Opioid Treatment for Refractory Restless Legs Syndrome


I'm dr. Mike Silber I'm a professor of

neurology at the Mayo Clinic College of

Medicine and science where I work in the

Sleep Center that is my subspecialty in

neurology I'm also chair of the opioid

subcommittee of the restless leg

syndrome foundation scientific and

medical advisory board and it's in that

capacity that we have written an article

about the appropriate use of opioids in

the management of refractory restless

legs now Reese's leg syndrome is a very

common condition and it is most often

eminently treatable by a series of

first-line medications including

dopamine agonists

and alpha 2 Delta ligands such as

gabapentin but these drugs are not

without problems and many patients with

time that devan become refractory to

first-line therapies and this includes

the development of side effects such as

impulse control disorders with dopamine

agonists as well as the phenomenon

called augmentation where perhaps as

many as 50 to 70 percent of patients on

dopamine agonists will develop worsening

restless legs with time in which the

symptoms spread to the arms they are no

longer so responsive to therapy during

the night and perhaps most important

spread early and early in the day as a

result of these and other side effects

there is a significant group of patients

who need further treatment and long

clinical experience as well as some

excellent studies including a large

controlled trial of the use of oxycodone

have shown that opioids are effective in

this group of patients now we're all

aware of the terrible problems of opioid

overuse and opioid use disorder is

starting sometimes with the use of

opioids prescribed for

acute pain and for chronic pain and we

want to be responsible prescribers of

opioids for restless legs but refractory

restless leg syndrome is very different

from chronic pain it has a different

path of physiology at different

epidemiology and patients with

refractory restless legs are often

desperate their quality of life is low

they have intense insomnia they may have

suicidal depression and we really do not

want to deprive these patients of the

appropriate use of opioids so in our

paper we review some of the basic

science of opioids in restless legs some

of the studies done with on opioids but

the most important part of our paper for

practicing clinicians is a guideline of

when they should be used and how they

should be used opioids for restless legs

are used in far lower doses than for

chronic pain for instance oxycodone

either short acting or long acting the

average dose is about 20 milligrams

daily and even methadone which is highly

effective in restless legs the dose is

usually on an average about 10

milligrams daily and at these doses the

risk of opioid use disorder is far far

lower than in heart with higher doses

not non-existent but much lower so we

really want to restrict the use of

opioids to patients with refractory

restless legs who failed other forms of

first line therapy second we want to

look at other contributing causes such

as iron deficiency other medications

such as serotonin Erdrich working

antidepressants which could worsen

restless legs or concomitant disorders

that haven't been properly treated such

as sleep apnea we want clinicians to

think about using other medications in

combination in lower doses but when

these don't apply we really ask that

patients not be deprived of opioids when

starting opioids for restless legs one

wants to do a proper assessment of risk

of addiction and there are various tools

that can be used an opioid contract

should be signed

a urine drug screen done and then the

patients followed regula generally every

three to six months and to be sure that

they are benefiting from the drugs that

we've got them on the right dose and the

right schedule and that there's no

evidence of abuse and we check the state

databases regularly and a urine drug

screen is generally done at least once a


patients finds that these precautions

are perfectly reasonable when explained

carefully to them and what after once

treated a few of these patients with

opioids one realizes the immense change

in their quality of life um in summary

we believe that opioids for refractory

restless legs are highly effective in

most patients that the doses are low

that the risk of opioid use disorder is

low they're not negligible that it is

manageable with careful precautions and

basically that the risk benefit ratio is

low and we have published this paper so

that both specialists and primary care

physicians can feel more comfortable

with their use not feel that they are at

risk as prescribing physicians in you in

pretty in treating these patients and

can help relieve their suffering we hope

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