Opioid-induced constipation compromises pain management
and impacts patient quality of life
John Leslie, MD, MBA1; Timothy Bell, MHA2; Katherine Annunziata, MA3; Deborah Freedman3
Mayo Clinic College of Medicine, Scottsdale, AZ, USA; 2GlaxoSmithKline, Research Triangle Park, NC, USA; 3Consumer Health Sciences, Princeton, NJ, USA
Updated abstract Objective Pain severity Figure 4. Presence of ≥1 other opioid-induced side effect in respondents with
opioid-induced constipation and without opioid-induced constipation
G The objective of this analysis of the large National Health and Wellness Survey G Pain severity was significantly greater in individuals reporting opioid-induced
Objective: Constipation is the most common of the opioid-induced bowel p<0.0001
(NHWS) 2004 was to determine the impact of opioid-induced constipation on constipation than in those without opioid-induced constipation (Figure 1). 100
dysfunction (OBD) symptoms associated with opioid use for chronic pain. No
This study documents the impact of opioid-induced constipation on chronic pain management, work productivity, and patient health-related quality Work productivity 21% Yes (≥1 other side effects)
of life (HRQOL).
chronic pain management, work productivity, and patient health-related G Compared with individuals without opioid-induced constipation, those individuals 75
quality of life (HRQOL). Methods with opioid-induced constipation reported:
– higher percentage of work time missed 78%
Methods: The effects of opioid-induced constipation on these patient- G The NHWS 2004 is a comprehensive, annual, cross-sectional study of a wide range – greater impairment while working 50
reported outcomes have been evaluated using data from the National of healthcare situations in the USA and three major European markets, in terms – greater overall work impairment
of demographics, resource utilization, and consumer attitudes and behaviors. 79%
Health and Wellness Survey 2004. This is a comprehensive, annual, – greater activity impairment (Figure 2).
This poster focuses on US results only. 25
cross-sectional study of a wide range of healthcare situations in the USA HRQOL
and three major European markets, in terms of demographics, resource G Data were collected via an internet survey from individuals in the USA receiving
opioids for chronic pain, and were analyzed according to those who reported G On the mental and physical health components of the SF-8, mean scores were
utilization, and consumer attitudes and behaviors. Data were collected 0
opioid-induced constipation and those who did not. significantly worse in individuals with opioid-induced constipation than in those
from 2,137 individuals in the USA receiving opioids for chronic pain, without constipation (Figure 3). With opioid-induced Without opioid-induced
G Pain severity was assessed by asking respondents to rate their pain as mild, constipation constipation
and were analyzed according to those who reported opioid-induced
moderate, or severe. Other opioid-induced side effects
constipation (n=300) and those who did not (n=1,837). Pain severity was
assessed by asking respondents to rate their pain as mild, moderate, G Work productivity was evaluated using the Work Productivity and Activity Impairment G Of those individuals experiencing opioid-induced constipation, 79% also had ≥1
other opioid-induced side effect, including GI side effects (Figure 4).
or severe. Work productivity was evaluated using the Work Productivity
and Activity Impairment Questionnaire, and HRQOL was evaluated using G HRQOL was evaluated using the Short-Form 8 (SF-8) health survey.7 Figure 1. Pain severity in respondents with opioid-induced constipation
the Short-Form 8 (SF-8) health survey. G Limitations of this methodology include:
and without opioid-induced constipation Conclusions
– potential misclassification bias as a result of self-reported opioid use and 100
G Chronic opioid recipients with associated opioid-induced constipation
Results: There were significant differences between the groups in terms Severe
opioid-induced constipation by respondents p<0.0001
have significantly more severe pain and impaired HRQOL, compared
of age (p<0.0001), race (p=0.0013), and education (p<0.0001), but not in – potential for sampling bias due to self-selection for participation Mild with those without constipation.
gender or income. The majority of respondents (99% with opioid-induced – unknown frequency/strength of opioid dosing. 75 48%
constipation and 98% without opioid-induced constipation) experienced 75%
G Whether patients take fewer opioid doses to try and minimize the
pain of non-malignant origin. Pain severity was significantly greater in Results side effects, or whether opioid-induced constipation itself causes
individuals reporting opioid-induced constipation versus those without Survey respondents 50% greater pain, is uncertain.
opioid-induced constipation (59% vs 48% with severe pain, p<0.0001).
G A total of 2,137 individuals who participated in the survey reported using opioids G The presence of constipation also limits work productivity and
Individuals with opioid-induced constipation reported a higher percentage 49% Respondents (%)
for pain relief: 300 reported opioid-induced constipation and 1,837 did not. 25 49%
of work time missed (21.1% vs 18.8%), greater impairment while working
40% 25% patients'
abilities to perform daily activities.
