Doctors and Patients Communicate Poorly about Constipation

Doctors and Patients Communicate Poorly about Constipation

Constipation is a topic most people would try to avoid. But the two people who should be talking about it — doctors and their patients — appear to be avoiding it as well.

Nearly 4 out of 10 doctors whose patients have opioid induced constipation (OIC) don’t know that their patients are constipated, according to a new study being presented at PAINWeek, a national conference of practitioners in the field of pain management.

OIC is a common side-effect of opioid painkillers, with 40% to 80% of patients taking opioids for chronic non-cancer pain suffering some degree of constipation.

Researchers followed nearly 500 patients with OIC in the United States, Canada, Germany and the United Kingdom for six months. Most of the patients were female (62%); with lower back pain (77%) and joint pain (51%) the most frequently reported pain condition. The most common opioids prescribed to them were oxycodone, hydrocodone, morphine and tramadal.

Bad NewsWhat set this study apart from others is that the patients’ physicians were also questioned about their treatment  and interaction with patients.

Only 61% of the doctors knew that their patients were constipated and 25% didn’t know their patients were taking laxatives.

Clearly, there’s a communication problem between doctors and patients when it comes to OIC.

“Patients are either too embarrassed to talk to their physicians about it or physicians aren’t listening or aware,”  said Hilary Wilson, co-author and research scientist for Evidera, which conducted the study. “My guess is the conversation isn’t happening. Patients aren’t bringing it up and doctors aren’t asking about it.”

“If the physician isn’t asking about constipation, the patient may not feel empowered enough to bring that up with the provider. They may want to prioritize their pain medication refill or pain medication treatment over the constipation issue. The patient may also feel that they can manage their constipation on their own.”

Over-the-counter laxatives, as well as increased fluid and dietary fiber intake, can often be used to relieve OIC, but even when those treatments fail  — many doctors remain in the dark about what their patients are going through or that its interfering with their pain management.

Nearly one in four patients (23%)  said they were “very dissatisfied” with their OIC treatment. But only about 3% of doctors thought their patients were unhappy with their treatment.

Nearly half (49%) of patients with constipation reported moderate or complete interference with the ability of their opioid medication to control pain; but only 27% of doctors knew that. That knowledge is important because many patients  reduce how often they take pain medication in an attempt to self-manage their OIC  symptoms.

“The thing that surprised me most was the lack of awareness. The doctors didn’t even know,” said Wilson. “Clearly there needs to be education for patients and clinicians to have this conversation. There are adequate treatments out there. There are thing that can be used to treat constipation and this does impact patients and so that conversation needs to happen. Physicians need to ask and patients need to feel comfortable bringing it up with their doctors.”

Authored by: Pat Anson, Editor

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Kurt W.G. Matthies

Back in the late 1990s a clever pharmaceutical engineer devised a large molecule opiate antagonist — methylnaltrexone.

This molecule binds opiate receptors in the gut, but is too large to cross the blood brain barrier and enter the brain. Therefore, this medication can treat opioid-induced constipation while at the same time allowing opioid analgesics to treat pain.

When the medication was invented, the large pharmaceutical companies would not invest in this treatment. They figured the market was too small to justify the expense of a full-blown FDA study on efficacy and risk for a new medication. Besides, they were too busy developing half a dozen kinds of ED medications. That’s where the money was.

Enter the 21st century and the decade of pain. With millions of more patients being treated with opiate analgesics, all of a sudden the figures worked for methylnaltrexone.

Today we have a medication called Relistore based on this molecule. Unfortunately, it is under patent and very expensive. Most pharmacy benefits management companies do not include this on their list of covered drugs (the formulary).

What I’d like to see is a company like Purdue manufacture a long acting pain pill containing both opioid and methylnaltrexone. This one pill would simultaneously treat chronic pain and associated constipation. Good medicine?

Heng Hai

Beside birth trauma and aging, pelvic floor sag due to chronic straining during defecation. Constipation of what ever reason will make the person strain more during defecation and sag further to form a bad vicious cycle. Studies found great majority of constipation are obstructive type secondary to pelvic floor weakness especially the rear portion. Latest medical breakthrough bowel aid, in the form of special toilet seat with a clinically proven mechanical support at area behind anus during defecation. It facilitate defecation by straightening the rectal passage and enhance reflex of defecation. It is just an “mechanical laxative”. It should be recommended to patient with OIC to avoid exposing to side effect conventional pharmacological side effect.


