What does opioid-induced constipation (OIC) have to do with the Super Bowl?Not much, I would have imagined, but thinking broadly, after the 112 million people who tuned in1 finished laughing, maybe a few hundred thousand viewers might connect the dots.
That’s because, in 2014, an estimated two million people in the United States suffered from substance use disorders related to prescription opioid pain medicines2. And nearly half of those on long-term opioids experience OIC3.
At a recent continuing medical education event, I was surprised to find an entire 90 minute session (plus a non-credit mini-session provided by a pharmaceutical company) devoted to opioid-induced constipation.
Apparently, as a nation, we are such avid users of prescription drugs like oxycodone, hydrocodone and codeine, that we must now be concerned about people blowing out their colons because of severe OIC3. This goes far beyond stool softeners and every-so-often laxative use. Bowel perforation is certainly no laughing matter.
But the topic made me think of the common complaint of garden-variety constipation, and so I polled my colleagues at NIHA for their favorite approaches to constipation.
What You Need for Optimal Bowel Function
Although mundane and unsexy in any conventional medical practice, prevention and treatment of constipation has a number of applications specific to a holistic practice; for example, when attempting to facilitate the adsorption of toxins using activated charcoal, or in the treatment of small intestinal bacterial overgrowth (SIBO) with a botanical like berberine (which can be constipating for some), or when providing support for detoxification using chlorella.
In general, everyone, constipated or not, should have a diet that includes sufficient clean water, fruit and vegetables - organic, at least where necessary - with emphasis on a variety of brightly colored and green leafy veggies and those of the Brassicaceae family, and sources of essential fatty acids, vitamins and minerals (which, if in supplement form, contain a minimum of “inactive ingredients”). Additionally, fermented food is an integral part of the human diet across cultures.
Also important to optimal bowel function is regular, moderately vigorous to vigorous physical activity, which incorporates a balance of aerobics, resistance (working against weight), balance, core, and flexibility work. Sufficient restful sleep, and enough routine to actually get to the bathroom in a timely fashion are both key. Listening to your colon telling you to visit the bathroom shortly after a meal (attending to your gastro-colic reflex) is working with, rather than against, the natural function of your gastrointestinal tract. Effective methods of managing stress are also critical to optimal colon function.
So here, in no particular order, are some of the ways NIHA providers prevent/ treat constipation. Note that more than one approach may be required, depending upon the cause of the constipation and the severity; if you end up with a loose stool with any of these, back off of the dose a bit. The most bothersome side effects are usually gas and bloating. Because constipation can be a symptom of a serious disorder, none of the recommendations should be undertaken to manage a change in bowel habits that persists, without first seeking the recommendation of your healthcare provider.
Help for Constipation
- Vitamin C powder or capsules – buffered or a whole food source, to minimize acidity
- Magnesium citrate or magnesium oxide caps, tabs or powder, divided throughout the day, saving one dose for bedtime. Neither mag citrate nor mag oxide are very absorbable forms of magnesium (remember Milk of Magnesia?), which is what makes them useful for constipation; if you need the magnesium supplementation, magnesium threonate or glycinate may be better choices
- Aloe vera gel
- Optimize probiotics. This is often a trial and error process, but since it is generally preferable to change your probiotic every so often, this approach is almost always harmless. A mix of lactobacillus and bifidobacteria tends to be most helpful for the majority of people, but there is evidence for benefit with specific probiotics, for example - artichoke as a prebiotic, enriched with Lactobacillus paracasei5. We still have a lot to learn in this area.
- Triphala is an herbal approach
- Stool softeners (like docsate sodium, better known as Colace) are an old conventional standby that can be helpful
- Energetically speaking, people may be troubled by constipation when their tendency is to hold on too tightly (to people, things, positions, ideas)
- Increase physical activity (frequency and/ or intensity where there is room for improvement)
- Increase fluids and/ or fiber
- Colon hydrotherapy, with the guidance of an experienced practitioner
By the way, the OIC and the Super Bowl connection is . . . money.
1Pallotta F and Stelter B. Super Bowl 50 audience is third largest in TV history. CNN Money US. Available at http://money.cnn.com/2016/02/08/media/super-bowl-50-ratings/ Accessed February 14, 2016.
2Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Detailed Tables, 2015. Available at http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2014/NSDUH-DetTabs2014.pdf Accessed February 14, 2016.
3Opioid-Induced Constipation. Pain Medicine [serial online]. October 2, 2015;16:S16-S21 6p. Available from: CINAHL with Full Text, Ipswich, MA. Accessed February 15, 2016.
4George J, Ben-Sassi A, Dixon R. Spontaneous haemoperitoneum due to a sigmoid diverticulum. BMJ Case Reports [serial online]. December 5, 2014;2014. Available from: MEDLINE, Ipswich, MA. Accessed February 14, 2016.
5Riezzo G, Orlando A, Russo F, et al. Randomised clinical trial: efficacy of Lactobacillus paracasei-enriched artichokes in the treatment of patients with functional constipation--a double-blind, controlled, crossover study. Alimentary Pharmacology & Therapeutics [serial online]. February 2012;35(4):441-450. Available from: MEDLINE, Ipswich, MA. Accessed February 15, 2016.
Dr. Dawn Cannon, MD, MS, is an integrative physician at National Integrative Health Associates, serving the metropolitan Washington, D.C. area. Her focus is adult primary care and preventive medicine, approached holistically. Her special interests include detoxification for the damaging effects of environmental exposures and toxins, women's health, and a functional medicine approach to finding the root cause of disease.