Comprehensive Chronic Pain Management
A Focus on Patients With Opioid-Induced Constipation
Guidelines
The functional gastrointestinal disorders and the Rome III process, 2006.
Drossman DA. Gastroenterology. 2006;130(5):1377-1390.
Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain, 2009.
Chou R, et al. J Pain. 2009;10(2):113-130.
VA/DoD Clinical Practice Guideline: Management of Opioid Therapy for Chronic Pain, 2010.
Department of Veterans Affairs, Department of Defense
CDC Guideline for Prescribing Opioids for Chronic Pain
The Centers for Disease Control and Prevention developed and published these guidelines to provide recommendations for the prescribing of opioid pain medication for patients ≥18 years of age in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting ≥3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care
Patient Resources
Patient Conversation Guide
This patient tool can be completed prior to the visit with the health care provider to guide a meaningful conversation about bowel habits and constipation symptoms.
Patient Education Handout
This leaflet provides patients with approaches to mitigating opioid-induced constipation and includes a list of questions about constipation for patients to ask their doctors or clinics.
My GI Health
This free, downloadable app allows patients to measure and track constipation symptoms weekly. Educational resources specific to patient-reported symptoms are available.
Clinical Assessment Tools
Bowel Function Index (BFI)
The BFI provides a numerical score for the prior 7 days based on ease of defecation, feeling of incomplete evacuation, and personal judgment of constipation.
Bristol Stool Form Scale
This visual scale is used to help patients characterize their stool. It classifies the most commonly passed stool forms into 7 types.
Patient Assessment of Constipation (PAC-SYM)
This 12-item questionnaire of patient-reported symptoms assesses 3 subscales of symptoms (bowel movements, rectal symptoms, and abdominal symptoms) over the prior 2 weeks.
Patient-Reported Measurement Information System (PROMIS) Constipation Scale
This 9-item questionnaire of patient-reported symptoms assesses the frequency and severity of constipation symptoms over the prior 7 days.
Other Resources
A Clinical Guide to Opioid Analgesia. 2nd edition.
Fine PG, Portenoy RK. New York, NY: Vendome Group, LLC; 2007.
Responsible Opioid Prescribing: A Clinician’s Guide. 2nd edition, revised and expanded.
Fishman SM. Washington, DC: Waterford Life Sciences; 2012.
Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation.
Camilleri M, et al. Neurogastroenterol Motil. 2014;26(10):1386-1395.
Suggested Readings
Chronic opioid induced constipation in patients with nonmalignant pain: challenges and opportunities.
Nelson AD, Camilleri M. Ther Adv Gastroenterol. 2015;8(4):206-220
The impact of opioid-induced constipation among chronic pain patients with sufficient laxative use.
LoCasale RJ, et al. Int J Clin Pract. 2015;69(12):1448-1456
Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach.
Dorn S, et al. Am J Gastroenterol Suppl. 2014;2(1):31-37.
Opioid-induced constipation in patients with chronic noncancer pain in the USA, Canada, Germany, and the UK: descriptive analysis of baseline patient-reported outcomes and retrospective chart review.
Coyne KS, et al. Clinicoecon Outcomes Res. 2014;6:269-281.
Constipation in people prescribed opioids.
Ahmedzai SH, Boland J. BMJ Clin Evid (Online). 2010;pii:2407
The narcotic bowel syndrome: a recent update.
Drossman D, Szigethy E. Am J Gastroenterol Suppl. 2014;2(1):22-30
Opioids in chronic non-cancer pain: systematic review of efficacy and safety.
Kalso E, et al. Pain. 2004;112(3):372-380
A multi-institutional study analyzing effect of prophylactic medication for prevention of opioid-induced gastrointestinal dysfunction.
Ishihara M, et al. Clin J Pain. 2012;28(5):373-381.
A volunteer model for the comparison of laxatives in opioid-related constipation.
Sykes NP. J Pain Symptom Manage. 1996;11(6):363-369.
Establishing "best practices" for opioid rotation: conclusions of an expert panel.
Fine PG, et al. J Pain Symptom Manage. 2009;38(3):418-425
Naloxegol for opioid-induced constipation in patients with noncancer pain.
Chey WD, et al. N Engl J Med. 2014;370(25):2387-2396
Clinical evaluation of the efficacy of methylnaltrexone in resolving constipation induced by different opioid subtypes combined with laboratory analysis of immunomodulatory and antiangiogenic effects of methylnaltrexone.
Jamal MM, et al. Am J Gastroenterol. 2015;110(5):725-732.
A randomized, placebo-controlled trial of lubiprostone for opioid-induced constipation in chronic noncancer pain.
