What is the treatment for chronic small bowel obstruction due to opioid (narcotic analgesic) use?

From the Guidelines

Treatment of chronic small bowel obstruction due to opioid use primarily involves opioid dose reduction or discontinuation when possible, combined with a bowel regimen to restore normal motility, as recommended by the most recent and highest quality study 1. The cornerstone of treatment is a scheduled stimulant laxative such as senna (8.6-17.2 mg twice daily) or bisacodyl (5-10 mg daily), often combined with an osmotic agent like polyethylene glycol (17 g in 8 oz water daily) 1. For more severe cases, methylnaltrexone (450 mg orally once daily or 12 mg subcutaneously every other day) may be used as it blocks peripheral opioid receptors without affecting pain control, as shown in a study published in 2021 1. Naloxegol (12.5-25 mg daily) is another peripheral opioid antagonist option that can be considered 1. Patients should increase fluid intake to 2-3 liters daily and physical activity as tolerated, and dietary modifications including increased fiber (25-30 g daily) can help, though fiber should be introduced gradually 1. Prokinetic agents like metoclopramide (10 mg before meals) may provide additional benefit, especially if gastroparesis is suspected 1. It is essential to note that opioids should not be prescribed for chronic gastrointestinal pain due to disorders of gut-brain interaction, and if patients are already on opioids, these medications should be prescribed responsibly and discontinued when possible, as recommended by a 2021 expert review 1. These interventions work by counteracting opioids' effect on μ-receptors in the gastrointestinal tract, which normally decrease peristalsis, increase sphincter tone, and reduce secretions. If conservative management fails, surgical intervention may be necessary, particularly if there are signs of complete obstruction or perforation. Key considerations in the management plan include:

• Determining and ordering primary symptoms
• Excluding mechanical obstruction
• Evaluating contributing factors, including drug therapy and psychosocial issues
• Performing nutritional assessment and starting nutritional treatment
• Establishing a clinical diagnosis and considering surgical options
• Regular review and reconsideration of diagnosis as the clinical situation changes, as outlined in a 2020 study on the management of adult patients with severe chronic small intestinal dysmotility 1.

From the FDA Drug Label

The efficacy of lubiprostone in the treatment of OIC in patients receiving opioid therapy for chronic, non-cancer-related pain was assessed in three randomized, double-blinded, placebo-controlled studies.

The proportion of patients in Study 1 qualifying as an "overall responder" was 27.1% in the group receiving lubiprostone 24 mcg twice daily compared to 18.9% of patients receiving placebo twice daily (treatment difference = 8.2%; p-value = 0.03).

The efficacy of RELISTOR tablets in the treatment of OIC in patients with chronic non-cancer pain was evaluated in a randomized, double-blind, placebo-controlled study (Study 1).

A responder analysis was performed which defined the proportion of patients with 3 or more spontaneous bowel movements (SBMs)/week, with an increase of 1 or more SBM/week over baseline, for 3 or more out of the first 4 weeks of the treatment period.

Treatment of Chronic Small Bowel Obstruction due to Opioid Use:

• Lubiprostone 24 mcg twice daily may be effective in treating opioid-induced constipation (OIC) in patients with chronic non-cancer pain, with 27.1% of patients qualifying as "overall responders" compared to 18.9% of patients receiving placebo.
• Methylnaltrexone (RELISTOR) 450 mg orally once daily may also be effective in treating OIC in patients with chronic non-cancer pain, with 52% of patients responding to treatment compared to 38% of patients receiving placebo.
• However, there is no direct information in the provided drug labels that specifically addresses the treatment of chronic small bowel obstruction due to opioid use.
• Therefore, the treatment of chronic small bowel obstruction due to opioid use should be approached with caution and under the guidance of a healthcare professional, as the available evidence may not be directly applicable to this specific condition 2 3.

From the Research

Treatment of Chronic Small Bowel Obstruction due to Opioid Use

• The treatment of chronic small bowel obstruction due to opioid use typically involves a multi-faceted approach, including pharmacological therapies and supportive care 4, 5, 6.
• Pharmacological therapies for opioid-induced constipation (OIC) include μ-opioid receptor antagonists (such as methylnaltrexone, naloxone, and alvimopan), lubiprostone, and prucalopride 4, 5, 6.
• μ-Opioid receptor antagonists have been shown to be safe and effective for the treatment of OIC, with a relative risk of failure to respond to therapy of 0.69 (95% CI 0.63-0.75) 6.
• Lubiprostone, a locally acting type 2 chloride channel activator, has also been shown to be effective in treating OIC, with a significant increase in responder rates compared to placebo 5, 6.
• Supportive care for patients with chronic small bowel obstruction due to opioid use may include intravenous fluid resuscitation, analgesia, and nasogastric tube placement to decompress the bowel 7.

Management of Small Bowel Obstruction

• The management of small bowel obstruction (SBO) typically involves determining the need for operative vs. nonoperative therapy, with surgery indicated for strangulation and those who fail nonoperative therapy 7.
• Imaging studies, such as computed tomography and ultrasound, are reliable diagnostic methods for SBO, while plain radiographs may not be sufficient to exclude the diagnosis 7.
• Patients with SBO may require hospital admission and surgical service evaluation, with a focus on optimizing diagnosis and management 7.

Opioid-Induced Bowel Dysfunction

• Opioid-induced bowel dysfunction (OBD) is a prevalent condition that can lead to reduced opioid use, human suffering, and a high burden on the healthcare system 5, 8.
• Opioid-induced constipation (OIC) is the most troublesome aspect of OBD, for which standard laxatives are often ineffective 4, 5, 6, 8.
• The development of quaternary opioid receptor antagonists and other targeted therapies may provide effective treatment options for OBD 8.