Friday, May 18, 2018

FDA Commissioner Listening to Chronic Pain Patients. Pain News Network

Pain News Network reports the Food and Drug Administration is seeking comments from patients only on the challenges they face finding treatment and on the effectiveness of opioids and other types of pain medication. Patients are invited to submit their comments by mail or in the Federal Register, and to attend a public meeting on July 9. Click Here for more details.

Pain News Network LINK to whole story


Has a Pharmacist Lowered Your Pain Medication Without Your Physicians Permission?

Pharmacist are telling patients all over Arizona they can't fill a prescription for 6 pain pills, only 3-4 and lowering the patients dose without contacting the physician first?

FILE a COMPLAINT with the Arizona Board of Pharmacy at the link in the email below....

Send email to the governor and Kam Gandhi, PharmD the Executive Director of the Arizona Board of Pharmacy and ask why this is allowed to happen. Her email address is

I asked Kam Gandhi – Executive Director Comments: Can a pharmacist change a patients prescription dose without contacting the prescribing physician? If not please send me a complaint form..

Copy of email
Kamlesh Gandhi
 to me
Show more
May 17

A pharmacist needs to call the practitioner to change the dose (strength) on a prescription.

Below is a link to file a complaint.

Thank you,

Kam Gandhi, PharmD
Executive Director

---------- Forwarded message ----------
From: Arizona State Board of Pharmacy <>
Date: Thu, May 17, 2018 at 2:22 PM
Subject: - CONTACT US -

Submitted on Thursday, May 17, 2018 – 14:22 Submitted by user: Anonymous Submitted values are:
Your Name: Jay Fleming Email Address: Phone Number: Business Name: Select Staff Member: Kam Gandhi – Executive Director Comments: Can a pharmacist change a patients prescription dose without contacting the prescribing physician? If not please send me a complaint form..

Why Can't Pain Management Physicians Understand the 2018 Arizona Prescribing Law?

My pain doctor's office called today to tell me the physician was refusing to sign my refill prescription unless I agreed to lower the dose again.... 

Why is it so hard for otherwise smart people like physicians to read and understand the laws that govern them?

The 2018 opioid prescribing law says it has exemptions for current patients... 

This is what the law says.....
New Prescribing Limits on Opioids

Under the new Arizona Opioid Epidemic Act, beginning April 26, 2018, the prescribing of opioids will be limited in two significant ways. 

First, a health professional shall limit the initial prescription for a schedule II opioid to a five-day supply, except an initial opioid prescription following a surgical procedure is limited to a 14-day supply. 

Additionally, the Act prohibits a prescriber from issuing a new prescription for a schedule II opioid that exceeds 90 morphine milligram equivalents (MMEs) per day. 

There are exemptions to these prescribing laws and a complete list of exemptions can be found in A.R.S. §§ 32-3248 and 32-3248.01. SEE BELOW

Dose Limits 2018
Arizona Revised Statute 32-3248.01. Schedule II controlled substances; dosage limit; exceptions; morphine; opioid antagonist; definition
A. A health professional who is authorized under this title to prescribe controlled substances may not issue a new prescription order for a schedule II controlled substance that is an opioid that exceeds ninety morphine milligram equivalents per day.
B. The limit prescribed by subsection A of this section does not apply to:
1. A continuation of a prior prescription order that was issued within the previous sixty days.

In other words they shouldn't reduce the dose to under 90 mg's if the patient was already receiving a higher dose.

Thursday, March 22, 2018

If You Take NSAIDs for Pain Relief You Are Putting Your Life At Risk

If you take any of the following non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief you are putting your life at risk:
 aspirin, celecoxib (Celebrex), diclofenac (Cambia, Cataflam, Voltaren-XR, Zipsor, Zorvolex), ibuprofen (Motrin, Advil), indomethacin (Indocin), naproxen (Aleve, Anaprox, Naprelan, Naprosyn), oxaprozin (Daypro), piroxicam (Feldene). 

This is from the article NSAIDs Unsafe for Chronic Pain
Posted on February 18, 2018 
By Cindy Perlin.

It has long been known that NSAIDs increase the risk of potentially fatal stomach and intestinal adverse reactions including bleeding, ulcers, and perforation of the stomach or intestines. These events can occur at any time during treatment and without warning symptoms. Elderly patients are at greater risk for these adverse events. Aspirin, for instance, despite being less popular than in the past due to the availability of other options, causes over 3000 deaths annually in the United States

This is from the National Pain Report. If you take NSAID's or know someone who does, please have them read the whole article, it could save their life. Use the title above or the link below..... 

