What to do if you suspect a patient of abusing a gabapentinoid
Dr Alun George, Leeds GPSI in substance misuse and clinical development director for substance misuse charity DISC, offers tips
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1. Consider whether they may be drug misusers
The signs that someone may be misusing include losing prescriptions or requesting them early, and attending appointments under the influence. Use your local laboratory – it can screen a urine sample for commonly used drugs of abuse. Do not prescribe to anyone with an active substance misuse problem. If they are being prescribed gabapentinoids, look to reduce and stop.
2. Consider their history of drug abuse
If the patient is receiving treatment for a substance problem, liaise with their treatment providers about the suitability of initiating or continuing their gabapentinoid prescription. If there is a history of substance misuse, monitor closely for signs of dependence or relapse. You do not need to exclude those with a history of substance dependence/misuse automatically. When GPs refer to pain clinics it is vital they record current or historical substance problems, and advise that gabapentinoids are inappropriate.
3. Ensure it is prescribed for the right reasons
Only prescribe where indicated. For example, lower back pain is largely musculoskeletal in nature and therefore it is not appropriate to prescribe as you would for neuropathic pain. If continuing a prescription, check the diagnosis; if it is neuropathic pain, there should be examination findings to back this up, such as allodynia. If prescribing and monitoring, focus on the patient’s function in day-to-day activities, not their mood – if there is a little benefit to function, then it may be prudent to reduce and stop.
4. Be sensitive
The majority of patients who become dependent will not have a history of substance misuse. They are likely to be frustrated that they are unable to control their use and may feel deeply ashamed of it. Be compassionate, empathetic and transparent. Let them know your concerns that they may be misusing their prescription and the need to reduce and stop.
5. Wean patients off
Your local substance misuse service may be able to offer psychosocial support while you are weaning patients off their prescription. Pregabalin can be reduced by 50-100mg per week and gabapentin by 300mg every three to four days. If there is a confirmed diagnosis of epilepsy and it is prescribed for this, liaise with neurology.
6. Use alternatives where possible
Tricyclics such as amitriptyline or nortriptyline can be used and the nerve pain drug carbamazepine is an option. Persistent pain is unlikely to respond to pharmacological interventions. It is a complex behavioural phenomenon and need psychosocial interventions. A pain toolkit can be useful.