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Pain medication and constipation.....

Wolfi's picture
Wolfi
Posts: 425
Joined: Aug 2009

I was back at the hospital yesterday afternoon due to severe constipation problems due to my pain medication.

I had not had a regular bm since my surgery last Wednesday and by yesterday morning was in such pain I knew I wouldn't be able to deal with it myself. I asked my husband to drive me to the hospital and they had to give me an enima and some anti-anxiety medication. They took x-rays and found I had fecal matter very high up in my intestines which was causing major bloating and pain. Everything ended up ok but I don't remember anything after 2:00 yeserday afternoon. I woke up in my bed this morning at 8:30.

Please make sure that when you are discharged after surgery you get a stool softener (if needed) to take with any pain medicaitons. My discharge nurse should have mentioned this before I left the hospital last Thursday, but she was in such a hurry to get us out of there that she didn't cover much of the after care instructions.

chenheart's picture
chenheart
Posts: 5182
Joined: Apr 2003

I had the same problem, only mine was due to chemo! This had never been a problem in my entire life, so I was actually embarrassed to call the cancer center one Saturday at 2 AM when I just couldn't stand the pain anymore! I remember telling the on call Dr that I was positive when she had dreams of becoming a Dr it wasn't so that she could counsel someone with constipation over the phone! The dr acgtually just had me take Milk of Magnesia, and it truly helped. I still recall the pain, and hope to never, ever, r-elive that experience. It still makes me shudder...and I can say I have an idea what childbirth is like. Bowling ball being pushed though a straw! OUCH!

Glad you're feeling better~ thanks for the tip about stool softeners; I am sure they will be used religiously by those who read your post! If my drs had only told me about them.... LOL

And, like my Reggie said, how many people can say they are not fulla s*^# and actually be telling the truth??? Always finding a silver lining, that Reggie! LOL

Hugs,
Chen♥

cats_toy's picture
cats_toy
Posts: 1463
Joined: Feb 2009

I can't believe they didn't warn you. I know Vicodin is the big pain pill they dispense, and it is the biggest one to cause constipation. Not great to have to worry about that on top of surgery etc.
Glad you are OK now
Cat

m_azingrace
Posts: 399
Joined: Jul 2009

Thanks for mentioning this. Often, the care professionals neglect to inform patients about this, so they have to find out the hard way.

Some pain killers are notorious for slowing everything down. Yes, patients should be warned about the unpleasant side affects of these drugs, and also given stool softeners. When I had the lumpectomy, I was given a prescription for oxycodone, but I asked the dr. if I could switch to something else as soon as I felt the pain was manageable with something less strong. She said I could use extra strength tylenol. For me, I can deal with some pain better than I can handle being constipated.

Noel's picture
Noel
Posts: 3101
Joined: Apr 2009

I am so sorry. Your nurses should have not only told you, but, they sent home a couple of pieces of paper, called patient's discharge instructions, with me saying what you should do, not do and what to look out for. And, one of them said to use a stool softener as the pain meds would constipate you. I tried the Vicodin, but, found I did not like the constipation and didn't like the stool softener, so, I just quit taking it and used ibuprofen. So glad that you are ok now. You poor thing.

♠♥ Noel ♠♥

chenheart's picture
chenheart
Posts: 5182
Joined: Apr 2003

I think Tasha and I must have the 2 worst docs on the planet! When I came home from the hospital, with the drains etc, by the time I was scheduled for my next dose of meds (antibiotics and pain meds) I was one walking case of hives! Allergic to one or the other or both, evidently! So, instead of prescribing me anything else, I had the drains in and went through it all Cold Turkey...no antibiotics no pain meds at all. So, in hindsight, I am really not surprised that I wasn't told about or given stool softeners! Is "hindsight" really the right word to use when talking about constipation??????

Oh well....and here I am still alive and kicking! In spite of him! :-)

Hugs,
Chen♥

Akiss4me's picture
Akiss4me
Posts: 2192
Joined: May 2009

I had no idea that you had to go through all that! It just makes me admire you all that more for being so strong! Pammy

Bev1969's picture
Bev1969
Posts: 48
Joined: Jul 2009

I had the problem too but not as bad. I talked to the nurse at my doctor's office and they told me to take a stool softener and that worked. When I went for the chemo teach they told me not to go a day without a bm so after my first chemo I had to take a stool softener the first day but I quickly went the other way. Now Immodium is my best friend about five days after chemo.

