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ctollar

Distinguished member
Joined
May 17, 2017
Messages
100
Reason
Lost a loved one
Diagnosis
03/2017
Country
US
State
FL
City
North Port
Hi all,

Quick question.... My dad was recently put into hospice and is on the Morphine cocktail. The problem is he is severly constipated from the medicene and the stool softner and laxatives are causing severe stomach cramping as well as "sludge" type bowel movements. He is on Senna for the laxative. Any thoughts on how we can relieve his pain. It is so very awful to watch him in terrible pain.
 
There are 2-3 drugs used for management of opioid-induced constipation. These include Movantik (Naloxegol) and Relistor (Methylnaltrexone). They are not cheap. It’s important to continue with stool softeners and lots of fluids. Discuss with your doctor or hospice team as they likely have a protocol for managing this common problem.
 
I am on opioid meds for pancreatic and gastric nerve pain. For slow bowel evacuations, I take Domperidone, Resotran which need prescription for, and take OTC Senna, Laxaday(Restoralax) and 30 ml of Lactulose when needed, if things get really sluggish.
 
I would also ensure that hospice re-evaluates the "cocktail." Even at the end of life, PALS do not necessarily require large morphine doses to manage air hunger; not knowing the dosages prescribed, some hospices, for example, are more familiar with the pain relief requirements of terminal cancer patients as their guide for morphine administration. And there are many interventions besides opiates that can bring comfort, from music to massage -- it is a total package.
 
The hospice nurse came in and gave him an enema, finger probe, and as a last result a suppository. He is on stool softners and I just don't get it. Why all the problems even with them??
 
Lactulose is a wonderful drug for med-induced constipation. Just make sure to take LOTS of water with it.

Some folks on morphine are going to have a tough time even with a good bowel program. With ALS, the problem is also going to be exacerbated by generalized immobility and inability to “bear down”.
 
I'm writing down everything Karen and Laurie posts. Ever since I started Remeron in 2003, I've had constipation. When I was running and drinking lots of water, it was managed without meds. Now that I'm not as active it is managed with psyllium which, I know is only temporary. I'll have to find the right combo that won't throw me into SVT. Thank you both for the info.

I developed hemorrhoids from Oxy and even though I'm off it they didn't go away. I'm getting them banned after the holidays because I don't want to be in bed with a burning butt.

Laurie, your suggestion of other things that help pain and promote relaxation is a wonderful reminder.
 
So the saga continues. He has been able to go but it is sludgy.... Still in a lot of pain. I hate seeing him go through this.
 
When you say sludgy, do you mean pudding consistency that is hard to pass or something else. Does it seem like he is passing a normal amount? You can have blockages even with diarrhea. Could his pain be gas or some form of stomach irritation besides constipation? I really empathize because I've had bowel issues and it makes life miserable so I can't imagine how miserable it must be when confined to a bed 12/7.
 
It is sludgy like pudding. He says that he feels like he has to keep going. The nurse will be by today to check on him again. The pain is irritation from trying to poop so much. More like burning at the site with additional stomach cramping right before he tries. Honestly, he has had so many different medications I would be suprised if there is anything left. To top it off he is down to 2-3 feeds a day...
 
My guess is that he has painful internal hemorrhoids. Try putting a Preparation H suppository in him. They usually can relieve the burning in a short time. I had burning so badly I thought I would have to go to the emergency room. I put one in and another in about 45 minutes later. They help shrink the irritated tissue. It worked. It can't hurt to try.

I'm so sorry he and you are going through this.
 
While hemorrhoids certainly are possible, he could also have areas of pressure sores in the perianal area causing localized burning pain. Before giving something like Preparation H, have the hospice nurse (or doctor) carefully inspect the area for signs of skin breakdown.

Another issue with morphine is some patients get what’s called a paralytic ileus, which is a fancy way of saying the gut just isn’t moving. This can cause a bowel obstruction. Sometimes sludge or diarrhea can leak out past the blockage. Diarrhea can also exacerbate skin breakdown around the angus. He really does need a good exam.
 
The hospice nurse came in and gave him an enema, finger probe, and as a last result a suppository. He is on stool softners and I just don't get it. Why all the problems even with them??

I hope she was gentle with the enema because that could cause a tear in thin or already irritated skin. My housemate got a small tear from a routine rectal exam at a gastro's office.
 
I have had problems with a paralytic ileus several times since Feb 2017, since getting my Peg put in. I have to take opioid meds for pain (non ALS related) and they can really mess up bowel motility. If you have access to a stethoscope, or have a nurse listen for bowel sounds in four areas of the mid lower to lower abdomen. If the sounds are absent, I would suggest you ask your medical practioner to see about a scan or xray of the abdomen to see if an ileus or a blockage is present. For me, to keep things regular, in addition to the prescribed motility meds, I take restoralax x1 daily, senna (when needed) if my poop gets hardened, and LACTULOSE 30ML (when needed) if things get really sluggish. I take in lots of water, 1.5 litres per day to keep things regular. I only take senna and Lactulose if I go 2.5 or more days without bowel evacuations.
 
One of members, Diane Huberty, has a very informative website alsfrombothsides.org. Her section called " Toilet Troubles" was very helpful to us when my PALS was having a lot of constipation problems.
 
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