Working on the ambulance in Spokane I could always diagnose a lower GI bleed from the front door. There are no solid figures on how many people die from NSAID's, but it GI bleeds were a common call on the ambulance.

If you use NSAID's pleas use with them with caution. I know when you're in pain you will take whatever it take to make it stop. To die from a GI bleed is a slow painful way to die, so please be careful.

Friday, March 16, 2018

The Politics of Pain Another Side of the Opioid Story Kingman Daily Miner 02-23-2017

The Politics of Pain Another Side of the Opioid Story Kingman Daily Miner 02-23-2017

Dolan Springs resident Jay Fleming has safely taken opioids to tamp down chronic pain he has suffered for 20 years. Public policy is in chaos today due to thousands upon thousands of overdose deaths in recent years, which has resulted in the health care of people like Fleming to be compromised.

·  Originally Published: February 23, 2017 6 a.m.
Most people who take prescription pain medication do so responsibly – and live a better quality of life in the process. But a national epidemic of fatal opioid overdoses has made getting these drugs increasingly difficult for the very people they are supposed to help.
It’s unfortunate that thousands of people die each year from opioid overdoses, and it’s unfortunate that hundreds of thousands of people who don’t need painkillers take them anyway in order to get high.
They’re making it tough on people like Jay Fleming, a legitimate prescription opioid user who can’t make it through the day without his drugs.
He feels shots of pain fire down his right leg like electrical shocks, and his calf muscle is gone, the aftereffects of the back surgery he had 20 years ago that screwed up his nerves.
Fleming, of Dolan Springs, has been taking morphine for his pain, and now his doctor is switching over to a different drug, hydromorphone, sold under the brand name Dilaudid, among others, because of federal cutbacks in opioid medications.
“I have been a good patient for many years,” Fleming said. “I have never abused my medications. It’s sad when patients abuse their medications. It’s tragic when a patient takes their life because of lack of pain relief.”
Indeed, there are many dangers of opioid use, as the Centers for Disease Control has been pounding in recent campaigns, but a majority of long-term users find opioids essential for reducing their pain.
Now they’re having trouble getting their medications, in large part due to abusers who are driving the spike in opioid overdoses that have been pegged as a national health issue.
Mohave County saw a dramatic increase in suicides after Dr. Albert Yeh surrendered his medical license in 2011 for prescribing controlled substances for other than legitimate medical needs. Yeh operated a pain management clinic in Golden Valley from 2006 to 2009.
“There was a big spike in suicides after Dr. Yeh,” Fleming said. “Because of what they’re doing now, you watch, suicide rates will go up next year.”
Serious Problem
Abuse and addiction to opioids such as heroin, morphine and prescription pain relievers are a serious problem that affects the social and economic welfare of all societies.
Drug overdose is the leading cause of accidental deaths in the United States, with tens of thousands lethal drug overdoses in 2015, according to the American Society of Addiction Medicine.
Opioid addiction is driving this epidemic with 20,101 overdose deaths related to prescription pain relievers and 12,990 overdose deaths related to heroin in 2015. The numbers have quadrupled since 1999.
Consequences have been devastating and are on the rise.
It’s estimated that 2.1 million people in the United States suffer from substance abuse disorders related to prescription opioid pain relievers, and there’s growing evidence of a relationship between increased use of non-medical opioid analgesics and heroin abuse.
Dr. Benjamin Venger of Tristate Pain Institute in Fort Mohave sees it every day.
Too Many People Are Dying
“The problem is there are a very high number of overdoses and death,” he said. “In response to that, there is a movement by regulatory agencies to rein this in. People like Jay, they’ve been on medications for a long time and, right or wrong, their body has adjusted. So it’s difficult to lower the level of medication.”
Venger said many patients are responsible users. Obviously, if you’re suffering from terminal illness, you need the medication, he said.
One step to mitigating opioid abuse is to develop better communication and more cooperation between hospitals and providers, he said. Rarely is he told when one of his patients is treated at an emergency room for overdose symptoms.
“There has to be notification so we can effectively treat people who are having problems. Not just opioids. The common drug here is methamphetamine and the increase in heroin. That’s another problem. It’s very difficult.”
Venger said he monitors patients carefully and nurtures a dialogue with them based on trust and respect. A lot of them will admit they screwed up, abused the system and hit the streets to buy heroin.
“There’s no easy answer,” Venger said. “I feel bad for people who started their medication at a different time and now the rules are changing.”
Lower Dosage
Fleming said one of his doctors told him at his last appointment that the Drug Enforcement Agency had mandated a reduction of dosage to 100 milligrams of morphine or the equivalent.
“The DEA sets quotes, but they don’t tell doctors what to do and how much to prescribe,” Fleming said.
It was actually the Centers for Disease Control that provided a guideline for primary care physicians who prescribe opioids for chronic pain outside of cancer treatment and palliative care.
The guidelines are not directed at pain specialists, and recommends consultation with pain specialists when doses are over 90 milligrams.
“I have been on the dose for many years and cutting my dose by more than half was cruel and unjust and caused problems,” Fleming said. “A couple years ago, when prescriptions were hard to fill, I went through withdrawals. I had sweats and chills, violent vomiting, and my heart would have palpitations and skipped beats.”
Fleming said men taking opioids should have their testosterone levels checked. It can cause problems with their relationships.
“If you stop making love to your wife, she’ll think you’re either cheating on her or you don’t love her,” Fleming said. “Neither is good for a relationship.”

