Opioid Induced Constipation.MAT

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Patient Name* This field is required.

First Name

Last Name

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UniqueID* This field is required.

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Email

example@example.com

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Opioid induced constipation (OIC) is a common side effect of opioid medications like Suboxone (buprenorphine). Approximately 50% of patients may experience OIC.

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Do you have difficulty with your bowel movements (i.e., constipation)?

YESNO

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Symptomscheck all that apply

bloating or pain in your stomach area

sense of incomplete emptying

less frequent bowel movements

more straining/ pushing harder

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Score Symptoms

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Signscheck all that apply

hard, dry stools

3 or less bowel movements/ week

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Score Signs

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Today's Provider* This field is required.

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If patient has symptoms or signs of OIC plus failure of over the counter remedies, then please prescribe Relistor (methylnaltrexone bromide) 450mg tablet -- 1 tablet q morning with water and on empty stomach. Use daily until bowel movement.

Side effects to discuss: diarrhea, small risk of mild withdrawal symptoms

May be used in renal and liver disease; see prescribing information HERE

Please use the following billing codes:

K59.03

F11.99

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Screening Test

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Date

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Grading

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ALERT