Constipation and Narcotics
Ms. Violet is a 58-year-old female who has been on narcotics for 10 years to manage Ankylosing
Spondylitis of the spine. She currently takes Methadone 10 mg three per day and 10 mg of oxycodone
every 4 to 6 hours for break through pain. She was referred you to discuss a plan of care for her severe
constipation.
Medical Problem List:
Ankylosing Spondylitis
Depression
Constipation
Current Therapies: She is participating in the Care Management Program. She sees a social worker and
has her own therapist. She has a private psychiatrist as well.
Her BMI is 27. Vital signs are stable. She is still independent in all activities of daily living. She drives as
well. She rates her pain without medication as 10/10 in her neck, back and thighs. With medication, she
can function and rates the pain as 5/10.
She does not exercise. She spends most days watching TV, cooking for her husband, spending time with
her pets, reading and visiting with family. She does try to get out of the house at least once per day.
Medications:
Methadone 10 mg 3 x per day
Oxycodone 10 mg every 6 hrs as needed (and she takes it).
Prozac 20 mg daily
Abilify 15 daily
Calcium 600 mg twice daily
Vitamin D 2000 iu daily
Medications associated with Constipation
Prescription Drugs
opiates
Anticholinergic agents
Tricyclic antidepressants
Calcium Channel blockers
Anti-Parkinsonian drugs
Antipsychotics
Diuretics
Nonprescription Drugs
Antacids, especially containing calcium
Calcium supplements
Iron Supplements
Antidiarrheal agents
Nonsteroidal anti-inflammatory agents
Antihistamines
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Assessment:
Patient History should include the following questions:
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How long have you experienced constipation symptoms?
Does constipation limit your daily activities?
What is your most distressing symptom?
What is your approximate intake of dietary fiber?
What laxatives have you tried? Are you currently taking any? If so how often and do you know
the dosage?
Are you using enemas or suppositories?
Are you taking any herbal medications or teas?
How often do you have bowel movements?
What is the consistency of your stools?
How often do you feel the urge to defecate? When you have this feeling do you try to have a
bowel movement?
What other symptoms do you experience? Straining? Feeling of incomplete evacuation? Need
to manually maneuver?
Is there any blood present in the stool? Have you ever had a positive test for blood in your
stool?
Do you have a family history of colon cancer?
Is there a family history if Irritable Bowel Disease?
Is there a history of anemia?
Is there any unexplained weight loss of more than 10 pounds?
Has anything been effective in managing the constipation?
MAKE NO ASSUMPTIONS AND REVIEW THE CHART
Check history of labs:
Thyroid levels (TSH, T4)
Electrolytes
Serum Calcium
CBC
Read and review the colonoscopy report. If not available, get it.
Read and review any GI Consults or notes specifically evaluating the constipation.
Check medication history to see if you can find out more about medications used to treat constipation.
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Bristol Form Form Scale
Review other symptoms of constipation:
 Back pain
 Distended abdomen or pain
 Dizziness or confusion
 Leaking stool
 Fever
 No bowel movements
 Nausea and/or vomiting
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Constipation Treatment Options
1. Life style changes. Though very important, when narcotics are in use, changes are typically not
enough.
a. Hydration
i. 6 to 8 glasses of water per day minimum
b. Fiber intake
i. Start with increasing 4 to 6 grams per day and increasing to 20 to 25 gm daily.
ii. Evaluate for bloating, flatulence and fecal impaction
c. Exercise (15 to 30 minutes)
d. Dedicated time to have a bowel movement
i. If you wait you increase transit time and loose fluid.
ii. Go when you have the urge
2. Traditional Laxatives
a. Bulking Agent
i. Psyllium seed, methylcelluose and calcium polycarbophil.
ii. Absorbs liquid in the intestine and then swells
iii. Bowl then becomes stimulated by the mass and stool is softer.
b. Osmotics
i. Three types: saline, lactulose and polymer (Milk of Mag, magnesium citrate,
phosphate solutions, lactulose, polyethylene glycol (PEG, MiraLax) Sorbitol.
ii. Draw water into the bowel from surrounding tissue & provide soft stool mass
and increased bowel action.
c. Stimulants such as senna and bisacodyl encourage bowel movements by acting on the
intestinal wall to promote muscle contractions that transport stool mass.
d. Lubricants (mineral oil) coat the bowel and the stool mass with water proof film. Stool
remains soft and its passage is made easier.
e. Stool softeners help liquids mix into the colonic material and prevent dry, hard stools.
