Monday, November 25, 2019

Managing Constipation When Using Opiates

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Defining the Problem

As a daily opioid user who also suffers IBS-C (constipation-dominant), I know a thing or two about chronic constipation.  "Severe constipation" was the first thing noted on my barium X-ray--I can go 2 or even 3 weeks only having 1 or 2 tiny, insignificant bowel movements the size of a ping pong ball.  Then it all comes out on that 4th week (or at least a good amount).  Sorry if this is TMI but this is an article on constipation so we might as well get down to brass tacks, right?

A lot of people think they're constipated if they don't poop daily or every other day. Not so.  According to the Rome IV criteria, you're only considered constipated if you have two of following for the last 3 months:
  • Hard stools in at least 25 percent of defecations
  • Straining in at least 25 percent of defecation
  • A sensation of incomplete evacuation in at least 25 percent of defecations
  • Less than 3 bowel movements per week
  • Use of manual measures to help move or remove the stools from the rectum

Opioids like hydrocodone, oxycodone, heroin & morphine are known to cause or worsen existing constipation in many users.  Between 40-60% of long-term users develop this side effect, making it one of the most commonly reported opioid side effects.  While rarely dangerous, severe constipation is uncomfortable & can in rare cases lead to fecal impaction & other serious complications if left untreated.  

Treating Opioid-Induced Constipation

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Who can relate?

So what actually works for opioid-induced constipation?  Beginners might start with Miralax or Epsom salts, as both are gentle & don't tend to cause urgency or major changes in fecal texture.  (Make sure to follow directions carefully with Epsom salts to avoid magnesium overdose, and only use the unscented salts).  However, if your constipation is severe you may require something more drastic.  A bottle of magnesium citrate is sure to get the job done, though you may be caught short if you're not by a bathroom when it kicks in.  I've had it happen & it wasn't pretty.

For me, mag citrate is not a long-term solution because the side effects are too drastic.  Ditto for stimulant laxatives like Dulcolax--they can be acceptable as emergency options but the side effects are too intense for regular use.  And magnesium citrate tastes incredibly sour.  Definitely chill it in the fridge before drinking to improve the taste.  There are weaker powdered supplement forms that can be taken daily, which I prefer over the liquid concentrated form that comes in a bottle.

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Drink the whole bottle & prepare to poo.

If none of these things work, talk to your doctor about a prescription option like Linzess, Amitiza or Movantik, the latter of which is made specifically for Opioid-Induced Constipation (OIC).  I haven't tried these but have heard they can work for severe/resistant cases.  However, I much prefer to stick with the safest & most basic options whenever possible.  Opiates cause constipation by slowing movement in the intestines & causing mild dehydration, so exercising daily & upping your water intake can help.  Also be sure to ingest enough soluble fiber--preferably in foods like fruits, veggies & whole grains--every day to stay regular.  But remember:  fiber can worsen constipation if not taken with adequate water.  Caffeine & alcohol don't count toward your daily water intake, as they make you pee & sweat out more water than they contain.

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High-fiber foods keep things moving.

Prune juice
is another safe & natural option that many opiate users swear by...if you can tolerate the taste.  I like to take a big swig followed immediately by an even bigger swig of soda or Slim Fast.  Other supplements that may help include probiotics, vitamin C & soaked chia seedsTiming your opioid dose after breakfast & a workout can also help ensure a proper bowel movement each day if you're used to dosing all day.  Adding a cup of coffee or another caffeine source is often helpful too.  Taking occasional med breaks to reduce tolerance & allow your GI tract to catch up is a good idea if you can swing it.  If your dose is too high & you'd get sick by quitting completely, try cutting it in half for one day a week to see if that helps.  Your bowels & pain tolerance will thank you.

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Prune juice = gentle constipation relief

Not all constipation remedies are taken by mouth.  I've found enemas to be extremely uncomfortable bordering on dangerous.  They make me weak & shaky for hours, so I avoid them at all costs.  Particularly the Fleet brand.  However, glycerin suppositories are a nearly instant way to unblock the lower part of your intestines & get things moving.  I actually prefer them to most oral options since they work so quickly & are more predictable.  Simply insert the suppository all the way, lie down on your side for 5-30 minutes & then evacuate.  Make sure to wash your hands after insertion.

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Glycerin suppositories.  Keep refrigerated.

If you can prevent OIC before it starts, do that.  Begin taking preventative measures as soon as you start taking opioids so you don't develop it.  Once OIC is established, it becomes harder & harder to treat according to some studies.  Bulk-forming laxatives like psyllium husks should be avoided when dealing with OIC.  Everything else is relatively safe in a healthy adult.

To wrap it up, there is no one-time fix for opioid-related constipation.  As long as you're taking this class of drugs, you will continue to experience constipation unless you're vigilantly taking preventative measures like exercise, drinking lots of water, eating fiber & drinking prune juice or taking probiotics (if not something stronger).  Thankfully, constipation is one of the only major side effects of opioids when they're taken responsibly... even long-term.  While uncomfortable & annoying, it's far from the worst that can happen in terms of medication side effects.  If you can avoid addiction & overdose, you shouldn't expect any organ damage even with heavy chronic use of opiates.

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