All About Telehealth for Opioid-Induced Constipation Telehealth allows doctors to care for people virtually over a phone call, text message, or most commonly, video chat. Although some situations require an in-person visit, telehealth is a great option when you can't get to the doctor's office for your OIC. If you're new to telehealth, here's what you need to know. Medicare will cover telehealth visits just like in-person visits, but state Medicaid programs and private insurers vary, so confirm your coverage in advance. With telehealth, even though you're not in the doctor's office, your private health information is still covered by HIPAA, so it will remain confidential and secure. Although your gastroenterologist can't give you a physical exam via telehealth, they can write prescriptions and offer quality care, especially if you prepare in advance. Before your telehealth appointment:- Ask your gastroenterologist if you need to make any dietary changes ahead of time- List any OIC symptoms, including dates and severity- Note any side effects from your OIC medications or therapies, such as nausea, vomiting, diarrhea, or headache- Write down any questions you have for your gastroenterologist- Record your vital signs if you own a blood pressure monitor, thermometer, or another device- Compile a list of your health conditions and all medications, including supplements, lubricants, suppositories, and enemas - Charge your computer or phone- Make sure your internet is reliable- Download any telehealth apps your specific provider may require- Find a quiet, private space to conduct the call- Be prepared with pen and paper or a note-taking app Turn to Healthgrades to connect with the right gastroenterologist to treat OIC via telehealth. And share this video to spread the word!

Dr. Dorette: In opioid-induced constipation, the root cause is not the medication. The root cause is pain. Dr. Moore: Opioid-induced constipation is an expected effect of taking an opiate. It's hard to treat because it's hard for patients to figure out what to do. Dr. Patel: There is an old adage that the hand that prescribes opioids also needs to prescribe a bowel prophylactic regimen. Tamara Freuman: We're really trying to work on interventions that address all aspects of the underlying problem. Dr. Erber: I think the emphasis with OIC really has to be in prophylaxis. Dr. Dorette: One of the ways that we work to relieve pain is by virtue of diet. Dr. Patel: You want to make sure that you have adequate fiber intake and adequate hydration. Dorothy: The opiates are going to dry the system out. Beth Warren: So drink tons of fluid to hydrate yourself to pass that fiber through. Dr. Moore: One way to avoid any kind of constipation is to be active, to move around a lot. Dorothy: Opiate slows everything in the body, in the digestive system, down. Dr. Moore: Lifestyle changes may be the first step. If those don't work, then we move to medications which might include laxative stimulants. Dr. Patel: Most of them are over-the-counter and there are multiple options. It depends on what the patient's bowel habits are at baseline. Do they normally have hard stools? They probably could benefit from a stool softener. Do they have a motility issue? Put them on a promotil medication. Dr. Moore: That works by stimulating the bowels to just move faster. Dr. Patel: If one type of laxative is not enough, that can be combined with another. Dr. Moore: They don't all work immediately, so one needs to know the type of medicine that they're using and what to expect. Dr. Erber: If lifestyle modification, dietary interventions don't work, typically we move to prescription therapy. Dr. Patel: One of them is actually what we call peripherally-acting-mu-opioid receptor antagonists, also known as PAMORAs. Dr. Erber: They block what the opiates do in the GI tract. Dr. Patel: And directly, in that way, alleviate the symptoms of opioid-induced constipation. Dr. Erber: And by blocking it, it prevents the problems with GI motility. Dr. Moore: Thereby reducing any constipation and not reducing the analgesic effect of the medicine. Dr. Erber: And sometimes it's that, in combination with other therapies that we use, or sometimes we have to move on to another class. Dr. Moore: Check in with your prescriber. Have that conversation. It's not just a matter of, "Okay, I need a new prescription." It is how things are going. If the physician doesn't offer that conversation, you make that conversation happen.

