Just a query on behalf of a colleague......
Some clients develop severe constipation on opiate substitutes. One of our clients has recently had 2 episodes on the surgical wards, having gone to theatre twice for evacuation under anaesthetic. She is only 18, undernourished, poor home conditions, has been on methadone but now on subutex lowish dose and still has symptoms. Does use heroin on top at present so increasing the dose of Subx seems sensible. I discussed the options with my colleague and we don't think she has any other medical probolems, but obviously all sorts of psychological problems spring to mind. She has been given the usual dietary and fluid advice, softeners, bulking agents, bowel stimulants etc and won't engage with the district nurse for regular micro enemas. Doesn't use psychoactive stimulants regularly ( we wondered about sweating and dehydration ).
Has anyone got further ideas on treatment, or do we gently probe ( if that's the right word ) into the psychological aspects, or wait until she vomits and obstructs .... if that's likely.
Your experience and advice welcome
Many thanks
Gill

I'd say we often forget to ask about bowel habits and it is something that people are embarrassed about.
I try to remember and should stick a note on the front of my pc at work. The district Nurses always tell me to use Movicol as a first line treatment. I guess not everyone has the same access to food that most of us have but maybe some local service does provide some free meals from time to time.
The slight laxative effects of sugar-free methadone is sometimes of use.

I don't have a great deal to add, except that it is as you say a very common problem. As Simon says, I think it is important we remember to ask about it as many patients seem astonished when I tell them this new problem they've got is caused by the methadone. They struggle on for too long before mentionning it.

In this 18 yr old's case it does sound extreme. I can only suggest continue to explain the mechanisms that are causing it, and that movicol or similar must be taken daily for several weeks at least, after a period of severe constipation. I hope she is not taking "build up" type drinks...she clearly needs the old "fresh fruit and vegetables " which many people seem to struggle to get hold of each day.

If she is still using heroin, the subutex option may not be very comfortable..might be better back on methadone. She is very young. Needs of course lots of explanations of what is happenning to her body, and what would help.

Would an admission for a couple of weeks for stabilisation of medication (and encouragement of eating routines) be possible in her area?

There is a Regional Drugs and Therapeutics Centre update on laxatives in palliative care I saw recently which stresses the importance of using daily laxatives and combining different types. Also the use of methylnaltrexone (!) though this is only licensed for palliative care. I think you can find this update, which was March09 on www.nyrdtc.nhs.uk
I was also surprised to read in NICE coeliac guidelines that coeliac disease can present as intractable constipation. Might be worth testing?

Thanks all for your good ideas - i will pass this on to my colleague
Gill