Saturday, March 10, 2018

Arizona Society for Action on Pain

Pain is under treated in America and it's going to get worse with the "opioid crisis"....

Back in the 1990's pain treatment was pretty bad. Pain patients would be given 30 4 hour pain pills for a month. It actually takes 180 4 hour pills for a month.

I fear it's going to get bad again. If you're a chronic pain patient please check out my new Facebook page the Arizona Society for Action on Pain at

The fear of DEA was so bad in the 1990's we had a group of patients that maintained a secret list of physicians willing to treat pain. It was called the American Society for Action on Pain and it was ran by Skip Baker. We had patient advocates with a list of physicians in their state.

This is the story of the American Society for Action on Pain

If you're a chronic pain patient please contact your state and federal legislators and tell them your story.

Wednesday, March 7, 2018

WHY did the AZ Medical Board Repeal the Only Guidance for Physicians on Treating Chronic Pain?

Why did the Arizona Medical Board repeal the only guidance for physicians on the treatment of chronic pain with opioids? 

Substantive Policy Statement or SPS #7 was published in November 1997 as guidelines for physicians on how to treat chronic pain with opioids without getting in trouble.
SPS #7 was revised in May 1999, and then revised again in June 2003. Then in December 2014 for some reason it was repealed. All guidance for physicians on how not to get in trouble with the Arizona Medical Board or DEA for treating patients with opioid's was gone....

9545 East Doubletree Ranch Road, Scottsdale, Arizona 85258

The Arizona Medical Board (“Board”) strongly urges physicians to view effective pain management as a high priority in all patients, including children and the elderly. Pain should be assessed and treated promptly, effectively and for as long as pain persists. The medical management of pain should be based on up-to-date knowledge about pain, pain assessment and pain treatment. Pain treatment may involve the use of several drug and nondrug treatment modalities, often in combination. For some types of pain the use of drugs is emphasized and should be pursued vigorously; for other types, the use of drugs is better de-emphasized in favor of other therapeutic modalities. Physicians should have sufficient knowledge or consultation to make such judgments for their patients.
Drugs, in particular the opioid analgesics, are considered the cornerstone of treatment for pain associated with trauma, surgery, medical procedure and cancer. Physicians are referred to the U.S. Agency for Health Care Policy and Research Clinical Practice Guidelines as a sound yet flexible approach to the management of these types of pain.
The prescribing of opioid analgesics for other patients with intractable non-cancer pain also may be beneficial, especially when efforts to remove the cause of pain or to treat it with other modalities have been unsuccessful. For the purposes of these guidelines, intractable pain is defined as:
A pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts including, but not limited to, evaluation by the attending physician and surgeon and one or more physicians and surgeons specializing in the treatment of the area, system or organs of the body perceived as the source of the pain.
Therefore, these guidelines are an attempt to communicate to physicians who prescribe opioids for intractable pain not to fear disciplinary action from this Board for prescribing or administering controlled substances in the course of treatment of a person for intractable pain. Also, physicians should use sound clinical judgment, and care for their patients according to the following principles of responsible professional practice.
Pursuant to Arizona Revised Statutes § 32-1403(A)(3), the Board may develop and recommend standards governing the profession in Arizona.
A) Pain Assessment
Pain assessment should occur during initial evaluation, after each new report of pain, at appropriate intervals after each pharmacological intervention, and at regular intervals during treatment. Unless a patient is terminally ill and death is imminent (in which case the diagnosis is usually evident and diagnostic evaluations may be of little value and discomforting to the patient), the evaluation should include:
1. Medical history, including the presence of a recognized medical indication for the use of a controlled substance, the intensity and character of pain, and questions regarding substance abuse;
2. Corroboration of medical history by reviewing patient’s medical records and/or speaking with patient’s former physicians. Patients frequently seek out a new prescribing physician after their previous prescribing physician has terminated them for non-compliance, substance abuse, and/or drug diversion;
3. Psycho-social assessment, which may include but is not limited to: 

