William F. Peacock, MD: Welcome to “Expert Perspectives in the Management of Opioid-Induced Constipation.” I’m Frank Peacock, and I’m an emergency physician at Baylor College of Medicine in Houston, Texas. I’m joined by my esteemed colleagues, Dr Neel Mehta, the medical director of pain medicine at Weill-Cornell Medical Center at New York Presbyterian Hospital in New York City, and Dr Conar Fitton, a gastroenterologist at SLMA [South Louisiana Medical Associates] in New Orleans.
I’m glad to join you guys. Both of you know more about this than I do. As an emergency doctor, I see it a lot, but it isn’t the same as what you guys have to do. I’m happy to have some conversations. We’re going to have several segments for discussion. The first one will be the overview and disease awareness, and then we’ll progress along the disease spectrum. Let’s start with a definition. Conar, what is opioid-induced constipation [OIC]? Why is it a concern?
Conar Fitton, MD: Thanks for having us. I look forward to having a chat with you guys about this. It’s obviously a huge burden for our patients, and we’ll all be able to provide different perspectives on who and what we see. From the GI [gastrointestinal] perspective, we have our Rome criteria, and we have the Rome IV criteria, which came out about opioid-induced constipation essentially being new or worsening symptoms of constipation when initiating or changing opioid therapy.
It has to include at least 2 of the following at least a quarter of the time. Patients need to notice a change in consistency, where they’re noting lumpy or harder stools; straining, which is a very frequent symptom they complain of; the sense of incomplete evacuation—we’ll talk about the mechanism and why that’s very unique to opioids; a sense of anorectal dysfunction, whether they feel obstruction or are using manual techniques to have a bowel movement; and then less than or equal to 3 spontaneous bowel movements a week. You have to have at least 2 of those, but most patients complain of all of them or at least 2 of them very frequently.
William F. Peacock, MD: Sure. Neel, you’re a pain management doctor.
Neel Mehta, MD: That’s right.
William F. Peacock, MD: You prescribe opioids frequently. How often do you see this?
Neel Mehta, MD: Thanks for having me. Like Conar said, it’s exciting to be able to talk about this here. Believe it or not, people are suffering in silence. One of the eye-opening things that I talk about with my residents and fellows is that I was once invited to a consulting/product investigation. It’s one of those things where you’re sitting behind a 2-way mirror where the participants can’t see you. It was basically patients who were talking about opioid-induced constipation. All of them didn’t know who they could turn to, or that it was happening because of their medication. It was eye-opening.
We started to use electronic intakes—electronic questionnaires that highlight constipation-type questions. We found that almost 40% to 50% of our patients on opioids were having what we would define as OIC, just like what Conar talked about. Many of them thought that it was due to things like their diet or exercise, but never once thought about constipation from the medication that they were taking. That’s a long way to say that it’s very prevalent, and we aren’t completely aware of how many are suffering and who aren’t telling us.
William F. Peacock, MD: That’s amazing—the 50% number—which I have read before as well. But think about the other drugs we use. If they had a 50% complication rate, we’d start to think we won’t use them anymore.
Conar Fitton, MD: Yes. When you’re talking about the scope of the problem, we were saying 9 million to 12 million Americans—almost 4% to 5% of the population—uses opioids regularly. Like Neel said, it’s even 40% to 50% quoted for chronic pain. The advanced illness statistics can sometimes be even higher. Some of them can be upwards of 60% or 80% in some of the smaller studies. With the prevalence of chronic pain and the reliance of patients for quality of life on opioids, we can do a better job through education of trying to get ahead of it and not being so reactive.
Neel Mehta, MD: Yes. Part of the issue is that as we have put out regulations regarding opioids to rightfully give it to the right patients and not where we think it may cause harm. People are worried that we may be impacting their ability to get their pain medication if we ask about adverse effects and they answer truthfully, which is unfortunately a sad state of. We want the ability to understand that the patients who truly benefit and need the opioids are getting the maximum benefit without all these other adverse effects. Because there are such great tools to treat OIC, we hopefully have a better opportunity to educate and understand the scope of the problem in our own practices.
Transcript Edited for Clarity