A Q&A with Jeffrey Fudin, BS, PharmD, FCCP, FASHP, FFSMB
Opioid medications are rarely the first choice of individuals with chronic pain. But for people with severe pain who have not found relief from other therapies, opioids may be necessary. Unfortunately, opioids can have a number of side effects, including opioid-induced constipation or OIC.
Below, Dr. Jeffrey Fudin talks about OIC, how it differs from regular constipation, and treatment options.
1. Why is OIC important to treat?
“Most patients that experience opioid-induced constipation (OIC) try and treat it themselves first. They’re embarrassed to bring it up with their doctors, so they take over-the-counter (OTC) medications, which often leads to frustration because they don’t treat the underlying cause of their constipation.
Properly diagnosing and treating OIC is important for several reasons. First, OIC can cause distress and discomfort for patients, leading to more doctor’s visits, more absences from work and decreased productivity. Worse yet, serious complications such as aspiration, possibly leading to painful reflux, difficulty breathing, or aspiration pneumonia, and/or bowel perforation, fecal impaction and hemorrhoid formation can occur if left untreated. When uncontrolled, OIC can lead to longer hospital stays, increased emergency department (ED) visits and increased readmissions. Ultimately, treating OIC can help the patient return to their normal quality of life, as well as reduce the burden on the health care system.”
2. How common is OIC among chronic pain patients on long-term opioid therapy?
“OIC affects between 40 to 80 percent of chronic pain patients on long-term opioid therapy. Of which, 77 percent report suffering from OIC for at least one year and 43 percent for more than three years.”
3. Is OIC managed and treated the same as other types of constipation?
“While patients and health care providers might try to treat OIC the same way as other types of constipation, such as using laxatives or making lifestyle changes (e.g., increasing fluid and exercise), it is often ineffective. Because OIC occurs as a direct result of the way opioids work in the gut, it must be managed differently. Targeted OIC treatments such as PAMORAs (peripherally-acting mu-opioid receptor antagonists), may be the most effective option for treating the root cause of OIC and providing relief to patients. PAMORAs are not laxatives; instead they actually block the problem that causes constipation.”
4. Why don’t patients with OIC generally respond to laxatives?
“Laxatives do not effectively target the underlying cause of OIC – which is the binding of opioids to receptors in the gut. Therefore, a medication that targets this may prove more effective in providing relief by prevention. Also, according to data from a national survey, one of the biggest challenges for chronic pain patients suffering from OIC is that medications to relieve this problem often don’t work quickly enough to relieve their constipation symptoms, cause undesirable side effects like cramping, and are unpredictable in terms of when or how drastically they will work after leaving their home. As a pharmacist, I’ve noticed that the benefits of flexible dosing and predictability are important to many patients.”
5. What types of medications are most effective in helping to treat OIC?
“PAMORAs (peripherally-acting mu-opioid receptor antagonists), are typically most effective for treating OIC. These medications are designed to target the action that decreases opioid-induced constipating effects without decreasing the effectiveness of opioids to treat pain. However, it is important for patients to speak with their physician or pharmacist about OIC and find a treatment plan option that works best for them.”
6. What should patients know about medications for OIC?
“It is important for patients to know that they have options when it comes to treating their OIC. Medications used to treat OIC are different from over-the-counter (OTC) laxative medications. There are several PAMORAs available to treat OIC; however, it’s important to speak with your doctor or pharmacist about which option is right for you. Consider other medications you may be taking, and how quickly you want to experience a bowel movement. There are some PAMORAs available that vary in dosage, oral absorption, and the way they are metabolized within the body. For example, methylnaltrexone does not have any known drug-to-drug interactions, can be taken orally or by injection, and offers quick and predictable relief.
It is always important for patients to keep an open-line of communication with their HCP regarding symptoms and medication use and effectiveness.”
Dr. Fudin is the owner and managing editor for www.paindr.com and founder and CEO of Remitigate LLC, which offers software to doctors looking to more safely prescribe opioids. He has participated in developing practice guidelines for use of opioids in chronic noncancer pain (American Pain Society, American Academy of Pain Management collaborative) and participated in national (U.S. Department of Health and Human Services) and international guideline development for various pain types, including but not limited to, arthritis, fibromyalgia, and palliative care. He has also participated in the development and co-authored consensus guidelines for the treatment of opioid-induced constipation (OIC) and for urine drug monitoring.
Dr. Fudin practices as a Clinical Pharmacy Specialist and Director, PGY-2 Pharmacy Pain Residency Programs at the Stratton Veterans Administration Medical Center in Albany, NY.