methadone vs buprenorphine/naloxone

[Dr.Placebo]

Hello all.

I am in the "fortunate" <snicker> position of being offered either methadone or Suboxone (buprenorphine/naloxone) for my refractory RLS. I have been taking a very low dose of methadone --1/4 of a 5mg tab once daily--for only 3-1/2 weeks and I fall asleep quickly and sleep uninterrupted about 5 hours and then wake up and feel restless and unable to get back to sleep. Also my RLS symptoms (involuntary twitching) start to come back around 4 AM and bother me all morning until early afternoon. But my main problem is still extreme tiredness and cognitive dullness, as well as worsening anxiety and depressive symptoms. For most of the day I do very little and I often feel too impaired to drive.

I related the above to my RLS doctor via the patient portal and he wrote back, "if you think the cognitive issues are related to the methadone, rather than sleep deprivation or mood disorder, then it makes sense to try switching to buprenorphine/naloxone."

The problem is, I don't know if the cognitive, and mood, problems are due to the methadone or not. I tend to think not, since the main reason I have been seeking help for years is the extreme tiredness and cognitive dullness due to poor sleep, and just recently with intense anxiety and depression which I feel is secondary to the RLS and poor sleep rather than primary (I never had any anxiety or depression until my sleep deteriorated). I also understand methadone can cause or exacerbate depression, and depression in the elderly (i am 62) can cause "pseudodementia" with impaired memory and cognition.

So it's just clear as mud.

My thought right now is initially to stick with the methadone and try increasing to 1/2 a tablet daily and see if I get better (more sleep, less restlessness) or worse (methadone side effect), and then get back to Dr. Winkelman.

Any thoughts? Personal experiences?

Also, even if the methadone wasn't "causing my cognitive issues", if one could choose either medication, is there a good reason to choose one over the other?

Thanks in advance for any input.

Paul

[Rustsmith]

This is one of those situations were we all become an experiment of one. You have probably chosen a good choice to start in that it doesn't require having to get a new med. If that doesn't help after a day or two, then try the Suboxone. I was told to titrate up to 10mg of methadone, but felt groggy, so I dropped back to five for several years. Now I take 7.5mg and do well with it (at least after I started testosterone supplementation to counter that side effect).

[Dr.Placebo]

Yes, I will push my methadone dose a bit and see what happens. Also, any thoughts on the best time to take it? I believe, Steve, you take yours at noon to avoid alerting. I fall asleep very rapidly but wake too early, so don't know if that is "alerting" or not enough methadone. Thoughts?

[Rustsmith]

For me, alerting means that I am wide awake after taking it and cannot fall asleep at all until the alerting side effect has passed. So your situation sounds like it is different than mine.

[tea4one]

Hi Dr. Placebo,

I was wondering if you wouldn't mind giving us an update on your situation. I know that the methadone I'm taking is exacerbating or causing depressive symptoms. Currently, I'm attempting to stay on a lower dose but the RLS symptoms are brutal. Did you ever try the buprenorphine to see if it made a difference?

Thanks, and praying you're doing better.

[debbluebird]

I used to take methadone and gabapentin. They would no longer prescribe methadone. I now take buprenorphine and gabapentin and I'm actually doing better.

[Dr.Placebo]

I just came back to this discussion board (have been too dysfunctional to do much of anything) and noticed a request for follow-up. Well, it's a long story, with no answers, and no happy ending. I ended up switching from methadone 10 mg to buprenorphine transdermal patch (Butrans) at 5 mcg/hr every 7 days. My mood seemed to improve at first and I thought I was going to get my life back.

It was wonderful not having to take pills and be reminded twice a day (I was splitting my methadone dose) that I was opioid-dependent, but the 5 mcg patch didn't control my motor symptoms (involuntary movements) so I actually had to supplement with methadone until I increased to 7.5 mcg/hr patch at which point I stopped the methadone completely.

Then my twitching got progressively worse and I blamed the patch, thinking it was too high a dose; although now I realize the problem is that is was too low and I was having rebound RLS due to abruptly stopping the methadone (dumb, but what do you expect from someone who is cognitively impaired?). My RLS doctor was not familiar with the patch and appeared to be too busy to learn, or even think, about it, so I was self-diagnosing and treating again. and I ended up weaning off it and going back to methadone.

My sleep and mood deteriorated and daytime fatigue, cognitive impairment and twitchiness worsened. I blamed the methadone and had developed a fear of opioids so i never increased the dose beyond 3.75 mg. My doctor never advised me to push it higher. I was having suicidal ideation every day. I follow the UK RLS forum and found that only in the US do we use methadone for RLS; elsewhere they use buprenorphine. I asked to be put on SL buprenoprhine, thinking it would be easier to adjust the dose. I refused to take anything containing naloxone (Suboxone)-(good reasons for that which I won't go into here, but please avoid it if you can), my doctor couldn't figure out how to prescribe generic SL bup sans naloxone, I couldn't get insurance approval for Belbucca film, so I am back on the 7-day patches; which is fine except dosage adjustments are difficult. Started at 7.5 (7.5 mcg/hr x 24 hr/day= 180 mcg/day = 0.18 mg; i.e. a very low dose) and stopped methadone cold turkey. Was not controlled at all on that dose and wanted to die. Just went up to 10 mcg/hr (0.24 mg /day) and now my RLS twitching seems to be almost gone.

Unfortunately my sleep is still poor, my daytime somnolence, fatigue and brain fog are bad and I still have depression, anxiety and suicidal thoughts.

Of course, I can't judge accurately because I am in the midst of my second bout of COVID and this time it's worse than the first. I fear the combination of RLS and Long COVID would be game over.

[Dr.Placebo]

Sorry about that rambling mish mash of a post. One error: I was only taking 5 mg methadone when I first switched to Butrans.

But the short answer is, as far as the depressive symptoms go, i don't see a clear winner yet, but the jury is still out. I have only been on the 10 mcg patch for less than a week. After I get over the COVID I will reassess and let you know.