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Transcript — Airing Pain 125: Opioid-Induced Constipation

Look­ing at the side effects of opi­oids for chron­ic pain man­age­ment 

To lis­ten to this pro­gramme, please click here.

This edi­tion of Air­ing Pain has been fund­ed by an edu­ca­tion­al grant from Kyowa Kirin

While opi­oids are seen as an effec­tive treat­ment method for acute pain, there is an increas­ing debate on the effi­ca­cy of opi­oids when treat­ing chron­ic pain con­di­tions. One of the most com­mon side effects of long-term opi­oid usage is con­sti­pa­tion. Con­di­tions like irri­ta­ble bow­el syn­drome are more com­mon in peo­ple who are liv­ing with chron­ic pain con­di­tions, so bet­ter under­stand­ing of the con­nec­tion between opi­oids and con­sti­pa­tion is key for med­ical pro­fes­sion­als cur­rent­ly work­ing with chron­ic pain patients. 

Fol­low­ing on from Air­ing Pain 123, this edi­tion sees Paul Evans speaks to Dr Maria Eugeni­cos, who is a gas­troen­terol­o­gist at the Uni­ver­si­ty of Edin­burgh. Dr Eugeni­cos starts by out­lin­ing the dif­fer­ent con­di­tions that are treat­ed at her gas­tro-intesti­nal clin­ic and how these con­di­tions can present. Dr Eugeni­cos then dis­cuss­es the preva­lence of opi­oid-induced con­sti­pa­tion in clin­i­cal patients and how shift­ing treat­ment meth­ods and prop­er­ly edu­cat­ing patients on their con­di­tions can help to improve their stan­dard of liv­ing. 

Issues cov­ered in this pro­gramme include: Opi­oids, abdom­i­nal pain, amitripty­line, bow­els, con­sti­pa­tion, side effects, fatigue, fibromyal­gia, IBS: irri­ta­ble bow­el syn­drome, neu­ro­mod­u­la­tors, painkillers, pelvic pain, stom­ach pain, stool and tri­cyclic anti­de­pres­sants. 

Paul Evans: This is Air­ing Pain, a pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain, and for those who care for us. I’m Paul Evans, and this edi­tion of Air­ing Pain has been fund­ed by Kyowa Kirin. In a recent edi­tion of Air­ing Pain – that is num­ber 123, which is still avail­able to down­load, we looked at issues around the use and overuse of opi­oid-based med­ica­tions for the man­age­ment of chron­ic pain. One of the con­trib­u­tors in that pro­gramme was Dr Cathy Stan­nard, an inter­na­tion­al­ly recog­nised expert on aspects of pain man­age­ment, and par­tic­u­lar­ly opi­oid ther­a­py. I’ll just remind you some­thing she said in that programme. 

Cathy Stan­nard: Do you think the med­i­cines are mak­ing much dif­fer­ence? And there is a dawn­ing real­i­sa­tion that it’s just like tak­ing Smar­ties. [That’s] some­thing that we com­mon­ly hear. We know that patients are fear­ful of reduc­ing because of course, if your pain is bad, and you’re on med­i­cines, what if it’s worse [off med­i­cines]? It’s very dif­fi­cult, and it depends on the individual’s per­cep­tions and so on. But we do have evi­dence from a huge num­ber of patient reports that, freed from the many bur­den­some side effects, peo­ple feel much more alert, able to engage with their fam­i­lies and engage them­selves in strate­gies which help man­age their pain. So we know that most of the med­i­cines that we pre­scribe for pain which actu­al­ly stop the way that nerves talk to oth­er nerves do have side effects which make peo­ple sleepy, sedat­ed, gid­dy and so on. And all those things make it very dif­fi­cult to start try­ing to man­age peo­ple’s lives to try and mit­i­gate the effects of long term pain. 

