Glossary
January 16, 2009 – Jennifer M. Gangloff
Breaking News from ASCO
June 09, 2006 – Staff Reports
House Call
June 09, 2006 – Jay Thomas, MD, PhD
Breast Cancer & MDS
January 09, 2009 – Elizabeth Whittington
Bookshelf
June 09, 2006 – Kathy LaTour
Web Exclusive: Follow-Up Care for Skin Cancer
June 09, 2006 – The National Cancer Institute
Weighing Prevention Versus Cost
June 09, 2006 – Melissa Knopper
Diagnosing Skin Cancer
June 09, 2006 – Susan R. Peck, PhD
Sharing a Lifetime
June 09, 2006
Sunburn Reasons & Remedies
June 09, 2006 – Monica Zangwill, MD
Inherited Syndromes Link Cancers
June 09, 2006 – Elizabeth Whittington
Future Risk for Survivors
June 09, 2006 – Rabiya S. Tuma, PhD
Nature's Spoils
June 09, 2006 – Elizabeth Whittington
The Discovery of Taxol
June 09, 2006 – Frank Stephenson
Melanoma: The Other Skin Cancer
June 09, 2006 – Elizabeth Whittington
Picture Not Perfect
June 09, 2006 – Elizabeth Whittington
Science of Suncreen
June 09, 2006 – Elizabeth Whittington
Planning for Death
June 09, 2006 – Elizabeth Whittington
Does Heaven Exist?
June 09, 2006 – Jo Cavallo
To Be or Not To Be: Is That the Right Question?
June 09, 2006 – Harvey Max Chochinov, MD PhD
Is It Time to Change the Design of Clinical Trials?
June 09, 2006 – Alice McCarthy
Drink Up
June 09, 2006 – Elizabeth Whittington
A Life Well-Lived
June 09, 2006 – Deborah Lang Hampton
Web Exclusive: Caregivers Often Neglect Their Mental Health
June 09, 2006 – The American Cancer Society
Letters from Our Readers
June 09, 2006
Message from the Editor-at-Large
June 09, 2006 – Kathy LaTour
Choosing a Counselor
June 09, 2006 – Elizabeth Whittington
Tips for Preventing Infection
June 09, 2006 – Elizabeth Whittington
Cancer as a Legacy
June 09, 2006 – Kathy LaTour
Fighting Cancer Together
June 09, 2006 – Elizabeth Whittington
Running on Empty
June 09, 2006 – Melissa Knopper
The Blame Game
June 09, 2006 – Kathy LaTour
People & Places
June 09, 2006 – Elizabeth Whittington
A Beautiful Day: The Story of a Son's Loss
June 09, 2006 – Kevin Cropp
Surf & Turf
June 09, 2006 – Jennifer M. Gangloff
Nonmelanoma Skin Cancer: Saving Your Skin
June 09, 2006 – Monica Zangwill, MD
Confronting Death
June 09, 2006 – Jo Cavallo
Glossary
January 16, 2009 – Jennifer M. Gangloff
Breaking News from ASCO
June 09, 2006 – Staff Reports
Currently Viewing
House Call
June 09, 2006 – Jay Thomas, MD, PhD
Bookshelf
June 09, 2006 – Kathy LaTour
Web Exclusive: Follow-Up Care for Skin Cancer
June 09, 2006 – The National Cancer Institute
Weighing Prevention Versus Cost
June 09, 2006 – Melissa Knopper
Diagnosing Skin Cancer
June 09, 2006 – Susan R. Peck, PhD
Sharing a Lifetime
June 09, 2006
Sunburn Reasons & Remedies
June 09, 2006 – Monica Zangwill, MD
Inherited Syndromes Link Cancers
June 09, 2006 – Elizabeth Whittington
Future Risk for Survivors
June 09, 2006 – Rabiya S. Tuma, PhD
Nature's Spoils
June 09, 2006 – Elizabeth Whittington
The Discovery of Taxol
June 09, 2006 – Frank Stephenson
Melanoma: The Other Skin Cancer
June 09, 2006 – Elizabeth Whittington
Picture Not Perfect
June 09, 2006 – Elizabeth Whittington
Science of Suncreen
June 09, 2006 – Elizabeth Whittington
Planning for Death
June 09, 2006 – Elizabeth Whittington
Does Heaven Exist?
June 09, 2006 – Jo Cavallo
To Be or Not To Be: Is That the Right Question?
June 09, 2006 – Harvey Max Chochinov, MD PhD
Is It Time to Change the Design of Clinical Trials?
June 09, 2006 – Alice McCarthy
Drink Up
June 09, 2006 – Elizabeth Whittington
A Life Well-Lived
June 09, 2006 – Deborah Lang Hampton
Web Exclusive: Caregivers Often Neglect Their Mental Health
June 09, 2006 – The American Cancer Society
Letters from Our Readers
June 09, 2006
Message from the Editor-at-Large
June 09, 2006 – Kathy LaTour
Choosing a Counselor
June 09, 2006 – Elizabeth Whittington
Tips for Preventing Infection
June 09, 2006 – Elizabeth Whittington
Cancer as a Legacy
June 09, 2006 – Kathy LaTour
Fighting Cancer Together
June 09, 2006 – Elizabeth Whittington
Running on Empty
June 09, 2006 – Melissa Knopper
The Blame Game
June 09, 2006 – Kathy LaTour
People & Places
June 09, 2006 – Elizabeth Whittington
A Beautiful Day: The Story of a Son's Loss
June 09, 2006 – Kevin Cropp
Surf & Turf
June 09, 2006 – Jennifer M. Gangloff
Nonmelanoma Skin Cancer: Saving Your Skin
June 09, 2006 – Monica Zangwill, MD
Confronting Death
June 09, 2006 – Jo Cavallo

