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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.
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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).

Last updated on: February 5, 2018
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