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Achieving Balance Practical Management Strategies for Opioid-Induced Constipation

Charles E. Argoff, MD, Brooks D. Cash, MD, Aaron Tokayer, MD

Jointly provided by Albert Einstein College of Medicine of Yeshiva University, Montefiore Medical Center, and Integritas Communications

This activity is supported by an educational grant from AstraZeneca.

Faculty

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

Brooks D. Cash, MD
Professor of Medicine
University of South Alabama Health System
Digestive Health Center
Mobile, Alabama

Peer Reviewer

Aaron Tokayer, MD
Associate Professor of Clinical Medicine, Department of Medicine
Division of Gastroenterology and Liver Diseases
Albert Einstein College of Medicine of Yeshiva University
Montefiore Medical Center
Bronx, New York

Intended Audience

This activity is intended for pain specialists, primary care providers, and other health care professionals who manage patients on chronic opioid therapy.

Learning Objectives

At the conclusion of this educational activity, participants should be better prepared to:

  • Assess patients selected for long-term opioid therapy for baseline bowel patterns, risk factors for constipation, and changes in bowel function over time
  • Prescribe prophylactic bowel regimens for patients starting chronic opioid therapy
  • Differentiate between approved medications for OIC based on mechanism of action, efficacy, and safety
  • Tailor regimens for patients who develop OIC that address individual bowel symptoms, prior treatment response, and patient preferences
  • Coordinate interdisciplinary patient care throughopen patient-centered communication andcollaboration with the health care team

Needs Assessment and Learner's Gap

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 have gained increasing acceptance as an important therapeutic option for carefully selected patients with chronic noncancerpain.2,3 Therapeutic outcomes, however, are often suboptimal—at times, because of poorly managed opioid-induced side effects.4,5 For instance, up to half of patients on long-term opioid therapy experience symptoms of constipation, yet this common side effect is often not identified and treated by prescribing clinicians.6,7 Unaddressed opioid-induced constipation can result in a number of medical complications, impair quality of life, and cause patients to skip their opioiddoses.8 This Clinical Research Report will provide practical insights into efficiently assessing bowel patterns and prescribing both prophylactic and more intensive bowel management regimens. Pain-treating clinicians will gain a deeper understanding of the effects of opioids on the gastrointestinal tract and effective strategies to alleviate constipation symptoms in patients on chronic opioid therapy.

References

  1. Institute of Medicine. Relieving Pain in America:A Blueprint for Transforming Prevention, Care, Education,and Research. 2011.
  2. Chou R, Fanciullo GJ, Fine PG, et al. J Pain.2009;10(2):113-130.
  3. National Comprehensive Cancer Network. NCCN ClinicalPractice Guidelines in Oncology: Adult Cancer Pain.2010;2010.
  4. Daniel 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. Cook SF, Lanza L, Zhou X, et al. Aliment Pharmacol Ther.2008;27(12):1224-1232.
  7. Coyne KS, LoCasale RJ, Datto CJ, et al. ClinicoeconOutcomes Res. 2014;6:269-281.
  8. Bell TJ, Panchal SJ, Miaskowski C, et al. Pain Med.2009;10(1):35-42.

How to Obtain Credit

Participants must complete the preactivity questionnaire, posttest, and program evaluation online. Participants must also score at least 70% on the posttest in order to receive credit.

Estimated time to complete this activity is 1 hour.

Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Albert Einstein College of Medicine of Yeshiva University and Integritas Communications. Albert Einstein College of Medicine of Yeshiva University is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation

Albert Einstein College of Medicine of Yeshiva University designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™.Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Conflict of Interest

The Conflict of Interest Disclosure Policy of Albert Einstein College of Medicine of Yeshiva University requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical, product, or device company. Any presenters whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity will not be permitted to present.

The Albert Einstein College of Medicine of Yeshiva University also requires that faculty participating in any CME activity disclose to the audience when discussing any unlabeled or investigational use of any commercial product or device not yet approved for use in the United States. Albert Einstein College of Medicine of Yeshiva University, CCME staff, has no conflicts of interest with commercial interests related directly or indirectly to this educational activity.

