GPs in Northern Ireland have been told they should no longer initiate prescriptions of pregabalin for neuropathic pain following a ‘significant increase’ in deaths related to the drug.
In a letter to GPs this month, Northern Ireland’s Health and Social Care Board (HSCB) said that pregabalin has been removed from the country’s formulary for neuropathic pain.
Patients currently on pregabalin should ‘continue to be reviewed and stepped down slowly as appropriate’, with amitriptyline to be considered as the ‘first-line pharmacological option’ and gabapentin the second, it added.
The letter, seen by Pulse, said: ‘Due to a significant increase in drug-related deaths where pregabalin was mentioned on death certificates, and the risks of dependence, misuse and diversion, pregabalin has been removed from the Northern Ireland Formulary for Neuropathic Pain.’
It added that the prescribing of gabapentinoids ‘outside recommended guidance for managing chronic pain’ should also be ‘reviewed as part of shared decision making and stepped down slowly where appropriate’.
Gabapentinoids should not be offered to treat other types of pain such as fibromyalgia, low back pain and sciatica, it said.
According to the Northern Ireland Statistics and Research Agency, there were 77 drug-related deaths involving pregabalin in 2019 – appearing in 40% of all drug-related deaths recorded that year – rising from 54 in 2018.
A spokesperson for the HSCB told Pulse: ‘It is evident that over the past number of years there has been an increase in the reporting of deaths that have involved pregabalin.
‘Addiction services have reported the risk of dependence and misuse of pregabalin. Furthermore, drug enforcement agencies have identified the potential of pregabalin being diverted from the lawful supply chain.’
They added: ‘Given that there are safe and effective alternatives to pregabalin, a review of the HSCB neuropathic pain guidance has been undertaken in conjunction with clinicians and a decision has been made to remove pregabalin from the guidance and the NI Formulary.’
The change – which means pregabalin is no longer on the formulary as the preferred option for the treatment of neuropathic pain – applies only to new patients, they clarified.
But GPs will still be able to prescribe pregabalin where they deem it to be ‘clinically appropriate’, they said.
Patients already prescribed pregabalin will be reviewed and will not need to be referred to hospital in order to continue their treatment, they added.
BMA NI GP committee chair Dr Alan Stout said: ‘There have always been high levels of pregabalin prescribed in Northern Ireland, and given the increasing levels of addiction attempts were made to reduce that level with mixed success.
‘Tragically we have also seen a number of deaths particularly in younger people through addiction to pregabalin.’
However, he added that the removal of the drug from the formulary is a ‘blunt instrument’ and that other services and investment must be in place.
He said: ‘Removing it completely is a pretty blunt instrument and we need to have other services in place and investment in primary care teams, CBT clinics and physiotherapy to combat both the addiction and those who were prescribed it in good faith to address chronic pain issues.
‘Our waiting lists here are disgraceful and someone waiting years to attend a pain management clinic will still need their pain managed until they can access an appropriate service.’
Pregabalin is a medication that has increasingly been prescribed to treat chronic pain, however, it is also used to treat epilepsy, fibromyalgia, restless leg syndrome, and generalised anxiety disorder.
In April, NICE’s first-ever guideline on chronic pain recommended that GPs should not prescribe gabapentinoids such as pregabalin to patients with chronic primary pain because they could be ‘harmful’.
And the MHRA warned in February that pregabalin may be associated with serious breathing problems in certain patients.
NICE is developing a guideline on medicines associated with dependence or withdrawal symptoms, due to be published in November 2021.
Public Health England’s landmark 2019 review into prescription drug addiction concluded that one in four adults – over 11m adults in England – received a prescription for antidepressants, opioids, gabapentinoids, benzodiazepines or z-drugs in the previous year.
At the time, public health officials said they recognised the ‘great pressure’ GPs are under to provide access to addictive medication and said alternative treatments needed to be considered.
Existing MHRA advice asks healthcare professionals to check the patient for a history of drug abuse before prescribing pregabalin and to observe patients who have been prescribed the drug for signs of drug abuse and dependence.
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