Recommendations for the management of opioid-induced constipation - how to improve usability in clinical practice

Figures & data

Table 1. Overview of current guidelines for management of opioid-induced constipation.

Reference	Title	Year	Published in
Brenner et al. [20]	An evidence-based review of novel and emerging therapies for constipation in patients taking opioid analgesics	2014	The American Journal of Gastroenterology
Drewes et al. [21]	Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction – Recommendations of the Nordic Working Group	2016	Scandinavian Journal of Pain
O’Brien et al. [22]	European Pain Federation position paper on appropriate opioid use in chronic pain management	2016	European Journal of Pain
Müller-Lissner et al. [23]	Opioid-induced constipation and bowel dysfunction: a clinical guideline	2017	Pain Medicine
Brenner et al. [24]	Opioid-related constipation in patients with non-cancer pain syndromes: a review of evidence-based therapies and justification for a change in nomenclature	2017	Current Gastroenterology Reports
Crockett et al. [7]	American Gastroenterological Association Institute guideline on the medical management of opioid-induced constipation	2019	Gastroenterology
Farmer et al. [8]	Pathophysiology and management of opioid-induced constipation: European expert consensus statement	2019	United European Gastroenterology Journal

Table 2. Overview of studies comparing proposed simple guidelines to standard guidelines.

Reference	Medical area	Aim	Validation process	Main findings
Avansini et al [33]	Hypertension	To assess the effect of a simple guideline on optimal antihypertensive treatment	Comparison of cases (n = 1049) treated by general practitioners (n = 48) according to the simple guideline and cases (n = 722) treated by general practitioners (n = 42) according to standard procedure	Improved systolic and diastolic blood pressure control in the intervention cohort compared to the control cohort Increased patient compliance with therapy in the intervention group
Ting [34]	Asthma	To assess the effect of a simple guideline for asthma treatment	Data extraction on asthma-related emergency room visits and hospitalization from a target community, in which the simple guideline was made available for primary care physicians	Decreased rates of asthma-related emergency room visits (22.5%) and hospitalizations (26.9%)
Wong et al [35]	Gentamicin dosing	To explore if a simple guideline for calculation of gentamycin dosing in neonates and children leads to fewer dosing errors	Nurses (n = 51) were asked to perform four standardized calculations of gentamycin dosing. 2 calculations were made using the standard guideline, and 2 calculations were made using the simple guideline	Higher proportion of correct calculations when applying the simple guideline
Cabrera et al [36]	Chronic obstructive pulmonary disease (COPD)	To validate a simple dyspnea-based guideline for treatment of COPD	Assessment of cases diagnosed with COPD (n = 100) using the standard guideline and new simple guideline	No differences in treatment recommendations when applying the simplified guideline compared to the more comprehensive guideline
Russell et al [37]	Enteric fever	To assess a simple guideline for public health management of enteric fever	Analysis of all cases of enteric fever in England before implementation of a simple guideline (n = 989) and all cases after implementation of the simple guideline (n = 637)	No differences in secondary transmission of enteric fever Reduced burden for both health care professionals and patients
Bates et al [38]	Minor skin lesions	To validate a simple guideline for inpatient nursing care of minor skin lesions	Comparison of wound care prior to (n = 231) and after (n = 260) implementation of the guideline Survey regarding self-rating of knowledge before (n = 89) and after (n = 96) implementation of the guideline	Percentage of appropriately treated minor skin lesions improved from 45% to 80% Nurses self-rating of knowledge on appropriate treatment improved from 18% to 57% agreement

Figure 1. Proposed simplified recommendations for the management of opioid-induced constipation. See text for elaboration.

Figure 2. Biggest challenges and unmet needs of current OIC guidelines. On the left, percentage of healthcare practitioners reporting specific issues with the current guideline is displayed. On the right, ability of the new simplified recommendations to improve individual issues is shown.

Figure 3. Individual scores regarding the credibility, clarity, relevance, and usability of the current guideline and new simplified recommendations. Each domain was rated by healthcare practitioners (n = 52) on a 7-point Likert scale ranging from 1 (not at all) to 7 (very). Mean and standard deviation (SD) are shown to the right. **p < 0.01, ***p < 0.001.

