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Pregabalin and gabapentin set to become controlled drugs

Gabapentinoids are set to become controlled drugs, after a spike in the number of related deaths and series of studies warning about the adverse effects of the medication.

Home Office minister Sarah Newton told Pulse that the Government had accepted recommendations from advisers to make them a class C drug, subject to a consultation.

It comes after official figures revealed there were 111 deaths related to pregabalin in 2016 and 59 related to gabapentin, compared with four and eight respectively in 2012.

The Advisory Council on the Misuse of Drugs (ACMD) wrote to the Home Office in January 2016 calling for the drugs to be controlled, warning that ‘pregabalin and gabapentin present a risk of addiction and a potential for illegal diversion and medicinal misuse’.

A series of studies in recent months have recommended that GPs refrain from prescribing the medication.

An Addiction paper in May this year, from University of Bristol researchers, suggested GPs consider alternatives to pregabalin and gabapentin after finding the recent substantial increase in prescriptions to be closely correlated with a rise in the number of deaths associated with gabapentinoids in England and Wales, with a 5% increase in deaths per 100,000 increase in prescriptions.

A Cochrane Review from June this year concluded that gabapentin ‘can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy’, but added: ‘Evidence for other types of neuropathic pain is very limited… Over half of those treated with gabapentin will not have worthwhile pain relief but may experience adverse events.’

They followed a study by researchers from the University of Kentucky in the US, published in Addiction last year, that found that misuse of gabapentin was at a staggering ‘40-65% among individuals with prescriptions’.

The drugs are often mixed with opioids by abusers, but addiction experts have said there is evidence patients can become dependent on gabapentinoids on their own.

GPC clinical and prescribing policy lead Dr Andrew Green says: ‘It has become increasingly clear over recent years that these drugs have a significant potential for dependence… We would support this change in legislation, which brings these drugs into line with others with similar problems.’

Dr Steve Brinksman, clinical director of the drug and alcohol treatment professionals group SMMP and a part-time GP in Birmingham, said that the drugs particularly have a lot of adverse interactions with opioids, which they are often prescribed alongside when used for pain, especially an ‘increased risk of depression of the central nervous system’.

He added: ‘They have psychotropic effects, which means patients are likely to continue taking them even if they are not proving effective. They probably do have a withdrawal effect – though that has not been proven conclusively yet.’

The Government’s latest announcement follows a long-running row over the use of a ‘second patent’ by Pfizer, the makers of Lyrica – the patented version of pregabalin.

GPs were told by NHS England to prescribe Lyrica, and not pregabalin, when prescribing for neuropathic pain. However, a High Court overturned the decision.

Related images

  • Lyrica - drugs – tablets – online

Readers' comments (23)

  • Good. They are dirty drugs and I'm glad their risk combined with limited therapeutic efficacy is being highlighted.

    Time to stop trying to fix patients and practice acceptance/adaptation instead.

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  • Long overdue; minimal therapeutic value, often prescribed beyond both evidence and licence, widely abused.

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  • Mr Mephisto

    Oh well. Back to amitriptyline then. It has so many side effects no one could possibly abuse it could they? Some individuals will abuse anything including imodium and cyclizine. According to the new NICE guidelines on back pain all that we can offer patients is our commiserations - x-rays and analgesia are off the table. Someone is going to get sued at some point for failing to x-ray what later turns out to be metastatic disease, multiple myeloma or osteoporotic collapse!

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  • Soon we won't be allowed to prescribe any painkillers. *sigh

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  • Mr Mephisto

    In what percentage of the deaths attributed to these drugs were they being "taken as prescribed" by the individuals that they were prescribed for?

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  • Better tell the pain clinics then

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  • I know we can give people with chronic pain colouring books and teach them to be resilient.

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  • Can’t use NSAIDs, opioids, or gabapentinoids. I do agree they should be a controlled drug. But what I am supposed to use when paracetamol is leaving my patients in pain?

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  • some patients will have to live with pain, doctors are not gods

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  • From personal experience, for sciatica, which was causing me to have to crawl to bathroom, 24 hrs gabapentin allowed me to carry on working. On for 2 weeks and then stopped as really slows the brain down, but was completely fantastic for pain. Anecdotal I know, but short courses would possibly seem the way forward.

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  • Interestingly, the vet put my basset hound on a slightly bigger dose for his back and he too improved markedly. Again short course!

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  • more details required re the circumstances of these deaths I think before drawing conclusions??

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  • Mr Mephisto

    Dear Peter - I hope your Basset Hound doesn't get addicted! How much did the vet charge you for the gabapentin and what is the dose in mg/kg? Our vet wanted to put our dog on tramadol. The illegal ketamine trade was initially sourced from veterinary supplies (not much use of ketamine in GP land). Are veterinary supplies policed in the same was as medical supplies? If not then all of the prescription drug abusers can go and get an old dog and get all the tramadol and gabapentin they want - possibly some ketamine too if they are lucky!

