Opioid-Induced Constipation

September 17, 2015 Marquis Ballroom B Atlanta Marriott Marquis Atlanta, Georgia

This activity is supported by an educational grant from AstraZeneca.

CME/MEDICAL COMMUNICATIONS INQUIRIES info@integritasgrp.com integritasgrp.com

FACULTY FACULTY

CHARLES E. Argoff, MD Professor of Neurology Albany Medical College Director, Comprehensive Pain Center Albany Medical Center Albany, New York

Dr. Charles E. Argoff is Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in New York. He is a member of the American Academy of Neurology, the International Association for the Study of Pain, the American Academy of Pain Medicine, and the American Pain Society, among other professional organizations.

Dr. Argoff is one of the editors of the recently published textbook, Raj’s Practical Management of Pain, Fourth Edition. Coauthor of Defeat Chronic Pain Now, a recently published book for people with chronic pain, he has also recently released the third edition of Pain Management Secrets.

Dr. Argoff received his medical degree from Northwestern University Medical School in Chicago, Illinois. He completed his medical internship in internal medicine and residency in neurology at Stony Brook University in New York and a fellowship in neurology at the National Institutes of Health in Bethesda, Maryland.

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FACULTY

PATRICIA M. Bruckenthal, PhD, APRN-BC, ANP, FAAN Chair and Clinical Associate Professor Department of Graduate Nursing Education Stony Brook University School of Nursing Stony Brook, New York

Dr. Patricia M. Bruckenthal is an Associate Professor in the Stony Brook University School of Nursing and has worked as a nurse practitioner in pain management for over 20 years. She received her undergraduate and graduate nursing degrees at Stony Brook and her PhD at the UMass, Amherst. Her post doctorate traineeship was completed at the Applied Behavioral Medicine Research Institute at Stony Brook University.

Dr. Bruckenthal has presented at numerous national conferences on pain management issues and is a member of several clinical and research nursing societies. She is the immediate past president of the American Association for Pain Management Nurses. She also serves as a member of the ethics committee for the American Pain Society, a member of the State Pain Policy Advocacy Network Leadership Advisory Council, and a member of the American Academy of Pain Medicine Foundation Board. She is on the editorial board of Pain Management Nursing and has authored numerous peer-reviewed publications.

Dr. Bruckenthal’s research focuses on self-management of chronic pain and pain assessment and management in older adults. She was a coinvestigator on a multisite clinical trial, funded by the National Institutes of Health and completed in 2013, of Pain Coping Skills Training (PCST) for patients with chronic osteoarthritis pain. This trial demonstrated the effectiveness of PCST treatment delivery by nurse practitioners and constituted a major advance for improving access to this option for pain management.

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ANTHONY J. Lembo, MD FACULTY

Associate Professor of Medicine Director, GI Motility Laboratory Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts

Dr. Anthony J. Lembo is an Associate Professor of Medicine at Harvard Medical School. He also serves as the Director of the GI Motility Laboratory at the Beth Israel Deaconess Medical Center (BIDMC) Division of Gastroenterology in Boston, Massachusetts.

Dr. Lembo earned his undergraduate degree in Mathematics at Amherst College in Amherst, Massachusetts, and then received his medical degree from Tufts Medical School in Boston, Massachusetts. He subsequently completed his Internal Medicine Internship/Residency as well as Gastroenterology Fellowship at UCLA Medical Center in Los Angeles, California. After completing his Fellowship, he joined the faculty at UCLA Medical Center where he was Co-Director of the FBD [functional bowel disorders] and GI [gastrointestinal] Motility Center. In 1997 he joined the faculty at Beth Israel Deaconess Medical Center.

His research has focused on functional bowel disorders such as irritable bowel syndrome, chronic constipation, and dyspepsia. His research interests also include the role of placebo in functional bowel disorders.

