Best med. to alternate with methadone?

Use this section to discuss your experiences with prescription drugs, iron injections, and other medical interventions that involve the introduction of a drug or medicine into the body. Discuss side effects, successes, failures, published research, information about drug trials, and information about new medications being developed.

Important: Posts and information in this section are based on personal experiences and recommendations; they should not be considered a substitute for the advice of a healthcare provider.
Post Reply
pgwarren
Posts: 7
Joined: Tue Jun 02, 2020 1:23 pm

Best med. to alternate with methadone?

Post by pgwarren »

Hi, All, this is my first post to this wonderful forum.
Some background: I am 71, live in USA, and have had RLS for 14 years. Took pramipexole for 11 years at up to 4 mg/day (far too much; I and my GP didn't know better). Reduced that to 0.5 mg by adding 2100 mg gabapentin. Worked well for awhile until augmentation set in. Switched to Neupro 2 mg, then 3 mg. Then augmented on that. Started methadone in 2018, reduced Neupro. Finally, in 2/2019 I eliminated Neupro (my last DA) over a psychologically hellish month, even with methadone, which kept the RLS in check. Since then, I've been on 12.5 mg methadone at 6:00 PM and 900 mg gabapentin at 9:00 PM. This regimen gave me my life back, no lie. Usually complete control of RLS symptoms, and very little buzz. Able to go out evenings again.
Oh, yes, iron: I had 2 IV iron infusions (InjectaFer) in 2018. Brought my ferritin up from 18 to ~350. Is now ~280. I take supplements now which helps keep it up.

However, there was trouble in paradise: depression emerged starting about 6 months later. (Also, I lost 40 lbs in one year, but my doc said methadone can do that by slowing down digestion. Weight is now stable, and healthy level.) The depression got worse, and starting last Spring I started trying antidepressants. Settled on Wellbutrin XR, but only able to take 150 mg due to side effects at 300.

Recently, at the RLS Summit, I learned about alternating RLS medications from Dr. B.'s talk. He does this with many patients. And now I see some of you are doing that. So I thought it would be better to try to deal with the depression at the source, which is almost certainly methadone, due to the timing. (Although it *could* be the elimination of DAs 3 months later; but I had no other DAWS symptoms that I can recall.) I learned from him that this method can reduce or eliminate depression if it's from methadone, and if alternating with a DA, it can catch augmentation if you switch back at, or just before, first signs of that.

So, my question: what would be the best drug to alternate methadone with (I plan to keep taking gabapentin, 900-1500 mg):
Pramipexole? Prob. no more than 0.25 mg.
Tramadol? I've never taken that, but am seeing some of you have had success with this. However, I'm wondering about too much buzz, or other side effects? And how much would I need?
Other? (Perhaps oxycodone?)
(I considered Neupro, but couldn't figure out how to manage the switchover. Plus, harder to detect arising augmentation...)

And if you've done this, how do you switch over? All at once, or cross-titrate over a few days or more?
Finally, how many weeks or months are you spending on each drug?

Thank you so much for your patience. You are a wonderful group.

Rustsmith
Moderator
Posts: 6476
Joined: Sat Sep 28, 2013 9:31 pm
Location: Colorado Springs, Colorado

Re: Best med. to alternate with methadone?

Post by Rustsmith »

So, my question: what would be the best drug to alternate methadone with (I plan to keep taking gabapentin, 900-1500 mg):
Pramipexole? Prob. no more than 0.25 mg.
Tramadol? I've never taken that, but am seeing some of you have had success with this. However, I'm wondering about too much buzz, or other side effects? And how much would I need?
I also developed depression as a side effect of methadone. At one point I was almost suicidal and would not have survived that week if I wasn't married. I also tried Wellbutrin, which was a major mistake for me. Wellbutrin is in the same chemical family as Sudafed and meth, which caused me such severe arousal symptoms that I did not sleep for a week and my RLS was off the charts.

I switched to Tramadol ER, which has the "benefit" of being a weak opioid and an SNRI anti-depressant. My current treatment regime is 200mg Tramadol ER, 0.125mg pramipexole (to help keep my opioid dose lower), 900mg gabapentin to help me fall asleep and 5mg edible THC to keep me asleep when the gabapentin wears off around 2A to 3A. And for comparison, I have taken from 5 to 7.5mg methadone.