Evans: That was Dr Cathy Stan­nard, remind­ing us from an ear­li­er edi­tion of Air­ing Pain of some of the issues and side effects expe­ri­enced by those pre­scribed opi­oid-based med­ica­tions for the man­age­ment of their chron­ic pain. Well, in this edi­tion of Air­ing Pain, I want to look at anoth­er side effect that’s – judg­ing by the vol­ume of calls Pain Concern’s helpline received – is of par­tic­u­lar con­cern to those using opi­oid-based med­ica­tions for the man­age­ment of their chron­ic pain, and that is constipation. 

Maria Eugeni­cos: 27% of the con­sti­pat­ed patients may relate their con­sti­pa­tion to med­ica­tions. In my last clin­i­cal audit, I found that approx­i­mate­ly 30% of the patients who present with con­sti­pa­tion would be on opi­oid treat­ments for [a] chron­ic pain condition. 

Evans: This is Dr Maria Eugeni­cos. And as we record­ed this inter­view dur­ing the Covid-19 cri­sis – social­ly dis­tanced, of course, via a video con­fer­ence line – there are ref­er­ences to the cri­sis in 2020. So Dr Eugeni­cos asked is a clin­i­cian gas­troen­terol­o­gist and senior lec­tur­er at the Uni­ver­si­ty of Edin­burgh and Edinburgh’s West­ern Gen­er­al Hos­pi­tal. She spe­cialis­es in func­tion­al gut disorders. 

Eugeni­cos: Con­sti­pa­tion is defined by sev­er­al cri­te­ria that may include dif­fi­cult, painful defe­ca­tion, incom­plete bow­el-emp­ty­ing, decreased fre­quen­cy of emp­ty­ing [and] man­u­al manoeu­vres. And by def­i­n­i­tion for func­tion­al con­sti­pa­tion, this should be the diag­no­sis if there is insuf­fi­cient cri­te­ria to make a diag­no­sis of irri­ta­ble bow­el syn­drome, as in func­tion­al con­sti­pa­tion. And usu­al­ly, when we do diag­nose con­sti­pa­tion, peo­ple do not present with loose stools, but with hard, lumpy stools, and may present with loose stools only in the pres­ence of lax­a­tives, if they have been using lax­a­tives prob­a­bly [due to] their symptoms. 

Evans: One ques­tion we have to ask is, what does reg­u­lar mean? What [are] reg­u­lar bow­el movements? 

Eugeni­cos: If I were to reverse the ques­tion, I sup­pose, I would say, ‘Is it abnor­mal to have less than one bow­el move­ment per day?’ And that per­haps is not nec­es­sar­i­ly the case, in that when [we] have done a study ques­tion­ing healthy con­trols, then their fre­quen­cy of bow­el move­ments var­ied from three times per week to six times per week. So just fre­quen­cy does not define con­sti­pa­tion. But if the decreased fre­quen­cy is asso­ci­at­ed with sev­er­al oth­er cri­te­ria already men­tioned, like strain­ing, dif­fi­cult emp­ty­ing, painful emp­ty­ing, then per­haps this allows you to make the diag­no­sis of con­sti­pa­tion. If you com­pare that with patients with con­sti­pa­tion, the major­i­ty of patients with con­sti­pa­tion would admit to fre­quen­cy [of] less than once per week. That’s the major­i­ty of patients – about 60% of these patients. About 20% of patients would say once a week, [and] maybe 5% would say twice a week. 

So yes, the major­i­ty of patients with con­sti­pa­tion would have decreased bow­el [move­ment] fre­quen­cy. The patients with con­sti­pa­tion are a great health­care bur­den, in that, in pre­vi­ous stud­ies, 80% of the patients attend­ed com­mu­ni­ty nurs­es request­ing treat­ment for their con­sti­pa­tion. So if we track admis­sions to hos­pi­tal, where per­haps the pri­ma­ry end­point, if you like, would be con­sti­pa­tion, then it amounts to 70,000,000 in recent stud­ies. The con­sul­tant or GP con­sul­ta­tions with regard to treat­ment for con­sti­pa­tion man­age­ment may amount up to 30,000,000 per year, so it’s not a dis­mis­sive cost. And fur­ther­more, patients who may suf­fer from con­sti­pa­tion may call more often absent from their work – absen­teeism is quite high. 