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PREAMBLE

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 the cornerstone for cancer pain treatment and palliative care, and they have gained increasing acceptance as an important therapeutic option for carefully selected patients with chronic noncancer pain.2,3 Yet, opioid side effects 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 Opioid-induced constipation is especially burdensome because—unlike 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 Clinicians must proactively consider and appropriately manage opioid-related side effects—most notably, constipation. By pre-emptively explaining the risk for opioid-induced constipation, clinicians can prepare patients to discuss changes in their bowel habits and adopt prophylactic or additional management strategies that can ease this burdensome side effect. During this Interactive Exchange™ program, expert faculty will provide practical insights into structured evaluations of bowel habits, prophylactic bowel regimens, and newer pharmacologic approaches that antagonize opioid receptor activation in the gastrointestinal tract, thereby targeting the underlying cause of opioid-induced constipation.

REFERENCES 1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011. http://www.iom.edu/Reports/2011/Relieving-Painin-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx.

Accessed March 2015.

2. Chou R, Fanciullo GJ, Fine PG, et al. J Pain. 2009;10(2):113-130.

3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. 2010;2010. http://www.nccn.org/professionals/ physician_gls/f_guidelines.asp. Accessed March 2015.

4. Daniell HW. Am J Med. 2007;120(9):e21.

5. McNicol E, Horowicz-Mehler N, Fisk RA, et al. J Pain. 2003;4(5):231-256.

6. Bell TJ, Panchal SJ, Miaskowski C, et al. Pain Med. 2009;10(1):35-42.

7. Cook SF, Lanza L, Zhou X, et al. Aliment Pharmacol Ther. 2008;27(12):1224-1232.

8. Panchal SJ, Muller-Schwefe P, Wurzelmann JI. Int J Clin Pract. 2007;61(7):1181-1187.

9. Villars P, Dodd M, West C, et al. J Pain Symptom Manage. 2007;33(1):67-77.

10. Benyamin R, Trescot AM, Datta S, et al. Pain Physician. 2008;11(suppl 2):S105-S120.

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TARGET AUDIENCE The educational design of this activity addresses the needs of nurses and other health care providers involved in the treatment of patients with opioidinduced constipation (OIC).

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

PREAMBLE

• Evaluate baseline bowel habits, risk factors for OIC development, and ongoing changes in bowel function in patients on long-term opioid therapy • Implement a prophylactic treatment plan to address OIC concurrent with the initiation of opioid therapy • Analyze current pharmacotherapies for OIC based on mechanisms of action and data on efficacy and safety • Tailor treatment regimens for patients experiencing OIC according to symptom severity, past treatment responses, and patient preferences • Collaborate with PCPs and other providers to ensure that opioid-treated patients are routinely assessed for changes in bowel habits

ACCREDITATION Greater Kansas City Chapter of the American Society for Pain Management Nursing is approved as a provider of continuing nursing education by the Kansas State Board of Nursing. This course offering has been submitted for approval for nursing contact hours applicable for RN, LPN, and LMHT relicensure.

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Bristol Stool Form Scale Bristol Stool Description

Form Scale

Image

Bristol Stool Description

Form Scale

Image

Bristol Stool Form Scale

Bristol Stool Form Scale CLINICAL ASSESSMENT TOOLS Description

Description Separate hard lumps, like nuts

Bristol Stool Form Scale

Description Separate hard lumps, like nuts

Bristol StoolStool Form Scale Bristol Form Scale Description

Separate hard hard lumps, lumps, like like nuts nuts Separate

Description Separate hard lumps, like nuts Sausage-shaped but lumpy

Type

Description

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smooth and soft

Like a sausage or snake, smooth and soft

Soft blobs blobs with with clear-cut clear-cut edges edges Soft

Like a sausage or snake, smooth and soft Soft blobs with 5 clear-cut edges Soft blobs with clear-cut edges

Fluffy pieces with ragged edges edges, a mushy stool Soft blobs with clear-cut

Fluffy pieces with ragged edges, a mushy stool

Fluffy pieces with 6 ragged edges, a mushy stool

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withWatery, permission Lewis SJ, Heaton KW, Scandinavian Journal of Gastroenterology, 1997; 32(9):920–924. nofrom solid pieces »» http://bowelcontrol.nih.gov/Bristol_Stool_Form_Scale_508.pdf Healthcare.

