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Clinical Research Updates

Comprehensive Chronic Pain Management

A Focus on Patients With Opioid-Induced Constipation

Guidelines

The functional gastrointestinal disorders and the Rome III process, 2006.

Drossman DA. Gastroenterology. 2006;130(5):1377-1390.

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.

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

Department of Veterans Affairs, Department of Defense

CDC Guideline for Prescribing Opioids for Chronic Pain

The Centers for Disease Control and Prevention developed and published these guidelines to provide recommendations for the prescribing of opioid pain medication for patients ≥18 years of age in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting ≥3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care

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.

Patient Education Handout

This leaflet provides patients with approaches to mitigating opioid-induced constipation and includes a list of questions about constipation for patients to ask their doctors or clinics.

My GI Health

This free, downloadable app allows patients to measure and track constipation symptoms weekly. Educational resources specific to patient-reported symptoms are available.

Clinical Assessment Tools

Bowel Function Index (BFI)

The BFI provides a numerical score for the prior 7 days based on ease of defecation, feeling of incomplete evacuation, and personal judgment of constipation.

Bristol Stool Form Scale

This visual scale is used to help patients characterize their stool. It classifies the most commonly passed stool forms into 7 types.

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.

Patient-Reported Measurement Information System (PROMIS) Constipation Scale

This 9-item questionnaire of patient-reported symptoms assesses the frequency and severity of constipation symptoms over the prior 7 days.

Other Resources

A Clinical Guide to Opioid Analgesia. 2nd edition.

Fine PG, Portenoy RK. New York, NY: Vendome Group, LLC; 2007.

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

Fishman SM. Washington, DC: Waterford Life Sciences; 2012.

Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation.

Camilleri M, et al. Neurogastroenterol Motil. 2014;26(10):1386-1395.

Suggested Readings

Chronic opioid induced constipation in patients with nonmalignant pain: challenges and opportunities.

Nelson AD, Camilleri M. Ther Adv Gastroenterol. 2015;8(4):206-220

The impact of opioid-induced constipation among chronic pain patients with sufficient laxative use.

LoCasale RJ, et al. Int J Clin Pract. 2015;69(12):1448-1456

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

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

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.

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

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.

Jamal MM, et al. Am J Gastroenterol. 2015;110(5):725-732.

A randomized, placebo-controlled trial of lubiprostone for opioid-induced constipation in chronic noncancer pain.

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

Balancing opioid-induced gastrointestinal side effects with pain management: insights from the online community.

Whitman CB, et al. J Opioid Manag. 2015;11(5):383-391.

Consensus recommendations on initiating prescription therapies for opioid-induced constipation.

Argoff CE, et al. Pain Med. 2015;16(12):2324-2337.

Comparison of straining during defecation in three positions: results and implications for human health.

Sikirov D. Dig Dis Sci. 2003;48(7):1201-1205

Influence of body position on defecation in humans.

Sakakibara R, et al. Low Urin Tract Symptoms. 2010;2(1):16-21.

Interactive Presentation

Comprehensive Chronic Pain Management: A Focus on Patients With Opioid-Induced Constipation

