Painkilling Drugs and Constipation: How to Solve the Dilemma

Down the Rabbit Hole

In Wonderland, Alice drinks from a bottle labeled with the instruction, “Drink me.” When she takes a drink, she shrinks to less than one foot tall. Later she finds a cake with the words “Eat me,” spelled out in currants. When she eats the cake, she grows to a height of more than nine feet.

You have to wonder if the bizarre details of Lewis Carroll’s story might be based on personal experience. During Carroll’s day, the standard painkiller was laudanum, a tincture of opium. And opiate painkillers often prompt the side effect of constipation, which would require another treatment, which would prompt another side effect, and another treatment, and another side effect and so on, down the rabbit hole.

Things haven’t changed much in the 143 years since Alice’s adventures were first published.

I recently came across details about an upcoming clinical study of constipation caused by opiate-based pain medications. I wouldn’t judge anyone who carefully uses a drug to relieve pain that’s truly chronic. But before adding more drugs to counteract the side effects of painkillers you should know that there are some very effective, non-drug treatments that safely alleviate constipation and other bowel dysfunctions.

Silly wabbit

The new study is called OPAL (Opioid-Induced Bowel Dysfunction Pivotal Assessment of Lubiprostone). See, it’s not really a constipation study, it’s a drug study that will assess lubiprostone – a drug that increases intestinal fluid and relieves constipation. Primary side effects include diarrhea (who saw THAT coming?), nausea, abdominal pain, and sinusitis.

Sinusitis? Your doctor might prescribe an antibiotic for that, along with a common over- the-counter drug to control mucus. And while you’re at it, you might want to take some Imodium for the diarrhea. And so on, down the rabbit hole.

When I asked HSI Panelist Allan Spreen, M.D., for an alternative to the madness of lining a medicine cabinet with drugs to treat painkiller side effects, he said he would start with probiotics, “due to my conviction that the painkillers disrupt normal gut flora. Such a start should always be accompanied by prebiotics (FOS, or Fructo-Oligo-Saccharides) to assure the bugs set up well.

“However, I doubt that alone will be enough (though others I’ve read think so). After that challenge I’d add both soluble and insoluble fiber (Benefiber is the most common of the former, psyllium is the most common of the latter), along with plenty of good water.

“At some point, bowel tolerance vitamin C probably should be done as a clean-out, but it really can take a lot (4-8 grams/hour, in some cases), and I don’t think I’d use that as a standard ‘loosen-upper’.

“‘Pain-killer constipation’ – don’t we have a sorry state of affairs! Except for the morphine-induced type for terminal patients it sure shouldn’t be common enough for a big study. Wellunless you wanted to sell more drugs.”

Gut check

A number of previous e-Alerts have featured the importance of probiotic organisms.

In a healthy individual, these beneficial bacteria inhabit the digestive tract in huge numbers, balancing out harmful bacteria, aiding digestion, and supporting immune function. This healthy gut flora can usually be maintained with sufficient dietary sources such as yogurt and kefir (only products that contain “living cultures”), and lignans (such as flaxseed), carrots, spinach, cauliflower, broccoli, millet, and buckwheat.

But the gut flora ecosystem can be easily disrupted by poor nutrition, stress, surgery, parasitic infestation, and drugs – including painkillers. This opens the door for the proliferation of harmful bacteria, which prompts bowel dysfunction.

The digestive tract can be recolonized by introducing enough good bacteria to overpower bad bacteria, but dietary sources alone can’t provide organisms in the vast numbers required to correct an imbalance. That job usually requires a high-potency probiotic nutritional supplement. You can find detailed information about two HSI-recommended probiotic products in the e-Alert “Send in the Pro” (8/17/06).

A PREbiotic is a carbohydrate that nourishes the growth and activity of probiotics. FOS comes from inulin, a fiber carbohydrate, and can be found in dietary supplement stores and through various sources online.

Dr. Spreen also recommends that aloe juice be taken with probiotics. Aloe has a long history of calming bowel problems.