a. The patient's understanding of the medical diagnosis, expectations about pain relief and pain management methods, concerns regarding the use of controlled substances, and coping mechanisms for pain;
b. Changes in mood which have occurred secondary to pain (i.e., anxiety, depression); and
c. The meaning of pain to the patient and his/her family.
4. Physical examination, including a neurologic evaluation and examination of the site of pain.
5. Urine drug screen, testing for commonly abused street drugs as well as prescription pain drugs that are known abused or diverted drugs. Such screening will help identify drug abusers and drug diverters.
B) Treatment Plan
A treatment plan should be developed for the management of chronic pain and state objectives by which therapeutic success can be evaluated, including:
1. Pain relief; 

2. Improved physical functioning;

3. Proposed diagnostic evaluations (i.e., blood tests, radiologic, psychological and social studies such as CAT and bone scans, MRI and neurophysiologic examinations such as electromyography); and

4. Analysis of inclusion and exclusion criteria for opioid management: Inclusion criteria includes a clear diagnosis consistent with symptoms, all reasonable alternative therapies have been explored; the patient is reliable and communicates well, there has been informed consent or a treatment agreement signed; Potential exclusion criteria include a history of chemical dependency, major psychiatric disorder, chaotic social situation, or a planned pregnancy.
C) Informed Consent
The physician should advise the patient, guardian, or designated surrogate of the risks and benefits of the use of controlled substances. The patient should be counseled on the importance of regular visits, the impact of recreational drug use, the number of physicians and pharmacies used for prescriptions, taking medications as prescribed, etc.
The physician and the patient should enter into a pain treatment contract that specifically states the patient’s required compliance with the treatment plan and what the consequences of non-compliance, misuse and abuse will be. It is particularly important that patients understand that they will be discontinued from the prescribed controlled substances, in a safe manner, should it be revealed that they are abusing or diverting drugs.
D) Ongoing Assessment
The assessment and treatment of chronic pain mandates continuing evaluation, and if necessary, modification and/or discontinuation of opioid therapy. If clinical improvement does not occur, the physician should consider the appropriateness of continued opioid therapy, and consider a trial of alternative pharmacologic and nonpharmacologic modalities.
E) Consultation
The physician should refer the patient as necessary for additional evaluation to achieve treatment objectives. Physicians should recognize patients requiring individual attention, in particular, patients whose living situations pose a risk for misuse or diversion of controlled substances. In addition, the prescription of controlled substances to patients with a history of substance abuse requires extra care, monitoring, and documentation, and may also require consultation with an addiction medicine specialist.
F) Documentation
The physician must maintain adequate, accurate and timely records regarding items A-E from above. "Adequate Records," pursuant to A.R.S. ยบ32-1401(2), "means legible records containing, at a minimum, sufficient information to identify the patient, support the diagnosis, justify the treatment, adequately document the results, indicate advice and cautionary warnings provided to the patient, and provide sufficient information for another practitioner to assume continuity of the patient's care at any point in the treatment." Specific to chronic pain patients, the documentation should include:
1. The medical history and physical examination; 
2. Related evaluations and consultations, treatment plan and objectives;
3. Evidence of discussion regarding informed consent;
4. Prescribed medications and treatments;
5. Periodic reviews of treatments and patient response; and
6. Any physician-patient agreements or contracts.
G. Counting and Destroying Medication
The physician may desire to see and count a patient’s medication to determine if the patient is taking the medication as prescribed. The patient should display and count the medication in front of the physician. Under no circumstance should the physician touch a patient’s controlled substances. If the medication must be destroyed, the patient should flush the medication down the toilet in the physician’s presence. The physician should document this fact in the patient’s chart.
H. Post-Dated Prescriptions
Post-dated prescriptions are illegal in the State of Arizona. Therefore, physicians may not issue post-dated prescriptions.
I. Referral of Patients with Active Substance Abuse Problems
Patients discovered to have an active substance abuse problem should be referred to either a detoxification and rehabilitation program or to an appropriate maintenance program for addicts.

