriate analgesia may reduce OIC symptoms. In addition, it is important to promote behavioral changes such as water intake, high fiber diet, movement, and physical activity.1 Even certain types of meditation may help influence the neurologic system by reducing sympathetic tone and increasing parasympathetic response, which, by extension, may improve bowel function.14

Biomechanical

The goal of the biomechanical model is to identify and treat musculoskeletal dysfunctions and improve motion of joints, muscles, fascia, and visceral organs. Addressing these musculoskeletal dysfunctions may relieve constipation as a result of the reflex autonomic interaction between the musculoskeletal system and the visceral system (see also the Neurologic section below).15

Specific osteopathic treatments geared toward the biomechanical model may strive to eliminate muscle hypertonicity, myofascial restrictions, spinal alignment issues, and other joint restrictions—especially at levels of sympathetic input to the GI system from T5-L2 and parasympathetic input from the occiput, C1-C2 and S2-S4. Improvement of musculoskeletal dysfunction may also lead to better mobility and increased physical activity, which is important for healthy bowel function.

A variety of osteopathic treatment modalities may be applied, including myofascial release, muscle energy, strain-counterstrain, and visceral manipulation.16 For example, transabdominal stimulation of the entire length of the colon is a simple visceral technique that directly contributes to gastrointestinal muscular movement and peristalsis. This method may be taught to patients or their families for at-home application.16

Biomechanical osteopathic approaches may also help to alleviate pain that is driving the utilization of opioids, thereby removing the root problem. For instance, successful treatment of a patient’s back pain, headache, neuropathic pain, or fibromyalgia may eliminate the need to continue pain management with opioids.17 Since the opioid epidemic began, this aspect has risen in interest with regard to OMT.18

Metabolic

This model examines energy processes that affect bowel absorption, elimination, and motility. Improving motion of the gastrointestinal tract through previously mentioned techniques may improve metabolic processes. Additionally, treatment may focus on decreasing elevated sympathetic input to the viscera including the pancreas, liver, gallbladder, kidney, and adrenals, as well as their respective enzymes and hormones. Proper nutrition and hydration may play an important role in promoting bowel health. For example, certain foods high in fiber may help promote bowel movements,19 whereas constipating foods such as red meat, dairy, white flour, and white rice should be avoided if possible.20

Finally, certain nutritional supplements, such as magnesium oxide, may benefit OIC and, in many cases, provide a low-cost alternative to medications with fewer side effects.21 Magnesium is an important mineral required for normal function of cells, nerves, muscles, bones, and the heart.

A well-balanced diet provides normal blood levels of magnesium, but supplementation of 500 to 2000 mg has laxative effects.22 In patients with cancer who are taking opioid analgesics, magnesium has been reported to markedly reduce the incidence of constipation (21% in the treatment group versus 56% in the control group) with minimal adverse effects.22 Based on the supplement’s cost and safety profile, magnesium may be considered in the treatment of OIC.

Neurologic

Given the pathophysiology of opioid-
induced constipation, balancing autonomic inputs to the enteric system may result in improved gut function and, thus, more inherent peristalsis and gut motility. Osteopaths may do this distally by manipulating the neuronal ganglia that innervate the gastrointestinal system, namely the vagus nerve, pelvic splanchnics, and the sympathetic chain ganglion. For instance, the sympathetic influence of the GI tract largely stems from T5-L2 spinal levels, so treatment of mechanical dysfunction at those spinal levels (ie, spine out of alignment, muscle spasm, tissue texture abnormalities) may reduce sympathetic overload that might impede proper function and maintain constipation.15,16

Sympathetic influences to abdominal viscera from T5-T12 proceed anteriorly into the abdomen via the thoracic splanchnics. These tracts physically pass through the diaphragm.23 Therefore, treatment of diaphragmatic restrictions may be utilized to normalize thoracic splanchnic innervation.24 Additionally, osteopathic manipulative treatment of sacral dysfunctions in the S2-S4 region may improve parasympathetic tone of the colon increasing peristalsis.25 Since this model is paramount to successful OMT intervention for OIC, specific examples of these treatments are below:17

  • Ventral abdominal inhibition: a gentle procedure that involves inhibitory pressure over the three midline sympathetic collateral ganglia (ie, celiac, superior mesenteric, and inferior mesenteric ganglion) that reduces hyperactive sympathetic activity of the GI system.26
  • Rib raising: an articulatory technique designed to affect the sympathetic chain ganglia bilaterally. Treatment initially increases sympathetic tone followed by a subsequent longer-lasting decrease in sympathetic tone.16
  • Respiratory diaphragm myofascial release: treats myofascial restrictions of the respiratory diaphragm, which affect the transit of thoracic splanchnics to the abdominal viscera.24 Thoracic splanchnics must physically pass through the diaphragm to provide sympathetic innervation to abdominal organs such as the small intestine, ascending colon, and transverse colon.16,23-25
    This technique typically results in improved diaphragm motion and removal of restrictions impacting thoracic splanchnic function to balance sympathetic control to abdominal viscera.24
  • Occipito-Atlantal release: treats the muscular tension overlying the inferior occipital region as well as C1 reducing myofascial restrictions of the vagus nerve as it exits the jugular foramen. This technique may lead to improved motion of the upper cervicals and occiput, improving vagal parasympathetic control to the small intestine, ascending colon, and transverse colon.16,25
  • Sacral inhibition or rocking: improves pelvic splanchnic function, S2-S4, which balances parasympathetic control to the descending colon, sigmoid colon, and rectum.16,25

Respiratory-Circulatory

Extrinsic and intrinsic mechanical motion is integral to adequate circulation to and from the GI tract. Problems with motion may lead to dysfunction of absorption, excretion, and immune response within the intestines or colon. Venous, arterial, and lymphatic circulatory stasis may contribute to proliferation of constipation whether due to physical immobility of the colon itself or immobility of surrounding structures (eg, thoracic diaphragm). Improvement of physical motion as well as diaphragmatic motion augments circulation and lymphatic drainage, which may improve function.

In addition to addressing neurologic tone as described, respiratory diaphragm myofascial release is an osteopathic technique that reduces myofascial restrictions of the respiratory diaphragm, restoring thoracoabdominal pressure gradients that drive circulatory flow and lymphatic drainage of the GI tract.16

Conclusion

Opioid-induced constipation is a chronic problem for many patients managing their pain with opioids and is unlikely to be cured by one modality alone. A multiperspective osteopathic approach that includes osteopathic manipulation may be considered as a first-line treatment for a patient experiencing OIC due to its conservative nature, its prevention of polypharmacy, and its ability to reduce pain by relieving structural impediments. Osteopathic manipulative treatment offers a valid, noninvasive modality that seeks to improve dysfunction in the musculoskeletal system through a series of manual techniques in conjunction with integrated medical understanding and management.

The authors have described several osteopathic treatments, but realize that there are many other possible therapies that may be beneficial in treating OIC. Ascribing to the philosophy that structure begets function, finding and fixing areas of restriction in the musculoskeletal system may allow the body to utilize its inherent ability to heal, improve, and restore natural function. In partnership with this perspective, other conservative treatments, including dietary supplementation, may be considered. Further studies are needed to elucidate the improvement of gastrointestinal function following administration of osteopathic manipulation treatment in cases of opioid-
induced constipation.

 

 

Last updated on: February 5, 2018
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