Evans: So how much of a prob­lem is opi­oid relat­ed constipation? 

Eugeni­cos: Now, the opi­oid relat­ed con­sti­pa­tion, it is some­times hard to define, because in a recent study that we per­formed, we found that patients may be start­ed on opi­oids with­out pri­or inquir­ing about their symp­toms. What we know [is] that 27% of the con­sti­pat­ed patients may relate their con­sti­pa­tion to med­ica­tions. Now, opi­oids are not the only med­ica­tion that may cause con­sti­pa­tion, but it’s the most com­mon med­ica­tion that [is] pre­scribed and does cause [con­sti­pa­tion]. So it’s not a neg­li­gi­ble amount either. Only 46% of patients with con­sti­pa­tion may present with a pri­ma­ry, the rest of them are on sec­ondary. So when we have tried to iden­ti­fy how many of the patients devel­op con­sti­pa­tion, once they have start­ed opi­oids, it was dif­fi­cult to define because we did not have that infor­ma­tion. For those patients that we had the infor­ma­tion – it was about 34% [who] may not have had any symp­toms what­so­ev­er, and may devel­op con­sti­pa­tion, fol­low­ing opioids. 

From anec­do­tal evi­dence, though, we know that if we do not treat the con­sti­pa­tion, if we do not address that, and peo­ple con­tin­ue to be opi­oids, then they may devel­op opi­oid induced con­sti­pa­tion fur­ther down the line. And this is what some­times may per­haps affect the patien­t’s judge­ment to say, ‘But I have been on opi­oids and they did­n’t [cause] the symp­toms in the begin­ning, [but] now I’ve devel­oped the symp­toms.’ It could be cumu­la­tive effect, because the patient may start on a low dose of the opi­oids, and then they may increase the dose and then may devel­op fur­ther symptoms. 

Evans: How do you address that with a patient com­ing to you say­ing, ‘I have con­sti­pa­tion, and I’m on opi­oids’, and they’ve already made that link between them – whether it’s a cor­rect link or not? How do you address it? 

Eugeni­cos: That may vary depend­ing on the cause of why the patient was start­ed on the opi­oids in the first place. Edu­ca­tion of patients is very impor­tant in these cas­es. So we try to explain to the patient that the opi­oids in the treat­ment of pain per­haps are most suc­cess­ful for the acute pain sit­u­a­tion. Yes, we do offer opi­oid treat­ment for patients who have got can­cer pain, but for chron­ic con­di­tions, per­haps it’s bet­ter to try oth­er neu­ro­mod­u­la­tors rather than go direct­ly to the opi­oid, for the par­tic­u­lar rea­son that con­sti­pa­tion itself may cause pain. So we may be aggra­vat­ing the ‘syn­drome’ – if you like, in invert­ed com­mas – of pain, because we’re try­ing to address one type of pain by replac­ing [it] with some­thing else. I would go through their lifestyle [and] try to address lifestyle mea­sures, and we address their diet [and] their liq­uid intake. I advo­cate water – hot water regimes, [as well as] reg­u­lat­ing the bow­el habits. Try­ing to make the bow­el habits pre­dictable is very impor­tant. Exer­cis­ing, phys­i­cal activ­i­ty, the posi­tion on the toi­let to facil­i­tate relax­ation of the pelvic floor, avoid­ing strain­ing – all of these play a role [in man­ag­ing con­sti­pa­tion] and we try to iden­ti­fy those. 

Once a patient though, has been referred to my clin­ic, which is [specif­i­cal­ly] a ter­tiary refer­ral clin­ic, almost always they would have been tried on oth­er med­ica­tions. So, we do not only address the lifestyle mea­sures, we would address what med­ica­tions they have, what dos­es have they had [of] these med­i­cines. And we are address­ing this with the sim­ple lax­a­tives –  osmot­ic lax­a­tives, which is the first choice of treat­ment, or oth­er sim­i­lar lax­a­tives if they have had some­thing like that. And if they have not been respond­ing to these, then we would go on to pre­scrib­ing spe­cial­ist med­ica­tions to con­tract the opi­oid effect on the bow­el motil­i­ty. [There is] a new opi­ate recep­tor antag­o­nist that we have got avail­able, which can be pre­scribed oral­ly, and the patient can take it at home. 

