Embarrassment and communication

Two women in conversation

Image for illustrative purposes only. Posed by model.

Opioids are associated with several adverse events, of which opioid-induced constipation (OIC) is the most common.1–5

Patients experience a number of physical symptoms, including difficulty going to the toilet, flatulence, abdominal cramps, bloating, feeling full or heavy, and pain when going to the toilet.1,3,6 Beyond this, OIC can lead to other clinical conditions, including haemorrhoids, bowel obstruction, intestinal perforation and potential bowel rupture.6–8

“No movement at all will lead to an impaction which will be painful and annoying to solve, possibly requiring a trip to the emergency room”9

As a result of these symptoms, patients with OIC have been reported to experience embarrassment, depression, low self-esteem, social isolation, anger and frustration.5,8,10 Some patients would rather not take opioids and endure their original pain, than experience the distressing pain of OIC.6,9,10

However, as patients often do not report or fully describe their symptoms, their physician may not fully appreciate the extent of OIC symptoms, the limited effectiveness of laxatives, and the negative effects of OIC on pain management and quality of life.11

This disconnect between patient and physician understanding is not unique to OIC and has been observed in other chronic conditions.11 A disparity between patient-reported symptom severity, patient-reported quality of life and physician assessments has been observed in cardiovascular disease, psoriatic arthritis, rheumatic diseases, and systemic sclerosis.11
Effective communication between patients and their physicians, while essential for optimal patient outcomes, can be hindered by time constraints and a reluctance to discuss embarrassing topics.5,11–13

In an online survey of 489 chronic pain patients who were prescribed opioids for their pain, almost 70% of patients said that constipation is a topic which they were ashamed or embarrassed to talk about.5 In addition, some patients would prefer to suffer in silence, afraid that if they mentioned their OIC to their physician, they would potentially have to change or reduce their pain medication.11

How can physicians help bridge the gap and make the most of their consultation time? And support patients in having these conversations? Increasingly, physicians have seen value in asking patients to complete brief questionnaires about their pain severity and other symptoms including OIC as part of the check-in process for routine care visits.9,10 Use of these brief and easy-to-administer questionnaires help in understanding the extent and burden of pain and OIC, facilitating effective treatment.10

Inclusion of additional questions to help assess the presence, impact and ongoing burden of gastrointestinal symptoms, such as constipation, may prompt physicians to follow up with patients about this issue.11 Alternatively, patients could be asked to write down their symptoms as they find it less embarrassing and easier to be clearer and more specific on the impact of their OIC on their daily lives.11

Currently, there are a number of clinically available tools and assessments that can be used to help facilitate conversations with patients.13 Recommendations from a multiple disciplinary group investigating OIC assessment focused on the use of the Bristol Stool Form Scale (BSFS), the Bowel Function Index (BFI) and the Patient Assessment of Constipation Quality of Life (PAC-QOL) for both clinical trials and general clinical practice.13,14

  • The BSFS is an aid designed to help to determine stool frequency and classify the form/consistency of bowel movements into seven categories15
  • The BFI is a patient-reported outcome tool administered by physicians. It has a numerical scale measuring the mean of three variables: ‘ease of defaecation’, ‘feeling of incomplete bowel evacuation’ and ‘personal judgement of constipation’13
  • The PAC-QOL is a 12-item questionnaire developed to measure patients’ health-related quality of life, based on the patient’s experience of OIC and response to treatment16

Assessing bowel function with these tools, especially early on in treatment, could help to decrease the burden of constipation in opioid treated chronic pain patients.14 However, these tools may be time consuming, making their practical use a potential challenge given the short consulting times available to doctors.11,12

Beyond these tools, the development of evidence-based treatment guidelines, increased access to educational aids and a validated assessment tool could also help to bridge the gap between patient experience and physician perception, and ultimately improve the clinical management of OIC.11,17,18

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  4. Veterans’ MATES. Therapeutic brief 27. Opioid-induced constipation – a preventable problem. Available at: https://www.veteransmates.net.au/documents/10184/23464/M27_TherBrief-RefList_Merge.pdf Accessed: June 2017;
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  16. Frank L et l. Scand J Gastroentrol 1999;34:870–7;
  17. Dean D, et al. Presented at American College of Gastroenterology Congress, 2015.
  18. Datto et al. Poster presented at Association for Paediatric Palliative Medicine, 2015;