GraciesMom's picture
GraciesMom
Posts: 3
Joined: Aug 2009

Both common problems, I hear. I took a little too much of a stool softener initially and had a couple days of diarrhea. I quickly learned that I had to watch how much roughage I consumed. I love whole-grains and fresh fruits & veggies, but got diarrhea at the drop of a hat.
During chemo I switched to refined carbs and cooked most of my fruits & vegetables, at least a little (to help break down the fiber). If constipation is the issue, try the reverse -- unrefined carbs, more healthy fiber foods. (I was given a great booklet-- maybe from the NIH? -- about living with chemo. It had tons of info about every aspect of chemo Tx. They're free on request.) Good luck!

phoenixrising's picture
phoenixrising
Posts: 1510
Joined: Feb 2007

This is called Opioid induced constipation. From what I understand there are 3 muscles that move fecal through the bowel and the opioids stop 1 of them. My husband used to have ileus attacks after his bowel surgery due to the Tylenol 3's. The pain was so severe he was actually delirious. He soon learned to take a senna if he thought he was going to have another attack. Here is an article about it and hope you can get things "moving" soon.
Although it mentions palliative care in the article and none of us are in that category, it still provides good information about how to handle this type of constipation.

Management of Opioid-Induced Gastrointestinal Effects: Treatment
Authors and Disclosures

Information from Industry
Assess clinically focused product information on Medscape.
Click Here for Product Infosites – Information from Industry. Treatment
Constipation is the most frequent side effect associated with long-term opioid therapy. Monitoring should begin with a thorough history of the patient's bowel habits before starting opioids. More objective tools than those used to assess nausea are available, but aside from digital rectal examination, radiographic assessments are often of little value to terminally ill patients receiving palliative care.[11,61,63] Opioid-associated constipation should be monitored frequently, if not daily. Site-specific protocols should be developed to describe interventions for the specific length of time the patient has been without a bowel movement. Impaction must be ruled out before starting treatment for constipation.

Several confounding factors may aggravate constipation during palliative care (dehydration, confusion, drugs, immobility); opioids are a common cause.[61,64] Prophylaxis should be considered when starting opioid therapy, although common constipation prophylaxis (e.g., fiber, fluids, exercise) may not be sufficient for patients receiving palliative care.[61] In fact, fiber-based laxatives may be dangerous in those with fecal impaction and may result in impaction without adequate water intake. Oral laxatives are the mainstay in the treatment of this symptom and may be classified into two general categories, softening and peristalsis-inducing agents ( Table 2 ).[12]

Docusate is the stool softener most widely used in palliative care. It acts to increase secretions in the gastrointestinal tract, as well as absorption of these secretions by hard stool. Dosages at or above 400 mg/day may produce increases in peristalsis.[12] Unfortunately, the drug has very little utility when given alone for opioid-induced constipation. Because gastric motility is decreased in these patients, softening of the stool may not alleviate the symptom, and its efficacy has been questioned.[65,66] Docusate facilitates systemic absorption of mineral oil, resulting in potential inflammatory responses that contraindicate its administration with mineral oil laxatives. Docusate is largely ineffective when administered without appropriate amounts of ingested fluids, which is often difficult during palliative care. Dosages may range from 200-800 mg/day in two divided doses. Onset of action is typically 1-3 days, so the drug should be given an adequate trial.[12]

Often considered first-line therapy for idiopathic constipation, bulk-forming laxatives, such as fiber, psyllium, and bran, may have a smaller role in nonambulating patients. Opioid-induced constipation is caused by decreased intestinal motility, and a bulk mass may predispose these patients to obstruction and potential impaction.[15,18,19,53,60] These agents should be reserved for patients who are not receiving long-term opioid therapy and maintain appropriate hydration.

Osmotic laxatives, such as mannitol, lactulose, and sorbitol, are effective in palliation of opioid-induced constipation.[7,21,63,67-69] They produce an osmotic-directed influx of fluid into the small intestine, thus increasing peristalsis as well as softening stool.[12,62] Further peristalsis may be augmented by these sugars' breakdown, which may lower intestinal pH.[70] Lactulose frequently is given despite sorbitol's superiority in cost, side effect profile, and proved equality of efficacy.[69,71] Mannitol is rarely prescribed in the U.S. for this indication. Typical onset of action is 1-2 days.[70] Sorbitol may be administered orally as a 70% solution in dosages of 15-30 ml twice/day. Lactulose oral dosages are 15-30 ml twice/day. Both agents may be given rectally in similar dosages.