Neefjes ECW, et al. BMC Palliative Care. 2014;13:42.
Balancing opioid-induced gastrointestinal side effects with pain management: insights from the online community.
Whitman CB, et al. J Opioid Manag. 2015;11(5):383-391.
Consensus recommendations on initiating prescription therapies for opioid-induced constipation.
Argoff CE, et al. Pain Med. 2015;16(12):2324-2337.
Comparison of straining during defecation in three positions: results and implications for human health.
Sikirov D. Dig Dis Sci. 2003;48(7):1201-1205
Influence of body position on defecation in humans.
Sakakibara R, et al. Low Urin Tract Symptoms. 2010;2(1):16-21.
Interactive PresentationComprehensive Chronic Pain Management: A Focus on Patients With Opioid-Induced Constipation
Brooks D. Cash, MD; Jeffrey A. Gudin, MD; Bill H. McCarberg, MD, FABPM
A Focus on Patients With Opioid-Induced Constipation
Relevant Resources
Balancing the Benefits and Risk of Opioid-Based Therapy
Individualized Assessment and Mechanism-Based Multimodal Treatment
Responsible Opioid Prescribing to Achieve Individualized Functional Goals
Overcoming Pain and Gastrointestinal Distress to Improve Patient Outcomes
Proactive Diagnosis and Targeted Management
Selecting Patients and Optimizing Long-Term Outcomes
Evidence-Based Strategies for Improved Patient Outcomes
Proactive Diagnosis and Targeted Management
Differential Diagnosis and Comprehensive Management Strategies
Optimizing Maintenance Therapy Across Healthcare Settings
Evolving Strategies for Diagnosis and Long-Term Management
Consensus and Controversies for Responsible Opioid Prescribing
Best Practices in Combination Therapy
The Role of Nurses in Optimizing Long-term Outcomes
Evolving Approaches to Insulin Based Therapy
Evolving Best-Practice Strategies to Maximize Efficacy and Safety
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New Strategies for Insulin Replacement Therapy
Clinical Updates in LDL-C Management
Improving Comprehensive Patient Care
Identifying Patients and Tailoring Therapy
Collaborative Approaches to Guideline-Concordant Patient Care
New Strategies for Individualizing Long-term Care
Consensus and Controversies Across the Spectrum of Patient Presentations
Evolving Treatment Algorithms and Expert Perspectives on Biosimilars
Patient Selection, Treatment Initiation, and Ongoing Monitoring
Engaging With Patients About Opioid-Induced Constipation
Evolving Best Practices to Optimize Outcomes
The PCP’s Role in Timely Recognition and Referral
Debates and Discussions About Therapeutically Targeting Nerve Growth Factor Signaling
Differential Diagnosis, Multidisciplinary Management, and Patient Engagement
Key Issues Impacting OB/GYN Practice
Expanding the Conversation on Opioid-Induced Constipation
Volume II: Expanding Evidence for the Role of Rapid ART Initiation in HIV Practice
Translating Guidelines Into Patient Care
Improving Patient Outcomes Through Shared Clinical Decision Making
Mechanistic Insights and Evolving Treatment Options
Clinical Resource Center
A Case-Based Conversation on Managing Asthma and Chronic Rhinosinusitis With Nasal Polyposis
The Clinical and Utilization Benefits of Exacerbation Prevention
A PrEP Primer
A Foundation for Managed Care
Cardiovascular and Renal Outcomes With SGLT2 Inhibitors
Best Practices for Primary Care
New Paths to Chronic Pain Management
What the Pharmacist Needs to Know about PrEP
Unlocking Novel Paths to Patient Care
The Increasing Role of JAK Inhibitors
Preventing COPD Exacerbations to Improve Outcomes
A Whole Patient Case Series
Getting on the Fast Track to Identify AxSpA
Establishing Clinical Readiness Through Mentored Learning
Interdisciplinary Strategies for Adult and Pediatric Patients
Interdisciplinary Management of Eosinophilic Esophagitis and Hereditary Angioedema
Reducing LDL-C and a Lifetime of Cardiovascular Risk
Updates, Clinical Scenarios, and Future Directions
A Multidisciplinary Look at Early Diagnosis and Management
Best Practices for Diagnosis and Management
An Update on Best Practices
New Avenues to Pre-Exposure Prophylaxis
Are You Aware of New Blood-Based Multi-Cancer Screening Tools
A Look at the Changing HIV Playing Field
A “How To” Series Spanning Policy to Practice
Test Your Mastery!
Building Bridges to Reach People who Inject Drugs with the Goal of Employing PrEP for HIV Prevention
Strengthening Your Knowledge of Blood-Based Screening Tools
Bringing HIV Prevention to a New Level
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