Abstract
Purpose: Opioid-induced constipation (OIC) is highly prevalent in patients with cancer-related pain on opioid analgesics and has negative consequences on physical and psychological well-being and quality of life. Oncology clinical practice guidelines recommend the use of osmotic and stimulant laxatives for the prevention and management of opioid-induced constipation, not stool softeners such as docusate sodium. Prescribing practices continue to fall behind these recommendations. Methods: This quality improvement project revised the laxative options available in the standard admission order set in the electronic medical record. Specifically, docusate sodium was removed and replaced with senna and polyethylene glycol 3350. Results: A total of 2,742 patient admissions preintervention were compared to 2,752 admissions postintervention. The number of orders for docusate (p < .001) and docusate-senna (p = .002) orders decreased significantly after the intervention, in addition to the number of OIC diagnoses (p < .001). However, the number of orders for polyethylene glycol (p = .559), senna (p = .582), other laxatives (p = .245), or functional bowel disorder medications (p = .533) did not change significantly. No significant differences were observed in the frequency of laxative orders placed within 24 hours of an opioid order, number of laxatives prescribed at discharge, admissions related to bowel-related complications, or length of stay. Conclusions: Interventions utilizing the electronic medical record can facilitate evidence-based management of OIC. Development of clinical practice guidelines and tailoring these interventions further is needed to adapt this approach at other institutions and sustain practice change.
References
ALMouaalamy, N. (2021). Opioid-induced constipation in advanced cancer patients. Cureus, 13(4), e14386. https://doi.org/10.7759/cureus.14386
Al-Naeem, M., Al Qadire, M. I., & Alasad, J. (2018). Effects of prophylactic laxatives for opioid-induced constipation on constipation severity and quality of life among patients with cancer. Open Journal of Nursing, 8, 505–517. https://doi.org/10.4236/ojn.2018.88038
Argoff, C. E. (2020). Opioid-induced constipation: A review of health-related quality of life, patient burden, practical clinical considerations, and the impact of peripherally acting μ-opioid receptor antagonists. The Clinical Journal of Pain, 36(9), 716–722. https://doi.org/10.1097/AJP.0000000000000852
Brown, T. J., Keshvani, N., Gupta, A., Yang, H., Agrawal, D., Le, T. C.,…Alvarez, C. A. (2020). Rates of appropriate laxative prophylaxis for opioid-induced constipation in veterans with lung cancer: A retrospective cohort study. Supportive Care in Cancer. Advance online publication. https://doi.org/10.1007/s00520-020-05364-6
Canadian Society of Palliative Care Physicians. (2020). Five things physicians and patients should question. Choosing Wisely Canada. https://choosingwiselycanada.org/palliative-care
Chineke, I., Adams Curry, M., Bell, W., Flood, D., Mishra, P., Power, S., & Bernal-Mizrachi, L. (2020). Improving documentation of pain and constipation management within the cancer center of a large urban academic hospital. JCO Oncology Practice, 16(3), e251–e256. https://doi.org/10.1200/JOP.19.00332
Corli, O., Santucci, C., Corsi, N., Radrezza, S., Galli, F., & Bosetti, C. (2019). The burden of opioid adverse events and the influence on cancer patients’ symptomatology. Journal of Pain & Symptom Management, 57(5), 877–885. https://doi.org/10.1016/j.jpainsymman.2018.12.328
Crockett, S. D., Greer, K. B., Heidelbaugh, J. J., Falck-Ytter, Y., Hanson, B. J., & Sultan, S. (2019). American Gastroenterological Association Institute guideline on the medical management of opioid-induced constipation. Gastroenterology, 156(1), 218-226. https://doi.org/10.1053/j.gastro.2018.07.016
Davies, A. N., Leach, C., Butler, C., Patel, S. D., Shorthose, K., & Batsari, K. (2023). Opioid-induced constipation: A stepwise treatment algorithm feasibility study. BMJ Supportive & Palliative Care, 13(e2), e446–e453. https://doi.org/10.1136/bmjspcare-2020-002754
De Bruin, F., Hek, K., van Lieshout, J., Verduijn, M., Langendijk, P., Bouvy, M., & Teichert, M. (2019). Laxative co-medication and changes in defecation patterns during opioid use. Journal of Oncology Pharmacy Practice, 25(7), 1613–1620. https://doi.org/10.1177/1078155218801066
Edrees, H., Amato, M. G., Wong, A., Seger, D. L., & Bates, D. W. (2020). High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: Override appropriateness and adverse drug events. Journal of the American Medical Informatics Association, 27(6), 893–900. https://doi.org/10.1093/jamia/ocaa034
Engle, A. L., & Winans, A. (2021). Rethinking docusate’s role in opioid-induced constipation: A critical analysis of the evidence. Journal of Pain & Palliative Care Pharmacotherapy, 35(1), 63–72. https://doi.org/10.1080/15360288.2020.1828529
Fakheri, R. J., & Volpicelli, F. M. (2019). Things we do for no reason: Prescribing docusate for constipation in hospitalized adults. Journal of Hospital Medicine, 14(2), 110–113. https://doi.org/10.12788/jhm.3124
Farmer, A. D., Drewes, A. M., Chiarioni, G., De Giorgio, R., O’Brien, T., Morlion, B., & Tack, J. (2019). Pathophysiology and management of opioid-induced constipation: European expert consensus statement. United European Gastroenterology Journal, 7(1), 7–20. https://doi.org/10.1177/2050640618818305
Ginex, P. K., Hanson, B. J., LeFebvre, K. B., Lin, Y., Moriarty, K. A., Maloney, C.,…Morgan, R. L. (2020). Management of opioid-induced and non-opioid-related constipation in patients with cancer: Systematic review and meta-analysis. Oncology Nursing Forum, 47(6), E211–E224. https://doi.org/10.1188/20.ONF.E211-E224
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? The Journal of Continuing Education in the Health Professions, 26(1), 13–24. https://doi.org/10.1002/chp.47
Hawley, P. H., & Byeon, J. J. (2008). A comparison of sennosides-based bowel protocols with and without docusate in hospitalized patients with cancer. Journal of Palliative Medicine, 11(4), 575–581. https://doi.org/10.1089/jpm.2007.0178
Jesuyajolu, D. A., Abubakar, A. K., Kowe, T., Ogunlade, S., Abioye, A. I., Tangeman, J.,…Omotayo, M. O. (2023). The management of opioid-induced constipation in cancer and advanced illness: A meta-analysis. Journal of Pain and Symptom Management, 67(4), E285–E297. https://doi.org/10.1016/j.jpainsymman.2023.12.010
Kaye, A. J., Atkin, S., Ziobro, A., Donnelly, J., & Ahlawat, S. (2023). Analysis of the economic burden of docusate sodium at a United States tertiary care center. Hospital Practice (1995), 51(3), 168–173. https://doi.org/10.1080/21548331.2023.2225964
Larkin, P. J., Cherny, N. I., La Carpia, D., Guglielmo, M., Ostgathe, C., Scotté, F.,…ESMO Guidelines Committee. (2018). Diagnosis, assessment, and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Annals of Oncology, 29(Suppl. 4), iv111–iv125. https://doi.org/10.1093/annonc/mdy148
Lexicomp. (2023). Laxatives, classification, and properties. Lexi-Drugs Online. https://online.lexi.com.