A. Prescribing Controlled Substances
To prescribe controlled substances, physicians must comply with all applicable laws, including the following:
1. Possess a valid current license to practice medicine in the State of Arizona; and
2. Possess a valid and current controlled substances Drug Enforcement Administration registration for the schedules being prescribed.
B. Dispensing Controlled Substances
To dispense controlled substances, physicians must comply with all applicable laws, including the following:

1. Possess a valid current license to practice medicine in the State of Arizona;
2. Possess a valid and current controlled substances Drug Enforcement Administration registration for the schedules being prescribed;
3. Comply with Arizona Revised Statutes § 32-1491, et seq. and A.A.C. R4-16-201 through R4-16-205; and
4. Comply with 22 CFR 1306.07(a) if controlled substances are dispensed for detoxification.

Tuesday, March 6, 2018

State Board of Pharmacy Says NO New Law Limiting Opioid prescriptions to 15 Days

I contacted the Arizona State Board of Pharmacy after being told pain management physicians were limited to 15 day prescriptions. Again pharmacies are blaming DEA... It's NOT DEA they don't tell physicians what to do...

AZ State Board of Pharmacy Reply
Greetings. There is new legislation that becomes effective in April that will limit a prescription for a new condition to 5 days with some exceptions, but not 15 days for ongoing therapy. As the Board of Pharmacy does not have jurisdiction over prescribes, you may want to contact the respective medical board with questions on individual practitioners.

Dennis Waggoner, RPh, MBA | Compliance Officer | AZ State Board of Pharmacy | 1616 W. Adams, Suite 120, Phoenix, AZ 85007 | Phone602.761.8371 |

Simultaneous Use of Stimulants 
and Opioids

Stimulants should be added to a chronic opioid regimen to maximize pain relief and prevent opioid complications. By Forest Tennant, MD, DrPH 
It’s a puzzling situation. History and science are pretty clear: the simultaneous use of stimulants and opioids have, for over a century, been reported to be a superior combination for pain relief. 1 So, based on history, why isn’t every patient who’s taking opioids also taking a stimulant? For example, in 1977 the renowned analgesic researcher, William Forest, led a national cooperative study which clearly showed that a dose of dextroamphetamine with morphine increased morphine’s pain-relieving potency one and a half to two times. 2 Forest and colleagues posited that the great therapeutic benefit of the combination of dextroamphetamine and morphine wasn’t widely used because, “We suspect that the combination has not been accepted clinically at least, in part, because physicians do not want to subject their patients to the risk of abuse if these drugs (dextroamphetamine and morphine) are used.”

Although these pioneering researchers lamented the non-use of this combination in their seminal study, it turns out that they may, after all, get their wish. Sophisticated pain practitioners everywhere are starting to use various combinations of stimulants and opioids to enhance their pain therapeutics. What’s more, all parties concerned—including those who foot the bill—are benefitting. 

An Old History of Use and Effectiveness

It has been long-established that amphetamines and other stimulants have an analgesic effect in their own right and significantly enhance the analgesic effects of opioids. 1-9 The first person to suggest this combination was probably Dr. Herbert Snow of London (in 1896) who recommended an oral mixture of morphine and cocaine for patients suffering in agony from an advanced disease. 1 In the 1920s, the “Brompton Cocktail” was invented at the Royal Brompton Hospital in London. 1 The cocktail consisted of morphine or diacetylmorphine (heroin), cocaine, ethyl alcohol, and chlorpromazine (e.g., Thorazine ® ) for nausea. It was usually reserved for terminally ill patients with cancer or tuberculosis. Dextroamphetamine and morphine were found to be an excellent combination for pain relief during World War II. 3 Also, during this war-time period, it was found that stimulants would counteract the respiratory depression and sedation of opioids. 4,5 Although the use of this combination was known, it was seldom used clinically and essentially unreported in the medical literature after the war. Instead, researchers, commercial producers, and practitioners turned their attention to combining stimulants, including caffeine, into single commercial products. 6-8 This interest led to the development of popular combination drugs consisting of weak stimulants with opioids and/or inflammatory agents. The combination products of codeine with aspirin or acetaminophen and caffeine are widely known and have been highly prescribed for over two generations.

