Advances in the Management of Opioid-Induced Constipation Restoring Balance

Jeffrey Gudin, MD; Anthony Lembo, MD; Bill McCarberg, MD

This activity is jointly sponsored by Global Education Group and Integritas Communications.

This activity is supported by an educational grant from AstraZeneca.


Jeffrey A. Gudin, MD
Pain Management and Wellness Center
Englewood Hospital and Medical Center
Englewood, New Jersey

Anthony J. Lembo, MD
Associate Professor of Medicine
Harvard Medical School
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Bill H. McCarberg, MD
Adjunct Assistant Clinical Professor
University of California, San Diego
Founder, Chronic Pain Management Program
Kaiser Permanente San Diego
Family Practitioner
Neighborhood Health
San Diego, California

Target Audience

The educational design of this activity addresses the needs of physicians and other healthcare providers involved in the treatment of patients with opioid-induced constipation (OIC).

Statement of Need/Program Overview

As many as 100 million adults in the United States suffer from chronic pain.1 Among the multitude of available treatment modalities, opioids are generally regarded as the cornerstone for cancer pain treatment and palliative care, and have gained increasing acceptance as an important therapeutic option for carefully selected patients with chronic noncancer pain.2,3 Yet the side effects of opioid therapy often create significant barriers to good patient outcomes.4,5 Constipation is the most common opioid-related adverse effect, affecting up to 50% of patients on long-term therapy.6-10 OIC is especially burdensome because—unlike for many other adverse effects of opioids—patients do not develop tolerance to treatment-related reductions in bowel motility and increases in gastrointestinal fluid absorption.5 Thus, clinicians who manage patients on opioid therapy must be prepared to integrate approaches that target adequate analgesia and reduce risks of aberrant prescription drug use with efforts to proactively consider and appropriately manage opioid-related side effects—most notably constipation. During this program, expert faculty will provide practical insights into structured evaluation of bowel habits, prophylactic bowel regimens, and newer pharmacologic approaches that antagonize opioid receptor activation in the gastrointestinal tract.


  1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011. Accessed September 2014.
  2. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
  3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. 2010;2010. Accessed August 2014.
  4. Daniell HW. Opioid-induced androgen deficiency discussion in opioid contracts. Am J Med. 2007;120(9):e21.
  5. McNicol E, Horowicz-Mehler N, Fisk RA, et al. Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain. 2003;4(5):231-256.
  6. Bell TJ, Panchal SJ, Miaskowski C, et al. The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1). Pain Med. 2009;10(1):35-42.
  7. Cook SF, Lanza L, Zhou X, et al. Gastrointestinal side effects in chronic opioid users: results from a population-based survey. Aliment Pharmacol Ther. 2008;27(12):1224-1232.
  8. Panchal SJ, Muller-Schwefe P, Wurzelmann JI. Opioid-induced bowel dysfunction: prevalence, pathophysiology and burden. Int J Clin Pract. 2007;61(7):1181-1187.
  9. Villars P, Dodd M, West C, et al. Differences in the prevalence and severity of side effects based on type of analgesic prescription in patients with chronic cancer pain. J Pain Symptom Manage. 2007;33(1):67-77.
  10. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11(suppl 2):S105-S120.

Educational Objectives

After completing this activity, the participant should be better able to:

  • Discuss the fundamentals of opioid pharmacology with an emphasis on clinical effects of opioid receptor activation in the gastrointestinal tract
  • Proactively implement plans to address OIC in patients who have been selected for long-term opioid therapy
  • Longitudinally assess opioid-treated patients for problematic bowel function
  • Describe the clinical profiles of current and emerging opioid receptor antagonists for the management of OIC
  • Individualize multimodal bowel regimens based on the degree of symptoms, treatment responses, and patient preferences
  • Counsel patients who have been selected for chronic opioid therapy about the risks of OIC, dietary recommendations, and potential benefits and drawbacks of various treatment approaches

Term of Offering

This activity was released on December 15, 2015 and is valid for 1 year. Requests for credit must be made no later than December 15, 2015.

Physician Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Global Education Group (Global) and Integritas Communications, LLC. Global is accredited by the ACCME to provide continuing medical education for physicians.

Physician Credit Designation

Global Education Group designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Global Contact Information

For information about the accreditation of this program, please contact Global at 303-395-1782 or

Instructions for Obtaining Credit

In order to receive credit, participants must complete the preactivity questionnaire, view the activity, and complete the posttest and evaluation form. Participants must also score at least 75% on the posttest.

Fee Information & Refund/Cancellation Policy

There is no fee for this educational activity.

Disclosure of Conflicts of Interest

Global Education Group (Global) requires instructors, planners, managers, and other individuals and their spouses/life partners who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity:

Jeffrey Gudin, MD: Consultant/Independent Contractor to Nektar Therapeutics and Speakers Bureau for AstraZeneca plc and Salix Pharmaceuticals, Inc.

Anthony Lembo, MD: Consultant/Independent Contractor to AstraZeneca plc, GlaxoSmithKline, Ironwood Pharmaceuticals, Inc., Prometheus Laboratories Inc., and Salix Pharmaceuticals, Inc. Grant/Research Support from Prometheus Laboratories Inc. 

Bill McCarberg, MD: Consultant/Independent Contractor to AstraZeneca plc, Collegium Pharmaceutical, Inc., Depomed, Inc., Inspirion Pharmaceuticals, LLC, Iroko Pharmaceuticals, LLC, Janssen Pharmaceuticals, Inc.,  Kaléo, Inc., Mallinckrodt Pharmaceuticals, Inc., Millennium Pharmaceuticals, Inc., Pfizer Inc., Salix Pharmaceuticals, Inc., Takeda Pharmaceuticals U.S.A., Inc., and Zogenix, Inc. Stockholder of Biospecifics Technologies Corp., Galena Biopharma, Inc., Johnson & Johnson, Nektar Therapeutics, Protein Design Labs, Inc.

The planners and managers reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity: 

Ashley Marostica, RN, MSN: Nothing to disclose
Amanda Glazer, PhD: Nothing to disclose
Andrea Funk: Nothing to disclose
Rose O'Connor, PhD: Nothing to disclose

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global Education Group (Global) and Integritas Communications, LLC, do not recommend the use of any agent outside of the labeled indications. 

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.


Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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expiration 12/15/2015

type Webcast