Chronic pain is one of the most common conditions in the United States, with approximately 50 million Americans reporting incidence. For Americans ages 65 years and older, chronic pain is even more prevalent, affecting nearly 53%of all seniors.
For those who suffer from chronic pain, managing the pain is an essential part of everyday life as it has been linked to restrictions in mobility and daily activities, anxiety and depression, poor perceived health, all leading to poor quality of life. Patients have treatment options, but between five and eight million Americans require opioid-therapy for long-term pain management.
While long-term opioid use can certainly help patients manage chronic pain, it can also result in various side effects such as constipation and dizziness. each of which may increase patient discomfort. The most common side effect of opioids is opioid-induced constipation, with up to 80% of patients on opioid therapy experiencing it. Despite these statistics, many remain unaware of this condition and are unsure how to address this form of constipation and health care providers often miss the opportunity to inquire about it. Additionally, because older adults already demonstrate higher rates of constipation due to other medical conditions like dehydration and decreased mobility, the under-detection and mismanagement of OIC in senior patient populations remains high.
In long-term care settings, the under diagnosis of OIC is extremely prevalent, with as many as 74 percent of residents suffering from this condition. In fact, the concurrent prevalence of opioid and laxative use by patients in LTC facilities is nearly 55 percent. As a result, many seniors turn to over the counter (OTC) medications as a first line of defense to relieve their constipation symptoms. However, not all constipation is the same and these methods are often ineffective in relieving OIC because of the fundamental way in which opioids react in the gut. Because of these gastrointestinal-opioid reactions, OIC mechanistically differs from other forms of constipation, making medical intervention frequently necessary. For seniors already living with chronic pain — who also suffer from OIC — effective symptom relief is vital.
When left untreated, OIC places an unnecessary burden on both patients and the healthcare system at large. Most importantly, needless suffering occurs from constipation, often leading to discomfort at best to risk for small bowel obstruction. Patients may skip opioid medication doses due to OIC, which leads to worsening of pain, or be unaware of the new abdominal pain and take more pain medication to treat this.
Economic costs can be troublesome as well. For instance, in LTC facilities, patients with OIC have higher total medical costs than those who don’t experience OIC. In fact, one study found that elderly patients living with OIC had an overall increased rate of healthcare resource utilization, as well as significantly higher inpatient and emergency department costs regardless of whether they lived in a LTC facility or not. Further, a cost-comparison revealed that elderly patients suffering from OIC had average healthcare costs of $19,963, while costs for those without OIC were roughly $10,556. This is an estimated 89% difference for patients with OIC, suggesting an extreme cost disparity associated with the occurrence of this condition.
Between the financial implications and decreased quality of life for patients living with OIC, it is imperative for healthcare professionals to provide diagnosis and effective treatment options – especially for older Americans living with chronic pain who are disproportionally affected by the condition. There are several options available to treat the specific constipation experienced from opioid use.
One such option is methylnaltrexone, which has a long history of providing patients with rapid, reliable relief. This may also be an effective option for the older population as they are often on several types of medications and methylnaltrexone has no known drug-to-drug interactions. Providers should initiate discussions about OIC with chronic pain patients taking opioids and attempt to create a space that allows for an open dialogue on the likelihood and occurrence of this condition. One way to start this conversation is to ask how a patient’s bowel movements – both consistency and frequency – have changed since they began opioid therapy.
Overall, creating conversations surrounding OIC is the first step to providing faster and more effective relief for patients. Doing so will help to give patients an opportunity to discuss their symptoms and voice concerns on a typically taboo subject. From there, patients, caregivers and physicians can work together to devise an appropriate treatment plan. This will not only allow for patient relief but will also offer the opportunity to significantly reduce the high costs and resource overextension that frequently accompanies untreated OIC.
OIC is a condition too often overlooked and untreated. Addressing this issue, especially for older Americans, should be a priority for healthcare professionals as it holds the potential to simultaneously improve patient outcomes and reduce overextension of the healthcare system.
Neel Mehta, M.D., is an an anesthesiologist in New York City.
