Ranjit Singh, MB, BChir, MBA

Patients and their surgeons are increasingly looking to alternative pain medications to reduce the risks associated with opioids. Gabapentin has been touted as a safer alternative but does itself carry significant risks, particularly for older adults, especially if used long-term.

To address these concerns, Bongiovanni and colleagues used Medicare data to identify patients who were prescribed gabapentin perioperatively and calculated the proportion that remained on this medication for longer than 90 days. Finding that 20% of short-term prescriptions led to long-term prescribing, the authors raise important concerns about the risks posed to this population. While gabapentin may be viewed as the lesser of two evils when compared to opioids, it remains to be seen whether the risk posed by gabapentin to older adults at commonly used doses is indeed less than that posed by the opioids that they might replace.

In addition to the adverse effects identified by the authors of this study, there are growing concerns about gabapentin’s potential for abuse and addiction. Furthermore, despite Beers Criteria recommendations to avoid the combination, concurrent use of gabapentin with opioids is still commonly seen in both surgical and nonsurgical patients. To make matters worse, in my experience, many patients presenting with adverse effects of these medications are misdiagnosed (for example, altered mental status is blamed on a urinary tract infection) leading to missed opportunities to deprescribe.

While the study does not address the reasons for long-term continuation of gabapentin, it is interesting to reflect on the various factors that may have contributed to it. These may include the patient’s desire for continued use because of perceived benefits (that may or may not exist) or because of addiction. Another cause of long-term prescribing is inertia on the part of the prescriber who reflexively orders refills without stopping to check whether each medication is still needed and is offering a benefit that exceeds the risk.

The risk vs. benefit calculation is one that needs to be made early and often. While I agree with the authors that there is a need for strategies to prevent short-term use from becoming long-term use, I would suggest that accurately assessing risks and benefits before the initial prescription might be the most effective approach. As prescribers and patients alike, we tend to overestimate the benefits and underestimate the harms of many medications. I thank Bongiovanni and colleagues for reminding us of this.

Lewis Nelson, MD

The fact that the opioids have made national headlines due to their highly addictive nature and risk for unintentional overdose and death should not eliminate the concerns associated with other classes of medications. In a well-meaning attempt to reduce opioid use, many clinicians have adopted gabapentin, a medication that exerts its pain-reducing effects quite differently than do opioids. Although reasonably well-accepted for use in neuropathic chronic pain, the value of gabapentin for acute, postsurgical pain is poorly understood and widely debated.

We know for certain that gabapentin carries many of the same concerns as do the opioids. The potential for gabapentin to be misused for its psychoactive effect is increasingly recognized, but the risk for death from overdose is markedly lower than with opioids. Thus, while safer than opioids, they are not risk free.

However, as this paper by Bongiovanni and colleagues shows, the development of long-term use of gabapentin, either due to withdrawal or the worsening of chronic pain, is becoming apparent. The study, which looked at older adults, noted that one-fifth of patients started on gabapentin for postoperative pain developed long-term use, defined as still taking the medication 3 months later. Since intense postoperative pain should generally fade by a week or 2, anyone on gabapentin (or any analgesic) for longer than this should raise red flags.

It appears that almost any pain medication can lead the development of analgesic-induced hyperalgesia, in which the exposure to a pain medication causes adaptations of the nerves that reset the steady state. This is not unlike tolerance to the sedating effects of alcohol or benzodiazepines, and as the pain resets additional analgesic becomes required to maintain a relatively pain-free new steady state.

The lessons learned about safe opioid use are applicable to gabapentin. Only use the medication when other treatments, medication or otherwise, are not sufficient. The threshold should be relatively high. When used, gabapentin should be prescribed for the shortest possible duration at the lowest possible dose. Patients should be monitored for signs of problematic use and for the transition to chronic pain, both of which can be done through prescription monitoring and regular clinical reassessment.