Reviewed by MedNext Clinical Team
Gabapentin and pregabalin — collectively known as gabapentinoids — have become among the most widely prescribed drugs in many countries. Despite their broad use, their misuse potential and potential for dependence were underappreciated for years before their controlled drug reclassification [1].
Clinical Indications
Gabapentinoids are licensed for neuropathic pain, including diabetic peripheral neuropathy, postherpetic neuralgia, and central neuropathic pain. Pregabalin additionally holds a licence for generalised anxiety disorder (GAD) and as adjunctive therapy in epilepsy. Both are commonly used off-label for fibromyalgia, restless legs syndrome, and alcohol withdrawal.
Pregabalin in Anxiety
Pregabalin's anxiolytic effect is clinically significant and relatively rapid in onset compared to SSRIs. However, this same property contributes to its misuse potential, particularly in patients with a history of substance use disorder. It produces euphoric and sedative effects at higher doses that can be sought recreationally.
Controlled Drug Reclassification
Both gabapentin and pregabalin were reclassified as Schedule 3 controlled drugs in Great Britain in 2019 following evidence linking them to deaths, often in combination with opioids [1]. This means prescriptions must include the prescriber's address and be handwritten or computer-generated with specific requirements. Misuse is particularly prevalent among people who use opioids, where gabapentinoids potentiate respiratory depression.
Tapering and Discontinuation
Abrupt discontinuation of gabapentinoids can cause withdrawal symptoms including insomnia, nausea, headache, and in severe cases, seizures. A gradual taper over at least four weeks is recommended, with slower tapers for patients who have been on high doses or long-term therapy. Patients should be counselled about withdrawal symptoms before starting treatment.
Practical Prescribing Tips
- Screen for substance use history before initiating, especially in patients already on opioids
- Start at low doses and titrate slowly to effect
- Avoid combination with opioids unless clinically essential, with close monitoring
- Plan a tapering schedule before long-term prescribing commences
- Adhere to controlled drug prescribing requirements
References
- Goodman CW, Brett AS. Gabapentin and pregabalin for pain — is increased prescribing a cause for concern? JAMA Intern Med. 2017;177(10):1529-1530.