A 40-year-old man presents to urgent care with lower abdominal pain that has been intermittent for months. He reports taking oxycodone daily for chronic back pain, and even though he has tried “every laxative in the store,” he often goes a week without a bowel movement. He denies no nausea, vomiting, gastrointestinal bleeding, and weight loss. His vital signs are normal, and his examination demonstrates a soft, nontender, and nondistended abdomen with present but hypoactive bowel sounds. He takes oxycodone 10 mg twice a day and a nonsteroidal anti-inflammatory drug on occasion. You recognize that the likely etiology of his symptoms is opioid-induced constipation.
Which of the following is the best next step in managing this patient’s opioid-induced constipation?
- Discontinue oxycodone and initiate high-fiber supplements.
- Refer the patient to the emergency department immediately for further evaluation.
- Recommend bulk-forming laxatives alone with increased water intake.
- Begin combination therapy with an osmotic and stimulant laxative and refer him to a gastrointestinal specialist.
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Correct Answer: d. Begin combination therapy with an osmotic and stimulant laxative.
Opioids reduce peristalsis and increases fluid absorption, leading to hard, infrequent stools. It is a complicated process that is sometimes—but not always—amenable to treatment with standard laxatives. Discontinuing opioids abruptly may be unsafe and unrealistic for chronic pain management. You would also not want to refer him to the emergency department, as his condition is not emergent and the ED would most likely refer him to a gastrointestinal specialist. You informed him that there may indeed be other options available by prescription, and that while these are not yet commonly prescribed by UC clinicians, you would provide a referral to a gastroenterologist with expertise in this area. In the meantime, you recommended that he initiate a regimen combining an osmotic and stimulant laxative daily until he can see the specialist.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
