Use of Central Nervous System Stimulants
66. D.H., a 34-year-old man, is diagnosed with acquired immunodeficiency syndrome (AIDS) and Kaposi's sarcoma. He was discharged from the hospital with a prescription for oral morphine solution, 30 mg every 3 hours. He has been relatively pain free for about a month, but now returns to the clinic complaining of excessive morning sedation. He cannot reduce his morphine dose because the pain makes him too uncomfortable. What therapeutic intervention can be used to alleviate D.H.'s problem of excessive morning sedation?
Limited clinical data suggest that a morning dose of methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) could both relieve opioid-induced drowsiness and potentiate analgesia.222 Less sleepiness has been associated with these combinations than with opioid analgesics alone, and a 10-mg dose of amphetamine combined with the opioid analgesic improved pain tolerance more than the analgesic alone.223,224 Although these studies involved only single doses, these agents should cause sufficient CNS stimulation to obviate morning drowsiness. D.H. should try a morning dextroamphetamine dose of 5 to 20 mg. A somewhat smaller dose may be added around noon if he desires increased alertness in the late afternoon and early evening hours. Another alternative would be to switch D.H. to an opioid analgesic that is less sedating. Drugs such as hydromorphone, levorphanol, methadone, and fentanyl often produce the desired clinical response in a patient such as D.H.225
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