Chronic pain is a widespread problem in the United States, affecting many Americans’ physical and mental health, work performance, and quality of life. When over-the-counter pain relievers like ibuprofen and acetaminophen don’t do the trick, physicians often turn to prescribing opioid analgesics, also known as narcotics, to ease pain. Opioids were once reserved for short-term pain and cancer-related pain, but in the 1990s, a variety of long-acting opioids came to the market, leading to a dramatic increase in the long-term use of opioids for chronic, non-cancer related pain. While opioids provide needed relief to those suffering from chronic pain, they’re not a magic fix. These drugs come with a long list of side effects, as well as the risk of addiction and overdose. Common side effects, like nausea, mental cloudiness, drowsiness and dizziness tend to go away with time. Unfortunately, the most common side effect, constipation, stays with patients for the duration of the treatment period. This frustrating issue can be so intolerable that patients would rather stop taking opioids than live with constipation. My heart goes out to these patients, as I don’t want them to live in pain or have to deal with gastrointestinal (GI) problems. When patients ask me about opioid-induced constipation (OIC), I emphasize that there are treatment options available so they can get relief from pain while also easing OIC. Causes of Opioid-Induced Constipation Opioids work by attaching to and activating small proteins called receptors. Opioid receptors are present throughout many locations in the body. Which receptors are activated determines what effect the opioids will have. For example, activation of opioid receptors in the spinal cord produces pain relief. Activation of the receptors deep inside the brain can create feelings of pleasure (which is one of the reasons people can become addicted to opioids). And activation of the receptors in the GI tract impairs the function of the entire digestive system, causing bloating, abdominal discomfort, reflux, loss of appetite, nausea, vomiting, and constipation. Constipation is the most common GI complaint and affects up to 47% of patients on opioids. However, that number may be greater, as not all patients disclose the issue with their doctors. It’s so common, in fact, that I recommend beginning a preventive bowel regimen when starting opioid therapy. Preventing and Treating Opioid-Induced Constipation The initial bowel regimen may include increased fluid intake, increased dietary fiber or fiber supplements, stool softeners, and laxatives. Adding exercise to your routine can help, as well as reserving adequate time and privacy for bowel movements. If the preventive regimen isn’t effective, I recommend different treatment options to my patients: Laxatives There are several types of laxatives available—bulk-forming laxatives, osmotic laxatives, and stimulant laxatives. Bulk forming laxatives include natural fiber and commercial fiber preparations like psyllium (Metamucil), methylcellulose (Citrucel), calcium polycarbophil (Fiber-Lax), and wheat dextrin (Benefiber). Some experts believe these laxatives are not as beneficial for treating OIC, because of the way they work, but the recent recommendations from leaders in pain medicine have included them in their treatment plan. It’s very important that patients taking these laxatives stay well hydrated and combine this therapy with exercise and dietary changes. Osmotic laxatives are essentially sugars that the body doesn’t absorb—they stay inside the gut and increase the amount of water in the gut, relieving constipation. One osmotic laxative, polyethylene glycol (MiraLax, Glycolax), is generally preferred since it doesn’t cause gas or bloating and is available without a prescription in the U.S. Two osmotic laxatives, lactulose and sorbitol, can be prescribed by your doctor and may produce gas or bloating. Stimulant laxatives like bisacodyl (Correctol, Dulcolax), senna (Ex-Lax, Senokot), and sodium picosulfate (Dulcolax Pico) increase the movement in your intestines, combatting constipation. They may cause abdominal pain, and prolonged daily use can lead to low potassium levels and salt overload, so these drugs should be used with caution if taken long-term. Prescription Medications Researchers have developed a variety of medications specifically to ease constipation and counteract the effects of opioids on the gut. If you don’t respond to other therapies, ask your doctor about a prescription option. One new drug, lubiprostone (Amitiza) acts to increase fluid secretion in the gut, which alleviates constipation. Linaclotide (Linzess) is another prescription medication approved for the treatment of chronic constipation if you don’t respond to other treatments. A new class of drugs, called peripherally selective opioid antagonists, is specifically designed to treat OIC. These medications reverse the effects of opioids on the receptors in the gut without impacting pain relief. Currently, two of these medications are available: naloxegol (Movantik) and methylnaltrexone (Relistor). Switching Pain Medications Not all opioid formulations affect patients the same, so it might be worth trying a new opioid to see if side effects are reduced. Patients may also benefit from a new medication, called Targinact, which is a combination of oxycodone (an opioid) and naloxone (an opioid antagonist). This drug provides pain relief while also protecting the opioid receptors in the gut, so it’s much less likely to cause OIC. You may also want to try lowering your dose of opioids or only taking them intermittently when you experience pain. OIC is more likely in patients with higher doses and longer durations of opioid therapy. The First Step: Talk to Your Doctor A big challenge of treating OIC is patients are sometimes reluctant to tell doctors they’re having these problems. I always advise my patients to talk to me if they’re experiencing constipation, because there are treatment options out there that can improve quality of life without hampering pain relief.