1180 Restlessness Is a Pain: Methadone Induced Augmentation

• Published in: Sleep (New York, N.Y.) Vol. 47; no. Supplement_1; pp. A504 - A505
• Main Authors: Bliton, Kyle, Jordan, Melissa, Patterson, Patricia, Warren, Josh
• Format: Journal Article
• Language: English
• Published: 20.04.2024
• ISSN: 0161-8105; 1550-9109
• DOI: 10.1093/sleep/zsae067.01180

Abstract Introduction Characterized by a sensation of discomfort in the lower extremities during times of inactivity at night, relieved with movement, and resulting in sleep disturbances, restless leg syndrome (RLS) is a common concern addressed in Sleep Medicine. Providers are equipped with an array of effective non-medicinal and pharmaceutical treatment options including alpha-2-ligands, dopaminergic agents, and opioids. The phenomenon of augmentation is a well described complication of dopamine therapy in patients with RLS wherein symptoms intensify in severity and may spread to include the upper extremities. Here we describe an unexpected case of methadone induced augmentation in a patient with treatment refractory RLS. Report of case(s) Our patient is a 75 year old male who initially presented to our clinic in February 2021 with concern for a >10 year history of treatment refractory RLS. Patient exhibited symptoms typical for RLS with absence of daytime symptoms, muscle cramping, neuropathy, and lower back pain. He had undergone a sleep study in 2013 which demonstrated mild sleep apnea with an AHI of 6.4/hr and periodic limb movement disorder with a PLMI of 105.9/hr. Over the last several years he had failed multiple treatment regimens including low dose lorazepam, Lyrica, Baclofen, Amantadine, and Ambien all of which were ineffective. Both Gabapentin (titrated to 600mg maximum dose) and Mirapex were discontinued due to side effects including itching and constipation/anosmia respectively. Ropinirole was discontinued due to augmentation characterized by worsening symptom severity. Ferritin levels were optimized with iron supplementation. Non-medical interventions including efforts at improved hydration, a structured exercise regimen, and reduced caffeine intake were employed without symptom improvement. He would eventually be initiated on Methadone at a dose of 10mg with marked symptom improvement over the initial 2 months; however, symptoms would once again worsen and progress to involve his arms. Patient self weaned methadone to a 2.5mg dose with good response. Conclusion Though previously reported with Tramadol use, augmentation is rare phenomenon outside the use of dopaminergic agents. We were unable to find other reports of augmentation in the setting of methadone use; however, our patient exhibited worsening symptom severity and progression with improvement on dose reduction. Support (if any)