Figure 4. Pie charts displaying perception of the benefit of the new simplified recommendations, over and above the current guideline.

Brenner DM, Chey WD. An evidence-based review of Novel and emerging therapies for constipation in patients taking opioid analgesics. Am J Gastroenterol Suppl. 2014;2(1):38–46. doi: 10.1038/ajgsup.2014.8

 Google Scholar

Drewes AM, Munkholm P, Simrén M, et al. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–recommendations of the Nordic Working Group. Scand J Pain. 2016;11(1):111–122. doi: 10.1016/j.sjpain.2015.12.005

 PubMedGoogle Scholar

O’Brien T, Christrup LL, Drewes AM, et al. European pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain (United Kingdom). 2017;21(1):3–19. doi: 10.1002/ejp.970

 PubMed Web of Science ®Google Scholar

Müller-Lissner S, Bassotti G, Coffin B, et al. Opioid-induced constipation and bowel dysfunction: a clinical guideline. Pain Med. 2017;18(10):1837–1863. doi: 10.1093/pm/pnw255

 PubMed Web of Science ®Google Scholar

Brenner DM, Stern E, Cash BD. Opioid-related constipation in patients with non-cancer pain syndromes: a review of evidence-based therapies and justification for a change in nomenclature. Curr Gastroenterol Rep. 2017;19(3):2–7. doi: 10.1007/s11894-017-0560-2

 PubMedGoogle Scholar

Crockett SD, Greer KB, Heidelbaugh JJ, et al. American Gastroenterological Association Institute guideline on the medical management of opioid-induced constipation. Gastroenterology. 2019 Jan 1;156(1):218–226. doi: 10.1053/j.gastro.2018.07.016

 PubMed Web of Science ®Google Scholar

Farmer AD, Drewes AM, Chiarioni G, et al. Pathophysiology and management of opioid-induced constipation: European expert consensus statement. UEG J. 2019 Feb 1;7(1):7–20. doi: 10.1177/2050640618818305

 Google Scholar

Avanzini F, Corsetti A, Maglione T, et al. Simple, shared guidelines raise the quality of antihypertensive treatment in routine care. Am Heart J. 2002 Oct;144(4):726–732. doi: 10.1016/S0002-8703(02)00149-7

 PubMed Web of Science ®Google Scholar

Ting S. Multicolored simplified asthma guideline reminder (MSAGR) for better adherence to national/global asthma guidelines. Ann Allergy Asthma Immunol. 2002;88(3):326–330. doi: 10.1016/S1081-1206(10)62016-9

 PubMed Web of Science ®Google Scholar

Wong E, Taylor Z, Thompson J, et al. A simplified gentamicin dosing chart is quicker and more accurate for nurse verification than the BNFc. Arch Dis Child. 2009 Jul;94(7):542–545. doi: 10.1136/adc.2007.137026

 PubMed Web of Science ®Google Scholar

Cabrera C, Casanova C, Martín Y, et al. Agreement between a simple dyspnea-guided treatment algorithm for stable COPD and the GOLD guidelines: a pilot study. Int J Chron Obstruct Pulmon Dis. 2016 Jun 8;11(1):1217–1222. doi: 10.2147/COPD.S100853

 PubMedGoogle Scholar

Russell K, Addiman S, Grynszpan D, et al. The impact of new national guidance for the public health management of enteric fever in England. Public Health. 2018 Jan 1;154:79–86. doi: 10.1016/j.puhe.2017.10.018

 PubMed Web of Science ®Google Scholar

Bates AN, Ercolano E. Development and implementation of a simple wound care guideline for minor skin lesions: a quality improvement project. J Wound, Ostomy Cont Nurs. 2021;48(4):285–291. doi: 10.1097/WON.0000000000000778

 PubMed Web of Science ®Google Scholar

Data availability statement

The data presented in this study are available on request from the corresponding author.