One word of warning about Tramadol, since it is an anti-depressant, it also depresses your sex drive. A frequent off-label us of Tramadol is to treat premature ejaculation in men. I can manage to stay on Tramadol for about a year and then I need to switch back to methadone, which I can stay on for about 9 months before depression starts to be an issue again. I am hoping to be able to try buproprion for my next "cycle" since it is also an opioid with anti-depressant properties, but my doctor needs something to be published in the literature about buproprion and RLS before she is willing to go to battle with my insurance. I am hoping that such a publication occurs soon (by Dr Rye).
Steve

https://www.mayoclinicproceedings.org/a ... 0/fulltext
Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation, and are not medical advice.

pgwarren
Posts: 7
Joined: Tue Jun 02, 2020 1:23 pm

Re: Best med. to alternate with methadone?

Post by pgwarren »

Thanks for your reply, Steve. That's very helpful. You've certainly been through a lot. I'm glad that you seem to have found a mix that's working for you. Interesting that you're finding the THC edible helpful. I should look into that.

So a few more questions, if I may:
- Do you take the pramipexole with both the methadone and Tramadol ER? Or only with the latter?
- Do you get any augmentation with Tramadol?
- How does the Tramadol feel, i.e., the amount of buzz, or high, as compared with methadone? (One of the things I like about methadone is it has minimal buzz for me, so my mental clarity is mostly unaffected.)
- How long did it take for the methadone-induced depression to clear up once you've switched over to Tramadol?
- Any other side effects for Tramadol that I should watch out for, other than the effect on one's sex drive?
- Does the THC edible create much of a buzz? Again, for me, less is better.

Also, I wanted to respond about buprenorphine (I assumed that's what you meant, not bupropion, which is Wellbutrin). You probably know this, but in case not: there are a couple of forms worth considering: Subutex (sublingual tablets), and the less-common, because newer, Belbuca (inner cheek films). (There's also Suboxone, which is buprenorphine plus naloxone, and is geared toward drug abuse treatment. Dr. B. told me that only Dr. Earley uses that form for RLS; most others use Subutex.) Dr. B. favors Belbuca, which he claims is "the best form" of buprenorphine, because it's available in much lower doses than Subutex, and because of this, he says, it may have milder side effects. I haven't tried that yet. I did try Subutex for a few weeks because it was easier for me to get a prescription. But then I started feeling bad from it, and had to stop. However, that's just me. It definitely controlled my RLS symptoms. And it had very minimal buzz.

Rustsmith
Moderator
Posts: 6476
Joined: Sat Sep 28, 2013 9:31 pm
Location: Colorado Springs, Colorado

Re: Best med. to alternate with methadone?

Post by Rustsmith »

Okay, here are my replies:

- I take the pramipexole with both methadone and tramadol ER. With methadone, it helps me drop my dose from 7.5 to 5mg. At 7.5mg, I start to get a spacey feeling and 5mg isn't enough by itself. I have never tried tramadol ER without pramipexole, but it is a weaker opioid and although the MEU calculators are not real accurate from methadone or tramadol, my 200mg tramadol dose is comparable to 5mg methadone.
- I have not had augmentation with Tramadol, but I also don't stay on it long enough for that to happen. Augmentation on tramadol is rare, but it does happen. It took me over a year to augment on pramipexole, so I cannot say what would happen if I stayed on tramadol for longer periods.
- Because tramadol only has a weak affinity for the mu-opioid receptors and is Class IV instead of Class II, I would have been amazed if it did cause a buzz.
- It only took a few days for my methadone-induced depression to lift. Since I quit methadone for a week before switching to tramadol the first time, I know that this was not due to the tramadol's SNRI chemistry but was simply due to stopping methadone. During my last methadone period, I was at a 7.5mg dose (without pramipexole) for a while but started to get depressed again. I dropped my dose back to 5mg plus pramipexole and the depression lifted in about 2 days.
- I haven't had any other side effects from tramadol (other than a lighter pocket book) that I didn't mention earlier. I wish it would help with depression, but I appear to have the genetics that prevent SSRI and SNRI anti-depressants from working.
- Yes, a THC edible will create a significant buzz. The normal "dose" recommended at the shops is 10mg for marijuana novices. I tried that the first night and was barely able to stagger to the bathroom at 2A. I now use 5mg at bedtime and can feel it at 2A (comparable to 2 drinks), but that effect is usually gone (for me) by morning. The edible candies that I buy come in 10mg servings, so I simply cut them in half.

