As the U.S. continues to grapple with its worsening drug epidemic, attention has focused on curbing the abuse of opioids. However, under the radar, another drug has now become an ever-growing target for misuse; this time, it’s a non-opioid: Gabapentin.
Gabapentin, also sold under the brand name Neurontin, is a multi-purpose drug used as an anticonvulsant for epileptic seizures, as well as to treat pain induced by a myriad of neuropathies. These include pain from diabetic neuropathy, pain from opiate withdrawal, and more commonly, neuropathic pain following episodes of shingles.
It works by binding to voltage- dependent calcium channels to inhibit excitatory neurotransmitter release, and ultimately attenuate the transmission of pain (Bennett & Simpson, 2004).
This drug also shows promise as a therapeutic for alcohol and cannabis abuse (Furieri & Nakamura-Palacios, 2007; Mason et al., 2012). Also available as a generic drug, gabapentin’s versatility and effectiveness as a non-narcotic alternative to opioids have made it one of the top 10 most prescribed drugs in the U.S. today (Goodman & Brett, 2017).
In the process, however, there has been a significant spike in gabapentin misuse in states marred by the opioid crisis, such as Kentucky and Ohio. In fact, in Kentucky’s Jefferson County, of the more than 400 overdose deaths in 2016, up to a quarter of these deaths arose in the presence of gabapentin (Courier Journal, 2018).
Meanwhile, in Ohio, the Ohio Substance Abuse Monitoring (OSAM) Network has detected illicit use of gabapentin at moderately to high levels in six out of eight OSAM regions (Ohio MHA, 2017).
Gabapentin, by itself is not inherently addictive. However, possessing sedative properties, gabapentin, when taken in very high doses, can elicit feelings of euphoria in its users (Smith et al., 2012). Pursuit of this ‘high,’ coupled with the risk of withdrawal effects from abrupt termination of gabapentin consumption, has led to growing recreational use of the drug.
However, the most dangerous effects manifest when gabapentin is taken in tandem with other drugs. Studies have suggested a synergistic effect, whereby gabapentin actually enhances the effects of drugs such as alcohol, benzodiazepines, and more disconcertingly, opioids such as heroin.
It is this synergistic effect of gabapentin, when taken in concert with opioids, which has proven to be particularly lethal. As it turns out, over a quarter of opioid abusers have also been found to seek out gabapentin, to augment the effects of their opioids (Bastiaens et al., 2016).
Gabapentin and Opioids
Furthermore, as of 2018, analyses of drug users in Appalachian Kentucky revealed that these individuals reported consumption of gabapentin in tandem with opioids such as cocaine.
Their intention was to achieve desired physiological effects such as pain alleviation, sleep induction, and generating that sought-after ‘high.’ These individuals indicated that gabapentin was a low-cost, readily prescribed drug that has become increasingly popular both among physicians and patients as an alternative to opioids (Smith et al., 2018). When taken alongside opioids, gabapentin has been found to increase the risk of death by opioid overdose by almost 50% (Gomes et al., 2017).
Putting this drug into the wrong hands (those of opioid abusers) could potentially cause the number of opioid overdose fatalities to rise substantially.
On the other hand, gabapentin’s synergistic effect could be harnessed to actually benefit those recovering from opioid addiction through medication assisted treatment (MAT). Addiction medications such as buprenorphine and methadone have been found to exhibit enhanced therapeutic effects when supplemented with gabapentin.
This use has manifested as decreases in opioid levels in urine and relief of withdrawal symptoms over time (Sanders et al., 2013; Moghadam & Alavinia, 2013). Such results, alongside the aforementioned results of alleviating alcohol and cannabis abuse, bode well for gabapentin, provided that this drug is allocated for supervised treatment.
Gabapentin, while an integral drug for a wide array of patients, is clearly a ‘double-edged sword’ with respect to drug abusers. What is key is preventing easy access of the drug to ongoing abusers of opioids and hard drugs, while also exploring its benefit as a supplement for MAT.
The state of Kentucky took the correct approach, by deeming the drug a schedule 5 controlled substance in 2017. This means that the drug, while not having a severe risk of abuse, is one that can still elicit psychological dependence, and can only be issued by practitioners registered with the Drug Enforcement Administration (DEA).
Additionally, patients will not be allowed to receive samples of gabapentin, and prescriptions will have to be reported and tracked on Kentucky’s prescription drug monitoring program, the Kentucky All Schedule Prescription Electronic Reporting System (KASPER). Moreover, prescriptions would be deemed as ‘expired’ after five refills, so as to make it more difficult to potentially overuse of the drug (Kentucky CHFS, 2017).
