Treatment of Functional Constipation Due to Alcohol Use
The primary treatment for functional constipation in patients with alcohol use is addressing the underlying alcohol dependence through brief motivational interventions combined with pharmacotherapy (baclofen for those with advanced liver disease, or acamprosate/naltrexone for those without), while simultaneously managing constipation with stimulant laxatives like bisacodyl and osmotic agents. 1, 2
Address the Root Cause: Alcohol Cessation
The most critical intervention is treating the alcohol use disorder, as persistent alcohol intake drives disease progression and worsens gastrointestinal dysfunction 1:
- Screen using AUDIT (Alcohol Use Disorders Identification Test) as the gold standard tool 1, 2
- Implement brief motivational interventions immediately using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy), which reduces alcohol consumption by an average of 57 g per week 1, 3
- Assess for acute withdrawal syndrome - if present, benzodiazepines are the treatment of choice to prevent complications 1, 2
Pharmacotherapy for Alcohol Dependence
The choice depends on liver disease status:
For patients WITHOUT advanced liver disease:
- Acamprosate 666 mg three times daily OR naltrexone 50 mg daily, combined with counseling 1, 2, 3
- These medications reduce relapse to heavy drinking and maintain abstinence 3
For patients WITH advanced alcoholic liver disease:
- Baclofen is the only safe and effective option for preventing alcohol relapse in this population 1, 2, 4
- Naltrexone and disulfiram are contraindicated due to hepatotoxicity risk 1, 4
Manage Constipation Directly
While addressing alcohol use, implement concurrent constipation management 1:
Initial Steps
- Discontinue any non-essential constipating medications 1
- Rule out fecal impaction - especially important if diarrhea accompanies constipation (suggests overflow around impaction) 1
- Rule out mechanical obstruction via physical exam and abdominal x-ray 1
- Increase fluid intake and encourage physical activity when appropriate 1
Pharmacologic Management Algorithm
First-line: Stimulant laxative
- Bisacodyl 10-15 mg daily to three times daily with goal of 1 non-forced bowel movement every 1-2 days 1
- May combine with stool softener (senna ± docusate 2-3 tablets twice to three times daily), though evidence suggests docusate addition may not be necessary 1
If constipation persists, add osmotic agents:
- Polyethylene glycol (1 capful in 8 oz water twice daily) 1
- Lactulose 30-60 mL twice to four times daily 1
- Magnesium hydroxide 30-60 mL daily to twice daily 1
- Magnesium citrate 8 oz daily 1
For refractory cases:
- Linaclotide 145 mcg once daily - FDA-approved guanylate cyclase-C agonist that increases intestinal fluid secretion 5, 6
- Bisacodyl suppository (one rectally daily to twice daily) 1
- Consider prokinetic agent like metoclopramide 10-20 mg orally four times daily if gastroparesis suspected 1
Management of Impaction
If fecal impaction is present 1:
- Glycerine suppository ± mineral oil retention enema 1
- Manual disimpaction following pre-medication with analgesic ± anxiolytic 1
- Tap water enema until clear 1
Critical Pitfalls to Avoid
Do not use peripherally-acting μ-opioid receptor antagonists (methylnaltrexone, naloxegol) unless constipation is specifically opioid-induced - these are not indicated for alcohol-related functional constipation 1
Do not rely solely on increased dietary fiber - this requires adequate fluid intake and physical activity, which may be compromised in patients with alcohol use disorder 1
Do not use naltrexone or disulfiram in patients with any evidence of liver disease due to hepatotoxicity risk 1, 4
Do not treat constipation without simultaneously addressing alcohol dependence - the constipation will persist or worsen without treating the underlying cause 1, 4
Monitor for hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus as treatable secondary causes of constipation 1