What You Can Do About Opioid Induced Constipation

For those with chronic pain, constipation can be a significant problem

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Opioid-induced constipation (OIC) is a common condition that occurs as an adverse effect of the use of painkillers (analgesics). Opioids are painkillers containing a substance chemically similar to the alkaloids that are found in the opium poppy.

Prescription medications that contain opioids include methadone, percocet, vicodin, demerol, dilaudid, and fentanyl. They are prescribed for pain relief, usually for acute pain such as after an injury or surgery, but also for long-term pain such as that caused by cancer.

 In some cases, opioids are used to treat diarrhea, usually in quite small doses to avoid potential side effects.

Studies have shown that many physicians do not know their patients are experiencing constipation when receiving opioids. However, virtually all patients receiving opioids report having digestive side effects and up to 40 percent may have constipation.

Constipation can lower quality of life significantly and therefore, it’s worth talking about with a physician in order to get treatment and find relief.

OIC vs. Functional Constipation

Constipation occurs when stools are infrequent, hard, and difficult to pass. However, it’s not exactly an exact science because a person's stools and how often they pass them is individualized.

In general, having healthy bowel movements could mean going anywhere from three times a day to three times a week. However, a change in bowel movements may indicate constipation.

If it’s suddenly more difficult to go to the bathroom—this could mean straining on the toilet bowl or bowel movements that are a lot less frequent—constipation may be occuring.

Symptoms of constipation can include:

  • Straining on the toilet bowl

Opioid-induced constipation is different than constipation that is functional. Functional constipation could be from a variety of causes ranging from not enough fiber in the diet to a disease or condition in the digestive tract. Opioid-induced constipation, however, is a direct result of the way that opioid medications affect the small intestine and the colon, by slowing down digestion.

Why Do Opioids Cause Constipation?

Opioids have several different effects that slow down digestion. In the stomach, opioids can cause gastroparesis, which means that the stomach takes longer to empty than it should because the muscles are not working effectively.

Food moves through the small intestine because of muscle contractions known as peristalsis. Opioids affect the middle of the small intestine (jejunum) by increasing circular muscle contractions, which are non-propulsive contractions, and this decreases the peristalsis that normally moves food along. This can also create harder stools, making them more difficult to pass.

Opioids also affect how the anal sphincter responds to the drug. When stool is in the rectum there is a natural urge to go to the bathroom and pass it.

Opioids can dampen this sensation so that when there is stool to be passed, a person doesn’t feel it. That could lead to holding stools in too long.

Overall, these effects on the digestive system mean that some people will experience constipation when using opioids. For people who need long-term pain management with these medications, this can be a significant problem.

Treatment for Opioid-Induced Constipation

Treatment for opioid-induced constipation could include both lifestyle changes and medications. The approach to treatment is going to depend heavily on the current state of your health as well as other factors such as the medications.

In many cases, lifestyle changes and over the counter laxatives are not effective enough to provide complete relief and prescription.

Lifestyle Changes

Making some changes to the everyday routine, along with other treatments, may help with constipation.

Diet is a factor in constipation because eating enough of the right kinds of fiber and drinking enough water can help get the bowel moving and keep stools soft and easily passed. Insoluble fiber, which is primarily found in fruits and vegetables, makes stools softer and bulks them up. Soluble fiber will dissolve into a substance that’s like a gel and will also help in relieving constipation.

Fiber can be added into the diet but it can also be taken as a supplement. Some people will need to try different supplements and determine which type of fiber will work the best to relieve constipation. A dietitian may also be able to narrow fiber choices down and recommend diet changes and supplements, including foods that are natural laxatives (such as prunes).

Drinking enough water and other liquids every day can also help in dealing with constipation. Stools are easier to pass when there is enough liquid drawn into the bowel to make them softer. For those that already drink enough, adding more water or other liquids to the diet won’t necessarily make a big impact on a digestive system that’s being affected by opioids. However, being properly hydrated is important to overall health, so it’s worth paying attention to how much water is being taken in every day.

Exercise is another factor that can help relieve constipation. Again, the ability to exercise is going to depend on overall health. However, even walking can make a difference when it comes to moving the bowels on a regular basis. Physicians can help in recommending the best form of exercise and if necessary, a referral to a physical therapist may help in developing an overall plan that takes any other health conditions into account.

Laxatives

Laxatives that counteract the constipating effects of opioids may be needed in most cases and might be prescribed at the same time as the opioid. Frequently, a laxative might be the first option in preventing and/or treating the constipation.

Osmotic laxatives are those that draw more water into the intestine, which has the effect of making stools softer and easier to pass. Certain osmotic laxatives are available over the counter while others are by prescription, and some of the different types include miralax, lactulose, and milk of magnesia (which is not prescribed as often). There aren’t usually too many side effects with these types of laxatives—they are generally considered safe and effective, but some people may have bloating or diarrhea.

Stimulant laxatives are also available over the counter and include bisacodyl, sodium bicarbonate with potassium bitartrate, senna, and castor oil. This type of laxative works by increasing the movement of the muscles in the digestive system (peristalsis). They are not usually recommended for long-term use because of potential side effects, and tolerance may vary (which means it may stop working after a while).

Rectal Interventions

In some cases, removing impacted stool might be necessary. This could be done with an enema or colonic irrigation (water or another liquid inserted through the anus and into the rectum), suppositories, or manual evacuation.

Glycerin suppositories might be the first step in moving stool, followed by an enema, irrigation, or manual evacuation (inserting a gloved finger into the rectum to break up the stool and remove it).

Prescription Medications

There are prescription medications available for the treatment of opioid-induced constipation. Relistor and Movantik are two such drugs. These medications work by blocking the effects that opioids have on slowing down the bowel.

These medications may help in bringing on a bowel movement a short time after taking or receiving them. Some of the potential side effects of these medications can include nausea, diarrhea, abdominal pain, and gas.

A Word From Verywell

Opioid-induced constipation is a common problem for people that are receiving opioids for the treatment of pain, and in particular, for chronic pain. It’s a problem that can be embarrassing for many people to discuss, but constipation can significantly decrease the quality of life, so it’s worth bringing it up with a physician.

In addition, there are treatments available that are safe and effective and can reduce the symptoms of constipation and thereby avoid potential complications. While constipation is a difficult topic to bring up at a doctor’s visit, it’s one that is not unexpected when coping with chronic pain.  

Sources:

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Galligan JJ, Sternini C. "Insights into the Role of Opioid Receptors in the GI Tract: Evidence and Therapeutic Relevance." Handb Exp Pharmacol. 2017;239:363-378. doi: 10.1007/164_2016_116

Gupta S, Patel H, Scopel J, Mody RR. "Impact of constipation on opioid therapy management among long-term opioid users, based on a patient survey.” J Opioid Manag. 2015 Jul-Aug;11:325-38. doi: 10.5055/jom.2015.0282

LoCasale RJ, Datto C, Margolis MK, Coyne KS. "Satisfaction with Therapy Among Patients with Chronic Noncancer Pain with Opioid-Induced Constipation.” J Manag Care Spec Pharm. 2016;22:246-253. doi: 10.18553/jmcp.2016.22.3.246

LoCasale RJ, Datto C, Wilson H, Yeomans K, Coyne KS. "The Burden of Opioid-Induced Constipation: Discordance Between Patient and Health Care Provider Reports.” J Manag Care Spec Pharm. 2016;22:236-45. doi: 10.18553/jmcp.2016.22.3.236

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