Methadone & Tramadol together?

[Gerret]

Hello All,

57 year old male with 10 years RLS “experience”.
Currently taking methadone, kratom & med marijuana.

Here’s my story:
I used to think I had insomnia and on sleepless nights I would often take 3 AM walks abound the block. I went to my GP for this and was prescribed Ambien which barely worked. I took Ambien for 2 years then on one sleepless night in 2012 I found myself stumbling onto this bulletin board after some Google keyword searches. I had never heard of RLS before landing here but immediately knew I had found a new home. Almost every post I read sounded like my own story. Armed with this new info I went back to my GP and said “I think I have RLS”. She prescribed Mirapex and to her credit gave me some accurate info on augmentation and rebound. I was started on .125 mg and was warned that when I hit a dose of 1.5 mg that she was going to cut me off cold turkey for 8 weeks and then we would start all over at .125 mg.

At first Mirapex was a godsend. It completely “cured” my RLS but I was also horrified of being cut off in the future so I did every thing I could to stretch out the upcoming dose increases. I lasted 6 months on .125 mg so on to .25, .375, .5 & then (7 years later) .75 mg where I started having rebound & nausea. My GP suggested I see a neurologist for future treatment and as luck would have it there was one listed in my hometown on the RLS.org website.

The first thing this neurologist did was cut back the Mirapex to .5 mg max daily (in 2 doses) and added oral magnesium, vitamin B and the OTC sleep aid Alteril. At first this seemed to work, especially with the nausea, but I soon found myself getting less & less sleep. I would take .25 mg Mirapex at 7 PM & another .25 mg 2 hours later at 9 PM then would go directly to bed and last until 5 AM, then 4 AM, then 3 AM…

I planned on bringing this to the neurologist’s attention at my next visit but it was now the middle of Covid and he was only doing virtual visits and my plan was to ask for methadone. I went ahead and scheduled a virtual visit which had the most unexpected outcome. I was told to expect a video call from the Dr. at 2:40 PM but he instead called at 1:00 PM. It wasn’t until we got to discussing my meds that I figured out that the Dr. had accidentally called me instead of his real 1 PM patient whose file was in front of him. Once I pointed out who I really was we both chuckled, the office manager was yelled at and my file was produced so that we could start over. I told him about the increasing lack of sleep and he added a low dose of Doxepin. Even tough I really wanted methadone I could tell that asking for it now would be awkward so I let it be.

Having never heard of Doxepin I Googled it and read enough user stories to know that this was a drug I wanted to avoid so I decided to not even pick it from the pharmacy. But this presented a problem…I was also almost out of Mirapex that day and too lazy to go pick it up. So I came up with the following solution: I had some left over Mirapex in my car which I would survive on until Monday (it was now Thursday) when I would take another crack at the neurologist for methadone.

That Thursday night I took my last current .25 mg Mirapex at 7 PM then one of my “spares” at 9 PM. I woke up at the usual time but strangely felt almost good. I usually woke up with nausea. The next night I took 2 of my “spares” and although I woke up ½ hour earlier, I felt GREAT! Completely confused by this I checked the Rx bottle to make sure it really was Mirapex and noticed it had expired 4 years ago. So the next night I only took 1 of my “spares” and woke up feeling just as great. The next night I dared to take none but broke down at 11 PM and took one, but the following night I made it Mirapex free and continued to feel great.

I need to bring in Kratom at this point. I learned of Kratom on this BB years ago and soon developed a great and lasting relationship with it. I can’t say enough good things about Kratom. I have always taken Kratom as needed (with Dr. approval) but was now using it to fill in for the missing Mirapex. Even though Kratom takes away my RLS 100% it has an Achilles heal in that it only provides relief for 2 hours.

So I started taking Kraton at night for sleep which required getting up every 2-3 hours and taking an additional dose. Fortunately at my age I’m getting up to pee at night more often so it really wasn’t that bad and was WAY better than Mirapex hell.

I lasted on this Kratom only diet for 4 months until sleep deprivation started kicking in. I was only getting sleep in 2 hour increments and I guess you can’t do that long term. If you’ve ever had real sleep deprivation you’ll appreciate why it’s used as a very successful torture method.