Brooks D. Cash, MD; Jeffrey A. Gudin, MD; Bill H. McCarberg, MD, FABPM


Activity
Comprehensive Chronic Pain Management

A Focus on Patients With Opioid-Induced Constipation

Relevant Resources

Persistent and Breakthrough Pain

Balancing the Benefits and Risk of Opioid-Based Therapy

Improving the Care of Patients With Chronic Pain

Individualized Assessment and Mechanism-Based Multimodal Treatment

Caring For Patients With Chronic Pain

Responsible Opioid Prescribing to Achieve Individualized Functional Goals

Acute Management of Migraine Attacks

Overcoming Pain and Gastrointestinal Distress to Improve Patient Outcomes

Opioid-Induced Constipation

Proactive Diagnosis and Targeted Management

Intrathecal Drug Delivery for Chronic Pain

Selecting Patients and Optimizing Long-Term Outcomes

Clinical Updates on the Management of Gout

Evidence-Based Strategies for Improved Patient Outcomes

Opioid-Induced Constipation

Proactive Diagnosis and Targeted Management

Chronic Obstructive Pulmonary Disease, Asthma, or Both

Differential Diagnosis and Comprehensive Management Strategies

Improving Outcomes in Chronic Obstructive Pulmonary Disease

Optimizing Maintenance Therapy Across Healthcare Settings

Managing Gout in Primary Care

Evolving Strategies for Diagnosis and Long-Term Management

Clinical Issues in Chronic Pain

Consensus and Controversies for Responsible Opioid Prescribing

Noninsulin Approaches to Managing Type 2 Diabetes

Best Practices in Combination Therapy

Intrathecal Drug Delivery for Chronic Pain

The Role of Nurses in Optimizing Long-term Outcomes

Hitting the Target in Type 2 Diabetes

Evolving Approaches to Insulin Based Therapy

Intrathecal Drug Therapy for Chronic Pain

Evolving Best-Practice Strategies to Maximize Efficacy and Safety

Clearing the Air

Improving Outcomes for Patients with COPD

Clinical Updates in Type 2 Diabetes

New Strategies for Insulin Replacement Therapy

How Low Do You Go?

Clinical Updates in LDL-C Management

Incretin-Based Therapies For Type 2 Diabetes

Improving Comprehensive Patient Care

Improving Outcomes in Non–24-Hour Sleep-Wake Disorder

Identifying Patients and Tailoring Therapy

Comprehensive Management of Chronic Obstructive Pulmonary Disease

Collaborative Approaches to Guideline-Concordant Patient Care

Clinical Updates in the Management of Severe Asthma

New Strategies for Individualizing Long-term Care

Clinical Issues in Bipolar Depression

Consensus and Controversies Across the Spectrum of Patient Presentations

Clinical Updates in Rheumatoid Arthritis

Evolving Treatment Algorithms and Expert Perspectives on Biosimilars

Best Practices in Intrathecal Therapy for Chronic Pain

Patient Selection, Treatment Initiation, and Ongoing Monitoring

Overcoming Challenges in Cancer Pain Management

Engaging With Patients About Opioid-Induced Constipation

Caring for Patients with Severe Asthma

Evolving Best Practices to Optimize Outcomes

Can You Spot Axial Spondyloarthritis?

The PCP’s Role in Timely Recognition and Referral

Clinical Issues in Chronic Pain

Debates and Discussions About Therapeutically Targeting Nerve Growth Factor Signaling

Advancing the Care of Severe Asthma

Differential Diagnosis, Multidisciplinary Management, and Patient Engagement

Updates in HCV Screening and Treatment

Key Issues Impacting OB/GYN Practice

Comprehensive Relief from Cancer Pain

Expanding the Conversation on Opioid-Induced Constipation

Evolving Models of HIV Care

Volume II: Expanding Evidence for the Role of Rapid ART Initiation in HIV Practice

Managing Opioid-Induced Constipation

Translating Guidelines Into Patient Care

Clearing the Air in Severe Asthma Management

Improving Patient Outcomes Through Shared Clinical Decision Making

GLP-1 Receptors Agonists in Type 2 Diabetes

Mechanistic Insights and Evolving Treatment Options

Airing It Out

A Case-Based Conversation on Managing Asthma and Chronic Rhinosinusitis With Nasal Polyposis

COPD in Managed Care

The Clinical and Utilization Benefits of Exacerbation Prevention

Assimilating the Evidence in T2DM

Cardiovascular and Renal Outcomes With SGLT2 Inhibitors

Demystifying New Evidence for COPD Management

Best Practices for Primary Care

Finding Relief in Osteoarthritis

New Paths to Chronic Pain Management

The Changing Landscape of HIV Prevention

What the Pharmacist Needs to Know about PrEP

What’s New in Systemic Lupus Erythematosus?