Magnesium hydroxide and magnesium sulfate are effective for constipation associated with opioid therapy. They are rarely considered first-line therapy due to their undesirably strong and quick laxative activity. They are cost effective and may have a place in therapy of resistant opioid-induced constipation.[21]

Peristalsis-increasing agents, or stimulant laxatives, are senna and bisacodyl. Casanthranol, an anthraquinone derivative, is given frequently in combination with docusate. Phenolphthalein was a popular laxative but was removed from the U.S. market. Both bisacodyl and senna rely predominantly on their ability to stimulate the myenteric plexus directly.[72-75] Some water and electrolyte flux does occur, but an increase in longitudinal smooth muscle contractions associated with these agents is the reason for their clinical utility. Onset of action is typically 6-12 hours.[12] Of the two agents available in the U.S., senna is by far the most commonly administered for treatment of opioid-induced constipation. It produces a greater effect on peristalsis than bisacodyl, although the onset of this action is usually somewhat more delayed comparatively.[12] Senna is commercially available in tablets containing 8.6 mg of sennosides. The starting dosage is typically 17.2 mg (2 tablets) at bedtime. Bisacodyl usually is started at 5-10 mg orally at bedtime, although switching to morning dosing may be necessary if the drug's action is quicker than 12 hours. Increasing the dosage as the dosage of opioid increases is common. These agents should not be given on an as-needed basis. Patients should continue taking them unless diarrhea occurs. If diarrhea does become a problem, the dosage of laxative or softener is decreased until the patient is comfortable.

Suppositories and enemas are alternatives to oral therapy for palliative care. They are uncomfortable and embarrassing for most patients and should be reserved for refractory constipation. Stimulant laxative suppositories act largely by local effect and may prove ineffective if feces are located in the colon or higher in the gastrointestinal tract.[76] Enemas are effective, and several are readily available premade; alternatives include soapsuds and tap water enemas. Tap water enemas should be given with extreme caution in all patient populations due to the risk of fluid and electrolyte abnormalities, which may result with continued application.[77]

Naloxone, nalmefene, and methylnaltrexone (not available in the U.S.) are all pure opioid antagonists that produce laxation in constipated individuals maintained with opioid agonists.[78-87] In addition, naltrexone possesses opioid antagonism, but it has been studied less frequently for this indication than the other agents. These agents may exert their effect on local opioid receptors in the gastrointestinal tract. The exact mechanism of action is theorized to reside within the myenteric plexus, where most gastrointestinal opioid side effects originate.[53] Naloxone was the first opioid antagonist available, and reports of its efficacy in opioid-induced constipation surfaced in the late 1980s. Oral dosages of naloxone 4 mg/day titrated to as high as 18 mg/day may alleviate opioid-induced refractory constipation.[78,83] It should be noted, however, that dosages approaching 24 mg/day may cause significant systemic absorption, and pain crisis and opioid withdrawal may begin to manifest.[78,83-86] Because of the risk of systemic opioid reversal, as well as cost considerations, naloxone is infrequently prescribed for this indication.

Nalmefene, a derivative of naltrexone, was assessed for its potential role in the treatment of constipation induced by these analgesics.[87] Although promising due to perceived selectivity for the gastrointestinal tract, a high rate of withdrawal symptoms was reported, and it was concluded that the active glucuronide of the drug was not selective enough for the gastrointestinal tract to be administered for this purpose.[87]

Methylnaltrexone has been widely studied for correction of opioid-induced constipation.[80-82,88] Due to its quaternary ammonium structure, it has very little permeability at the blood-brain barrier and thus should have little effect on systemic opioid receptor binding. Unavailable in the U.S., it shows promise for refractory constipation in patients receiving long-term opioid analgesics.

Also of interest may be the role of polyethylene glycol (GoLytely; Braintree Laboratories, Braintree, MA), normally taken for evacuative purposes to correct opioid-induced constipation. A prospective, randomized, double-blind, triple-crossover study comparing lactulose, polyethylene glycol, and placebo was performed in 57 patients maintained with methadone.[89] No significant difference was seen between the two treatment arms (p>0.05) in hard stool frequency or defecation frequency, although both agents were superior to placebo (p<0.01). Polyethylene glycol caused a greater rate of loose stools and cramping than lactulose, but whether this difference was significant was not reported.

