Laxatives And Tramadol: Safe Mix?

Tramadol is a pain medication that can cause constipation in around 40% to 60% of patients without cancer who take it. This is known as opioid-induced constipation (OIC). Laxatives are commonly used to treat OIC, but they are often ineffective and can cause side effects such as abdominal symptoms that negatively impact quality of life. It is recommended that laxatives are started at the same time as opioid medication to prevent OIC. However, once OIC is established, laxatives may not be effective in treating the constipation. Other treatments, such as prescription medications specifically for OIC, may be more effective. These medications include lubiprostone (Amitiza), methylnaltrexone (Relistor), naldemedine (Symproic), and naloxegol (Movantik). These medications block the effects of opioids in the gut and help stools pass more easily.

Laxatives and stool softeners are the first line of treatment for opioid-induced constipation

Opioids are a common treatment for pain, but they can cause opioid-induced constipation (OIC) in 40% to 60% of patients without cancer who take them. OIC can be a serious problem, and it can occur quickly—sometimes in a matter of days. It can also lead to more serious complications like anal fissures, rectal bleeding, or bowel perforation. Therefore, it is important to address and treat OIC.

Laxatives and stool softeners are the first line of treatment for OIC. They are the same medications that anyone with constipation might use and can be bought over the counter. However, it is important to note that bulk-forming laxatives like psyllium should be avoided as they can worsen OIC. The most common regimen for OIC is a stimulant (senna/bisacodyl) with or without a stool softener (docusate) or the daily administration of an osmotic laxative (polyethylene glycol). Stool softeners are ideal for preventing constipation but are less effective for established cases.

Laxatives and stool softeners should be started at the same time as opioid therapy to prevent OIC. They can also be used in combination with other treatments for OIC, such as increasing fluid intake, dietary fiber, and physical exercise. It is important to note that even with these treatments, returning bowel function to pre-opioid status can be difficult.

Drink more water to prevent dehydration, a common cause of constipation

Tramadol is an opioid drug that can cause constipation by reducing the movement of the intestines and increasing fluid absorption, leading to hard and dry stools. While laxatives are commonly used to treat constipation, they do not address the underlying cause of opioid-induced constipation and can have unpleasant side effects. Instead, it is recommended to focus on preventing constipation by making lifestyle changes, such as increasing fluid intake, eating more fibre, and exercising.

Drinking more water can help prevent dehydration, which is a common cause of constipation. Water helps to soften stools and makes them easier to pass. The recommended daily fluid intake is 11.5 cups for women and 15.5 cups for men. However, when experiencing constipation, it is suggested to drink an additional 2 to 4 cups of water per day. Along with water, other fluids such as tea, milk, and juice also contribute to daily fluid intake. It is important to avoid alcoholic and caffeinated beverages, as they can contribute to dehydration.

By staying hydrated, increasing fibre intake, and incorporating regular exercise, individuals can effectively prevent and manage constipation, including constipation caused by opioid medications like tramadol.

Increase your fibre intake to keep your bowels regular

While laxatives are commonly used to treat constipation, they are not always effective and can cause side effects such as abdominal symptoms that negatively impact quality of life. In addition, laxatives do not address the underlying cause of opioid-induced constipation. Therefore, it is important to consider other strategies to keep your bowels regular, such as increasing your fibre intake.

A high-fibre diet offers several health benefits, including reducing the risk of heart disease, diabetes, diverticular disease, constipation, and colon cancer. It is important for the health of the digestive system and for lowering cholesterol. There are two main types of fibre: water-soluble and water-insoluble. Soluble fibre, found in fruits like apples, oranges, and grapefruit, as well as vegetables, legumes, barley, oats, and oat bran, absorbs water during digestion, increasing stool bulk and potentially lowering blood cholesterol levels. Insoluble fibre, found in fruits with edible peels or seeds, vegetables, whole grain products, bulgur wheat, stone-ground cornmeal, cereals, bran, rolled oats, buckwheat, and brown rice, remains unchanged during digestion, promoting normal movement of intestinal contents.

The recommended daily fibre intake for adults is 25 to 30 grams, but the average intake in the United States is only about 15 grams. To increase your fibre intake, consider the following tips:

• Include at least one serving of whole grain in every meal.
• Sprinkle oat bran or wheat germ on salads, soups, breakfast cereals, and yogurt.
• Use whole-wheat flour in your cooking and baking.
• Choose whole grain bread with the highest amount of fibre per slice.
• Opt for cereals with at least 5 grams of fibre per serving.
• Keep whole-wheat crackers on hand for a fibre-rich snack.
• Cook with brown rice instead of white rice.
• Add beans, garbanzos, or other bean varieties to your salads.
• Experiment with international dishes that use whole grains and legumes as part of the main course or in salads.
• Eat at least five servings of fruits and vegetables each day, including fresh fruit, which has a slightly higher fibre content than canned.
• Eat the fruit peel whenever possible.
• Choose whole fruits instead of drinking fruit juices, as juices do not contain fibre.
• Add dried fruits to your baked goods, as they have a higher fibre content than their fresh counterparts.
• Add sliced fruit or grated carrots to your cereal.

