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Restlessness in Opioid Withdrawal: A Unique Presentation of Whole-Body Involvement


Nikita Mehdiratta, Shweta Kalita, Chiraag Ashokkumar, Tejashwi Paruchuri and Alan R. Hirsch

Introduction: Restless Leg Syndrome (RLS) is a known phenomenon observed in individuals experiencing opioid withdrawal, which can worsen heroin dependence. Typically,RLS affects only the legs, but this case report presents a unique instance of generalized Restless Body Syndrome (RBS) induced by opioid withdrawal.
Case presentation: The report describes a 67-year-old male undergoing opioid detoxification who experienced restlessness throughout his body, resembling RLS sensations.The restlessness affected various areas, including the thorax, abdomen, back of legs, lower back, arms, and legs, excluding the face. The sensations were described as periodic electric waves that intensified at night or during periods of inactivity and improved with physical activity, mainly walking. Similar sensations were also noted during withdrawal from opioids or buprenorphine/naloxone, significantly when the dose was reduced to 1mg/day, and they resolved upon reintroduction of buprenorphine/naloxone.
Results: Neurological examination revealed specific abnormalities, such as recent impaired recall, facial akinesia, decreased blink frequency, cog wheeling in upper extremities,a stooped, shuffling gait, and resting tremor in both upper extremities. Neuropsychiatric tests showed abnormal results in the Go-No-Go Test (4/6) and a minimal level of depression according to the Beck Depression Inventory Type-II (score: 9). The patient also scored as a problem drinker on the Michigan Alcohol Screening Test (score: 35).
Discussion: Exploration of the similarities between RBS and RLS, highlighting that RBS affects additional areas of the body, including the upper extremities, thorax, and back. While RBS may represent a variant of RLS, it could also be a different condition. Another potential explanation is that it may be a form of serotonin syndrome induced by opioid use, including fentanyl, which can lead to generalized myoclonus. Although RLS associated with opioid withdrawal is well-documented, the underlying mechanisms responsible for its manifestation throughout the body, including the neck, remain unclear. One hypothesis suggests a generalized polyneuropathy affecting the upper limbs and lower extremities, particularly in cases of iron deficiency. The report suggests that variants of RBS may occur in individuals undergoing opioid withdrawal, potentially requiring low-dose opioids for treatment. Consequently, evaluating RBS as part of the assessment for opioid withdrawal is necessary.

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