One of my chronic pain patients recently called for an appointment, complaining of increased pain. I asked her to bring her opioid prescription so that the office could perform a pill count. The count ending…
One of my chronic pain patients recently called for an appointment, complaining of increased pain. I asked her to bring her opioid prescription so that the office could perform a pill count. The count ending up being off — not because she was increasing her dosage, but because she was taking less of her opioid medication than prescribed. So, I began to wonder: Why would a chronic pain patient taking opioids reduce her medication and then come in complaining about an increase of pain? Furthermore, why hadn’t she brought this up with me during her prior appointment?
After an exchange with the patient, I determined this patient had opioid-induced constipation, which impacts 40 to 80 percent of patients on long-term opioid therapy. The burden of OIC often impacts patients’ lives, as they may experience distress and discomfort, increased doctor visits, absences from work and reduced productivity.
This patient reported altering her dosage of the opioid medication after she became constipated, in hopes of relieving the discomfort of her OIC. While this helped relieve her OIC, taking less opioids than prescribed compromised her pain relief. It is important to note that the patient eventually returned to taking the appropriate amount of opioids she was prescribed. However, altering the dose of prescription medication is, in fact, misuse. And this is especially concerning for patients who rely on opioid therapy for chronic pain.
A recent survey found that certain patients resorted to altering their opioid regimen to alleviate OIC. According to a national, one-week online survey sponsored by Salix Pharmaceuticals and the U.S. Pain Foundation and conducted by Wakefield Research — which evaluated responses from 441 U.S. adults ages 18 years or older who were living with chronic pain, on opioid therapy and suffering from OIC — 37 percent reported changing the dosage of their opioid medication to try to alleviate the pain or discomfort from OIC.
In my experience and contrary to popular belief, conventional laxatives are not a reliable treatment for OIC. Typically, for OIC, the treatment plan includes monitoring bowel movements and making lifestyle adjustments in conjunction with conventional laxatives. Over-the-counter therapies, such as laxatives, do not target the opioid-receptor mediated mechanism of OIC. While I believe opioids are necessary for certain patients with chronic pain, it is my duty to help prevent patients from misusing these medications.
Health care providers must remember that patients may feel uncomfortable talking about their bowel movements; therefore we must do more to facilitate that dialogue. I encourage a “Do Ask, Do Tell” policy with my patients by making sure we’re asking them the appropriate questions about their bowel habits and discussing OIC as a potential side effect of opioid therapy.
Unfortunately, this policy is not the norm. The survey uncovered that while most patients surveyed (58 percent) believed their doctor was concerned with helping them get faster relief for their OIC, only 50 percent recalled that they were informed by their doctor prior to taking their opioid medications that constipation is a potential side effect. As a physician specializing in pain management, this is a real concern to me.
By implementing an open discussion policy and considering other conditions that patients are experiencing, physicians will be more effective in identifying the proper treatment options to help people who are living with chronic pain, while potentially reducing the likelihood of patient non-adherence with their opioid regimen/therapy. As health care providers, we can initiate this dialogue by asking questions such as, “How have your bowel habits changed since taking the opioid?” If you or a loved one suffer from chronic pain and are on opioid therapy, I encourage you to talk with your health care provider about the symptoms of OIC and the treatment options that may be right for you.