Managing Constipation; Relistor

Buprenorphine Post
Posts: 187

Postby Dave » Mon May 09, 2016 9:12 am

I've heard about the squatting position before, but I don't see the difference between that and sitting on the toilet while bending forward as far as the thighs will allow.

Posts: 90

Postby rickbennettmd » Mon May 09, 2016 9:12 am

re opiates and constipation:

Mattkeene's post regarding local drug interaction with gut opiate receptors is interesting. I will note that opiates exert a very strong constipating effect SYSTEMICALLY, as well, of course. Parenteral narcotics constipate also.

I have studied the constipation issue to an extent that is satisfactory for me. In fact, I now consider myself somewhat of a opiate induced constipation expert and proselyte. I think the people in my office probably agree with that.

To begin, I believe I have seen a 40% incidence quoted in some specified context or another.

I have observed that some patients are much more constipated by their abuse opiates prior to Suboxone therapy, and the reverse is true for others.

A quick question about constipation is one of the four routine questions I use every visit: craving, sleep, constipation, and sexual function (males.)

I also have a shelf in my office displaying the preferred products which address this problem. Both brand name and generics are displayed. I invariably recommend generic preparations from discount suppliers, typically Wal-mart. Patients are much more likely to follow up on my recommendations if they are introduced concretely to the products, I find.

Contents of the shelf are as bellow:

1) ** Metamucil -- psylliium. This is the fundamental fiber that I recommend to EVERYONE on a daily basis, not to opiate patients uniquely. It is the standard fiber supplement that enables****urance that we obtain the daily minimum of 28 grams of fiber daily. This is fundamental to colon, rectal, and anal health. Psyllium is a INSOLUBLE fiber. At present it is the sole fiber that has been demonstrated to lower LDL (the undesirable) cholesterol.

I should note that this fiber therapy should not be begun in the current presence of constipation. Mixing the fiber in milk or some other prefered drink may make these products more palatable. I tell patients to start with the container's recommended dose, but this can be easily exceeded for more fiber benefit. The products produce loose stool at excess doses.

2) Benefiber -- dextrin, and Citrucil -- methylcellulose. These preparations provide SOLUBLE fiber. Daily consumption of BOTH types of fiber is the standard general health recommendation. I have not been able to locate a reference to comparative bowel movement efficacy of the two fibers, but My predjudice is that the insoluble fiber may be somewhat superior in this respect. However the soluble fiber preparations are far easier to take.

3) Colace -- docusate. By no means essential, but this standard stool softner is appreciated by many patients.

3 1/2) Fiber Gummies! Thank you mattkeene for that one. I checked them out, and they look like excellent supplements. Very convenient, and palatable. Administration hassles are a hindrance to supplemental fiber intake. The gummies contain soluble fiber. 4 to 5 grams per piece is a lot of fiber. Two or three brands are going to The Shelf.

4) Miralax -- polyethylene glycol. This osmotic laxative is the most benign laxative if such a medication is needed often or on a chronic basis.

5) Fleets enema. The last effort prior to digital deimpaction in the ER.

Attention to proper hydration is helpful. Also, note that prunes are one of the most nutritionally beneficial fruits. Prune juice, of course, is the old traditional tonic.

The MOST FUNDAMENTAL recommendation is an extremely important one, but it is very, very often neglected.

That is, in difficult defecation the physiologically designed SQUATTING POSITION is mechanically far superior to the contrived "seated" posture that is now used universally. The prof taught us this our first year at KU Med in 1975, and I think it may still be true. Patients invariably find this practice helpful and thank me often for this advice.

Formal Protocol: I suggest to patients that they take paper towels and a plastic shopping sack to the restroom. Aim, defecate on the paper strategically positioned on the floor, wrap it up and tie it, and straight to the outside trash bin.

I will note that I have one patient who built a step for his feet to position at the toilet for his anticipated chronic use. He likes it.


Posts: 187

Postby Dave » Mon May 09, 2016 9:12 am

I have not used methylnaltrexone, but I have used Amitiza (lubiprostone) in one patient, who said he had tried everything else without success. He was afraid to try methylnaltrexone because of the possibility of withdrawal. Amitiza worked well for him.

Posts: 111

Postby fishdoc » Mon May 09, 2016 9:12 am

Not approved by insurance companies in 4-5 patients. One patient paid cash for it and had good response.

Posts: 32

Postby mattkeene » Mon May 09, 2016 9:12 am

No, I have not. The key to minimizing constipation with buprenorphine is to minimize the amount of bup that is "swallowed" vs absorbed. Once buprenorphine hits the gut, it is converted into norbuprenorphine which acts as a full mu agonist to the enteric nervous system...leading to constipation. I have found three things that seem to help.

1. If patients are taking any of the sublingual versions of buprenorphine, have them swallow as little as possible. And at the end of the dosing experience, when nothing is left but nasty saliva...spit that saliva out, as anything you swallow will only offer side effects but no benefit.

2. When insurance permits, I almost always use Bunavail. The buccal absorption leads to 50% less norbuprenorphine levels and thus much less constipation. It is also less likely to be diverted, which certainly is important in this population.

3. Gummy Fiber. The sell gummy fiber at Costco and Walmart. Little squares that contain 5G of fiber and taste just like a gummy bear. As silly as this sounds, it truly helps folks on buprenorphine poop. It is an inexpensive and effective solution.

Posts: 35

Postby compchat57 » Mon May 09, 2016 9:12 am

Relistor is an injectable which is used by surgeons for post op ileus.

Try Amatiza or linzess. Movantik is new and works in a similar fashion to resistor but is oral inject of injectable.

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