House Call

Dr. Jay Thomas discusses solutions to opioid-induced constipation. 

BY Jay Thomas, MD, PhD
PUBLISHED June 09, 2006

Question: How do you treat constipation caused by pain-relieving opioid use?

Answer: Opioids are commonly used to treat cancer-related pain, which is experienced by nearly 90 percent of patients. These drugs, which include morphine, hydrocodone (Vicodin, Lortab) and oxycodone (Percocet, OxyContin), bind to receptors in the brain and spinal cord to bring relief. But they also bind to receptors in the gut, which can lead to constipation in about half of patients.  

While the human body can adjust to many opioid-induced side effects, such as nausea, the body never becomes tolerant to the constipating effects of the opioids. Opioids disrupt the normal contractions of the bowel, resulting in stool staying in the body longer and becoming harder and dryer as the body absorbs water out of the stool.

Because constipation can be reliably predicted when using opioids on a continuous basis, a bowel regimen should start at the same time as opioid use. Typically, two medications are given: a stimulant, such as Senokot (senna), which increases the contractions of the bowel, and a stool softener, such as Colace (docusate), a pill that breaks up the fat content in stool so water can more effectively penetrate it. If constipation remains despite these medications at reasonable doses, lactulose is often added. Lactulose works by using the physical property of osmosis to pull water into the intestines. The goal of these interventions is to keep the intestines contracting and to soften the stool.

If constipation is present before starting opioids, there may be an impaction or a dam caused by hard, dry stool. In this case, rectal interventions, such as enemas and suppositories like Dulcolax (bisacodyl), are often needed in conjunction with the above oral medications to break the dam.

The goal would be to specifically reverse the negative effects of the opioids on the intestines without reversing the beneficial effects on pain, and the good news is that new agents, such as methylnaltrexone, are doing exactly that. Methylnaltrexone is a novel drug in development that can’t cross the barrier that separates the brain and the spinal cord from the rest of the body. Its unique chemical structure allows the drug to knock the opioids off the intestines without affecting the pain control in the central nervous system. A recent study looked at patients with advanced medical illness who had opioid-induced constipation. About 60 percent of the patients who received methylnaltrexone had a bowel movement within about one hour. The average time to a bowel movement for patients taking a placebo was more than 24 hours. Although some patients experienced nausea and dizziness, no patient had signs of increased pain or opioid withdrawal.

Studies with oral forms of methylnaltrexone and a similar agent called Entereg (alvimopan) are under way. Thus, together with current medications, these new agents may help doctors not only treat but prevent opioid-induced constipation in cancer patients and prevent the immense suffering that is associated with it.

—Jay Thomas, MD, PhD, is an associate clinical professor of medicine in the Cancer Symptom Control Program at the University of California, San Diego.

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