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Teachable Moment
August 24, 2020

Preventing Opioid-Induced Constipation: A Teachable Moment

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
JAMA Intern Med. 2020;180(10):1371-1372. doi:10.1001/jamainternmed.2020.3285

A man in his 70s with advanced prostate cancer diagnosed 6 months previously presented with progressive disease, as demonstrated by an increasing prostate-specific antigen level and worsening restaging scans, to discuss new treatment options. He reported generalized bone pain (6 out of 10 in intensity, worse with activity). His Eastern Cooperative Oncology Group performance status was 1 (scale, 0-5, with 0 = fully active and 5 = dead). Prior imaging showed no fractures. His oncologist discussed initiating therapy with oral abiraterone (CYP17A1 inhibitor, reducing androgen production). The oncologist also prescribed as-needed oxycodone instant-release 5-mg tablets, which he started taking 1 to 2 times a day.

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    2 Comments for this article
    Pharmacological Prevention of Opioid-induced Constipation
    David Keller, MS, MD | Internal Medicine
    Preventing opioid-induced constipation (OIC) in patients who take opioids daily for chronic pain requires aggressive prophylaxis.

    Daily use of over-the-counter peristalsis stimulants, like sennosides and bisacodyl, can result in tachyphylaxis, with loss of efficacy despite the use of increasing doses.

    Daily ingestion of polyethylene glycol 3350 osmotic agents (PEG-3350, Miralax) can be titrated to prevent hard stool, but may result in a lax colon bloated with soft stool.

    A more physiologically reasonable strategy is to start with regular everyday use of a PEG-3350 agent, adding a peristalsis stimulant only when
    no defecation has occurred in 36 to 72 hours, with the aim of minimizing the use of bowel stimulants to avoid their loss of effect by tachyphylaxis.

    For a patient who has failed the above prophylaxis, a pharmacological agent should be considered, to prevent the pain and expense of another admission for fecal impaction. Methylnaltrexone (Relistor) is designed to block the effects of opioids on the colon, without triggering opioid withdrawal, nor reducing opioid analgesic effect.
    "A Paradigm for Persistent Pain therapy using a Parable-Propagated Protocol"
    Charles Hubbert, MD | Self
    Kudos for the article authors for using a "memorable dictum," an old saying or parable to remind us of the need for good patient care, particularly as it addresses the much neglected function of bowel elimination caused by medication therapy. And almost as efficacious as the prescription of narcotic pain relief for needy patients is the assurance that they have appropriate bowel movements. While on the subject I must say that on a few occasions, having been required as a last resort to manually relieve a psychotropic medication-induced fecal impaction in a miserable psychiatric patient ("any port in a storm," and, "damn the torpedoes," that is, the psychoanalytic implications), these patients experienced significant positive transference and thus emotional relief. While, as the authors suggest for similar situations, "an ounce of prevention is worth a pound of cure," the "laying on of hands," or should we say "finger" in this corrective therapeutic procedure powered by "memorable dicta," is commendable and truly efficacious. Who says that there is no humor in medicine?