Constipation : Buprenorphine Induced
What is constipation?
Having fewer than three bowel movements a week is, technically, the definition of constipation. However, how often you “go” varies widely from person to person. Some people have bowel movements several times a day while others have them only one to two times a week. Whatever your bowel movement pattern is, it’s unique and normal for you – as long as you don’t stray too far from your pattern.
Regardless of your bowel pattern, one fact is certain: the longer you go before you “go,” the more difficult it becomes for stool to pass. Other key features that usually define constipation include:
Your stools are dry and hard.
Your bowel movement is painful and stools are difficult to pass.
You have a feeling that you have not fully emptied your bowels.
Why can buprenorphine or other opioids cause constipation?
These drugs are known to slow down gastric emptying and slow down the smooth muscular propulsion (peristalsis) in the intestines. This results in increased fluid absorption in the intestines. The lack of fluid leads to hardening of the stool and constipation. Opioids also increase anal sphincter tone impairing the reflex to have a bowel movement.
What are the symptoms of constipation?
Symptoms of constipation include:
You have fewer than three bowel movements a week.
Your stools are dry, hard and/or lumpy.
Your stools are difficult or painful to pass.
You have a stomach ache or cramps.
You feel bloated and nauseous.
You feel that you haven’t completely emptied your bowels after a movement.
Alternating episodes of diarrhea and constipation
Fecal impaction: unusually large hard stool mass stuck in the distal rectum
What causes constipation?
There are many causes of constipation – lifestyle choices, medications, medical conditions, and pregnancy.
Common lifestyle causes of constipation include:
Eating foods low in fiber.
Not drinking enough water (dehydration).
Not getting enough exercise.
Changes in your regular routine, such as traveling or eating or going to bed at different times.
Eating large amounts of milk or cheese.
Stress.
Resisting the urge to have a bowel movement.
Many drugs can cause constipation. Medications that can cause constipation include:
Strong pain medicines, like the narcotics containing codeine, oxycodone (Oxycontin®) and hydromorphone (Dilaudid®), Buprenorphine.
Nonsteroidal anti-inflammatory drugs, like ibuprofen (Advil®, Motrin®) and naproxen (Aleve®).
Antidepressants, including the selective serotonin reuptake inhibitors (like fluoxetine [Prozac®]) or tricyclic antidepressants (like amitriptyline [Elavil®]).
Antacids containing calcium or aluminum, such as Tums®.
Iron pills.
Allergy medications, such as antihistamines (like diphenhydramine [Benadryl®]).
Certain blood pressure medicines, including calcium channel blockers (like verapamil [Calan SR], diltiazem [Cardizem®] and nifedipine [Procardia®]) and beta-blockers (like atenolol [Tenormin®]).
Psychiatric medications, like clozapine (Clozaril®) and olanzapine (Zyprexa®).
Anticonvulsant/seizure medications, such as phenytoin and gabapentin.
Antinausea medications, like ondansetron (Zofran®).
Medical and health conditions that can cause constipation include:
Endocrine problems, like underactive thyroid gland (hypothyroidism), diabetes, uremia, hypercalcemia.
Outlet dysfunction constipation. (A defect in the coordination of pelvic floor muscles. These muscles support the organs within the pelvis and lower abdomen. They are needed to help release stool.)
Neurologic disorders including spinal cord injury, multiple sclerosis, Parkinson’s disease, and stroke.
Lazy bowel syndrome. The colon contracts poorly and retains stool.
Structural defects in the digestive tract (like fistula, colonic atresia, volvulus, intussusception, imperforate anus, or malrotation.)
Multiple organ diseases, such as amyloidosis, lupus, and scleroderma.
Pregnancy.
Treatment/Management
Most cases of mild to moderate constipation can be managed by you at home. Self-care starts by taking an inventory of what you eat and drink and then making changes.
Some recommendations to help relieve your constipation include:
Increase fluid intake. Drink two to four extra glasses of water a day. Avoid caffeine-containing drinks and of course no alcohol, which can cause dehydration.
A diet with 20 to 30 grams of fiber daily helps in the formation of soft, bulky stool. Adding foods such as beans, whole grains, fresh fruits and vegetables is helpful in adding fiber to the diet.Fiber rich foods include: apples, bananas, prunes, pears, raspberries, string beans, broccoli spinach, kale, squash, lentils, peas, and beans.
Limiting foods such as ice cream, cheeses, meats, and processed foods, which contain little or no fiber can also be helpful.
Eat bran cereal and nuts.
Get moving, exercise.
Check how you sit on the toilet. Raising your feet, leaning back or squatting may make having a bowel movement easier.
Initially, if needed, take a very mild over-the-counter stool softener or laxative (such as docusate [Colace®] or Milk of Magnesia®). Mineral oil enemas, like Fleet®
The most common regime for opioid induced constipation is a stimulant laxative, like bisacodyl (Dulcolax®) or senna (Senokot®). These are taken with or without a stool softener(docusate).
Daily administration of an osmotic laxative such as polyethylene glycol (MiraLAX) is also commonly used.
Saline laxative such as Magnesium Citrate
The only laxatives that should be avoided are the bulk-forming laxatives such as psyllium. These laxatives increase the bulk of the stool, may distend the large intestine (colon), and increase the muscular propulsion (peristalsis) but the buprenorphine can prevent the peristalsis of the increased bulk which can worsen abdominal discomfort and even may contribute to bowel obstruction.
Do not read, use your phone or other devices while trying to move your bowels.
Courtesy of: Cleveland Clinic Foundation, Drs. O Sizar, R. Genova, M.Gupta Affiliation CCF, Univ. of Tennessee, St. Lucie Medical Center
updated August 10, 2020