Evans: Now, I guess you’re see­ing peo­ple who are com­ing to you because they are unwell. Con­sti­pa­tion is a prob­lem to them. What would you sug­gest peo­ple do if they know they’re going to be pre­scribed opi­oids, to pre­vent this from the very start. 

Eugeni­cos: We try and edu­cate the patients, in that patients who are on chron­ic opi­oid treat­ment may devel­op hyper­sen­si­tiv­i­ty, vis­cer­al hyper­sen­si­tiv­i­ty, which is the case in patients who have got IBS, and in par­tic­u­lar, in this group of patients, IBS con­sti­pa­tion. So if I treat their pain with some­thing that, in the long run, may make their body debil­i­tat­ed to address pain, then per­haps I’m not address­ing the ques­tion cor­rect­ly. So what I try and do usu­al­ly – I would appre­ci­ate [that] the patient is in pain, [and] the patient may need to be treat­ed. So I would usu­al­ly advo­cate neu­ro­mod­u­la­tors, and the neu­ro­mod­u­la­tors of choice – and these are the med­i­cines that they would be pre­scribed usu­al­ly, as a first choice in the pain clin­ics, espe­cial­ly pain clin­ics –  is tri­cyclic anti­de­pres­sants in small dos­es, either amitripty­line if it’s tol­er­at­ed or nor­tripty­line. Nor­tripty­line has got less seda­tive effect. And [we] only take the opi­oid over and above for an acute sit­u­a­tion [that it] would work bet­ter [in]. Some­times the patients are pre­scribed mild opi­oids when patients present with abdom­i­nal pain and they are real­ly try­ing to con­trol their symp­toms and that may lead to con­sti­pa­tion. And then we’re deal­ing with a mixed type of dis­or­der, which some­times is hard­er to treat. 

Evans: You men­tioned IBS, irri­ta­ble bow­el syn­drome. Explain what that is. 

Eugeni­cos: The irri­ta­ble bow­el syn­drome is a syn­drome char­ac­terised by abdom­i­nal pain, which is asso­ci­at­ed with altered bow­el habits. So it may relate either to diar­rhoea [and] the pres­ence of abdom­i­nal pain, or con­sti­pa­tion [and] the pres­ence of abdom­i­nal pain. We would make the diag­no­sis if the symp­toms have been present for at least three months pri­or to the pre­sen­ta­tion. So it has to be a con­tin­u­ous type of effect. Any­body may devel­op abdom­i­nal pain. When [some­one has] altered bow­el habits, it does­n’t mean that [they] have IBS. But if this is per­sis­tent pre­sen­ta­tion over a peri­od of time, then it would make the diag­no­sis of IBS. Peo­ple who may have had chron­ic con­sti­pa­tion for years may devel­op IBS, when espe­cial­ly each time they have got altered bow­el habits, this relates to abdom­i­nal pain. And we do warn them that some­times it can fluc­tu­ate. The recent Rome IV cri­te­ria have defined that dis­com­fort is not part of the IBS as a syn­drome. It has to be pain. And the rea­son for that is that any­body with con­sti­pa­tion may have dis­com­fort, when they become bloat­ed, when the bow­el dis­tends with fae­cal load­ing, etc. But [when] the pain is present, it’s char­ac­ter­is­tic of the IBS, irri­ta­ble bow­el syndrome. 

Evans: You said con­sti­pa­tion or diar­rhoea. I’ve talked to some peo­ple who have both. 

