Re: Med. to counteract drowsiness of opiates?


Point well taken, Wolf,
I was originally prescribed this drug due to the fact that sleep apnea had
pretty much erased any regularity I had getting to be and waking up at
"normal" hours. Even after using the C-Pap machine, I find I do not get deep
sleep, even with adequate pain medication and other downers. Even with
Provigil, I tend to sleep up to 12-14 hrs. still awakening tired and
listless. The Provigil gives me enough pep to get interested in projects I'd
always been interested before.
I went to the sleep doc and he showed me that my CFS causes part of my
brain to stay "on" all through the sleep process. I simply never quite
sleep, at least not fully.
As I spent 9 of the worst months of my life as a speed freak (back in
college), I neither wish to try amphetamine or amphetamine like drugs again.
They made me very edgy and kept me up for days on one pill the last time I
tried it and that was many years ago. I tend to vomit if I so much as look
at pictures of them. That's just not worth the try.
Provigil has been a miracle for me. I'm sure it's being over prescribed, but
for many of us it's a dream come true. No side effects, I can even nap on
them. But when I get interested in something I'll stick with it for hours.

Cabbi

"The Wolf With the Red Roses" <after-dark-arms@xxxxxxx> wrote in message
news:p7rbb3ps0kkai8puqkeaaqsaooect9breq@xxxxxxxxxx
On Thu, 2 Aug 2007 09:29:34 -0500, "Cabbi" <cabbi@xxxxxxx> wrote
something wonderfully witty:

Add my name to the supporters of Provigil. It is a wonder drug for me. I
had
no drive to get out of bed before I started using it everyday (200 mg. in
the morning).
I swear by it. It's nothing like caffeine and very subtle in what it does.
The insurance companies are out of their minds if they think this is an
unnecessary drug for their formularies.
Purple

An interesting article on all of this & some possible solutions to the
problem co-authored by a Nurse is at the following url:
http://www.supportiveoncology.net/journal/articles/0101053.pdf

The overall problem, if you want to classify it as a 'problem', isn't
that they think it is an unnecessary drug. It is the current approved
uses and the way some Dr's both prescribe & defend it's use in their
patients. Some of them are really lazy bastards & corporate toads.

Back in September of 2003 the FDA review panel said the drug, Provigil
(Modafinil), now approved only for narcolepsy, could also be used to
fight sleepiness in workers who cannot adjust to night shift jobs and
in people who do not sleep well because of a breathing disorder known
as obstructive sleep apnea.

Cephalon (the manufacturer of Modafinil) had hoped to get approval for
sleepiness caused by all sleep disorders by showing that the drug
worked in three representative conditions - narcolepsy, shift work
sleep disorder and sleep apnea, a condition in which people awaken
briefly many times a night because their breathing stops. The F.D.A.
has approved drugs to treat pain without requiring clinical trials for
all causes of pain, but weren't willing to approve Modafinil as an
adjutants in Opiate Drowsiness nor did Cephalon seek approval for this
use at that time.

This gives Dr's a lot more latitudes in both prescribing the drug as
well as defending its prescription. However, that being said; there
are also studies going on to use Modafinil to actually treat Drug
Dependance and there is some anecdotal evidence that it can decrease
drug cravings in recovering addicts as well as decrease the
effectiveness of Opiates. Of course each individual milage may vary.
Since most Chronic Pain Patients are not 'addicts' and do not 'crave'
their medications, this may be a moot point.

Once sedation is identified as a clinical problem, a number of
therapeutic approaches can be utilized to minimize its severity. These
include the exclusion of other causes of sedation, the reduction
or elimination of potentially sedating adjuvant agents, and opiate
rotation. The medications most commonly prescribed to treat
opiate-induced drowsiness are the psychostimulants, including
methylphenidate (Concerta, Ritalin) and dextroamphetamine (Dexedrine,
Dextrostat).

Though empirically efficacious, the potential side effects of these
agents, including weight loss, anxiety, and exacerbation of delirium,
may limit their use. Preliminary reports suggest that Modafinil
(Provigil), an agent approved for the treatment of narcolepsy, can
also be used as a wake-promoting agent. A small placebo controlled
trial of opiate-treated patients indicated modest benefit from
modafinil treatment. (Webster L, George K. Modafinil treatment in
patients with opioid-induced sedation. American Pain Society, Poster
#844, Chicago 2003).

Suggested Approach to the Management of Opiate-Associated
Sedation and Deliriuma:

1. Rule out other causes of sedation, eg, "catch-up" sleep due to
adequate analgesia, toxic-metabolic disorders, sepsis, fever,
dehydration, structural brain disorders, retarded depression or
anxiety, other sedative agents, corticosteroid withdrawal, misuse of
opiates for non-nociceptive suffering, stool impaction, or severe
constipation

2. Allow up to 7 days for tolerance to develop to sedative
effects of the opiate

3. Reduce or discontinue nonessential adjuvant medications,
especially those having anticholinergic activity, such as
antihistamines and tricyclic antidepressants

4. Add psychostimulant agents, eg, caffeine, pemoline,
methylphenidate, dextroamphetamineb

5. Reduce opiate dosing by 25% (if patient is already experiencing
adequate analgesia); add non-sedating adjuvant medications as
necessary to achieve good pain relief, and consider fluid
administration to increase opiate metabolite excretion

6. Rotate to an alternative opiate, since incomplete analgesic
cross-tolerance may permit use of a lower dose of an alternative
opiate agent, and therefore less sedation

7. Consider alternative means of analgesia:

. Alternative routes of opiate administration, eg, parenteral or
intraspinal administration
. Radiation therapy
. Nerve blocks
. Neurostimulatory procedures









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