Reduce straining. A common stool softener is docusate sodium.
f. Combination Laxatives. Combines two or more of the above.
Think of this as Gush, Push, and Mush. It is a different approach when you are up against
Narcotics.
“GUSH” – osmotic laxative. Miralax 1 scoop or capful (17 grams0 in juice once per day.
“PUSH” - Stimulant is like a “whip” on the bowel to get it moving. Take regularly.
Senna 8.6 mg: 1 to 2 tablets at bedtime. May increase to 2 tablets twice daily.
Senna Tea “Smooth Move” or other brands. 1 cup of tea twice daily.
Ducolax (Bisacodyl) 5 mg: 1-2 tablets at bedtime Nat ubcrease ti 2 tablets twice daily.
Note: Senna and Ducolax can cause cramping.
“MUSH”- Stool softner: for stools that are hard or like ‘rabbit pellets’
Docusate 250 mg: Take 1 capsule once or twice a day, may increase to 2 caps twice a
day. Take regularly. Available over-the-counter in 100 mg capsules.
The goal may be to have 2-3 stools per day using this approach.
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Yakima Fruit Paste Recipe
4 oz senna tea leaves or tea bags.
1 pound of prunes
1 pound pitted raisins
1 pound figs
1 cup brown sugar
1 cup lemon juice
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Prepare tea using about 2.5 cups boiled water added to tea: steep for 5 minutes.
Strain tea to remove tea leaves and add only 2 cups tea to large pot, and then add fruit.
Boil fruit and tea for 5 minutes.
Remove from heat and add sugar and lemon juice and allow to cool.
Use hand mixer or food processor to blend fruit mixture into a smooth paste.
Place in plastic container and place in freezer. The past will not freeze but it will keep
indefinitely in the freezer without spoiling.
7. Spoon 1 to 2 tablespoons each day. Eat with spoon or spread on toast or crackers. You can
also add to hot water and make a tea.
Prescription Treatments are available. One example is Lubiprostone. This is a chloride channel
activator. Patient’s insurance may pay for prescriptions of higher doses of the over-the-counter
options.
Here's a look at the fiber content of some common foods. Read nutrition labels to find out
exactly how much fiber is in your favorite foods. Women should try to eat at least 21 to 25
grams of fiber a day, while men should aim for 30 to 38 grams a day.
Fruits
Serving size
Total fiber
(grams)*
Raspberries
1 cup
8.0
Pear, with skin
1 medium
5.5
Apple, with skin
1 medium
4.4
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Banana
1 medium
3.1
Orange
1 medium
3.1
Strawberries (halves)
1 cup
3.0
Figs, dried
2 medium
1.6
Raisins
1 ounce (60
raisins)
1.0
Grains, cereal & pasta
Serving size
Total fiber
(grams)*
Spaghetti, whole-wheat, cooked
1 cup
6.3
Barley, pearled, cooked
1 cup
6.0
Bran flakes
3/4 cup
5.3
Oat bran muffin
1 medium
5.2
Oatmeal, instant, cooked
1 cup
4.0
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Popcorn, air-popped
3 cups
3.5
Brown rice, cooked
1 cup
3.5
Bread, rye
1 slice
1.9
Bread, whole-wheat or multigrain
1 slice
1.9
Legumes, nuts and seeds
Serving size
Total fiber
(grams)*
Split peas, cooked
1 cup
16.3
Lentils, cooked
1 cup
15.6
Black beans, cooked
1 cup
15.0
Lima beans, cooked
1 cup
13.2
Baked beans, vegetarian, canned, cooked
1 cup
10.4
Sunflower seed kernels
1/4 cup
3.9
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Almonds
1 ounce (23 nuts)
3.5
Pistachio nuts
1 ounce (49 nuts)
2.9
Pecans
1 ounce (19
halves)
2.7
Vegetables
Serving size
Total fiber
(grams)*
Artichoke, cooked
1 medium
10.3
Green peas, cooked
1 cup
8.8
Broccoli, boiled
1 cup
5.1
Turnip greens, boiled
1 cup
5.0
Brussels sprouts, cooked
1 cup
4.1
Sweet corn, cooked
1 cup
4.0
Potato, with skin, baked
1 small
3.0
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Tomato paste
1/4 cup
2.7
Carrot, raw
1 medium
1.7
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