The Use of Stimulants to Combat Opioid-Induced Sedation (OIS)

by Michael Giusani R.Ph, ScripNet

Stimulants, such as Provigil (modafinil) and Nuvigil (armodafinil), are typically used in the management of narcolepsy, obstructive sleep apnea, and shift-work disorder. Other stimulants, such as Ritalin and Concerta, are used to treat attention-deficit hyperactivity disorder (ADHD).  However, physicians have increasingly prescribed these drugs to combat drowsiness associated with the use of opioid analgesics for the treatment of chronic pain.  Use of these drugs in the management of opioid-induced sedation (OIS) is ‘off-label’, meaning not FDA approved.   Provigil is consistently one of the top 25 medications in workers’ compensation and has a large price tag ($20 per tablet).  The Average Wholesale Price (AWP) for Provigil increased by 35.7% in 2011, although it is going off patent in April 2012.  Nuvigil sells for $14 per tablet.  There is little clinical research to support the use of these drugs for OIS in chronic pain patients.   In past years, OIS was addressed by making narcotic dosing adjustments or changing to different opioids. Claimants who use Provigil or Nuvigil for OIS are being exposed to potentially habit forming medications that may not be beneficial in treating their condition and may have other risks associated with their use in addition to the risks associated with the use of opioids.  ScripNet’s CU℞ES program tracks claimants who use these drugs and stratifies them for risk profile analyses on a retrospective basis.


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