Hi Everyone, For a chance, you'll understand why I haven't explicitly sourced some stuff! I've been looking through the scattered information on constipation due to opiate use, and haven't found a single place where resources are available. Thus I thought I'd start a thread where people could put in the methods and products that have helped them over time. Kailey_Elise has put some useful info into other threads, but which might be a bit hard to find for the casual user. I'm hoping she'll contribute here! So I'll start with products and options that are available in Australia and I believe sold internationally. I'll add US/UK brands as they come up. This topic may be a bit explicit, but constipation is a minor thing, fecal impaction a major thing, and fecal incontinence is a MASSIVE thing. Remember that one leads to the next if not fixed soon enough. Whether you want to hear this or not, you should be going to the loo every day. That's healthy bowel movements. Every second day is okay too, for a while. Every third day means you're backing up. If it's uncomfortable or physically hurts to go, seek some medical advice. While it's usually just that you've packed more excrement into a smaller space (packing), and it's pushing on a rectal nerve, it could be triggered by something else. So, starting off with the 'normal' routes: Water Stay hydrated. Drink at least 2 litres of water a day in any form you like, except for caffeinated forms. Caffeine Caffeine in large quantities dehydrates. For americans, we're talking about one large mug of drip filter normally being enough to dehydrate your bowel. A couple of shots of espresso in the morning won't do much harm however, especially if taken before your opiates, and may even help. Fibre This means stuff like Brown Bread, Bran Flakes, etc. Wheat bran, Oatmeal and oat bran. Changing fro 'white' to 'brown' for rice and bread is a great way to easily boost your fibre consumption. Veggies that are good include: artichoke, green peas, kidney beans, broccoli, spinach, carrots and pinto beans. Corn is also good, while stuff like tomatos, celery and eggplant are low in fibre. Fruits that are particularly high in fibre are pears, apricots, apples (with peel), dried prunes (eew), blackberries and raspberries. If you're not on opiates, your recommended daily intake of fibre is about 30g for a male and 25g for a female. Use this as the starting point of your fibre increases. Indian Veggie Curry Usually high in fibre, high in oils (greasers) and easily digested, this can be one of the more pleasant ways to go, depending on the amount of un-digested chilli & chilli powder involved. Concentrate on the curry itself, go low on rice, and you may be exploding nicely by morning. -------------------------- Products -------------------------- Hydrolyte, Gatorade, Powerade, dilute Apple Juice Well well, boys and girls. 1/4 apple juice to 3/4 water will give you the same effect as all these expensive hydrating energy drinks. If you have a taste for any of them, spend up and drink up. They're all hydrating. Unfortunately, they're very good at hydrating most of you, but there is a limit on how much they hydrate your gut. Hydrolyte is just a branded orange flavour electrolyte powder, but these electrolytes, you want them,and lots of them. remember, if your urine is yellow, you either have way too much sugar in you, or are dehydrated. It should be clear. That's a lot of hydrating to do! This is a good first step, but you're probably past this point already. So while you can start drinking this stuff for good gut health, you're more likely to need... Coloxyll with Senna This comes in a little white pill bottle with a red/dark magenta label. It's also available in versions with a green label and brown label. You want the standard one unless a doctor has advised otherwise. This is a combined stool softener and laxative, and quite effective. It does take a day or so to build up to full dose (eg. there's still some in your system after 24 hours) If you're finding you're having trouble, normal dose is 1-2, in the evening, however if you're having an 'episode' you're safe for a few weeks on 4. my doctor said I could push up to 6 for a couple of days if he had to. They contain 50mg of docusate sodium and 8mg of total sennosides (calculated as sennoside B). With coloxyll, it starts working where you last ate, and works it's way down. If it can't work all the way down because you're too hardened, you may need to increase the potency of the thing you're working with, or work from the other end. Metamucil and other fibre supplements This is pretty much just a way of softening your stool. If