OIC and opioid adherence

Female coiled up with negative emotion

Image for illustrative purposes only. Posed by model.

What is the impact of OIC on patients’ lives, and why are patients resorting to self-modulation of their opioid dose?

Opioids are an essential tool for managing chronic pain, endorsed by international guidelines and societies across the world.1–5 However, despite opioids proven analgesic action, their use may be limited due to associated adverse events, which can affect pain control and patient quality of life.6,7

These include constipation, nausea, vomiting, dizziness, sedation, respiratory depression, tolerance, and physical dependence.7

Of these, opioid-induced constipation (OIC) is the most common, with reported prevalence rates ranging from 40% to 90% in patients.8 But, unlike many of the other adverse events experienced with opioids, constipation does not improve over time. This is because patients rarely develop a tolerance to the gastrointestinal side effects.6 So, as OIC persists, it should be anticipated, monitored and addressed throughout the patient’s opioid treatment course.1,6,7

Debilitating, distressing and a daily burden

Given its frequency and persistence, OIC is seen as the most debilitating and distressing opioid-related adverse event.6,9,10

“I have had many surgeries and injuries in my life and nothing compares to the pain of severe constipation”11

“My constipation was so bad I thought I was going to die… actually, I wanted to die.”11

In a PainPathways survey, almost 50% of patients reported that OIC impaired their performance and productivity at work, altered their sexual and social lives and prevented them from performing even basic activities of daily living, such as being able to leave the house.12

Not only is OIC distressing, it also can result in significant morbidity and mortality among patients who are given opioids long term.13,14 Also, serious medical consequences such as bowel obstruction, faecal impaction and colonic perforation can occur. In some cases these may require surgical intervention.6

“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. So I worry a lot about not having a bowel movement” 15

For some patients, OIC is so severe that they will reduce, miss or completely stop taking their pain medication, even if this causes their pain to return.14–17 In a patient survey, 86% of patients who changed their opioid dose in an attempt to manage their gastrointestinal side effects reported an increase in pain that had a moderate to great impact on their quality of life and activities of daily living.6

Adjusting the dosing of opioids and other pain therapies can help manage changes in patients’ pain, including breakthrough pain.18,19 However, patients suffering with OIC frequently modulate their opioid dose without consulting with their doctor – at the expense of effective pain management.9,17 Also, despite self-modulating their opioid dose, patients often find their constipation can persist.12

“I am always conscious of not overdoing the pain meds. When I am faced with taking a pain med, I will always think about the constipation that might result, and so I will try to take the smallest dose possible or do without”15

Why do patients modulate their opioid dose?

For patients who are already in a vulnerable state due to their chronic pain, having to choose between that pain and OIC is an additional burden. 18,19 So why are patients resorting to modulation of their opioid dose? What other options do they have?

Laxatives, including stimulants and osmotics, are the most commonly used therapy choices for OIC.9 Laxatives and other stool softeners are recommended for the short-term relief of OIC symptoms, and may act as a preventative measure.9,12,20 However, despite taking laxatives and other therapies, many patients continue to experience the effects of OIC that compromise their pain management.15

The PROBE 1 study — a multinational internet survey of 322 patients — was designed to assess the prevalence, frequency, severity and impact of opioid-induced gastrointestinal side effects (termed opioid-induced bowel dysfunction) in patients receiving opioid therapy for chronic pain and taking laxatives.6

It highlighted the limited efficacy of laxatives in treating OIC.6 Furthermore, it found that approximately one third of patients who were treated with oral opioids and laxatives reported modulating their opioid dose due to the associated side effects.6

Of these patients:

  • 28% used a lower dose of their opioids
  • 33% skipped, decreased or eliminated their opioid dose in an attempt to facilitate a bowel movement6

As a result of dose modulation, the majority of patients (92%) experienced an increase in pain.6 However, some patients reported that they would rather endure the pain than continue to experience OIC as a result of their opioid therapy.6

 “I’d much rather live with pain than the side effect of severe constipation”11

Open dialogue leading to optimal outcomes

Opioids are essential for the management of moderate to severe chronic pain, but OIC is causing reduced adherence and, as a consequence, potentially compromising the effectiveness of opiod therapy.6

Clearly, there is a need for improved communications. Open dialogue about OIC between patients and healthcare providers is key in overcoming barriers, supporting adherence and providing optimal pain management.17,20 This effective communication is acknowledged as a fundamental aspect of optimal patient outcomes and adherence.20,21

Download the PowerPoint presentation

Click the slideshow to download a PowerPoint version of the slideshow for PC and Mac

References

  1. O’Brien T, et al. Eur J Pain 2017;21:3–19;
  2. World Health Organization. WHO’s cancer pain ladder for adults. Available at: http://www.who.int/cancer/palliative/painladder/en/. Accessed: June 2017;
  3. Ripamonti CI, et al. Ann Oncol 2012;23 Suppl 7:vii139–54;
  4. Paice JA, et al. J Clin Oncol 2016;34:3325–45;
  5. Chou R, et al. J Pain 2009;10:113–30;
  6. Bell TJ, et al. Pain Med 2009;10:35–42;
  7. Benyamin R, et al. Pain Physician 2008;11:S105–20;
  8. Chey WD, et al.N Engl J Med 2014;370:2387–96;
  9. Coyne KS, et al Clinicoecon Outcome Res 2014;6:269–81;
  10. 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: July 2017;
  11. Gudin J, et al. Practice pain management 2015 update. Available at: https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/opioid-induced-constipation-new-emerging-therapies-update-2015. Accessed: June 2017;
  12. Rauck RL, et al. Pain Pract 2017;17:329–35;
  13. Hjalte F, et al. J Pain Sympt Manag 2010;40:696–703;
  14. Kurz A, Sessler DI. Drugs 2003;63:649–71;
  15. Dhingra L, et al. Pal Med 2012;27:447–56;
  16. LoCasale RJ, et al. Int J Clin Pract 2015;69:1448–56;
  17. LoCasale RJ, et al. J Manag Care Spec Pharm 2016;22:236–45;
  18. Hagen NA, et al. Curr Pain Headache Rep 2008;12:241–8;
  19. Morlion B, et al. Clin Drug Investig 2015;35:1–11;
  20. Satyavan K, et al. Pharmacy Times. Managing Opioid-Induced Constipation. Available at: http://www.pharmacytimes.com/publications/issue/2009/september2009/counselingconstipation-0909. Accessed: July 2017.
  21. Haskard Zolnierek KB and DiMatteo MR. Med Care. 2009;47:826–34.