The impact of pregabalin reclassification on GP prescribers
Dr Martyn Hull
Mention addiction and most people think of illegal drugs, such as heroin or cocaine. But dependency and misuse of prescription medications is becoming a significant public health issue in the UK.
As a GP and clinician, I’m only too aware of the risks of overprescribing drugs that people can end up craving, sometimes with fatal consequences. Becoming reliant on licensed treatments like pain-killers is still a problem that’s only now being more widely recognised. But practitioners and patients are still largely in the dark about what to do, or where to seek help.
A major current concern is around the rise in deaths related to gabapentin and pregabalin, treatments now widely used for conditions including chronic pain and anxiety. The number of patients taking them who’ve then died has soared in just a matter of years, with these often avoidable incidents linked to a huge increase in prescriptions.
Increasingly, these licensed drugs are being used recreationally too because of their euphoric effects. Demand has also risen in prisons where staff, already overburdened tackling soaring use of the drug Spice, face a considerable challenge getting inmates to withdraw.
At Turning Point, we currently support a number people who misuse pregabalin or gabapentin. Some may have obtained either drug through a GP prescription for chronic pain or anxiety. Others have bought these tablets or capsules on the street.
Some take them with other drugs such as heroin or with alcohol to enhance the sense of pleasure and calm they induce. This ‘poly-substance’ misuse is a major concern because it increases the risk of overdose and death. So is bingeing on the drug in the same way as alcohol.
There are no easy answers to solve the misuse of prescription drugs
What our specialists including nurses, doctors and pharmacists and support teams do is provide education on the risks, and develop a plan based around their specific needs. This is usually aimed at reducing then eventually stopping use.
The government has now taken a step in the right direction over gabapentin and pregabalin use. As of this month (April), all these type of drugs known as gabapentinoids are now class C drugs in a bid to increase safety.
Using reclassification as a means of changing the law can be a blunt tool. The harms associated with pregabalin and gabapentin are complex, and penalising people through the threat of fines or prison is unlikely to address the issues behind their drug misuse.
We must also be cautious to ensure the pendulum doesn’t swing too far in the other direction. Patients with a genuine clinical need should not be denied therapies that evidence shows are effective. A downside of reclassification could be that cautious clinicians will be reluctant to prescribe, even to patients who genuinely benefit from gabapentinoids.
GPs are already limited in the treatment options available. Pressure on specialist pain management and mental health teams means that access to programmes are limited. That leaves prescribers including doctors, nurses and pharmacists with pharmaceutical approaches but nerve pain rarely gets better with common painkillers. Therefore, restricting the use of gabapentinoids could leave prescribers including GPs with few effective alternatives.
However, my view is that change brought about by tougher restrictions will be largely positive. That they will help reduce the tragic deaths that have resulted from misuse and overprescribing. And that the law change will help further in educating prescribers such as pharmacists, nurses and GPs about the risks.
Public Health England does already issue guidance around misuse of pregabalin and gabapentin, and appropriate prescribing. But there’s some evidence that reclassification can have an impact on prescribing. Tramadol is a good example of this effect- issuing of the opioid pain-killer has levelled out after many years of increases. This follows tramadol’s reclassification as a controlled drug in 2014.
Other measures though are needed too. Drug dependence services have faced significant cuts which only serve to cost the taxpayer in the end. What’s needed is proper investment from the government in specialist support services. This would enable people who are dependent on prescription drugs get the help they so desperately need.
There are no easy answers to solve the misuse of prescription drugs. However, tackling the problem early before it’s too late could help prevent more needless tragedies.
Dr Martyn Hull is a GP principal and clinical director of Turning Point, a social care organisation that supports people who misuse drugs such as pregabalin