Although not yet widely adopted, a number of excellent studies on stimulants and opioids were done between 1950 and the end of the last century. 10-16 All of these studies—whether done in animals or humans—showed remarkable enhancement of pain relief when stimulants were combined with opioids. 8-14 One of the surprising and positive finding in these studies was that stimulants not only gave better pain relief but subjects (animals and humans) routinely performed mentally and physically better and had less respiratory depression and sedation than with opioids alone. 15-19 Clinical studies outside the seminal study by Forrest et al 2 are sparse but those that have been reported show the significant advantage of the simultaneous use of opioids and stimulants. 10,17 Even obstetrical analgesia is enhanced by this combination. 20 

Why a Need for Stimulants?

The “Decade of Pain” has brought opioids to the forefront of chronic pain treatment. It is estimated that about 10 million patients in the United States now use them. The exposure of millions to opioids has given us a population of patients who now know that the opioid class of drugs is indispensable for their pain relief. Although hardly news, practitioners, patients, and families are now beginning to observe the complications of opioids including sedation, fatigue, mental dullness, constipation, falls, and hormone suppression. Since no caring practitioner or patient who experiences pain relief with opioids is about to give them up, a stimulant added to the opioid regimen can enhance pain relief, limit opioid dosage, and prevent some opioid complications.

Mechanism Of Action

Too often it is perceived that the endogenous endorphin-opioid receptor system is the only pain control mechanism in the central nervous system. 21,22 In reality, multiple neurochemical systems are at play in pain relief. 22 They include, among others, the serotonergic, gamma-amino-butyric acid (GABA-ergenic), and adrenergic (norepinephrine-dopamine)systems. 8,21-23 Pain relief with stimulants appears to be primarily mediated by norepinephrine and not dopamine. 23 It is the simultaneous triggering of the endorphin and adrenergic neurochemical systems that gives the combined administration of opioids and stimulants a pain-relieving effect much greater than either one alone. 8,13,17 

Obvious Benefits

When a chronic pain patient on opioids adds a stimulant to their regimen, they and their observing family usually note less fatigue and lethargy and accompanied by intellectual awakening and more energy. Patients will frequently report less depression, better memory and more intense concentration ability (see Table 1). Enhanced pain relief may occur with the first dosage of stimulant. Stimulants can also lower an opioid daily dosage and ease the discomfort of opioid rotation or forced withdrawal due to loss of financial support of an expensive opioid.

How To Administer

Stimulants generally fit a dose response curve. They are not effective until the dosage reaches a specific level for a patient’s specific need. For safety, start with a low dosage and titrate upward over four to eight weeks until a therapeutic effect is reached. Stimulants can be given on their own fixed schedule such as two or three times a day or they can be simultaneously given with an opioid dosage. Table 2 presents several tips on how to administer stimulants.

Unanswered Questions

The use of stimulants with opioids, while historic, has been a seldom-used procedure in contemporary medicine. 2Consequently, 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.


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. 17-19Phentermine 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.


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.

  • 1. Melzak R, Mount BM, and Gordon JM. The Brompton mixture versus morphine solution given orally: effects on pain. In: Ajemian I and Mount BM (Eds).The RVH Manual on Palliative/Hospice Care: A Resource Book. Palliative Care Service: Royal Victoria Hospital. Montreal, Quebec, Canada, 1980. p 172.

  • 2. Forrest WH Jr, Brown BW Jr, Brown CR, et al. Dextroamphetamine with morphine for the treatment of postoperative pain. N Engl J Med. Mar 1977. 295(13): 712-715.

  • 3. Ivy A, Goetzl FR, and Burril DY. Morphine-dextroamphetamine analgesia. War Med. 1944. 6: 67-71.

  • 4. DeVoine GJ. The use of Benzedrine sulfate to overcome the untoward effects of morphine in the treatment of coronary occlusion. J Mo Med Assoc. 1941. 38: 93-94.

  • 5. Handley CA and Ensberg DL. A comparison of amphetamine sulfate with other stimulants of the central nervous system in morphine respiratory depression. Anesthesiology. 1945. 6: 561-564.

  • 6. Ahmed SS, Joglekar GV, and Balwani JH. Potentiation of the analgesic effect of codeine in rates by d-amphetamine. Arch Int Pharmacodyn Ther. Jan 1966. 159(1): 185-188.

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