Gabapentinoid misuse, abuse and non-prescribed obtainment in a United States general population sample

Community pharmacists' experience of gabapentin misuse and abuse: A quantitative study from Jordan

Gabapentin is an anticonvulsant that has an abuse potential. The aim of this study was to investigate the misuse and abuse of gabapentin in Jordan from the perspective of community pharmacists. A cross-sectional survey using a self-reported structured questionnaire was used with a convenience sample of pharmacists employed by various independent and chain community pharmacies. An online technique was used in this study using Google forms. A total of 215 questionnaires were completed, with 200 respondents (93%) reporting awareness of cases of gabapentin abuse in their pharmacies. Less than half of the respondents (n = 94; 43.7%) indicated that gabapentin requests were not accompanied by prescriptions. Almost two-thirds of respondents (63.6%) noticed an increased pattern of gabapentin abuse/misuse during the last 6 months. The study underscores the need for regulatory efforts and pharmacovigilance to manage potential gabapentin abuse, along with pharmacist and patient education at the community pharmacy, regarding potential abuse of gabapentin.

Trends in Pregabalin Use and Prescribing Patterns in the Adult Population: A 10-Year Pharmacoepidemiologic Study

BACKGROUND AND OBJECTIVE

Pregabalin is steadily gaining popularity worldwide, with epidemiological studies indicating an increase in labeled, off-labeled, and recreational uses. In Israel, pregabalin prescriptions are not regulated by the controlled substances legislations, prompting a need to examine its usage trends for potential policy adjustments. The objective of this study was to assess trends in pregabalin prescribing during a 10-year period, to characterize demographic and clinical characteristics of individuals prescribed pregabalin, and to identify risk factors associated with high-intensity pregabalin use.

METHODS

This retrospective, longitudinal study examined trends in pregabalin prescribing from 2010 to 2019 based on data extracted from the Clalit Health Services (CHS) electronic database. Annual pregabalin prescribing rate was calculated individually for each reporting year. A univariable analysis was conducted to compare the demographic and clinical characteristics of pregabalin users in 2019 with those in 2010. Multivariable regression analysis was performed to assess dose-related patterns by specific demographic and clinical characteristics.

RESULTS

Pregabalin prescription rate more than doubled over 10 years [odds ratio (OR) 2.3, p = 0.001], reaching 7.2 [95% confidence interval (CI) 7.18-7.28] prescriptions per 100 CHS members in 2019. The highest prescription rates were observed among the elderly population (13.2 and 24.1 prescriptions per 100 CHS members for those aged 55-74 and over 75 years old, respectively). Same-year administration of pregabalin with opioids, benzodiazepines, and Z-drugs was common; however, the percentage of patients using these drugs together declined in 2019 compared with 2010 (p < 0.001). Males, patients with low socioeconomic status, patients aged 35-54 years, and those who consumed opioids, benzodiazepines, and Z-drugs received higher pregabalin doses.

CONCLUSION

Pregabalin use has increased significantly in the Israeli adult-based CHS population, consistent with worldwide data. A growing use over time may indicate overprescription. More studies are needed on misuse patterns to identify populations most susceptible to high-dose and high-intensity pregabalin use.

Pregabalin use in forensic hospitals and prisons in German speaking countries-a survey study of physicians

Background

Pregabalin is a gamma-aminobutyric acid (GABA) analog that was approved in the EU in 2004 for the treatment of neuropathic pain, generalized anxiety disorder and epilepsy. Since its introduction, pregabalin abuse and misuse has increased significantly. In Switzerland, clinical reports suggest that pregabalin misuse is common among patients in forensic hospitals and prisons. However, data on pregabalin use is scarce, especially in these settings. Therefore, we conducted a study to explore patterns of pregabalin use among prison and forensic patients.

Methods

We used a questionnaire to survey physicians working in prison and forensic medicine in German-speaking countries. A total of 131 responses were received.

