Opioids and Laxatives

- July 1, 2015

Clinical guidelines recommend that patients prescribed opioids should be co- prescribed laxatives. However, opioid induced constipation remains a common local and international problem associated with morbidity and mortality occurring in up to 90% of those taking opioids. Within CDHB hospitals from July 2010 to June 2014, 693 out of 827 cases of patients (84%) with constipation coded as an adverse drug reaction were linked to opioids. As a result a study to evaluate the extent of laxative co-prescribing with opioids on hospital discharges at CDHB was recently studied and is reported on here.

CDHB Guidelines

Some guidance on opioid-induced constipation is provided in the CDHB Blue Book (see below). There are also departmental constipation guidelines throughout the DHB. These aim to avoid constipation by initiating laxatives at the same time as opioids. They also provide guidance on what to do once constipation, including faecal impaction, has already occurred.

Recommendations

Blue Book (Pain in oncology/palliative care patients)

  • Regular stool softeners (e.g. docusate) with stimulants (e.g bisacodyl, senna) or a combination laxative such as docusate and senna should be used routinely when taking opioids
  • Macrogol 3350 with electrolytes (Lax-sachets™) requires Special Authority and is recommended for faecal impaction (up to 8 sachets per 24 hours) or can be used as chronic constipation treatment (up to 3 sachets a day)

Note The Blue Book also discussed PinoraxTM which is no longer available.

Poster campaign

Regular Opioids=Regular Laxatives

4 easy steps for prevention

Prescribe Docusate and senna

(Unless major GI surgery/obstruction-confirm plan with senior staff. Still follow the other 3 steps)

Administer Give laxatives

(Do not need to wait until day 3 Bowels Not Open (BNO). Explain to patient why this is important.)

Monitor  Record bowel motions on the observation chart and number of days BNO in nursing care plan.
Act Ensure action taken by day 3 BNO.

Ensure laxatives are being used.

Adjust dose as needed.

First Line

Chart when opioids are initiated

Docusate & Senna (LaxsolTM) 1-2 tablets twice a day

Second Line

Mineral Oil Enema 1 once a day prn
Glycerol Suppositories 3.6 g 1-2 a day prn
MicoletteTM Enema 1 prn
Macrogol 3350 (Lax-SachetsTM, MovicolTM) 1-2 sachetsup to twice a day

Note Maximum 8 sachets per day for impaction (Use is restricted by HML: Lactulose must have been tried and rectal preparations considered.)

 

Opioids and Laxatives Audit

Aim
To quantify and describe laxative co-prescribing in patients prescribed opioids on discharge from Christchurch hospitals.

Method
Consecutive patients discharged from Christchurch hospitals over two weeks in 2014 were studied. Discharge summaries and dispensing data were reviewed. Data collected included demographics, opioid/laxative dose/ frequency, other constipating drugs.

Results
Of 1267 patients discharged, 321 were prescribed opioids on discharge. Laxatives were prescribed for 141/321 (44%, 95%-confidence interval 39%-49%). (See Table 1)

Table 1. Opioid and laxative co- prescribing

Patient (n=321) Laxative (n=141) No laxative (n=180)
Age (median, range) (yrs) 54 (16-96) 54 (17-96)     53 (16-93)
Sex (M/F)  131/190  52/89 79/101
Strong opioids        Total 83 43 40
morphine 37 26 11
oxycodone 16 5 11
fentanyl 5 3 2
methadone 4 0 4
combination * 21 9 12
Weak opioids          Total 238 95 143
codeine 147 70 77
tramadol 85 24 61
combination 6 1 5
Other constipating meds 115 56 59

* at least one strong opioid; 18/21 were in combination with a weak opioid.

Laxatives prescribed are shown below. Docusate and senna (LaxsolTM) was most commonly prescribed (120/321 patients).

Discussion

  • Only 44% of patients prescribed opioids were co-prescribed laxatives on discharge.
  • Laxative co-prescribing varied by opioid
  • There were significantly lower rates of laxative co-prescribing with tramadol (expected) and oxycodone (unexpected).
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