This site is intended for health professionals only

At the heart of general practice since 1960

Read the latest issue online

Gold, incentives and meh

Gabapentinoids - the new diazepam?

  • Print
  • Comments (30)
  • Rate
  • Save

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

Rate this blog  (4.45 average user rating)

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Readers' comments (30)

  • Whilst I agree there is abuse potential in gabapentine and pregabalin, I don't agree that it is directly comparable to benzodiazepines. The degree to which people become attached to a benzo prescription can be truly weary making. I have worked in prisons, community drug services and general practice and I say with out doubt benzodiazepines are one of the hardest drugs to get someone to accept to come off...harder, to be honest, than opiates in that whilst people generally accept heroin isn't good for you, plenty of folk on benzos are convinced they couldn't live without their benzo. You really don't get that degree of angst from the typical gabapentine user confronted with the prospect of a declined prescription. The prospect of no prescription for a benzodiazapne user can be abject terror.

    Unsuitable or offensive? Report this comment

  • Excellent article. Similar to Tramadol. It is a CD drug now, but nothing has changed. Patients who get these drugs on prescription, share them with like habits. In A/E, we often see drug addicts coming and pretending to have pain and actually saying that the only analgesics that works is Tramadol. Both have a high street value.

    Unsuitable or offensive? Report this comment

  • some commentators clearly believe they have to provide a pill for every ill. We need as a group to better define the limits of the possible/sensible

    Unsuitable or offensive? Report this comment

  • Good article. Now to get the GMC and RCGP to acknowledge that a doctor's job is to give patients what they need not what they want. Complaints do not mean the doctor is wrong.

    Unsuitable or offensive? Report this comment

  • It is VERY interesting that my challenging post has been removed !
    Did I tread on someone's toes ? If so,
    what are you afraid of, the truth ?

    Unsuitable or offensive? Report this comment

  • Dear Dr Des Spence
    What a breath of fresh air.
    I had pinched nerve in my cervical spine. A&E Misdiagnosed ended up with Acute glaucoma. The later was seen to by my Opthal. dept. It's now 8months and my neck is not addressed. I have been given all sorts then Diaza. which I felt it was foul. Now Geba. when I read the dependency and side effects I refuse to take it. What do I do. For the sake of proper assessment I have been left to suffer. I have had mini stroke high BP and latest neuropothy, so what do I do? i wish I was registered with your practice.

    Unsuitable or offensive? Report this comment

  • Huge problem as traded in prisons. There attempts there to phase them out is undermined by outside doctors not appreciating the problem and dish them out.

    But there is a role for them. When I first went to Australia there were not available for pain at all. As a result there is an epidemic of prescribed opiate dependency.

    I just wonder for the angry, personality disordered chronic pain sufferer who has had opioid and other dependencies, these drugs may act as a mood stabiliser and help in many ways. I have no evidence for that. They may not have the paradoxical aggression that benzos give, and clearly benzos drugs must be avoided above all else. Benzos, in making people feel invulnerable, cause crime.

    Unsuitable or offensive? Report this comment

  • Gabapentin has a side effect of tinnitus and I lost the hearing in my dominant right ear (used for the phone) through taking it. Tell your patients that as it might put them off.

    Unsuitable or offensive? Report this comment

  • Yes to all this. And it ties in with : first do no harm. However most of us find it harder to tell those in pain to continue suffering, or pain clinic may have said so but I am more interested in psychotropic problems, or better that you live a long miserable painful bitter life than have some relief. I haven't been in the typical patient's predicament (yet) so I can't comment but life must be pretty hard if you are in constant pain and pain clinics, physiotherapists and dozens of consultants and consultations later you are told to go back home and continue suffering. I feel for them.

    Unsuitable or offensive? Report this comment

  • Thank you Dr. Shah for your compassion & insight.
    Some time in the future, not long I hope, doctors & powers that be will realise the gross mistake they made to withdraw co-proxamol. Yes, it is a dangerous drug, but so are MANY others, MUCH more & at least many thousands of chronic pain sufferers WERE taking them responsibly, safely & with few side effects AND with fantastic pain relief ! WITHOUT being addicted too !!! It's all about genotypes !

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page50 results per page

Have your say

  • Print
  • Comments (30)
  • Rate
  • Save