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Simultaneous Use of Stimulants 
and Opioids

Stimulants should be added to a chronic opioid regimen to maximize pain relief and prevent opioid complications.
Page 2 of 2

Unanswered Questions


The use of stimulants with opioids, while historic, has been a seldom-used procedure in contemporary medicine. 2 Consequently, there are some unknown questions that will require some tincture of time and some observant physicians to provide answers. First, what should the dosage be? Given the plethora of toxic reactions being served up by the methamphetamine-abuse epidemic, caution is advised. No one really knows what methamphetamine dosages are used by street abusers, so it is impossible to compare street dosages with low dose prescription products. A recommended course with a selected stimulant is to start low in dosage and titrate upward over time. For example, I like to start dextroamphetamines at one of the two lowest commercial dosages, 5 or 10mg, two or three times a day. I initially start phentermine at 30 or 37.5mg once or twice a day. The second unanswered question is whether we will see long-term toxic complications of stimulants. Reports to date indicate that stimulants have negligible effects on blood pressure, heart rate, or mental abilities. 2,17,18 The third unanswered question is therapeutic tolerance. Will patients who find a stimulant-opioid combination to be effective later find out that tolerance sets in and effectiveness vanishes? No one really knows. I have now had patients on stimulant-opioid combinations for over two years, and the stimulants continue to appear safe and effective with no toxic complications. 


Abuse Caution


All available stimulants, with the possible exception of caffeine, have some abuse potential. For this reason, the author recommends that stimulants only be prescribed to chronic pain patients who are known to the practitioner to take their opioids in a responsible, non-abuse fashion.


Side-Effects


Stimulants in a chronic pain patient who takes opioids have a negligible effect on blood pressure and pulse rate. In the author’s experience, stimulants taken too close to bedtime may cause insomnia. The toxic reactions, psychosis, hyperthermia, weight loss, and violence that are observed in street methamphetamine-abusers have not been reported with the prescription stimulants used with opioids. Despite millions of dosages prescribed over three decades in appetite suppressants used for obesity, there have been remarkably few claims of addiction. 24

Available Stimulants


The stimulants most used with opioids have been dextroamphetamine and methylphenidate. 17-19 Phentermine and phendimetrazine are old-time stimulants normally used for weight control. They are amphetamine derivatives with little abuse potential, low cost, and yet are effective opioid potentiators. The newest prescription stimulants are combinations of amphetamine derivatives and modafinil (Provigil ® , Nuvigil ® ). A summary of available stimulants is presented in Table 3.


Case Reports


Practitioners will find that the addition of a stimulant can help in a number of situations involving patients who take opioids. For example, there are patients who don’t wish to take opioids or who wish to at least maintain a low opioid dosage. Other opioid patients may lose health plan coverage and be forced to switch from an expensive opioid to a new regimen. Practitioners may simply want to lower an opioid daily dosage because they perceive it to be too high or producing a complication such as hormone suppression.


Case 1. Avoiding a Long-Acting Opioid


A 39-year-old, active-duty law enforcement officer weighed over 275 pounds and had degenerative spine and hip disease. He was taking a hydrocodone/acetaminophen combination in a dosage of about 80mg of hydrocodone a day. He resisted taking long-acting opioids or raising his opioid dosage. He was given phentermine 30mg twice a day that gave him about 25% more pain relief. This was enough to enable him to work full time and function well. As an added benefit, he lost 20 pounds.


Case 2. Forced Removal of a Long-Acting Opioid


A 57-year-old male severely injured his lumbar spine while parachuting. He controlled his pain quite well for several years with long-acting oxycodone. He lost many of his insurance benefits and could not afford to purchase long-acting oxycodone. He was switched to a less expensive regimen of a fentanyl transdermal patch (25mcg/hr) and phentermine 37.5mg twice a day. He claims this regimen is as effective as his previous one. 


Case 3. Cytochrome P450 Abnormality


A 62-year-old female had degenerative spine disease with multiple surgeries as well as severe knee arthropathy. Complicating matters is a documented cytochrome P450-2C9 defect. To maintain pain control, she required three different opioids with a total daily morphine equivalency dosage of over 2,000mg a day. The stimulants modafinil and phentermine were added to her regimen and she reduced her daily opioid dosage over one-third while claiming about 25 to 30% better pain relief. She has taken stimulants over two years, works full-time, and believes her stimulants are still very effective and indispensable to her pain control regimen.


Case 4. Withdrawal From Opioids


A 43-year-old woman had persistent disabling headaches for 17 years following suspected viral encephalitis. She maintained with three opioids: a daily long-acting morphine, propoxyphene, and hydromorphone. Morphine equivalence was over 1,000mg a day. Phentermine 37.5mg, given 3 times a day, was added to her regimen. She was able to totally cease morphine and propoxyphene within four months.


Summary

The simultaneous use of a stimulant with an opioid should be routinely considered as part of a clinical regimen in those patients who responsibly and reliably take opioids. Benefits include enhanced pain relief, reduction of opioid dosage, cost, and minimization of the side-effects of sedation, fatigue, depression, and mental dullness.

Last updated on: March 7, 2011
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