About William J. Walker, Pharm.D. Expertise Homeopathic, alternative, herbal, natural, adverse drug reactions, side effects, risks, outcomes, research, medication, rational therapeutics, infectious diseases, cardiology, pain management, nutrition, psychopharmacology, oncology, pediatrics, sleep disorders, tropical diseases, HIV, drug interactions, substance abuse, illicit drugs of abuse, geriatrics
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Question I am also an expert on this site in the field of orthopedics.
I am currently taking 30mgs of Avinza daily to combat the pain of AVN of the hips and knees. After the initial problems of getting used to the drug, I find that I am extremely constipated and I am taking over the counter Senna vegetable laxative for help (this was approved by my doctor), but it's not helping. I have begun to have problems with hemorrhoids and gas pain.
What can I do to combat the constipation. I have tried prune juice and the senna that colace which is not really helping. The Avinza is perfect for my chronic pain, but the constipation is extremely troubling
Thank you for your time.
Sharon DAvis
Answer One of the most compelling reasons behind the development of sustained release preparations of the potent narcotic agents such as morphine is that they tend to reduce many of the troublesome side effects. They also allow for the use of higher dosages for analgesia without giving rise to huge spikes in peak blood levels. They have provided major improvements in pain management. Patients are able to tolerate much higher dosages than they would if taking an immediate release preparation.
However, of all of the annoying narcotic side effects constipation is the sole problem that neither dissipates with time nor with the use of such release systems. While patients, as well as abusers, rapidly develop a tolerance to these drugs including most of the bothersome side effects constipation is also the one thing that they never get immune to.
You are taking most of the recommended measure already. The advice that I can give you is to maximize all of your treatment options and also to continue doing these things on a regular basis (no pun intended). After you have done all of that then there are at least two other measures that you can take that will work but that are more or less on the aggressive unconventional side of treatment recommendations.
The measures to consider are bulk forming agents daily such as psyllium or fiber. Add to that the maximum dosages of stool softeners. Docusate sodium 500 mg twice daily. With as much water as you can drink. Senna products are very useful. In our pain clinics we also incorporate the use of magnesium citrate solutions whenever constipation exceeds 48 hours. The similar use of milk of magnesia or other available stimulant cathartic can be employed. Bisacodyl for instance. Or even glycerine. We favor the use of Miralax which is a PEG preparation. In more critical situations we have to use enema preparations and mineral oil. Even phospho-soda oral preparations. The point is that we use whatever it takes to get the job done and also attempt to find the right balance of regular product use to fit the needs of each patient. Once you have that determined it stands to reason that you will want to closely monitor this problem and use the regimens regularly. We always condone dietary approaches. Use of Fiber Rich and prune juice for instance.
On the more unconventional side are two other recommendations that we reserve only for this circumstances that are unresponsive to other measures and when the patient in question has been screened as appropriate to the method. Both are based on the same idea. That being that the constipation problem itself is rapidly reversed by simply removing the offending agent. In other words, by skipping a regular dosage or even backing down the dosage in most patients on a chronic regimen is enough to bring about frank diarrhea. Caution must be used though as both diarrhea and constipation can co-exist. Consider a hyperactive bowel that contains a hard and dry stool. It could be problematic if all of the above has not been adequately employed. The other method is similar but utilizes one of the narcotic reversal agents. Such as is present in products such as Talwin-NX. A small oral dosage of naloxone or naltrexone can rapidly reverse the effect of the morphine on the opiate receptor and obviate this problem right away. The problem is that is also reverses the analgesia quite promptly. This can be very disconcerting and should never be tried without full medical supervision of the treating physician. But under the right circumstances it can be useful.
MS-Contin as well as Avinza are excellent choices, perhaps some of the best, for pain management. But in my experience these products cause more severe constipation than almost any other narcotic I have seen used.
