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OPIOID-INDUCED CONSTIPATION (OIC)

Diagnosis

In clinical trials, the prevalence of OIC varies widely from 15% to 95%.1,2 Much of this variation may be due to differences in patient perception of the condition, definitions of OIC and heterogeneity of study populations. However, in clinical practice, OIC is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options.3 

In the StOIC 1 real-world study, it was found that a simple question (“Are you constipated?”) is inadequate in diagnosing OIC.4 A thorough clinical assessment by an experienced clinician remains the gold standard for diagnosing/excluding OIC, and other types of constipation.4

Watch the video below to hear from expert speakers on the clinical problem of OIC, the need for consensus guidelines, the diagnosis of OIC and specific information on the Rome IV criteria, Bristol Stool Form Scale and the Bowel Function Index. Featuring Dr Francesca Caputo, Dr Andrew Davies, Dr Adam Farmer, Dr Palin Hungin, Dr Antoine Lemaire and Professor Jan Tack.

Expert opinion on the diagnosis of OIC

Tools to assist in the diagnosis of OIC

Rome IV criteria

One of the difficulties in diagnosing and reporting opioid-induced constipation is the lack of a standard medical definition. Clinicians and patients tend to define constipation differently.5 To address this issue, an international panel of experts convened to develop the Rome IV criteria for the diagnosis of constipation.3

According to the Rome IV criteria, OIC is present if patients report new or worsening of symptoms of constipation when initiating, changing or increasing opioid therapy that must include 2 or more of the following:3

  • Straining during at last 25% of defaecations
  • Sensation of incomplete evacuation for at least 25% of defaecations
  • Sensation of anorectal obstruction/blockage for at least 25% of defaecations
  • Lumpy or hard stools in at least 25% of defaecations
  • Manual manoeuvres to facilitate at least 25% of defaecations
  • Fewer than 3 defaecations per week

In addition, the following criteria must be met:

  • Loose stools are rarely present without the use of laxatives
Rome IV criteria

Bowel Function Index

The Bowel Function Index (BFI) is a validated tool developed specifically for OIC. It is a simple questionnaire that captures the patient’s personal experience of their constipation.6 Once the three questions have been discussed, add the three scores together and divide by three to get an average score. Scores of >30 are consistent with OIC.7

BFI

Bristol Stool Form Scale

The Bristol Stool Form Scale (BSFS) evaluates stool consistency and is a widely used tool which pictorially describes stool ranging from type 7 to type 1, with the latter representing separate hard lumps of stool. BSFS type 1 and 2 would be consistent with, but not specific for, OIC.8

These instruments are copyrighted by the Rome Foundation and use of them in clinical practice or for research use is prohibited without a license. Licenses can be obtained at: https://theromefoundation.org/products/copyright-and-licensing/

Copyright 2000 © by Rome Foundation. All Rights Reserved.

Bristol Stool Form scale

Assessment of OIC 

If a diagnosis of constipation is suspected, some points of enquiry could be:9 

  • What the person means by constipation and their normal pattern of defaecations
    • The person’s perception of a normal bowel habit may influence the diagnosis of constipation
  • The duration of constipation, and the frequency and consistency of stools, such as hard/small (pebble-like) or large stools (for example, do they block the toilet); any nocturnal symptoms
    • Consider the use of the Bristol Stool Form Scale to provide an objective record of the person’s stool form
  • How symptoms affect the person and impact on quality of life and daily functioning
    • Any self-help measures or drug treatments tried, including over-the-counter medication, and symptom response

Guidance taken from NICE Clinical Knowledge Summary "Constipation"; accessed at https://cks.nice.org.uk/topics/constipation/diagnosis/assessment/ 
 

Contents

Resources

Support Materials

Bristol Stool Form Scale

The Bristol Stool Form Scale is a visual aid to assist patients and healthcare practitioners identify constipation. There are 7 types of stool shown, with types 1 & 2 indicating constipation, 3 & 4 being the ideal stools (especially the latter) and 5, 6 & 7 tending towards diarrhoea.

Download

Support Materials

Rome IV Consensus Criteria

Clinicians and patients tend to define constipation differently. To address this issue, an international panel of experts convened to develop the Rome IV criteria for the diagnosis of constipation. This healthcare professional consultation guide provides a helpful overview of the Rome IV criteria.

Download

Support Materials

Bowel Function Index

The BFI is a validated tool developed specifically for OIC. It is a simple questionnaire that captures the patient’s personal experience of their constipation.

View Publication

For advice on the responsible use of opioids to treat pain, please click here

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  • References

    1. Panchal S, Müller-Schwefe P, Wurzelmann J. Int J Clin Pract. 2007;61(7):1181-1187.

    2. Benyamin R, Trescot A, Datta S, et al. Pain Physician. 2008;11:S105-S120.

    3. Farmer A, et al. United European Gastroenterol J. 2019;7(1):7-20.

    4. Davies A, Leach C, Butler C, et al. Pain. 2021;162:309-318.

    5. Arce D, Ermocilla C, Costa H. AFP. 2002;65(11):2283-2290.

    6. Ducrotté P, Caussé C. Curr Med Res Opin. 2012;28(3):457-466.

    7. Ueberall M, et al. J Int Med Res. 2011;39(1):41-50.

    8. Lewis S, Heaton K. Stool Form Scale as a Useful Guide to Intestinal Transit Time. Scand J Gastroenterol. 1997;32(9):920-924.

    9. NICE. Clinical Knowledge Summaries - Constipation - Assessment. September 2021. Available at: https://cks.nice.org.uk/topics/constipation/diagnosis/assessment/ Accessed August 2022.

    KKI/INT/KKI/0611 November 2023