you're going this route, you need to be taking it every day, and either mixing it into food/drink as a powder, or taking it as a capsule (gelatin covered). Metamucil is just psyllium husk. It expands very rapidly in the gut (actually, in contact with water) and is light, voluminous and easily passed because of this. It's not much use if you have impaction when you have impaction but I know a few people who use this. Personally, I'd find it embarrassing to have a big bottle of this on display, as it's usually considered a 'food supplement' and people add it to meals - I don't want to make someone else's gut fluffy when I cook for them. I think gut products are better left in the bathroom cupboard or hidden away in the bedroom. Maybe I've got modesty issues. When using as a fibre supplement: Adults - Take one serving in 250ml of liquid for Powders or Capsules, 1-3 times daily. Product Serving Size/Dose (1 spoon = 5ml medicinal measuring spoons) Capsules - 6 Capsules Granular - 2 spoons Smooth - 1 1/2 spoons This works out quite expensive in terms of amount needed and is more often used to maintain digestive balance (eg. avoid both diarrhoea and constipation) rather than to 'fix bowel issues' as they come up. I'd think of this as the least effective option here, but the gentlest. Lactulose Lactulose is a synthetic, non-digestible sugar, essentially used as a 'gut greaser'. It tastes horrible, but unless for some odd reason you're galactose intolerant, it's safe to use on anyone. It should be taken in the morning, and takes 24-48 hours to start working on most people. Dosage should be slowly titrated upwards until you have a daily bowel movement, and onset is then usually 4 hours after you take it (eg. around noon for most people). It works by increasing the water content and volume of the stools in the gut, making them softer and easier to pass. A downside to this is that you may feel bloated as your stool expands in your bowel. As lactulose is broken down by the bacteria in the gut, this makes to the contents of the gut more acidic because the lactulose breakdown releases carboxylic acids among its metabolites, which are not absorbed from the lower bowel. That causes water to be retained in the lower bowel, increasing the amount of water in the stools, softening them and making them easier to pass. Unfortunately, the breakdown of lactulose is a fermentation process, so it produces GAS (and flatulence). This is meant to happen, so you can fart while you're pushing and really expel that stool! The added volume of gas and flatulence caused by fermentation of the lactulose adds to the volume of the fecal material, and makes it easier to expel. The lactulose makes the colon slightly acidic, which causes something called a peristaltic wave. This is the rippling contracting effect in your gut that pushes food out. That lactulose does all of these things very effectively makes it difficult to pass up as a solid defence against constipation. Be careful with doseages though - the first time you use this, you'll likely take enough that you're exploding like you've set up an anal fireworks display. With this stuff, if you feel the need to go, go! Microlax The problem with lactulose (apart from getting dose right), is that if you're backed up because of opiates, you're usually packed up - hard-packed. This is a bit of an issue. Microlax comes in a pack containing 4 tubles with 5ml of stuff in, each. Each tube contains sodium citrate (450mg), sodium lauryl sulfoacetate (45mg) and 3.125g sorbitol, and is filled out with glycerol, sorbic acid and water. It's in a little pipetted with a cap on it, and is inserted rectally. That's why I've put this little baby last. Devastatingly effective, you twist and pull the seal off the nozzle, and squeeze a drop onto the tip to lube up the microlax nozzle for insertion. Assuming you're over 16, insert the nozzle all the way into your rectum and check it's in as comfortable a place as possible. Then squeeze the shoulder (widest/biggest) part of the tube as hard as you can (may take a couple of goes if you're bricking it) and you'll start to feel very uncomfortable in your back passage. Ignore that feeling of discomfort for a minute, and, keeping the shoulders of the tube squeezed tightly, withdraw the nozzle and wrap it up in tissue then bin it. After 5-15 minutes (the pack says less than half an hour), you'll need to go. If it hasn't worked after 30 minutes, repeat with a second tube. Gentle Note: Unless you're french or have a few kinks, the idea of stuffing anything up your butt probably doesn't appeal to you. Get over yourself right here, right now. Backing up for 3 days