Painkillers associated constipation management

[Olga]

Constipation is a very well known side effect of the pain controlling medications.
Debbie found this very helpful article on the http://www.bccancer.bc.ca/nr/rdonlyres/ ... pation.pdf
I decided to copy the full text for our patients to use:

SUGGESTIONS FOR DEALING WITH CONSTIPATION
Being constipated is uncomfortable and can make you feel unwell. The guidelines in this handout can
help you keep bowel movements soft and regular.
It is not necessary to have a bowel movement every day. As long as your stools are soft and easy to
pass, it is okay to have a movement every 2 or 3 days. If you have not had a movement within the last
3 days, please contact your doctor or nurse before using this handout.
Note: If you have just started taking morphine-type pain medications, you will need to start with
step 2.
FOOD CHOICES
Drink eight or more cups of liquid each day. Your body needs liquids to help to keep stools soft.
Water, juice, soup and soft drinks are good choices. Limit coffee, tea and alcohol, because they cause
water loss.
If your appetite is smaller than usual, include nutritious liquids such as:
Milkshakes Hot chocolate Warm milk Ovaltine® Cream soup Soy milk Fruit juice Nutritional
supplement drinks
Choose foods that are natural laxatives such as prunes, prune juice, papayas and rhubarb. These
should be taken every day to work their best. The recipe below makes a pleasant-tasting, natural
laxative.
FRUIT LAX
125 ml pitted dates (1/2 cup)
310 ml prune nectar (1 1/4 cups)
125 ml figs (1/2 cup)
200 ml raisins (3/4 cup)
125 ml pitted prunes (1/2 cup)
Simmer dates and prune nectar until dates are very soft. Put date mixture in a food processor and add
figs, raisins and prunes. Blend to a smooth paste. Store in the refrigerator. Use on toast, crackers, ice
cream etc.
Eat foods that contain fibre such as vegetables, fruit, cereals and whole grain breads. Eating these
foods will help to keep stools soft.
Have meals and snacks at the same time everyday. This may help to make bowel movements regular.
Do some light exercise, such as a short walk, after each meal.
MEDICATIONS FOR CONSTIPATION
If you are still constipated after following the suggestions on the previous page, you will need to take
medications. They need to be taken daily in order to be most effective. The goal is to prevent
constipation.
STEP ONE: Use a Stool Softener Stool softeners work by making bowel movements easier to pass.
They are not laxatives. Here is a daily plan for taking them:
Breakfast: Take 2 stool softeners
Supper: Take 2 stool softeners
The name of the recommended stool softener is docusate sodium. It is sold under brand names like:
Regulex®
Colace®
Colace® syrup (50 mL of syrup = 2 softeners)
Please ask your pharmacist to help you choose the softener that is right for you.
If you have diarrhea after taking stool softeners, decrease the amount taken.
STEP TWO: Add a Laxative
If you do not have a bowel movement for up to 2 days after starting stool softeners, you will need to
add a laxative. Here is a plan that uses laxatives and stool softeners together:
Breakfast: Take 2 stool softeners
Supper: Take 2 stool softeners
Bedtime: Take 2 laxatives
The name of the recommended laxative is sennosides. Familiar brand names include:
Glysennid®
Senokot®
Senokot® syrup (2 tsp (10 ml) = 2 laxative tablets)
Please ask your pharmacist to help you choose the brand that is right for you.
If you have severe cramps after taking laxatives, stop taking them and consult your health care team.
STEP THREE: Increase the Laxatives and Stool Softeners
If you do not have a bowel movement after 2 days, increase the number of stool softeners and
laxatives, as below:
Breakfast: Take 2 stool softeners and 2 laxatives
Lunch: Take 2 stool softeners Supper: Take 2 stool softeners
Bedtime: Take 2 laxatives
If you do not have a bowel movement after a further 24 hours, you can add 2 more tablets of
laxatives at lunchtime.
After a further 24 hours, you can increase the number of laxatives to 9 tablets per day, or 3 at each
meal.
STEP FOUR: Add a Suppository
