Constipation Case: What Would You Do?

Constipated?

I am looking for some feedback here.  How would you manage this case?

A patient in her early 30s states that she has taken a Dulcolax tablet daily for over ten years.  She states she spent most of that time in correctional facilities but never had any problem receiving an order for daily Dulcolax.  She was out of jail for a time and continued to take OTC Dulcolax.  She reports no abdominal work ups.  Her only surgery was an appendectomy.  Her only other medical problem is episodic asthma.  Her physical exam is normal.

She now has arrived at one of my jails and wants me to continue her daily Dulcolax prescription.  Should I?  Here is my thought process:

My problem with this is that this is not optimal medical care.  I’m sure that she is having problems with having a BM since her Dulcolax stopped–Dulcolax is habituating.  But is the answer to continue to give her Dulcolax every day for the rest of her life?

If I prescribe the Dulcolax, will she really never ever have a bowel problem again?  I doubt this.  My sense is that those who take chronic laxatives have more ongoing bowel complaints, not fewer.  Those of us not habituated to Dulcolax experience occasional constipation issues–from not eating enough fiber to getting sick and having transient gut slowing.  Taking daily Dulcolax will not change this–those habituated to laxatives  need the laxative to be at “baseline,” but still will have normal bowel fluctuations like the rest of us.  In fact, my sense is that these fluctuations are more severe in those taking chronic laxatives–or, at least, they complain about them more.

Plus, this is a young patient.  My wife’s grandmother used to purchase Milk of Magnesia by the case (no exaggeration!) but she was in her 90s.  I would think twice about withdrawing chronic laxatives from a 90-year-old–is that really in her best interest?  But in a healthy young woman?  The best medical care I can provide to her would be to return her to normal bowel health.

Also, there is the Principle of Fairness to consider.  If I prescribe Dulcolax to this patient based on her verbal history of constipation, I should fairly prescribe it to any inmate who states that he or she is constipated and wants Dulcolax.  I guarantee that would be popular!  I would get lots of requests!

In the end, I finally decided not to continue the ongoing Dulcolax prescription.  However, I recognize that those with longstanding dependence on laxatives will have problems adjusting and will benefit from short-term use of a different laxative agent, preferably from a different class.  My choice is polyethylene glycol (Miralax).  My plan is to make this available to her for a couple of weeks during the transition phase.

However, obviously other doctors would approach this patient much differently.  What would you do?

Please comment.

 

 

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24 thoughts on “Constipation Case: What Would You Do?

  1. Christina

    I think using miralax during the “transition phase” is a good alternative I think there really wouldnt be much of a reason to continue a stimulant laxitive that would just be making the bowel “lazy” they should also be educated to go when they feel the urge.. Not hold it!!! Exercise, drink more water, keep a chart of glasses you drink… Most people think they drink Tons of water, they don’t!! Mabey try to train the bowel a bit by establishing a time of day to go, like after the first meal of the day. I agree with you…. The word will get around fast and before you know it every inmate will be saying that they have been taking laxitive for years and can’t go without them. I have an example…. Sorry this post is so long. A gentleman come into our jail, came in with about 800 colace pills. Stated he took them 3 times a day for over 4 years. We elected to not give them…. He has been in the jail for several months and only 2 weeks ago asked if he could have them because it wasn’t as easy to go as with the pills. (im not lying….he told me his bm was no longer slippery)….. Ugh seriously!! I’m sure my facial expression confirmed to him that it wasn’t at the top of my priority list!! So I’m guessing hes had a BM within that 2 month time frame….. but sounds like not as comfortable 🙂 I’m sure there are people who won’t do as well and I think miralax sounds like a good plan 🙂 …. There I’m done 🙂

    Reply
  2. Joan

    It has been my experience working in a male population prison for 21years that the request for laxatives has been a cultural event and despite health care teaching they feel they will “clean themselves out” after anal sex. There is one particular culture that always requests laxatives the most. Of course I do realize that stress will cause constipation but I agree that constant use of laxatives will lead to problems down the road.

