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Gabapentinoids - the new diazepam?

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The establishment ignores GPs. It prefers the advice and glamour of ‘expert’ or media doctors. But the deference shown to the ‘expert’ is creating overtreatment, medicalisation and iatrogenic harm.

GPs have to ignore this advice. We won’t prescribe statins to everyone because it is irrational and stupid. We don’t accept that ‘pain is what the patient says it is’, because common sense dictates that it isn’t.

And we have seen the damage when experts have free rein. Diazepam was peddled as a safe and effective treatment for anxiety by companies and experts alike. When I started work in the early 1990s the consequence of this advice was evident everywhere. Herds of middle-aged patients zonked out and dependent on benzodiazepines. And benzodiazepines were being widely abused by a younger generation. My surgeries were spent dealing with drug-seeking behaviours, lies, confrontation, rebound agitation, insomnia and withdrawal seizures. It took the establishment decades to realise the harms we caused. Even today, we are still dealing with it.

GPs are first to notice the danger posed by psychoactive drugs. In the past five years my sensor has been off the scale with the gabapentinoids (gabapentin and pregabalin). Patients are seeking them using the crude acting skills that I used to witness with benzodiazepines: anger, tears and threats; constant requests for dose increases; stories of lost scripts; and a tag-team approach with friends who ‘corroborate’ stories.

If you google ‘gabapentinoids’, it is clear they are being widely abused. Large quantities are taken as single doses. Users describe them as the ‘ideal psychotropic drug’ with effects of ‘great euphoria’, ‘disassociation’ and an ‘opiate buzz’ as they boost the effects of these drugs.[1,2]

I wrote an article in the BMJ in 2013[3] highlighting these concerns. Since then, prescriptions have nearly doubled in three years to 10 million scripts and more than £300m in costs.[4] Such rapid increases are the signature of inappropriate prescribing and iatrogenic harm. Many practices started prescribing gabapentinoids on the back of specialist endorsement, despite the existence of effective and less harmful alternatives.[5,6] But requests from pain clinics and psychiatry come thick and fast. We decline many, then weather the storm of protest.

Do we have a problem with gabapentinoid abuse? If it quacks like a duck and looks like a duck, then it’s a ducking duck. Pregabalin is already a controlled medication in the US and there is debate about controls in the UK. The research base for the benefits of gabapentinoids is of short duration and in a small, defined population where as few as one in 10 benefits.[7] We need to change our prescribing policy now and limit the use of gabapentinoids.[2]

We know the pattern: GPs will be blamed even if we just follow orders. I get tired that no one listens to generalists. This is déjà vu. Do we want another benzodiazepines disaster?

 

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

References

  1. Schifano F, D’Offizi S, et al. Is there a recreational misuse potential for pregabalin? Analysis of anecdotal online reports in comparison with related gabapentin and clonazepam data. Psychother Psychosom 2011;80:118-22
  2. Advice for prescribers on the risk of the misuse of pregabalin and gabapentin. Public Health England, 2014
  3. Spence D. Bad medicine: gabapentin and pregabalin BMJ 2013; 347 08 November 2013 
  4. NHS Prescription Cost Analysis data. NHS Business Services Authority, 2016 
  5. Wiffen P, Derry S, et al. Antiepileptic drugs for neuropathic pain and fibromyalgia - an overview of Cochrane reviews  Cochrane Database Syst Rev 11 November 2013; (11):CD010567
  6. Moore R, Derry S, et al. Amitriptyline for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2012 Dec 12;12:CD008242
  7. Advice on the anticonvulsant drugs pregabalin and gabapentin. Advisory Council on the Misuse of Drugs, 2106

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Readers' comments (30)

  • Superb article on a massive problem. Hopefully Pulse can lead a campaign to draw more attention to this growing menace..

    I always issue a dire warning about "piling on weight" which sometimes helps reduce demand, and I've noticed that the connoisseur addicts turn their noses up at gabapentin compared to pregabalin (and pregabalin still costs a fortune).

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  • Hmmm what are the alternatives- carbamezapine? duloxetine? imipramine?. I can see logic to his argument however gabapenitn/ pregabalin are useful drugs. I think he may be overegging the pudding by comparing these drugs to benzo's. Lets not search the internet because I would probably find paracetamol causes harm...

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  • Expect gabapentin and pregabalin to be winging their way in to schedule three soon https://www.gov.uk/government/publications/advice-on-the-anticonvulsant-drugs-pregabalin-and-gabapentin

    i.e. no emergency supply, except maybe for epilepsy like with phenobarbital, Rx to hqve a specific dosage on it, Rx lasting only 28 days, supplies limited to 30 days (unless significant clinical need), quantity on Rx in words and figures.

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  • I heard pregabalin described as "poor man's cocaine" 5 years ago, been wary with it ever since but this article will make me more cautious again. Thanks Des.

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  • Vinci Ho

    If I am correct , the culprit is down to this GABA receptors in the brain on which all these drugs including gabapentin , pregabalin , benzodiazepines as well as tramadol(which is hence not a pure opiate), have pharmacological effects.
    You wonder whether the lesson of benzos had been learnt before these drug companies were pushing these neuropathic pain drugs into the market . We all know very well the agenda of Pfizer on the argument about Lyrica. Ethical , not ethical ? History may judge all of us 'painfully' once again.

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  • My Mothers GP has prescribed this drug to my mother for symptoms of eye movement! Eye consultant asked GP to refer her for a neurology apt.Mother is 80 years old and a bit tottery on her feet at the best of times.Gabapentin has left her zonked out in the chair for many hours at a time she sounds drugged. Before she started the treatment Mother was active and enjoying her gardening. I now fear for my Mothers life.

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  • round my way pregabalin is called the 'dustbin drug' and patients on it have usually been tried on everything else with no success. If a patient now comes in and you see they are on it you know immediately that you are on a hiding to nowhere trying to cure their ills so in this respect it is a useful indicator of a heartsink and you consult accordingly.

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  • Agree agree agree. The trouble is pain is what you perceive it, and the type of pain. I had a terrible accident with multiple fractures ( head chest legs) and probably took just the occasional paracetamol, but post shingles pain left me blubbling, and as for chronic shoulder pain...
    Its how we deal with it, and I have to say ive found pain clinics disappointing. Patients seem to go there and come back with a worse problem / habit.

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  • I also think its about expectation. Some patients think they should be absoluetly pain free, or their lives are ruined, where as others have lower expectations and get used to a fair amount of aches and pains

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  • Mr Mephisto

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