Gabapentinoids: has reclassification really solved the problem?BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m114 (Published 13 January 2020) Cite this as: BMJ 2020;368:m114
In October 2018, the UK government announced that it would be reclassifying gabapentin and pregabalin1—known collectively as gabapentinoids—after experts pointed out the rising numbers of deaths linked to the drugs.
Gabapentinoids—which are indicated for the treatment of epilepsy, peripheral and neuropathic pain, and generalised anxiety disorder in adults—were officially reclassified as class C controlled substances in April 2019. Reclassification has made it illegal to supply pregabalin and gabapentin through repeat dispensing, and pharmacists now need to dispense the drugs within 28 days of a prescription being written. Doctors must also hand sign prescriptions.2
In the UK, the rate of patients newly treated with gabapentinoids in primary care tripled between 2007 and 2017, according to research published in JAMA.3 By 2017, 50% of gabapentinoid prescriptions were for an off-label indication and 20% had a co-prescription for opioids.
Prescribing numbers still rising
Reclassification was expected to prompt a decline in use of the drugs due to prescribing, dispensing, and collection becoming more difficult. But data since then show no major changes in prescribing trends, with monthly numbers continuing to fluctuate as they have done in previous years, and overall numbers are still rising.4
Comparing April 2018 to April 2019, the number of prescriptions increased from 138.42 items per 1000 patients to 141.9 items. Comparing October 2018 (when the changes were first announced) to October 2019, the number of prescriptions increased from 151.71 items to 151.93 items per 1000, with a drop in London countering increased prescribing across other areas such as the South East and North West.
When Tramadol—an opioid used for pain—was reclassified under similar circumstances in June 2014, there was an almost immediate effect on prescribing data.5
Ian Hamilton, a senior lecturer in addiction and mental health at the University of York, said the difference between the two cases was the availability of other options. “GPs are really going to struggle to get the prescribing numbers [of gabapentinoids] down, because what alternatives do they have?”
Experts told The BMJ that reclassification alone cannot tackle the problems around gabapentinoids because the changes do not get to the root of the problem.
Niamh Eastwood, executive director of Release, the national centre of expertise on drugs and drugs law, said that limiting their availability will simply shift the problem to other, sometimes more harmful, substances, as the underlying issues are not being tackled. People can also turn to the illicit market, she added. “Essentially, increased criminalisation will create greater harms for individuals and can increase barriers to treatment but will do nothing to deter use.”
Hamilton also drew attention to prescribing data for England, which shows that the highest levels of prescribing (items per 1000 patients) are seen in the North East and Yorkshire and North West commissioning regions.
“It’s clear that the areas with the highest levels of deprivation are also the areas with the most gabapentinoid prescription,” he said. “The high numbers are a reflection of the limits of what GPs can do when they are seeing patients with no hope or capacity to change their situation. There are very few alternatives for pain that do not carry risks. What do you do when you’re faced with someone who is in pain and has very little hope or social support? GPs are stuck in the middle.”
Azeem Majeed, GP and head of public health and primary care at Imperial College London, said his practice had become “more cautious about initiating gabapentinoids,” but said the “challenge is getting people who are on long term gabapentinoids off these drugs.”
GPs under pressure
Although many GPs and medical bodies supported reclassification, they also urged the government to simultaneously improve support services to help people with dependence to come off the drugs. Experts think this has not happened.
Andrew Green, who was clinical lead for the BMA’s GP Committee when the changes were being consulted on, told The BMJ, “I said that the government must invest in specialised support services for prescription drug dependence. Unfortunately I have not seen any evidence of this investment taking place, so GPs and their patients remain unsupported.”
Preeti Shukla, the committee’s current clinical and prescribing policy lead, raised similar concerns. “We are still short of alternative treatments, which can make coming off the drugs difficult for those without access to psychology support, physiotherapy, or similar specialised services,” she said.
Addiction services have seen heavy cuts across England. In 2018, the BBC found that budgets for treatment services fell by 18% between 2013-14 and 2017-18, which contributed to a 26% rise in drug related deaths between 2013 and 2016.6
Meanwhile, the Care Quality Commission estimates that the number of live-in drug and alcohol rehabilitation services in England has fallen from 195 in 2013 to 132 in 2019.7
“The solution is not complicated,” said Hamilton. “We need more support services and for drug treatment to be invested in. People are paying with their lives.”