This site is intended for health professionals only

At the heart of general practice since 1960

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 (17)

  • What are the rates in France and Canada...?

    Unsuitable or offensive? Report this comment

  • It doesn't matter what the rates are in France and Canada, but clearly they are increasing -

    https://www.theglobeandmail.com/life/health-and-fitness/article-class-of-drugs-used-as-alternative-to-opioids-for-back-pain-are/

    http://www.encepp.eu/encepp/openAttachment/fullProtocol/10292

    Fundamental truth of life - if you subsidise it, it will increase.

    Unsuitable or offensive? Report this comment

  • Medical establishment for most of last 15 years: "prescribe gabapentin for chronic pain its much better than opioids and not addictive"

    Medical establishment in last couple of years "don't prescribe gabapentin its addictive and gets abused"

    Patients to GPs "take responsibility for all my symptoms there must be a pill for it and not at all related to my lifestyle or lack of engagement in physical/psychological therapy that I refuse to consider"

    Unsuitable or offensive? Report this comment

  • Vinci Ho

    I think that this simply reflects how poorly we have been understanding Pain as a syndrome ( or I prefer a disease) all these times . NICE typically(and repeatedly) fell into the trap of giving recommendations to manage specific , physical entity called neuropathic pain , instead of managing a person with chronic complex pain . And we are all guilty of that from time to time. Clearly , various drugs tried through history and should presumably have taught us some lessons( or not )?
    Physical , emotional and social (I would argue even political and economic) circumstances all contribute to pain. The fantasy of ‘ take this pill and the pain will go’ is always a slippery slope.

    Unsuitable or offensive? Report this comment

  • No surprises since we are medicalising everything from behaviour at home to not eating their greens. With papers campaign groups and the government encouraging a "Doctor has all the answers and a pill will sort it mentality", there can be no other result other than more prescribing. Once again the doc. is bashed for being unable to treat their "diseases" or if they decide to take some extra pills.

    Unsuitable or offensive? Report this comment

  • Did the study find out how much coprescribing of gabapentinoids and opiates was started by pain clinics?

    Unsuitable or offensive? Report this comment

  • David Banner

    If the DOH had the sphericals then they would BAN GP initiation of BOTH strong opioids and gabapentinoids.
    Pain clinics need to be stringently monitored, and keep patients on their books if they choose to initiate, NOT simply discharge to GP with a “titrate up the drugs” letter.
    A shared care protocol (like e.g. rheumatology drugs) would be sensible too.
    The current Wild West free for all will inevitably lead to a USA style addiction disaster.
    The DOH must act NOW!!

    Unsuitable or offensive? Report this comment

  • October 03, 2017
    Gabapentin, Opioid Combo May Up the Risk of Opioid-Related Death
    Additive respiratory depression, coupled with an increase in gabapentin absorption, are likely factors
    Additive respiratory depression, coupled with an increase in gabapentin absorption, are likely factors
    Patients taking concomitant prescription opioids and gabapentin may be at an increased risk for opioid-related death, according to a new study published in PLOS Medicine.

    Both gabapentin and opioids are commonly prescribed for the treatment of pain, making the likelihood of these two agents being prescribed together high, however, according to lead study author Tara Gomes, “no published studies have examined whether concomitant gabapentin therapy is associated with an increased risk of accidental opioid-related death in patients receiving opioids.”

    To investigate whether co-prescription increases the risk of opioid-related death, the researchers conducted a population-based nested case-control study using a cohort of patients receiving prescriptions for opioids in Ontario, Canada. “Cases, defined as opioid users who died of an opioid-related cause, were matched with up to 4 controls who also used opioids on age, sex, year of index date, history of chronic kidney disease, and a disease risk index,” the authors write. “After matching, we included 1,256 cases and 4,619 controls.”

    Concomitant use of gabapentin in the 120 days preceding the index data was considered the primary exposure. The researchers also looked at how gabapentin dose factored into risk.

    RELATED ARTICLES
    Law Enforcement Data Indicate a Rise in Gabapentin Misuse
    Clinicians Increasingly Prescribing Gabapentinoids to Avoid Opioids
    Managing Diabetic Peripheral Neuropathic Pain: What's Most Effective?
    The data showed that in the prior 120 days, 12.3% of cases and 6.8% of controls were prescribed gabapentin. Compared to opioid prescription alone, co-prescription significantly increased the odds of opioid-related death by 49% (adjusted odds ratio [aOR] 1.49, 95% CI 1.18–1.88, P

    Unsuitable or offensive? Report this comment


  • The data showed that in the prior 120 days, 12.3% of cases and 6.8% of controls were prescribed gabapentin. Compared to opioid prescription alone, co-prescription significantly increased the odds of opioid-related death by 49% (adjusted odds ratio [aOR] 1.49, 95% CI 1.18–1.88, P

    Unsuitable or offensive? Report this comment

  • sorry - rest of it not pasting - basically no evidence it works in sciatic pain anyway, co-codamol and ibuprofen as effective as morphine, i don't prescribe it any more for sciatica like pain, may help in diabetic neuropathy, avoid with opiods, it is a popular drug of abuse now so beware the not responding to treatment back pain who really needs the gaba!!!

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page

Have your say