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Mayo Clin Proc. 2018 Jan;93(1):59-67. doi: 10.1016/j.mayocp.2017.11.007.

The Appropriate Use of Opioids in the Treatment of Refractory Restless Legs Syndrome.

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Department of Neurology and Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN. Electronic address:
Sleep Medicine Associates of Texas and Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX.
Department of Psychiatry and Behavioral Science, Stanford School of Medicine, Stanford, CA.
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.
Methodist Research Institute and Department of Neurology, Weill Cornell Medical School, Houston, TX.
Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, TN.
Department of Psychiatry and Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.


Restless legs syndrome (RLS) is a distinct disorder, differing from chronic pain in many ways. Refractory RLS is characterized by unresponsiveness to dopamine agonists or alpha-2-delta ligands due to inadequate efficacy, augmentation, or adverse effects. This may result in severely impaired quality of life, profound insomnia, and suicidal depression. Opioid therapy is a mainstay in the management of these patients. This article summarizes the basic science and clinical evidence in support of their use, including the positive result of a large controlled multicenter study of 306 subjects, and outlines an approach to their use in clinical practice. Treatable explanations for RLS refractoriness, such as low iron stores, and other therapeutic options, such as combination therapy, should be considered before prescribing opioids. The agents most commonly used are oxycodone and methadone, but tramadol, codeine, morphine, and hydrocodone can also be considered. Controlled-release medication should be used for evening dosage and short-acting drugs, if needed, during the day. Effective doses are considerably lower than used for chronic pain (oxycodone 10-30 mg daily; methadone 5-20 mg daily) and the risk of opioid use disorder is relatively low. However, sensible precautions should be undertaken, including assessing opioid risk with standard questionnaires, using an opioid contract, using urine drug screens, consulting state prescription drug monitoring programs, and frequent reevaluation of effectiveness and side effects. Opioid use in selected patients with refractory RLS may be life-transforming with favorable risk-benefit ratio.

[Indexed for MEDLINE]

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