Dr. Moore: Opioid-induced constipation is an expected effect of taking an opiate. Dr. Moore: When we encounter the condition of opioid-induced constipation, we're dealing primarily with someone who is in pain. Dr. Siddiqui: Typically a lot of times the patients are on chronic opioids. After surgery, a lot of patients are still on opioids. Dr. Patel: Opioids provide their pain-relieving benefit by working on the mu receptors. Dr. Siddiqui: And that's just a specific type of receptor. It's located all throughout your body. So in your gut, there is a large amount of these opioid receptors. And when opioids and medications bind to that receptor, it slows down the gastrointestinal motility and causes slowing of the bowel system. And you get constipation. Tamara Freuman: So you've got this sort of double-whammy going on with OIC. The first is that you're having less frequent urges to go to begin with, but the second problem is, when you do have the urge to go, your stools can be much harder. Tamara Freuman: And once a stool is very hard and dry, it becomes very difficult to pass. Paul: You feel extremely bloated. You become very drowsy. Sam: Nausea. It's like, sort of terrifying and jarring. Paul: I mean, there's a lot of bowel pain, there's a lot of stomach pain. Dr. Siddiqui: There are different types of constipation. You may have it due to your gastrointestinal tract not moving rapidly enough. Beth Warren: It could just be a simple dietary issue like you don't have fiber. Dr. Siddiqui: And then with OIC, it's actually a completely different mechanism. Dr. Moore: The way these medicines work in the gut, it's going to slow the gut down. So we know that constipation is going to be a side effect. Dr. Siddiqui: Some of the conservative treatment that you had for other modes of constipation are not effective. Paul: I had to make a choice on a daily, weekly basis, if I'm going to take my pain meds, or am I going to deal with the constipation from the opioids? Dr. Moore: Fortunately, nowadays we have new medicines, medicines that actually selectively block the opioids in the gastrointestinal tract. Dr. Siddiqui: The great thing is, with the treatments, you still get the pain relief that you would with opioids, but you don't get the constipation.

Paul: My name is Paul. I've been managing my OIC for 13 years. Sam: I was diagnosed with a blood clot. Paul: I used to be a chef caterer, lifting a box, working at a catered event. I was twisting, my spine snapped, making me pass out, which at the time started my pain journey. Sam: I was put on pretty strong painkillers. Paul: In the beginning, they helped my pain a little bit. But as I got used to it, they had a lot of side effects. I first realized I had constipation, and I didn't realize it was from my pain medicine. Sam: I talked to my doctor. Paul: He said he should've brought it up to me earlier so we could address this. Sam: Constipation, it's a very pervasive thing. You can't just brush it off. Paul: There's actually a lot of pain. There's a lot of bowel pain. There's a lot of stomach pain. Sam: It feels like there's jagged knives coming out. It's really painful. Paul: It's not something I wanted to talk about. It's kind of embarrassing. Sam: It was scary too because it's like, you just feel plugged up, and you want release. Paul: You feel extremely bloated. Sam: I lost a lot of weight, in part because of the pain of constipation. I wanted to eat as little as possible. Paul: Dealing with the constipation from the pain medicine, it's terrible because it isolates you even more. You're afraid to leave the house because you don't know when you're going to have a bowel movement. Sam: It was sort of a weird trade-off because on the one hand, you're in pain from the surgery. Paul: A lot of times I had to suffer in more pain just so I could relieve the constipation. Sam: Just like, which pain do you choose? Paul: You're kind of like, a trial and error. You try to figure out what works best for you, what foods might trigger your pain, that might cause the constipation. I knew I needed to add more water. I knew I needed to exercise. Most people with chronic pain are afraid to talk about the side effects because they're afraid that their doctor will stop prescribing the medicine that's giving them quality of life. That's not the case at all. Sam: Don't be hesitant to discuss your pain even if it's in a place that might embarrass you. Paul: As far as OIC, you have to talk to your doctor and realize it's actually a condition. You need to talk about that because it can be treated, and you don't have to be afraid to talk about it.

Dr. Moore: The thing with opioid-induced constipation is that even if one has regular bowel movements, the medicine is going to have some effect on your gut. Tamara F.: Typically when a person eats a meal, you chew your food, it goes to your stomach. Beth Warren: Our stomach is the size of this fist. Tamara F.: It's a reservoir that blenderizes your food, and liquefies it. That liquid meals starts emptying out of your stomach in small little spurts, and enters into your bowel. There's two parts of your bowel. You have your small intestine, which is where your food is absorbed. Beth Warren: Your gut are your intestines. Tamara F.: Anything our bodies can't break down digestively with enzymes and get absorbed, continues traveling on past the small intestine into your colon. Your colon is where your bowel movements are formed. The stool that is formed kind of stimulates the walls of the colon, and lets it know, "Hey, we're full, let's push on, and move us out of here." Dr. Erber: This is called the gastrocolic reflex. So you eat, and then there is receptors in the stomach that tells the lower part of the GI tract to empty. Tamara F.: When someone is on opioid medications, or has opioid-induced constipation, there's a few factors at play that can really impede this process. Beth Warren: Opioids, once we make them inside our bodies naturally, what they're responsible for is kind of halting rapid movement through the gut. Tamara F.: There's just less frequent forward motility. Beth Warren: Now that you're taking it from an external source like a medication, you're constantly having these opioids so you get really halted inside the gut, and your stool is completely blocked. Tamara F.: The longer that stool is sitting in the colon not moving, the more water is reabsorbed from the colon, back into the body. Dr. Moore: The stool gets hard. Hard stools are difficult to deal with. Dorothy H.: Probiotics... We are starting to understand digestion in a totally new way. The inside of our digestive system is mostly populated by bacteria that actually digests our food for us. Beth Warren: And all those bacteria inside the gut need to be balanced. Dorothy H.: One way you can help someone with opioid-induced constipation is to increase the bacteria, which will help in the digestion of the food.

