What medication is used to prevent constipation when taking opioids (opiate narcotics)?

From the Guidelines

Stimulant laxatives, such as senna or bisacodyl, are recommended as the primary treatment to prevent or manage opioid-induced constipation, with a dose of 5-15 mg/day for bisacodyl or 8.6-17.2 mg/day for senna 1.

Key Points

• Opioids cause constipation by slowing gut motility and decreasing intestinal secretions, making preventive treatment essential from the start of opioid therapy rather than waiting for constipation to develop.
• Stimulant laxatives, such as senna (Senokot) or bisacodyl (Dulcolax), are effective in preventing or treating opioid-induced constipation.
• Polyethylene glycol (Miralax) at 17g daily mixed in water is another good option for managing opioid-induced constipation.
• For severe cases, prescription medications specifically designed for opioid-induced constipation include methylnaltrexone (Relistor), naloxegol (Movantik), and lubiprostone (Amitiza), which work by blocking opioid receptors in the gut without affecting pain relief.
• Increasing fluid intake, maintaining physical activity when possible, and consuming fiber-rich foods are also important while taking these medications.
• The American Gastroenterological Association recommends the use of laxatives as first-line agents for opioid-induced constipation, with stimulant laxatives being a preferred option 1.

Treatment Approach

• Assess the cause and severity of constipation before initiating treatment.
• Start with a stimulant laxative, such as senna or bisacodyl, and adjust the dose as needed to achieve one non-forced bowel movement every 1-2 days.
• Consider adding other laxatives, such as polyethylene glycol, if constipation persists.
• Use peripherally acting mu opioid receptor antagonists, such as methylnaltrexone, for severe cases of opioid-induced constipation.
• Monitor patients regularly to assess the effectiveness of treatment and adjust the treatment plan as needed.

From the FDA Drug Label

Purpose Laxative The drug to use with opiates to avoid constipation is Senna.

• Senna is a laxative, which can help prevent constipation caused by opiates. 2

From the Research

Treatment Options for Opioid-Induced Constipation

To manage opioid-induced constipation, several treatment options are available, including:

• Laxatives and stool softeners, such as senna, docusate, and bisacodyl 3
• Newer agents like lubiprostone, linaclotide, and prucalopride, which can be used when first-line therapies are not effective 4, 3
• μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, and naloxone, which can help restore bowel function 5, 6

Recommended Treatment Approach

A proposed clinical management algorithm for treating opioid-induced constipation includes:

• Carefully re-evaluating the necessity, type, and dose of opioids at each visit 6
• Lifestyle modification and alteration of aggravating factors 6
• Use of simple laxatives, such as senna and docusate, as first-line treatment 3
• Addition of newer laxatives or opioid antagonists, such as methylnaltrexone, when essential 5, 6

Effective Medications

Studies have shown that medications like methylnaltrexone can be effective in treating opioid-induced constipation, with laxation occurring within 24 hours in 86% of patients treated with methylnaltrexone, compared to none of the patients receiving conventional rescue therapy 5. Other medications, such as lubiprostone and linaclotide, have also been shown to be effective in managing opioid-induced constipation 4, 3.