Opioids and Laxatives
- July 1, 2015
Clinical guidelines recommend that patients prescribed opioids should be co- prescribed laxatives. However, opioid induced constipation remains a common local and international problem associated with morbidity and mortality occurring in up to 90% of those taking opioids. Within CDHB hospitals from July 2010 to June 2014, 693 out of 827 cases of patients (84%) with constipation coded as an adverse drug reaction were linked to opioids. As a result a study to evaluate the extent of laxative co-prescribing with opioids on hospital discharges at CDHB was recently studied and is reported on here.
Some guidance on opioid-induced constipation is provided in the CDHB Blue Book (see below). There are also departmental constipation guidelines throughout the DHB. These aim to avoid constipation by initiating laxatives at the same time as opioids. They also provide guidance on what to do once constipation, including faecal impaction, has already occurred.
Blue Book (Pain in oncology/palliative care patients)
- Regular stool softeners (e.g. docusate) with stimulants (e.g bisacodyl, senna) or a combination laxative such as docusate and senna should be used routinely when taking opioids
- Macrogol 3350 with electrolytes (Lax-sachets™) requires Special Authority and is recommended for faecal impaction (up to 8 sachets per 24 hours) or can be used as chronic constipation treatment (up to 3 sachets a day)
Note The Blue Book also discussed PinoraxTM which is no longer available.
Regular Opioids=Regular Laxatives
4 easy steps for prevention
|Prescribe||Docusate and senna
(Unless major GI surgery/obstruction-confirm plan with senior staff. Still follow the other 3 steps)
(Do not need to wait until day 3 Bowels Not Open (BNO). Explain to patient why this is important.)
|Monitor||Record bowel motions on the observation chart and number of days BNO in nursing care plan.|
|Act||Ensure action taken by day 3 BNO.
Ensure laxatives are being used.
Adjust dose as needed.
Chart when opioids are initiated
|Docusate & Senna (LaxsolTM)||1-2 tablets twice a day|
|Mineral Oil Enema||1 once a day prn|
|Glycerol Suppositories||3.6 g 1-2 a day prn|
|MicoletteTM Enema||1 prn|
|Macrogol 3350 (Lax-SachetsTM, MovicolTM)||1-2 sachetsup to twice a day|
Note Maximum 8 sachets per day for impaction (Use is restricted by HML: Lactulose must have been tried and rectal preparations considered.)
Opioids and Laxatives Audit
To quantify and describe laxative co-prescribing in patients prescribed opioids on discharge from Christchurch hospitals.
Consecutive patients discharged from Christchurch hospitals over two weeks in 2014 were studied. Discharge summaries and dispensing data were reviewed. Data collected included demographics, opioid/laxative dose/ frequency, other constipating drugs.
Of 1267 patients discharged, 321 were prescribed opioids on discharge. Laxatives were prescribed for 141/321 (44%, 95%-confidence interval 39%-49%). (See Table 1)
Table 1. Opioid and laxative co- prescribing
|Patient (n=321)||Laxative (n=141)||No laxative (n=180)|
|Age (median, range) (yrs)||54 (16-96)||54 (17-96)||53 (16-93)|
|Strong opioids Total||83||43||40|
|Weak opioids Total||238||95||143|
|Other constipating meds||115||56||59|
* at least one strong opioid; 18/21 were in combination with a weak opioid.
Laxatives prescribed are shown below. Docusate and senna (LaxsolTM) was most commonly prescribed (120/321 patients).
- Only 44% of patients prescribed opioids were co-prescribed laxatives on discharge.
- Laxative co-prescribing varied by opioid
- There were significantly lower rates of laxative co-prescribing with tramadol (expected) and oxycodone (unexpected).