Management of Cancer Patients with Opioid-Induced Constipation (OIC): The Experience of Three Italian Centres

Research Article

Ann Hematol Onco. 2023; 10(2): 1418.

Management of Cancer Patients with Opioid-Induced Constipation (OIC): The Experience of Three Italian Centres

Guardamagna V¹*, Salé EO¹, Paolo MDP², Nardulli P³, Giotta F³ and Gini G²

¹Istituto Europeo di Oncologia, Milan, Italy

²AOU Ospedali Riuniti, Ancona, Italy

³IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy

*Corresponding author: Guardamagna VIstituto Europeo di Oncologia, Milan, Italy

Received: January 10, 2023; Accepted: February 24, 2023; Published: March 03, 2023


Objectives: To present the Training on the field about OIC undertaken by three Italian oncological centres involving professionals of different sub-specialties.

Methods: Four on-site interactive meetings of multidisciplinary hospital teams; interactive presentation and discussion, questionnaires administration at the baseline and at the end of the field programme over two years (2019-2021). Outcomes evaluated by estimated increase of OIC diagnosis and OIC treatments.

Results: Shared principles about OIC prevention and management in all the steps (from laxatives to PAMORAs), and use of PROMs.

Participants were asked about their initial awareness at the inception of the Training on the field programme and their final experiences at the end.

Discussion: The experience of this Training on the field underlined the cardinal role of a constant teamwork in the Onco-ematology and Palliative Care Departments and the territory with a shared and tested algorithm. The proposed platform of activities is a call to action to mitigate the burden of pain and OIC if specialists act in concert during all the steps of the trajectory of cancer patients requiring opioid treatment. Multidisciplinary teamwork may help redefine and optimize doses and time schedules tailored to each patient and can contribute to designing controlled studies of OIC


Opioid-Induced Constipation (OIC) increases the suffering of cancer patients and can interfere with opioid therapies for cancer pain [1-4]. OIC is engendered by the agonism of opioid receptors in the gastrointestinal tract leading to reduced intestinal secretion and motility [5]. Although variable, the OIC prevalence in the populations of cancer patients is high (60-90%) [6,7]. OIC increases with age (e.g., in older patients, it can be five times more than in younger subjects) and in those undergoing palliative care was reported as 51-55% [7,8]. OIC does not depend on the opioid type and dose; thus, patients do not develop tolerance [9]. Although common and burdensome, OIC is overlooked and consequently undertreated [10]. The need for extended care for OIC is arising, especially with the increased use of opioids for pain therapy. In Italy, in 2014, the number of Defined Daily Doses (DDD) was 6.9, while in 2020; it was 7.6, with an increase of 1.7% [11].

The lack of a standardized definition of OIC may hinder the early detection of the disorder, even among specialists. The Rome IV criteria were set for Functional Gastrointestinal Disorders (FGIDs) and, in 2016, included OIC among the bowel disorders of chronic constipation as “a constipation triggered or worsened by opioids analgesics” [12]. Given that the clinical presentation of OIC and other FGIDs can be similar, a differential diagnosis is required [7,13]. Common misalignments in the perception and communication between healthcare providers and patients further hinder the improvement of OIC management and sustainment of optimal pain therapy [14-16].

Although some controlled trials have been recently published, the general level of evidence about OIC is still moderate or low. This limited evidence about OIC may explain the high number of expert consensus publications about best practices [7] and entails the need for studies with high-quality designs and structured analyses of local experiences provided by oncological specialists. Also, educational programmes devoted to OIC aimed at sharing experiences can increase awareness and optimize management [10]. The present study described the experience of a field training programme about OIC undertaken by three Italian centres that involved professionals of different sub-specialties in charge of oncological patients.

Materials and Methods

The present study was conducted according to the World Medical Association’s Declaration of Helsinki (1964, version 2013) [17] and Good Clinical Practice. The medical institutional board of IEO, AOU Ospedale Riuniti, and IRCCS Istituto Tumori Giovanni Paolo II approved this study.

