Let’s be perfectly honest. Most doctors have a difficult time with chronic pain patients. One physician described it to us many years ago: “When I see a patient suffering severe chronic pain come in the front door I want to go out the back door.” That’s because there are few good options. Drugs like hydrocodone or oxycodone used to be prescribed in huge quantities. Now gabapentin (Neurontin) and pregabalin (Lyrica) are on the ascendency and opioids are shunned.
The Opioid Epidemic:
Doctors are dismayed by the opioid epidemic sweeping the nation. Over the last year, the drumbeat of headlines about opioid overdoses and deaths has scared a lot of physicians into cutting back on prescribing drugs like hydrocodone or oxycodone.
Many of the overdose deaths are caused by illicit fentanyl. People OD because they have no idea how potent the narcotics are that they are snorting, swallowing, or injecting. According to the CDC (Nov. 3, 2017):
“Preliminary estimates of U.S. drug overdose deaths exceeded 60,000 in 2016 and were partially driven by a fivefold increase in overdose deaths involving synthetic opioids (excluding methadone), from 3,105 in 2013 to approximately 20,000 in 2016. Illicitly manufactured fentanyl, a synthetic opioid 50–100 times more potent than morphine, is primarily responsible for this rapid increase. In addition, fentanyl analogs such as acetylfentanyl, furanylfentanyl, and carfentanil are being detected increasingly in overdose deaths and the illicit opioid drug supply.”
Fentanyl powder does not come from your local pharmacy. Most of it is illicit and is coming from foreign countries (CBS News; New York Times, Aug. 10, 2017). China and Mexico are major suppliers. It is being added to heroin or even counterfeit opioid pills that look like Percocet (CNN June 8, 2017) or Oxycontin. The government does not seem to know how to stem the flow of illicit fentanyl that is flooding the country.
Doctors and Opioids:
It is hardly any wonder that doctors have cut back on prescriptions for hydrocodone and oxycodone. Like the rest of us, they read horrifying reports about opioid deaths. The evening news often leads with graphic accounts of accidental overdoses. Federal guidelines and restrictions have made it harder for physicians to prescribe opioids.
Gabapentinoids: What Are They?
As a result of the negative publicity and constraints about opioids, many people who are in severe pain have been left without relief. Consequently, physicians are searching for other drugs they can prescribe instead of narcotics. They may turn to gabapentinoids (gabapentin and pregabalin).
Gabapentin (Neurontin) and pregabalin (Lyrica) are both used to treat nerve pain. Doctors prescribed these medications three times more often in 2015 than they did in 2002, despite no radical change in the number of patients with neuropathic pain (JAMA Internal Medicine, online Jan. 2, 2018).
The author advises his colleagues to use these drugs cautiously:
“The combination of a dearth of long-term safety data, small effect sizes, concern for increased risk of overdose in combination with opioid use, and high rates of off-label prescribing, which are associated with high rates of adverse effects, raises concern about the levels of gabapentinoid use. While individual clinical scenarios can be challenging, caution should be advised in the use of gabapentinoids, particularly for those individuals who are longterm opioid users, given the lack of proven long-term efficacy and the known and unknown risks of gabapentinoid use.”
A perspective published in the New England Journal of Medicine goes even further (Aug. 3, 2017).
The authors note that guidelines from the CDC recommend acetaminophen and NSAIDs as first-line options for osteoarthritis and low back pain. The physicians point out that “acetaminophen is often ineffective, and NSAIDs are associated with adverse effects that limit their use…”
They go on to say:
“The CDC guidelines also recommend gabapentinoids (gabapentin or pregabalin) as first-line agents for neuropathic pain. We believe, however, that gabapentinoids are being prescribed excessively — partly in response to the opioid epidemic”
They conclude:
“Patients who are in pain deserve empathy, understanding, time, and attention. We believe some of them may benefit from a therapeutic trial of gabapentin or pregabalin for off-label indications, and we support robust efforts to limit opioid prescribing. Nevertheless, clinicians shouldn’t assume that gabapentinoids are an effective approach for most pain syndromes or a routinely appropriate substitute for opioids.”
Gabapentin Side Effects:
The history of gabapentin (Neurontin) is fascinating. It was originally approved by the FDA for treating epilepsy in 1993. There is a tale of woe and intrigue about how the company that marketed Neurontin got into trouble with the FDA for illegal off-label marketing practices. We won’t go into that here, but you can read all about it in this article:
Surprising Gabapentin Side Effects
Gabapentin has become a go-to drug for doctors who are trying to control chronic pain problems. At last count, dispensed prescriptions have gone from 39 million in 2012 to 51 million in 2014 to 64 million in 2016 (Quintiles IMS, May 2017, now IQVIA Institute).
Gabapentin can cause depression, dizziness, fatigue, drowsiness, digestive tract upset, trouble with balance, cognitive difficulties, and visual problems. The official prescribing information warns:
“Antiepileptic drugs (AEDs), including gabapentin, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.”
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