Faculty and Planning Committee Disclosures

Charles E. Argoff, MD, is a member of the speakers' bureaus for Allergan, Inc., AstraZeneca plc, Depomed, Inc., Iroko Pharmaceuticals, LLC, Janssen Pharmaceuticals, Inc.,Teva Pharmaceuticals USA, Inc., and Xenoport, Inc. He has received grant/research support from Endo Pharmaceuticals Inc., Eli Lilly and Company, and Forest Laboratories. Dr. Argoff is a consultant/independent contractor for AstraZeneca plc, Collegium Pharmaceutical Inc., Daiichi Sankyo Co., LTD., Depomed, Inc., IndiviorPLC.,Kaléo, Inc., Nektar Therapeutics, Pfizer Inc., Teva Pharmaceuticals USA, Inc., and Xenoport, Inc. He receives royalties from Elsevier B.V.

Brooks D. Cash, MD, is a consultant to Allergan, IM HealthScience LLC, Ironwood Pharmaceuticals Inc., Prometheus Laboratories Inc., and Salix Pharmaceuticals.  He is a member of the speakers' bureaus for Allergan, AstraZeneca, Ironwood Pharmaceuticals Inc., Salix Pharmaceuticals, and Takeda Pharmaceutical Company Ltd

Aaron Tokayer, MD, of Albert Einstein College of Medicine has nothing to disclose.

Rose O’Connor PhD, of Integritas Communications has nothing to disclose.

Albert Einstein College of Medicine, CCME staff, has no relevant conflicts of interest with commercial interests related directly or indirectly to this educational activity.

Victor B. Hatcher, PhD, Associate Dean, presents no relevant conflict of interest.

Off Label or Investigational Use

Albert Einstein College of Medicine also requires that faculty participating in any CME activity disclose to the audience when discussing any unlabeled or investigational use of any commercial product or device not yet approved for use in the United States. Faculty will be responsible for making these disclosures, if applicable.

Disclaimer

The opinions expressed herein are those of the faculty and do not necessarily represent the views of the Albert Einstein College of Medicine, Montefiore Medical Center, AstraZeneca, or Integritas Communications. Please review complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.

Click "Begin Activity" to acknowledge that you have reviewed the preamble information for this activity.

