Opioid induced constipation (OIC)

Effect of opioids on the gut

Opioids have a range of effects throughout the gut1,2
SITE PHARMACOLOGICAL ACTION CLINICAL EFFECT
Stomach Decreased gastric motility
Decreased pyloric tone
Anorexia
Nausea and vomiting
Small intestine Reduced propulsion
Increased fluid absorption
Decreased pancreatic and biliary secretion
Delayed absorption of medications
Hard, dry stool
Delayed digestion
Large intestine Increased non-propulsive contractions
Increased fluid absorption
Increased anal sphincter tone
Spasm, abdominal cramps, pain
Hard, dry stool
Incomplete evacuation


CNS3
BRAIN AND SPINAL CORD

Clinical Effect:
Provides analgesia

Side Effects:
Sedation
Respiratory depression
Nausea/vomiting


GI TRACT WITH MYENTERIC AND SUBMUCOSAL PLEXUS1,2

Clinical Effect:
Slows GI propulsion
Reduces intestinal secretion

Side Effects:
Constipation


CNS3
BRAIN AND SPINAL CORD

Clinical Effect:
Provides analgesia

Side Effects:
Sedation
Respiratory depression
Nausea/vomiting


GI TRACT WITH MYENTERIC AND SUBMUCOSAL PLEXUS1,2

Clinical Effect:
Slows GI propulsion
Reduces intestinal secretion

Side Effects:
Constipation

DEFINITION OF OIC

New or worsening symptoms of constipation when initiating, changing, or increasing opioid therapy that must include 2 or more of the following:4
  • Straining during more than one-fourth (25%) of defecations
  • Lumpy or hard stools (BSFS 1-2) more than one-fourth (25%) of defecations
  • Sensation of incomplete evacuation more than one-fourth (25%) of defecations
  • Sensation of anorectal obstruction/blockage more than one-fourth (25%) of defecations
  • Manual manoeuvres to facilitate more than one-fourth (25%) of defecations
  • Fewer than 3 spontaneous bowel movements per week

To find out more about OIC and its impact on patients, visit the OIC eLearning module

Differential diagnosis of oic

OIC is mechanistically distinct from functional constipation, so requires treatment with appropriate agents
OIC5 FUNCTIONAL CONSTIPATION6
Mechanism Persistent activation of colonic mu-receptors Diminished intestinal motility or mechanical, physiologic or congenital inability to propagate the stool out of the rectum
Causes Opioid treatment
  • Medications: antacids, iron and calcium supplements, anticholinergics, calcium channel blockers, diuretics, NSAIDs, tricyclic antidepressants
  • Mechanical: cancer, stricture, rectocele, rectal prolapse, megacolon, anal fissure
  • Metabolic: diabetes mellitus, hypothyroidism, hyperparathyroidism, hypercalcemia, hypokalaemia, uraemia, depression
  • Neuropathies: Hirschsprung’s disease, Parkinson’s disease, injury to nerves, paraplegia, multiple sclerosis
  • Myopathies: scleroderma, amyloidosis
Treatment Specific blockade of mu-opioid receptor stimulation in the gastrointestinal tract Dietary changes: increased fluid and fibre intake; exercise; stool softeners; various laxatives

BSFS = Bristol Stool Form Scale

References: 1. Kurz A. Opioid-induced bowel dysfunction: pathophysiology and potential new therapies. Drugs. 2003;63(7):649-671 2. Nelson A, Camilleri M. Chronic opioid induced constipation in patients with nonmalignant pain: challenges and opportunities. Therapeutic Advances in Gastroenterology. 2015;8(4):206-220. 3. Holzer P. Pharmacology of Opioids and their Effects on Gastrointestinal Function. The American Journal of Gastroenterology Supplements. 2014;2(1):9-16. 4. Simren M, Palsson O, Whitehead W. Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Current Gastroenterology Reports. 2017;19(4). 5. Camilleri M, Drossman D, Becker G, et al. Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation. Neurogastroenterology & Motility. 2014;26(10):1386-1395. 6. Alame A, Bahna H. Evaluation of Constipation. Clinics in Colon and Rectal Surgery. 2012;25(01):005-011.

KKI/UKIRE/MOV/0153 01/20     This website is intended for UK and IRE healthcare professionals and is provided as a service to medicine by Kyowa Kirin
KKI/UKIRE/MOV/0153 01/20
This website is intended for UK and IRE healthcare professionals and is provided as a service to medicine by Kyowa Kirin