Laxative co-medication and changes in defecation patterns during opioid use

Abstract

Introduction Opioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions. Objectives To describe the presence of laxative co-medication, the reasons for not starting laxatives and to evaluate changes in stool patterns of opioid initiators. Methods In this observational study community pharmacists evaluated the availability of laxative co-medication in starting opioid users and registered reasons for non-use. Two opioid initiators per pharmacy were invited to complete questionnaires (‘Bristol stool form scale’ and ‘Rome III Diagnostic Questionnaire for the Adult Functional Gastrointestinal Disorders’) on their defecation prior to and during opioid use. Descriptive statistics and Chi square tests were used to analyse reasons for non-use of laxatives and changes in defecation patterns. Results Eighty-one pharmacists collected data from 460 opioid initiators. Of those, 344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives was that either prescribers or patients did not consider them necessary. Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires completed were not constipated at opioid start. Eleven of them (16%) developed constipation during opioid use (Chi square p=0.003). At follow-up within laxative users 10.6% were constipated compared to 20.7% in subjects without laxatives. Conclusion One in four opioid starters did not dispose of laxative co-medication, mainly because they were not considered necessary by either the prescriber or the patient. The prevalence of constipation doubled during opioid use. A watchful waiting strategy for the use of laxative co-medication might include a monitoring of defecation patterns with validated questionnaires.

Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands

“…The level of adherence in this study is in line with or slightly higher than in older studies both in the Netherlands [ 14 , 15 ] and outside [ 17 – 19 ], while more recent studies tend to show higher levels of adherence [ 16 , 20 ] However, while these studies only looked at overall adherence, we investigated practice variation. Since the upper level of the range of adherence is 88%, an increase in the overall level of adherence seems achievable.…”

“…Especially since OIC carries a risk of hospitalisation [ 31 ]. The study by De Bruin et al [ 16 ] confirmed that patients are not always convinced they need laxatives when using opioids, further stressing the need for patient information.…”

“…A Dutch study among patients in a community pharmacy setting showed that in 2002 only 37% of patients who received an opioid also started taking laxatives within 5 days [ 14 ], whilst in 2012 another Dutch study showed that 54% of opioid users used a laxative [ 15 ]. In a more recent study among opioid initiators in the Netherlands, concomitant use of laxatives was found to be 74.8% [ 16 ]. Similar percentages have been reported in studies performed in the United States (55% [ 17 ] and 23% in patients with lung cancer [ 18 ]) and Switzerland (50% in noncancer and 67% in cancer populations) [ 19 ] Non-adherence to coprescribing of laxatives in opioid therapy remains an issue up to this day, as a recent study in palliative care has shown: one third of patients receiving opioids in the last year of their lives were not prescribed laxatives [ 20 ].…”

“…The main reason not to use laxatives in the recent Dutch study was that patients did not consider them necessary [ 16 ], but the underlying motivation for these perceptions remains unclear as well as the perceptions of prescribers. Non-adherence to guidelines by physicians may be caused by factors such as lack of agreement with guideline recommendations [ 21 , 22 ], lack of outcome expectancy or self-efficacy [ 23 ], external limitations (e.g.…”

Clinical audit to measure compliance with coprescription of laxative with Opioids for patients undergoing palliative care treatment: Results of process analysis

“…An observational study conducted in the Netherland identified that OIC was a major reason of unplanned hospital admissions, which is a preventable side effect. 5 Considering the situation of Pakistan where the availability hospital beds is quite challenging, and the patients access to treatment is also difficult. The physician should co-prescribe any form of laxative along with opioids.…”