States across the country should look to replicate the efforts of Kentucky. Closely monitoring and regulating gabapentin distribution, making the drug a controlled substance, and limiting who can dispense and receive the drug are essential in minimizing the proliferation of gabapentin among opioid abusers.
Additionally, expanding on, and increased funding into clinical research delving into the therapeutic effects of gabapentin as an adjunct to MAT therapeutics could go a long way in improving the lives of those marred by this opioid crisis.
At the end of the day, the objective should be to use gabapentin solely as a therapeutic, to treat patients who genuinely need it most. Meanwhile, ensuring that the drug does not fall into the wrong hands is vital in minimizing its misuse, and making an already severe opioid crisis even worse.
Bastiaens, L., Galus, J., & Mazur, C. (2016). Abuse of Gabapentin is Associated with Opioid Addiction. Psychiatric Quarterly, 87(4), 763-767. doi:10.1007/s11126-016-9421-7
Bennett, M. I., & Simpson, K. H. (2004). Gabapentin in the treatment of neuropathic pain. Palliative Medicine, 18, 5-11. Courier journal. (2018, March 26).
Drug touted as a safe alternative to painkillers has been found in more Louisville deaths. Retrieved April 6, 2018, from https://www.courier-journal.com/story/news/crime/2018/03/26/gabapentin-overdose-deaths-louisville-fatal-addiction/372489002/
Furieri, F. A., & Nakamura-Palacios, E. M. (2007). Gabapentin Reduces Alcohol Consumption and Craving. The Journal of Clinical Psychiatry, 68(11), 1691-1700. doi:10.4088/jcp.v68n1108
Goodman, C. W., & Brett, A. S. (2017). Gabapentin and Pregabalin for Pain —Is Increased Prescribing a Cause for Concern? New England Journal of Medicine, 377(5), 411-414. doi:10.1056/nejmp1704633
Gomes, T., Juurlink, D. N., Antoniou, T., Mamdani, M. M., Paterson, J. M., & Brink, W. V. (2017). Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–control study. PLOS Medicine, 14(10). doi:10.1371/journal.pmed.1002396
Kentucky, U.S.A., Kentucky Cabinet for Health and Family Services (CHFS). (2017, March 3). Important Notice: Gabapentin Becomes a Schedule 5 Controlled Substance in Kentucky. Retrieved April 8, 2018, from http://www.chfs.ky.gov/NR/rdonlyres/92D10F1A-8842-4E6D-B9D2- 5741E2926E/0/KentuckyGabapentinFactSheet.pdf
Mason, B. J., Crean, R., Goodell, V., Light, J. M., Quello, S., Shadan, F., . . . Rao, S. (2012). A Proof-of-Concept Randomized Controlled Study of Gabapentin: Effects on Cannabis Use, Withdrawal and Executive Function Deficits in Cannabis-Dependent Adults. Neuropsychopharmacology, 37(7), 1689-1698. doi:10.1038/npp.2012.14
Moghadam, S. & Alavinia, M. (2013). The effects of gabapentin on methadone based addiction treatment: A randomized controlled trial. Pakistan journal of pharmaceutical sciences. 26. 985-9.
Ohio Department of Mental Health and Addiction (Ohio MHA) Services. (2017). Neurontin® Widely Sought for Illicit Use (Rep.). Columbus, OH: The Ohio Substance Abuse Monitoring Network. Retrieved April 6, 2018, from http://mha.ohio.gov/Portals/0/assets/Research/OSAM-TRI/Neurontin-OSAM-O-Gram_Feb2017.pdf
Sanders, N. C., Mancino, M. J., Gentry, W. B.,…., & Oliveto, A. H. (2013). Randomized, placebo-controlled pilot trial of gabapentin during an outpatient, buprenorphine-assisted detoxification procedure. Experimental and Clinical Psychopharmacology, 21(4), 294-302. doi:10.1037/a0033724
Smith, B. H., Higgins, C., Baldacchino, A., Kidd, B., & Bannister, J. (2012). Substance misuse of gabapentin. The British Journal of General Practice, 62(601), 406–407. http://doi.org/10.3399/bjgp12X653516
Smith, R. V., Boland, E. M., Young, A. M., Lofwall, M. R., Staton, M., & Havens, J. R. (2018). A qualitative analysis of gabapentin misuse and diversion among people who use drugs in Appalachian Kentucky. Psychology of Addictive Behaviors, 32(1), 115-121. doi:10.1037/adb0000337
Racheed Mani, B.A. is now pursuing a medical degree at the Stony Brook University School of Medicine. He previously received his Bachelor’s degree in Biochemistry and Psychology at New York University, while also serving as a psychiatric clinical research assistant.