Opioid-induced Constipation: Old and New Concepts in Diagnosis and Treatment

Abstract

Daily use of opioid analgesics has significantly increased in recent years due to an increasing prevalence of conditions associated with chronic pain. Opioid-induced constipation (OIC) is one of the most common, under-recognized, and under-treated side effects of opioid analgesics. OIC significantly reduces the quality of life by causing psychological distress, lowering work productivity, and increasing access to healthcare facilities. The economic and social burden of OIC led to the development of precise strategies for daily clinical practice. Key aspects are the prevention of constipation through adequate water intake and fiber support, avoidance of sedentariness, and early recognition and treatment of cofactors that could worsen constipation. Recommended first-line therapy includes osmotic (preferably polyethylene glycol) and stimulant laxatives. Peripherally acting μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, or naldemedine, should be used in patients that have not responded to the first-line treatments. The bowel functional index is the main tool for assessing the severity of OIC and for monitoring the response. The paper discusses the recent literature on the pathophysiology, clinical evaluation, and management of OIC and provides a pragmatic approach for its assessment and treatment.

Keywords: Constipation; Laxatives; Methylnaltrexone; Naldemedine; Naloxegol.

Figure 1

Bristol stool chart.

Figure 2

Management of opioid-induced constipation (OIC). BFI, bowel function index; BSC, Bristol stool chart; MRI, magnetic resonance imaging; PAMORA, peripherally acting μ-opioid receptor antagonist.