222 Biofeedback Therapy for Dyssynergic Defecation Is Effective Among Patients With Opioid Exacerbated Constipation

Abstract

INTRODUCTION: Up to 90% of patients on opioids complain of constipation (Wurzelmann et al, 2007). Among opioid users, causes of chronic constipation can be multifactorial and related to other contributing factors such as dyssynergic defecation (DD). Biofeedback (BFB) therapy has been shown to be effective in patients with DD, but has not been studied among those who have DD and are on opioids. METHODS: This study was a retrospective analysis of patients enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. For patients that had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each BFB visit. RESULTS: 117 patients met criteria, of these, 20 patients were on active opioid therapy. Compared to those not on narcotic analgesics, opioids users were more likely to have a higher baseline defecation index (DI), intrarectal pressure divided by intra-anal pressure during simulated defecation (0.669 vs. 0.456 P < 0.0007). Decreased rectal sensation at baseline was seen in 20% of opiate patients and 19% of those not on opioids (P = 1.0). Opiate users compared to those not on narcotic analgesics also had a lower baseline health rating on the SF-36 scale (3.9 vs. 3.4 1-5 Likert scale P = 0.05) and were more likely to withdraw before completing a full course of BFB (P < 0.01). On stool diary, opiate users did not report a significant improvement in global bowel satisfaction rating (2.9 to 4.2, 10-point Likert scale P = 0.13), in contrast to non-opiate users who did repot improvement (2.7 to 4.9, P < 0.0001). Opiate users, however, had a significant decrease in number of stooling medications used (1.8 to 1.1 P = 0.04). On HR-ARM, there was a greater change in DI among non-opiate users as compared to opiate users. After BFB, opiate users effectively normalized their dyssynergia (79% improved) (P < 0.0001). Non-opiate users also showed significant improvement in normalizing their dyssynergia (74%) (P < 0.0001). CONCLUSION: Patients with opioid exacerbated constipation and DD showed meaningful clinical improvement in both subjective outcomes as well as manometric parameters. While they had lower baseline health rating at the outset and did not report significant improvement in global bowel satisfaction rating, unlike the non-opioid users, they nevertheless clearly benefited from BFB therapy. Overall, this data suggests that opioid users with DD may benefit from enrollment in BFB therapy.