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  • It is instructive I think to look at this marketing conflated as "education" from four years ago:

    https://holeousia.com/2013/03/18/medical-education-revisited/

    My petition fort a Sunshine Act for Scotland was closed a year-and-a-half ago. The public were consulted and agree, in majority, that it is a necessary first step to ensuring scientific integrity.

    However the Scottish Government has provided no updates on this to the public that they consulted:

    Here is a letter just published in the BMJ that I wrote with my wife Sian who is a GP in Falkirk:

    "We want to gain the public’s trust, but are we listening to them?" : http://www.bmj.com/content/358/bmj.j4203.full?ijkey=N6rPw2zzNPnc9J6&keytype=ref

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  • I have not seen many patients who get much relief with these drugs. they take it as per advise. some think it is stopping deterioration they were not available in 1980's we still managed.
    any pain not responding to usual analgesics become neuropathic pain as we are struggling to find alternative

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  • Short courses may be beneficial But risk of abuse must not be ignored.Controlled Drug ststus wise.

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  • Just Your Average Joe

    Tried to wean an a Mental health patient off Pregabalin as taking 600mg bd!, and they declined saying started by psychiatrist and so as a GP not appropriate for me to stop.

    Went to refer to MH team to review and stop as felt inappropriate - got a letter back saying we asked him to stop in the last appointment we saw him, and he declined so we discharged him to GP follow up. Our recommendation remains the same, so we decline to accept the referral!

    Don't start inappropriate doses in pain and MH clinics and dump them on GPs to continue prescribing.

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  • Edoardo Cervoni

    Following a paper (N Engl J Med 2017; 377:411-414) which highlighted concerns about their prescribing, coupled with "new evidence" that their effectiveness as a treatment for chronic backache was to be questioned, I wrote elsewhere:
    "That is sad news as I for sure have been quite strongly under this impression for many years, that is more than 10 years. I cannot refrain from thinking that the price drop of those medications may have reduced the interest in highlighting benefits we should have been more cautious about. Also, worthwhile exploring other mid and long term downsides on the CNS, including mental health and addiction, or other forms of impacts. Co-prescribing with opiates and coexistence of drug abuse and hyperalgesic states appear to be of common observation. Perhaps "negative" studies should have a louder resonance to avoid similar, too late, "discoveries".
    Ever since, a heroin addicted trying to detox shared his knowledge of them. He had known for many years too well first hand about them and why they should have been controlled drugs, in his humble opinion. However, it has to be said that making a drug controlled does not necessarily limit its diffusion. The opioid epidemic can just confirm my consideration. It is our prescribing and the way we explain what we know about pros and cons of any prescription that may make a significant difference. Often, a 10 minutes consultation may not be long enough. Furthermore, we should be most mindful of the unknown unknowns for any new drug, particularly if acting on the CNS.

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  • Useful for a small group of people, but addictive and abusable. In the acute setting and some cases of true neuropathic pain, have some benefits.

    Like opioids, the problem is they induce euphoria - and persistent pain is a complex phenomenon with low mood being one of the components. So we prescribe a drug which isnt helping the pain, but it temporarily makes patients feel better for a few hours - so of course they will like it. But is it much better than asking them to drinking a few pints to take their minds off things? No - very short term, great - but long term, harm and dependence have potential to rear their heads.
    Persistent pain doesnt respond well to pharmacology - it needs a psychosocial approach (Pain toolkit is good as a starting point) - this takes time, we dont have much of it, nor resources. So can see why prescribing a short acting euphoriant can be seen initially as success.....until they come back for more wanting higher doses........Same principle as applies to opioid prescribing concerns - and benzos etc....

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  • Well my cats have been prescribed this by my vets .
    One has it for dental pain, another for pain after facial fractures from RTA.
    Latter cat has also had tramadol.
    Trouble is you can't give PCM to cats.
    Meloxicam only alternative , but cat is on steroids.
    Ho hum.

    I have used gaba myself for CRPS ( now recovered) and never felt euphoria, nor the potential for addiction.

    We are diverse in our reactions to medications.

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  • David Banner

    A while ago 300mg pregabalin was being sold on the North West streets at around £100 per pill. It remains highly prized amongst abusers, which undoubtedly explains the sudden surge in scrofulous skinny 25 year olds presenting with severe sciatica for which "only the gabbies" work. Making these drugs controlled is a (belated) step in the right direction, but far tighter controls are needed both in GP land and (especially) Pain Clinics. A move toward "acute" rather than "repeat" scrips would help.

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  • Pregabalin was widely marketed, not just for pain, but to reduce anxiety.

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  • Pregabalin fine, but gabapebtin? Yes can be abused, but far easier drugs to abuse over the counter. It actually works (unlike pregabalin) and is not very addictive.

    What are we supposed to prescribe now for chronic pain patients? We prescribe meds because the other 'social' prescribing is notoriously difficult to access and rarely works if at all.

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