What is best medication for restless leg syndrome
Opioid Treatment for Refractory Restless Legs Syndrome
[Music]
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
year
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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