Opioid Analgesics and Constipation
|Mr. Cliver is an 80-year-old newly admitted resident of a nursing facility. He has a history of chronic pain secondary to lumbar degenerative disc disease that has been poorly managed prior to admission with acetaminophen.
Lumbar degenerative disc disease
Coronary artery disease
Medications on admission:
ASA 81 mg
In an attempt to manage his pain better he is started on Vicodin, one tab every 6 hours and every 4 hours as needed for breakthrough pain. He has improved pain control but after 5 days of therapy he becomes confused, agitated, and has fluctuating levels of alertness during the day with day-night reversal in his sleep patterns. The certified nursing assistants (CNA) caring for him have changed daily but one CNA notes that he has not had a bowel movement in 5 days. His oral intake of fluids and solids has been good up to this point.
Findings from Mr. Cliver's examination and evaluation include the following:
General physical examination: Afebrile; oxygen saturation (pulse oximetry) 98%, blood pressure/pulse/respiration normal
Abdominal examination: Normal
Rectal examination: Hard stool in ampulla
Neurological examination: Consistent with delirium, no focal findings
Lab results: Complete metabolic panel, urinalysis, and complete blood count normal
X-Ray: Flat plate; large stool mass in rectum; otherwise negative
The working diagnosis is delirium secondary to fecal impaction. He is manually disimpacted and started on senna 2 tabs daily, lactulose 15cc daily, and has a lidocaine patch (5%) applied to his lumbar spine daily. His delirium clears, his bowel movements become regular, and he is able to minimize the as-needed use of Vicodin.
The old adage that "the same hand the writes the narcotic analgesic should write the constipation prophylactic regime" was not applied in this case. Although the narcotic itself may have contributed to the delirium, it was most likely due primarily to the fecal impaction. About 40% of long-term care residents on long-term opioids develop constipation. Fiber and fluids are usually ineffective in prophylaxis. It is generally best to:
Initiate laxatives prophylactically:
- Use regular doses of stimulant laxatives (senna) and a stool softener in combination with lactulose or sorbitol, as indicated
If no bowel movement occurs in 2-3 days:
- Milk of Magnesia, a bisacodyl suppository, or enema can be used
- Decrease opioids and other drugs that affect bowel motility when possible
Opioids provide pain relief by specifically interacting with mu-opioid receptors within the central nervous system (CNS)--the brain and spinal cord. However, opioids also interact with mu-opioid receptors found outside the CNS, such as those within the gastrointestinal tract, resulting in constipation due to delayed gastric emptying, delayed stool transit, and decreased peristalsis. Mu-receptor antagonists, such as methylnaltrexone, selectively displace opioids from the mu-opioid receptors outside the CNS, including those located in the gastrointestinal tract, thereby decreasing their constipating effects. These drugs do not readily cross the blood-brain barrier thus opioid-mediated analgesic effects on the CNS are not affected by their use.
Case contributed by:
Mario Cornacchione, DO, CMD, FAAFP
Geriatric Research & Consulting Group
Northeastern PA Memory & Alzheimer's Center
Wilkes Barre, PA
Clinical Associate Professor
The Commonwealth Medical College
Clinical Assistant Professor
Institute for Successful Aging
University of Medicine & Dentistry of NJ
School of Osteopathic Medicine
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Pain Management in the Long-Term Care Setting (AMDA Clinical Practice Guideline published 1999, revised 2003)
The E-IMPACCT (Elderly IMProvements & Advances in Chronic Constipation Treatment) educational initiative is sponsored through a collaboration of ASCP, AKH Inc., and Medical Communications Media, Inc.
Supported by an educational grant from Sucampo Pharmaceuticals, Inc. and Takeda Pharmaceuticals North America, Inc.