Begin Activity

expiration 09/01/2016

type Monograph


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1 0.001557 0.001557 0.001557 0.001557
SHOW COLUMNS FROM `events`
1 0.001416 0.001416 0.001416 0.001416
SHOW COLUMNS FROM `users`
1 0.001370 0.001370 0.001370 0.001370
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
2 0.001164 0.000582 0.000241 0.000923
SHOW COLUMNS FROM `resources`
1 0.001084 0.001084 0.001084 0.001084
SHOW COLUMNS FROM `view_log`
1 0.001075 0.001075 0.001075 0.001075
SHOW COLUMNS FROM `questionnaires`
1 0.001044 0.001044 0.001044 0.001044
SHOW COLUMNS FROM `user_activitiesstatus`
1 0.001025 0.001025 0.001025 0.001025
SHOW COLUMNS FROM `interactions`
1 0.000972 0.000972 0.000972 0.000972
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
2 0.000971 0.000486 0.000481 0.000490
SELECT `t`.`id` AS `t0_c0`, `t`.`group_id` AS `t0_c1`, `t`.`resource_id` AS `t0_c2`, `t`.`title` AS `t0_c3`, `t`.`type` AS `t0_c4`, `t`.`facultyNames` AS `t0_c5`, `t`.`shortDescription` AS `t0_c6`, `t`.`fullDescription` AS `t0_c7`, `t`.`creditAmount` AS `t0_c8`, `t`.`shortAddress` AS `t0_c9`, `t`.`creditType` AS `t0_c10`, `t`.`startDate` AS `t0_c11`, `t`.`finishDate` AS `t0_c12`, `t`.`sponsors` AS `t0_c13`, `t`.`status` AS `t0_c14`, `t`.`createDate` AS `t0_c15`, `t`.`image` AS `t0_c16`, `t`.`image_featured` AS `t0_c17`, `t`.`archived` AS `t0_c18`, `t`.`managers_list` AS `t0_c19`, `t`.`is_send_pp_email` AS `t0_c20`, `t`.`muvi_sync_date` AS `t0_c21`, `t`.`expert_questions` AS `t0_c22`, `interaction`.`id` AS `t1_c0`, `interaction`.`activity_id` AS `t1_c1`, `interaction`.`title` AS `t1_c2`, `interaction`.`link` AS `t1_c3`, `interaction`.`type` AS `t1_c4`, `interaction`.`status` AS `t1_c5`, `interaction`.`createDate` AS `t1_c6` FROM `activities` `t` LEFT OUTER JOIN `interactions` `interaction` ON (`interaction`.`activity_id`=`t`.`id`) WHERE (`t`.`id`=32)
1 0.000613 0.000613 0.000613 0.000613
SELECT `resource`.`id` AS `t1_c0`, `resource`.`shortAddress` AS `t1_c1`, `resource`.`status` AS `t1_c2`, `resource`.`title` AS `t1_c3`, `resource`.`type` AS `t1_c4`, `resource`.`image` AS `t1_c5`, `resource`.`slides` AS `t1_c6`, `resource`.`linkedResources` AS `t1_c7`, `resource`.`reading` AS `t1_c8`, `resource`.`shortDescription` AS `t1_c9`, `resource`.`fullDescription` AS `t1_c10`, `resource`.`link` AS `t1_c11`, `resource`.`createDate` AS `t1_c12`, `resource`.`archived` AS `t1_c13` FROM `resources` `resource` WHERE (`resource`.`id`=:ypl0)
1 0.000509 0.000509 0.000509 0.000509
SELECT `activity_id` AS `c`, COUNT(*) AS `s` FROM `user_activitiesstatus` `t` WHERE (user_id=:user AND isFinished=1) AND (`t`.`activity_id`=32) GROUP BY `activity_id`
1 0.000495 0.000495 0.000495 0.000495
SELECT * FROM `questionnaires` `t` WHERE t.activity_id=:id AND t.type=:type LIMIT 1
1 0.000437 0.000437 0.000437 0.000437
SHOW CREATE TABLE `activities`
1 0.000350 0.000350 0.000350 0.000350
SHOW CREATE TABLE `events`
1 0.000347 0.000347 0.000347 0.000347
SHOW CREATE TABLE `users`
1 0.000326 0.000326 0.000326 0.000326
SHOW CREATE TABLE `interactions`
1 0.000305 0.000305 0.000305 0.000305
SHOW CREATE TABLE `user_activitiesstatus`
1 0.000301 0.000301 0.000301 0.000301
SHOW CREATE TABLE `view_log`
1 0.000292 0.000292 0.000292 0.000292
SHOW CREATE TABLE `resources`
1 0.000284 0.000284 0.000284 0.000284
SHOW CREATE TABLE `questionnaires`
1 0.000277 0.000277 0.000277 0.000277
# Query Time (s)
0
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
0.000923
1
SHOW COLUMNS FROM `activities`
0.001557
2
SHOW CREATE TABLE `activities`
0.000350
3
SHOW COLUMNS FROM `users`
0.001370
4
SHOW CREATE TABLE `users`
0.000326
5
