The Elvis Cocktail --- a guide

Sometimes, in my blog, I refer to the "Presley cocktail", or the "Elvis cocktail"; having nothing else to write, I will try to explain what this means.  Due to possible interactions, and due to the habit-forming effect of some of the ingredients, these drugs, including those obtainable over the counter, must be reported to your doctor.

The principal raison d'être of this drug cocktail is for chronic pain; the various components of this cocktail treat the physical and mental effects of pain, although only the opioids (opiates, or narcotics) described below, are indicated specifically for pain.  Because some of these drugs pre-date the introduction of the metric system into Europe, their dosages are occasionally written in grains, or fractions thereof; one grain is sixty-four milligrammes, often rounded down to sixty.

Severe chronic pain reduces the patient's attention; one becomes so fixated on the pain that it becomes hard to focus on a task.  Accordingly, the first ingredient in a Presley cocktail is a psychostimulant; Presley himself used dextroamphetamine, usually sold as Dexedrine, and racemic (half-and-half) amphetamine, then known as Biphetamine and now (in a slightly different formulation) known as Adderall.  Here is a list of psychostimulants most used in Canada, Great Britain, and the United States, along with my recommendations:

• 50:50 Amphetamine (Benzedrine) - not recommended, because it is too mild
• 75:25 Amphetamine (Adderall/Biphetamine)
• Lisdexamphetamine (Vyvanse) - time-released form of Dexedrine.  Multiply by 2.5 to get the Dexedrine Spansule dose.
• Dextroamphetamine (Dexedrine) - double the dose of Benzedrine, or multiply the dose of Adderall by 1.35.  Recommended by psychiatrists, Elvis, and me.
• Methamphetamine (Methedrine or Desoxyn) - the undisputed best, but also highly abusable.  Used to come in many formulations, now comes in only one: the 1/12 gr. (5 mg) instant-release form.  The blue ribbon goes to this one; by far, it's the best amphetamine out there.
• Methylphenidate (Ritalin) - chemically not related to any of the above, but can also be used to good effect.  Not to be combined with any of the above.

The pain itself must also be treated; the drugs most common for treating pain are what I have termed the typical opioids (these include those naturally harvested from poppies with no modifications, those modified in the laboratory, and fentanyl, which is completely synthetic but behaves like the natural and semi-synthetic opioids).  Atypical opioids (most synthetic ones) are also used, but these have some very different, and sometimes unpleasant, side effects.  Presley himself preferred hydromorphone; I entirely agree with his recommendation.  Because these drugs are very old (possibly the oldest class of drug in existence), no brand names will be listed except for certain drugs that are mostly known under their (usually American) brands.

• Codeine - 1/10 the strength of morphine; very mild and not recommended for moderate-to-severe chronic pain.  Over the counter in almost every country.
• Dihydrocodeine - See codeine.
• Morphine (Sevredol, MS Contin, and many others) - The gold standard.  Used for everything from headaches to terminal cancer.  Also very mild, and over the couwritten some countries, as a result.  This drug is nine times the strength of morphine; the dosages Browne's Chlorodyne, Kaolin and Morphine Mixture, and Diocalm.
• Morphine diacetate (Heroin) - This is a form of morphine used mostly in the United Kingdom, but also elsewhere.  It works just as morphine sulphate and morphine hydrochloride do, with one exception: it is twice as potent by injection than other morphine salts.
• Dihydromorphine - Most commonly used in Japan.  Dosages and effects are roughly equivalent to morphine.
• Dihydrodiacetylmorphine - Just as dihydrocodeine is codeine with two atoms of hydrogen bound to it, and dihydromorphine is morphine with two atoms of hydrogen bound to it, the same is true of dihydrodiacetylmorphine; the duration of action and doses are slightly different (unlike oxycodone versus hydrocodone.)
• Oxycodone (OxyIR, Percocet, Percodan, Percolone, Supeudol, and OxyContin) - Oxycodone is an odd drug from its family.  Unlike every other opioid, oxycodone has stimulant qualities; for those suffering from pain together with fatigue, oxycodone is a blessing.  This 
• Dihydromorphinone/Hydromorphone/Dilaudid - Different names for the same drug; Dilaudid is a trade name that in America has almost become the generic name and written with a small 'd' as a result.  This drug is nine times the strength of morphine; the dosages available are 1/30, 1/15, 2/15, 4/15, 8/15, and 1 gr.  Because of its strength, the higher dosages are available only as slow-release tablets.
• Buprenorphine (Butrans, Buprenex, Subutex, Suboxone) - An excellent drug; ounce-for-ounce and pound-for-pound the most potent semi-synthetic opioid used in humans.  Butrans is a one-a-week patch; the others are twice-a-day tablets.   As a result of its potency, it is measured in microgrammes, not milligrammes or grains (patch only).  Subutex sublingual tablets are available in 1/32 and 1/8 gr. strengths.  The one-eighth-grain tablet is equivalent to 240 mg. (over four grains) of morphine at once; it is less sedating, but it still packs quite a punch for pain.
• Fentanyl - Entirely synthetic; comes in many strengths, but must be placed under the tongue or on skin, just like buprenorphine.  It's far shorter-acting; the instant-release fentanyl is for breakthrough pain only, and the patch lasts for three days only.  The patch can leak, which can be deadly.

