For many people who take gabapentin – a drug prescribed to treat seizures and pain caused by shingles – side effects such as sedation can be a challenge, as those who take it off-label for neuropathic pain told MedShadow in the past.
But an increasing number of opioid abusers crave that side effect, reporting a calm feeling when combining gabapentin – developed by Pfizer under the brand name Neurontin – with opioids, muscle relaxants and anxiety medications. Some also get a marijuana-like high and an enhanced euphoria. But when overused or abused, it can cause significant organ or brain damage.
“Gabapentin was prescribed off-label for pain because it was thought to be a safer alternative to opioids,” said Steven Evans, MD, medical director of American Addiction Centers/Nevada. “But now people who don’t need it are starting to use it,” he said.
According to American Addiction Centers, rates of gabapentin misuse are 1.1% in the general population and 22% among those who abuse opioids. The most serious problems resulting from abuse are rash, itching, swelling of the face or mouth, hoarseness, difficulty swallowing or breathing and seizures.
The pills are known as “gabbies” or “johnnies” on the street, where a 300 mg tablet goes for 75 cents.
At Solutions Recovery Treatment Center in Las Vegas, where gabapentin is used in addiction treatment, “In the last two years we’ve noticed a spike in clients losing medications and needing more refills,” said David Marlon, an addiction specialist and CEO of the center.
“It also happens in sober living communities and outpatient addiction treatment,” he said.
Given off-label in addiction treatment and for migraine, hot flashes, fibromyalgia, neuropathy and more, it is the 7th-most prescribed drug in the United States. Pharmacy Times reported that 57 million prescriptions for gabapentin were written in the United States in 2015, a 42% increase since 2011.
“My radar was not on in terms of gabapentin being abused,” said Michele Matthews, associate professor of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences in Boston.
“With the shift from prescription opioids, there was an increase in non-opioid alternatives, and gabapentin was at the top of the list,” she said. “For the most part it wasn’t something we had to worry about. We’re seeing something different now.”
Matthews works with high-risk patients in the pain management clinic at Brigham and Women’s Hospital.
She said that a typical dose for pain is between 1,800 and 3,600 mg a day.
“Instead of taking it throughout the day, they might take it all at once, and that would cause a mood-altering effect,” she said. “Or they are taking it as part of a cocktail [of drugs].”
“We’re starting to see requests for early refills,” Matthews said. “It’s similar to patients maybe misusing opioids. You can also tell if patients are difficult, [such as] yelling.”
“It reminds prescribers that medications need to be monitored closely,” she said.
Gabapentin is not scheduled as a controlled substance because when given alone it has not been considered addictive. When the drug is taken with other medications, gabapentin’s potential for abuse and addiction increases.
“Gabapentin has been linked with impaired driving and opioid use, highlighting the need to understand more fully its risk profile,” the authors of a 2017 study wrote in
the Journal of Addictive Behaviors.
They questioned 33 drug users in Appalachian Kentucky reporting nonmedical use of gabapentin after first being prescribed it for not unusual off-label uses such as pain, anxiety and opioid detoxification.
“Focus group responses highlighted the low cost of gabapentin for the purpose of getting high and noted increasing popularity in community, particularly over the last two years,” researchers wrote.
It doesn’t have the same risk of deadly overdose as opioids, but overdose can happen, and it carries the risk for significant organ or brain damage.
However, unlike opiates, there is no antidote for an overdose. Because of the drug’s long half-life — the amount of time in the body before it is half gone — immediate medical attention is necessary to manage the complications associated with a toxic amount of this drug,
The Charlestown Gazette-Mail reported that the number of fatal overdoses related to gabapentin in West Virginia jumped from 3 in 2010 to 109 in 2015.
Between 2008 and 2011 the number of emergency room visits in metropolitan areas for misuse or abuse of gabapentin increased by nearly 5 times, according to the Drug Abuse Warning Network.
Andrew Kolodny, MD, co-director of Opioid Policy Research at the Heller School for Social Policy and Management at Brandeis University, said that because of the abuse potential, it should probably be scheduled as a controlled drug.
“Then people can’t doctor-shop for it. That’s where drugs with abuse potential belong,” he said.
He noted that Lyrica (pregabalin) is closely related, but is classified as schedule 5.
“It doesn’t make sense for Lyrica to get scheduled as controlled and for gabapentin not to be,” he said.
According to GoodRx, in July 2017, Kentucky became the first state to make gabapentin a schedule 5 controlled substance, even though the FDA is the authority that schedules drugs.
Ohio, Minnesota, Virginia, Illinois, Wyoming and Massachusetts have started to track gabapentin through prescription drug monitoring and reporting programs, seen as a precursor to making it a schedule 4 or 5 substance.
Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.