TY - JOUR
T1 - The Appropriate Use of Opioids in the Treatment of Refractory Restless Legs Syndrome
AU - for the
AU - Scientific and Medical Advisory Board, Restless Legs Syndrome Foundation
AU - Silber, Michael H.
AU - Becker, Philip M.
AU - Buchfuhrer, Mark J.
AU - Earley, Christopher J.
AU - Ondo, William G.
AU - Walters, Arthur S.
AU - Winkelman, John W.
N1 - Funding Information:
This article was approved by the Scientific and Medical Advisory Board (SMAB) of the RLS Foundation. Members of the SMAB are as follows: Christopher J. Earley, MB, BCh, PhD, Johns Hopkins University, Baltimore, MA (Chair); Michael Aschner, PhD, Albert Einstein College of Medicine, Bronx, NY; Philip Becker, MD, Sleep Medicine Associates of Texas and University of Texas Southwestern, Dallas, TX; Marie-Françoise Chesselet, MD, PhD, University of California Los Angeles, CA; Stefan Clemens, PhD, East Carolina University, Greenville, NC; James R. Connor, PhD, Pennsylvania State College of Medicine, Hershey, PA; Jeffery S. Durmer, MD, PhD, Fusion Health, Suwanee, GA; Sergi Ferré, MD, PhD, National Institute on Drug Abuse, Baltimore, MD; Jennifer G. Hensley, EdD, CNM, WHNP, Vanderbilt University, Nashville, TN; Byron C. Jones, PhD, University of Tennessee, Memphis, TN; Brian B. Koo, MD, Yale University, New Haven, CT; Mauro Manconi, MD, PhD, Neurocenter of Southern Switzerland, Lugano, Switzerland; Mark P. Mattson, PhD, National Institute on Aging, Baltimore, MD; Emmanuel Mignot, MD, PhD, Stanford University, Palo Alto, CA; William Ondo, MD, Weill Cornell Medical School, Houston, TX; John W. Winkelman, MD, PhD, Harvard University, Boston, MA; Michael H. Silber, MB, ChB, Mayo Clinic College of Medicine and Science, Rochester, MN; Lynn Marie Trotti, MD, MSc, Emory University, Atlanta, GA; George Uhl, MD, PhD, VA Health Care System, Albuquerque, NM; Arthur S. Walters, MD, Vanderbilt University, Nashville, TN.
Publisher Copyright:
© 2017 Mayo Foundation for Medical Education and Research
PY - 2018/1
Y1 - 2018/1
N2 - Restless legs syndrome (RLS) is a distinct disorder, differing from chronic pain in many ways. Refractory RLS is characterized by unresponsiveness to dopamine agonists or alpha-2-delta ligands due to inadequate efficacy, augmentation, or adverse effects. This may result in severely impaired quality of life, profound insomnia, and suicidal depression. Opioid therapy is a mainstay in the management of these patients. This article summarizes the basic science and clinical evidence in support of their use, including the positive result of a large controlled multicenter study of 306 subjects, and outlines an approach to their use in clinical practice. Treatable explanations for RLS refractoriness, such as low iron stores, and other therapeutic options, such as combination therapy, should be considered before prescribing opioids. The agents most commonly used are oxycodone and methadone, but tramadol, codeine, morphine, and hydrocodone can also be considered. Controlled-release medication should be used for evening dosage and short-acting drugs, if needed, during the day. Effective doses are considerably lower than used for chronic pain (oxycodone 10-30 mg daily; methadone 5-20 mg daily) and the risk of opioid use disorder is relatively low. However, sensible precautions should be undertaken, including assessing opioid risk with standard questionnaires, using an opioid contract, using urine drug screens, consulting state prescription drug monitoring programs, and frequent reevaluation of effectiveness and side effects. Opioid use in selected patients with refractory RLS may be life-transforming with favorable risk-benefit ratio.
AB - Restless legs syndrome (RLS) is a distinct disorder, differing from chronic pain in many ways. Refractory RLS is characterized by unresponsiveness to dopamine agonists or alpha-2-delta ligands due to inadequate efficacy, augmentation, or adverse effects. This may result in severely impaired quality of life, profound insomnia, and suicidal depression. Opioid therapy is a mainstay in the management of these patients. This article summarizes the basic science and clinical evidence in support of their use, including the positive result of a large controlled multicenter study of 306 subjects, and outlines an approach to their use in clinical practice. Treatable explanations for RLS refractoriness, such as low iron stores, and other therapeutic options, such as combination therapy, should be considered before prescribing opioids. The agents most commonly used are oxycodone and methadone, but tramadol, codeine, morphine, and hydrocodone can also be considered. Controlled-release medication should be used for evening dosage and short-acting drugs, if needed, during the day. Effective doses are considerably lower than used for chronic pain (oxycodone 10-30 mg daily; methadone 5-20 mg daily) and the risk of opioid use disorder is relatively low. However, sensible precautions should be undertaken, including assessing opioid risk with standard questionnaires, using an opioid contract, using urine drug screens, consulting state prescription drug monitoring programs, and frequent reevaluation of effectiveness and side effects. Opioid use in selected patients with refractory RLS may be life-transforming with favorable risk-benefit ratio.
UR - http://www.scopus.com/inward/record.url?scp=85040626619&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85040626619&partnerID=8YFLogxK
U2 - 10.1016/j.mayocp.2017.11.007
DO - 10.1016/j.mayocp.2017.11.007
M3 - Article
C2 - 29304922
AN - SCOPUS:85040626619
SN - 0025-6196
VL - 93
SP - 59
EP - 67
JO - Mayo Clinic Proceedings
JF - Mayo Clinic Proceedings
IS - 1
ER -