Is Suboxone (buprenorphine/naloxone) effective for treating constipation?

Suboxone Is Not Effective for Treating Constipation

Suboxone (buprenorphine/naloxone) is not effective for treating constipation and may actually worsen constipation due to its opioid component. Buprenorphine, like other opioids, causes constipation through its effects on the gastrointestinal tract, and the addition of naloxone does not adequately counteract this effect when administered orally.

Understanding Opioid-Induced Constipation (OIC)

Opioids, including the buprenorphine component in Suboxone, commonly cause constipation:

• Approximately 50% of patients receiving opioids experience constipation 1
• OIC occurs because opioids bind to μ-opioid receptors in the gastrointestinal tract, decreasing motility and secretions
• The naloxone component in Suboxone has minimal effect on preventing constipation when taken orally as prescribed (sublingually), as it has poor oral bioavailability

Recommended Treatments for Constipation

First-line treatments for constipation:

1. Osmotic laxatives:

   • Polyethylene glycol (PEG) - particularly effective with good safety profile 1
   • Lactulose
   • Magnesium salts (use cautiously in renal impairment) 1

2. Stimulant laxatives:

   • Senna
   • Bisacodyl (10-15 mg, 2-3 times daily) 1
   • Sodium picosulfate

For opioid-induced constipation specifically:

1. Peripherally acting μ-opioid receptor antagonists (PAMORAs):

   • Methylnaltrexone - effective for OIC while preserving analgesia 1
   • Naloxegol - oral agent with similar properties 1

2. Combined opioid/naloxone formulations:

   • Oxycodone/naloxone has shown reduced risk of OIC in clinical trials 1
   • Note: This is different from Suboxone, where the naloxone is primarily included to deter misuse

Management Algorithm for Constipation

1. Prevention measures:

   • Ensure adequate fluid intake
   • Increase physical activity when possible
   • Optimize toileting position (small footstool may help) 1
   • Prophylactic laxative therapy when starting opioids 1

2. If constipation develops:

   • Start with osmotic or stimulant laxatives 1
   • Goal: one non-forced bowel movement every 1-2 days 1
   • Avoid bulk laxatives (psyllium) in OIC 1

3. For persistent constipation:

   • Consider adding a PAMORA (methylnaltrexone or naloxegol) 1
   • Consider suppositories or enemas if digital rectal exam identifies a full rectum 1
   • For impaction: glycerin suppositories or manual disimpaction may be required 1

Important Considerations and Pitfalls

• Do not use Suboxone to treat constipation - it contains buprenorphine which will likely worsen constipation
• Magnesium-based laxatives should be used cautiously in patients with renal impairment due to risk of hypermagnesemia 1
• Bulk-forming laxatives should be avoided in opioid-induced constipation 1
• Patients with constipation should be assessed for other causes (hypercalcemia, hypothyroidism, medications) 1
• Plain abdominal X-ray may be useful to assess fecal loading and exclude bowel obstruction in severe cases 1

In summary, rather than using Suboxone for constipation, patients should be treated with appropriate laxatives based on the cause and severity of their constipation, with special consideration given to peripherally acting μ-opioid receptor antagonists if the constipation is opioid-induced.