By incorporating these simple tips into your daily routine, you can increase your fibre intake and promote regular bowel movements, which may help alleviate constipation associated with opioid use.

Exercise and physical activity stimulate intestinal contractions, helping to relieve constipation

Exercise and physical activity are essential for regular bowel movements and can help relieve constipation. Inactivity is a common cause of constipation, and exercise can help speed up the time it takes for food to move through the large intestine. This is because exercise stimulates intestinal contractions, which help move stools out quickly.

The large intestine absorbs water from stool, and the longer stool remains in the large intestine, the more water is absorbed, resulting in hard, dry stools that are difficult to pass. Exercise helps to reduce the time it takes for food to move through the large intestine, limiting the amount of water absorbed from the stool. Additionally, aerobic exercise increases breathing and heart rate, which helps to stimulate the natural squeezing or contractions of the muscles in the intestines.

Any form of physical activity can help with constipation. Walking for 10 to 15 minutes several times a day can be beneficial. For those who are already fit, aerobic exercises such as running, jogging, swimming, or swing dancing can be excellent choices to keep the digestive tract healthy. Stretching and yoga may also help ease constipation.

It is recommended to wait for an hour after a big meal before engaging in strenuous physical activity. This is because, after eating, blood flow increases to the stomach and intestines to aid digestion. If you exercise immediately after eating, blood flows away from the stomach and towards the heart and muscles, resulting in weaker gut contractions and slower movement of food through the intestines. This can lead to bloating, gas, and constipation.

Prescription medications for opioid-induced constipation include naloxegol, methylnaltrexone, lubiprostone, and naldemedine

Prescription medications are indicated when opioid-induced constipation (OIC) persists despite conservative approaches (e.g., increased fiber and fluid intake, exercise, over-the-counter laxatives and stool softeners). Phase 3 studies have demonstrated the efficacy of peripherally acting μ-opioid receptor antagonists (PAMORA) and a chloride channel activator for improving OIC in patients with chronic noncancer pain. The four prescription medications for OIC include naloxegol, methylnaltrexone, lubiprostone, and naldemedine.

Naloxegol is the first once-daily oral peripherally acting μ-opioid receptor antagonist (PAMORA) approved by the Food and Drug Administration (FDA) in September 2014 for the treatment of OIC in adult patients with noncancer pain. It is available in 12.5 mg and 25 mg doses and can be crushed if necessary. Naloxegol may be given via a nasogastric tube and should be taken on an empty stomach 1 hour before or 2 hours after the first meal of the day. Grapefruit and grapefruit juice should be avoided as they may increase the concentration of naloxegol and the risk of adverse effects. The most common side effects of naloxegol are abdominal pain, nausea, vomiting, diarrhea, flatulence, arthralgia, and headache.

Methylnaltrexone is the first available peripherally acting opiate antagonist used to treat OIC and does not cross the blood-brain barrier, thus not inducing symptoms of opioid withdrawal. It is available in both oral and subcutaneous injection formulations. The recommended dosage for the oral formulation is 450 mg once daily in the morning on an empty stomach, while the injectable formulation is dosed based on body weight. Methylnaltrexone should not be used in patients with peptic ulcer disease, diverticulosis, colon cancer, or obstruction. The most common side effects of this medication include abdominal pain, flatulence, and nausea.

Lubiprostone is a type-2 chloride channel activator that increases fluid secretion in the gastrointestinal tract, resulting in enhanced peristalsis and increased acceleration of small bowel and colonic transit times. It is available in 8 mcg and 24 mcg capsules, with the recommended dosage being 24 mcg twice daily with food and water. Lubiprostone is well tolerated and effective for long-term use of up to 13 months. The most common side effects are nausea and diarrhea. Lubiprostone should not be used in patients with mechanical gastrointestinal bowel obstruction.

Naldemedine is the newest PAMORA, approved in March 2017, for the treatment of OIC in adults with chronic noncancer pain. The recommended dosage is 0.2 mg once daily with or without food. The most common side effects are abdominal pain, diarrhea, nausea, and gastroenteritis. Concomitant use with strong CYP3A4 inducers should be avoided as they may increase naldemedine concentrations in the body.

Frequently asked questions