Opiods and Constipation.

[Formaleins]

Wonder if anyone can help on this rather delicate subject?

I have to take opioid pain medication on a regular basis, Tramadol 50mg x 3 per day. This tends to cause constipation. (I have asked the doctors if there is any other pain relief available but they say that Tramadol is the most effective and that any opioid pain med. will cause constipation - However, they have not prescribed any meds to help with the constipation)

 

I currently use Senna capsules that I can get easily from 7/11 as and when needed, however this is becoming more an more a regular requirement, and I believe that the more I use the more I will need. Also, they can be a bit harsh and sudden for what I really need as I believe they work by essentially irritating the gut.

 

Does anyone have experience with long term opioid use and can they suggest something that might relieve the constipation. I believe I probably need something more akin to a stool softener rather than a laxative, and there seems to be a wealth of negative effects from long term laxative use, i.e. I don't want to end up with bowel problems or bone deficiencies from long term laxatives.

 

Any info would be appreciated. I would prefer to buy over the counter meds rather than have to go down the prescription route if at all possible.

 

Thanks.

[Sheryl]

If you have not already, start eating stewed prunes every day, readily found in supermarkets near the raisins.  Also try to eat as much else high in fiber as you can. Oatmeal, salads (western and also the Thai som tam) and Kelloggs all bran cereal are all good choices. Be sure to also drink enough water. These changes you should make permanent.

 

If that does not work, a stimulent laxative like Senna is probably your best bet .A stool softener alone is unlikely to help and studies indicate a stool softener plus senna is not better than senna alone but if you want to try one, get docusate  (brand name: Dewax) . The problem is not caused by  stool hardness (though the stool may become hard due to being in the intestine too long). It is caused by reduced motility of the entire GI tract.

 

There is a drug developed specifically for opoid-induced constipation (Lupristone ) but it is not yet available in Thailand. Other drugs are under development.

 

What the doctors told you re all opoids and opoid-like drugs causing constipation is, unfortunately, very true. There are other opoid pain killers available that may be more effective for your pain but they will also also cause constipation, likely worse than the tramadol, and Thai doctors are very hesitant to prescribe them because of stringent Thai FDA regulations.  You are lucky in a way that you suffer only constipation; the GI effects cause some people severe nausea and vomiting as well (I can't take any type of opiate, even in low dose, without vomiting).

 

Should things get really bad and if the hardened stool is low down, you can self administer an enema, small prefilled bulb syringes are sold in pharmacies for this purposes. Suggest keeping a few on hand, they only ocst around 50 baht and are easy to self-administer seated on the toilet.

 

The best solution if possible would be to get off the tramadol or reduce its dose & frequency but without knowing more about the type of pain you have,  I have no idea how feasible that is. Might be worth consulting a pain specialist to see what they can offer, they know a lot more than regular doctors in this regard. There are drugs that can be given in combo with pain killers that enhance their effectiveness and reduce the needed dosage in many types of pain, for example. But it does depend on the type/cause of the pain.

 

 

[Formaleins]

2 minutes ago, Sheryl said:

If you have not already, start eating stewed prunes every day, readily found in supermarkets near the raisins.  Also try to eat as much else high in fiber as you can. Oatmeal, salads (western and also the Thai som tam) and Kelloggs all bran cereal are all good choices. Be sure to also drink enough water. These changes you should make permanent.

 

If that does not work, a stimulent laxative like Senna is probably your best bet .A stool softener alone is unlikely to help and studies indicate a stool softener plus senna is not better than senna alone but if you want to try one, get docusate  (brand name: Dewax) . The problem is not caused by  stool hardness (though the stool may become hard due to being in the intestine too long). It is caused by reduced motility of the entire GI tract.

 

There is a drug developed specifically for opoid-induced constipation (Lupristone ) but it is not yet available in Thailand. Other drugs are under development.

 

What the doctors told you re all opoids and opoid-like drugs causing constipation is, unfortunately, very true. There are other opoid pain killers available that may be more effective for your pain but they will also also cause constipation, likely worse than the tramadol, and Thai doctors are very hesitant to prescribe them because of stringent Thai FDA regulations.  You are lucky in a way that you suffer only constipation; the GI effects cause some people severe nausea and vomiting as well (I can't take any type of opiate, even in low dose, without vomiting).

 

Should things get really bad and if the hardened stool is low down, you can self administer an enema, small prefilled bulb syringes are sold in pharmacies for this purposes. Suggest keeping a few on hand, they only ocst around 50 baht and are easy to self-administer seated on the toilet.

 

The best solution if possible would be to get off the tramadol or reduce its dose & frequency but without knowing more about the type of pain you have,  I have no idea how feasible that is. Might be worth consulting a pain specialist to see what they can offer, they know a lot more than regular doctors in this regard. There are drugs that can be given in combo with pain killers that enhance their effectiveness and reduce the needed dosage in many types of pain, for example. But it does depend on the type/cause of the pain.

