Prescribing gabapentin with opioids may increase risk for OUD, overdose

Adam D. Scioli, DO, DFAPA, FASAM, FAOAAM

The findings of this study aren’t surprising. At Caron [Treatment Centers], we often see this combination in our clinical practice, especially in our patients with chronic pain. Often in patients with chronic pain, multiple medications have been added over time in an effort to manage pain without fully addressing all of the underlying issues that may enhance or intensify the sensation of pain. Specifically, the area of our brains that regulate and process pain from our nervous system is adjacent to the areas responsible for regulating emotions, thoughts and judgment. As a result, emotional dysregulation can activate our pain receptors. When people experience anxiety or depression, pain signals from the peripheral nerves become amplified by the brain. The pain itself is the same, but a person’s perception of the pain becomes much greater.

There are many factors that contribute to the development of an opioid use disorder or other use disorders including genetics, co-occurring mood disorders, adverse events and the substance itself. When it comes to what was addressed in this study, patients who have taken both gabapentin and opioids, we need to look clinically at why a patient would be prescribed both of these medications. Specifically, when gabapentin is prescribed for a mood disorder or other off-label use for patients with uncontrolled pain where we would see a layering of medications, that suggests further evaluation is needed before adding in an opioid for pain management. As for the substance itself, gabapentin and other gabapentinoids can result in relaxation and euphoria that can enhance the effect of an opioid. Both medications also have a dose-dependent effect that can suppress the respiratory system, which can be deadly.

The one caveat in this study is it doesn’t address the dosage or duration of use for either drug. How much and how long both of these medications are used can factor into the development of an opioid use disorder.

Clinically, I think, before prescribing gabapentin or another gabapentinoid, the prescriber needs to be clear on why they are choosing this medication, as well as the short- and long-term management of this patient. If it is for pain, what other modalities — physical therapy, psychosocial supports — are being used to manage the underlying pain. For a mood disorder, there are FDA-approved medications for anxiety and other mood disorders that have greater efficacy than gabapentin.

When there is a short-term, clinical need for using these analgesics together to treat an acute condition, the physician needs to explain the risks to the patient and seek the patient’s full, informed consent before prescribing. The physician should also document in the patient’s chart a well-articulated plan that includes a transition to other non-addictive pain management modalities such as physical therapy, psychosocial support and complementary therapies. If an opioid use disorder is suspected, a consultation with an addiction medicine professional would be appropriate.

Joshua J. Lynch, DO, EMT-P, FAAEM, FACEP

Initially, gabapentin was FDA approved to treat seizure disorder. It is now FDA approved for neuropathic pain from nerve injuries, fibromyalgia and diabetes. It is also prescribed off label for many other conditions. Various brand-name forms of gabapentin are even used for panic attacks, anxiety disorders and impulse control disorders. Over the past nearly 20 years, we have seen the prescriptions for gabapentin increase about 250%. A potential explanation for the rise in gabapentinoids’ (inclusive of both gabapentin and Lyrica) prescribing rates may be a result of doctors seeking alternatives to opioids for pain management. This increase is seen without well-established evidence demonstrating significant improvement in pain with the use of the gabapentinoids vs. placebo. 

It is concerning that when opioids are combined with gabapentin, the risk of opioid use disorder and opioid overdoses may be increased. While the nation continues to deal with ever-rising opioid overdose deaths, caution must be used when seeking alternative medications to treat pain. Additional research is needed to further evaluate the safety profile of gabapentin and other non-opioid medication options when treating pain, especially in patients already taking opioids.