Now December 2020, my Neurologist was seeing masked patients in his office so I decided to try for methadone again. I took a print out of the Mayo Clinic study with me which he copied and put in my file. It was quite easy to talk him into methadone so he prescribed 5 mg tablets & I took ½ for 3 days, 1 for 3 days, 1-1/2 for 3 days and then 2 tabs (10 mg) daily for 9 months.

Once on 10 mg my RLS was again “cured” and I could sleep at will whenever I wanted. What a luxury! And sleep I did! Adding up my multiple daytime naps plus nights I was snoozing 18 hours / day. At first this was OK since I hadn’t been vaccinated yet and was isolating with my wife but once I did get jabbed it became a problem.

Again with the help of this BB I soon found other postings about methadone causing “apathy” and as before they were almost all “my story”. Armed with printouts of all these apathy postings I went to the neurologist and asked to try a different opioid. My first choice was morphine but he wasn’t willing to stick his neck out that far but was willing to try Tramadol. He prescribed 2X daily Tramadol 50 mg but I immediately found out 2 things, 1) Although Tramadol knocks down my RLS 100%, it only lasts 3 hours after taking it and takes 2 hours to kick in (Kratom lasts 2 hours and kicks in within 10 minutes). The other problem is that 50 mg of Tramadol gets me so high that taking in the daytime would be prohibitive.

I lasted 8 days on this Tramadol test then phoned the Dr. and got put back on 10 mg methadone until my next monthly appointment.

At this next appointment (2 weeks ago) we discussed many strategies but both settled on retrying Mirapex which I had been off of for 13 months. He prescribed .25 mg tabs which I have been cutting in ½ and taking 1 daily while slowly reducing the methadone. I am now 9 days in and am experiencing quite bad nausea even tough it took 4 times this dose for nausea to rear its head the first time around. As a side note, during these 9 days a .125 mg dose has provided 100% RLS relief.

Faced with nausea again last night I passed on the Mirapex with the intention of returning to methadone which was now tapered down to 2.5 mg daily. But instead of taking 10 mg methadone I only took 5 mg with the intention of slowly increasing it in hopes of finding relief below 10 mg. I took this 5 mg at 5 PM but when I went to bed at 9 PM I added a single, one time, 50 mg Tramadol “just to knock me out quick” and ended up having a reasonably good night’s sleep and woke up feeling good and energetic.

So this got me thinking… Is concurrently taking 2 miniscule doses of 2 different opioids an RLS strategy that any of you have experience with?

My guess is that the Tramadol is contributing some anti-depressant effects which when added to the 50% reduction in my methadone dose is countering its apathy side effect.

Since I have enough of both drugs on hand, and considering how low the doses are, I feel safe in continuing this experiment for the next 2 weeks until my next appoint where I will discuss this as a viable strategy with the neurologist.

I’m also curious if any of you brave souls that have retried Mirapex after quitting for a while have experienced any nausea immediately upon restarting at a low dose. Did it get better over time?

Sorry for such a long post but since I so enjoy, and benefit from, reading your postings, I thought I’d give you as much detail as possible.

Thanks.

[Rustsmith]

Gerret, I have never had any nausea issues with pramipexole, so I cannot provide much constructive info to your question. What I can tell you is that "Mirapex" is a tradename and applies to just one company's product. However, there are a number of companies that produce generic pramipexole. I have seen comments about pramipexole from one company not being the same as true "Mirapex", which probably has to do with the fillers used to manufacture the pills.

As for methadone vs. tramadol, it is pretty obvious from your message that what you were prescribed is tramadol, which is a short acting form of the mild opioid/anti-depressant. The half life of methadone is 36 to 48 hrs. The half life of tramadol is 5-6 hrs. Tramadol is also a weaker opioid than methadone. My current RLS treatment plan has me switching between methadone and tramadol about every six months. However, when I am taking tramadol, I take Tramadol ER (extended release). The ER form is intended to last 24 hrs, which makes it more like methadone. However, the doses of methadone and tramadol ER are not equal. When I am on methadone, I take 5 mg/day. When I am on tramadol ER, I take 400mg/day. So you 50mg tramadol pill is not a replacement for 10mg of methadone.

