A ReLACSing Blog #21: Why Are Doctors Unwilling to Prescribe Opioids for Restless Legs Syndrome?
With the medical field moving (too slowly) away from dopamine agonists (DAs) as the mainstay of treatment for restless legs syndrome (RLS), opioids have become increasingly needed for moderate-to-severe RLS when first-line therapies like iron or alpha-2-delta ligand medications (e.g. gabapentin, Lyrica) have not been effective or tolerated. They seem to be needed the majority of the time in those with augmentation to get off the DA causing it. Why is it then that many patients with RLS find it hard to find doctors willing to prescribe them? Here we will assess the numerous reasons for opioid hesitancy (not to steal a COVID-era term) among medical professionals.
Opioids are potentially dangerous, even life-threatening drugs. The CDC (gosh, can’t seem to avoid these COVID-related hot button terms!) reports 564,000 opioid-related deaths from 1999–2020. Opioids at a higher dose than a person is accustomed to can cause the breathing centers of the brain to become impaired, leading the body to be unable to breathe for itself, possibly resulting in death. This is one of the many reasons I advocate for buprenorphine as the opioid of choice as its unique properties generally avoid this risk. If you overdose on your iron supplement, you probably get a stomachache, throw up, or get really really constipated. If you overdose on gabapentin, you may get loopy and off-balance. If you overdose on a standard opioid, you could be dead. In addition, opioids have a risk for chemical dependence and addiction. Given the relative dangers compared to other treatments, clinicians want to avoid prescribing them.
As a result of the last point, clinicians are afraid of repercussions from writing opioid prescriptions whether real or perceived. You hear in the news of physicians having licenses revoked related to inappropriate opioid-prescribing or even going to jail for kickbacks and illegal money-making schemes. Doctors are afraid of something bad happening to a patient and then getting sued, particularly as society is looking to point the blame amidst the opioid epidemic. With careful patient selection, thorough education of patients, monitoring, and other good practice principles in place, these risks and those discussed in #1 are dramatically reduced, but providers’ perceptions may not be.
3. The pendulum has swung too far to the other side. Maybe 20 years ago, we were handing out opioids like candy on Halloween. Strained your low back lifting a heavy pillowcase of the (aforementioned) Halloween candy without bending your knees properly? Here’s a few dozen oxycodone to help with the pain. Now? Opioids are poison. Lop off a few fingers with the chainsaw you used as an ill-advised prop during Halloween festivities? Well, anti-inflammatories and ice may be a better option. (As an aside, this post is clearly from January, so I have no idea why Halloween is on my mind. Maybe it’s because retail stores are already clearing the shelves from Valentine’s Day treats and even 4th of July decor to make way for the Halloween candy). The problem in this tribal, black-and-white, us-versus-them, post-COVID era is that the medical field may be applying a morality judgment to opioids now. That judgment is that opioids are evil.
4. Opioid-prescribing is a tremendous hassle. Aside from having to spend considerable time discussing the above risks and vetting patients for appropriateness, you have urine drug screens, opioid contracts, one-week initial prescriptions, then 30-day maximum prescriptions, no refills allowed for most opioids, frequent clinic visits, reviewing the pharmacy database prior to every prescription, and other work beyond a standard medication. Physicians and staff spend time on the phone with pharmacies regarding finite changes to prescriptions now. If a patient is due their Day 30 methadone refill on a Saturday but is going out-of-town for the weekend, the pharmacy may not fill the prescription a day early without a new prescription written by the physician. What if a patient from Minnesota is traveling to Arizona for two months in the winter? Where will they get the refill? Will the pharmacy in Minnesota allow a two months’ supply? Probably not. Will the pharmacy in Arizona fill an opioid prescription from a Minnesota doctor? It is no doubt a laborious process.
5. Some doctors have blanket policies against opioids out of sheer convenience. Based on #1–4 above you may see why, but I contend it is cop-out to say, “we don’t prescribe opioids at this clinic.” Really? Are there no appropriate medical indications for opioids any more that you can just choose to leave them off the treatment list entirely? Why are opioids even on the market then if you are not going to use them in any of your patients under any circumstance?
Let’s say you are invited to your aunt’s house for Halloween dinner and she is serving up that dry meatloaf again. Wouldn’t it be easier just to be vegetarian? “Auntie, I’m sure it is succulent and savory, but I don’t eat meat. I am a vegetarian.” In a way, doctors have adopted the refusal to prescribe opioids like it’s a lifestyle choice, personal creed, or religious precept. “My physician-religion does not permit me to treat patients with opioids. You should go to those other people at that clinic who find this behavior acceptable.” Yes, many doctors may feel uncomfortable with the bullet points above or have insufficient knowledge of these medications. Unfortunately, it has become acceptable in medical culture to ignore the clear denial of a legitimate treatment option to patients out of convenience.
OK, I’m going to call out my own apparent hypocrisy to drug-prescribing before those of you who know me do. Yes, I generally have not prescribed hypnotics (sleeping pills like Ambien, Lunesta) for chronic insomnia. Cognitive and behavioral therapy for insomnia (CBT-I) is by far the gold standard of treatment. Most sleep physicians do not have the time to administer CBT-I, and it is hard to find therapists who offer this. Thus, many revert to sleeping pills even though they are not likely to be effective for long-term treatment. Historically, I have always tried non-medication, behavioral interventions first and then referred to a CBT-I provider if the patient is not responding. I have not, however, been fundamentally opposed to hypnotics if CBT-I had been ineffective. I fortunately can now do full CBT-I myself given autonomy over my clinic schedule within the direct care membership model, so this rarely comes up.
Yes, I am very tribal when it comes to being in the anti-dopamine agonist camp for RLS as well. Why? For long-term use, prescribing DAs, even to avoid using opioids, dooms a patient to what may be inevitable augmentation and chemical dependence, the result of which may lead to struggling with severe symptoms or impulse control problems for many years before having to use opioids anyway as the only option to get off DAs. This is not to mention going through an uncomfortable DA withdrawal process for weeks or months. Unless there is a big breakthrough in RLS treatment in the next five years, DA-prescribing today generally commits a patient to opioids in five years once augmentation occurs. DAs are not a viable long-term solution based on this logic, so I will accept being all or nothing regarding their use except in rare circumstances.
Opioids, however, particularly in an RLS patient population, have been demonstrated to be safe and highly effective for the vast majority despite the weighty risks of overdose, abuse, addiction, etc. Those of you with RLS who have been treated with opioids now or in the past may have discovered the juxtaposition of two odd experiences:
Opioids significantly improved your RLS and quality of life, and you cannot imagine where you would be without them.
You struggled for years without a provider mentioning this treatment, you requested this treatment and were brushed off, or you were even taken off the treatment when your doctor changed despite it being effective, all for unclear reasons.
I ask then, if “we” as a medical field adopt a universal creed that “we don’t prescribe opioids,” would you be better off?
-Andy Berkowski, MD of ReLACS Health, who has not strained his low back lifting a heavy sack of Halloween candy, as it is depleted and otherwise of reduced mass by January
