Opioid-Induced Constipation and Bowel Dysfunction: A Clinical Guideline

Abstract

Objective: To formulate timely evidence-based guidelines for the management of opioid-induced bowel dysfunction.

Setting: Constipation is a major untoward effect of opioids. Increasing prescription of opioids has correlated to increased incidence of opioid-induced constipation. However, the inhibitory effects of opioids are not confined to the colon, but also affect higher segments of the gastrointestinal tract, leading to the coining of the term "opioid-induced bowel dysfunction."

Methods: A literature search was conducted using Medline, EMBASE, and EMBASE Classic, and the Cochrane Central Register of Controlled Trials. Predefined search terms and inclusion/exclusion criteria were used to identify and categorize relevant papers. A series of statements were formulated and justified by a comment, then labeled with the degree of agreement and their level of evidence as judged by the Strength of Recommendation Taxonomy (SORT) system.

Results: From a list of 10,832 potentially relevant studies, 33 citations were identified for review. Screening the reference lists of the pertinent papers identified additional publications. Current definitions, prevalence, and mechanism of opioid-induced bowel dysfunction were reviewed, and a treatment algorithm and statements regarding patient management were developed to provide guidance on clinical best practice in the management of patients with opioid-induced constipation and opioid-induced bowel dysfunction.

Conclusions: In recent years, more insight has been gained in the pathophysiology of this "entity"; new treatment approaches have been developed, but guidelines on clinical best practice are still lacking. Current knowledge is insufficient regarding management of the opioid side effects on the upper gastrointestinal tract, but recommendations can be derived from what we know at present.

Keywords: Constipation; Laxatives; Opioid Antagonists; Opioids; PAMORAs.

Figure 1

Flow diagram showing review of literature to identify clinical research papers relating to OIBD.

Figure 2

Treatment guidance algorithm for patients initiating opioid treatment and patients presenting with OIC. Patients with previous constipation not responding well to laxatives and given an opioid therapy on top are probably best treated with an agonist-antagonist plus a laxative. *First choice laxatives—bisacodyl, sodium picosulfate, senna, macrogol. OIC = opioid-induced constipation.