Results

According to the physicians' subjective assessment, 82.5% of them had observed a recent increase in pregabalin use by their patients and 89.1% of them reported that their patients requested pregabalin without a clear medical indication. Patients misusing pregabalin in combination with other illicit substances were observed by 93.3% of the physicians surveyed. According to 73.5% of the physicians surveyed, they had already encountered patients on pregabalin doses of more than 600 mg/day (the maximum recommended daily dose); the highest dose reported was 4,200 mg/day. According to 85.0% of physicians surveyed, they have observed patients experiencing withdrawal symptoms from pregabalin, with the most commonly reported symptoms being displeasure and high aggression. Regarding the nationality of pregabalin-misusing patients, 58.3% of the interviewed physicians reported to be rather in contact with foreign patients, mainly from Northwest Africa (Maghreb). Only 45.0% of the surveyed physicians prescribe pregabalin. Among patients who developed behavioral problems while taking pregabalin, none of the physicians (0.0%) showed a tendency to continue pregabalin at the same dose; all respondents chose to reduce/substitute/discontinue.

Conclusion

Our study has provided confirmatory evidence that the use of pregabalin presents a significant issue in forensic and prison medicine across German-speaking countries. Prescribing pregabalin in this field can compound use disorder problems and exacerbate challenges in daily life for those in forensic institutions or prisons. It is necessary that all physicians who prescribe pregabalin are clearly informed about the management (including the risks) of this drug.

Misuse of gabapentinoids (pregabalin and gabapentin) in patients with neuropathic pain related to spinal cord injury

OBJECTIVE

To investigate the misuse of gabapentinoids (pregabalin and gabapentin) in patients with neuropathic pain related to spinal cord injury.

STUDY DESIGN

Cross-sectional study.

SETTING

Outpatient clinic in a physical therapy and rehabilitation hospital.

PARTICIPANTS

127 patients, aged 18-70 years, who had neuropathic pain related to spinal cord injury (SCI) and disease duration of at least 12 months.

OUTCOME MEASURES

Gabapentinoid use disorder of the patients was determined based on the DSM-5 diagnostic criteria for substance-related disorders. Patients were divided into 2 groups as those with drug misuse and those without drug misuse. Demographic and clinical information of the patients were compared between the groups. Factors associated with drug misuse were analyzed.

RESULTS

The misuse rate was 81.9% in patients using pregabalin and 69.69% in patients using gabapentin. Duration of disease and the Leeds assessment of neuropathic symptoms and signs (LANSS) score were statistically significantly higher in the drug misuse group. A statistically significant difference was found between the groups in terms of marital status, education and income level, and smoking and alcohol use. A statistically significant relationship was observed between drug misuse and duration of disease and LANSS score.

CONCLUSION

Misuse of gabapentinoids is prevalent in patients with neuropathic pain related to spinal cord injury. The duration of disease and the severity of NP are associated with misuse. Clinicians should exercise caution when prescribing gabapentinoids to patients with SCI.

Trends in overdose deaths involving gabapentinoids and Z-drugs in the United States

INTRODUCTION

As policies have been implemented to limit access to prescription opioids, other drugs have been prescribed off-label, sometimes concurrently with opioids, to manage pain. There are concerns about the use of gabapentinoids and "Z-drugs" with opioids. As the opioid crisis transitions to illicit opioids and polysubstance use, little work quantifies the concurrent involvement of non-opioid prescription drugs and illicit opioids in overdose deaths.

METHODS

Data from the census of deaths in the United States for 1999-2020 were used to understand trends in deaths involving gabapentinoids/Z-drugs and opioid co-involvement. These trends were studied overall and by sex, race, age, and education.

RESULTS

Per capita overdose deaths involving gabapentinoids/Z-drugs increased almost continuously since 1999, averaging 15.8% annual growth. This rate increased to 32% in 2020, primarily due to overdoses involving synthetic opioids. Women typically had higher rates of overdose deaths involving both opioids and gabapentinoids/Z-drugs, though this disparity disappeared in 2020. White Americans and American Indians/Alaskan Natives historically had higher rates than other racial groups; however, Black Americans experienced over 60% annual growth in recent years. Low education groups have been disproportionately impacted. The age incidence tends to be older than overdoses involving opioids more generally.

