methadone-gabapentin conundrum

[Bluejay]

I was diagnosed with RLS April, 2019. At that point I was down to as little as 2 hrs sleep per night wearing out the carpet with my walking. I'm new to the forum. Tried gabapentin alone initially but it didn't hold me--helped with the pain, but not enough. I was on Neupro for short period but didn't enjoy skin irritation. Methadone was added. At one point I was on gabapentin 2400 mg/day and I did not experience tremulousness or bothersome side effects at this level. When methadone was added gabapentin was tapered to 600 mg AM, 600 mg 8 PM, 600 mg hs. On this I was getting panic attacks in early evening (~4-8 PM) and about 6 AM. When gabapentin was changed to 600 mg 7 AM, 600 mg 3 Pm, 600 mg hs, my panic attacks went away. Seemed like I was very sensitive to peaks and troughs of gabapentin. Have been on same regime of gabapentin for 2 months. When got to 10 mg methadone/day at hs, pain was almost gone, but found myself awakening about 6 AM with horrendous tremors and feeling quite agitated. It could take until the afternoon to start feeling better. When decreased to 7.5 mg/day the tremulousness, and especially the agitation decreased, but tremulousness is still bothersome for me. I'm taking 2.5 mg methadone in AM and 5 mg hs. Have been on 7.5 mg total dose for 30 days. Sleep pattern is still pretty bad. I get sleepy after taking hs meds, but awaken after only about 1 hr with a start. Then sleep is very interrupted. I may get a 2 hr block of sleep if lucky. In period from bed time to 3 AM pain is pretty well controlled but I am still waking up after short stints of sleep. Some twitching present, but not a major problem for me compared to pain. Also beginning around 4 AM I begin to get uptight feeling and eventually find myself up pacing, only to have symptoms recur when I get back under the covers. Getting up, I find uptight feeling goes way very quickly, tremulousness noted at that time tends to start gradual decline during the day. I don't know what is producing what. Tremulousness seems worse in AM and lessens as day wears on. Anyone get tremulousness from methadone? I suppose the events post 4 AM could actually be RLS. Anybody out there have an experience similar to mine? Suggestions?

[Rustsmith]

I have never had the issues that you mention with gabapentin, but then I have only been to 1200mg/day.

You did not say what time of day that you take your methadone. Many doctors advise you to take it at bedtime thinking that it has sedative qualities. I found exactly the opposite. Methadone added to my insomnia and since it has a very long half life, I decided to take it at lunchtime rather than in the evening. The exta few hours helps the opioid induced insomnia to wear off and then allows my gabapentin to do it's job at bedtime.

[QyX]

I am sorry, what do you mean with "hs"? I tried to google it but couldn't come up with anything useful.

The issues you are having right now sound similar to the ones I was having for multiple years, just not being able to stay at sleep and being unable to sleep at certain hours altogether.

Most likely there are various factors at play: while Methadone seems to help you with pain related symptoms, it also seems to have stimulating properties. Methadon is well known for causing insomnia and keeping people awake. Additionally it seems your dose also is not high enough since you still seem to experience a significant urge to move. So before the exact reasons for the current insomnia can be determined, it would make sense to evaluate how things change when you would increase the Methadone further, like from 7,5 to 10 mg. But this is of course something you should speak with your Dr about.

Also it might make sense, if it is determined that Methadone itself is responsible for some of the symptoms you are experiencing, to switch to a morphine related opioid. Hydromorphone and Morphine seem to cause less insomnia than Methadone and Oxycodone, too.

Overall my impression is that you are not tolerating the Methadone very well. Of course, Methadone is known for having lots of side effects and therefore has a horrible reputation in patients who have to use it for opioid replacement therapy. However it is important to keep in mind that some people tolerate Methadone better than Morphine and its relatives.

Additionally: some people metabolize Methadone much much faster than the average person. In a certain way, it almost sounds like Methadone stops working in the middle of the night. Otherwise: why would you suddenly the need to get out of bed and pace around? There is a test available to check if you are a rapid metabolizer of Methadone. This is a somewhat common issue in opioid replacement therapy.

Your Gabapentin dose: why not increase it again and see if can improve the symptoms at night and help you stay asleep? At least I would try this before taking more opioids.

As you see, there are many potential explanations for your symptoms. You need to speak with doctor about it in detail. What has he said so far? Would he switch you to a morphine-like opioid?