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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)

  • Agree. Tramadol similar. Gabapentin of no use unless true neuropathic pains.

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  • I share Dr Spence's concerns.

    I am a specialist who believes that the true polymaths are the generalists.

    Thank goodness for folk like Dr Spence.

    Dr Peter J Gordon

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  • Great article. Humourous, informative, insightful and beautifully written. Bravo.

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  • and the next one is............Mirtazapine. Got a street value with nice hallucinogenic properties.

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  • I agree we need to be cautious about addiction but the problem is patients with chronic pain often back us into a corner:
    Paracetamol- 'useless'
    codeine-addictive and can't drive on it
    nsaids-risk of g.i. bleeds and no use anyway for chronic pain.

    Pain clinic/CBT/ acupuncture-'tried it no help'.
    amitriptyline-'makes me drowsy'

    They sit and look at you expecting something else and we are unable, as a profession ,to do nothing.

    I would also add I have had a lot of success treating chronic pain with gabapentin/pregabalin.

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  • Absolutely fantastic blog. I had this topic on my list of things to write about but you have done a far better job than I could ever do. Please share this sentiment wider as you are preaching to the converted. How I would love to work in a world without benzos, opiates, gabapentin, pregabalin.

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  • Excellent summary, and what is further worrying is the proliferation of these drugs in the custodial setting, it always amazes me as a forensic physician the number of detainees that demand to be given their pregabalin and always at maximum dose. I am afraid that the punters are miles ahead of the doctors regarding drug seeking behaviour

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  • Wonderful article. As a GP whow orks in a pain practice part tie and who has taken a Gabapentinoid for years for a rather rare cause of neuropathic pain I cannot fault Des' argument. Benzo's have no role in pain and perhaps some role in epilepsy and alcohol withdrawal. They and Opioids and gabapentinoids and all psycho active drugs for that matter (inc Dexies etc) should only be prescribed as appropriate. This isn't just a gabapentinoid problem, As Profession Doctors have to learn to say No. No to starting inappropriately, No to continuing inappropriately and no to escaleteing doses and feeding addictions.
    The problem is ourselves and it requires immense discipline and integrity to keep practicing good medicine. I must admit to the occasional lapsebof judgement and this article is a timely reminder that we must first do no harm.

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  • Health professionals working in secure environments have been flagging the abuse problem of these drugs for years and nobody was listening. As mentioned, tramadol is also a problem and has been inappropriately prescribed since it first came onto the market.

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  • Anyone can easily buy gabapentin, dihydrocodeine, diazepam, etc. on-line, without a prescription, for less than £1 a tablet. I couldn't believe it until I looked. It seems to be completely unregulated with no checks or proper assessment being made whatsoever.

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