Tamara: What you eat will have a big difference in how much you're able to go to the bathroom. Dorothy: My top tips for people with opioid-induced constipation are walking, squatting, natural foods, lots of fruits and vegetables, water. Dr. Dorette: You're going to start working on lifestyle changes. Dr. Patel: Increasing fiber intake and increasing water intake is a great place to start. Tamara: Fiber is basically undigestible plant material that human beings don't absorb and turns into bulk for your bowel movements. Dr. Dorette: The bulk helps with the stretch, and the stretch is what gives the signal to the brain that the colon needs to be emptied. Tamara: If you only eat foods that are super, super digestible, like starches and animal protein, there's very little left over, or what we call residue. Dorothy: I love to get people on as many greens as I possibly can. Beth: Broccoli and asparagus, grapes and raisins. Tamara: Smoothies for breakfast are really an easy way to kind of get some fiber in your body when your appetite is poor. It's important to choose a smoothie rather than a juice because a smoothie still has all of the intact fiber. Beth: And then there's also prunes and prune juice, which offer a natural laxative effect. Tamara: Coffee is health food, and it's bathroom health food. Dr. Dorette: Fiber is good, but without adequate water, fiber could also create more problems. Beth: If you have all this fiber, it just gets impacted. So drink tons of fluid to hydrate yourself to pass that fiber through. Dorothy: The opiate slows everything in the body in the digestive system down. Beth: Circulation in the body helps with the circulation inside the gut. Dorothy: You can increase your movement, and that will help increase the movement on the inside of your digestive tract. Beth: Any exercise is exercise. Dorothy: The best thing is to squat as long as you possibly can, then walk as long as you can. Dr. Dorette: When we are able to incorporate all of this, then we're able to take the body into a more relaxed state and experience a significant reduction in pain. Dorothy: There is nothing better than a healthy dose of endorphins. Put on a funny movie, laugh. There's lots of things. Don't feel powerless. You can shift.

Dorothy H.: The fear with the opioids often is that they're going to get constipated, that they're going to get dependent on the opioids, that they're not going to have a good quality of life. Beth Warren: There are a lot of myths associated with it, and one most common that I experience as a dietitian is that diet and foods have nothing to do with it. And they have everything to do with it. Dorothy H.: Sometimes people think, "These opiates, they're so powerful. What's a little bit of water going to do? What are some vegetables going to do? It doesn't seem powerful enough." It's very powerful. Dr. Siddiqui: OIC is one of the most common things that you see with opioids. Paul: A lot of people don't realize it's an actual condition of taking your pain meds. Dr. Erber: It probably happens anywhere from 40 to 50% of those taking opiates. Beth Warren: It's not something that people need to be living with the way ... the status quo. Dr. Siddiqui: Don't wait to contact your provider. It's better to contact them sooner rather than later, because there are a lot of different treatment options available. Dr. Moore: The question should always be, you know, well, what can I expect? What are the unwanted effects? Sam: Don't be hesitant to discuss your pain, even if it's in a place that might embarrass you. Paul: So you need to talk about that, because it can be treated, and you don't have to be afraid to talk about it. Dr. Erber: The biggest issue in individuals taking opiates is that, you know, when this goes either, a) unrecognized, or b) they don't report it. Dr. Moore: What if one just ignores the constipation, a week goes by and you are still bloated? Dr. Siddiqui: The patient can have fecal impaction. Dr. Patel: That can be dealt with by manual disimpaction at an ER visit, or even surgical intervention. Dr. Dorette: Constipation is constipation. What causes the constipation, however, is where it differs. Dr. Patel: There's an overlap between traditional functional constipation and opioid-induced constipation in that there are harder stools, more straining, difficulty in terms of abdominal distention. However, in opioid-induced constipation, you can get a different type of symptoms. Dr. Dorette: They may be experiencing some amount of nausea. They may be having cramping. Dr. Patel: Vomiting and gastric reflux. Dr. Erber: It's something that usually happens pretty early on, will be present for the duration of that therapy. Dr. Patel: If traditional methods to alleviate constipation such as increasing fiber intake or hydration are not enough, we need to kind of step it up and introduce prescription targeted therapy. Dorothy H.: I like to tell people, "You're really empowered to make these changes."