Jaime, it sounds like you are doing what’s right for your patients benefit. However, you are the exception not the rule as many docs don’t take it as a serious issue! The key is education for both the doc & the patient & docs REALLY need to work on their relationship w/ the patient. We need to be able to feel secure & not be afraid to speak up or worry that we will be punished & our meds taken away, just for complaining & being upfront & honest about any problems we may be having.

In the past I have had docs do this to me, the 1st was for rx theft. I had dropped off my rx for 120 roxicet as I did every mo. on a Friday as I was going out of town. When I came to pick them up on mon. at walgreens, I was told that they had already been picked up! I called my doc & when he called walgreens, the pharmacist ( who I had already had a conflict & filed a complaint against him 2 mo. earlier, for giving my 6yr. daughter the wrong med that could have killed her had I not caught it!) He told my doc that I picked it up myself 10-15min after dropping it off & that I was getting pain meds from 3 other docs!! A complete lie. The 3 other docs. was 2 dentists & a referring doc! None of these were at the same time & each were separated by months and/or years! That pharm. was not even there when I dropped it off & when I asked to see the security tape showing proof, he told me that It has already been recorded over! Yeah right!, only after 4 days? My doc took his side & dismissed me as a patient!
When all the stuff about oxycontin 1st came out, it scared me and told my pain doc at that time, that I wanted to change meds. So he tapered me off 40mg 3 a day that I had been on for 4yrs. in only 4 days!! by the 5th day, I thought I was dying as I had never had withdrawal before. I called my doc & they had me come in just to tell me that if I was that sick due to withdrawal, then I had been abusing it or lying about my pain because real patient that were in real pain & taking it as ordered, did not go into withdrawal after tapering nor did they get addicted!! This was from a pain specialist & confirmed that he had no idea what he was talking about as he clearly did not know the difference between addiction & dependence! So no great loss there when he dismissed me, as I did not want to go to a stupid doc anyway!!


There are 2 reasons. #1 is pure & simple FEAR! Fear that if they complain or have problems, that the doc may take away meds. #2 Is that many docs do not listen or just dismisses the patients concerns. If the patent really pushes the issue, sad to say that many docs will either take them off the current med or change it to a weaker strength.
Because of all the judgment & persecution, chronic pain patients are afraid to be completely honest w/ their docs. & complain about anything! This is not just w/ their pain docs as many will not seek care for any other health issues w/ other docs because many docs will pass judgment or diagnose them the moment they read that the patient takes opioids!!
There is also a growing amount of patients who will avoid going to the er at all costs even if their life is in danger!! I have personally been through all of this & much worse over the last 20 years!
I have had bowel problems all my life due to a negligent birth injury & at only 6 was diagnosed w/ lazy colon as I have never been able to go more than twice per week.
So when I 1st started pain management almost 20 yrs. ago, it was a big concern. I had done ok until the formula of oxycontin was changed. After 30 days of being on it, I was having major problems & a lot worse pain & nothing was working & my movements were getting further apart until it got to the point of only having 1 or 2 per MONTH!! I ended up having to go to the er one night after it had been 3wks & was in more pain than I could have ever imagined possible ( even 36 hrs. of hard labor w/o an epidural & giving birth to a 9lb. baby, did not hurt this bad!) I was humiliated, judged, belittled, blamed, accused of being a drug seeker, abused, & all around mistreated, until I walked out w/o getting any help!!
I could have died & no one cared as I was treated like I deserved it for taking drugs, even though I was a legit patient & was in no way abusing them! They even called someone in to talk to me about detox & rehab!
Unfortunately this is a common experience that most chronic pain patients have to deal with! Until this attitude toward pain patients change, the abuse we get, the fear we feel, & the danger to our lives will continue & will only get worse!!!

I was surprised to read that 77% of the patients with constipation reported back pain. I always ask on their intake and history of any bowel or bladder problems, and continue to ask when I interview the patient. However, some patients are embarassed to discuss these issues. I guess we all have to be more aware as practitioners to cover all the bases.

A few things that you can do to help reduce constipation:
1. Eat more fiber, it will add bulk to your diet, which can reduce constipation
2. Drink more water, it is important for consistent bowel movements. When you have more water in your body, the easier it is to have a bowel movement. If you aren’t drinking enough water then, the body takes water from your stool, which results in dry, hard bowel movements.
3. Re-train your brain that you need to go to the bathroom, sit on the toilet half an hour after eating.
4. Go for a walk, this stimulates the bowels.
5. Give your colon a break with a colon cleanse