Drugs for neuropathic pain
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7339 (Published 19 December 2013) Cite this as: BMJ 2013;347:f7339
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I share the concerns already expressed regarding the failure of this article to mention the abuse potential of gabapentin and especially pregabalin. The authors (who all declared conflicts of interest) should be referred to the excellent piece by Des Spence in 'Frontline' BMJ 8 November 2013 entitled "Bad medicine: gabapentin and pregabalin".
Whilst these drugs clearly have appropriate uses, they should be avoided in those with a history of drugs and/or alcohol dependency.
Competing interests: No competing interests
I have concerns about this article.
All the drugs mentioned will cause dizziness or tiredness or sickness or worse in a worryingly large percentage of patients, without any delay. The benefit is seen in 1:6 at best(PHN and full dose pregabalin is 1:4)-and the authors suggest that even these values are exaggerated because of trials not allowing for drop- outs .And the benefits are delayed.
The authors don't paint an attractive picture for anyone unless pain levels are severe.
In this context of poor effectiveness/side effects ratio,the authors mention duloxetine and pregabalin as probably being the most effective drugs for certain indications-they say this on page 34 and virtually the same words are repeated on p35.To make matters worse the combination of these is the cure in the patient scenario.
This seems to me to be an advertisement for these drugs based on minimal and debatable differences.
I share the views of a previous respondent to this article re the pharmaceutical affiliations of the authors.I welcome the day when academics have no perceived conflicts of interest.
Lastly the declaration of conflicts isn't reassuring- if a person was on trial on a serious charge and they revealed that they had previously committed murder and numerous other similar offences would we be more likely to believe in their innocence?
Competing interests: No competing interests
I agree with the concerns about abuse of gabapentin and the frequent use, and diversion of the drug for street use, to potentiate opiates. I have direct evidence from users that gabapentin is also crushed and snorted for a reported "cocaine like" high.
Competing interests: No competing interests
I was concerned to read no mention of the abuse potential or diversion potential of the GABAnergic drugs. Myself and my colleagues have been increasingly concerned about such drugs being prescribed to patients with current or a history of alcohol/drug dependence, particularly pregabalin which has been implicated in deaths in the area.
Illicit pregabalin is increasingly becoming part of the repertoire of our poly drug using patients and we would strongly recommend avoiding prescribing it or gabapentin to anyone in alcohol/drug treatment or who has had contact with such services.
We are also aware of its potential to lead to dependence and a advise all patients be counselled about this and steps taken to act quickly if this became apparent (closely monitoring repeat scripts, offering short scripts)
I also note the close affiliation the authors had with the pharmaceutical industry.
Dr Alun George
Competing interests: No competing interests
The authors provide a useful summary of the pharmacological management of neuropathic pain. However we feel there should have been at least a reference to the potential abuse of pregabalin and gabapentin, something highlighted by Dr Spence in the BMJ last year.[1] There are increasing numbers of reports of gabapentin and pregabalin being used alongside opiates to potentiate the opiate effects.[2,3] The drugs can also be used alone in higher than recommended doses to produce both sedative and psychedelic effects.[4,5] The consequences of overdose can be severe and unpredictable with seizures being a recognized presenting feature in emergency departments with a significant number requiring admission to intensive care.[6] The half-life of 5-7 hours necessitates prolonged monitoring of patients. A recently published study suggested that patients at a high risk of addiction were prescribed higher than the recommended dose of pregabalin.[7]
While we are confident that when used correctly gabapentinoids can provide great relief for patients experiencing neuropathic pain, consideration should be given to the potential for abuse before they are prescribed. Quantities supplied should be appropriately limited with due regard to the possibility of misuse.
References:
1. Spence D. BMJ. Bad medicine: gabapentin and pregabalin. BMJ 2013;347:f6747
2. Baird CR, Fox P, Colvin LA. Gabapentinoid Abuse in Order to Potentiate the Effect of Methadone: A Survey among Substance Misusers. Eur Addict Res. 2013;20(3):115-118.
3, Grosshans M et al. Pregabalin abuse among opiate addicted patients. Eur J Clin Pharmacol. 2013;69(12):2021-5.
4. Schifano F et al. Is there a recreational misuse potential for pregabalin? Analysis of anecdotal online reports in comparison with related gabapentin and clonazepam data. Psychother Psychosom 2011;80:118-22.
5. Smith BH, Higgins C, Baldacchino A, Kidd B, Bannister J. Substance misuse of gabapentin. Br J Gen Pract 2012;62:406-7.
6. Millar J, Sadasivan S, Weatherup N, Lutton S. Lyrica nights–recreational pregabalin abuse in an urban emergency department. Emerg Med J2013;30:874.
7. Bodén R, Wettermark B, Brandt L, Kieler H. Factors associated with pregabalin dispensing at higher than the approved maximum dose. Eur J Clin Pharmacol. 2014 ;70(2):197-204.
Competing interests: No competing interests
Just a cautionary note about Pregabalin and Gabapentin.
As a lot of us know, they are recognised as drugs that are becoming increasingly abused in the community.
Anything with "gaba" in the name seems to attract people who may also like things with "pam" in. Not surprising really, given the similar receptor sites affected.
I realise it is very difficult to objectively assess neuropathic pain and I would not be hard on doctors who find themselves in a dilemma about prescribing these medications.
I do think though that it is worth highlighting the problem following this article, as I don't think it was mentioned in the safety aspects of the discussion.
The more informed we are of the dangers of prescribing them then, hopefully, the less problems will arise.
Competing interests: No competing interests
Re: Drugs for neuropathic pain
In a previous rapid response, Mark Hallam wrote re gabapentin and pregabalin:
"Whilst these drugs clearly have appropriate uses, they should be avoided in those with a history of drugs and/or alcohol dependency."
I would like to take issue a bit with that statement. Perhaps a better wording would be "they should be used with caution in those with a history of drugs and/or alcohol dependency" rather than "avoided".
Otherwise we would be denying a whole swathe of people treatment which can be effective, for conditions that can be painful and/or disabling.
Surely, we must not believe that all people who have, or have had, substance misuse problems are either a) manipulative people who only want these drugs to get a "high" or b) if these drugs are prescribed they will automatically be abused or sold.
It is the same issue with opiate analgesia in people who have or have had an opiate addiction.
Each person is an individual and to make a blanket statement of "do not use" is not good medicine.
Do use if really needed clinically, but with informed caution and careful monitoring.
Of course, deciding on the clinical need is somewhat of an art as well as a science, given that the sorts of things treated by these substances are not really amenable to objective measurement. It's not easy, of course, but then that's why we are doctors....
I hope that this makes sense to people and that it takes the debate forward - and I hope that no one has taken offence with these observations - none was intended.
Competing interests: No competing interests