Can Opioid-Induced Constipation Be Avoided?

After surgery many years ago, I was prescribed opioids to manage the pain. At first, I was relieved as they really helped. But then came the constipation, and let me tell you, it was awful. I found myself wondering if the pain relief was even worth it. No one really talked to me about how to prevent it, so I just assumed I’d have to deal with it and stop complaining. Turns out, I was wrong. There are ways to deal with opioid-induced constipation (OIC) that we will explore in this article.

Constipation is the most common side effect of opioid use. Studies show that up to 95% of people taking opioids experience constipation, and it can start as early as the first dose. Older adults are more likely to experience opioid-induced constipation due to factors like limited movement, an unhealthy diet, not drinking enough water, and taking medications that can cause constipation. Those dealing with chronic pain or in palliative care are often less active and may take opioid painkillers long-term, which puts them at an even higher risk of developing constipation.

How do opioids cause constipation?

Opioids can lead to constipation because they attach to certain receptors in the brain and digestive system. This slows down how the bowels move, both directly and indirectly, by affecting nerve signals. Opioids can slow down the time it takes for food to move through the colon, making it harder to have a bowel movement. This delay causes the body to absorb more water and electrolytes from the stool, which makes it drier and harder to pass. 

Most people experience some level of constipation after starting opioids. While the body may adjust to some side effects of opioids over time, OIC in patients usually doesn’t improve without treatment.

What is the impact of opioid-induced constipation?

OIC in patients can be so uncomfortable that it seriously affects a person’s daily life and mental health. Many patients find it to be the most troubling side effect of taking opioid painkillers. If chronic constipation is not treated, it can lead to problems like pain and bleeding in the rectum, stomach pain, bloating, trouble controlling urine, stool blockages, rectal tears, and, in serious cases, a blocked bowel or a tear in the colon.

Opioid-induced constipation can affect a person’s quality of life as much as other chronic health problems. Some people even say they would prefer to deal with ongoing pain rather than the severe constipation that often comes with long-term opioid use, and I don’t blame them after my own experience from using them short term.

A study showed that about one-third of patients reduced, skipped, or stopped taking opioids to make it easier to have a bowel movement. Unfortunately, most of these patients experienced more pain, which negatively affected their quality of life. Lowering the opioid dose is not seen as helpful because it can weaken pain relief without fully solving the OIC in patients.

How many bowel movements a week is considered constipation?

Constipation doesn’t have a single clear definition because normal bowel habits can vary a lot from person to person. Patients and healthcare providers often have different views on what constipation means. In general, it’s described as having bowel movements less than three times a week, often involving straining and passing hard, uncomfortable stools.

How is opioid-induced constipation managed?

Opioids slow down the digestive system’s movement, which can lead to hard stools. To help with this, laxatives that soften stools and encourage bowel movements are the most effective. Fiber supplements are not usually a good choice. Enemas and suppositories are often suggested to clear the rectum before beginning a bowel care routine.

When someone has ongoing constipation, a rectal exam is often needed. This can help identify if there is soft or dry stool or a blockage, which can affect which laxative is recommended. In some cases, a simple abdominal x-ray is done, but the amount of stool seen on the x-ray doesn’t always match the severity of the symptoms. The type of laxative chosen should consider the patient’s preferences, how it will be taken, possible side effects, and how quickly it needs to work. 

Several formulations for the specific treatment of opioid-induced constipation are available:

Specific laxatives for OIC 

Movantik and Relistor are peripherally acting mu-opioid receptor antagonists (PAMORAs), meaning they block opioid receptors in the gut, reducing the constipating effects of opioids without affecting pain relief.

Stimulant laxatives with stool softeners

Combined stimulant laxatives with stool softeners, such as docusate sodium and senna (e.g., Coloxyl with Senna), are commonly used to manage constipation in individuals taking opioids. The stool softener (docusate sodium) works by increasing the water content in the stool, making it easier to pass, while the stimulant laxative (senna) stimulates the muscles of the intestines to promote bowel movements. Products like Senna (e.g., Midro Tea) are also effective in enhancing intestinal motility.