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
0.000481
6
INSERT INTO `users` (`role`, `sendEmails`, `sendSms`, `source`, `session`, `lastLogin`, `phone`, `createDate`) VALUES (:yp0, :yp1, :yp2, :yp3, :yp4, :yp5, :yp6, :yp7)
0.003537
7
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
0.000490
8
UPDATE `users` SET `lastLogin`=:yp0 WHERE `users`.`id`=2491833
0.002926
9
SELECT * FROM `activities` `t` WHERE `t`.`id`=32 LIMIT 1
0.000473
10
SHOW COLUMNS FROM `events`
0.001416
11
SHOW CREATE TABLE `events`
0.000347
12
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
0.001830
13
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
0.000241
14
SELECT * FROM `activities` `t` WHERE `t`.`id`=32 LIMIT 1
0.000292
15
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
0.000239
16
SELECT * FROM `activities` `t` WHERE `t`.`id`=32 LIMIT 1
0.000295
17
UPDATE activities SET archived=1 WHERE finishDate<now();
0.005863
18
SHOW COLUMNS FROM `view_log`
0.001075
19
SHOW CREATE TABLE `view_log`
0.000292
20
INSERT INTO `view_log` (`source`, `unique_id`, `resource_id`, `type`) VALUES (:yp0, :yp1, :yp2, :yp3)
0.003486
21
SHOW COLUMNS FROM `user_activitiesstatus`
0.001025
22
SHOW CREATE TABLE `user_activitiesstatus`
0.000301
23
SHOW COLUMNS FROM `interactions`
0.000972
24
SHOW CREATE TABLE `interactions`
0.000305
25
SELECT `t`.`id` AS `t0_c0`, `t`.`group_id` AS `t0_c1`, `t`.`resource_id` AS `t0_c2`, `t`.`title` AS `t0_c3`, `t`.`type` AS `t0_c4`, `t`.`facultyNames` AS `t0_c5`, `t`.`shortDescription` AS `t0_c6`, `t`.`fullDescription` AS `t0_c7`, `t`.`creditAmount` AS `t0_c8`, `t`.`shortAddress` AS `t0_c9`, `t`.`creditType` AS `t0_c10`, `t`.`startDate` AS `t0_c11`, `t`.`finishDate` AS `t0_c12`, `t`.`sponsors` AS `t0_c13`, `t`.`status` AS `t0_c14`, `t`.`createDate` AS `t0_c15`, `t`.`image` AS `t0_c16`, `t`.`image_featured` AS `t0_c17`, `t`.`archived` AS `t0_c18`, `t`.`managers_list` AS `t0_c19`, `t`.`is_send_pp_email` AS `t0_c20`, `t`.`muvi_sync_date` AS `t0_c21`, `t`.`expert_questions` AS `t0_c22`, `interaction`.`id` AS `t1_c0`, `interaction`.`activity_id` AS `t1_c1`, `interaction`.`title` AS `t1_c2`, `interaction`.`link` AS `t1_c3`, `interaction`.`type` AS `t1_c4`, `interaction`.`status` AS `t1_c5`, `interaction`.`createDate` AS `t1_c6` FROM `activities` `t` LEFT OUTER JOIN `interactions` `interaction` ON (`interaction`.`activity_id`=`t`.`id`) WHERE (`t`.`id`=32)
0.000613
26
SELECT `activity_id` AS `c`, COUNT(*) AS `s` FROM `user_activitiesstatus` `t` WHERE (user_id=:user AND isFinished=1) AND (`t`.`activity_id`=32) GROUP BY `activity_id`
0.000495
27
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
0.000288
28
SELECT * FROM `activities` `t` WHERE `t`.`id`=32 LIMIT 1
0.000283
29
SELECT * FROM `activities` `t` WHERE `t`.`id`=32 LIMIT 1
0.000281
30
SHOW COLUMNS FROM `questionnaires`
0.001044
31
SHOW CREATE TABLE `questionnaires`
0.000277
32
SELECT * FROM `questionnaires` `t` WHERE t.activity_id=:id AND t.type=:type LIMIT 1
0.000437
33
SHOW COLUMNS FROM `resources`
0.001084
34
SHOW CREATE TABLE `resources`
0.000284
35
SELECT `resource`.`id` AS `t1_c0`, `resource`.`shortAddress` AS `t1_c1`, `resource`.`status` AS `t1_c2`, `resource`.`title` AS `t1_c3`, `resource`.`type` AS `t1_c4`, `resource`.`image` AS `t1_c5`, `resource`.`slides` AS `t1_c6`, `resource`.`linkedResources` AS `t1_c7`, `resource`.`reading` AS `t1_c8`, `resource`.`shortDescription` AS `t1_c9`, `resource`.`fullDescription` AS `t1_c10`, `resource`.`link` AS `t1_c11`, `resource`.`createDate` AS `t1_c12`, `resource`.`archived` AS `t1_c13` FROM `resources` `resource` WHERE (`resource`.`id`=:ypl0)
0.000509
Log Messages
Message (details) Level Category Time