Gabapentin ‘Free for All’ in Addiction Treatment

By Pat Anson

The nerve drug gabapentin is increasingly being prescribed to patients undergoing treatment for substance use disorder (SUD), according to two new studies that highlight how the drug is being abused and used to treat health conditions it was never intended to treat.

The first study, published in the journal Drug and Alcohol Dependence, looked at over 200,000 urine drug test results from patients undergoing SUD treatment in all 50 U.S. states.   

Over the past decade, gabapentin (Neurontin) prescribing nearly doubled, from 3.9% of patients undergoing addiction treatment in 2016 to 7.6% in 2023. In addition, nearly one in ten patients being treated for SUD tested positive for gabapentin, even though they didn’t have a prescription for it.    

“A lot of that use is off label, and in the context of substance use, we're seeing it being prescribed to manage withdrawals, or for insomnia, pain, and anxiety. It’s just sort of a free-for-all in how it's prescribed,” says lead author Matthew Ellis, PhD, an Assistant Professor of Psychiatry at Washington University School of Medicine. 

“I think one of the big findings was that the positivity rate for those without a prescription for gabapentin was twice as big as those prescribed gabapentin.”

Gabapentin was originally developed as an anti-convulsant. It was first approved by the FDA as a treatment for epilepsy and later for neuropathic pain caused by shingles. But it is also routinely prescribed off-label for migraine, fibromyalgia, bipolar disorder, cancer pain, postoperative pain, and many other conditions.

Its off-label use as a pain reliever grew after the CDC recommended gabapentin in 2016 as an alternative to opioid analgesics. By 2024, gabapentin was prescribed to 15.5 million Americans, making it the fifth most prescribed drug in the U.S. 

Due to the nature of the study, Ellis says it’s difficult to know if patients were prescribed gabapentin before entering SUD treatment or if they started taking it after treatment started to help manage symptoms of withdrawal. Gabapentin prescribing increased to all patients, whether they were being treated for alcohol, cannabis, stimulant, sedative or opioid abuse.

Another possibility is that patients take gabapentin to heighten the effects of addiction treatment drugs like buprenorphine (Suboxone) or methadone. Gabapentin is prized as a street drug because it helps increase the euphoria or “high” that comes from psychoactive substances. 

“I don't want to give gabapentin a bad name at all. I think there's definitely potential for it. I think my biggest issue is that there's just so little evidence base for its use in substance use treatment settings,” Ellis told PNN. 

“And to have so many people using it outside of a prescription, it just may be a call to recognize that, one, there may be untreated comorbid conditions that people are self managing, or two, we need to do a lot better about building an evidence base to see what exactly is or could be the benefit of gabapentin in substance use treatment.”

One positive trend uncovered by the study is that the use of gabapentin without a prescription has declined in drug treatment settings, from 15.2% of patients to 9.9%. 

The second study, published in the same journal, also found that gabapentin prescribing has significantly increased over the past decade, but that its “nontherapeutic” use (another term for misuse) appears to be declining. 

Despite the decrease in misuse, FDA researchers found that the number of cases reported to U.S. poison control centers involving gabapentin greatly exceeded those for pregabalin (Lyrica) and the anti-anxiety drug diazepam. Most of the gabapentin cases involved other substances, particularly opioids. 

Pre-Existing Conditions Deserve Affordable Treatment

By Dr. Lynn Webster, PNN Columnist

The National Institutes of Health reports that about 10 percent of Americans experience a substance use disorder (SUD) at some point in their lives. Most of those who suffer from an SUD receive no treatment.

About twice as many Americans – 20 percent -- have chronic pain. Many of them also cannot find adequate treatment or even a provider willing to treat them. 

Making treatment accessible for both of these conditions -- which are defined as pre-existing for insurance purposes -- is always a topic of concern. These days, it is of paramount concern that access to treatment is available. And it requires us to take action.

We’re All at Risk for Pain and Drug Abuse

Poverty and hopelessness are risk factors for drug abuse, even though not everyone who is economically challenged develops an SUD. Unfortunately, prevention and treatment programs for SUDs are less available to those who cannot pay for them and who most need them.

Anyone can suffer from chronic pain, but even those with resources may not have access to adequate pain management.

My concern is more than theoretical. It is personal. I have friends, former patients and family members who suffer from SUDs. If the Affordable Care Act (ACA) — widely known as Obamacare — ends and we lose coverage of pre-existing conditions, I fear they will be abandoned in exactly the same way as people in pain have been abandoned ever since the CDC issued its 2016 opioid prescribing guideline.

In recent years, I have received hundreds of emails and calls from people in pain. Their medications have been tapered and they don't know where to turn for help. Untreated chronic pain, as well as untreated SUDs, can result in ruinous consequences: disability, destitution, isolation, poverty and suicide.

We need to help healthcare providers find more effective ways to treat their patients. The Centers of Excellence in Pain Education (CoEPEs) program was created to teach healthcare professionals about pain and its treatment. Since this is something most doctors do not study adequately during medical school, it's important to have continuing medical education opportunities to learn about the stigma associated with pain treatment and substance abuse disorders.

Abolishing ACA Could Have Devastating Consequences

The current administration has appealed to the Supreme Court to abolish the ACA. President Trump has said that Obamacare "must fall." Given the fact that we're in the middle of a pandemic and millions of people are unemployed and may have lost access to employer-sponsored healthcare, the timing seems terrible.  

But even without a pandemic, reversing the ACA would be devastating for millions of Americans who have an SUD or chronic pain. President Trump signed an executive order on September 24 that claims to protect people with pre-existing conditions. However, experts dispute whether his executive order can actually do what it promises.

Regardless, eliminating the ACA will likely allow insurance companies to charge higher rates for people with pre-existing conditions. This would essentially render treatment for chronic pain and SUD unaffordable for many people, leading to an increase of the terrible consequences mentioned above. And, of course, SUDs and chronic pain are only two of the pre-existing conditions that would no longer be protected. 

It is time for everyone to understand the consequences that losing the ACA may have for their community, family, friends and themselves. There is still time to be heard, but you have to act quickly. Click here to find your federal, state, and local elected officials and express your views.  

Let us also send healing thoughts and prayers to President Trump, the First Lady and everyone else infected with COVID-19.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book The Painful Truth, and co-producer of the documentary It Hurts Until You Die. Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences. You can find Lynn on Twitter: @LynnRWebsterMD.