In a similar study, low-dose polyethylene glycol was superior to lactulose with respect to efficacy and tolerability.[90] This study did not enroll patients with constipation due to opioids, however, which may account for the variability in results between the studies

Akiss4me's picture
Akiss4me
Posts: 2192
Joined: May 2009

Thanks for bringing this up. I took a stool softner 3x's a day and still didn't go for 4 days. I was told that even the anestesia can constipate you, as you are given drugs to paralize you during surgery and this slows you down. Part of the reason why they get you up walking as soon as they can after any surgery (to get your body moving). So, if you are taking pain meds or are going into surgery, ask your Doc about a stool softner before hand, then you will be prepared. Pammy

mlmjt1
Posts: 540
Joined: Jul 2009

I have been in health care for years and I cant count the patients I have seen post surgery who are constipated up to their eyeballs. What the heck is that?????

We get them in home health and they are miserable. When I worked in the hospital everyone got milk of mag if they hadnt had a bm in 2 days...automatically so they would go on day 3. And any good discharge instructions should include the constipating effects of not only the pain meds but iron when people are put on it as well.

Not that it matters now, but a good med for constipation is miralax. I think you can get it over the counter. Docusate sodium or senna s is also good. Dont forget to push fluids and eat lots of fresh fruits and veggies.

I am truly sorry this happened to you. If I had been your discharge nurse, I would have told you

Hang in there

Linda t

VickiSam's picture
VickiSam
Posts: 8477
Joined: Aug 2009

posting .. I am saving this thread of emails.

VickiSam

Tux's picture
Tux
Posts: 541
Joined: Aug 2009

My standard post-op remedy for constipation is to drink a can of prune juice each day. Helps move things along naturally. I had numerous foot surgeries prior to having the bc surgery, so I already was prepared for problems. It really helped me this time!

cabbott
Posts: 1046
Joined: Aug 2006

I had this problem too when I had breast surgery and I still remember how upset it made me. I made my husband run out to the pharmacy and get some Phillips Milk of Magnesia. I said "RUN!" and I meant RUN! It hurt and scared me enough that on surgeries since I have insisted that I won't leave the hospital until they get things working. I told them to put the Phillips or prune juice or whatever it takes right in the IV but I didn't want to have problems again. The nurses laughed, but I was serious. The nurses on the last operation also laughed, until they had tried just about everything and couldn't "normalize" things for me. They were being told to discharge me and I was telling them I wouldn't go until I could go, if you know what I mean. So they tried prunes--no luck. Psyllenium fiber--no luck. Phillips--no luck. Finally the head nurse ordered some sodium citrate and crushed ice. It was tolerable though not my beverage of choice. By the second glass I was able to be discharged--I'll spare you the details. If they had sent me home (100 miles from the hospital) I would have been clueless and would have ended up in the ER. I have no idea why hospitals allow any patient who has had pain medication to suffer needlessly when they know how to intervene and have the means to do so.

m_azingrace
Posts: 399
Joined: Jul 2009

A preventive measure is to eat very light meals, foods that will move through easily, the couple days prior to surgery, so there won't be a lot in there to get backed up in the first place. Then also after surgery, eat light again, and drink lots of fluids.

cats_toy's picture
cats_toy
Posts: 1463
Joined: Feb 2009

oops! I had a double double grilled onions, french fries and a strawberry shake! My friend brought it by because she knew it was my favorite take out meal, and we never do take out. She figured Robert didn't have to cook, and I got my yummies. Oh well, too late now. I didn't have a real problem though because my dad had always made me aware of those ss's. Had them bought and ready for when I got home from the hospital.
=^..^=

aztec45's picture
aztec45
Posts: 757
Joined: Jul 2009

Man, Wolfi,

I am glad to hear you are doing better. I got backed-up after my second round of chemo. It was surprising to me since I usually have the other problem. But I was so miserable and quite cranky. It was making me sweat profusely. My nurse practitioner warned me about constipation but it was my nosey neighbor who told me to get some Phillips and keep it on hand just in case I had that problem. I used it and then it was like the flood gates opened up. I was late to work because I was inseparable from the stool.

If it ain't one thing it's another my little Rosanne Rosanna Dana.

Chen,

You are more woman than me. I was popping the pain meds like candy when I had my nodes removed and tubes inserted.

jnl's picture
jnl
Posts: 3873
Joined: May 2009

Pain pills = constipation! Thank goodness the nurses told us before we left the hospital to use a stool softener. It was also on the papers they sent home.

Leeza

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