Stimulant laxatives

Bisacodyl (e.g., Dulcolax) is a stimulant laxative. It works by directly stimulating the nerve endings in the colon, which increases the muscle contractions (peristalsis) of the intestines. This action helps to move stool through the digestive tract more quickly. It also promotes the accumulation of water and electrolytes in the bowel, softening the stool and making it easier to pass. 

Osmotic laxatives

Peglax, also known as polyethylene glycol, is an osmotic laxative. It works by drawing water into the bowel, which softens stool and increases its volume, making it easier to pass. This mechanism is particularly effective for OIC because opioids slow down bowel movements by reducing intestinal motility and increasing water absorption in the gut. Peglax helps counteract these effects by maintaining moisture in the stool without causing significant irritation to the bowel. 

Other factors affecting constipation

Constipation can have many causes that are not opioid related, such as side effects from medications, nerve problems, or physical blockages. Doctors can figure out what might be causing the issue by asking questions and doing a careful check-up.

In addition to opioid painkillers, other medications can often lead to constipation. These include antacids that contain aluminum or calcium, as well as drugs with anticholinergic effects, like some antidepressants, antihistamines, and medications used to treat overactive bladder. Certain antipsychotics, such as clozapine and quetiapine, can also cause constipation. Other culprits include gabapentin, some iron supplements, some calcium supplements, and verapamil, a calcium channel blocker that is particularly known for this side effect.

Some people who already have constipation may already be using laxatives. For instance, if they are using a fiber-based laxative, it might be suggested that they switch to a stimulant laxative combined with a stool softener before beginning opioids so that their constipation does not get any worse.

What are some natural ways to prevent opioid-induced constipation in patients?

Along with using medication when needed, patients should be encouraged to follow healthy bathroom habits. They should try to use the toilet at the same time each day and take advantage of the body’s natural reflex to go after eating or drinking something warm. People should have a comfortable and private space to spend time in the bathroom without feeling rushed. They shouldn’t ignore the need to go; for instance, if they’re out, they should use public restrooms instead of waiting until they get home.

They should try to drink plenty of fluids and include more fiber-rich foods, like prunes or other fruits and vegetables, if they aren’t getting enough. It’s also essential to stay as active as possible and do some exercise within their limits, even though moving can be challenging with chronic pain.

Balancing bacteria in the gut may also be helpful as this can improve digestion and bowel movements. This can be achieved through probiotic supplements like The Gut Pack and by incorporating fermented foods like yogurt into the diet. Over-the-counter herbal laxatives such as Laxin Forte can be used once the main blockages caused by OIC have eased.

Frequently Asked Questions

Does prune juice help with constipation?

Prune juice is a natural way to help with constipation. It works because it contains fiber, sorbitol, and polyphenols, which can make going to the bathroom easier when used regularly. However, it might not be strong enough to treat very bad cases of constipation.

Should I force a hard stool out?

Pushing too hard to pass hard stool can harm the pelvic floor, lead to hemorrhoids, and create long-term problems with bowel movements.

What can I take for constipation that works immediately?

Rectal laxatives work quickly and are a good option for people who can’t take medicine by mouth. Enemas can start working in as little as 5 minutes, while suppositories usually take about an hour.

What is narcotic bowel syndrome?

Narcotic bowel syndrome (NBS) is a condition that happens when someone has ongoing or repeatedly returning stomach pain that gets worse the more they use or increase their dose of opioid painkillers.

How long can opioid constipation last?

Opioid medications can cause constipation, known as OIC, that may continue as long as the medication is being used. It usually doesn’t get better on its own, even if the dosage is reduced or the type of opioid is changed.

How long can you go without pooping?

It’s hard to say exactly how long someone can go without having a bowel movement, as it varies for everyone. If a person becomes constipated, it’s essential to address it quickly. If not, waste can build up in their intestines, making it more difficult to go and possibly causing them to feel unwell.