It's cheap for the user to purchase?
Also Splat, thanks for the info. I don't know much about it but I guess what I have heard about it sounded pretty serious. I hope they are maintaining it well for you. Are you saying the doses you are receiving are lower than the doses on a maintenance opiate plan would be?
All I know is I ended up trapped in a rehab facility on top of a mountain and they thought for the entire 30 days that I was a Methadone addict and I purchased it on the internet. -.- That was annoying.
No problem. I noticed even from people I am friends with, they don't quite understand what RLS and/or PLMS is, or just associate it with opioid WDs. Even physicians aren't very knowledgeable about the conditions, especially if they aren't say a specialist in neurology or sleep conditions. It hasn't been till recently that physicians are taking the condition much more seriously. Even patients/individuals who have/may have RLS take an extend period of time to seek help, or don't seek help for their problem. The condition can be seen as fake, resulting from other health conditions (physical or mental, which can be true), and even just ignored. Now some people can "get away" with not treating the condition, and just deal with the consequences (daily fatigue, poor concentration, depression, anxiety, etc.). These consequences can be more severe for some than others. Some individuals will have drastic negative problems in their life; loss of job, relationship issues, increase risk for physical health problems, etc. Others will just feel tired in the morning and have to work harder to get their day going. For individuals with less server RLS, or with a known cause for the RLS, can treat the problem with exercise (a period of time a few hours before bed), a warm bath at night, elimination of caffeine, alcohol and nicotine, iron supplements (iron deficiency can cause RLS), giving birth to a baby (RLS is seen in higher frequencies with women when they are preggos), having consistent sleep schedule, getting rid of stress/depression/anxiety etc. Others need drug therapy.
Dopamine agonists, specifically commonly in the recent years, prampiexole or ropinirole, will be the first line treatment. These dopamine agonists are D2, D3, D4 agonists with generally small Ki values for D2 and D3 receptors. These drugs are also used for Parkinsons treatment, helping with of similar physical movements resulting from an imbalance/abnormal concentrations of these receptors in specific areas of the brain (these receptors are inhibitory receptors unlike your D1 and D5s that excitatory [also are in higher concentrations in different parts of the brain], which some stimulants active in laymans terms). One annoying part about these agonists are they take a few weeks for them to start functioning properly, as they attach to the presynaptic receptors (auto-receptors - control the neurons which are sending the signals to the next neuron, aka altering functioning) which are of higher sensitivity from the get go. Once they sensitize the auto-receptors their action at post-synaptic receptors become predominate. Their specific mode of actions are seen to have a large number of potential side-effects as well. I personally couldn't stand them, even though I found them to be one of the best drugs for social anxiety I've ever tried, and have the potential be very good anti-depressants (especially for those with treatment resistant depression). They made my impulsiveness go nuts (waking up in the middle of the night to eat), steal drugs from relatives (I felt super bad about this), spend money I should have, made me extremely tired during the day, and the ropinirole actually made all my joints/muscles ache. Also, there is a thing called augmentation, which is the RLS symptoms occurring earlier and earlier everyday, and sometimes at greater intensity. So, in long term therapy one might need to take a holiday from them, or discontinue them indefinitely. When discontinuing dopamine agonists, the WDs have been compared to opioid WDs. The RLS symptoms become also intensified where opioids are commonly used to ween off the dopamine agonists to make the transition back to no medication easier. DAWs (dopamine agonist withdrawal), can be long lasting similar to PAWs as well.
Benzos, especially clonazepam are prescribed sometimes as first line, or after/with dopamine agonists. Clonazepam is the only FDA approved benzo for treatment for RLS. Temazepam is also used as well. The problem with benzos are they don't actually help/eliminate any of the symptoms of rls or plms (they are more commonly used to treat PLMS [periodic limb movement syndrom]), and can have a negative effect on ones sleep cycle. Not to mention the well known problems with dependence, which can result in lasting gaba a modulation once discontinued. Docs script them cuz they don't know better alot of the time, and they work well at knocking people out/keeping them asleep. So essentially they can be used to try and cover up the problems of RLS/PLMS.
Anti-convulsants like gabapentin (neurontin) or pregabalin (lyrica, btw expensive as shit), as also used for second line treatment or with dopamine agonists. They can be beneficial for a lot of individuals with RLS, ones with no neurological pain, and with neurological pain (they are also scripted for say fibromyalgia, or other neuropathic pain problems). They can be used incombination with dopamine agonists, or with benzos if they don't help one fall asleep. I personally didn't find gabapentin to do much at all for my RLS. It help a tiny, tiny bit, but I'd still be uncomfortable for a good portion of the day. It is fantastic for helping stabilize my mood and social anxiety, but I couldn't use it for RLS or PLMS.
