Stimulants sustained-release formulations

Children naive to stimulant treatment may be started directly on a sustained-release formulation. Starting doses could be any of the following 5 mg of Dexedrine spansules once in the morning, or 5 mg of Adderall bid, or 18 mg of Concerta, which is equivalent to MPH 5 mg tid. Before the availability of Concerta, it had become common practice to combine short-acting MPH with MPH-SR20 to increase efficacy and duration of effect and to allow for more flexible dosing. 

If disturbances of gastrointestinal function prevent the use of oral sustained-release morphine, the fentanyl transdermal system (fentanyl patch) can be used over long periods. Furthermore, buccal transmucosal fentanyl can be used for short episodes of breakthrough pain (see Alternative Routes of Administration). Administration of strong opioids by nasal insufflation has been shown to be efficacious, and nasal preparations are now available in some countries. Approval of such formulations in the USA is growing. In addition, stimulant drugs such as the amphetamines have been shown to enhance the analgesic actions of the opioids and thus may be very useful adjuncts in the patient with chronic pain. 

Ambulatory blood pressure monitoring showed changes in blood pressure and heart rate in boys aged 7-11 years taking stimulant therapy (13). This preliminary study with chronic methylphenidate or AdderaU (dex-amfetamine + levamfetamine) for ADHD showed alterations in awake and asleep blood pressures, with profound nocturnal dipping. Modified-release formulations of methylphenidate and AdderaU now allow more sustained blood concentrations in children. The effects of these newer formulations on cardiovascular indices should be evaluated. 

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