Unlocking Novel Paths to Patient Care

Expert Views on the Changing Landscape in RA

The Increasing Role of JAK Inhibitors

COPD Cases & Conversations

Preventing COPD Exacerbations to Improve Outcomes

Comprehensive Management in COPD

A Whole Patient Case Series

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SELECT r.id, COUNT(r.id) relevance FROM resources r join `resource_topics` rtj on rtj.`resource_id`=r.id WHERE rtj.`topic_id` in (SELECT topic_id from `resource_topics` rt where rt.`resource_id`=:rid AND rt.topic_id>0) AND r.id <> :rid AND r.status = 'active' Group by r.id order by relevance DESC, r.`createDate` DESC
1 0.003588 0.003588 0.003588 0.003588
SELECT * FROM `resources` `t` WHERE `t`.`id` IN (149, 145, 69, 41, 40, 36, 31, 23, 178, 172, 164, 163, 154, 153, 147, 144, 143, 141, 140, 139, 137, 136, 132, 126, 122, 116, 114, 111, 107, 96, 94, 91, 90, 83, 62, 61, 59, 58, 56, 54, 53, 52, 51, 50, 48, 47, 44, 42, 39, 38, 34, 35, 32, 28, 26, 25, 21, 17, 12, 10, 7)
1 0.003046 0.003046 0.003046 0.003046
SELECT `activities`.`id` AS `t1_c0`, `activities`.`group_id` AS `t1_c1`, `activities`.`resource_id` AS `t1_c2`, `activities`.`title` AS `t1_c3`, `activities`.`type` AS `t1_c4`, `activities`.`facultyNames` AS `t1_c5`, `activities`.`shortDescription` AS `t1_c6`, `activities`.`fullDescription` AS `t1_c7`, `activities`.`creditAmount` AS `t1_c8`, `activities`.`shortAddress` AS `t1_c9`, `activities`.`creditType` AS `t1_c10`, `activities`.`startDate` AS `t1_c11`, `activities`.`finishDate` AS `t1_c12`, `activities`.`sponsors` AS `t1_c13`, `activities`.`status` AS `t1_c14`, `activities`.`createDate` AS `t1_c15`, `activities`.`image` AS `t1_c16`, `activities`.`image_featured` AS `t1_c17`, `activities`.`archived` AS `t1_c18`, `activities`.`managers_list` AS `t1_c19`, `activities`.`is_send_pp_email` AS `t1_c20`, `activities`.`muvi_sync_date` AS `t1_c21`, `activities`.`expert_questions` AS `t1_c22` FROM `activities` `activities` WHERE (`activities`.`resource_id`=:ypl0)
1 0.001754 0.001754 0.001754 0.001754
SHOW COLUMNS FROM `resources`
1 0.001405 0.001405 0.001405 0.001405
SHOW COLUMNS FROM `activities`
1 0.001325 0.001325 0.001325 0.001325
SHOW COLUMNS FROM `users`
1 0.001241 0.001241 0.001241 0.001241
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
2 0.001189 0.000594 0.000289 0.000900
SHOW COLUMNS FROM `resource_videos`
1 0.001045 0.001045 0.001045 0.001045
SHOW COLUMNS FROM `interactions`
1 0.000967 0.000967 0.000967 0.000967
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
2 0.000942 0.000471 0.000418 0.000524
select id from resources where FIND_IN_SET(:shortAddress, shortAddress)
2 0.000837 0.000419 0.000252 0.000585
SELECT * FROM `resources` `t` WHERE `t`.`id`=55 LIMIT 1
1 0.000542 0.000542 0.000542 0.000542
SELECT `videos`.`id` AS `t1_c0`, `videos`.`vzaar_id` AS `t1_c1`, `videos`.`title` AS `t1_c2`, `videos`.`description` AS `t1_c3`, `videos`.`resource_id` AS `t1_c4`, `videos`.`type` AS `t1_c5` FROM `resource_videos` `videos` WHERE (`videos`.`resource_id`=:ypl0)
1 0.000493 0.000493 0.000493 0.000493
SHOW CREATE TABLE `activities`
1 0.000412 0.000412 0.000412 0.000412
SHOW CREATE TABLE `resources`
1 0.000334 0.000334 0.000334 0.000334
SHOW CREATE TABLE `resource_videos`
1 0.000297 0.000297 0.000297 0.000297
