Bowel Regimen in Chronic Narcotic Use

Aka: Bowel Regimen in Chronic Narcotic Use, Constipation Prophylaxis in Chronic Opioid Use, Narcotic Related Constipation, Opioid Induced Constipation

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II. Pathophysiology

  1. Constipation from Opioids is dose dependent
    1. No tolerance developed to Constipation
  2. Constipation prevention is much easier than treatment

III. Approach

  1. Use in combination with other general measures
  2. Maintain hydration with >64 ounces daily
  3. Maintain Physical Activity
  4. Fiber supplementation (e.g. Citrucel)
    1. Do not use in Acute Constipation (only for maintenance) and do not use if dehydrated
  5. Weaning Opioid dose after 4-11 days of use improves both Abdominal Pain and non-Abdominal Pain
    1. Drossman (2012) Am J Gastroenterol 107(9): 1426-40 [PubMed]
  6. Other measures
    1. See Functional Constipation
    2. Eliminate other Medication Causes of Constipation
    3. Peripheral Acting Mu-Opioid Receptor Antagonists (PAMORAs)

IV. Management: Protocol without Docusate and starting with Miralax (2015)

  1. Step 1
    1. Polyethylene Glycol (Miralax) one capful daily in 8 oz fluid (or Lactulose or Sorbitol 15 ml po bid)
  2. Step 2
    1. Polyethylene Glycol (Miralax) one capful daily in 8 oz fluid (or Lactulose or Sorbitol 15 ml po bid)
    2. Senna 1 tab po qd to bid
  3. Step 3
    1. Polyethylene Glycol (Miralax) one capful daily in 8 oz fluid (or Lactulose or Sorbitol 15 ml po bid)
      1. May temporarily increase dose to twice daily until stool, then decrease to once daily
    2. Senna 2 tab po bid (may advance to 4 tabs)
    3. Bisacodyl rectal suppository 1-2 after breakfast
  4. Step 4: Indicated for no Bowel Movement in 4 days
    1. Sodium Phosphate Enema or
    2. Oil retention enema or
    3. High-colonic tap water enema
    4. Continue until adequate results
  5. Step 5: Gastrointestinal Opioid Antagonist
    1. These agents are expensive at $10 to $70 per day, and result in one more Bowel Movement per week
    2. Mechanism: Block Opioid binding in the intestinal tract
    3. Preparations
      1. Movantik (Naloxegol) once daily orally in morning ($10/day, Renal Dosing required)
      2. Methylnaltrexone (Relistor) SQ Injection ($70/day, weight-based, Renal Dosing required)
      3. Symproic (Nalmedemedine, no Renal Dosing needed)
  6. Step 6: Amatiza (Lubiprostone, $12/day)
    1. Amatiza (Lubiprostone) orally twice daily
    2. May not be effective for Constipation due to Methadone
  7. References
    1. (2015) Presc Lett 22(6): 33-4
    2. Ford (2014) Am J Gastroenterol 108:1566-74 [PubMed]

V. Management: Stepped Protocol with Senna, Docusate, Bisacodyl and Polyethylene Glycol

  1. Approach
    1. Start with Step 1
    2. Move to next step if no response in 24 hours
    3. Docusate is less effective than other agents and may result in "mush without push"
  2. Step 1
    1. Docusate 100 mg PO bid and
    2. Senna 1 tab po qd to bid
  3. Step 2
    1. Docusate 100 mg PO bid and
    2. Senna 2 tabs po bid and
    3. Bisacodyl rectal suppository 1-2 after breakfast
  4. Step 3
    1. Docusate 100 mg PO bid and
    2. Senna 3 tabs po bid and
    3. Bisacodyl rectal suppository 3-4 after breakfast
  5. Step 4
    1. Docusate 100 mg PO bid and
    2. Senna 4 tabs po bid and
    3. Miralax 1 capful daily in 8 oz crystal light or similar (or Lactulose or Sorbitol 15 ml po bid)
    4. Bisacodyl rectal suppository 3-4 after breakfast
  6. Step 5 (Indicated for no Bowel Movement in 4 days)
    1. Sodium Phosphate Enema or
    2. Oil retention enema or
    3. High-colonic tap water enema
    4. Continue until adequate results
  7. Step 6
    1. Docusate 100 mg PO bid and
    2. Senna 4 tabs po bid and
    3. Miralax 1 capful 1-2 times daily in 8 oz crystal light or similar (or Lactulose or Sorbitol 30 ml po bid)
    4. Bisacodyl rectal suppository 3-4 after breakfast
  8. Step 7
    1. Docusate 100 mg PO bid and
    2. Senna 4 tabs po bid and
    3. Miralax 1 capful 2-3 times daily in 8 oz crystal light or similar (or Lactulose or Sorbitol 30 ml po four times daily)
    4. Bisacodyl rectal suppository 3-4 after breakfast
  9. References
    1. Mt Sinai Pain Card, Palliative Care, MSMC, NY, NY

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