Eugeni­cos: When you make a diag­no­sis of IBS con­sti­pa­tion, the patient presents with hard, lumpy stool. And we define that through our con­sis­ten­cy, the bow­el move­ment con­sis­ten­cy, because this may reflect more accu­rate­ly the patho­phys­i­ol­o­gy of the syn­drome. But these peo­ple may have loose stools, but it should be less than 25% of the time. Now, the patients who present with IBS diar­rhoea would have abdom­i­nal pain and would have loos­er, watery stools, they could have hard­er stools, but it should be less than – again – 25% of the time. Now [though], if peo­ple present with alter­nate bow­el habits – [as in] con­sti­pa­tion alter­nates with diar­rhoea – and this may hap­pen more than 25% of the time, then we are deal­ing with mixed type IBS. And we have got… there are sub­types that, at times, present with con­sti­pa­tion, at times they present with diar­rhoea, and they can fluc­tu­ate. So it’s four types. And again, the rea­son for the dif­fer­en­ti­a­tion of these four types is because the bow­el [move­ment] con­sis­ten­cy would be dif­fer­ent. And that reflects dif­fer­ent patho­phys­i­ol­o­gy. And as a result, it would mean dif­fer­ent types of treat­ment for these people. 

Evans: And the rea­son why I’m ask­ing about IBS is because IBS, irri­ta­ble bow­el syn­drome, does seem to go hand in hand with some chron­ic pain con­di­tions, like fibromyal­gia [and] like oth­er con­di­tions, and in some cas­es, phar­ma­ceu­ti­cal treat­ments are the same. They seem to be work­ing on the same sys­tems, am I right? 

Eugeni­cos: Yes, the pain con­trol for fibromyal­gia, for exam­ple, or for IBS is neu­ro­mod­u­la­tion. For all the chron­ic pain syn­dromes like this, [the treat­ment] would be neu­ro­mod­u­la­tion. We have come across, more often, patients who may have IBS, and may present with fibromyal­gia, or oth­er chron­ic con­di­tions. We do not real­ly know whether this is because it’s a very com­mon con­di­tion, or whether there is a causative effect, or whether phar­ma­ceu­ti­cal treat­ment to address one con­di­tion may lead to anoth­er. It is a very com­plex and inter­re­lat­ed sit­u­a­tion. But in my clin­ic, I get quite a few patients with IBS who have resis­tant symp­toms, quite a few of them would have fibromyal­gia, quite a few of them may have Ehlers-Dan­los syn­drome, and oth­er conditions. 

Evans: Now one of the rea­sons we’re doing this edi­tion of Air­ing Pain is because of the num­ber of peo­ple who phoned up our helpline about it. But also, because of the con­tro­ver­sies over using opi­oids for the man­age­ment of chron­ic pain. Do you get peo­ple who come to see you with chron­ic pain con­di­tions, who are heav­i­ly reliant on opi­oids and have constipation? 

Eugeni­cos: Yes, in my last clin­i­cal audit, I found that approx­i­mate­ly 30% of the patients who present with con­sti­pa­tion would be on opi­oid treat­ment for a chron­ic pain con­di­tion. So it’s quite a high pro­por­tion of the con­sti­pa­tion patients. Whether these peo­ple are referred to my clin­ic because their pri­ma­ry care pro­fes­sion­als or physi­cians would like us to [advise] these peo­ple on spe­cial­ist treat­ment or whether [it’s] because they are not famil­iar with a spe­cial­ist treat­ment, and the first and sec­ond lines of lax­a­tive treat­ment have failed, it is dif­fi­cult to know. 