or more can cause bowel necrosis, can start ruining your peristatlic reflexes (so you can't move stool down your bowel) and lead to you needing a colostomy bag. Draining your bowel out of a button into a bag is not somewhere you want to end up! If not for you, for your future sexual partner's sake. There's almost always a certain smell involved, and you don't want to be this person if you can avoid it. Head straight for the toilet. Do not pass go, stop to stroke your cat, get your iPod, whatever. Do not even stop to collect the £200 that someone at your doorstep is offering you before you head down to Old Kent Road. Just Go! You've just substituted the embarrassing nightmare of constipation for the embarrassing nightmare of "I can't stop going". Complications Verapamil. If for any reason you're on this drug, go straight to senna. Take 1 senna tablet for every 120mg of this drug. While opiates are universally constipatory, verapamil is known by doctors as "the universal constipator" Iron is constipatory. Avoid iron supplements if you don't need them. Antacids containing aluminium are also constipating Anticholinergic drugs such as anti-spasmodics, tricyclic antidepressants etc may also increase the effects of constipation. If you're taking any of these when you start taking opiates, you may need to take more than the dose specified above. Laxatives (lactulose) is actually addictive for some people, so try to have some time off the laxatives now and again, even if you're a chronic pain patient on both verapamil and a high dose of opiates. You don't want bowel motility to be affected by over-reliance on drugs. Fecal impaction. After constipation (not being able to pass feces) comes fecal impaction. That's what i've been referring to as "hard-pack". It's when your stool stops queuing up in your bowel, and starts pushing to get past, but doesn't have anywhere to go. That's bad. If not treated with stuff like Microlax, it can lead to fecal incontinence, where the muscles of the anus relax enough to let feces through, and don't have the tone to close again. This affects 15% of elderly hospitalised patients, according to the Textbook of Clinical Pharmacy. To quote further from the book: . Last but not least...manual de-impaction. If you're experiencing impaction, this is actually a serious medical condition. Thankfully, you can do something about it. Skip this if you don't want the gory details. Grab a latex glove (assuming you're not happy going bare) and put it onto your dominant hand. If you've got a bit of microlax, apply it to the tip of the finger, and slide into the rectum. Like in other activities involving the rectum, you want to pause, just touching, wait for the rectum to relax, and then push in a bit. As it tenses, stop. Repeat until your digit is fully in - you'll be angling past the first blocked bit and want to keep your fingernails facing the floor, to go in 'round the back'. Bend your finger into the impacted stool at the knuckle to grab with the first and second joint, and pull down towards your anus. Your rectum will probably tense at this point - just wait for it to relax, and pull the feces out. Do a bit at a time, and return your finger to the 'neutral' position. Then repeat. There's no need to grab massive blocks - it'll just hurt. Take your time, push with your gut muscles to move fecal matter down (after all, it's only stuck at the end) and keep going til you get to softer stuff or have nothing more to push. At this point, it's worth using a microlax if you haven't already, to prepare the way for the next thing you ate, and take some lactulose or coloxyll. It's better to be over-greased right now than find your finger up your ass again (at least, I think it is). Conclusion At this point, you'll remember what got you into this, head for the coloxyll with senna and make sure that you get towards a regular time to go. You're probably grossed out, but if you save yourself the embarrassment of a hospital trip, you're probably pretty happy. And if you're too embarrassed to ask for these products at your friendly neighbourhood pharmacist, remember the reason they sell them is because lots of people buy them because they need them. They're not gonna look at you and go "hahaha he's constipated". They don't want that mental image, for a start. Just man (or woman) up and go.... ... or do what I did, and send your partner! I'm happy to edit this to add any methods I've missed - I can think of at least a few. You're not alone - 90% of people who take strong opiates experience constipation as a side effect. Hopefully I've not missed a random topic or sticky with all this info in already.