How to Treat Opioid Induced Constipation
For those with chronic pain, constipation can be a problem
ByAmber J. Tresca Amber J. TrescaAmber J. Tresca is a freelance writer and speaker who covers digestive conditions, including IBD. She was diagnosed with ulcerative colitis at age 16.Learn about our editorial processUpdated on January 27, 2020Medically reviewedVerywell Health articles are reviewed by board-certified physicians and healthcare professionals. Medical Reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more.byRobert Burakoff, MD, MPH Medically reviewed byRobert Burakoff, MD, MPHRobert Burakoff, MD, MPH, is board-certified in gastroentrology. He is the vice chair for ambulatory services for the department of medicine at Weill Cornell Medical College in New York, where he is also a professor. He was the founding editor and co-editor in chief of Inflammatory Bowel Diseases.
Learn about our Medical Review BoardOpioid-induced constipation (OIC) is a common condition that occurs as an adverse effect of the use of painkillers (analgesics). Opioids are painkillers containing a substance chemically similar to the alkaloids that are found in the opium poppy.
Prescription medications that contain opioids include methadone, Percocet, Vicodin, Demerol, Dilaudid, and fentanyl. They are prescribed for pain relief, usually for acute pain such as after an injury or surgery, but also for long-term pain such as that caused by cancer. In some cases, opioids are used to treat diarrhea, usually in quite small doses to avoid potential side effects.
Studies have shown that many physicians do not know their patients are experiencing constipation when receiving opioids.
Virtually all patients receiving opioids report having digestive side effects. Up to 40 percent may have constipation.
Constipation can lower quality of life significantly and therefore, it’s worth talking about with a physician in order to get treatment and find relief.
OIC vs. Functional Constipation
Constipation occurs when stools are infrequent, hard, and difficult to pass. However, it’s not an exact science because a person's stools and how often they pass them is individualized.
In general, having healthy bowel movements could mean going anywhere from three times a day to three times a week. However, a change in bowel movements may indicate constipation. If it’s suddenly more difficult to go to the bathroom—this could mean straining on the toilet bowl or bowel movements that are a lot less frequent—constipation may be occurring.
Symptoms of constipation can include:
Opioid-induced constipation is different than constipation that is functional. Functional constipation could be from a variety of causes ranging from not enough fiber in the diet to a disease or condition in the digestive tract. Opioid-induced constipation, however, is a direct result of the way that opioid medications affect the small intestine and the colon, by slowing down digestion.
Why Do Opioids Cause Constipation?
Opioids have several different effects that slow down digestion. In the stomach, opioids can cause gastroparesis, which means that the stomach takes longer to empty than it should because the muscles are not working effectively.
Food moves through the small intestine because of muscle contractions known as peristalsis. Opioids affect the middle of the small intestine (jejunum) by increasing circular muscle contractions, which are non-propulsive contractions, and this decreases the peristalsis that normally moves food along. This can also create harder stools, making them more difficult to pass.
Opioids also affect how the anal sphincter responds to the drug. When stool is in the rectum, there is a natural urge to go to the bathroom and pass it. Opioids can dampen this sensation so that when there is a stool to be passed, a person doesn’t feel it. That could lead to holding stools in too long.
Overall, these effects on the digestive system mean that some people will experience constipation when using opioids. For people who need long-term pain management with these medications, this can be a significant problem.
Treatment
Treatment for opioid-induced constipation could include both lifestyle changes and medications. The approach to treatment depends heavily on the current state of your health as well as other factors such as the medications. In many cases, lifestyle changes and over-the-counter laxatives are not effective enough to provide complete relief.
Lifestyle Changes
Making some changes to your everyday routine, along with other treatments, may help with constipation.
Fiber-Rich Diet: Diet is a factor in constipation because eating enough of the right kinds of fiber and drinking enough water can help get the bowel moving and keep stools soft and easily passed. Insoluble fiber, which is primarily found in fruits and vegetables, makes stools softer and bulks them up. Soluble fiber will dissolve into a substance that’s like a gel and will also help in relieving constipation.
Fiber Supplements: Fiber can be added into the diet but it can also be taken as a supplement. Some people will need to try different supplements and determine which type of fiber will work the best to relieve constipation. For example, bulk-forming fiber supplements like psyllium may not be recommended as they could worsen symptoms. A dietitian may also be able to narrow fiber choices down and recommend diet changes and supplements, including foods that are natural laxatives (such as prunes).
Hydration: Drinking enough water and other liquids every day can also help in dealing with constipation. Stools are easier to pass when there is enough liquid drawn into the bowel to make them softer. For those that already drink enough, adding more water or other liquids to the diet won’t necessarily make a big impact on a digestive system that’s being affected by opioids. However, being properly hydrated is important to overall health, so it’s worth paying attention to how much water is being taken in every day.
Exercise: Exercise is another factor that can help relieve constipation. Again, the ability to exercise is going to depend on overall health. However, even walking can make a difference when it comes to moving the bowels on a regular basis. Physicians can recommend the best form of exercise and if necessary, a referral to a physical therapist may help in developing an overall plan that takes any other health conditions into account.
Laxatives
Laxatives that counteract the constipating effects of opioids may be needed in most cases and might be prescribed at the same time as the opioid. Frequently, a laxative might be the first option in preventing and/or treating constipation.
Osmotic Laxatives: Osmotic laxatives are those that draw more water into the intestine, which has the effect of making stools softer and easier to pass. Certain osmotic laxatives are available over the counter while others are by prescription, and some of the different types include Miralax, lactulose, and milk of magnesia (which is not prescribed as often). There aren’t usually too many side effects with these types of laxatives—they are generally considered safe and effective, but some people may have bloating or diarrhea.
Stimulant Laxatives: Stimulant laxatives are also available over the counter and include bisacodyl, sodium bicarbonate with potassium bitartrate, senna, and castor oil. This type of laxative works by increasing the movement of the muscles in the digestive system (peristalsis). They are not usually recommended for long-term use because of potential side effects, and tolerance may vary (which means it may stop working after a while).
Rectal Interventions
In some cases, removing impacted stool might be necessary. This could be done with an enema or colonic irrigation (water or another liquid inserted through the anus and into the rectum), suppositories, or manual evacuation.
Glycerin suppositories might be the first step in moving stool, followed by an enema, irrigation, or manual evacuation (inserting a gloved finger into the rectum to break up the stool and remove it).
Prescription Medications
There are prescription medications available for the treatment of opioid-induced constipation. Relistor and Movantik are two such drugs. These medications work by blocking the effects that opioids have on slowing down the bowel.
These medications may help in bringing on a bowel movement a short time after taking or receiving them. Some of the potential side effects of these medications can include nausea, diarrhea, abdominal pain, and gas.
A Word From Verywell
Opioid-induced constipation is a common problem for people that are receiving opioids for the treatment of pain, and in particular, for chronic pain. It’s a problem that can be embarrassing for many people to discuss, but constipation can significantly decrease the quality of life, so it’s worth bringing it up with a physician.
In addition, there are treatments available that are safe and effective and can reduce the symptoms of constipation and thereby avoid potential complications. While constipation is a difficult topic to bring up at a doctor’s visit, it’s one that is not unexpected when coping with chronic pain.
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