For sleep, there are essentially six options, as outlined below.  Due to the extreme variety of drugs available (there are far more sleeping powders and pills than pain medications), two drug groups will be covered only as such.  Each hypnotic loses effectiveness over time, so it is important to rotate them for chronic sleeplessness.

• Benzodiazepines - These are the most commonly-used prescription drugs for sleep.  There is a great variety of them, but all of them are controlled drugs, and for good reason: once benzodiazepine dependence forms, withdrawal (unlike the pain drugs above) can be deadly.  It parallels alcohol withdrawal (delirium tremens and seizures being very common).  However, benzodiazepines are safe in overdose unless combined with alcohol (which is highly contraindicated when on a benzodiazepine).
• Barbiturates - These are prescribed more rarely, but remain a valid option; these have most of the advantages of benzodiazepines, but many more disadvantages.  Barbiturates are extremely deadly in overdose, whether combined or not; the withdrawal usually is deadly (although substitution therapy works well), and addiction sets in earlier than with benzodiazepines.
• Chloral hydrate (trichloroacetaldehyde) - Very safe, as it is used in large amounts; however, this drug is uncommonly prescribed, and mostly used with children and seniors.  This drug is available as a liquid which tastes rather like acetone; (very large) gel capsules are available as well.  The main problems with chloral are a hangover effect, as well as stomach irritation (nausea, vomiting, ulcers).  Chloral addiction is uncommon, but can result, and is extremely uncomfortable, but rarely fatal.
• Quetiapine (Seroquel) - This is an antipsychotic often used also as a sleep aid, but this use is not suggested.  Should be used as a last resort only.
• Melatonin - An over-the-counter hormone that induces sleep; my own preferred sleep aid, aside from chloral and diphenhydramine.  Available in 3 mg and 5 mg.  Gently nudges you to sleep.
• Antihistamines - These are used for the relief of allergies and side-effects from pain medication far more than for sleep, but this remains a valid option.  The antihistamines to use for sleep are generally the older ones: diphenhydramine (Benadryl) and dimenhydrinate (Dramamine), both over-the-counter, work well.  The usual dose for sleep is 50-100 mg of Benadryl, or 100-200 mg of Dramamine.  THESE DRUGS ARE VERY DANGEROUS IN OVERDOSE (DELIRIANTS).    

These drugs must be properly spread out.  The most common practice is to take the opioid four times a day, the stimulant twice or three times, and the hypnotic once.  Some examples of the Presley cocktail in practice:

8:00 AM:  Hydromorphone 8 mg; dextroamphetamine 15 mg. 12:00 AM: Hydromorphone 8 mg.  4:00 PM: Hydromorphone 8 mg; dextroamphetamine 15 mg.  8:00 PM: Hydromorphone 8 mg; diphenhydramine 100 mg.  10:00 PM: Bedtime.

9:00 AM: Morphine 60 mg; one large coffee (caffeine 120 mg).  1:00 PM: Morphine 60 mg.  5:00 PM: Morphine 60 mg; one small coffee (caffeine 120 mg).  9:00 PM: Morphine 60 mg; one large glass of grapefruit juice (to make the morphine last out the night!); 1.2 g chloral hydrate.  12:00 PM: Bedtime.

This can be simplified with modified-release tablets, as well:

8:00 AM: Jurnista 64 mg; one large coffee.  Patient drinks coffee and grapefruit juice throughout the day.  8:00 PM: 600 mg of chloral hydrate is taken.  10:00 PM: Bedtime.  Patient wakes up at 8:00 AM with no pain.

My own Elvis cocktail (all drugs are instant-release):

9:00 AM: Oxycodone 10 mg; one large coffee; dexamphetamine 15mg.  Liberal amounts of nicotine throughout; Sativex (dronabinol spray) as needed.  5:00 PM:  Oxycodone 5 mg.  9:00 PM: Diphenhydramine 100 mg; melatonin 20 mg; chlordiazepoxide 25 mg; oxycodone 5 mg.