Pain medications are widely used for treatment of both chronic and acute pain, but they come with a common side effect: constipation. There are several variables that determine the severity of constipation and need to monitor dosage including age, comorbid conditions, drug interactions, and genetics.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), acetaminophen and opioid pain medications are the most common medications utilized for pain relief. All three medications come with constipation as a potential side effect. Out of the three, opioid medications tend to cause more severe constipation.
Acetaminophen and Constipation
While Acetaminophen can cause constipation, it is less likely to do so than either opioid medications or NSAIDS. Up to 10% of people taking acetaminophen in therapeutic doses reported constipation as a side effect. Acetaminophen can have other gastrointestinal problems as a side effect as well, such as nausea and vomiting, which were reported more frequently than constipation.
NSAIDs and Constipation
People generally know that NSAIDs can cause gastrointestinal distress, like bleeding and ulcers. It is less known, however, that NSAIDs can also cause constipation, particularly when taken in higher-than-recommended doses. A recent study showed that around 15% of American adults take more than the recommended dosage when attempting to relieve pain.
Opioids and Constipation
It is widely known that opioid pain medications have constipation as a common side effect. Forty to eighty percent of patients taking opioids over a longer period of time struggle with constipation and need to have an effective bowel management program for managing constipation as a result.
Opiates’ effects on gastrointestinal motility have long been recognized by the medical community, and Opioid-induced constipation (OIC) accounts for forty to sixty percent of cases in non-cancer patients (for cancer patients this percentage is as high as 90%) receiving opioids. Opiate receptors in the gastrointestinal tract reduce motility and increase transit time, and the resulting increased absorption of fluid by the intestinal tract leads to hardening of stool and constipation.
Functional vs. Opiate-Induced Constipation
Functional constipation is broadly defined as the difficult passage of hard, dry stool, less frequently than the patient’s typical pattern of bowel movements. Characterizing a patient as constipated cannot be based solely on the number of bowel movements per day, or week, but rather as a function of their normal regularity. The Rome IV criteria for functional constipation includes at least two of following for a period of at least 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 (digital evacuation and/or support of the pelvic floor) to help move or remove the stools from the rectum
Pharmacotherapy and OIC
All healthcare professionals prescribing opioids need to also consider prophylactic laxative therapy for constipation. Patients with predisposing factors (immobility, advanced age, poor diet, intra-abdominal pathology, neuropathy, concurrent use of other constipating drugs) are specifically indicated.
While most laxatives can work to relieve constipation, bulk-forming laxatives like psyllium should be avoided.
The most common regime for OIC is a stimulant (senna/bisacodyl) with or without a stool softener (docusate), or daily administration of an osmotic laxative (polyethylene glycol).
Stimulating agents such as senna and bisacodyl are not typically recommended for longer-term use due to adverse side effects. Bisacodyl stimulants work by irritating the lining of the intestine wall causing muscle contractions that move along stool mass. This process occurs whether bisacodyl is taken orally or as a suppository. The list of common side effects include rectal irritation, diarrhea, and abdominal cramping.
Constipation and Patient Education
There are common misconceptions about constipation, its treatment, and causes, and so it’s important to educate patients on constipation prevention when prescribing opiates. Increasing dietary fiber, fluid intake, and physical exercise are the backbone of prevention therapy.
Constipation Prevention Tips for Patients
Fiber Intake: Patients should be advised to consume fiber-rich foods, like apples, bananas, prunes, pears, raspberries, beans, broccoli, spinach, kale, squash, lentils, and peas. Any type of bran product is also helpful.
Hydration: Patients must stay hydrated when taking opioid medication. Fluids, especially water and non-diuretics, keep the digestive tract moving and promote healthy bowel movements. Lack of hydration slows the stool movement through the intestine which can cause constipation.
Physical Activity: Moderate increases in physical activity, as tolerated, can be beneficial in patients with mild constipation.
Routine: Advise patients to set aside the same time each day to have a bowel movement, especially after breakfast, and to respond to the urge to defecate right away and not withhold stool.
Patients should also be advised to limit their intake of foods and/or over the counter medications that cause or exacerbate constipation, such as processed grains, milk/dairy products, and fried foods.
The DocuSol® and DocuSol® Plus Advantage
DocuSol® mini-enema delivers 283mg of docusate sodium and is a stool softener hyperosmotic laxative that draws water into the bowel from surrounding body tissues, softening the stool and promoting a bowel movement.
For people with painful bowel movements, DocuSol® Plus also contains 20mg of benzocaine, assisting in the anesthetization of the rectum and lower bowel. The formulation was developed for patients who experience hemorrhoids, fissures, or painful bowel movements.
Enemeez® Products Can Help
The Enemeez® formulation is a stool-softening laxative that works by drawing water into the bowel from surrounding body tissues. The docusate sodium in this mini enema product prepares the stool to readily mix with watery fluids. Not only does it soften and loosen the stool, but it initiates a normal, replicated bowel movement, typically within 2-15 minutes. Effective for general constipation and neurogenic bowel resulting from spinal cord injury or disease, traumatic brain injury, multiple sclerosis, long term care and stroke.
Disclaimer: The material contained is for reference purposes only. Alliance Labs, LLC and Summit Pharmaceuticals do not assume responsibility for patient care. Consult a physician prior to use. Copyright 2021 Summit Pharmaceuticals and Alliance Labs, LLC.