Buprenorphine has become increasingly popular among experts in restless legs syndrome (RLS) for the treatment of moderatetosevere RLS when opioid treatment is required. @andyberkowskimd of ReLACS Health describes the three main forms of buprenorphine that can be prescribed for RLS in this week's video.

To understand why buprenorphine may be a good choice among opioids, watch this video on buprenorphine treatment for RLS:
   • Buprenorphine for Restless Legs Syndrome  

Opioids are a mainstay of treatment for moderatetosevere restless legs syndrome (RLS) when firstline medications have not worked. Buprenorphine is a unique opioid as it is a partial agonist at the muopioid receptor unlike most other opioids. The effect of this chemical difference is the reason buprenorphine has little risk of causing breathing problems that could lead to death in the event of a poisoning/overdose. This longacting drug is also less likely to be abused, which is the reason it has become the goto medication for treatment of opioid use disorder (OUD). However, the same benefits for OUD can be seen in its use for restless legs syndrome.

For RLS, there is a lot of confusion over forms and dosing for RLS, which will be substantially lower than for OUD and generally lower than for pain conditions. The three prime forms of buprenorphine for RLS are under the tongue (sublingual), through a patch against the skin (transdermal), and against the cheek and gum (buccal). They each have their pros and cons and Dr. Berkowski discusses each.

The sublingual film or tablet (e.g. Suboxone®, Subutex®) dissolves under the tongue to enter the bloodstream. Some forms like Suboxone come with naloxone added, which is an opioid blocker that can deter abuse from illicit injection, but it is almost completely inactive when absorbed under the tongue. The benefit to this form is the generally low outofpocket cost, but the downside is that it has a much higher strength, as intended for opioid use disorder originally. Thus, for RLS, the Suboxone film is often cut into smaller portions, such as 1/8 or 1/4 of 2 mg buprenorphine as a starting dose, which also makes it more cumbersome to administer. Another downside is the lack of awareness among clinicians that Suboxone can be prescribed by any provider with a DEA license for indications of RLS and pain; no special XDEA license is needed. In fact, it is a Schedule III drug, so less highly regulated than others like hydrocodone (e.g. Norco®), oxycodone, or methadone.

The transdermal patch (Butrans®) comes in increments of 5 mcg/hr/week up to 20 mcg/hr/week. It is much less potent than Suboxone so ideal for starting at 5 mcg/hr/week for RLS. The benefit is also a consistent level of medicine in the body 24/7 (in theory) so no, even minor, ups and downs from taking it. The downside is the patch lasts 7 days and then switched so it makes dosing and a daytoday changes less flexible. Also, it can occasionally cause skin irritation that the other preparations lack. It is more expensive outofpocket than Suboxone and other sublingual preparations.

The final form is the buccal film (Belbuca®) that is placed and dissolves between the cheek and gum. It comes in lower doses more appropriate for RLS but is probably the most expensive if not covered by insurance. It starts at 75 mcg and there are doses as high as 900 mcg, usually well beyond what is needed even for severe RLS.

Unfortunately, there are no good ways to compare the strength of each relative to each other. Even micrograms of one cannot be compare to micrograms of another so switching among forms may be challenging. Based on experience in RLS, a starting dose may be 1/8 Suboxone 2 mg film once daily, Belbuca 75 mcg once daily, or Butrans 5 mcg/hr/week, but the Suboxone may be stronger even at this dosage.

It is important to note that though buprenorphine has significantly lower risk of breathing problems, addiction, dependence, and other side effects than standard opioids, it is a DEA schedule III controlled substance. Misuse, overdose, abuse, and/or poisoning, particularly in combination with other drugs and substances can cause severe and potentially lifethreatening effects not limited to severe impairment, shallow breathing, coma, and death. Buprenorphine can be used inappropriately for nonmedical purposes, and there is a nonzero risk for dependence, even with appropriate use, though it has a significantly lower risk for dependence or abuse than standard opioids. Opioids like buprenorphine require strict supervision and management by a licensed medical practitioner.

Why are doctors afraid to prescribe opioids for RLS? Read here:
https://www.relacshealth.com/blog/why...

If videos aren't enough. Those living in or near MI, OH, or FL may hire @andyberkowskimd for personalized medical treatment for RLS and other sleep conditions by going to https://www.relacshealth.com.