There are some experiences using alpha-2 adrenergic agonists like clonidine for RLS, but there are mixed results, and can be tired at the discresion of the prescribing physician. People do find it helps with opioid induced RLS.
Opioids, both low potency and high potency are used as second line or third line (high potency) medications, also with or with out other medications discussed above. Opioids are used frequently for refractory cases (like daily cases) and painful RLS cases. Low potency opioids like tramadol or dextropropoxyphene (this used to be very successful for RLS before it was taken off the market) are commonly the first opioids tried. They can work very well, and when I had a low tolerance to opioids tramadol actually worked well, but currently (for the past 6-9 months) it just helps eliminate the painful sensations of RLS, but doesn't help my legs get comfortable. It also was too stimulating for me, especially the higher the dose (I was taking 200mg a day). Other low potency opioids like codeine or hydrocodone (more commonly hydrocodone) are also used. Hydrocodone more so, but the problem is the shorter duration and the only formulas available atm besides specialty compounded formulas have APAP which has no benefit. People sometimes have to take multiple doses through out the day or even wake up in the middle of the night when the hydrocodone stops working. Higher potency opioids like oxycodone, levorphenol, and methadone (particularly oxycodone and methadone) are used when the lower potency don't work or the doses become to high (no more than 400mg of tramadol a day, taking to much APAP with hydrocodone is a no no). These are always saved for for the most severe cases of RLS that are daily problems. On
http://www.rlshelp.org/ you an read stories of individuals who have such severe cases you'll understand why they need them. Depending on when the symptoms start or what the physician prefers scripting, oxy or methadone will be used. Methadone has been seen from my experience to be used in more studies, and have more advantages over oxycodone, but both work well. Methadone also has NMDA-antagonism and light SNRI effects (s-isomer is the potent nmda-antagonist, as well as a light SNRI) which has been seen to work well for pain involving neuropathic issues, as well as other forms of non-somatic pain. It also builds up a steady state concentration (though some studies show some fluctuation of concentration through out the day), and it's half-life increases the longer one takes it (going from 22-24 hours up to say 60 hours). The abuse potential of methadone is lower than that of oxycodone or other high potency opioids, has reported lower levels of euphoria, and is cheap as fuck. Especially if one needs the extended release oxycodone or other high potency opioid ERs, methadone is like a 1/10 of the price per month.
Not matter what opioid essentially is chosen, the efficiency of the opioids remain close to the same as when the therapy was initiated, even over a period of months and years. There are studies that show 75% of symptom reduction using opioids for 18+ months, with no increase of dosage. There also isn't the augmentation seen with the dopamine agonists, which can be a huge problem for individuals with severe RLS. The side-effects of opioids are pretty minimal, with the biggest being addiction. Constipation, and somnolence (which is seen with basically all other meds) are really the only other common side-effects that could be serious or very problem some. Opioids also don't have the negative impact on the natural sleep cycle like what is seen with benzos, and can reduce the number of limb movements per hour, which benzos also can't do (assocatiated with PLMS). So potentially opioids can help with both RLS and PLMS, not by masking the conditions but by preventing the symptoms from happening.
I need to read up more on what happens pharmacologically when opioids are used, but I'm quickly just spouting out the information I've learned over the past couple months from the top of my head.
Oh yeah, there are also some evidence that NMDA-antagonists like ketamine can be beneficial for RLS interestingly enough. Weed of course as dexter has mentioned can help, though there aren't really studies on it's use for the RLS sadly.
Also, anti-depressants (SSRIs, SNRIs, MAOIs) all can make RLS worse. Ironically as individuals with RLS and or PLMS have a high chance of also suffering from depression. Wellbutrin is the one anti-depressant I've seen that is recommend for individuals with RLS that also need an anti-depressant.
I personally find that methadone works well as an anti-depressant. Maybe it is it's effect on the kappa receptors (I find buprenorphine to be a pretty good anti-depressant and it has a decent effect on the kappa receptors), it's effect on the mu receptors, or even it's effect nmda-antagonism depressant effect through TOR like ketamine (I believe its activated through the nmda-antagonism, ?). I find tramadol to have decent anti-depressant effects as well, though it also has a strong SNRI effect with the nmda-antagonism. Methadone has some SNRI effect, seen with a higher activity from s-isomer (same with the nmda-antagonism), so that could also play a role. Maybe even just getting some solid sleep, and a healthier sleep cycle is where most of the anti-depressant effect comes from.
/rant