Heaton KW. ScandaJ Gastroenterol.

1997;32(9):920–924.

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nofrom solid pieces withWatery, permission Lewis SJ, Heaton KW, Scandinavian Journal of Gastroenterology, 1997; 32(9):920–924.

Healthcare.

nofrom solid pieces d withWatery, permission Lewis SJ, CME Heaton KW, Scandinavian Journal of Gastroenterology, 1997; 32(9):920–924.

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RESOURCE CENTER

Like a sausage or snake, smooth and soft Soft blobs with clear-cut edges

CLINICAL ASSESSMENT TOOLS Bowel Function Index Please answer the following three questions by making a mark on the line between 0 and 100. Please transfer the results to the open squares at the bottom of the page. Add the three results and divide by three.

Question 1 (Q1) How would you rate the ease of defecation during the last 7 days according to patient assessment?

0=Easy/no difficulty

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100=Severe difficulty

Question 2 (Q2) Does your patient feel that his/her bowel evacuation has been incomplete during the last 7 days?

0=Not at all

50

100=Very strongly

Question 3 (Q3) How would you judge your patient’s constipation throughout the last 7 days?

RESOURCE CENTER

0=No constipation at all

50

100=Very heavily constipated

Results Q1

Q2

+

Q3

+

Sum

=

Adapted from Rentz AM, et al. J Med Econ. 2009;12(0):371-383.

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Total

/3=

CLINICAL ASSESSMENT TOOLS »» 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. www.proqolid.org/content/download/11747/176511/version/2/ file/PAC-SYM12_2.1_eng-US_review+copy.pdf

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. www.theacpa.org/uploads/ACPA-Opioid_Constipation_Chart-V4.pdf

»» Patient Education Handout This leaflet provides patients with approaches to mitigate opioidinduced constipation and includes a list of questions about constipation for patients to ask their doctors or clinics. www.acponline.org/patients_families/products/health_tips/oic_en.pdf

PRACTICE GUIDELINES »» The Functional Gastrointestinal Disorders and the Rome III Process, 2006.

Drossman DA. Gastroenterology. 2006;130(5):1377-1390. www.ncbi.nlm.nih.gov/pubmed/16678553

RESOURCE CENTER

»» 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. www.ncbi.nlm.nih.gov pubmed/?term=Chou+R%2C+et+al.+Pain.+2009%3B10(2)% 3A113-130

»» VA/DoD Clinical Practice Guideline: Management of Opioid Therapy for Chronic Pain, 2010.

Department of Veterans Affairs, Department of Defense. www.healthquality.va.gov/guidelines/Pain/cot/COT_312_Full-er.pdf

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OTHER RESOURCES »» A Clinical Guide to Opioid Analgesia. 2nd edition.

Fine PG, Portenoy RK. New York, NY: Vendome Group, LLC; 2007. www.amazon.com/A-Clinical-Guide-Opioid-Analgesia/dp/1933692626#

»» Responsible Opioid Prescribing: A Clinician’s Guide. 2nd edition, revised and expanded.

Fishman SM. Washington, DC: Waterford Life Sciences; 2012. library.fsmb.org/cme/index.html

SUGGESTED READING »» Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach.

Dorn S, et al. Am J Gastroenterol. 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. 2014;2(1):22-30.

RESOURCE CENTER

»» 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.

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»» 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.

»» A randomized study of lubiprostone for opioid-induced constipation in patients with chronic noncancer pain.

Cryer B, et al. Pain Med. 2014; 15(11):1825-1834.

»» 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.

Neefjes ECW, et al. BMC Palliative Care. 2014;13:42.

»» Patient preference with respect to QoL and reduction in opioid-induced constipation after treatment with prolonged-release oxycodone/naloxone compared with previous analgesic therapy [PREFER study].

RESOURCE CENTER

van Dongen VCPC, et al. Int J Clin Pract. 2014;68(11):1364-1375.

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NOTES

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