SHOW CREATE TABLE `users`
1 0.000283 0.000283 0.000283 0.000283
SHOW CREATE TABLE `interactions`
1 0.000267 0.000267 0.000267 0.000267
# Query Time (s)
0
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
0.000900
1
select id from resources where FIND_IN_SET(:shortAddress, shortAddress)
0.000585
2
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
0.000289
3
select id from resources where FIND_IN_SET(:shortAddress, shortAddress)
0.000252
4
SHOW COLUMNS FROM `resources`
0.001405
5
SHOW CREATE TABLE `resources`
0.000334
6
SELECT * FROM `resources` `t` WHERE `t`.`id`=55 LIMIT 1
0.000542
7
SHOW COLUMNS FROM `resource_videos`
0.001045
8
SHOW CREATE TABLE `resource_videos`
0.000297
9
SELECT `videos`.`id` AS `t1_c0`, `videos`.`vzaar_id` AS `t1_c1`, `videos`.`title` AS `t1_c2`, `videos`.`description` AS `t1_c3`, `videos`.`resource_id` AS `t1_c4`, `videos`.`type` AS `t1_c5` FROM `resource_videos` `videos` WHERE (`videos`.`resource_id`=:ypl0)
0.000493
10
SHOW COLUMNS FROM `interactions`
0.000967
11
SHOW CREATE TABLE `interactions`
0.000267
12
SHOW COLUMNS FROM `activities`
0.001325
13
SHOW CREATE TABLE `activities`
0.000412
14
SHOW COLUMNS FROM `users`
0.001241
15
SHOW CREATE TABLE `users`
0.000283
16
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
0.000418
17
INSERT INTO `users` (`role`, `sendEmails`, `sendSms`, `source`, `session`, `lastLogin`, `phone`, `createDate`) VALUES (:yp0, :yp1, :yp2, :yp3, :yp4, :yp5, :yp6, :yp7)
0.006659
18
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
0.000524
19
UPDATE `users` SET `lastLogin`=:yp0 WHERE `users`.`id`=2540066
0.006314
20
SELECT `activities`.`id` AS `t1_c0`, `activities`.`group_id` AS `t1_c1`, `activities`.`resource_id` AS `t1_c2`, `activities`.`title` AS `t1_c3`, `activities`.`type` AS `t1_c4`, `activities`.`facultyNames` AS `t1_c5`, `activities`.`shortDescription` AS `t1_c6`, `activities`.`fullDescription` AS `t1_c7`, `activities`.`creditAmount` AS `t1_c8`, `activities`.`shortAddress` AS `t1_c9`, `activities`.`creditType` AS `t1_c10`, `activities`.`startDate` AS `t1_c11`, `activities`.`finishDate` AS `t1_c12`, `activities`.`sponsors` AS `t1_c13`, `activities`.`status` AS `t1_c14`, `activities`.`createDate` AS `t1_c15`, `activities`.`image` AS `t1_c16`, `activities`.`image_featured` AS `t1_c17`, `activities`.`archived` AS `t1_c18`, `activities`.`managers_list` AS `t1_c19`, `activities`.`is_send_pp_email` AS `t1_c20`, `activities`.`muvi_sync_date` AS `t1_c21`, `activities`.`expert_questions` AS `t1_c22` FROM `activities` `activities` WHERE (`activities`.`resource_id`=:ypl0)
0.001754
21
SELECT r.id, COUNT(r.id) relevance FROM resources r join `resource_topics` rtj on rtj.`resource_id`=r.id WHERE rtj.`topic_id` in (SELECT topic_id from `resource_topics` rt where rt.`resource_id`=:rid AND rt.topic_id>0) AND r.id <> :rid AND r.status = 'active' Group by r.id order by relevance DESC, r.`createDate` DESC
0.003588
22
SELECT * FROM `resources` `t` WHERE `t`.`id` IN (149, 145, 69, 41, 40, 36, 31, 23, 178, 172, 164, 163, 154, 153, 147, 144, 143, 141, 140, 139, 137, 136, 132, 126, 122, 116, 114, 111, 107, 96, 94, 91, 90, 83, 62, 61, 59, 58, 56, 54, 53, 52, 51, 50, 48, 47, 44, 42, 39, 38, 34, 35, 32, 28, 26, 25, 21, 17, 12, 10, 7)
0.003046
Log Messages
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