Cancer patients who receive opioid therapy for the management of persistent pain commonly experience opioid-induced bowel dysfunction. Constipation is one of the most frequent manifestations. Other symptoms include nausea, bloating, and reflux. According to studies, the prevalence of opioid-induced constipation (OIC) among people with advanced cancer varies from 25% to 90%.
“OIC is a complex and potentially serious problem,” says Lara K. Dhingra, PhD. “In addition to the physical effects from both OIC and the treatments used to manage it, OIC is associated with an emotional burden for patients.” Constipation may impair quality of life (QOL) and can potentially have serious complications, including bowel obstruction and severe anorexia. OIC can also lead to time missed from work, more healthcare utilization, and changes in opioid regimens.
Despite the growing recognition of adverse consequences that have been linked to OIC, little is known about the nature of psychological distress and the burden associated with this problem. There is a lack of systematic research on the affective and cognitive burden of OIC, particularly among cancer populations, a group that may be at higher risk for physical and psychological distress due to OIC. “Studies show that cancer patients are more likely to rate constipation as a cause of severe symptom distress than pain,” adds Dr. Dhingra. “This highlights the importance of developing effective treatment strategies and finding ways to reduce distress.”
A Qualitative Analysis
A study published in Palliative Medicine by Dr. Dhingra and colleagues used qualitative research methods to better understand the psychological distress and burden associated with OIC and its treatment in advanced cancer patients. “This type of design is ideal for investigating patient experiences with health and illness when little is known about a problem,” Dr. Dhingra says. “It helps identify important variables.” The authors recruited 12 patients with advanced cancer (Table 1) and persistent constipation. Transcripts recorded during semi-structured interviews were analyzed for recurring themes.
The patients were highly symptomatic (Table 2) and the qualitative analysis revealed complex types of negative affect and cognitions relating to OIC. Three major themes emerged:
Irrational Thoughts & Education
According to Dr. Dhingra, irrational thoughts and educational needs included several important factors to consider. “For example, some patients believed nutrition could improve OIC, a theme that persisted even though actual experiences did not support these strategies,” she says. “The reasons for this may be multi-factorial, so it’s important for healthcare providers to assess beliefs about nutrition and help patients develop realistic expectations when using self-management strategies.”
Some patients also thought OIC was an indicator of deteriorating health, whereas others had catastrophic beliefs about the problem. “Education for these patients should be designed to address inaccurate beliefs and clarify the causes of OIC and the factors that maintain it,” says Dr. Dhingra. “Psychotherapeutic strategies, such as cognitive-behavioral therapy, should be considered if patients have persistent negative thought patterns.”
The researchers also found that psychological distress associated with OIC included depressive symptoms and anticipatory anxiety related to constipation. “This distress may amplify over time and could lead to social isolation, agitation, and frustration with treatments that are believed to be ineffective,” Dr. Dhingra says. “Again, patient education and psychotherapeutic strategies should be used to help address psychological distress resulting from OIC.”
Effects on Treatment Decisions
Some patients indicated that OIC caused them to use lower doses of opioids or to stop taking them altogether. “This could compromise pain control and QOL,” says Dr. Dhingra. “Clinicians need to be vigilant about OIC when caring for patients taking long-term opioid therapy. Patients should be educated about the strategies that can help reduce the burden of OIC and those that don’t.”
In the future, Dr. Dhingra says that greater efforts should be made to target distress and misconceptions resulting from OIC and provide accurate information to symptomatic patients to improve care. “Patients need to learn about behavioral and psychological interventions that can help them cope with OIC as well as medications that can treat it,” she says. “We also need studies to address the multiple components of the cognitive and affective burden of OIC and investigate more interventions that aim to improve outcomes.”
Readings & Resources (click to view)
Dhingra L, Shuk E, Grossman B, et al. A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliat Med. 2013;27:447-456. Available at: http://pmj.sagepub.com/content/27/5/447.
Bell TJ, Panchal SJ, Miaskowski C, et al. The prevalence, severity and impact of opioid-induced bowel dysfunction: Results of a US and European patient survey (PROBE 1). Pain Med 2009;10:35-42.
Robinson CB, Fritch M, Hullett L, et al. Development of a protocol to prevent opioid-induced constipation in patients with cancer: A research utilization project. Clin J Oncol Nurs 2000;4:79-84.
Penning-van Beest FJ, van den Haak P, Klok RM, Prevoo YF, van der Peet DL, Herings RM. Quality of life in relation to constipation among opioid users. J Med Econ. 2010;13:129-135.
Robinson CB, Fritch M, Hullett L, et al. Development of a protocol to prevent opioid-induced constipation in patients with cancer: a research utilization project. Clin J Oncol Nurs. 2000;4:79-84.
Clemens KE, Klaschik E. Management of constipation in palliative care patients. Curr Opin Support Palliat Care. 2008;2:22-27.