How is opioid-induced constipation managed?

• A. Stool softener
• B. Stool softener plus stimulant laxative
• C. Diet high fiber only
• D. Enemas

Answer: (B)

Opioids slow bowel movements by activating μ receptors in the gut, which reduces peristalsis and causes more water to be absorbed from stool, leading to hard, difficult-to-pass stools. The best initial approach to manage this combines a stool softener with a stimulant laxative. The stool softener (like docusate) helps water and lipids mix into the stool, making it softer and easier to pass. The stimulant laxative (such as senna or bisacodyl) increases intestinal motility and secretions, helping propel the stool forward. Using both addresses both softness and movement, which is usually needed because opioids blunt propulsion and can make stools hard even if you only use one type of laxative.

Dietary fiber or a high-fiber diet alone isn’t enough here because the opioid-induced slowdown overrides the benefits of fiber. Enemas are more of a rescue or escalation option for severe constipation or impaction, not first-line therapy for opioid-induced constipation. If constipation persists despite this regimen, additional options like peripherally acting μ-opioid receptor antagonists can be considered to block opioid effects in the gut without reversing pain relief.