How does marijuana use affect constipation and what are the management options?

Marijuana and Constipation: Effects and Management Options

Marijuana use can cause constipation in some individuals, while paradoxically helping with constipation in others, depending on individual factors and usage patterns. Management should focus on lifestyle modifications and appropriate laxative therapy based on symptom severity. 1

Effects of Marijuana on Bowel Function

• Marijuana affects the endocannabinoid system, which plays a role in regulating gut motility, visceral sensation, and the gut microbiome 1
• Cannabis use can have variable effects on bowel function - some studies suggest it may improve symptoms in irritable bowel syndrome (IBS) patients, potentially through effects on the endocannabinoid system 2
• Chronic heavy cannabis use has been associated with cannabinoid hyperemesis syndrome (CHS), characterized by cyclic vomiting, nausea, and abdominal pain 3
• Cannabis use has been associated with reduced healthcare utilization in IBS patients, including shorter hospital stays and fewer endoscopic procedures 4, 2

Management of Constipation in Marijuana Users

First-Line Approaches

• Key factors for prevention and self-care include:
  • Ensuring privacy and comfort for normal defecation 3
  • Proper positioning (using a small footstool to assist gravity) 3
  • Increased fluid intake and physical activity within patient limits 3
  • Optimized toileting habits (attempting defecation at least twice daily, 30 minutes after meals) 3

Pharmacological Management

• When laxatives are needed, preferred options include:
  • Osmotic laxatives (polyethylene glycol, lactulose, magnesium salts) 3
  • Stimulant laxatives (senna, bisacodyl, sodium picosulfate) 3
  • Avoid bulk laxatives like psyllium if constipation is opioid-induced 3

Special Considerations for Cannabis Users

• For patients with cannabis-induced constipation:
  • Consider reducing cannabis use or taking breaks from use if constipation is persistent 1
  • For patients using cannabis for medical purposes who experience constipation, discuss alternative formulations or dosing schedules 5
  • If cannabinoid hyperemesis syndrome is suspected (characterized by cyclic vomiting with cannabis use), complete cessation of cannabis is recommended 6

Management of Opioid-Induced Constipation (If Relevant)

• If marijuana is being used alongside opioids for pain management:
  • Prophylactic laxative therapy should be initiated when opioids are prescribed 3
  • Osmotic or stimulant laxatives are generally preferred for opioid-induced constipation 3
  • For laxative-refractory opioid-induced constipation, peripherally acting μ-opioid receptor antagonists (PAMORAs) such as naldemedine or naloxegol may be considered 3

Special Populations

Elderly Patients

• Particular attention should be paid to elderly cannabis users with constipation 3
• Key prevention measures include:
  • Ensuring access to toilets, especially with decreased mobility 3
  • Dietetic support and managing decreased food intake 3
  • Polyethylene glycol (17 g/day) offers an efficacious and tolerable solution for elderly patients 3
  • Avoid liquid paraffin for bed-bound patients due to risk of aspiration 3

Common Pitfalls and Caveats

• Magnesium and sulfate salts can lead to hypermagnesemia and should be used cautiously in patients with renal impairment 3
• Enemas are contraindicated in certain conditions including neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, anal/rectal trauma, severe colitis, and undiagnosed abdominal pain 3
• Cannabis users with persistent gastrointestinal symptoms should be evaluated for cannabinoid hyperemesis syndrome, which requires cannabis cessation for resolution 3, 6
• When constipation occurs with cannabis use, it's important to rule out other causes including medication side effects, metabolic disorders, or structural abnormalities 3