August 2019 -Windmills, Beware!

…was the original title of an article I wrote for the American Academy of Pain Medicine/MedPage Today collaboration (“Pain Points”) this month. I’m supposed to be exposing folks around the country to how we do pain management here in AK, but I needed to get some stuff off my chest – see https://www.medpagetoday.com/blogs/pain-points/81569 for my rant if you’re so inclined.

The reader’s digest version is that I’m starting to field questions from a lot of folks from different agencies and also the community about the risks of the gabapentinoids: gabapentin (Neurontin) and Lyrica (pregabalin). A handful of slanted pharmacy pubications have come out over the past couple years alleging that these agents are being widely misused and abused, and questioning whether we’re doing the right thing prescribing it in chronic (neuropathic) pain.

First of all, to debunk that misconception, there’s a reason all major pain societies around the world advise gabapentinoids as first line treatment for neuropathic pain. The world’s best evidence-based medicine repository, the Cochrane database shows strong evidence of benefit for the class in many scenarios (and of course the FDA’s approval aligns with that.) Medicine is all about risk: benefit ratio, and there is hardly a safer class of “pain medicine” out there. They have a huge “therapeutic index” meaning the difference between effective and toxic dose is immense. They don’t require the liver to metabolize them into safely degraded substances for the kidneys to eliminate, which means we don’t have to worry about unsafe levels building up and also they don’t interfere with other drug metabolism (no interactions.)

Switching gears, let’s talk briefly about abuse liability. Yes, they are abuse-liable (which is why the FDA/DEA have scheduled Lyrica as a controlled substance since day 1) but as I point out in the article, paint and glue are abuse liable. Not to mention alcohol… These articles however paint the picture of an imminent global catastrophe of gabapentinoid abuse and addiction, and claim a prevalence of 1% - based solely on one internet survey conducted in Britain. The fact is, the FDA’s Adverse Events Reporting System logs only 600 some cases of suspected abuse in the US over a 5-year period – when 20 billion prescriptions were written in the U.S. And systematic reviews in the addictionology literature confirm only 4 (yes, FOUR) cases of behavioral dependence on gabapentinoids worldwide over the past two decades.The most compelling arguments against this sensationalized journalism comes though from hardcore laboratory research showing absolutely no evidence from a neurobiologic standpoint of addictive potential (no dopamine surges in the nucleus accumbens, which is something that occurs with every drug of abuse whether tobacco, alcohol, marijuana, opioids, methamphetamines, etc.)

I appreciate the concerns brought up about people mixing the gabapentinoids with opioids and increasing risks of overdose. However, we don’t have a very clear picture on that either, as these agents actually play a huge role in detoxification and withdrawal management, and as several studies suggest, people may be actually (mis)using the gabapentinoids in (granted, poorly thought through) attempts to ‘clean up.’

Any prescription drug is dangerous to some extent – that’s why they’re relegated to prescription by licensed medical professionals. And certainly some people are more prone to abusing anything; the responsibility of sorting out which certainly falls in large part on the prescriber. But keeping in mind the big picture view here, we are (rightly so) looking for better ways to manage chronic pain in this country, and balance in everything is usually a pretty good strategy. As many of you have heard me say (if you are patients at NAPM) “a little of this, and a little of that is a whole lot safer than a bunch of one or the other.” Too much gabapentin or Lyrica is certainly not good. But a little in the right situation (and again, there’s a reason all major pain societies around the world advise gabapentinoids as first line treatment for neuropathic pain) is key to winning the war against opioid overuse… and chronic pain. Let’s not lose sight of the forest for the trees.