Lipshaw, M. J., Zamor, R. L., Carson, R., Mallon, D., Sobolewski, B., Vukovic, A. A., & Kurowski, E. M. (2021). Evidence-based standardization of constipation management in the emergency department: A quality improvement study. Pediatric Quality & Safety, 6(2), e395. https://doi.org/10.1097/pq9.0000000000000395
Liu, S., Gnjidic, D., Patanwala, A. E., Rubin, G., Nielsen, M., & Penm, J. (2020). Effect of an electronic medical record design modification on laxative co-prescribing among hospitalised patients taking opioids: A before-and-after study. International Journal of Medical Informatics, 140, 104172. https://doi.org/10.1016/j.ijmedinf.2020.104172
Lucy, A. T., Massey, G. B., Cobbs, P., Miltner, R. S., Cox, M. G., Russ, K.,...Parmar, A. (2024). Successful de-implementation of an ineffective practice: The fall of docusate. American Journal of Surgery, 228, 126–132. https://doi.org/10.1016/j.amjsurg.2023.08.023
MacMillan, T. E., Kamali, R., & Cavalcanti, R. B. (2016). Missed opportunity to deprescribe: Docusate for constipation in medical inpatients. The American Journal of Medicine, 129(9), 1001.e1–1001.e7. https://doi.org/10.1016/j.amjmed.2016.04.008
Moore, A., Johnes, S. K., Kapil, A., & Lee, S. (2019). Physician perspective on inpatient constipation and the use of the EMR for prevention [Abstract]. The American Journal of Gastroenterology, 114, S1554. https://doi.org/10.14309/01.ajg.0000600804.22430.b2
National Comprehensive Cancer Network. (2023a). Clinical Practice Guidelines in Oncology: Palliative care. https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
National Comprehensive Cancer Network. (2023b). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain. https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
Roeland, E. J., Sera, C. J., & Ma, J. D. (2020). More opioids, more constipation? Evaluation of longitudinal total oral opioid consumption and self-reported constipation in patients with cancer. Supportive Care in Cancer, 28(4), 1793–1797. https://doi.org/10.1007/s00520-019-04996-7
Saha, S., Nathani, P., & Gupta, A. (2020). Preventing opioid-induced constipation: A teachable moment. JAMA Internal Medicine, 180(10), 1371–1372. https://doi.org/10.1001/jamainternmed.2020.3285
Sayuk, G. S., Yu, Q. T., & Shy, C. (2023). Management of constipation in hospitalized patients. Journal of Clinical Medicine, 12(19), 6148. https://doi.org/10.3390/jcm12196148
Shair, K. A., Espinosa, S. M., Kwon, J. Y., Gococo-Benore, D. A., McCormick, B. J., Heckman, M. G.,…Cowdell, J. C. (2023). A quality improvement approach to decrease the utilization of docusate in hospitalized patients. Quality Management in Health Care, 32(4), 263–269. https://doi.org/10.1097/QMH.0000000000000406
Tarumi, Y., Wilson, M. P., Szafran, O., & Spooner, G. R. (2013). Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients. Journal of Pain and Symptom Management, 45(1), 2–13. https://doi.org/10.1016/j.jpainsymman.2012.02.008
Van Orne, J. (2021). Implementation of a nurse-driven pediatric bowel management algorithm: A quality improvement project. Journal of Pediatric Nursing, 61, 224–228. https://doi.org/10.1016/j.pedn.2021.06.007
von Maltzahn, M., Tanzini, R. M., Leu, R., & Wong, C. L. (2022). When less may be more: Discontinuing docusate from a standardized hospital order set. Journal of Geriatric Oncology, 13(1), 111–113. https://doi.org/10.1016/j.jgo.2021.06.005
World Health Organization. (2020). WHO’s cancer pain ladder for adults. https://www.who.int/cancer/palliative/painladder/en/
Yang, A., Lam, T., Jierjian, E., Walden, S. G., & Coulson, E. E. (2022). An evaluation of docusate monotherapy and the prevention of opioid-induced constipation after surgery. Journal of Pain & Palliative Care Pharmacotherapy, 36(1), 18–23. https://doi.org/10.1080/15360288.2021.1884167