[Gerret]

Hi Rustsmith,

I have a few questions about your 6 month regimen of switching opioids but wanted to wait until my next neurologist appointment to report on his opinion of me taking both opioids concurrently and that appointment was yesterday.

As a quick update to my original post, instead of taking my prescribed 10 mg daily methadone I had taken 5 mg methadone and 50 mg tramadol the same evening as an experiment and had a very positive response. I continued this experiment for the next 16 evenings until my next appointment and my neurologist is just fine with this regimen and renewed both opioids with instructions to carry on. I continue to feel much better, especially mentally, when taking both than I did when taking 10 mg of methadone alone.

I also discussed with him the possibility of switching to just the extended version of tramadol which he was not in favor of at this time especially since this dual opioid therapy was working so well. He did warn me however that Tramadol ER would not be covered by my insurance because it would be an off label Rx and that the drug is quite expensive.

So, to my questions if you wouldn't mind...

What circumstances arise that cause you to switch from methadone to tramadol and back every 6 months?

Do you ever detect any signs of augmentation on either drug?

What side effects do you get from each drug?

What kind of RLS relief do you get from each drug? (i.e. 100% "I'm cured" type relief or does it just knock it down partially)

When you switch from tramadol to methadone, do you taper off the tramadol in any particular way? (I ask this question because I've read that quitting tramadol cold turkey can cause PTSD type symptoms)

Do you notice any mood changes between the two drugs?

Thanks.

[Rustsmith]

I switch between the two because of different side effects with each. With methadone, I start to get depressed, which can get increasingly severe the longer I wait. With tramadol, the issue is sexual. Tramadol is also used to treat premature ejaculation, which I do not have. So I can only stand taking it for so long before it becomes a case of enough is enough.

As for tapering the tramadol, I take the ER version and normally take 200mg. So I drop to 100mg ER for 3 or 4 days along with starting the methadone. Then I switch to 100 mg non-ER 2x/day for 4 days, then 100 mg day for 4 days, then 50 mg for 4 days. I didn't have any problems with that.

I am the person who was forced to stop it abruptly the first time that I stopped. The side effects included an abnormal migraine headache that required phenobarbital for relief, terrible nightmares and severe anxiety and depression that lasted for months and was only resolved through therapy with EMDR. There are several names that describe the problem, including SNRI withdrawal syndrome, SSRI withdrawal syndrome and serotonin withdrawal syndrome.

[Gerret]

I also read that Tramadol is prescribed (off label) for premature ejaculation. In addition to my neurologist I also saw my urologist last week so I asked him about just that and he replied that he had never heard that before. Doesn't mean it isn't true.

I had a similar effect when on 10 mg methadone alone and discovered that taking my dose immediately after sex resulted in that dose having deteriorated through my system for 23-1/2 hours and would be worn off just enough to make sex possible the next day. Any less than 23-1/2 hours and sex was neither possible nor even desirable.

I find sex far less challenging on my current 5 mg dose of methadone and since my Tramadol is the short acting variety which I take at bedtime (sleep time) it's long out of my system by the next day and doesn't seem to be interfering.

Time will tell how long this half methadone / half tramadol regimen works.

[badnights]

I continued this experiment for the next 16 evenings until my next appointment and my neurologist is just fine with this regimen and renewed both opioids with instructions to carry on. I continue to feel much better, especially mentally, when taking both than I did when taking 10 mg of methadone alone.

Yay!!!

I also discussed with him the possibility of switching to just the extended version of tramadol which he was not in favor of at this time especially since this dual opioid therapy was working so well.

"If it's not broken, don't fix it"

Tramadol is the only non-dopaminergic medication that has been reported to cause augmentation, and those reports are somewhat in doubt. So you shouldn't have to worry about augmentation with either Tramadol or methadone.

You actually shouldn't aim for 100% relief. Doctors and patients have noticed for years that 100% relief leads sooner to loss of efficacy of the medication and consequent dose increases (and side effects and so on that tend to come with dose increases).