CONCLUSION

Overdose deaths involving opioids and gabapentinoids/Z-drugs have tended to disproportionately affect women and older age groups compared to all opioid-involved overdoses. As deaths involving synthetic opioids likely reflect use of illicitly-obtained opioids, there may be less of a role for policies targeting the concurrent prescribing of gabapentinoids/Z-drugs with opioids to reduce these deaths.

Pharmacist, prescriber, and drug policy expert opinions on gabapentinoid misuse

BACKGROUND

Gabapentinoids (gabapentin and pregabalin) are widely used in clinical practice, but recent evidence indicates that they carry an increased risk of misuse. As healthcare professionals (HCPs) and policymakers plan different strategies to promote harm reduction, it is important to understand different interested party viewpoints.

OBJECTIVE

To explore prescriber, pharmacist, and drug policy expert (DPE) awareness, opinions, and experiences regarding gabapentinoid misuse.

METHODS

A qualitative description study using individual semi-structured virtual interviews was conducted between February and April 2021. Participants included prescribers (physicians, physician assistants [PA], or nurse practitioners [NP]) and pharmacists practicing in outpatient, ambulatory, or community-based healthcare settings; individuals with relevant drug policy expertise were also included. Qualtrics (Provo, Utah) and Zoom (San Jose, California) were used to facilitate quantitative (for initial screening and participant characteristics) and qualitative (interview) data collection. Data were coded and organized into themes in NVivo (QSR International; Burlington, Massachusetts) using thematic analysis steps.

RESULTS

A total of 43 individuals participated in this study, including 16 (37.2%) pharmacists, 13 (30.2%) physicians, seven (16.3%) NPs, four (9.3%) DPEs, two (4.7%) pharmacist/DPEs, and one (2.3%) PA. Results were organized along four themes: (1) challenges/opportunities in gabapentinoid use; (2) gabapentinoid misuse awareness; (3) solutions to gabapentinoid misuse and (4) contributing barriers in pain management. Participants invoked different opinions in their consideration of gabapentinoid misuse, including the desire for harm reduction, the limitations of the current healthcare and insurance system, the lack of options for pain and substance use disorder treatment, and the influence of patient expectations.

CONCLUSIONS

Gabapentinoid misuse was commonly framed in comparative fashion to ongoing concerns with opioids, and proposed solutions often focused less on regulatory control and more toward patient and HCP education and an overhaul of the health system approach to substance use and healthcare overall.

Nonmedical use of gabapentin and opioid agonist medications in treatment-seeking individuals with opioid use disorder

BACKGROUND

As prescriptions for gabapentin have increased in recent years, nonmedical use and risk of adverse outcomes (e.g., hospitalizations and overdose) have been identified, particularly in association with opioids, including opioid agonist medications (OAMs) buprenorphine and methadone. However, there is a lack of systematic, nationwide data assessing the relationship between the nonmedical use of gabapentin and OAMs.

METHODS

Data were sourced from two nationwide opioid surveillance programs of treatment-seeking individuals with opioid use disorder (OUD). Both programs utilized an identical serial, cross sectional survey of 12,792 new entrants to one of 163 substance use treatment programs for OUD in 46 states and the District of Columbia from January 2019 to December 2020.

RESULTS

Past month nonmedical use of gabapentin was endorsed by 9.3% of the sample. Of those using gabapentin nonmedically, 64.1% also endorsed nonmedical use of an OAM, including concomitant use of methadone (35.3%), and buprenorphine (49.0%). Concomitant nonmedical use of gabapentin and OAMs was more prevalent (versus nonmedical use of gabapentin alone) in the Southern region, among those living in a street dwelling, those with chronic pain and healthcare professionals.

CONCLUSIONS

Nonmedical use of gabapentin in people with OUD appears to frequently coincide with nonmedical use of OAMs. As prescriptions and off-label use of gabapentin increase, provider education should include the risks of concomitant gabapentin and OAM use, particularly amongst buprenorphine prescribers. Future research should investigate motivations (e.g., OUD self-management) for nonmedical use of gabapentin and OAMs within the context of OUD treatment access and retention.

