A new treatment for constipation, the curse of palliative care
Submitted by Dr.Kattlove’s Cancer Blog
One medical myth that I often hear is that it is possible to treat a cancer patient’s pain with opioids like morphine so that they can be completely comfortable. Not true. Doctors or nurses always need to balance the relief of pain with the side effects of these drugs - sedation, dry mouth, and that most major malady, constipation.
At several times in my career, I helped out at hospices, where I was a volunteer medical director. At the weekly meetings with the rest of the team, the most talked about subject was patients’ symptoms. Usually pain came first, followed closely by their constipation. Most of the patients had pain and were receiving opioids and all of them were constipated.
Opioids cause constipation. They paralyze the intestinal cells that cause the bowel to push stool through and out. Indeed, some of the drugs used to treat diarrhea, such as Imodium or Lomotil are opioid-like. During our team meetings, we would hear a battery of treatments that the nurses were using on their patients such as stool softeners, milk of magnesia, suppositories and the potion of last resort, Fleet’s phospho-soda.
All of these worked some of the time, but rarely was any of them successful most of the time. Now there is hope for overcoming this problem. A new drug, called Relistor, has been successfully tested in patients with terminal disease, mainly cancer, who were taking opioids. It was recently approved by the FDA and will be available by prescription in June 2008.
The drug is a contorted form of opioid, which because of its chemical nature actually blocks the effects of opioids. But, it doesn’t block their pain relieving properties. The reason for this is that opioids, such as morphine, have to get into the brain to block pain. The brain is a very fussy organ. It doesn’t allow many drugs in. They have to have some special chemical properties. Morphine and all the other pain-relieving opioids have these properties and can get into the brain to stop pain. But Relistor is chemically different and can’t get into the brain. So it can block the bowel effects of opioids but not the pain-relieving effects.
Some problems with the drug. First it isn’t a pill and has to be given by an injection under the skin – like insulin for diabetics. The good news is that a pill form is in the wings and now undergoing testing. In the study, the injections were given by health professionals, but I’m sure that any family member can do it. Second, some side effects – abdominal pain and flatulence occurred a little more than in terminal patients not taking the drug.
Finally, price. The drug will cost about $40 per dose or about $600 a month at the recommended every other day schedule. Hospices may be reluctant to prescribe it. Under the Medicare hospice plan, the hospice gets a fixed amount of money for each patient. From this, they have to pay for drugs. Unless Medicare changes its reimbursement policy, the cost of Relistor will eat into the money the government gives them for nursing care and other drugs.
By the way, even when the pill form of Relistor, if it works, comes on the market, don’t expect any price break.
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