As for buprenorphine, yes I am familiar with Suboxone, Subutex and Belbuca. I also saw that the smallest Subutex dose is rather high. I know of other RLS patients who use either Suboxone or Subutex and each of them cuts the film into halves or quarters to reduce the dose. I remember going through the MEU calculator to get an idea of the Subutex dose and saw that a single dose is more than I need, but I haven't started to worry about that just yet since I first need a publication on its use for RLS to hit the presses and also because I am not scheduled to see my doctor until February.
Steve

https://www.mayoclinicproceedings.org/a ... 0/fulltext
Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation, and are not medical advice.

pgwarren
Posts: 7
Joined: Tue Jun 02, 2020 1:23 pm

Re: Best med. to alternate with methadone?

Post by pgwarren »

Your replies are very helpful, very comprehensive, Steve. Thank you.
I hesitate to ask you for yet more, but there were two things that stood out for me:

- You are continuing with the pramipexole. It looks like you have not augmented on the 0.125 level. That's really encouraging, because I may do the same thing, for the same reason (keeping down the opioid dose)
- Depression: even though you say that reducing or stopping methadone clears up the methadone-induced depression, you say you wish the Tramadol would help with depression. Does that mean that you have some additional, or pre-existing, depression, beyond what methadone creates?

Update: I am starting on pramipexole, 1 x 0.125/day. I have to wait over 2 weeks to talk with my neurologist and try to get a Tramadol prescription. And I had a bottle of 0.125's around from a few years back. So far, in the 2 days since I started, I've been able to reduce the methadone from 12.5 mg down to 7.5 mg. I'll see how far I can go with the 0.125 pramipexole, since I'm somewhat wary of increasing it at all. And because there's a pretty strong mental effect even at this low dose - kind of like having a heavy blanket over my brain. I now remember that feeling, and I'm not crazy about it. However, I'll take that over depression...
I'll let you know how this goes.

ViewsAskew
Moderator
Posts: 16570
Joined: Thu Oct 28, 2004 6:37 am
Location: Los Angeles

Re: Best med. to alternate with methadone?

Post by ViewsAskew »

I augmented at the lowest dose of pramipexole in a week - the doc increased it from .125 up to .75 over about a year. Long story - - I decreased to .125, but couldn't stop it and finally found a doc to help me using methadone.

Sadly, I am one who has tolerance. So, the 10 mg became 12.5, which became 15, which became 20, etc. When 20 wasn't enough, I tried many things. We went through all but 2 opioids. We tried all the formulations of gabapentin. Finally, I said, can I swap pramipexole with methadone?

That was in 2008 or 2009, IIRC. I've been doing it since. I've tried many different ways. Short term wasn't good - I was always in withdrawal because of the long half life. BUT - if I'd done that from the beginning, it might have worked. The longest I was willing to go with the pramipexole was 5 days because I'd augmented in a week.

Around 2013 I had my first iron infusion. My serum ferritin had been 8 - no wonder I augmented. I've had 2 or 3 more since. As long as I keep the serum ferritin over 100, I don't augment quickly anymore. I have tested it over time, starting with one week, then 10 days, then two weeks, etc. I got up to 6 months after my third infusion.

Now, I know how much of each substance is required to manage symptoms to 95% or so coverage. I split the dose between the two, then, over the week, I take a bit more of the pramipexole so I can reduce the methadone, then go back to the 50/50 split. This keeps the methadone dose changing regularly and that seems to keep tolerance at bay.

About every 4-6 months, I completely stop the pramipexole for 2-3 weeks and use only methadone. Then, I go back to using both.

Hope you find something that works for you.
Ann - Take what you need, leave the rest

Managing Your RLS

Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation, and are not medical advice.

Rustsmith
Moderator
Posts: 6476
Joined: Sat Sep 28, 2013 9:31 pm
Location: Colorado Springs, Colorado

Re: Best med. to alternate with methadone?

Post by Rustsmith »

- You are continuing with the pramipexole. It looks like you have not augmented on the 0.125 level. That's really encouraging, because I may do the same thing, for the same reason (keeping down the opioid dose)
- Depression: even though you say that reducing or stopping methadone clears up the methadone-induced depression, you say you wish the Tramadol would help with depression. Does that mean that you have some additional, or pre-existing, depression, beyond what methadone creates?
You are correct that I have not reverted to augmentation on the low dose of pramipexole. But I should add that my ferritin level is quite high (ranges from 250 to 600). I am not sure what would happen if my iron levels were lower or if this is due to the opioid covering any symptoms of augmentation. Either way, I am not going to question the fact that the combination is working right now.