Overdose deaths involving non-BZD hypnotic/sedatives in the USA: Trends analyses

Background

There is sparse knowledge on overdose deaths resulting from non-benzodiazepines and gabapentinoids usage. We examined overdose death rate across demographics categories and the overdose death trends over time.

Methods

Using data from the National Center for Health Statistics (USA), we identified 21,167 persons that died with an overdose ICD code as the underlying cause of death and had a T42.6/T42.7 ICD code, which include gabapentinoids and z-drugs, among their multiple causes of death. The overdose death rate was calculated per 100,000 persons for every year between 2000 and 2018. We used joinpoint regression analyses to assess trends over time.

Results

We identified a rise in the proportion of deaths with a T42.6/T42.7 ICD code between 2000 and 2006 (yearly change: +0.06) and between 2006 and 2015 (yearly change: +0.32). From 2000 to 2008, the proportion of deaths with any other T code rose significantly (yearly change: +3.56). Between 2008 and 2018, there was also a significant rise (yearly change: +1.31). From 2000 to 2015, the proportion of deaths with a T42.6/T42.7 ICD code with any other T code rose (yearly change: +2.58). From 2000 to 2015, the proportion of deaths with a T42.6/T42.7 ICD code with a concurrent benzodiazepine T code rose (yearly change: +1.98). From 2000 to 2005, the proportion of alcohol T codes rose non-significantly (yearly change: +0.35). Finally, the proportion of alcohol T codes fell significantly between 2008 and 2018 (yearly change: - 0.74).

Interpretation

Deaths due to non-benzodiazepine hypnotics and gabapentinoids increased significantly over the last two decades. Clinicians should not assume that replacing benzodiazepines and opioids with these medications necessarily lowers risk to the patient.

Funding

This study was funded by an internal grant from the Columbia University President's Global Innovation Fund (PI: Martins).

The Impact of Regulatory Restrictions on Pregabalin use in Saudi Arabia: An Interrupted Time series Analysis

PURPOSE

The Saudi Food and Drug Authority (SFDA) added pregabalin to the list of controlled substances in December 2017 to minimize the risk of its possible abuse and misuse. This study was aimed at assessing the impact of this decision on the overall use of pregabalin in Saudi Arabia and in comparison, with drugs prescribed to treat neuropathic pain therapy (i.e. vs. gabapentin, tramadol, duloxetine, and amitriptyline).

METHODS

This was an interrupted time-series analysis of the Saudi quarterly sale data of the study drugs from October/2015 to September/2020. These data were obtained from IQVIA and were converted into use estimates (defined daily dose per 1000 inhabitant-days [DDD/TID]). Segmented regression models were conducted to assess the direct (level) and prolonged (trend) changes in use data after the decision. All analyses were completed using RStudio Version 1.4.1103.

RESULTS

Before the SFDA's decision, there was an increased quarter-to-quarter use of pregabalin (DDD/TID: 0.16; 95% confidence interval [CI] 0.04 to 0.28). Pregabalin overall use dropped sharply by -1.85 DDD/TID (95%CI -2.71 to -0.99) directly after the decision with a prolonged quarter-to-quarter declining effect (DDD/TID: -0.22, CI to -0.37 to -0.05). The decision was associated with a direct increase in the use of gabapentin by 0.62 DDD/TID (95%CI 0.52 to 0.72) without any impact on the use of other drugs.

CONCLUSIONS

The results of our study showed that the SFDA decision was associated with a decrease in the overall use of pregabalin, which may help minimize the risk of its abuse and misuse. This article is protected by copyright. All rights reserved.

Gabapentin reduces postoperative pain and opioid consumption in patients who underwent lumbar laminectomy

BACKGROUND

Postoperative pain management solely with opioids elevates the risk of opioid-related adverse events during hospitalization and after discharge from the hospital. Clinical trials have demonstrated gabapentinoids as viable adjunctive treatments for spinal surgeries. However, only a few practice-based studies have examined the efficacy of gabapentin as an opioid-sparing agent for patients undergoing lumbar laminectomy in rural hospital settings.