But yes, I do have a cohort of patients [who] present to my clin­ic with this prob­lem. A young man – he’s forty-two years old and was referred to my clin­ic because his symp­toms of con­sti­pa­tion and pain were not respond­ing [to treat­ment]. He had a diag­no­sis of IBS, [which was] con­sti­pa­tion-made, and one of my col­leagues, a gas­troen­terol­o­gist asked me to see him. I saw him last July, he was a very switched-on patient. So I took him through the patho­phys­i­ol­o­gy of the IBS syn­drome [and] of the con­sti­pa­tion and explained to him the long term effect of some­body being on the opi­oids to con­trol the pain, and offered him the mod­ern way of address­ing chron­ic pain through neu­ro­mod­u­la­tors. And when I explained to him that although I’m try­ing to treat [his pain] – although it was not me who ini­ti­at­ed the opi­oids – but I said to him, ‘I’m your physi­cian, I’m try­ing to treat your pain, and I’m giv­ing you opi­oids because they do con­trol the pain. But I have to tell you that in the long run, our stud­ies show that you may devel­op a hyper­sen­si­tiv­i­ty, so I’m giv­ing you opi­oids to treat the pain, [and they] may make you more hyper­sen­si­tive to pain and they may not be address­ing the pain con­trol at all. He was so moti­vat­ed, that he went home, stud­ied the infor­ma­tion leaflets I gave him on how to grad­u­al­ly reduce and come off the opi­oids, [and] he man­aged with­in three months’ time to stop the opi­oids. And [he] had a review [with] my col­league who saw him in the first instance, in Novem­ber – which makes it four months down the line – and declared that, ‘I fol­lowed Dr Eugeni­cos’ advice, I’m off the opi­oids now, my bow­els are back to nor­mal. I do not have much pain, very lit­tle pain at all. So I’m feel­ing much hap­pi­er.’ So you might say, ‘Oh, maybe this anec­do­tal, maybe it is dif­fer­ent.’ But there is a fol­low-on sto­ry, in that we ran into the [Covid-19] sit­u­a­tion. And the patient became quite stressed and quite anx­ious about his job about this and that, like most peo­ple nowa­days with the lock­down. And I reviewed him in my spe­cial­ist clin­ic only a month ago. And the symp­toms, were back to square one. So I was so dis­ap­point­ed. So I said to him, ‘What hap­pened?’ And he said to me, ‘I don’t know what hap­pened.’ And when I took the his­to­ry of med­ica­tions and stuff, he was back on opi­oids. But I said to him, ‘Do you remem­ber when you stopped the opi­oids, you went and saw so-and-so who wrote to me to say, “Thank you so much, because you man­aged to advise my patient, and he’s now free of symptoms.”?’ 

He could­n’t remem­ber it, of course, because he went into the sit­u­a­tion, had devel­oped pain – per­haps because of stress, because of anx­i­ety – start­ed the opi­oids because they were hand­ed to him. So when I remind­ed him and I read the detail of the let­ter my col­league sent me he said, ‘Yes you’re right, I was so much bet­ter off.’ I did say to him, ‘I do under­stand why you went back on them, maybe you are stressed.’ But I said to him, ‘If you can­not man­age with­out the opi­oids, I would sug­gest we do start the neu­ro­mod­u­la­tors.’ In the past, he man­aged to cut down the opi­oids, to stop the opi­oids, [and] he did­n’t even go back to the neu­ro­mod­u­la­tors. But I sup­pose, because of the cur­rent sit­u­a­tion, the wor­ries that he had, in par­tic­u­lar, he agreed to go on the neu­ro­mod­u­la­tors, and [he agreed] to a regime to try and cut back [the opi­oids]. And the habits of a few patients like that, that did say, ‘I stopped it, because I decid­ed I did­n’t want to be on this any­more.’ And sud­den­ly their symp­toms improve. Whether they need to be sup­port­ed with some form of treat­ment, either reg­u­lat­ing their bow­el habits bet­ter, or giv­ing them a form of neu­ro­mod­u­la­tor to avoid any of the symp­toms com­ing back. And rein­forc­ing this sort of depen­dence, if you like, is impor­tant as well. 

Evans: You men­tioned giv­ing out leaflets – edu­ca­tion is absolute­ly crucial. 

Eugeni­cos: I have got spe­cial inter­est in that. We have devel­oped, with med­ical stu­dents, edu­ca­tion­al leaflets to give to the patient. We did a tri­al where we have designed the symp­toms, lifestyle mea­sures, med­ica­tions to take, which are safer for long term, which are per­haps less often pre­scribed long term etc. And when we gave the patient the ques­tion­naire, what we want­ed to know more about, was the patho­phys­i­ol­o­gy behind their symp­toms. So what they enjoyed com­ing and lis­ten­ing about when they were com­ing to the clin­ic, is myself, show­ing them a pic­ture of the [CT scan] and explain­ing [to] them the jour­ney of the food through their stom­ach, through their small bow­el [and] the large bow­el, the func­tion of each one of these organs, the func­tion of the rest of the endocrine, if you like, the enzymes that we pro­duce, how our bow­el reacts to that [and] why we devel­op the symp­toms we develop. 