    Reply
    1. Jeffrey Keller Post author

      Thanks Joan! I work in jails, not prisons, and the contrast is interesting to me. The majority of inappropriate laxative requests I get are from women. As an example, more than once, I have seen multiple women from the same dorm complaining of constipation at the same time only to find out that there is a weight loss competition going on in that dorm.

      Reply
  3. R. Melton

    Do you have educational material that you give to them on this topic. If so could you share. Also is it actually helpful to reduce the multiple complaints?
    Thanks for any info you may have to share.

    Reply
      1. jozett kasyer

        Hello I am new to the jail environment. I was wondering if I could get a copy of the constipation protocol.
        Thanks

        Reply
      2. Natalie McCay

        I am also new to secure environments and would be grateful for a copy of your protocol. Many thanks

        Reply
  4. Trish

    It’s always somewhat ‘comforting’ to read your articles and replies..just nice to know that I am not alone in my thoughts and decisions on how to manage the particular quirks within this challenging population! Any protocols that can be shared would be much appreciated and thank you for your articles and blogs!!
    Trish

    Reply
    1. Jeffrey Keller MD Post author

      Thanks for the comments, Trish! If you are looking for my constipation protocol, it will be headed your way by email soon!

      Reply
  5. Clare

    It certainly sounds to me like you did the right thing – as you say, if you keep taking a laxative like Dulcolax, that becomes the normal level.

    How did the example that you mention resolve itself in the end?

    I’m guessing that she wasn’t that grateful when she found out you weren’t continuing the Dulcolax, or the first few times she tried to have a bowel movement after it was stopped?

    Reply
    1. Jeffrey Keller MD Post author

      The patient mentioned here did very well. We used Miralax as a “bridging medication” while we eliminated her dependance on Dulcolax. She was on no laxatives for several months before she was transferred out.

      Reply
  6. Clare

    Just to add to my earlier reply – I’d be interested to know if anyone agrees with me on this.

    In my experience, one of the most common causes of constipation (especially for those in prison for the first time) is not “real” constipation, but psychological constipation due to an inability to have a bowel movement without the privacy of their toilet back at home (i.e. anxiety about going without privacy, or in a stall with others in adjacent stalls, preventing a successful bowel movement).

    That’s a regular request that I get for laxatives, and I always decline (unless there is a genuine medical issue. If it’s just psychological then I leave them to – as frustrating and uncomfortable as it may be – resolve it themselves).

    Does anyone agree?

    Reply
    1. Jeffrey Keller MD Post author

      HI Clare,

      I agree that “pooping privacy” is an issue for many inmates. Another is thinking that we have to go every day or should be able to go whenever we choose (instead of when our bodies say “It’s time to go!).

      All of these are educational issues. It is my opinion that education is better and more appropriate medical treatment that are prescriptions for stool softeners or laxatives.

      Reply
      1. Clare

        Hi Jeffrey,

        I do wonder if the lack of privacy issue was one of the reasons why the person you mentioned said they needed Dulcolax every day?

        Perhaps she couldn’t “go” in a stall due to anxiety about people being in the adjacent stalls, but with the stronger urge from Dulcolax, the problem gets easier?

        I was still wondering how she reacted when you stopped the repeat prescription? Not happily I would imagine? How did she get on?

        Reply
  7. Martin Safaer

    Could you forward the constipation protocol over as well? In addition, how are you handling inmates who have IBS-C and IBS-D in their medical history? I have many IBS-C who have been prescribed by their doctor Miralax daily in order to conduct their daily bowel evacuation. I would be interested in learning how you handle these requests.

    Reply
  8. Tim M.

    Would you be able to email the constipation protocol as well as any patient education materials you care to share on the subject? I am teaching a class to my patients about common causes and solutions to constipation. Thanks!

    Reply
  9. Mark Anderson

    Hi!
    I’m having the constipation issue in the Jail setting. Could you please send me your protocol?
    Cheers,
    Mark

    Reply

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