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United European Gastroenterol J. 2019 Feb;7(1):7-20. doi: 10.1177/2050640618818305. Epub 2018 Dec 14.

Pathophysiology and management of opioid-induced constipation: European expert consensus statement.

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Institute of Applied Clinical Science, Keele University, Keele, UK.
Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
Centre for Trauma and Neuroscience, Queen Mary University of London, London, UK.
Division of Gastroenterology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, USA.
Department of Medical Sciences, University of Ferrara, Ferrara, Italy.
Marymount University Hospital and Hospice, Curraheen, Ireland.
Cork University Hospital, Wilton, Ireland.
Leuven Centre for Algology and Pain Management, University of Leuven, Leuven, Belgium.
Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium.



Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options.


The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice.


This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature.


The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed.


Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.


Opioid-induced constipation; bowel dysfunction; gastro-intestinal motility; gastroenterology; management algorithm

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