The ‘Mystery’ of Opioid‐Induced Diarrhea

Bril, Silviu; Shoham, Yoav; Marcus, J. Schultz

doi:10.1155/2011/309685

Cited by 8 publications

(5 citation statements)

References 25 publications

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“…monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, or serotonin and norepinephrine [ 32 , 68 , 69 , 75 – 78 ] 5 (4, 6) 7 13 4 Neutral (0.539) 4 (3, 5) 6 11 2 Neutral (0.479) $ 10 Acute or persistent co-prescription of opioid analgesics with a benzodiazepine [ 79 – 83 ] 4 (2, 5) 12 10 2 A/IA (0.461) 3 (2, 3) 14 4 1 A/IA (0.330) # 11 Acute or persistent co-prescription of opioid analgesics with a gabapentinoid, i.e. gabapentin or pregabalin [ 84 – 87 ] 5 (3, 5) 11 10 3 Neutral (0.564) 4 (3, 4) 9 10 0 Neutral (0.440) # 12 Acute or persistent prescription of opioid analgesics to a patient with galactose intolerance, lactase deficiency, or glucose-galactose malabsorption [ 88 , 89 ] 5 (5, 6) 5 13 6 Neutral (0.549) 5 (3, 5) 6 13 0 …”

Section: Resultsmentioning

confidence: 99%

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi study

Bansal,

Campbell,

Lin

et al. 2024

BMC Med

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Background Long-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care. Methods Scenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1–9 scale from inappropriate to appropriate. The score’s median, 30th and 70th percentiles, and disagreement index were calculated. Results The panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery. Conclusions The high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.

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Section: Resultsmentioning

confidence: 99%

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi study

Bansal,

Campbell,

Lin

et al. 2024

BMC Med

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“…Constipation can result in overflow diarrhea where liquid stool passes around the obstruction. Thus, diarrhea-related symptoms (including urgency, loose bowel movements and frequent bowel movements) have also frequently been reported in opioid-treated patients [Bril et al 2011; Wojciech, 2012].…”

Section: Prevalence Of Opioid-induced Bowel Dysfunctionmentioning

confidence: 99%

Evolving paradigms in the treatment of opioid-induced bowel dysfunction

Poulsen

Brock

Olesen

et al. 2015

Therap Adv Gastroenterol

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Abstract:In recent years prescription of opioids has increased significantly. Although effective in pain management, bothersome gastrointestinal adverse effects are experienced by a substantial proportion of opioid-treated patients. This can lead to difficulties with therapy and subsequently inadequate pain relief. Collectively referred to as opioid-induced bowel dysfunction, these adverse effects are the result of binding of exogenous opioids to opioid receptors in the gastrointestinal tract. This leads to disturbance of three important gastrointestinal functions: motility, coordination of sphincter function and secretion. In the clinic this manifests in a wide range of symptoms such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation, although the most known adverse effect is opioid-induced constipation. Traditional treatment with laxatives is often insufficient, but in recent years a number of novel pharmacological approaches have been introduced. In this review the pathophysiology, symptomatology and prevalence of opioid-induced bowel dysfunction is presented along with the benefits and caveats of a suggested consensus definition for opioid-induced constipation. Finally, traditional treatment is appraised and compared with the latest pharmacological developments. In conclusion, opioid antagonists restricted to the periphery show promising results, but use of different definitions and outcome measures complicate comparison. However, an international working group has recently suggested a consensus definition for opioid-induced constipation and relevant outcome measures have also been proposed. If investigators within this field adapt the suggested consensus and include symptoms related to dysfunction of the upper gut, it will ease comparison and be a step forward in future research.

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“…These numbers should be seen in light of the prevalence of chronic constipation in the general population, which has been estimated to affect – depending on the definition used – between 2% and 27% of the adult population with an average around 15% 21–23. However, conflicting clinical scenarios have also been reported where diarrhea-related symptoms (including urgency, loose bowel movements, and frequent bowel movements) appeared to be increased in patients treated with opioids, most likely a result of overflow diarrhea 24. Of note, constipation is often defined as the number of spontaneous bowel movements (SBMs), and in fact this is only ranked number five in patients suffering from constipation, where symptoms such as straining and gas are far more prevalent.…”

Section: Symptoms and Prevalence Of Oibdmentioning

confidence: 99%

“… 21 – 23 However, conflicting clinical scenarios have also been reported where diarrhea-related symptoms (including urgency, loose bowel movements, and frequent bowel movements) appeared to be increased in patients treated with opioids, most likely a result of overflow diarrhea. 24 Of note, constipation is often defined as the number of spontaneous bowel movements (SBMs), and in fact this is only ranked number five in patients suffering from constipation, where symptoms such as straining and gas are far more prevalent. This strongly emphasizes the limitations of subjective clinical symptoms such as constipation in clinical trials.…”

Section: Symptoms and Prevalence Of Oibdmentioning

confidence: 99%

Clinical potential of naloxegol in the management of opioid-induced bowel dysfunction

Poulsen¹,

Brock²,

Olesen³

et al. 2014

CEG

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Opioid-induced bowel dysfunction (OIBD) is a burdensome condition which limits the therapeutic benefit of analgesia. It affects the entire gastrointestinal tract, predominantly by activating opioid receptors in the enteric nervous system, resulting in a wide range of symptoms, such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation. The majority of studies evaluating OIBD focus on constipation experienced in approximately 60% of patients. Nevertheless, other presentations of OIBD seem to be equally frequent. Furthermore, laxative treatment is often insufficient, which in many patients results in decreased quality of life and discontinuation of opioid treatment. Novel mechanism-based pharmacological approaches targeting the gastrointestinal opioid receptors have been marketed recently and even more are in the pipeline. One strategy is prolonged release formulation of the opioid antagonist naloxone (which has limited systemic absorption) and oxycodone in a combined tablet. Another approach is peripherally acting, μ-opioid receptor antagonists (PAMORAs) that selectively target μ-opioid receptors in the gastrointestinal tract. However, in Europe the only PAMORA approved for OIBD is the subcutaneously administered methylnaltrexone. Alvimopan is an oral PAMORA, but only approved in the US for postoperative ileus in hospitalized patients. Finally, naloxegol is a novel, oral PAMORA expected to be approved soon. In this review, the prevalence and pathophysiology of OIBD is presented. As PAMORAs seem to be a promising approach, their potential effect is reviewed with special focus on naloxegol’s pharmacological properties, data on safety, efficacy, and patient-focused perspectives. In conclusion, as naloxegol is administered orally once daily, has proven efficacious compared to placebo, has an acceptable safety profile, and can be used as add-on to existing pain treatment, it is a welcoming addition to the targeted treatment possibilities for OIBD.

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The ‘Mystery’ of Opioid‐Induced Diarrhea

Cited by 8 publications

References 25 publications

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi study

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi study

Evolving paradigms in the treatment of opioid-induced bowel dysfunction

Clinical potential of naloxegol in the management of opioid-induced bowel dysfunction

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