What is the recommended daily dose of Colace (docusate) for a patient on Suboxone (buprenorphine/naloxone) to manage constipation?

Docusate (Colace) Should Not Be Used for Constipation in Patients on Suboxone

Based on the highest quality guideline evidence, docusate has not shown benefit for constipation and is therefore not recommended. 1 Instead, patients on Suboxone (buprenorphine/naloxone) who develop opioid-induced constipation should be managed with stimulant laxatives or osmotic agents as first-line therapy.

Why Docusate Is Not Recommended

The NCCN guidelines explicitly state that "based on the available literature, docusate has not shown benefit and is, therefore, not recommended" for managing opioid-induced constipation. 1 This recommendation is supported by systematic review evidence showing that prospective controlled trials of docusate in chronically ill patients demonstrated only small, clinically insignificant trends toward increased stool frequency, with overall poor quality evidence (quality scores 0.46-0.52 out of 1.0). 2

Recommended First-Line Approach for Suboxone Patients

Start with a stimulant laxative as prophylaxis when initiating Suboxone:

• Senna 8.6-17.2 mg daily (can titrate up to 4 tablets twice daily based on response) 1
• Bisacodyl 10-15 mg daily (can increase to three times daily) with goal of 1 non-forced bowel movement every 1-2 days 1

The 2016 NCCN Palliative Care guidelines specifically recommend increasing the dose of "laxative ± stool softener (senna ± docusate, 2-3 tablets BID-TID)" but note that one small study comparing senna alone versus senna-docusate combination demonstrated that "the addition of the stool softener docusate was not necessary." 1

Second-Line Options If Stimulant Laxatives Are Insufficient

Add an osmotic laxative:

• Polyethylene glycol (PEG) 17 g daily - most cost-effective option ($10-45/month), durable response over 6 months 1
• Lactulose 30-60 mL BID-QID 1
• Magnesium hydroxide 30-60 mL daily-BID 1

Peripherally Acting Mu-Opioid Receptor Antagonists for Refractory Cases

If constipation persists despite laxative therapy and is clearly related to opioid use:

• Naloxegol 25 mg daily - FDA-approved for opioid-induced constipation in adults with chronic noncancer pain, demonstrated 44.4% vs 29.4% response rate compared to placebo (P=0.001), with shorter time to first bowel movement 3
• Methylnaltrexone 0.15 mg/kg subcutaneously every other day (maximum once daily) 1
• Naldemedine - FDA-approved alternative 1

These agents work on gastrointestinal receptors without reducing opioid-mediated analgesia. 1, 3

Critical Caveats

Before escalating therapy, always rule out:

• Bowel obstruction (physical exam, abdominal x-ray) 1
• Fecal impaction (especially if diarrhea accompanies constipation - overflow around impaction) 1
• Hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus 1
• Other constipating medications that can be discontinued 1

Avoid oral naloxone in Suboxone patients: While oral naloxone can reverse opioid-induced constipation, even low doses (2-4 mg three times daily) caused reversal of analgesia in some patients, particularly those on high opioid doses. 4, 5 This risk makes it unsuitable for routine use.

Practical Algorithm

1. Prophylaxis at Suboxone initiation: Senna 8.6-17.2 mg daily OR bisacodyl 10-15 mg daily 1
2. If constipation develops: Add PEG 17 g daily 1
3. If inadequate response: Increase stimulant laxative dose (bisacodyl up to TID, senna up to 4 tablets BID) 1
4. If still refractory: Add naloxegol 25 mg daily 3
5. For impaction: Glycerine suppository, bisacodyl suppository, or manual disimpaction with pre-medication 1

Do not waste time or money on docusate - the evidence clearly shows it provides no meaningful benefit for opioid-induced constipation. 1, 2