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Authors

  1. Heidecker, Sharon MSN, CRNP, AP-BC

Article Content

Chun-su Yuan, MD, PhD, Ed. Haworth Medical Press 10 Alice Street, Binghamton, NY 13904 Telephone: (800) 429-6784 (USA and Canada) (607) 722-5857 (outside USA and Canada)E-mail: orders@HaworthPress.com Website: http://www.haworthpress.com Price: $39.95

 

Any clinician involved in the care of patients in hospice and palliative care understands the struggle with bowel issues. Disease process, opioids, declining mobility, and altered nutrition all combine to produce problematic issues in bowel function. Because opioids are a mainstay of treatment therapy in pain control, it is important to address this issue. Many clinicians hesitate to start treatment with opioids or do not increase dosage as needed because of patient concerns and problems with bowel function. This then contributes to poorly controlled pain and the unaddressed issue of constipation.

 

The editor, Chun-Su Yuan, MD, PhD, has assembled clinician-scientists with expertise in this area to provide pertinent information on a most important issue.

 

The book has three sections-Section I: Basic Concepts in Opioid Physiology; Section II: Clinical States; and Section III: Advances in Treating Opioid Bowel Dysfunction. Section I is composed of three chapters and is a primer, taking the reader through basic concepts such as opioid physiology and pharmacology, pathophysiology of opioid-induced bowel dysfunction, and opioid-induced immunosuppression. In the chapter discussing opioid-induced immunosuppression, the authors cite several studies that indicate that a close relationship exists between the use of opioids and immunological responses and infections. Further studies are indicated to establish safe use of opioids without producing immunosuppression.

 

Section II focuses on clinical states and is written at a clinical level for practitioners. Epidemiology is discussed within the US, and several studies are reviewed to compare bowel habits and constipation-related treatments. Recommendations are given for a proactive approach as well as prompt interventions to alleviate bowel symptoms of constipation.

 

Several other clinical states discussed to address opioid bowel dysfunction include palliative care, acute and chronic nonmalignant pain, postoperative bowel dysfunction, and postsurgical bowel dysfunction in gynecologic patients.

 

The palliative care chapter focuses on constipation as well as the frequent side effect of nausea and vomiting when opioids are administered. Specific opioids and their emetogenic properties are discussed, and recommendations about changing opioids to assist analgesia and decrease adverse side effects are given.

 

The chapter on acute and chronic nonmalignant pain addresses constipation, nausea, and vomiting and gives recommendations for both nonprescription options as well as pharmacological options for the prevention and treatment of opioid bowel dysfunction.

 

Postoperative bowel dysfunction is discussed in detail and the pathogenesis of postoperative ileus is explained. Bowel dysfunction postsurgery is described as almost inevitable because there is no single cause or cure. A multimodal approach is called for and recommendations are given. Long-accepted standards of postsurgical care, such as nasogastric intubation, are discussed, and studies that show possible worsening of bowel function are cited. Methods for promoting gastric motility, such as preoperative fiber, perioperative fluid administration, surgical technique, early mobilization,and psychological preparation, are discussed Alternate analgesics other than opioids or in conjunction with a lower-dose opioid are recommended to minimize problems with bowel dysfunction.

 

Postsurgical bowel dysfunction in the gynecologic patient is discussed briefly, and it is concluded that methodologies currently used are not necessarily evidence based. The reader is thus directed to the citations within the chapter for review and consideration in surgical practice.

 

Section III focuses on advances in treating opioid bowel dysfunction, and three investigational drugs are discussed. Oral naloxone, methylnaltrexone, and alvimopan have been studied, and all seem to show promise to reverse or prevent opioid bowel dysfunction while preserving analgesic effects. These drugs also show promise of blocking opioid action on lymphocytes, thus preventing immunosuppression.

 

The book is 256 pages long, and the content is extremely well written. Although it is not a "light read," enormous amounts of information are well explained and can be easily understood. It goes far beyond just a list of pharmacologic and nonpharmacologic interventions for opioid bowel dysfunction and addresses numerous scenarios from palliative care to surgery. I would recommend this book to any physician or nurse who is interested in an in-depth understanding of this problem and how to correct or minimize it.