Author: Yvette Brazier
Healthcare professionals prescribe opioids to treat pain due to a number of conditions and especially during the later stages of cancer. While opioids are very effective in providing pain relief, these medications can cause constipation and other side effects.
People take opioids to manage different types of pain. Opioid-induced constipation (OIC) can cause further discomfort, which can affect a person’s quality of life.
OIC treatments include natural remedies and over-the-counter or prescription medications.
This article discusses the link between opioids and constipation, OIC symptoms, and treatments for OIC.
Opioids bind to specific proteins in the body called opioid receptors. The brain, spinal cord, and gastrointestinal tract all contain these receptors.
By binding to these receptors, opioids block the brain’s ability to perceive pain. However, opioids also depress or slow down the central nervous system.
The central nervous system oversees how the body responds to pain. It also controls involuntary movements, including those of the digestive tract.
For this reason, taking opioids can result in constipation.
Medications that cause OIC contain substances such as morphine, codeine, oxycodone, and methadone.
Common medications that cause OIC include:
- buprenorphine (Belbuca, Probuphine, Buprenex)
- codeine (APAP wCodeine, Capital wCodeine, Pyrigesic-C, Tylenol wCodeine, Vopac)
- fentanyl (Actiq, Duragesic, Sublimaze)
- hydrocodone (Anexsia, Ceta Plus, Co-Gesic, Dolorex Forte, Hycet, Lorcet, Lortab, Maxidone, Norco, Stagesic, Vicodin HP, Zydone)
- hydromorphone (Dilaudid, Dilaudid-5, Exalgo, Palladone)
- meperidine (Demerol, Pethidine)
- methadone (Dolophine, Methadone HCl Intensol, Methadose)
- morphine (AVINza, Kadian, Morphabond, MS Contin, Oramorph SR, Roxanol)
- oxycodone (OxyContin, Xtampza ER, Roxicodone, OxyIR, Percocet, Endocet, Percodan, Endodan)
- oxymorphone (Opana)
- tapentadol (Nucynta)
- tramadol (ConZip, FusePaq Synapryn, Rybix ODT, Ryzolt, Ultram)
Common gastrointestinal symptoms of OIC include:
- abdominal tenderness
- bloating, distention, or bulging in the abdomen
- constant feeling of needing to use the bathroom
- alternating episodes of constipation and diarrhea
- difficulty defecating, which can result in straining, forcing, and pain
- dry, hard stools
- nausea and vomiting
- tiredness and lethargy
- weight loss
Several treatments can help ease OIC. They include lifestyle changes, medication, and natural remedies.
Lifestyle changes can include dietary and behavioral modifications. Some lifestyle changes that may help alleviate OIC include:
- drinking more fluid
- consuming more fiber
- getting some or more exercise, if possible
Over-the-counter and prescription medications may also help. A healthcare professional may prescribe preventative medication when they prescribe an opioid to a person.
Over-the-counter OIC medication options include:
- Bulk-forming laxatives: These undigestable fiber supplements move through the body and absorb liquid in the digestive system to form a stool that is easier to pass. Examples include methylcellulose (Citrucel), polycarbophil (FiberCon), and psyllium (Metamucil).
- Osmotic laxatives: Osmotic laxatives work by helping the colon hold more water, which can soften the stool — making it easier to pass — and increase the frequency of bowel movements. One example is magnesium hydroxide (milk of magnesia).
- Saline laxatives: These encourage bowel movements by drawing water into the intestines. Magnesium citrate supplements are one example.
- Stool softeners: These increase the amount of water stools absorb, making them softer and easier to pass. Examples include docusate sodium (Colace) and docusate calcium (DulcoEase, Phillips Liqui Gels).
- Lubricant laxatives: Lubricant laxatives coat the intestine walls and the stool to soften and lubricate the stool. One type is mineral oil.
- Stimulant cathartics: These medications (Correctol, Dulcolax, Senna) promote movement in the intestines.
The American Gastroenterological Association Institute recommends traditional laxatives as a first-line treatment for OIC. The organization provides guidelines for medical management of OIC when over-the-counter laxatives do not provide relief.
These prescription medications can help ease constipation experienced with opioids:
- Peripheral μ-opioid receptor antagonists (PAMORA): These medications counter the effects of OIC and can offer similar pain relief as opioids. PAMORA medications include methylnaltrexone (Relistor), naldemedine (Symproic), and naloxegol (Movantik).
- Intestinal secretagogues: These medications increase secretions of chloride and water in the intestines and include lubiprostone (Amitiza).
- Selective 5-HT agonists: These medications may help enhance gastrointestinal movements. These medications include prucalopride (Resolor, Motegrity), cisapride (Prepulsid, Propulsid), and tegaserod (Zelnorm, Zelmac).
- Prostaglandins or prokinetic medications: These medications increase the bulk and movement of stools by changing how the intestines take in water and electrolytes.
Herbal or natural remedies
In addition to drinking more water, eating more fiber, and getting exercise where possible, some natural ingredients may also help relieve OIC. These include:
- fiber supplements
- products containing sennosides (such as Senna)
- aloe vera
Consult with a healthcare professional or pharmacist before taking herbal remedies, as they may interact with or decrease the effectiveness of certain medications.
A healthcare professional may recommend a person take over-the-counter fiber supplements, such as Citrucel, Metamucil, or FiberCon. These may help a person produce a bowel movement.
A person should talk with their healthcare professional before taking an herbal remedy because it may interfere with certain medications.
Healthcare professionals generally consider laxatives safe and effective when taken as directed and for short periods. However, like all medications, a person may develop side effects from using laxatives to treat OIC. Some common side effects include:
- fluid loss
- abdominal cramping
A person taking a laxative for OIC should talk with their healthcare professional if symptoms do not improve or they experience concerning symptoms related to laxative use.
Healthcare professionals prescribe opioids to treat chronic pain due to various conditions. They also prescribe opioids to treat pain during cancer treatment and during the later stages of cancer.
Conditions that cause chronic pain
Healthcare professionals may prescribe opioids to treat chronic pain, including:
- back pain
- joint pain
- degenerative joint disease
According to data collected from 1999–2012, about 22% of United States adults experience chronic pain, with about 7% reporting moderate to severe pain. Further, the results of various studies suggest that opioid-induced constipation affects 41–81% of people with chronic pain that does not result from cancer.
Palliative cancer care
Healthcare professionals often prescribe opioid medications for people living with cancer, especially when the disease progresses to later stages.
In 2017, researchers published the results of an investigation into opioid prescription trends over a 6-year period for people living with cancer. They looked specifically at changes in the type and dose of opioids prescribed.
The researchers studied 750 relevant U.S. health records from 2010–2015. Their findings suggest that pain affects:
- about 39% of people who have survived cancer
- around 55% of people who are currently receiving treatment for cancer
- about 66% of people with cancer that is in an advanced, metastatic, or terminal stage
In addition to OIC, opioids can have other serious adverse effects. These include:
- slower breathing and general depression of the respiratory system
- physical dependence
- misuse or potential to develop opioid use disorder
Both the Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) have expressed concern about the overprescription of these types of medications.
Opioid pain relief can cause constipation and other digestive problems, as they reduce nervous system activity. OIC is a common complaint among people who take opioids for pain relief.
Drinking plenty of water, eating high-fiber foods, and keeping active, where possible, can help reduce the impact.
If these natural means do not provide relief for OIC, a healthcare professional can recommend additional treatment options, such as laxatives, supplements, or prescription medications.