It is not unusual for the patient to sleep more during the first few days of good pain control. Patients and families should be cautioned to expect this as the sleep deprivation is corrected and be reassured that should the problem persist, it can usually be managed without sacrificing pain control, by reducing the dose gradually or by changing the opioid. Administering the stimulant later than 2PM may interfere with normal sleep as the drug can last as long as 6 to 8 hours. The dose should be titrated upward in 5 mg increments every 2 to 3 days until the desired effect is achieved, or the patient encounters unwanted side effects. Often the stimulant medication may enhance the effect of the opioid and the opioid dose can be reduced.
Respiratory depression is perhaps the most serious impediment to adequate pain control with opioids.
In particular, inordinate fear of respiratory depression prevents adequate opioid use resulting in inadequate pain relief. In considering this side effect, the most important distinction to be made is whether the patient is tolerant to opioids or not. The opioid-tolerant patient, i.e., the patient who has been taking them regularly for several weeks or more, is tolerant to the respiratory depressant effects and respiratory depression is highly unlikely, no matter what the dose administered. Closer monitoring is warranted in opioid-naive patients or when another pain intervention, such as an anesthetic block , effectively takes away the pain stimulus. Care must be taken in these situations to titrate the opioid dose downward without precipitating a withdrawal reaction.