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Number of GP patients co-prescribed gabapentinoids and opioids triples

The number of patients prescribed both gabapentinoids and an opioid has tripled over the last decade, with 20% of all patients taking either gabapentin or pregabalin also taking an opioid, according to a new study.

Researchers from France and Canada studied prescribing levels in the UK and found that the proportion of the general population prescribed both opioids and gabapentinoids rose from 56.4 to 148.1 per 100,000 persons per year for gabapentin and from 28.7 to 91.2 for pregabalin.

They also saw that the overall number of patients prescribed gabapentinoids by GPs tripled from 2007 to 2017.

The study team called for patients taking this combination of drugs to be closely monitored, as it 'increases the risk of serious side-effects and overdose', while GPs stressed the importance of the initial diagnosis being 'accurate' and highlighted the lack of assessment guidance in the NICE neuropathic pain guidelines.

The study, published in JAMA, looked at trends in gabapentin and pregabalin prescriptions in UK primary care from 1993-2017.

Researchers used a UK database of primary care medical records (CPRD) with more than 15m patients, and identified all those registered for at least one day between 1993 and 2017.

They found that from 2007 to 2017, the rate of patients newly treated increased from 230 to 679 per 100,000 persons per year for gabapentin, and from 128 to 379 per 100,000 persons per year for pregabalin.

Meanwhile the rate of patients with a co-prescription for opioids and/or benzodiazepines also increased from 56.4 to 148.1 per 100,000 persons per year for gabapentin, and from 28.7 to 91.2 per 100,000 persons per year for pregabalin.

Off-label prescribing increased, from 58.7 to 216.0 per 100,000 persons per year for gabapentin and from 34.7 to 117.8 per 100,000 persons per year for pregabalin.

The researchers found that by 2017, 21.8% of patients newly treated with gabapentin and 24.1% newly treated with pregabalin received a concomitant prescription, primarily for opioids, while off-label prescriptions accounted for 52% of gabapentin and 54.8% of pregabalin prescriptions with an identified indication in 2017.

The findings come after the Government announced in October that pregabalin and gabapentin will be reclassified as class C drugs, starting from April 2019. This will add a number of restrictions, such as GPs needing to sign their patients' prescription in person and pharmacists dispensing the items within 28 days.

The change follows a drastic rise in prescribing, thought to be the result of NICE recommending gabapentinoids as a first-line treatment for neuropathic pain in 2013

The paper said: ‘The rate of patients newly treated with gabapentinoids has tripled from 2007 to 2017 in primary care in the United Kingdom. By 2017, 50% of gabapentinoid prescriptions were for an off-label indication and 20% had a co-prescription for opioids…

‘Given the safety concerns of gabapentinoids and the lack of robust evidence supporting their efficacy in cases of non-neuropathic pain, caution is necessary when prescribing gabapentinoids, especially among patients also prescribed opioids.’

Study author and assistant professor Christel Renoux, from McGill University, Canada, said: 'These trends are of concern because co-prescription with these medications increases the risk of serious side-effects and overdose in combination with opioids use. 

'Therefore, the potential benefit of such combination should be carefully weighed against risks and these patients should be closely monitored.'

According to the Office for National Statistics, there were 165 drug-related deaths involving gabapentin or pregabalin across England and Wales in 2016, with 147 of these involving an opiate.

But RCGP clinical champion for chronic pain Dr Martin Johnson said that while the figures seem 'concerning', it's a 'complex' area.

He said: 'On first glance the gabapentinoid prescriptions are concerning however, pain is complex and we don’t know the reasons for the gabapentin or pregabalin prescriptions (e.g. pain, anxiety, migraine, epilepsy).'

'The key with pain, especially neuropathic pain, is making an accurate diagnosis at the start - there are no assessment guidelines in the NICE neuropathic pain guidelines though others - such as the British Pain Society guidelines - do exist. 

'One question I always ask is how often are these patients being followed up, as once stable they should be reviewed at least once annually according to available guidance.'

Last year, a Pulse investigation revealed the extent to which GP prescribing of pregabalin and gabapentin had risen over the past decade.

Readers' comments (18)

  • this will get worse as continuity breaks down.

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  • We are going to the USA septic tank health system,commonest cause of death in the USA under 40s?????

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  • come back amitriptyline . (If only I could remember how to spell it.)

    A much under used drug that has been around for 70 years now and used in homeopathic doses but peculiarly effective for pain and insomnia.

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  • Pain clinic wait 9 months. Alternative services nil. Unlimited access and complaints aplenty if we don’t try and fix everything immediately. Tell us what works instead, tell the public this true and sorted.

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  • This is a Public Health disaster driven by the drug companies and NICE to implement acute pain evidence into chronic pain when they are different diseases.
    Pain clinics have initiated a lot of these medications in good faith.
    The resources to get these addicts off just aren’t there
    Our main mission should be not to addict a further generation and to learn to say no to prescriptions when simple analgesia isn’t helping
    Most of our difficult pain patients are either worrying too much, aren’t moving enough or abusing their meds
    We will be having the same debate about SSRIs in a few years
    This is our generation of GPs equivalent of the benzo issues of the 60s

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  • Macaque

    I like your sum-up very much @Vinci Ho.

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  • As always, Vinci sprinkles us with his wise words.

    Agree with all that has been said already.

    But we,as doctors, are the ones that need to change.

    Move away from the medical model of co-dependency and the facade of pretending to fix everything.

    We need to be honest with patients about our limitations, refuse to become drug pushers and empower them to develop an internal locus of control.

    But all that is nigh on impossible in a 10 minute consultation

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  • @DavidBanner, sorry, but you are completely WRONG!
    Only GPs aee trained and qualified to safely initiate these drugs, Other doctors, in pain clinics, orthopaedics, neurology,psychiatry, are NOT, and it is they who should be banned from even mentioning them to patients!
    Shared Care protocols that force GPs to sign a document acceptingall and any responsibility for the advice from the clinic, who never do the monitoring, dose adjusting, orreviews properly or accept any responsibility, leave alone seee the patient again, are evil, and should be stopped.
    DoH need do nothing, for once it is not their fault!
    GPs are the ones who should do something NOW and IN UNISON : we should stop allowing such patient access to cliicians who might start these drugs. We must be clear in our referals that we want the injections given,or whatever, and that mentioning such drugs to patients may result in a GMC referral!
    GPs should stop sending patients to Psychiatry teams, due to the high risk of adverse prescribing initiation.
    GPs should refuse to issue prescriptions that secondary care or private doctors should take clinical responsibility for : after all, GP clinical prescribing systems can now cope (some of them!) with electronic repeat prescrioptions electronically reviewed and signed and issued by non-GP staff at sites other than the registered surgery, and no paper bits need signing that the consultants cannot also sign and post!
    Come on GPs, especially Principals and Partners, DO YOUR BIT for patient safety NOW!
    Happy CHristmas,

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