Effective Laxatives For Opioid-Induced Constipation: Options And Insights

Opioid-induced constipation (OIC) is a common side effect of opioid medications, affecting 40-60% of patients without cancer who are receiving opioids. OIC can significantly reduce a person's quality of life, causing psychological distress, lowering work productivity, and increasing the need for healthcare services. To prevent OIC, laxatives must be started simultaneously with opioid treatment. Once OIC is established, both pharmacological and non-pharmacological therapies are required.

The first line of treatment for OIC involves lifestyle changes, such as increasing fluid intake, engaging in physical activity, and consuming more dietary fibre. If these measures are insufficient, laxatives are typically the next step. Osmotic laxatives like polyethylene glycol and lactulose are often recommended as a first choice. Stimulant laxatives, such as senna and bisacodyl, can also be used.

In cases where laxatives are ineffective, treatment may involve peripherally acting μ-opioid receptor antagonists (PAMORAs) like methylnaltrexone, naloxegol, and naldemedine. These drugs block the effects of opioids in the gut while preserving their analgesic effects. Other prescription medications specifically for OIC include lubiprostone and alvimopan.

It is important to note that some laxatives and fibre supplements may worsen OIC, so consulting a healthcare professional is essential to determine the most appropriate treatment.

Drink more water

Water is essential for digestion, and increasing fluid intake is a recommended first step in preventing and treating opioid-induced constipation (OIC). Dehydration is a common cause of constipation, and opioids can worsen this condition. Therefore, drinking more water throughout the day is crucial for individuals experiencing OIC. Even sipping small amounts at a time can help.

Water is necessary for proper digestion and the formation of stool. It helps to soften the stool, making it easier to pass. When the body is dehydrated, water is drawn from the colon, resulting in harder, drier stools that are more difficult to pass. This can lead to straining during bowel movements, which is a common symptom of OIC. By increasing water intake, individuals can help ensure that there is enough fluid in the intestine to keep the stool soft and promote regular bowel movements.

Additionally, opioids can inhibit gastric emptying and peristalsis in the gastrointestinal tract, further contributing to constipation. Peristalsis is the wave-like muscle contractions that move food through the digestive system. By increasing fluid intake, individuals can help promote peristalsis and support the natural movement of food through the intestines.

It is important to note that while increasing water intake is crucial, it should be done in conjunction with other lifestyle changes and medical treatments. A comprehensive approach to treating OIC may include dietary changes, such as increasing fibre intake, as well as physical activity, and medication.

In summary, drinking more water is an important first step in preventing and treating OIC. It helps to soften stools, promote peristalsis, and ensure regular bowel movements. However, it should be combined with other strategies for effective management of OIC.

Eat more fibre

Opioids are a type of prescription pain medication that can trigger a specific type of constipation known as opioid-induced constipation (OIC). This occurs when opioids attach to receptors in the gut, lengthening the time it takes for stool to pass through the gastrointestinal system. OIC can cause physical discomfort and negatively impact a person's quality of life.

One way to help relieve OIC is to eat more fibre. Fibre has a laxative effect as it increases water absorption in the colon, forming bulkier stools that are easier to pass. The National Academy of Sciences' Institute of Medicine recommends a daily fibre intake of 38 grams for men and 25 grams for women aged 50 and younger. For men and women older than 50, they recommend 30 grams and 21 grams, respectively. It is important to note that if you are taking opioids, ensuring adequate fibre intake is even more crucial for maintaining a healthy digestive system.

Good sources of fibre include fruits, vegetables, legumes (peas, nuts and beans), and whole-grain breads and cereals. The skin of fruits tends to have the most fibre, as do fruits with edible seeds like strawberries. Bran, which can be added to foods like soup or yoghurt, is another excellent source of fibre.

When increasing your fibre intake, it is important to do so gradually and ensure you are also consuming plenty of fluids. This is because too much fibre, especially without enough water, can lead to bloating, gas, and abdominal discomfort. Additionally, some high-fibre foods may cause gas, so it is advisable to introduce new fibre-rich foods one at a time and monitor your body's response.

While increasing your fibre intake is a natural way to help with OIC, it is always a good idea to consult your doctor or a registered dietitian for personalised advice. They can guide you on the appropriate amount of fibre for your individual needs and help you make any necessary dietary adjustments.

Get active

Physical activity is a great way to get your bowels moving and can help with opioid-induced constipation. Even a little gentle movement can make a difference. If you're experiencing constipation, try to incorporate some light exercises into your routine, such as:

• Walking: Start with a 10-minute walk and gradually increase the duration or pace as you feel comfortable.
• Light Stretches: Gentle stretches can help stimulate your bowels and improve overall digestion.
• Chores: Believe it or not, doing chores around the house can count as physical activity! Vacuuming, gardening, or even just walking up and down the stairs can get your body moving and help relieve constipation.

It's important to consult your doctor before starting any new exercise routine, especially if you have underlying health conditions. They can advise you on the types and amounts of physical activity that are safe and suitable for you. Additionally, try to stick to a routine by engaging in physical activity at the same time each day. This can help regulate your bowel movements and prevent constipation from becoming a recurring issue.

Remember, even a small amount of physical activity can have a positive impact on your digestion. So, get moving and give your bowels a boost!

Laxatives and stool softeners

Opioid-induced constipation (OIC) is a common adverse effect experienced by patients on opioid therapy for chronic pain. Laxatives and stool softeners are often the first line of treatment recommended by doctors. These are the same medications that anyone with constipation might use.

Laxatives

Laxatives help the bowels move stools out. There are several types of laxatives available over the counter, including:

• Stimulants: These include biscacodyl (Ducodyl, Dulcolax) and senna-sennosides (Senokot). They induce bowel activity by increasing intestinal contractions.
• Osmotics: Osmotics help fluid move through the colon. These include oral magnesium hydroxide (Phillips Milk of Magnesia) and polyethylene glycol (MiraLAX).
• Saline laxatives: An example is magnesium citrate, which has an onset of action of 30 to 180 minutes.

Stool softeners

Stool softeners make hard, dry waste easier to pass out of the body. They are ideal for preventing constipation but may not work as well for established cases. There are three types of stool softeners:

• Surfactants: These include docusate (Colace) and docusate calcium (Surfak). They are emulsifiers that facilitate the admixture of fat and water in the faeces.
• Lubricants: Mineral oil is an example of a lubricant. It delays the absorption of water from stools in the colon, thus softening the faeces.
• Osmotics: These draw water into the colon to hydrate the stools.

Drugs for opioid constipation

Opioid-induced constipation (OIC) is a common side effect of opioid analgesics, affecting 40-60% of patients without cancer who are receiving opioids. OIC significantly reduces patients' quality of life and is often under-recognised and under-treated.

The first step to preventing OIC is to increase dietary fibre, fluid intake, and physical exercise. In addition, laxatives must be started at the same time as opioid therapy to prevent OIC. The only laxatives that should be avoided are bulk-forming laxatives, such as psyllium, as opioids can prevent peristalsis of the increased bulk, worsening abdominal pain and potentially causing bowel obstruction.

The most common treatment 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. Saline laxatives, such as magnesium citrate, can also be used and have an onset of action of 30-180 minutes.

For refractory cases of OIC, peripherally acting μ-opioid receptor antagonists (PAMORAs) are used. These include methylnaltrexone, naloxegol, and naldemedine. PAMORAs selectively block μ-receptors in the gastrointestinal tract, thereby counteracting the side effects of opioids without blocking their analgesic effects.

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