As for depression, I have had a chronic low level depression ever since high school (I am now 68). I also experienced severe trauma last Christmas at the hands of a psychiatric hospital. I wish that I could explain more, but I have a medical malpractice suit that is pending and cannot document anything about it in any written form (except to my attorney) other than the fact that the state recently closed the facility and moved all of their patients to other hospitals. Conventional anti-depressants are not effective for me and the only med that I have found that helps my mood is a serotonin agonist (sumatriptan) that I take for migraines. Unfortunately, the triptan class meds can only be taken ~9 times/month without risking rebound migraines, which for me is a condition that is comparable to suicidal level depression for sheer misery.
Steve

https://www.mayoclinicproceedings.org/a ... 0/fulltext
Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation, and are not medical advice.

pgwarren
Posts: 7
Joined: Tue Jun 02, 2020 1:23 pm

Re: Best med. to alternate with methadone?

Post by pgwarren »

Thank you both for your replies.
Ann, your solution is interesting. I'm glad that has solved the tolerance buildup issue. Do you find that you augment on the pramipexole after awhile and need to take a break from it for awhile? And if so, do you increase the methadone during that break?

Steve, I'm very sorry to hear that you had such a traumatic experience at that hospital. I wish you luck with the malpractice suit.
Regarding your regimen, when you switch between methadone and Tramadol, do you do it all at once, or over several days?
And do you ever experience any withdrawal symptoms when you switch from one to the other?

Since this is my first switchover from methadone to pramipexole, I'm taking it a little slowly. I think I'll take a week. It's now day 4, and I'm down from my usual methadone dose of 12.5 mg to 5 mg. I'm taking just 0.125 mg pramipexole throughout, along with 1500 mg gabapentin. (I usually take just 900 mg, but I wanted to give the pramipexole a helping hand.)
Even though I'm trying this methadone/pramipexole alternation, I am still planning to try it with Tramadol in place of (or in addition to) the pramipexole. Will be seeing my neurologist in a week to ask for that prescription.

Rustsmith
Moderator
Posts: 6476
Joined: Sat Sep 28, 2013 9:31 pm
Location: Colorado Springs, Colorado

Re: Best med. to alternate with methadone?

Post by Rustsmith »

when you switch between methadone and Tramadol, do you do it all at once, or over several days?
The first time that I switched, I had been off of methadone for seven very miserable days (due to uncontrolled RLS and not withdrawal, which was the easiest first 24 hrs). The second time, I started from 5mg methadone, so I took 2.5mg methadone and 100mg tramadol ER for five days and then went to zero methadone and 200mg tramadol ER. Throughout this process, I was also taking 0.125mg pramipexole, 900mg gabapentin and a 5mg THC edible at bedtime. That process went very smoothly with no withdrawal.

I am not sure how we will work the reverse process since I have no desire to go through SNRI withdrawal again. If I don't switch to buprenorphine, then I suspect that instead of a five day transition, that it will be more like 25 days. It may also involve taking 50mg tramadol for a while even once I get to 5mg methadone. The thought of opioid withdrawal doesn't bother me (uncontrolled severe RLS is far worse), however, the thought of SNRI withdrawal bothers me quite a bit.
Steve

https://www.mayoclinicproceedings.org/a ... 0/fulltext
Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation, and are not medical advice.

ViewsAskew
Moderator
Posts: 16570
Joined: Thu Oct 28, 2004 6:37 am
Location: Los Angeles

Re: Best med. to alternate with methadone?

Post by ViewsAskew »

pgwarren wrote:
Wed Nov 04, 2020 11:26 pm
Thank you both for your replies.
Ann, your solution is interesting. I'm glad that has solved the tolerance buildup issue. Do you find that you augment on the pramipexole after awhile and need to take a break from it for awhile? And if so, do you increase the methadone during that break?
I haven't augmented yet. But, I took YEARS of increasing it slowly and I also get iron infusions to keep my serum ferritin quite high. I originally augmented in about a week. So, I was SO careful initially. Once my ferritin was over 100, I slowly increased it - a week, then two weeks, etc. I'd take a break in between. Once I got up to 6 months, I stopped. I just take a break at 6 months - take 2 weeks off and increase the methadone to cover the symptoms.

It's too late for me to prevent dependence, so I cannot stop the methadone without withdrawal. But, I do reduce it to as low as I can over 2 weeks and increase the pramipexole. I usually do that right after I start the pramipexole again. All of that helps with the tolerance.
Ann - Take what you need, leave the rest

Managing Your RLS

Opinions presented by Discussion Board Moderators are personal in nature and do not, in any way, represent the opinion of the RLS Foundation, and are not medical advice.

Post Reply