by Chun-Su Yuan Haworth Medical Press, 10 Alice Street, Binghamton, NY 13904

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Any clinician involved with the care of patients in hospice and palliative care understands the struggle with bowel issues. Disease process, opioids, declining mobility, and altered nutrition all combine to form problematic issues in bowel function. Because opioids are a mainstay of treatment therapy in pain control, it is important to address this issue. Many clinicians hesitate to start opioids or do not increase them as needed because of patient concerns and problems with bowel function. This contributes to poorly controlled pain and the unaddressed issue of constipation. The editor, Chun-Su Yuan, MD, PhD, has assembled clinician-scientists with expertise in this area to provide pertinent information on a most important issue.

The book is divided into three sections: Section I-Basic Concepts in Opioid Physiology; Section II-Clinical States; and Section III-Advances in Treating Opioid Bowel Dysfunction. Section I comprises three chapters and is a primer for taking the reader through basic concepts: opioid physiology and pharmacology, pathophysiology of opioid-induced bowel dysfunction, and opioid-induced immunosuppression. In the chapter that discusses opioid-induced immunosuppression, the authors cite several studies indicating that a close relationship exists between the use of opioids and immunological responses and infections. Further studies are indicated to establish safe use of opioids without producing immunosuppression.

Section II focuses on clinical states and is written at a clinical level for practitioners. Epidemiology within the United States is discussed, and several studies are reviewed to compare bowel habits and constipation-related treatments. The book provides recommendations for a proactive approach and prompt interventions to alleviate bowel symptoms of constipation. Several other clinical states are discussed to address opioid bowel dysfunction: palliative care, acute and chronic nonmalignant pain, postoperative bowel dysfunction, and postsurgical bowel dysfunction in gynecologic patients.

The palliative care chapter focuses on constipation and the frequent side effects of nausea and vomiting when opioids are administered. Specific opioids are discussed on their emetogenic properties, and recommendations are given about changing opioids to assist analgesia and decrease adverse side effects.

The chapter on acute and chronic nonmalignant pain addresses constipation and nausea and vomiting and gives recommendations for nonprescription options and pharmacological options for prevention and treatment of opioid bowel dysfunction. The author discusses postoperative bowel dysfunction in detail and the pathogenesis of postoperative ileus is explained. The chapter also states that bowel dysfunction after surgery as almost inevitable because there is no single cause or cure. A multimodal approach is called for, and recommendations are given. The author discusses long-accepted standards of postsurgical care, such as nasogastric intubation, and cites studies that show possible worsening of bowel function. Methods for promoting gastric motility are discussed, such as preoperative fiber, perioperative fluid administration, surgical technique, early mobilization, and psychological preparation. The chapter recommends analgesics other than opioids or in conjunction with a lower dose opioid to minimize problems with bowel dysfunction.

Postsurgical bowel dysfunction in the gynecologic patient is discussed briefly, and the chapter concludes that methodologies currently used are not necessarily evidence based. The reader is directed to the citations within the chapter for review and consideration in surgical practice.

Section III focuses on advances in treating opioid bowel dysfunction and discusses three investigational drugs. Oral naloxone, methylnaltrexone, and alvimopan have been studied, and all seem to show promise to reverse or prevent opioid bowel dysfunction while preserving analgesic effects. These drugs also show promise of blocking opioid action on lymphocytes, thus preventing immunosuppression.

The content of this book covers 256 pages and is extremely well written. Although it is not a "light read," enormous amounts of information are well explained and can be easily understood. It goes far beyond just a list of pharmacologic and nonpharmacologic interventions for opioid bowel dysfunction and addresses numerous scenarios from palliative care to surgery. I recommend this book to any physician or nurse who is interested in an in-depth understanding of this problem and how to correct or minimize it.

Sharon Heidecker, MSN, CRNP,

AP-BC, is the Nurse Practitioner Consultant and Coordinator for Hamot Medical Center's Palliative Care Consult Service, Erie, PA.