 

 

Thank you so much for your help, really appreciated!

[Airalee]

Resolor (Prucalopride) is available at pharmacies now.

[Chivas]

Taking a higher daily dose of tramadol dating back to 1999 and have never ever had constipation thats for sure.

Am guessing everyone is different

[Sheryl]

2 hours ago, Airalee said:

Resolor (Prucalopride) is available at pharmacies now.

Thanks, did not realize that.

 

However I see the Thai FDA has classified it as a category "S" drug (prescription only) so doubt many pharmacies other than hospital pharmacies will have it.

 

It will also be very expensive as it is a foreign import.

 

However studied s have shown it is often g=helpful for opoid patients who do nto get relief from laxatives so if original advice fails, OP, ask your doctors for this. It helps counteract the slowing of the GI tract.

[Airalee]

10 minutes ago, Sheryl said:

Thanks, did not realize that.

 

However I see the Thai FDA has classified it as a category "S" drug (prescription only) so doubt many pharmacies other than hospital pharmacies will have it.

 

It will also be very expensive as it is a foreign import.

 

However studied s have shown it is often g=helpful for opoid patients who do nto get relief from laxatives so if original advice fails, OP, ask your doctors for this. It helps counteract the slowing of the GI tract.

Yeah...it was only available in the hospital when I first tried it.  If I remember correctly, the GI doc told me that I would only be able to obtain it there for two years as it was a “new drug” and then it would be released to the pharmacies.  The large(ish) pharmacy in the bottom of Kad Suan Kaew in CM was able to order it for me about 18 months ago.  It was a bit pricy but still far less than I have seen it elsewhere (US or online Canadian pharmacies)

Edited September 30, 2018 by Airalee

[Airalee]

Oh...and definitely see a gastroenterologist, good luck getting off the senna.

[Airalee]

Just a follow up FYI.  Saw my Gastroenterologist today at Vichaiyut (Bangkok) and had him fill a 30 day prescription for 2mg Resolor.  The cost at the hospital pharmacy was ฿3300 for 30.  The GI doc confirmed with me that it is in fact now available outside of the hospitals.

[Sheryl]

great. Let us know if it works.

[Airalee]

3 hours ago, Sheryl said:

great. Let us know if it works.

Oh....it works for getting the colon moving for sure.  Now just have to get it past the nonrelaxing puborectalis muscle.  Gonna have to check the price at the local pharmacies as I hate paying so much in the hospital.

[arjunadawn]

I have to have Colace/Docusate Sodium over the counter sent to me from the states; I cannot find here. Softener is not the same as Laxative stimulant- both intolerable options. I comment because I use same meds, same dose, long term from injuries. One thing that makes a big difference is Metamucil- here in Thailand, Muclin. Basically, insoluble fiber. One or 2 large Tablespoons in 6-8oz water/day may well be enough. I am so confident of this that I strongly suggest you at least try it.  400 gm/approx 270 THB. (Learning from this thread today, I will also look into the Rx some of you speak of above. Thanks for that.

[JAS21]

After I had Laser TURP, three weeks ago now, for the evening of the operation and the next day they gave me morphine. On the 3rd day they let me go home with a few Tramadol. Throughout they gave me Mucilin SF and that worked for me.

[Sheryl]

An alternative to Muclin is to buy psyllium husks in bulk. Villa markets  stock it

[Deerculler]

I eat an apple every night before sleep and it works wonders.


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[madmen]

On Wednesday, December 19, 2018 at 11:51 AM, Sheryl said:

An alternative to Muclin is to buy psyllium husks in bulk. Villa markets  stock it

Yes and a cheap solution. You can also get it via post from good karma health store in phuket around 600 baht for 500 grams 

I take tramadol as part of a cocktail of pain killer's and that really puts the colon into sleep mode 

[Rimmer]

A post suggesting a dangerous activity have been removed

[geriatrickid]

The developed world's preferred treatment of opioid-induced constipation (OIC) in adult patients with non-cancer pain who have had an inadequate response to laxative(s), is Astra Zeneca's MOVANTIK® naloxegol tablet (naloxegol oxalate), a peripherally acting μ-opioid receptor antagonist. It is  available in Singapore and Hong Kong by way of  Daiichi Sankyo distrubution.

[Speedo1968]

Would de-toxing, the anal route help ?    It can easily be done at home and the cost of the bottle and tube is very cheap.

Obviously attention to diet, such has already been mentioned ( drink plenty of WATER ), will go a long way to reducing symptoms.

[snowballthecat]

I drink an Indian tea from Kerala. When I visited south India noticed the locals drink a red/pink tea all day along. Tried and liked it. Digestive and mild-laxative. No bloating. Now cannot travel without it. It is called "Karingali", "Dahamasani" mixture of the bark of 3 native trees, will not hurt. 

Sold all over Kerala, Tamul Nadu and in Singapore, Indian area. Also in Dubai, Madina supermarket branches, very very cheap.