Pain medication and constipation.....

OMG!
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

cats_toy said:

OMG!
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

YIKES!
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.

This is called Opioid
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
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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

HI Wolfi
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

Me too!
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.

cabbott said:

Me too!
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.

A preventive measure is to
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.

aztec45 said:

Man Wolfi
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.

OUCH
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

m_azingrace said:

A preventive measure is to
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.

lght meals???
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.
=^..^=