G There were significant differences between the groups with and without opioid-
(39.6% vs 36.7%), and greater overall work impairment (42.3% vs 40.2%). induced constipation, in terms of age (p<0.0001), race (p=0.0013), and education 1% 4% G Effective management of opioid-induced constipation should improve
0 0% 1% 4%
Activity impairment was significantly greater in individuals with opioid- (p<0.0001), but not in gender or income (Table 1). With opioid-induced Without opioid-induced these outcomes in patients receiving opioids for chronic pain.
With opioid-induced Without-opioid-induced
induced constipation versus those without opioid-induced constipation constipation constipation
G The majority of respondents in both groups experienced pain of non-cancer origin
– When a side effect constipation opioid-induced constipation is this
(65.6% vs 57.4%; p<0.0001). On the mental health component of the SF-8, (Table 1). Figure 2. Scores on domains of the Work Productivity and Activity Impairment Mild Moderate Severe
frequent and of such clinical consequence, it should be routinely
mean scores were significantly worse in individuals with opioid-induced Questionnaire in respondents with opioid-induced constipation
G More individuals in the group with opioid-induced constipation were receiving two or and without opioid-induced constipation prevented and treated when chronic opioids are prescribed.
constipation versus those without constipation (42.5 vs 45.0; p=0.0002). more opioids, compared with those in the group without opioid-induced constipation
p<0.0001 – Agents that directly antagonize the effects of opioids on the GI tract
A similar decline was observed on the SF-8 physical health component (25% vs 18%, respectively, p=0.0011; Table 1). Worse 70 With opioid-induced
65.6 and their potential to treat OBD should be investigated.
(32.4 vs 34.4; p=0.0013). Of the individuals experiencing opioid-induced constipation
Table 1. Baseline characteristics of respondents with opioid-induced constipation and 60 57.4
constipation, 79% also had ≥1 other opioid induced side effect, including without opioid-induced constipation
gastrointestinal (GI) side effects. 50
With opioid-induced Without opioid-induced 39.6 40.2
Conclusions: Chronic opioid recipients with associated opioid-induced Respondents (%) constipation (n=300) constipation (n=1,837) 40 36.7
constipation have significantly more severe pain and impaired HRQOL (%) (%) p-value
compared with those without constipation. Whether patients take fewer Gender
Male 31 36 NS 20 18.8
opioid doses to try and minimize the side effects or whether opioid-induced G Data from the large NHWS 2004 demonstrate that opioid recipients who
Female 69 64
constipation itself causes greater pain is uncertain. The presence of Age (years) 10 experience constipation have significantly more severe pain and
constipation also limits work productivity and patients' abilities to perform 18–44 34 38 <0.0001 impaired quality of life, compared with those without constipation.
45–64 54 42 Better 0
activities. Effective management of opioid-induced constipation should ≥65 12 20 Work time Impairment Overall work Activity
improve these outcomes in patients receiving opioids for chronic pain. Race missed while working impairment impairment
When a side effect such as opioid-induced constipation is this frequent, and White 69 75 0.0013
Black 6 8 Figure 3. Mean scores on the mental and physical health components of the SF-8 in
of such clinical consequence, it should be routinely prevented and treated Hispanic 17 10 respondents with opioid-induced constipation and without opioid-induced constipation
when chronic opioids are prescribed. Agents that directly antagonize the Other 8 7
Education Better 50 p=0.0002 References
effects of opioids on the GI tract and their potential to treat opioid-induced <High school 28 18 <0.0001 45.0
constipation and other specific OBD symptoms should be investigated. High school 23 34 Without
1. Kalso E, Edwards JE, Moore RA, McQuay HJ. Pain 2004;112:372–80.
>High school 49 48 40 p=0.0013 opioid-induced
Income ($US) 34.4 constipation 2. Moore RA, McQuay HJ. Arthritis Res Ther 2005;7:R1046–51. Epub 2005 Jun 28.
<25,000 35 36 NS
25,000–50,000 33 31 30 3. Pappagallo M. Am J Surg 2001;182 (Suppl):11S–18S.
50,000–75,000 16 16 25
75,000–100,000 7 9 4. Fallon MT, Hanks GW. Palliat Med 1999;13:159–60.
Introduction >100,000 9 7 20
Pain origin 15 5. Klepstad P, Borchgrevink PC, Kaasa S. J Pain Symptom Manage 2000;20:19–26.
G Constipation is a common manifestation of opioid-induced bowel dysfunction (OBD)
Non-cancer 99 98 NS 10
reported in patients receiving opioids for chronic non-cancer or cancer-related pain.1–3 Cancer 1 2 6. Reilly MC, Zbrozek AS, Dukes EM. Pharmacoeconomics 1993;4:353–65.
Number of opioids used 5
G Although OBD can lead to physical or functional deterioration in patients requiring 7. Ware JE, Kosinski M, Dewey JE and Gandek B. A Manual for Users of the SF-8 Health Survey.
1 75 82 0.0011 Worse 0
chronic pain relief, the impact of this on patient-reported outcomes has not been
≥2 25 18 Mental health Physical health Lincoln, RI: QualityMetric Incorporated, 2001.