They were real­ly fas­ci­nat­ed, and I think if we allow the patient to be well edu­cat­ed, to know why they get the symp­toms they get, what makes their symp­toms appear cer­tain times [in the] month, if you like, hor­mon­al changes maybe, stress sit­u­a­tions, and they know to address those and pre­vent their symp­toms hap­pen­ing. And if they are in con­trol, this per­haps is the key to suc­cess­ful treat­ment in gen­er­al. We man­age to know more about how a patient can con­trol their symp­toms bet­ter through the biofeed­back when we were giv­ing the patient the treat­ment modal­i­ties to take home and do it on their own. And because they had to edu­cate them­selves, how to work a biofeed­back machine: ‘What does it do? What does relax­ation mean?’ They were much bet­ter [at] con­trol­ling their symp­toms and much more suc­cess­ful. So I do [rou­tine­ly] give them leaflets, but nowa­days I give them leaflets relat­ing to their own symp­toms. What my task in the future [is], is to make a book­let which would con­tain all the infor­ma­tion [they need], so they don’t need to depend either [on] the GPs they’re vis­it­ing and [being told] this and that, or [depend on] fol­low­ing any health­care pro­fes­sion­al. They need to have own­er­ship of their symp­toms, of their treat­ment [and] know what to do in the future. 

Evans: Dr Maria Eugeni­cos, clin­i­cal gas­troen­terol­o­gist at Edin­burgh’s West­ern Gen­er­al Hos­pi­tal. Now, as always, I remind you that we, in Pain Con­cern, believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound, based on the best judg­ments avail­able. You should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well-being. He or she is the only per­son who knows you and your cir­cum­stances and, there­fore, the appro­pri­ate action to take on your behalf. You can find all the resources to sup­port the man­age­ment of chron­ic pain, includ­ing details of our videos, leaflets, all edi­tions of Air­ing Pain, of course, and Pain Mat­ters mag­a­zine at And Pain Con­cern is cur­rent­ly prepar­ing an infor­ma­tion leaflet and an arti­cle for Pain Mat­ters mag­a­zine on how to man­age opi­oid induced con­sti­pa­tion. So please look out for that in the future. Dr Maria Eugeni­cos also rec­om­mends the IBS net­work web­sites as an excel­lent online resource for the man­age­ment and under­stand­ing of IBS and oth­er relat­ed con­di­tions. The address is There are no gaps. 

Eugeni­cos: In that web­site, they would be able to ask any ques­tions. These bod­ies are linked to spe­cial­ists and if any­body asked ques­tions, they usu­al­ly would address them to us, and we would answer back. So it’s a big cohort of patients who usu­al­ly try to col­lab­o­rate. It’s more about IBS, but all of these con­di­tions are addressed under this umbrel­la, it does­n’t have to be only IBS. So peo­ple, for exam­ple, who may have bile acid diar­rhoea [and] may ask ques­tions – nobody would tell them, ‘By the way, this is not IBS’, or if some­body says. ‘I have been com­menced on the hydrocodone that devel­op these symp­toms, what can I do? Can we address all of these symptoms?’ 


  • Dr Maria Eugeni­cos, Senior Lecturer/Gastroenterologist at the West­ern Gen­er­al Hos­pi­tal Gas­troen­terol­o­gy Depart­ment, Uni­ver­si­ty of Edinburgh 
  • Dr Cathy Stan­nard, Con­sul­tant in Pain Med­i­cine and Pain Trans­for­ma­tion Pro­gramme Clin­i­cal Lead for NHS Glouces­ter­shire Clin­i­cal Com­mis­sion­ing Group.

More infor­ma­tion: 

With thanks to: 

  • Maggie’s Cen­tre, a resource net­work designed to help can­cer patients and their fam­i­lies –