Programme Structure

The Training on the field was performed on-site in four interactive meetings and targeted multidisciplinary teams of professionals working in oncological or palliative care centres and general practitioners involved in the pathways of diagnosis and care of OIC.

Interactive presentations performed by the experts of the three reference centres set the stage to open discussions about employing the most acknowledged guidelines, recommendations, and best practices of the consensus of advisory boards selected by the dedicated literature review. The follow-up was performed by simple questionnaires about the awareness of OIC, concepts or criteria of OIC management, knowledge and application of selected assessment, diagnostic, and monitoring tools for qualitative data to measure the outcomes.

The outcomes of the Training on the field were evaluated by the estimated increased OIC diagnosis, nutritional and lifestyle suggestions, and use of OIC treatments during the following months after the programme.

A literature search was conducted to select the most recent publications about OIC management focused on cancer patients and comparing the practical suggestions. The literature search was based on the database of the National Institutes of Medline (PubMed) and a manual search of the most recently published guidelines, recommendations, consensus, and best practices about OIC in cancer patients over the previous ten years. The search terms series included opioid-induced constipation, cancer, and OIC guidelines.


During the 2019-2021 periods, three Italian oncological centres were involved as expert centres in a field training programme for the practical management of OIC. The participants to the programme were:

• Oncologists: 15

• Haematologists: 3

• Pain therapy specialists: 4

• Radiotherapist: 1

• General practitioners (GPs): 4

• Clinical pharmacists: 7

• Nurses: 21

All participants acknowledged OIC as a central problem given the discomfort for patients with cancer, the delayed recovery, and discharge from the hospital. At the baseline, most of the participants felt inadequate for OIC management.

Prophylaxis and Treatments

Participants acknowledged lifestyle changes as an essential suggestion for the patient to prevent or lessen OIC during the opioid treatment. The shared suggestions furthered prolonging prophylaxis with laxatives during opioid therapy, especially for patients at high risk of developing OIC. For the OIC prophylaxis, most participants indicated a preference for osmotic laxatives and, as a first-line treatment for the management of OIC, a combination of stimulant laxatives. The therapeutic features of laxatives for the prevention and management of OIC were outlined and shared among the participants:

• Mass laxatives: increase residual in the colon, reabsorb water, stimulate the propulsion;

• Emollients and lubricants: enhance the link with water in the bowel lumen to allow a more interaction of the solid faeces with water, thus easing the passage of the faeces;

• Osmotic laxatives: draw water in the bowel according to the osmotic gradient;

• Stimulant laxatives: act on the colon, stimulate the intestinal motility or decrease the absorption of fluids in the colon, favour the secretions.

At the end of the programme, participants shared other principles for the management of OIC. In the case of inefficacy, the laxative could be substituted or associated with another one of different categories. However, the use of laxatives is often insufficient for OIC management and can cause gastrointestinal side effects. In patients who are refractory to laxatives, the OIC treatment guidelines include the prescription of Peripheral Mu-Opioid Receptor Antagonists (PAMORAs). Therefore, in the case of diagnosis of OIC, the participants in the field training considered: a) a combination of two laxatives and b) a PAMORA plus a laxative. If the PAMORA treatment fails, the most common rescue medications were evacuative enemas or glycerine, followed by Senna or Bisacodyl, or “others”.


As symptom is defined a “subjective perception expressed with a high level of subjectivity”, the patient is the most suitable subject to evaluate the symptoms. The Edmonton Symptom Assessment System (ESAS) is a simple and multidimensional tool that can be used quickly and assure the patients' compliance even in general compromised conditions. The ESAS scale was modified by including OIC and inserted in the clinical charts of the patients with diagnosed OIC. Also, a questionnaire for patients was added to the clinical chart with adjustments according to the local settings. Once defined and started the therapy for constipation, the Bristol Stool Form Scale (BSFS) can be a helpful diagnostic tool for patient monitoring (Figure 1). The BSFS enables the categorization form and compactness of human faeces. The form and compactness of the faeces and their permanence time in the colon are statistically correlated.