OBJECTIVE

To determine the effects of gabapentin on opioid consumption and pain perception in patients who underwent lumbar laminectomy at a rural community hospital.

METHODS

Data were collected by retrospective chart reviews of 99 patients who underwent lumbar laminectomy at Yavapai Regional Medical Center from January 1, 2017, to July 1, 2019. The patients were stratified into 2 groups: those who were taking gabapentin as outpatients before surgery and were continued on the same dose postoperatively (n = 50, gabapentin group) and those who were not taking gabapentin preoperatively or postoperatively (n = 49, usual-treatment group). The primary end points were opioid consumption in morphine milligram equivalents (MME) and pain for 24 hours postsurgery.

RESULTS

Outcomes from the mixed-model analysis of variance showed significant main effects of group and time for opioid consumption in MME (F_1,97 = 4.3, P < 0.05 and F_3,291 = 133.9, P < 0.001, respectively) and numerical pain scale scores (F_1,99 = 4.0, P < 0.05 and F_3,241 = 21.4, P < 0.001, respectively) and group-time interaction for opioid consumption in MME (F_3,291 = 2.6, P = 0.05). Post hoc analyses showed that opioid consumption in MME was significantly lower in the gabapentin group than in the usual-treatment group for the first 6 hours postoperatively. The pain scores were significantly lower in the gabapentin group than in the usual-treatment group across all time periods.

CONCLUSION

Patients on gabapentin showed reductions in pain perception and postoperative opioid consumption. The results extend the findings from randomized trials to a real-world clinical setting. These data support using gabapentin in conjunction with opioids for pain management of patients undergoing lumbar laminectomy.

Non-medical Use of Prescription Gabapentinoids (Gabapentin and Pregabalin) in Five European Countries

Background: Non-medical use (NMU) of prescription GABA analogs (pregabalin and gabapentin) has been reported especially in opiate dependent persons. However, by now the prevalence of NMU of gabapentinoids in the general population has not been sufficiently evaluated. The aim of this research paper is to determine the prevalence of prescription GABA analog NMU and associated demographics in five European countries with special detail of Spain. Methods: The RADARS Survey of Non-Medical Use of Prescription Drugs Program (NMURx) is a harmonized series of contemporaneous cross-sectional surveys of adults conducted in multiple countries. NMURx collects data from the general population in each participating country about NMU of prescription drugs, illicit drugs, and associated demographics. NMU was defined as "using a medication without a doctor's prescription or for any reason other than what was recommended by their doctor." Responses from Spain (4Q2017, n=10,062) were analyzed in detail. Comparative data were available from France, Germany, Italy, and UK. Responses were collected using non-probability quota sampling and post-stratification population weighting was applied to reflect the national distributions of adults, based on age, gender, and census region. Rates of NMU and associated demographics were reported as rate of past 90-day NMU per 100,000 adult population with 95% confidence intervals. Results: Germany (1,197 per 100,000 adult population [95% CI: 1,004.3-1,379.1]) and United Kingdom (1,067 per 100,000 adult population [95% CI: 851.3-1,283.2]) presented the highest prevalence of gabapentinoids NMU. In Spain the prevalence of past 90 days GABA analog NMU was: 344.4, 95% (CI 204.8-484.0), with male predominance. Those who non-medically use GABA analogs had a higher prevalence of lifetime chronic pain, lifetime illicit drug use, and previous substance abuse treatment. In Spain, 20% of respondents who ever have used gabapentinoids, reported a lifetime NMU; the prevalence was higher for pregabalin 624 (6.2%) than for gabapentin 444 (4.4%). The main reasons for use were to self-treat pain and other medical conditions. Conclusions: The risk of NMU of gabapentinoids should not be neglected. Subjects with a history of chronic pain and lifetime substance use disorders had an increased risk of NMU of gabapentinoids.