If you are still constipated after using stool softeners and laxatives, add a glycerin or bisacodyl
(Dulcolax®) suppository You should keep the suppository in place for at least 15 minutes. You should
not use a suppository if you are receiving chemotherapy unless your oncologist advises you
otherwise.
If you are still constipated after following these 4 steps, please consult your care team nurse for more
advice. They may advise you to add a liquid laxative called lactulose as well.
SOME IMPORTANT INFORMATION:
Do not use liquid laxatives that contain mineral oil or magnesium such as Magnolax®, Agarol®, or
Milk of Magnesia® without talking to your doctor or pharmacist first. These laxatives may not be safe
for long term use.
If you are thinking about using a bulk-forming laxative such as Metamucil® or Prodiem®, check with
your doctor or nurse first. These laxatives will make bowel movements very hard if fluid intake is not
adequate.
The medications discussed here are not habit-forming. They need to be taken regularly in order to be
most effective.
The doses of medications discussed here are higher than the directions given on the product labels.
Please follow the directions given in this information sheet because higher doses are usually needed in
patients who are taking morphine-type medications. These higher doses are safe.
If you are eating less then usual, you may notice that your stools become smaller – this is perfectly
normal. Even if you are not eating at all, you still need to have regular bowel movements. As a rule of
thumb, if 3 or more days pass without a bowel movement, please contact your doctor or nurse.
BCCA OUTPATIENT BOWEL PROTOCOL
Where to start:
• If you are not on any morphine-type medications (such as codeine, morphine, oxycodone,
methadone, fentanyl, hydromorphone), begin at STEP 1.
• If you have just started to take morphine-type pain medications, begin at STEP 2.
How to adjust:
• If you do not have a bowel movement after 2 days on STEP 1 or 2, go to the next step.
• Thereafter, if no bowel movement after 24 hours at a step, move to the next step.
• If able to have a satisfactory bowel movement at a step, stay at the same step.
Cautions:
• If you have diarrhea, stop taking laxatives until you have a normal bowel movement and then
decrease the daily amount of docusate taken.
• If you have severe cramps, stop taking sennosides and call your doctor or nurse.
• You should not use a suppository if you are receiving chemotherapy unless your oncologist
advises you otherwise.
Step Breakfast Lunch Supper Bedtime
1 2 x docusate 2 x docusate
2 2 x docusate 2 x docusate 2 x sennosides
3a 2 x docusate
2 x
sennosides
2 x docusate 2 x docusate 2 x sennosides
3b 2 x docusate
2 x
sennosides
2 x docusate
2 x
sennosides
2 x docusate 2 x sennosides
3c 2 x docusate
3 x
sennosides
2 x docusate
3 x
sennosides
2 x docusate
3 x
sennosides
4 . Unwrap and insert an adult bisacodyl or glycerin suppository into your rectum. . Keep
in place for at least 15 minutes. . If still no bowel movement after 1 hour, call your
doctor or nurse or pharmacist. You should not use a suppository if you are
receiving chemotherapy unless your oncologist advises you otherwise.
What to buy at the drugstore:
• docusate also known as “Colace” or other generic brand
• sennosides 8.6 mg tablets also known as “Senokot” or other generic brand
• bisacodyl 10 mg suppositories also known as “Dulcolax” or other generic brand
• glycerin adult suppository




and the recipe

FRUIT LAX

125 ml pitted dates (1/2 cup)
310 ml prune nectar (1 1/4 cups)
125 ml figs (1/2 cup)
200 ml raisins (3/4 cup)
125 ml pitted prunes (1/2 cup)
Simmer dates and prune nectar until dates are very soft. Put date mixture in a food processor and add
figs, raisins and prunes. Blend to a smooth paste. Store in the refrigerator. Use on toast, crackers, ice
cream etc.Eat foods that contain fibre such as vegetables, fruit, cereals and whole grain breads. Eating these
foods will help to keep stools soft.

Have meals and snacks at the same time everyday. This may help to make bowel movements regular.
Do some light exercise, such as a short walk, after each meal.